Psychosomatic Medicine



Psychosomatic Medicine





I. Psychosomatic Disorders


A. Definition.

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 term mind–body medicine); and psychological factors must be taken into account when considering all disease states. Although most physical disorders are influenced by stress, conflict, or generalized anxiety, some disorders are more affected than others.


B. Classification.

In the text revision of the fourth edition of the Diagnostic Statistical Manual of Mental Disorders (DSM-IV-TR), psychosomatic disorders are classified under the heading psychological factors affecting medical condition, which covers physical disorders caused by emotional or psychological factors and mental or emotional disorders caused or aggravated by physical illness (Table 23-1).


C. Diagnosis.

To meet the diagnostic criteria for psychological factors affecting a medical condition, the following two criteria must be met: (1) a medical condition is present and (2) psychological factors affect it adversely (e.g., the psychologically meaningful environmental stimulus is temporally related to the initiation or exacerbation of the specific physical condition or disorder). The physical condition must demonstrate either organic disease (e.g., rheumatoid arthritis) or a known pathophysiological process (e.g., migraine headache). A number of physical disorders meet these criteria and are listed in Table 23-2.


D. Etiology



  • Stress factors. This etiologic theory states that any prolonged stress can cause physiological changes that result in a physical disorder. Each person has a shock organ that is genetically vulnerable to stress: Some patients are cardiac reactors, others are gastric reactors, and others are skin reactors. Persons who are chronically anxious or depressed are more vulnerable to physical or psychosomatic disease. Table 23-3 lists life stressors that may herald a psychosomatic disorder.


  • Neurotransmitter response. Stress activates noradrenergic system release of catecholamines and serotonin, which are increased. Dopamine is increased via mesoprefrontal pathways.


  • Endocrine response. Corticotropin-releasing factor (CRF) is secreted from the hypothalamus, which releases cortisol. Glucocorticoids promote energy use in the short term. Increased thyroid hormone turnover also occurs during stress states.


  • Immune response. Release of humoral immune factors (called cytokines) such as interleukin-1 and -2 occurs. Cytokines can increase


    glucocorticoids. Some persons develop severe organ damage from overload of cytokine release under stress.








    Table 23-1 DSM-IV-TR Diagnostic Criteria for Psychological Factors Affecting Medical Condition










    1. A general medical condition (coded on Axis III) is present.
    2. 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 physiologic responses precipitate or exacerbate symptoms of a 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 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 physiologic response affecting general medical condition (e.g., stress-related exacerbation of ulcer hypertension, arrhythmia, or tension headache).
    • Other or unspecified psychological factors affecting 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; 2000, with permission.








    Table 23-2 Physical Conditions Affected by Psychological Factors


















































    Disorder Observations/Comments/Theory/Approach
    Angina, arrhythmias, coronary spasms Type A person is aggressive, irritable, easily frustrated, and prone to coronary artery disease. Arrhythmias common in anxiety states. Sudden death from ventricular arrhythmia in some patients who experience massive psychological shock or catastrophe. Lifestyle changes: cease smoking, curb alcohol intake, lose weight, lower cholesterol to limit risk factors. Propranolol (Inderal) prescribed for patients who develop tachycardia as part of social phobia—protects against arrhythmia and decreased coronary blood flow.
    Asthma Attacks precipitated by stress, respiratory infection, allergy. Examine family dynamics, especially when child is the patient. Look for overprotectiveness and try to encourage appropriate independent activities. Propranolol and beta blockers contraindicated in asthma patients for anxiety. Psychological theories: strong dependency and separation anxiety; asthma wheeze is suppressed cry for love and protection.
    Connective tissue diseases: systemic lupus erythematosus, rheumatoid arthritis Disease can be heralded by major life stress, especially death of loved one. Worsens with chronic stress, anger, or depression. Important to keep patient as active as possible to minimize joint deformities. Treat depression with antidepressant medications or psychostimulants, and treat muscle spasm and tension with benzodiazepines.
    Headaches Tension headache results from contraction of strap muscles in neck, constricting blood flow. Associated with anxiety, situational stress. Relaxation therapy, antianxiety medication useful. Migraine headaches are unilateral and can be triggered by stress, exercise, foods high in tyramine. Manage with ergotamine (Cafergot). Propranolol prophylaxis can produce associated depression. Sumatriptan (Imitrex) can be used to treat nonhemiplegic and nonbasilar migraine attacks.
    Hypertension Acute stress produces catecholamines (epinephrine), which raise systolic blood pressure. Chronic stress associated with essential hypertension. Look at lifestyle. Prescribe exercise, relaxation therapy, biofeedback. Benzodiazepines of use in acute stress if blood pressure rises as shock organ. Psychological theories: inhibited rage, guilt over hostile impulses, need to gain approval from authority.
    Hyperventilation syndrome Accompanies panic disorder, generalized anxiety disorder with associated hyperventilation, tachycardia, vasoconstriction. May be hazardous in patients with coronary insufficiency. Antianxiety agents of use: Some patients respond to monoamine oxidase inhibitors, tricyclic antidepressants, or serotonergic agents.
    Inflammatory bowel diseases: Crohn’s disease, irritable bowel syndrome, ulcerative colitis Depressed mood associated with illness; stress exacerbates symptoms. Onset after major life stress. Patients respond to stable doctor–patient relationship and supportive psychotherapy in addition to bowel medication. Psychological theories: passive personality, childhood intimidation, obsessive traits, fear of punishment, masked hostility.
    Metabolic and endocrine disorders Thyrotoxicosis following sudden severe stress. Glycosuria in chronic fear and anxiety. Depression alters hormone metabolism, especially adrenocorticotropic hormone (ACTH).
    Neurodermatitis Eczema in patients with multiple psychosocial stressors—especially death of loved one, conflicts over sexuality, repressed anger. Some respond to hypnosis in symptom management.
    Obesity Hyperphagia reduces anxiety. Night-eating syndrome associated with insomnia. Failure to perceive appetite, hunger, and satiation. Psychological theories: conflicts about orality and pathological dependency. Behavioral techniques, support groups, nutritional counseling, and supportive psychotherapy useful. Treat underlying depression.
    Osteoarthritis Lifestyle management includes weight reduction, isometric exercises to strengthen joint musculature, maintenance of physical activity, pain control. Treat associated anxiety or depression with supportive psychotherapy.
    Peptic ulcer disease Idiopathic type not related to specific bacterium or physical stimulus. Increased gastric acid and pepsin relative to mucosal resistance: both sensitive to anxiety, stress, coffee, alcohol. Lifestyle changes. Relaxation therapy. Psychological theories: strong frustrated dependency needs, cannot express anger, superficial self-sufficiency.
    Raynaud’s disease Peripheral vasoconstriction associated with smoking, stress, lifestyle changes: cessation of smoking, moderate exercise. Biofeedback can raise hand temperature by increased vasodilation.
    Syncope, hypotension Vasovagal reflex with acute anxiety or fear produces hypotension and fainting. More common in patients with hyperreactive autonomic nervous system. Aggravated by anemia, antidepressant medications (produce hypotension as side effect).
    Urticaria, angioedema Idiopathic type not related to specific allergens or physical stimulus. May be associated with stress, chronic anxiety, depression. Pruritus worse with anxiety; self-excoriation associated with repressed hostility. Some phenothiazines have antipruritic effect. Psychological theories: conflict between dependence–independence, unconscious guilt feelings, itching as sexual displacement.








    Table 23-3 Ranking of 10 Life-change Stressors








    1. Death of spouse
    2. Divorce
    3. Death of close family member
    4. Marital separation
    5. Serious personal injury or illness
    6. Fired from work
    7. Jail term
    8. Death of a close friend
    9. Pregnancy
    10. Business readjustment
    Adapted from Richard H. Rahe, M.D., and Thomas Holmes.


  • Physiological factors



    • Hans Selye described the general adaption syndrome, which is the sum of all the nonspecific systemic reactions of the body that follow prolonged stress. The hypothalamic–pituitary–adrenal axis is affected, with excess secretion of cortisol-producing structural damage to various organ systems.


    • George Engel postulated that in the stressed state, all neuroregulatory mechanisms undergo functional changes that depress the body’s homeostatic mechanisms, so that the body is left vulnerable to infection and other disorders. Neurophysiological pathways thought to mediate stress reactions include the cerebral cortex, limbic system, hypothalamus, adrenal medulla, and sympathetic and parasympathetic nervous systems. Neuromessengers include hormones such as cortisol and thyroxine (Table 23-4).


    • Walter Cannon demonstrated that under stress the autonomic nervous system is activated to ready the organism to the “fight-or-flight” response. When there is no option for either, psychosomatic disorders may result.

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Jun 8, 2016 | Posted by in PSYCHIATRY | Comments Off on Psychosomatic Medicine

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