PSYCHOSOMATIC PSYCHOSOMATIC MEDICINEMEDICINE

Dr. YASER ALHUTHAILDr. YASER ALHUTHAILAss. Professor & ConsultantAss. Professor & Consultant

Consultation Liaison PsychiatryConsultation Liaison Psychiatry

Psychosomatic medicine is an area of scientific Psychosomatic medicine is an area of scientific investigation concerned with theinvestigation concerned with the relationrelation between between psychological factors and physiological phenomena psychological factors and physiological phenomena in general and in general and disease pathogenesisdisease pathogenesis in particular. in particular.

Integrates mind and body into a psychobiological Integrates mind and body into a psychobiological

unit; to study psychological and biological processes unit; to study psychological and biological processes as as dynamic interacting systemsdynamic interacting systems..

It emphasizes the It emphasizes the unity of mind and bodyunity of mind and body and the and the

interaction between them. interaction between them. A A holisticholistic approach to medicine. 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 Psychological factors must be taken into account when consideringwhen considering all disease states

Emphasis on examining and treating Emphasis on examining and treating the whole the whole patientpatient, not just his or her disease or disorder. , not just his or her disease or disorder.

The concepts of psychosomatic medicine also The concepts of psychosomatic medicine also influenced the field of behavioral medicine influenced the field of behavioral medicine which integrates the behavioral sciences and the which integrates the behavioral sciences and the biomedical approach to the biomedical approach to the prevention, prevention, diagnosis, and treatment of diseases.diagnosis, and treatment of diseases.

Psychosomatic concepts have contributed Psychosomatic concepts have contributed greatly to those approaches of medical care.greatly to those approaches of medical care.

Biomedical Model:Biomedical Model:

The application of biological science to maintain The application of biological science to maintain health and treating disease.health and treating disease.

Engel (1977) proposed a major change inEngel (1977) proposed a major change in our our fundamental model of health care.fundamental model of health care.

The new model continues the emphasis on The new model continues the emphasis on biological knowledgebiological knowledge, but also encompasses the , but also encompasses the utilization of utilization of psychosocial knowledgepsychosocial knowledge..

““Biopsychosocial ModelBiopsychosocial Model””

Stress TheoryStress Theory Stress can be described as a circumstance that Stress can be described as a circumstance that

disturbs, or is likely to disturbdisturbs, or is likely to disturb, the normal , the normal physiological or psychological functioning of a physiological or psychological functioning of a person.person.

The body reacts to stress in this sense defined as The body reacts to stress in this sense defined as

anything (anything (real, symbolic, or imaginedreal, symbolic, or imagined) that by ) that by threatens an individual's survival by putting into threatens an individual's survival by putting into motion a set of responses that seeks to motion a set of responses that seeks to diminish the diminish the impact of the stressor and restore homeostasis. impact of the stressor and restore homeostasis.

THE STRESS MODELTHE STRESS MODEL

A psychosomatic framework.A psychosomatic framework.

Two major facets of stress response.Two major facets of stress response.

““Fight or Flight”Fight or Flight” response is mediated by response is mediated by hypothalamus, the sympathetic nervous system, hypothalamus, the sympathetic nervous system, and the adrenal medullaand the adrenal medulla..

If chronic, this response can have serious health If chronic, this response can have serious health consequences.consequences.

The hypothalamus, pituitary gland, the adrenal The hypothalamus, pituitary gland, the adrenal cortex mediate the second facet.cortex mediate the second facet.

Neurotransmitter Responses to StressNeurotransmitter Responses to Stress

Stressors activate Stressors activate noradrenergicnoradrenergic systems in systems in the brain and cause release of catecholamines the brain and cause release of catecholamines from the autonomic nervous system.from the autonomic nervous system.

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

Stress also increases Stress also increases dopaminergic dopaminergic neurotransmission in mesoprefrontal pathways. neurotransmission in mesoprefrontal pathways.

Endocrine Responses to StressEndocrine Responses to Stress

CRFCRF is secreted from the hypothalamus. is secreted from the hypothalamus.

CRFCRF acts at the anterior pituitary to trigger release of acts at the anterior pituitary to trigger release of ACTH.ACTH.

ACTH acts at the adrenal cortex to stimulate the ACTH acts at the adrenal cortex to stimulate the synthesis and release of synthesis and release of glucocorticoidsglucocorticoids..

Promote Promote energy useenergy use, increase , increase cardiovascular activitycardiovascular activity, , and inhibit functions such as and inhibit functions such as growth, reproduction, growth, reproduction, and immunity.and immunity.

Immune Response to StressImmune Response to Stress

InhibitionInhibition of immune functioning by of immune functioning by glucocorticoidsglucocorticoids.. Stress can also cause immune Stress can also cause immune activationactivation through a through a

variety of pathways including the release of variety of pathways including the release of humoral immune factors (cytokines) such as humoral immune factors (cytokines) such as interleukin-1 (IL-1) and IL-6. interleukin-1 (IL-1) and IL-6.

These cytokines can themselves cause further release These cytokines can themselves cause further release of CRF, which in theory serves to increase of CRF, which in theory serves to increase glucocorticoid effects and thereby self-limit the glucocorticoid effects and thereby self-limit the immune activation. immune activation.

High level of High level of CortisolCortisol results in suppression of results in suppression of immunity which can cause susceptibility to immunity which can cause susceptibility to infectionsinfections and possibly also in many types of and possibly also in many types of cancercancer..

Changes in the immune system in response to Changes in the immune system in response to stress are now very well established.stress are now very well established.

Immune suppression in response to stress occurs Immune suppression in response to stress occurs even after removal of the adrenal gland !!.even after removal of the adrenal gland !!.

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

PsychoneuroimmunologyPsychoneuroimmunology

DSM-IV Diagnostic Criteria for Psychological DSM-IV Diagnostic Criteria for Psychological Factors Affecting Medical ConditionFactors 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 condition.

(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 disease)

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 SystemCardiovascular 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 ConditionsGastrointestinal 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 DisordersSomatoform Disorders

Three enduring clinical features:

- Somatic complaints that suggest major medical problems.

- Psychological factors and conflicts that seem important.

- Symptoms or magnified health concerns that are NOT under the patient’s conscious control.

Somatoform DisordersSomatoform Disorders

Somatization disorder

Conversion disorder

Pain disorder

Hypochondriasis

Body Dysmorphic Disorder

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