Prezentace aplikace PowerPoint neurasthenia

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					 Psychosomatic Medicine
and somatoform disorders
3rd class of programme in General Medicine- English
                      programme
                 winter term 2007/8

                    Jan Libiger
Systemic Levels of Description in
          Psychiatry
 social          group, society       evironment



 psychological   individual



 physiological   brain systems
                 and functions


 neurochemical   cells and cellular
                 components

                                          genetic
 molecular       nucleic acids and     dispositions
                 genomic regulation
    Psychosomatic approach-Psychosomatic
                  disorders.
      Psychological Factors Affecting Physical Disorders

broad and narrow definition of psychosomatic
  approach
the reverse problem: physical conditions manifested
by psychological problems

The older view
Psychodynamic view of pathophysiological
mechanism:
conversion and dissociation mechanisms : F.
  Dunbar, F. Alexander
• Unspecific and specific emotional conflict in analogy
  to neurotic disorders in psychodynamic theories
• The symptoms have symbolic meaning
• Somatization complements anxiety-cathexis of
  emotions, communicative value

The big seven:
  •   peptic ulcer
  •   hypertension
  •   asthma
  •   thyreotoxicosis
  •   rheumatoid arthritis
  •   migraine
  •   ulcerative colitis
    Psychosomatic and Somatoform disorders
               Anxiety
       Coping mechanism


                                unconscious
       conscious

                                         conversion( dissociation,
release,                   defence            somatization)
rational                 mechanisms
work out       (projection, reaction formation)
                                            acute          chronic


                                                       without       with
                                                       organic       organic
                      phobia, OCD                      change        change
                                         hysteria
                                         raptus
                                         stupor
                                                     somatoform psychosomatic
Franz Alexander´s general scheme of the interaction of
                      conflict and
        overdrive in autonomic nervous system
Franz Alexander´s general scheme of the interaction of
                      conflict and
        overdrive in autonomic nervous system




                     block of need to be
                     passive and dependent
                     leads to parasympathetic
                     system overdrive with the
                     resulting dysfunctions:

                     •peptic ulcer
                     •ulcerative colitis
                     •asthma
Franz Alexander´s general scheme of the interaction of
                      conflict and
        overdrive in autonomic nervous system




                         Block of agression leads to
                         sympathetic system overdrive with
                         the resulting chronic dysfunction :

                         •hypertension
                         •migraine
                         •tyreotoxiciosis
                         •rheumatoid arthritis
    Stress based approach to psychosomatic
                   disorders
Sensitive or weak function or „shock organ“ exposed
to stress

Sress as an adaptive or maladaptive mechanism:
• it serves different purpose in human history
• it may generalize to non-salient stimuli
• it fails to habituate
• accumulation of vulnerability
• block of other mechanisms for coping with stress

alexithymia : inability to express or experience
feelings – the subjective part of emotions
Cannon, Seley, Sifneos, Sapolsky
                    „TYPE A“ BEHAVIOUR


TUI :Time Urgency, Impatience




                                ASC : Achievement Striving, Competitivness




                 HOS : Hostility



                                   Rosenman and Friedman, JAMA, Aug.1975
Coping styles: personality A and B (Rosenman,
Friedman)
Questionnaires of life styles

Stress and Immunity

Social role, dominance and submission and
corresponding changes of HPA axis regulation

Unity or diversity: dimensional or categorical classification
autonomic dysfuntion in particular systems and common
features constituting the neurasthenia, chronic fatigue cluster

Psycho-bio-social model (George Engel)
The significance of social standing: hierarchy of dominance :

Robert Sapolsky and his research in west-african baboons :

Dexamethason test and social interaction

High plasma level of cortisol and the failure of its feed back
regulation is associated with :

• readiness for submission in conflict
• lower number of fight initiations
• higher number of defeats and escapes from conflict
• inability to compensate losses in fights with lower ranking
individuals

The role of „ learned helplessness“:
inability to control situation and perfectionism (in humans)
The significance of social standing: hierarchy of dominance :

Robert sapolsky and his research in westafrican baboons :

Dexamethason test and social interaction

High plasma level of cortisol and the failure of its feed back
regulation is associated with:

• readiness for submission in conflict
• lower number of fight initiations
• higher number of defeats and escapes from conflict
• inability to compensate losses in fights with lower ranking
individuals

The role of „ learned helplessness“:
inability to control situation and perfectionism (in humans)
 Treatment of psychosomatic disorders

1. Listening to patients

Universal medical skill and specialized
consultation – liaison psychiatric service

2. Psychotherapy

Education, reeducation, CBT, dynamic
oriented approach: classical and
otherwise
3. Psychotropic drugs

Regulation of basic (cortical excitation and
inhibition) and modulatory processes
(subcortical neurotransmitters – serotonin,
dopamin)

4. Preventative efforts

lifestyle in the society and in the individual
           Ethical issues in medicine
1. What is my objective?

To maintain the life, improve its quality or
to alleviate suffering?

Problem of euthanasia

2. Whose interest do I serve?

Individual? Society?

Confidentiality problem,
Protective treatment problem
3. Who is in charge?

Patient? Doctor?

Full discloure problem,
Involuntary treatment problem,
                  Ethical issues in medicine
Utilitarian theory vs autonomy theory

Utilitarian theory: The fundamental ethical obligation is to
to act so as to bring the greatest possible happiness for
the greatest number of people.

Requirements:
• consider all the available evidence relevant to alternative courses
  of action
• take the action that leads either to the greatest happiness, or in
  case that it is impossible, to the least pain.
No obligation for informed consent, truth or
confidentiality, if it does not serve universal
maximum happiness.

Good for decisions on allocation of resources:
public health decisions

Paternalism: benefitting people without their
consent „ I know better…!“

Father- child relationship with all the implications,
protection from information that is difficult to accept,
threatening and incomprehensilbe.
                     Autonomy theory


Patient - doctor relationship is a relationship
between two autonomous persons

The patient has the ability and the right to
make rational and responsible decisions
and thus the right for self – determination.

The patient can decide for himself even if the
physician believes that his decision will harm
him.
Placebo
                 Ethical issues in medicine 3
psychological effect associated with the drug:
does it really help?

in research:
double blind placebo controlled clinical
testing: pro and cons

in practice:
problem of truthfulness and effectivity
therapeutical contract

Miscellaneous:

Involuntary treatment:
advance directive
  Thus the patient has right
• to informed consent on research and
  treatment programmes
• to refuse treatment
• to be told the full truth even if it is against his wishes or
  interests (principle of respect)

Institutional Review Boards and Ethics of
Research
rule of utility vs risk ratio
rule of full control – the patient may withdraw
anytime without being discriminated

Informed Consent: procedure and content,
comprehensible language,

exclude the use of incentives
Right to die (and its limits)

Right for the least restrictive treatment in
psychiatry ( and its limits)

Secondary gain and blackmail:

Priorites: quality vs the length of life
           HI-TECH vs comfort for many
           JUSTICE in access to treatment

Doctor-patient sexual relationship

				
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