<ul><li>Ongoing discussion will emphasize on</li></ul>Psychological Factors Affecting Medical Condition<br />Medical disorders/conditions Affecting Psychiatric conditions/disorders<br />Psychosomatic co-morbidities<br /> INTRODUCTION<br />
Mind–body interactions have long been a focus of interest, both in health and in disease.<br />Psychiatric illness and medical disease frequently coexist.<br />A more modern approach has been to recognize that all medical illnesses are potentially affected by many different factors in the biological, psychological, and social realms.<br />BACKGROUND<br />
<ul><li>Diagnostic category in DSM IV (PFAMC) recognizes the variety of ways in which specific psychological or behavioral factors can adversely affect medical illnesses.
Such factors may contribute to the initiation or the exacerbation of the illness, interfere with treatment and rehabilitation, or contribute to morbidity and mortality.
Psychological factors may themselves constitute risks for medical diseases, or they may magnify the effects of nonpsychological risk factors. The effects may be mediated directly at a pathophysiological level (e.g., psychological stress inducing myocardial ischemia) or through the patient’s behavior (e.g., noncompliance).</li></ul>PSYCHE SOMA INTERACTION-WHY SO IMPORTANT?<br />
The subject of psychological factors affecting medical condition (PFAMC) has become the focus of intense research because of the illumination it may provide of basic disease mechanisms (e.g., psychoneuroimmunology) and because of the intense interest in improving both the outcomes and the efficiency of health care delivery.<br />The diagnosis of PFAMC focuses attention on one causal direction in the interactions between psyche and soma, that is, the effects of psychological factors on the medical condition<br />In most patients, there are effects in the other direction as well (i.e., the effects of general medical illness on psychological function). <br />Furthermore, both mind and body interact with social and environmental factors both dramatic (e.g., poverty,racism, war) and more subtle (e.g., employment status,neighborhood) (Roux et al. 2001 ), that affect the incidence and outcome of medical illness.<br />PSYCHE SOMA INTERACTION-WHY SO IMPORTANT?<br />
‘PFAMC Diagnosis’ & complexities<br />The diagnosis of PFAMC differs from most other psychiatric diagnoses in its focus on the interaction between the mental and medical realms. <br />As noted, the criteria require more than that the patient have both a medical illness and contemporaneous psychological factors, because their coexistence does not always include significant interactions between them.<br />To make the diagnosis of PFAMC, either the factors must have influenced the course of the medical condition, interfered with its treatment, contributed to health risks, or physiologically aggravated the medical condition.<br />The psychological factor can be an Axis I or Axis II mental disorder (e.g., major depressive disorder aggravating coronary artery disease (CAD)), a psychological symptom (e.g., anxiety exacerbating asthma), a personality trait or coping style (e.g., type A behavior contributing to the development of CAD), maladaptive health behaviors (e.g., unsafe sex in a person with human immunodeficiency virus (HIV) infection), a stress-related physiological response (e.g., tension headache), or other or unspecified psychological factors.<br />
PFAMC Diagnosis’ & complexities<br />When a patient’s medical illness is faring worse than expected and not responding well to standard treatment, physicians should consider whether a psychological factor may be responsible for the poorer than expected outcome. <br />To ignore the possibility of PFAMC may miss the crucial barrier to the patient’s recovery. <br />On the other hand, premature or facile attribution to psychological factors may lead the physician to overlook medical or social explanations for “treatment-resistant disease” and unfairly blame the patient, with resultant further deterioration in health outcomes and the physician–patient relationship.<br />
‘PFAMC Diagnosis’ & complexities‘An illustration’<br />To illustrate, a common clinical problem is the brittle diabetic adolescent with labile blood glucose levels and frequent episodes of ketoacidosis and hypoglycemia, despite vigorous attempts by the physician to improve diabetic management and glucose control. <br />The considerable difficulty in controlling such patients’ diabetes is often attributed to adolescents’ dislike of lifestyle restrictions, their tendency to act out and rebel against authority figures, their denial of vulnerability, their ambivalence about their need for nurturance, and their wish to be “normal”. <br />There are many adolescent (and some adult) diabetic patients for whom these psychological issues do play an important role in undermining diabetes management through noncompliance regarding medication, diet, visits to the physician, substance use, and activity limitations. <br />However, psychological factors do not always account for brittleness and are sometimes incorrectly suspected. It has been demonstrated that much of the difficulty in achieving stable glucose control in adolescent diabetics is the result of the dramatically labile patterns of hormone secretion (cortisol, growth hormone) typical of adolescence, independent of psychological status.<br />
Epidemiology and Comorbidity<br />Because “PFAMC”describes a variety of possible interactions between the full range of psychiatric disorders (as well as symptoms and behaviors) on the one hand and the full range of medical diseases on the other, it is impossible to estimate overall rates of prevalence or incidence.<br />We can start, however, by noting how frequently medical and psychiatric disorders coexist. <br />Psychiatric problems are common in medical patients, although the measured frequency varies, depending on the criteria and method of measurement used. <br />A reasonable estimate is that 25−30% of medical outpatients and 40−50% of general medical inpatients have diagnosable psychiatric disorders.<br />
How do psychological factors affect medical illnesses?<br />May promote other known risks for medical illness.<br />e.g, Individuals with schizophrenia or depression are much more likely to smoke than the general population. A wide variety of psychiatric illnesses are associated with an increased likelihood of substance abuse. Depression and schizophrenia also are associated with a sedentary lifestyle.<br />Have an impact on the course of illness by influencing how patients respond<br /> to their symptoms, including whether and how they seek care. E.g., the defense mechanism of denial may lead an individual to ignore anginal chest pain, attribute it to indigestion, delay seeking medical attention, or minimize the pain when describing it to a physician.<br />Affect the course of illness through their effects on the physician–patient relationship, since they influence both patients’ health behaviors and<br /> physicians’ diagnostic and treatment decisions.<br />Can reduce a patient’s compliance with diagnostic recommendations, treatment, and lifestyle change, and can interfere with rehabilitation through impairment of motivation, understanding, optimism, or tolerance.<br />Have direct effects on pathophysiologic processes. E.g., stress has been experimentally shown to cause myocardial ischemia in patients with coronary disease.<br />
MANAGEMENT OF “PFAMC”<br />General guidelines<br />Management of psychological factors affecting the patient’s medical condition should be tailored both to the particular psychological factor of relevance and to the medical outcome of concern. <br />The physician, whether in primary care or a specialty, should not ignore apparent psychiatric illness. Unfortunately, this occurs all too often because of discomfort, stigma, lack of training, or disinterest. <br />Referring the patient to a mental health specialist for evaluation is certainly better than ignoring the psychological problem but should not be regarded as “disposing” of it, because the physician must still attend to its potential impact on the patient’s medical illness. <br />Similarly, psychiatrists and other mental health practitioners should not ignore coincident medical disease and should not assume that referral to a nonpsychiatric physician absolves them of all responsibility for the patient’s medical problem.<br />When prescribing psychiatric medications for patients with significant medical co morbidity, the psychiatrist should keep in mind potential adverse effects on impaired organ systems (e.g., anticholinergic exacerbation of postoperative ileus; tricyclic antidepressant causing completion of heart block<br />
Psychological Factors in Cardiology<br />Coronary Disease:<br />One of the most studied examples is the type A behavior pattern and its relationship to CAD. Type A is a complex set of traits including impatience, hostility, intense achievement drive, and time urgency, among others. Depression directly and indirectly E.g., (by increasing the incidence of smoking & sedentary life style), Generalized anxiety disorders, Psychological Stress, Psychological factors like denial, Maladaptive health behaviors etc.<br />Arrhythmias<br />psychological stressors can also play an important role in precipitating serious cardiac arrhythmias.<br />Congestive Heart Failure<br />Depression is independently associated with increased mortality and readmission rate.<br />Hypertension<br />Psychological stress, Depression, Anxiety, Type A personality are all independent risks for Hypertension.<br />
Relationships between emotional stress, <br />myocardial ischemia or infarction, and ventricular fibrillation<br />
Depression after a myocardial infarction predicts mortality<br />
Mental Disorder Affecting a General MedicalCondition<br />If the patient has a mental disorder meeting criteria for an Axis I or Axis II diagnosis, the diagnostic name is mental disorder affecting medical condition, with the particular medical condition specified.<br />Examples include <br />Major depressive disorder that reduces energy and compliance in a hemodialysis patient.<br />Panic disorder that makes an asthmatic patient hypersensitive to dyspnea.<br />Schizophrenia in a patient with recurrent ventricular tachycardia who refuses placement of an automatic implantable defibrillator because he fears it will control his mind.<br />
Patients who have psychological symptoms that do not meet the threshold for an Axis I diagnosis may still experience important effects on their medical illness, and the diagnosis would be psychological symptoms affecting a medical condition. <br />Examples include <br />Anxiety that aggravates irritable bowel syndrome (IBS).<br />Depressed mood that hinders recovery from hip replacement surgery.<br />Anger that interferes with rehabilitation after spinal cord injury.<br />Psychological Symptoms Affecting a GeneralMedical Condition<br />
This may include personality traits or coping styles that do not meet criteria for an Axis II disorder and other patterns of response considered to be maladaptive because they may pose a risk for particular medical illnesses. <br />An example<br />is the competitive hostility component of the type A behavior pattern, and its impact on CAD. <br /> Maladaptive personality traits or coping styles are particularly likely to interfere with the physician−patient relationship as well as the patient’s relationships with other caregivers.<br />Personality Traits or Coping Style Affecting a General Medical Condition<br />
Many maladaptive health behaviors have significant effects on the course and treatment of many medical conditions.<br />Examples include <br />Sedentary lifestyle, smoking, abuse of alcohol or other substances, and unsafe sexual practices.<br /> If the maladaptive behaviors can be better accounted for by an Axis I or Axis II disorder, the first subcategory (mental disorder affecting a medical condition) should be used instead.<br />Maladaptive Health Behaviors Affectinga General Medical Condition<br />
Examples include<br />precipitation by psychological stress of angina, cardiac arrhythmia, migraine, or attack of colitis in medically vulnerable individuals. <br />In such cases, stress is not the cause of the illness or symptoms; the patient has an underlying medical condition (CAD, migraine, or ulcerative colitis), and the stressor instead represents a precipitating or aggravating factor.<br />Stress-Related Physiological Response Affectinga General Medical Condition<br />
There are other psychological phenomena that may not fit within one of these subcategories. <br />An interpersonal example is marital dysfunction. <br />A cultural example is the extreme discomfort a woman from some cultures may experience being alone with a male physician, even while she is fully dressed. <br />A religious exampleIs a Jehovah’s Witness who ambivalently refuses blood transfusion. These fall under the residual category of other or unspecified psychological factors affecting a medical condition.<br />Other or Unspecified Psychological FactorsAffecting a General Medical Condition<br />
Differential Diagnosis<br />The close temporal association between psychiatric symptoms and a medical condition does not always reflect PFAMC. If the two are considered merely coincidental, then separate psychiatric and medical diagnoses should be made.<br />In some cases of coincident psychiatric and medical illness, the mental symptoms are actually the result of the medical condition (i.e., the causality is in a direction opposite from that of PFAMC).<br />When a medical condition is judged to be pathophysiologically causing the mental disorder (e.g., hypothyroidism causing depression), the correct diagnosis is the appropriate mental disorder due to a general medical condition (e.g., mood disorder due to hypothyroidism, with depressive features). In PFAMC, the psychological or behavioral factors are judged to precipitate or aggravate the medical condition. <br />
Differential Diagnosis<br />Substance use disorders may adversely affect many medical conditions, and this canbe described through PFAMC. However, in some patients, all of the psychiatric and medical symptoms are direct consequences of substance abuse, and it is usually parsimonious to use just the substance use disorder diagnosis. <br />For example, a patient with delirium tremens after alcohol withdrawal would receive a diagnosis of alcohol withdrawal delirium, not PFAMC, but a patient with alcohol dependence who repeatedly missed hemodialysis treatments because of intoxication would receive diagnoses of alcohol dependence and PFAMC (mental disorder affecting end stage renal disease).<br />Patients with somatoform disorders (e.g., somatization disorder, hypochondriasis) present with physical complaints which may mimic medical illness, but the somatic symptoms are actually accounted for by the psychiatric disorder. <br />In principle, it might seem that somatoform disorders are easily distinguished from PFAMC, because PFAMC requires the presence of a diagnosable medical condition. The distinction in practice is sometimes difficult because the patient may have both a somatoform disorder and one or more medical disorders. For example, a patient with seizures regularly precipitated by emotional stress might have true epilepsy aggravated by stress (PFAMC), pseudoseizures (conversion disorder), or both.<br />
Psychological Factors in Endocrinology<br />Diabetes Mellitus:<br /><ul><li>Psychological stress can adversely affect glucose control in diabetics seems expectable because the hormones of the stress response are part of the counter regulatory response to insulin.
Deterioration in glucose control in schizophrenic diabetics can be due to atypical antipsychotic drugs, but diabetes was also a major problem for schizophrenics before their advent, presumably because of obesity (a side effect of almost every antipsychotic), unhealthy diet, and poorer health care.
A meta-analysis of 24 studies concluded that depression consistently is associated with a small-to-moderate increase in hyperglycemia in both type 1 and type 2 diabetes (Lustman et al. 2000 ).</li></ul>Thyroid Disease:<br /><ul><li>Studies have supported stressful life events as a risk factor for Graves’ disease (e.g., Santos et al. 2002 )
Alterations in thyroid function or its hypothalamic-pituitary control have been demonstrated in relation to affective disorders, schizophrenia, and posttraumatic stress disorder (Mason et al. 1994 ).</li></li></ul><li>Psychological Factors in Pulmonary Disease<br /><ul><li>Psychological factors play an important role in the precipitation and aggravation of asthma, particularly anxiety & Stress. E.g., Asthma symptom severity increased in New York City following the terrorist attacks on September 11, 2001.
On the other hand, asthmawas associated with a significantly increased likelihood of anxiety disorders (especially panic, generalized anxiety disorder, and phobias) and affective disorders.
Psychological distress in COPDamplifies dyspnea without usually causing changes in objective pulmonary functions.
Depression and anxiety do lead to lower exercise tolerance.
Smoking is a well-established maladaptive health behavior causing and exacerbating chronic obstructive pulmonary disease, and its elimination is the most beneficial intervention available.</li></li></ul><li>Psychological Factors in RheumatoidArthritis<br />Psychological morbidity in RA results in more pain, poorer quality of life, more joint surgery, lower compliance, and increased use of health care resources.<br />Depression appears to adversely affect outcome in rheumatoid arthritis, aggravating chronic pain, increasing health care use, and increasing social isolation.<br />Passive, avoidant, emotion-laden coping strategies (e.g., wish-fulfilling fantasy, self-blame) are associated with poorer adjustment to illness in RA compared with active, problem-focused coping (e.g., information seeking, cognitive restructuring).<br />Cognitive−behavioral therapy as an adjunct to standard treatment in recently diagnosed patients with RA showed it efficacious in reducing both psychological and physical morbidity.<br />
Psychological Factors in Neurology<br />Depression is frequent after stroke, associated with poorer outcome; including higher later mortality (House et al. 2001 ), and functional status is improved with treatment of depression after stroke.<br />Stroke patients with extensive social support have better functional outcomes than those who do not have such support.<br />Depression is common in Parkinson’s disease, may antedate the development of motor symptoms, and is associated with cognitive dysfunction.<br />Depression is also common and erodes quality of life in multiple sclerosis and in epilepsy.<br />Patients with chronic migraine headaches have often been described as having a “typical” personality characterized as conscientious, perfectionistic, ambitious, rigid, tense, and resentful.<br />Migraine patients with anxiety and depression reported poorer treatment efficacy and satisfaction with treatment.<br />
Psychological Factors in End Stage RenalDisease<br />
Moersch (1925) described a 54-year-old man in whom, three months earlier, “a gradual mental change had been observed. The patient lost his ambition and interest in work . . . he became careless . . . and seemed little concerned about his shortcomings. For two weeks before his examination he had been content to sit aimlessly at home, or to play with his children. He voided at any time and even defecated in his clothes . . . .<br />During general examination, the patient was indifferent and aimless, would sit and look at a newspaper, which might be upside down. He was oriented in all spheres, and his attention might be held for a few moments when aroused. He would follow his son about in a fairly good-natured manner, but always object to being examined, saying that he was not sick. He showed considerable perseveration, repeating movements at times for long periods. For example, one evening he sat before a wash bowl for over a half-hour, turning the faucets on and off.”<br />This patient’s frontal lobe syndrome, manifest with apathy, disinhibition, and perseveration, constituted the presentation of a tumor of the anterior portion of the corpus callosum, to which the patient eventually succumbed.<br />CASE VIGNETTE 7<br />
Mental Disorder Not Otherwise Specified Due<br />to a General Medical Condition<br />