Psychosomatic Medicine and Consultation-Liaison Psychiatry
Psychosomatic medicine has been an area of concern in psychiatry for more than 50 years. The term psychosomatic derives from the Greek psyche (soul) and soma (body) and literally refers to how the mind affects the body. Today the term is used to describe individuals with medical complaints that have no physical cause. The primary focus of psychosomatic medicine is clinical problems that occur in patients being treated in medical settings, including primary psychiatric disorders such as delirium or dementia. The majority of practice is within the general hospital setting, but they can occur in outpatient settings as well. The basic approach is to make a psychiatric assessment; provide psychotherapeutic, behavioral, or pharmacological interventions to patients; and work closely with other medical professionals as a liaison.
Psychosomatic concepts have contributed many approaches to medical care. Concepts derived from the field of psychosomatic medicine influenced the emergence of complementary and alternative medicine (CAM). They have also influenced the field of holistic medicine with its emphasis on examining and treating the whole patient, not just his or her disease or disorder. Psychosomatic medicine has also influenced the field of behavioral medicine, which integrates the behavioral sciences and the biomedi cal approach to the prevention, diagnosis, and treatment of disease.
Consultation-liaison (C-L) psychiatry is the study, practice, and teaching of the relationship between medical and psychiatric disorders. In C-L psychiatry, the psychiatrist serves as a consultant to medical colleagues (either another psychiatrist or, more commonly, a nonpsychiatric physician) or to other mental health professions (psychologist, social worker, or psychiatric nurse). C-L psychiatrists also consult regarding patients in medical or surgical settings and provide follow-up psychiatric treatment as needed. C-L psychiatry is associated with all of the diagnostic, therapeutic, research, and teaching services that psychiatrists perform in the general hospital and serves as a bridge between psychiatry and other specialties. Virtually every major system of the body has been investigated with regard to the relationship between psychological factors and disease. Psychological factors affecting the cardiovascular, respiratory, immune, endocrine, gastrointestinal, and dermatologic systems are well known. Even the apparently simple act of correctly following a medication regimen can be complicated, and perhaps undermined, by unaddressed or unrecognized psychological factors.
Students should study the questions and answers below for a useful review of these factors.
Helpful Hints
These terms relating to psychophysiological medicine should be defined
alexithymia
atopic
autoimmune diseases
behavior modification deconditioning program
C-L psychiatry
congestive heart failure
conversion disorder
coronary artery disease
Crohn’s disease
diabetes mellitus
dialysis dementia
dysmenorrhea
fibromyalgia
general adaptation syndrome
gun-barrel vision
hay fever
hemodialysis units
hyperhidrosis
hyperthyroidism
hyperventilation syndrome
hypothyroidism
ICUs
idiopathic amenorrhea
menopausal distress
migraine
myxedema madness
neurocirculatory asthenia
organ transplantation
pain threshold and perception
Papez circuit
peptic ulcer
pheochromocytoma
PMS
postcardiotomy delirium
premenstrual dysphoric disorder
pruritus
psychogenic cardiac nondisease
psychophysiological
psychosomatic
Raynaud’s phenomenon
relaxation therapy
rheumatoid arthritis
skin disorders
somatization disorder
systemic lupus erythematosus
tension headaches
tension myositis syndrome
thyrotoxicosis
type A and type B personalities
ulcerative colitis
vasomotor syncope
vasovagal attack
Wilson’s disease
Questions
Directions
Each of the questions or incomplete statements below is followed by five suggested responses or completions. Select the one that is best in each case.
27.1 All of the following are cardiovascular effects of tricyclic antidepressants in patients with heart disease except
A. tachycardia
B. bradycardia
C. arrhythmias
D. hypotension
E. heart block
View Answer
27.1 The answer is B
Approximately 15 to 20 percent of patients with coronary artery disease (CAD) meet criteria for current major depression. Selective serotonin reuptake inhibitors (SSRIs) (not tricyclic antidepressants [TCAs]) cause bradycardia in patients with CAD (Table 27.1). TCAs cause orthostatic hypotension and cardiac conduction disturbances. In combination with diuretics, vasodilators, and benzodiazepines, their effect on blood pressure is exaggerated. In toxic levels, they may precipitate ventricular arrhythmias, but at therapeutic doses, they exhibit type 1A antiarrhythmic properties. Consequently, TCAs are no longer recommended as first-line drugs in treatment of depression in patients with ischemic heart disease.
Table 27.1 Cardiovascular Effects of Antidepressants in Patients with Heart Disease | ||||||||||||||||||||||||||
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27.2 True statements about research in psychocardiology include
A. The most consistent psychological correlates of hypertension are inhibited anger expression and excessive anger expression.
B. Stress leads to excess secretion of epinephrine, which increases cardiac contractility and conduction velocity.
C. Cardiac surgery patients at greatest risk for complications are depressed and in denial about their anxiety.
D. Mental stress leads to diminished cardiac perfusion.
E. All of the above
View Answer
27.2 The answer is E (all)
Psychocardiology encompasses the spectrum of interactions of psychiatric disorders, cardiac symptoms, and cardiac disease, including associated complicating health behavior. For the past several decades, attention to the psychosocial and behavioral factors in cardiovascular disease has increased significantly. The research has taken two primary pathways: one has examined hypertension, and the other has looked generally at coronary artery disease (CAD), including myocardial infarction and sudden cardiac death.
Hypertension, one of the originally hypothesized psychosomatic illnesses, is a major risk factor for CAD and cerebrovascular disease. Psychological factors have been studied closely as part of the pathogenesis of the condition. Some research examining psychological aspects of hypertension has focused on personality traits or coping styles. Traits such as submissiveness and distorted expression of anger have emerged as correlates of hypertension. The most consistent correlates have involved anger-coping styles, both inhibited anger expression and excessive anger expression.
Stress causes a sympatheticoadrenal medullary alarm reaction characterized by excess catecholamine secretion. Specifically, excess epinephrine is secreted under what the body interprets as stressful conditions. The outpouring of epinephrine increases blood pressure and heart and respiratory rates; enhances neuromuscular transmission; elevates the concentration of blood sugar by glycogenolysis; mobilizes fat; redirects hemodynamic patterns to suit muscular activity; and while increasing blood oxygenation, increases oxygen consumption. More specific β-adrenergically mediated cardiac effects include increased heart rate, contractility, and conduction velocity and a short arteriovenous refractory period. These catecholamine-mediated cardiac effects are thought to be pathogenically related to adverse cardiac events.
Studies of stress-induced cardiac changes and studies examining stress, arrhythmias, and sudden cardiac death suggest a significant relation in the pathophysiology of CAD. One study found that the cardiac surgery patients at greatest risk for complications, including arrhythmias and sudden death, were depressed, anxious, and in denial of their anxiety.
Other studies have documented diminished cardiac perfusion during mental stress via positron emission tomography and radionucleotide ventriculography in patients with CAD.
27.3 Antidepressants should be used cautiously in cardiac patients because of increased risk of which of the following?
A. Conduction side effects
B. Hypertension
C. Noncompliance
D. Suicide
E. All of the above
View Answer
27.3 The answer is A
Consultation-liaison psychiatrists must make a careful assessment of drug-drug interactions before prescribing medications, and this should be undertaken in collaboration with the patient’s primary physician. Antidepressants should be used cautiously in cardiac patients because of conduction side effects and orthostatic hypotension (not hypertension). It is typically depressed patients who may be at increased risk for suicide after they are started on antidepressants, not cardiac patients. Noncompliance, although an issue with all patients for various reasons, is not specifically troublesome with cardiac patients.
27.4 Phantom limb occurs after leg amputation in what percentage of patients?
A. 10 percent
B. 50 percent
C. 80 percent
D. 90 percent
E. 98 percent
View Answer
27.4 The answer is E
Phantom limb occurs in 98 percent of patients—not 10 percent, 50 percent, 80 percent, or 90 percent—who have undergone leg amputation. The experience may last for years. Sometimes the sensation is painful, and a neuroma at the stump should be ruled out. The condition has no known cause or treatment and usually stops spontaneously.
27.5 Which of the following is not a physiological response of the gastrointestinal (GI) system to acute stress?
A. Increased resting tone of the upper esophageal sphincter
B. Decreased contraction amplitude in the distal esophagus
C. Decreased antral motor activity in the stomach
D. Reduced migrating motor function in the small intestine
E. Increased myoelectrical motility in the large intestine
View Answer
27.5 The answer is B
Acute stress can induce physiological responses in several GI target organs. In the esophagus, acute stress increases the resting tone of the upper esophageal sphincter and increases (not decreases) contraction amplitude in the distal esophagus. Such physiological responses may result in symptoms that are consistent with globus or esophageal spasm syndrome. In the stomach, acute stress induces decreased antral motor activity, potentially producing functional nausea and vomiting. In the small intestine, reduced migrating motor function can occur, and in the large intestine, there can be increased myoelectrical and motility activity under acute stress. These effects in the small and large intestine may be responsible for bowel symptoms associated with irritable bowel syndrome.
27.6 The most frequent functional GI disorder is
A. globus
B. irritable bowel syndrome
C. functional abdominal bloating
D. functional heartburn
E. functional chest pain
View Answer
27.6 The answer is D
Functional disorders are common syndromes associated with significant subjective distress and abnormalities of bowel function without evidence of structural abnormalities. Functional GI disorders frequently have high rates of psychiatric comorbidity. Functional heartburn is the most common functional GI disorder. Functional heartburn needs to be distinguished from gastroesophageal reflux disease. In functional heartburn, symptoms of acid reflux are present (i.e., heartburn, regurgitation of food), but there is no evidence of anatomical abnormality or esophagitis on endoscopy or radiography.
Emotional distress and anxiety disorders may result in abnormal respiration and air swallowing or aerophagia. Swallowed air produces distension of the stomach and feelings of abdominal fullness or bloating along with belching.
Chest pain frequently prompts attention for potential cardiac causes. However, functional esophageal motility disorders can produce chest pain and need to be considered in patients with chest pain and no evidence of cardiac abnormalities. Psychiatrists need to be aware of the possible GI causes of chest pain, particularly when there is limited evidence for a psychiatric disorder in an unexplained chest pain presentation (Table 27.2).
Irritable bowel syndrome is the prototypical functional GI disorder characterized by abdominal pain and diarrhea or constipation. Globus, the Latin word for lump, indicates a sensation of having a lump in the throat. Alternate terms for globus include globus pharyngeus, globus hystericus, and globus syndrome. Globus must be distinguished from dysphagia, or difficulty swallowing. Patients complaining of globus may also report dysphagia and fear of choking, but most patients with globus report neither of these other symptoms.
Table 27.2 Common Gastrointestinal Diseases | ||
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27.7 Which of the following is not a sign of overt hypothyroidism?
A. Normal thyroid hormone concentrations
B. Patients are symptomatic
C. Thyroid-stimulating hormone (TSH) is elevated
D. Low thyroid hormone concentrations
E. None of the above
View Answer
27.7 The answer is A
Hypothyroidism is the diminished production of thyroid hormone leading to clinical manifestations of thyroid insufficiency (i.e., low metabolic rate, somnolence, weight gain). It is categorized as either overt or subclinical. In overt hypothyroidism, thyroid hormone concentrations are abnormally low (not normal), the thyroid-stimulating hormone (TSH) level is elevated, and patients are symptomatic. In subclinical hypothyroidism, patients have normal thyroid hormone concentrations, have elevated TSH levels, and are asymptomatic. Subclinical hypothyroidism can produce depressive symptoms and cognitive defects, although they are less severe than those produced by overt hypothyroidism. The lifetime prevalence of depression in patients with subclinical hypothyroidism is approximately double that in the general population. These patients display a lower response rate to antidepressants and a greater likelihood of responding to liothyronine (Cytomel) augmentation than euthyroid patients with depression.
27.8 Which of the following statements regarding psychogenic excoriations is true?
A. Freud believed the skin is susceptible to unconscious sexual urges.
B. Lesions are typically found in hard-to-reach areas.
C. Scratching does not occur in response to an itch.
D. The behavior never becomes ritualistic.
E. All of the above
View Answer
27.8 The answer is A
Psychocutaneous disorders encompass a wide variety of dermatological diseases that may be affected by the presence of psychiatric symptoms or stress and psychiatric illnesses in which the skin is the target of disordered thinking, behavior, or perception.
Psychogenic excoriations (also called psychogenic pruritus) are lesions caused by scratching or picking in response to an itch or other skin sensation or because of an urge to remove an irregularity on the skin from preexisting dermatoses such as acne. Lesions are typically found in areas that the patient can easily reach (e.g., the face, upper back, and the upper and lower extremities). The behavior in psychogenic excoriation sometimes resembles obsessive-compulsive disorder in that it is repetitive, ritualistic, and tension reducing, and patients attempt (often unsuccessfully) to resist excoriating. The skin is an important erogenous zone, and Freud believed it susceptible to unconscious sexual impulses.
27.9 Which of the following statements about psychoneuroimmunology is true?
A. Immunological reactivity is not affected by hypnosis.
B. Lymphocytes cannot produce neurotransmitters.
C. The immune system is affected by conditioning.
D. Growth hormone does not affect immunity.
E. Marijuana does not affect the immune system.
View Answer
27.9 The answer is C
The immune system is affected by conditioning. According to Robert Ader, immunological reactivity is affected by hypnosis, lymphocytes
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