PSYCHOSOMATIC MEDICINE

Presentees: Priya Puri and Soma Pramanik Date: 2-07-12 Chairperson: Time: 9:00 am Dr. Bidita Bhattacharya

What is Psychosomatic Medicine?

The term psychosomatic is derived from the Greek words psyche (soul) and soma (body). The term literally refers to how the mind affects the body. Psychosomatic medicine maybe defined as an interdisciplinary medical field studying the relationships of social, psychological, and behavioral factors on bodily processes and quality of life in humans and animals. The primary objective for psychosomatic medicine is the diagnosis and treatment of psychiatric disorders in patients with complex medical conditions. It focuses on a variety of clinical problems that occur in patients being treated in medical settings, which occur as a result of a medical condition as well as anxiety, or depression, which occur in the setting of chronic medical conditions and somatoform disorders.

Evolution of the concept

Heinroth first used the word psychosomatic in 1817, applying it to problems of insomnia. Freud (1900) elucidated mechanisms whereby psychic conflicts expressed themselves in disorders of the voluntary nervous system--the conversion reactions. Ferenczi (1910) expanded the concept of conversion hysteria to apply it to the autonomic nervous system. Cannon (1927) showed how different emotions produced patterns of physiological alterations, emphasizing the importance of the autonomic network. Alexander (1934) stated that psychosomatic illnesses were mediated only through the autonomic nervous system--by definition--and that, in contrast to conversion hysteria, did not have specific symbolic meanings; rather, he felt they derived from chronic psychological states connected to unconscious drives in the context of constitutional predisposing factors. Dunbar (1936) suggested specific personality patterns to fit each psychosomatic disease; her approach, although intuitively attractive, did not bear conclusive results. Deutsh (1939) and Greenacre (1949) searched, equally inconclusively, for early putative traumatic experiences. Seyle (1950) described the stress syndrome, emphasizing the importance of hormonal factors.

 Wolff (1943) stated that physiological changes, if prolonged, could lead to organ damage. Horney (1939) and others postulated the importance of cultural influences. Grinker (1953) and Lipowski (1970) championed the comprehensive, multifactorial approach to psychosomatic disorders, viewing the patient in a holistic biopsychosocial context. DSM, in 1980, deleted the nosological term psychophysiological (or psychosomatic) disorders and replaced it with psychological factors affecting physical conditions. Nonetheless, the term continues to be used by researchers and is in the title of major journals in the field (e.g., Psychosomatic Medicine, Psychosomatics, and Journal of Psychosomatic Research). It is also used by the two major national organizations in the as well as international organizations.

A discussion over some psychosomatic diseases:

Cardiovascular Diseases Hypertension: A population-based prospective cohort study of 3,310 normotensive patients who were initially free of chronic disease, with four waves of follow-up for as long as 22 years, found that negative affect (a combination of depression and anxiety) was associated with incident hypertension. Another study with 15-year follow-up of 3,308 white and black men aged 18 to 30 and free of hypertension at study intake showed that specific components of the type A behaviour pattern (i.e., time urgency and impatience and hostility) predicted the development of hypertension in a dosedependent manner. Non-cardiac pain: At least 60 percent of patients with this condition have psychiatric disorders, mostly anxiety, depressive, and somatization disorders. Coronary Artery Disease and Angina Pectoris : Depression, vital exhaustion, anxiety, type A behaviour, hostility, anger, and acute mental stress have been evaluated as risk factors for the development and expression of coronary disease. Negative affect in general, low socioeconomic status and low social support have been shown to have significant relationships with each of these individual psychological factors, and some investigators have proposed these latter characteristics as more promising indices of psychological risk.

Gastrointestinal Disorders: Peptic Ulcer: A few recent research studies have demonstrated an association between self-reported peptic ulcer disease and generalized anxiety disorder, neuroticism, and childhood abuse after adjusting for confounders. It is likely that the onset of generalized anxiety disorder precedes the onset of peptic ulcer, as do childhood abuse and neuroticism, so these psychosocial factors presumably precede, rather than follow, the development of peptic ulcer. Alternatively a third factor, such as genetic predisposition, might lead to both anxiety and peptic ulcer, as genetic factors are considered to account for approximately 40 percent of variability of susceptibility to peptic ulcer disease.

 Irritable Bowel Syndrome (IBS) : Studies suggest that Anxiety appears to be more common among patients attending for the first time with IBS, whereas depression is more prominent in chronic IBS. Panic disorder is frequent in some specialist settings, although the group of patients with Gastrointestinal symptoms as part of their panic disorder may be an atypical group of functional Gastrointestinal disorder patients.

Respiratory Disorders: Asthma: Research suggests that psychiatric forces may affect the clinical expression of asthma in several ways: Altered awareness of airway resistance, suggestibility to airway constriction, comorbidity with panic disorder, and depression. Coexisting anxiety or panic disorder probably worsens the course of asthma, and the prevalence of panic disorder and agoraphobia is considerably higher among asthma patients than in the general population. As many as 30 percent of persons with asthma meet criteria for panic disorder or agoraphobia. Chronic obstructive pulmonary disease (COPD) : Clinicians usually recognize two forms of the disease: Chronic bronchitis and emphysema. The former classically presents with CO2 retention, hypoxemia, bronchial symptoms, dyspnea on exertion, and a history of recurrent bouts of acute bronchitis: The blue bloater. The latter syndrome (the pink puffer) manifests as severe hypoxemia, little CO 2 retention, dyspnea on exertion, asthenic habitus, and severe air trapping with large residual volumes. As for asthma, prevalence rates for panic disorder and anxiety disorders are increased among COPD patients. Anxiety disorders occur at rates of 16 to 34 percent, which are greater than the rate of 15 percent for the general population. Panic disorder prevalence rates among COPD patients range from 8 to 24 percent, higher than the general prevalence of 1.5 percent.

Diabetes: Thomas Willis, an early British physician, stated in the 17th century that diabetes is caused by sadness or long sorrow and other depression and disorders. Indeed, in recent years, researchers have shown that the rate of diabetes is approximately 1.5- to twofold higher in patients with affective disorders (major depression and bipolar disorder) and schizophrenia compared to the general population. The increased risk of diabetes in patients with depression has also been shown to be present within all racial/ethnic groups in the Multiethnic Study of Atherosclerosis (MESA). Chronic stress was also found to play an important role. Type II diabetes has been shown to be associated with a greater prevalence of cognitive impairment, incidence of cognitive decline, and incidence of Alzheimer's disease. A recent review of 25 prospective studies found that people with diabetes had a 1.2 to 1.5 greater risk of cognitive decline as compared with people without diabetes.

Obesity: Although the consensus of opinion is that no specific personality is associated with obesity, traits of poor impulse control, lower compliance, and self-discipline are associated with poor self-esteem, depressive traits, and emotional eating, leading to obesity. Most patients who are obese admit to overeating, and the majority report poor control of eating. A significant number of patients report they eat regularly in response to stress, anxiety, or boredom. Although many patients report they have enormous appetites and can consume large portions before they feel full, it is fairly common for obese patients to report that they rarely experience hunger. They eat in response to all kinds of uncomfortable emotions such as anger, sadness, anxiety, and boredom. They use food as a coping mechanism for most of their lives. Eating becomes a learned response to reducing anxiety or stress. Studies suggest that there is a high prevalence of depression among people who are obese.

Headache Migraine: Migraine is a disorder characterized by recurrent attacks or episodes of headache accompanied by other neurologic and gastrointestinal systems. Migraine presentation is multifaceted with symptoms emanating from multiple systems, including vascular, neurologic, gastrointestinal, endocrine, and visual. Anxiety and mood disorders are strongly associated with migraine. Prospective data from community studies of youth reveal that anxiety in childhood is associated with the subsequent development of headache in young adulthood. Migraine may be associated with irritability, mood swings, and in some cases, impulsive temper outbursts. Tension type headache: Tension-type headache is characterized by episodes of stable bilateral pain lasting several days at a time. It is distinguished from migraine headache by its generally longer duration, the lack of pulsating quality of the pain, the lack of worsening with physical activity, and the absence of GI concomitants.

Treatment plans for psychosomatic illnesses: