Psychosomatic Disorders
Two overlapping classifications exist here. A PSYCHOSOMATIC DISORDER (not in DSM-IV) is a physical disease partially caused or exacerbated by psychological factors, whereas the new DSM-IV category, PSYCHOLOGICAL FACTORS AFFECTING MEDICAL CONDITION (p. 731, 316), broadly identifies those psychological and social factors that influence the development and maintenance of medical disease (1,2). Both classifications apply only to those conditions in which psychological or behavioral influence (or both) is of major significance (but be aware that any physical disease may be modified by psychological stress). Neither the term “psychosomatic” nor the DSM-IV category refers to (a) a physical symptom or clinical presentation caused by psychological factors for which no organic basis exists (e.g., conversion disorder, pain disorder, somatization disorder); or (b) a patient with knowingly spurious physical complaints (e.g., factitious disorder, malingering), but the DSM-IV condition does allow physical complaints due to habit disorders (e.g., dyspnea due to excessive smoking, problems from obesity).
MECHANISMS OF DISEASE PRODUCTION
Many specific diseases are influenced greatly by the “psyche” (see later), but although much studied, the mechanisms by which the brain produces such organic pathology are unclear.
Psychological Mechanisms
“Stress,” either internal or external, is required but is much more likely to cause disease if
The stress is severe (e.g., death of a loved one, divorce or separation, major illness or injury, financial crisis, incarceration). Holmes and Rahe developed a ranked scale of stressful life events (rated by life change units; LCUs) and found a close
correlation between an event’s stress (in LCUs) and the patient’s likelihood of a physical illness developing.
The stress is chronic.
The patient perceives the stress as stressful.
The patient has an increased level of general instability (e.g., difficult job, troubled marriage, urban dweller, socially disrupted environment).
It was once thought (F. Dunbar) that specific superficial personality traits produced specific organic diseases (e.g., that a “coronary personality” or an “ulcer personality” exists). It was also held (F. Alexander) that specific deep and unconscious, unresolved neurotic conflicts caused specific physical disorders. Currently, the specificity that is generally accepted associates the “type A” personality (i.e., sense of time urgency, impatience, aggressiveness, upward striving, competitiveness, tendency to anger when frustrated, and particularly a “cynical hostility”) with coronary artery disease. More generally accepted are nonspecific hypotheses that link a wide variety of stresses to the development of disease in an individual placed at risk by one or more of the following:
A genetic susceptibility.
A degree of chronic debilitation, a current illness, or “an organ vulnerability.”
A tendency to react to stress with anger, resentment, frustration, anxiety, or depression.
A “psychological susceptibility” (e.g., patient is pessimistic and “expects the worst” vs. being optimistic and actively working to overcome stress) (3).
An “alexithymic” personality (4) (e.g., a person who is in poor contact with his emotions and has an impoverished fantasy life).
Physiological Mechanisms
These mechanisms are poorly understood, and only the broad outline can be sketched. Stress is perceived cognitively (by the cerebral cortex) but, once recognized, is meditated primarily by the limbic system, which, under chronic stress, stimulates the hypothalamus and the vegetative centers in the brainstem over the long term. This stimulation produces a direct effect on the various organs by
Activation of the autonomic nervous system (sympathetic and adrenal medulla; parasympathetic).
Involvement of the neuroendocrine system i.e., releasing hormones from the hypothalamus travel through the pituitary portal system to the anterior pituitary, where they cause the release of the tropic hormones [e.g., adrenocorticotropic hormone (ACTH), thyroid-stimulating hormone (TSH), growth hormone (GH), follicle-stimulating hormone (FSH)], which either act directly or release other hormones from the endocrine glands [e.g., cortisol, thyroxin, epinephrine, norepinephrine (NE), sex hormones]. These produce a variety of changes in structures throughout the body. Hans Selye (1976) emphasized the central role of cortisol as a primary mediator of the body’s stress response (general adaptation syndrome; GAS). If cortisol is released over too long a period, various organs are damaged, producing psychosomatic diseases.
The details have yet to be worked out: more questions than answers remain. The recently identified hormones, endorphins, may play a major role in stress-response regulation. Central to all of these physiologic systems is the concept of homeostasis: psychosomatic diseases occur when the body’s “natural balance” is upset, particularly if it is chronically upset.
Although psychosomatic medicine has been concerned primarily with those diseases thought to be “psychosomatic,” recently the concept has been broadened to include (or overlap with) the field of behavioral medicine. The essence of behavioral medicine is the application of behavior-modification techniques derived from learning theory to various medical problems (e.g., chronic pain, hypertension and other psychosomatic diseases, habit disorders). Techniques used include behavioral self-management methods, biofeedback, hypnosis, and various relaxation procedures.
SPECIFIC PSYCHOSOMATIC DISORDERS
Although (a) stress can increase the susceptibility to any disease, and (b) most diseases are currently viewed as multifactorially determined, those that most clearly have a major psychosomatic contribution include the following disorders.
Cardiovascular
Coronary artery disease: This is more common in “type A” personalities. These patients have increased serum cholesterol, low-density lipoproteins, and triglycerides; also increased
urinary 17-ketosteroids, 17-hydroxycorticosteroids, and NE. Sudden death by myocardial infarction (MI) is increased in patients experiencing a severe recent loss (first 6 months). Likewise, depression is correlated with increased risk for heart disease (5).
urinary 17-ketosteroids, 17-hydroxycorticosteroids, and NE. Sudden death by myocardial infarction (MI) is increased in patients experiencing a severe recent loss (first 6 months). Likewise, depression is correlated with increased risk for heart disease (5).
Hypertension: Chronic psychosocial stress probably plays a role in its development in genetically predisposed patients. Mechanism is uncertain but may not be related to the brief hypertension that occurs during periods of acute stress. May occur more frequently in type A people and in compulsive people who “store resentment” and who handle angry feelings poorly. Treat first with antihypertensives. Relaxation therapy (e.g., progressive relaxation, meditation, hypnosis) is an effective adjunct to drugs; biofeedback also may help.
Arrhythmias: Palpitation, sinus tachycardia, and worsening of preexisting arrhythmias may all be produced by stress, probably through a sympathetic-parasympathetic imbalance.
Hypotension (fainting): Produced by fear, probably due to peripheral vasodilation and a decreased ventricular filling.
Congestive heart failure: Frequently develops after periods of stress. Anxiety tends to exacerbate the condition.
Raynaud disease: Can often be treated effectively with progressive relaxation or biofeedback.
Migraine: Attacks are often precipitated by stress. Treatment should include medication and biofeedback. Consider relaxation and psychotherapy also.
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