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  Ass. Professor & Consultant
 Consultation Liaison Psychiatry
  Psychosomatic medicine is an area of scientific
investigation concerned with the relation between
psychological factors and physiological phenomena
in general and disease pathogenesis in particular.

Integrates mind and body into a psychobiological
unit; to study psychological and biological processes
as dynamic interacting systems.

 It emphasizes the unity of mind and body and the
interaction between them.

A holistic approach to medicine.
Two basic assumptions:
There is a unity of mind and body (reflected in
 the term mind-body medicine)

Psychological factors must be taken into account
  when considering all disease states

Emphasis on examining and treating the whole
 patient, not just his or her disease or disorder.
 The concepts of psychosomatic medicine also
influenced the field of behavioral medicine
which integrates the behavioral sciences and the
biomedical approach to the prevention,
diagnosis, and treatment of diseases.

Psychosomatic concepts have contributed
greatly to those approaches of medical care.
 Biomedical Model:
The application of biological science to maintain
health and treating disease.

Engel (1977) proposed a major change in our
fundamental model of health care.
The new model continues the emphasis on
biological knowledge, but also encompasses the
utilization of psychosocial knowledge.

            “Biopsychosocial Model”
              Stress Theory
 Stress can be described as a circumstance that
disturbs, or is likely to disturb, the normal
physiological or psychological functioning of a

 The body reacts to stress in this sense defined as
anything (real, symbolic, or imagined) that by
threatens an individual's survival by putting into
motion a set of responses that seeks to diminish the
impact of the stressor and restore homeostasis.
A psychosomatic framework.
Two major facets of stress response.
“Fight or Flight” response is mediated by
   hypothalamus, the sympathetic nervous system,
   and the adrenal medulla.
If chronic, this response can have serious health
The hypothalamus, pituitary gland, the adrenal
   cortex mediate the second facet.
Neurotransmitter Responses to Stress
  Stressors activate noradrenergic systems in
 the brain and cause release of catecholamines
 from the autonomic nervous system.

  Stressors also activate serotonergic systems
 in the brain, as evidenced by increased
 serotonin turnover.

  Stress also increases dopaminergic
 neurotransmission in mesoprefrontal pathways.
   Endocrine Responses to Stress
CRF is secreted from the hypothalamus.
CRF acts at the anterior pituitary to trigger release of
ACTH acts at the adrenal cortex to stimulate the
  synthesis and release of glucocorticoids.
Promote energy use, increase cardiovascular activity,
  and inhibit functions such as growth, reproduction,
  and immunity.
        Immune Response to Stress
Inhibition of immune functioning by glucocorticoids.

Stress can also cause immune activation through a
  variety of pathways including the release of
  humoral immune factors (cytokines) such as
  interleukin-1 (IL-1) and IL-6.

These cytokines can themselves cause further release
 of CRF, which in theory serves to increase
 glucocorticoid effects and thereby self-limit the
 immune activation.
 High level of Cortisol results in suppression of
immunity which can cause susceptibility to
infections and possibly also in many types of

Changes in the immune system in response to
stress are now very well established.
 Immune suppression in response to stress occurs
even after removal of the adrenal gland !!.

 There appears to be an alternative path, other
than through the adrenals, for the brain to
influence the immune response.

  DSM-IV Diagnostic Criteria for Psychological
     Factors Affecting Medical Condition
A. A general medical condition (coded on Axis III) is present.

B. Psychological factors adversely affect the general medical
     condition in one of the following ways:

(1) the factors have influenced the course of the general medical
     condition as shown by a close temporal association between the
     psychological factors and the development or exacerbation of,
     or delayed recovery from, the general medical condition.
(2) the factors interfere with the treatment of the general medical
(3) the factors constitute additional health risks for the individual.

(4) stress-related physiological responses precipitate or exacerbate
      symptoms of a general medical condition.
 Mental disorder affecting medical condition (e.g., an Axis I
disorder such as major depressive disorder delaying recovery
from a myocardial infarction)

 Psychological symptoms affecting medical condition (e.g.,
depressive symptoms delaying recovery from surgery; anxiety
exacerbating asthma)

 Personality traits or coping style affecting medical condition (e.g.,
pathological denial of the need for surgery in a patient with
cancer, hostile, pressured behavior contributing to cardiovascular
 Maladaptive health behaviors affecting medical condition (e.g.,
lack of exercise, unsafe sex, overeating)

 Stress-related physiological response affecting general medical
condition (e.g., stress-related exacerbations of ulcer, hypertension,
arrhythmia, or tension headache)
 Other unspecified psychological factors affecting medical
condition (e.g., interpersonal, cultural, or religious factors)
 The essential challenge in psychosomatic-
psychobiological research is to delineate the
mechanisms by which experiences cause
certain types of physiological reactions that
result in disease states.
         Cardiovascular System
 Psychological factors have been closely studied as part
of the pathogenesis of the cardiovascular diseases.
Depression is an independent risk factor for the
development of coronary artery disease.
 Depression increases mortality rates following
myocardial infarction (MI).
 Hyperactivity of the hypothalamic-pituitary-adrenal
(HPA) axis, immune activation with release of
proinflammatory cytokines, and activation of the
sympathetic nervous system and of corticotropin-
releasing factor (CRF) pathways in the central nervous
system (CNS).
     Gastrointestinal Conditions
Functional disorders represent 50% of
complaints in GI clinics

There is a strong & consistent association
between functional gastrointestinal disorders and
psychological factors.
Irritable Bowel Syndrome is the most common.
Brain-Gut axis
Hypersensitivity of GI tract
Role of stress
       Somatoform Disorders
Three enduring clinical features:

- Somatic complaints that suggest major
  medical problems.

- Psychological factors and conflicts that seem

- Symptoms or magnified health concerns that
  are NOT under the patient’s conscious
Somatoform Disorders

  Somatization disorder
   Conversion disorder
      Pain disorder
Body Dysmorphic Disorder

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