psychosmatic medicine

Psychosomatic Medicine د.وليد عزيز العميدي
I. STRESS AND HEALTH
A. Psychological factors affecting health
Psychological factors may initiate or exacerbate symptoms of medical disorders (psychosomatic symptoms) involving almost all body systems. These factors include
1. Poor health behavior (e.g., smoking, failure to exercise)
2. Maladaptive personality style (e.g., type A personality)
3.Chronic or acute life stress caused by emotional (e.g., depression), social (e.g., divorce), or economic (e.g., job loss) problems

B. Mechanisms of the physiologic effects of stress
Acute or chronic life stress leads to activation of the autonomic nervous system , which in turn affects
1.cardiovascular and respiratory systems.
2.Stress also leads to altered levels of neurotransmitters (e.g., serotonin, norepinephrine), which result in changes in mood and behavior.
3.Stress can increase the release of adrenocorticotropic hormone (ACTH), which leads to the release of cortisol, ultimately resulting in depression of the immune system as measured by decreased lymphocyte response to mitogens and antigens and impaired function of natural killer cells.

C. Stressful life events
High levels of stress in a patient s life may be related to an increased likelihood of medical and psychiatric illness.
1.The Social Readjustment Rating Scale by Holm e s and Rahe (which also includes "positive" events like holidays) ranks the effects of life events . Events with the highest scores require people to make the most social readjustment in their lives.

2.The need for social readjustment is directly correlated with increased risk of medical and psychiatric illness; in studies by Holmes and Rahe, 80% of patients with a score of 300 points in a given year became ill during the next year.

Magnitude of Stress Associated with Selected Life Events According to the Holmes
and Rahe Social Readjustment Scale
1- Very high : Death of a spouse , Divorce , Marital separation , Death of a close family member .
2- High : Major personal loss of health because of illness or injury , Marriage . Job loss , Retirement , Major loss of health of a close family member , Birth or adoption of a child .
3- Moderate : Assuming major debt (e.g., taking out a mortgage) , Promotion or demotion at work , Child leaving home.
4- Low : Changing residence ,Vacation , Major holiday.

D. Other psychosomatic relationships
1- Medical conditions that can present with psychiatric symptoms such as depression, include neurologic illnesses (e.g., dementia), neoplasms (particularly pancreatic or other gastrointestinal cancers), endocrine disturbances (e.g., hypothyroidism, diabetes), and viral illnesses (e.g., AIDS) .

2- Non-psychotropic medications can produce psychiatric symptom s such as confusion (e.g., antiasthmatics), anxiety (e.g., antiparkinson agents), depression (e.g., antihypertensives), sedation (e.g., antihistamines), agitation (e.g., steroid hormones), and even psychotic symptoms (e.g., analgesics, antibiotics, antihistamines).
3- Medical conditions such as diabetes and medications such as antihypertensives also commonly produce sexual symptom s such as erectile dysfunction . These symptoms in turn can lead to depression or other psychiatric problems in patients.

II. PSYCHOLOGICAL STRESS IN SPECIFIC PATIENTS
A. Overview
1- Not uncommonly, medical and surgical patients have concurrent psychological problems. These problems cause psychological stress, which can exacerbate the patient s physical disorder.
2- Usually, the treating physician handles these problems by helping to organize the patient s social support system s and by using specific psychotropic medications.
3- For severe psychiatric problems (e.g., psychotic symptoms) in hospitalized patients, consultation–liaison (CL) psychiatrists may be needed.

B. Hospitalized patients
1- Common psychological complaints in hospitalized patients include anxiety, sleep disorders, and disorientation, often as a result of delirium .
2- Patients who are at the greatest risk for such problems include those undergoing surgery or renal dialysis, or those being treated in the intensive care unit (ICU) or coronary care unit (CCU).
3- Patients undergoing surgery who are at greatest psychological and medical risk are those who believe that they will not survive surgery as well as those who do not admit that the y are worried before surgery.
4-Patients treated in the ICU or CCU because their illnesses are often life threatening are at increased risk for depression and delirium (ICU psychosis).
5-Psychological and medical risk can be reduced by enhancing sensory and social input (e.g., placing the patient s bed near a window, encouraging him or her to talk), providing information on what the patient can expect during and after a procedure, and allowing the patient to control the environment (e.g., lighting, pain medication) as much as possible.

C. Patients undergoing renal dialysis
1- Patients on renal dialysis are at increased risk for psychological problems (e.g., depression, suicide, and sexual dysfunction) in part because their lives depend on other people and on machines.
2-Psychological and medical risk can be reduced through the use of in-home dialysis units, which cause less disruption of the patient s life.

D. Patients with sensory deficits
1- Patients with sensory deficits such as blindness or deafness are also at increased psychological risk in part because they can become more easily disoriented when ill.
2- Permitting such patients to use their support technology or helper animals, e.g., hearing aid, seeing-eye dog, can increase a patient s sense of control and thus reduce his or her stress during illness.


III- PATIENTS WITH CHRONIC PAIN
A. Psychosocial factors
1- Chronic pain (pain lasting at least 6 months) is a commonly encountered complaint of patients. It may be associated with physical factors, psychological factors, or a combination of both.
a- Decreased tolerance for pain is associated with depression, anxiety, and life stress in adulthood and physical and sexual abuse in childhood.

b-Pain tolerance can be increased through biofeedback, physical therapy, hypnosis, psychotherapy, meditation, and relaxation training.

2- Chronic pain often leads to a loss of independence, which can lead to depression. Practical suggestions for self care as well as pain relief can be helpful for such patients.

3- Depression may predispose a person to develop chronic pain. More commonly chronic pain results in depression.
4-People who experience pain after a procedure have a higher risk of morbidity and mortality and a slower recovery from the procedure.

4-Religious, cultural, and ethnic factors may influence the patient s expression of pain and the responses of the patient s support system s to the pain.

B-Treating pain
1-Pain relief in pain caused by physical illness is best achieved by analgesics (e.g., opioids), using patient-controlled analgesia (PCA), or nerve-blocking surgical procedures.
2- Antidepressants, particularly tricyclics, are useful in the management of pain.
a. Antidepressants are most useful for patients with arthritis, facial pain, and headache.
b. Their analgesic effect may be the result of stimulation of efferent inhibitory pain pathways.
c-Although they have direct analgesic effects, antidepressants may also decrease pain indirectly by improving symptoms of depression.

3-According to the gate control theory , the perception of pain can be blocked by electric stimulation of large-diameter afferent nerves. Some patients are helped by this treatment.
4-Patients with pain caused by physical illness also benefit from behavioral, cognitive , and other psychological therapies, by needing less pain medication, becoming more active, and showing increased attempts to return to a normal lifestyle.

C. Programs of pain treatment
1-Scheduled administration of an analgesic before the patient requests it (e.g., every 3 hours) and PCA are more effective than medication administered when the patient requests it (on demand). Scheduled administration separates the experience of pain from the receipt of medication.
2-Many patients with chronic pain are undermedicated because the physician fears that the patient will become addicted to opioids. However, recent evidence shows that patients with chronic pain easily discontinue the use of opioids as the pain remits.
3- Pain patients are at higher risk for depression than they are for drug addiction.

D. Pain in children
1. Children feel pain and remember pain as much as adults do.
2-Because children are afraid of injections, the most useful ways of administering pain medications to them are orally (e.g., a fentanyl "lollipop"), transdermally (e.g., a skin cream to prevent pain from injections or spinal taps), or, in older children and adolescents, via PCA.

IV. PATIENTS WITH ACQUIRED IMMUNE DEFICIENCY SYNDROME
A. Psychological stressors.
Acquired immune deficiency syndrome (AIDS) and HIV-positive patients must deal with particular psychological stressors not seen together in other disorders.
1-These stressors include having a fatal illness, feeling guilt about how they contracted the illness (e.g., sex with multiple partners, intravenous drug use) and about possibly infecting others, and being met with fear of contagion from medical personnel, family, and friends.
2-HIV-positive homosexual patients may be compelled (because of their illness) to "come out" (i.e., reveal their sexual orientation) to others.
3-Medical and psychological counseling can reduce medical and psychological risk for HIV-positive patients.
4-It is important to note that psychiatric symptoms such as depression or psychosis in AIDS patients may also result from infection of the brain with HIV or with an opportunistic infection such as group B streptococcus.

B. Contagion
1-If they comply with methods of infection control, HIV -positive physicians do not risk transmitting the virus to their patients.

2-Few health care workers have contracted HIV from patients. The main risk of transmission is through accidental contamination from needles and other sharps, although this risk is very low.

3-Physicians can identify their HIV-positive patients to those they put at imminent risk (e.g., sexual partners)