Psychosomatic Medicine

Psychosomatic (psychophysiological) medicine has been a specific area of study within the field of psychiatry for more than 75 years. It is informed by two basic assumptions: There is a unity of mind and body (reflected in the term mind-body medicine); and psychological factors must be taken into account when considering all disease states.

No classification for psychosomatic disease is listed in the text revision of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). The concepts of psychosomatic medicine are subsumed in the diagnostic entity called Psychological Factors Affecting Medical Conditions. This category covers physical disorders caused by emotional or psychological factors. It also applies to mental or emotional disorders caused or aggravated by physical illness.

CLASSIFICATION

The DSM-IV-TR diagnostic criteria for psychological factors affecting medical condition are presented in Table 24-1. Excluded are (1) classic mental disorders that have physical symptoms as part of the disorder (e.g., conversion disorder, in which a physical symptom is produced by psychological conflict); (2) somatization disorder, in which the physical symptoms are not based on organic pathology; (3) hypochondriasis, in which patients have an exaggerated concern with their health; (4) physical complaints that are frequently associated with mental disorders (e.g., dysthymic disorder, which usually has such somatic accompaniments as muscle weakness, asthenia, fatigue, and exhaustion); and (5) physical complaints associated with substance-related disorders (e.g., coughing associated with nicotine dependence).

STRESS THEORY

Stress can be described as a circumstance that disturbs, or is likely to disturb, the normal physiological or psychological functioning of a person. In the 1920s, Walter Cannon (1875-1945) conducted the first systematic study of the relation of stress to disease. He demonstrated that stimulation of the autonomic nervous system, particularly the sympathetic system, readied the organism for the “fight or flight” response characterized by hypertension, tachycardia, and increased cardiac output. This was useful in the animal who could fight or flee; but in the person who could do neither by virtue of being civilized, the ensuing stress resulted in disease (e.g., produced a cardiovascular disorder).

Hans Selye (1907-1982) developed a model of stress that he called the general adaptation syndrome. It consisted of three phases: (1) the alarm reaction, (2) the stage of resistance, in which adaptation is ideally achieved, and (3) the stage of exhaustion, in which acquired adaptation or resistance may be lost. He considered stress a nonspecific bodily response to any demand caused by either pleasant or unpleasant conditions. Selye believed that stress, by definition, need not always be unpleasant. He called unpleasant stress distress. Accepting both types of stress requires adaptation.

The body reacts to stress—in this sense defined as anything (real, symbolic, or imagined) that 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. Much is known about the physiological response to acute stress, but considerably less is known about the response to chronic stress. Many stressors occur over a prolonged period of time or have long-lasting repercussions. For example, the loss of a spouse may be followed by months or years of loneliness, and a violent sexual assault may be followed by years of apprehension and worry. Neuroendocrine and immune responses to such events help explain why and how stress can have deleterious effects.

Neurotransmitter Responses to Stress

Stressors activate noradrenergic systems in the brain (most notably in the locus ceruleus) and cause release of catecholamines from the autonomic nervous system. Stressors also activate serotonergic systems in the brain, as evidenced by increased serotonin turnover. Recent evidence suggests that, although glucocorticoids tend to enhance overall serotonin functioning, differences may exist in glucocorticoid regulation of serotoninreceptor subtypes, which can have implications for serotonergic functioning in depression and related illnesses. For example, glucocorticoids can increase serotonin 5-hydroxytryptamine-mediated actions, thus contributing to the intensification of actions of these receptor types, which have been implicated in the pathophysiology of major depressive disorder. Stress also increases dopaminergic neurotransmission in mesoprefrontal pathways.

Endocrine Responses to Stress

In response to stress, corticotropin-releasing factor (CRF) is secreted from the hypothalamus into the hypophysial-pituitaryportal system. CRF acts at the anterior pituitary to trigger release of adrenocorticotropic hormone (ACTH). Once ACTH is released, it acts at the adrenal cortex to stimulate the synthesis and release of glucocorticoids. Glucocorticoids themselves have myriad effects within the body, but their actions can be summarized in the short term as promoting energy use, increasing cardiovascular activity (in the service of the “flight or fight” response), and inhibiting functions such as growth, reproduction, and immunity.

Table 24-1 DSM-IV-TR Diagnostic Criteria for Psychological Factors Affecting General 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 the general medical condition
Choose name based on the nature of the psychological factors (if more than one factor is present, indicate the most prominent):
	Mental disorder affecting … [indicate the general medical condition] (e.g., an Axis I disorder such as major depressive disorder delaying recovery from a myocardial infarction)
	Psychological symptoms affecting … [indicate the general medical condition] (e.g., depressive symptoms delaying recovery from surgery; anxiety exacerbating asthma)
	Personality traits or coping style affecting … [indicate the general 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 … [indicate the general medical condition] (e.g., overeating; lack of exercise; unsafe sex)
	Stress-related physiological response affecting … [indicate the general medical condition] (e.g., stress-related exacerbations of ulcer, hypertension, arrhythmia, or tension headache)
	Other or unspecified psychological factors affecting … [indicate the general medical condition] (e.g., interpersonal, cultural, or religious factors)
From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington, DC: American Psychiatric Association; copyright 2000, with permission.

Immune Response to Stress

Part of the stress response consists of the inhibition of immune functioning by glucocorticoids. This inhibition may reflect a compensatory action of the hypothalamic-pituitary-adrenal axis to mitigate other physiological effects of stress. Conversely, stress can also cause immune activation through a variety of pathways. CRF itself can stimulate norepinephrine release via CRF receptors located on the locus ceruleus, which activates the sympathetic nervous system, both centrally and peripherally, and increases epinephrine release from the adrenal medulla. In addition, direct links of norepinephrine neurons synapse on immune target cells. Thus, in the face of stressors, profound immune activation also occurs, 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.

Life Events

A life event or situation, favorable or unfavorable (Selye’s distress), often occurring by chance, generates challenges to which the person must adequately respond. Thomas Holmes and Richard Rahe constructed a social readjustment rating scale after asking hundreds of persons from varying backgrounds to rank the relative degree of adjustment required by changing life events. Holmes and Rahe listed 43 life events associated with varying amounts of disruption and stress in average persons’ lives and assigned each of them a certain number of units: for example, the death of a spouse, 100 life-change units; divorce, 73 units; marital separations, 65 units; and the death of a close family member, 63 units. Accumulation of 200 or more life-change units in a single year increases the risk of developing a psychosomatic disorder in that year. Of interest, persons who face general stresses optimistically rather than pessimistically are less apt to experience psychosomatic disorders; if they do, they are more apt to recover easily.

Specific versus Nonspecific Stress Factors

In addition to life stresses such as a divorce or the death of a spouse, some investigators have suggested that specific personalities and conflicts are associated with certain psychosomatic diseases. A specific personality or a specific unconscious conflict may contribute to the development of a specific psychosomatic disorder. Researchers first identified specific personality types in connection with coronary disease. An individual with a coronary personality is a hard-driving, competitive, aggressive person who is predisposed to coronary artery disease. Meyer Friedman and Ray Rosenman first defined two types of personalities: (1) type A, similar to the coronary personality, and (2) type B, calm, relaxed, and not susceptible to coronary disease (see later discussion).

Franz Alexander was a major proponent of the theory that specific unconscious conflicts are associated with specific psychosomatic disorders. For example, persons susceptible to having a peptic ulcer were believed to have strong ungratified dependency needs. Persons with essential hypertension were considered to have hostile impulses about which they felt guilty. Patients with bronchial asthma had issues with separation anxiety. The specific psychic stress theory is no longer considered a reliable indicator of who will develop which disorder; the nonspecific stress theory is more acceptable to most workers in the field today. Nevertheless, chronic stress, usually with the intervening variable of anxiety, predisposes certain persons to psychosomatic disorders. The vulnerable organ may be anywhere in the body. Some persons are “stomach reactors,” whereas others are “cardiovascular reactors,” “skin reactors,” and so on. The diathesis or susceptibility of an organ system to react to stress is probably of genetic origin, but it may also result from acquired vulnerability (e.g., lungs weakened by smoking). According to psychoanalytic theory, the choice of the afflicted region is determined by unconscious factors, a concept known as somatic compliance. For example, Freud reported on a male patient with fears of homosexual impulses who developed pruritis ani and a woman with guilt over masturbation who developed vulvodynia.

Another nonspecific factor is the concept of alexithymia, developed by Peter Sifneos and John Nemiah, in which persons cannot express feelings because they are unaware of their mood. Such patients develop tension states that leave them susceptible to develop somatic diseases.

SPECIFIC ORGAN SYSTEMS

Gastrointestinal System

Gastrointestinal (GI) disorders rank high in medical illnesses associated with psychiatric consultation. This ranking reflects the high prevalence of GI disorders and the link between psychiatric disorders and GI somatic symptoms.

The following case history is presented to illustrate the relationship between psychiatric illness, GI disease, and GI disorders.

A freshman, male, college cross-country athlete was referred for psychiatric consultation with complaints of frequent belching and anxiety. The patient had been a successful high school runner, but had struggled in his early adjustment to college athletics. His performance was below that of his high school level. Consultation with a gastroenterologist failed to find a physical cause for his complaints.

Only gold members can continue reading. Log In or Register to continue