Psychosomatic medicine in relation to cardiovascular disease


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Psychosomatic medicine in relation to cardiovascular disease

  1. 1. Psychosomatic Medicine in relation toCardiovascular Disease<br /> 30th March 2010<br />:: Speaker ::Dr. Santanu GhoshPostgraduate Student<br /> :: Moderator ::Dr. P. K. ChoudharyProfessor & HOD<br />Assam Medical College & Hospital<br />1<br />
  2. 2. Layout of presentation:<br />Introduction<br />Concepts of Psychosomatic Medicine<br />Psychoneuroimmunological basis of disease<br />Psychiatric Disorders in Heart Disease<br />Diagnostic Issues<br />Management<br />Take home message<br /> Conclusion<br /> Bibliography<br /> Acknowledgement. <br />2<br />
  3. 3. Introduction<br /> Cardiovascular disease is now an epidemic. WHO estimates that by 2020 close to 60 % of cardiac patients worldwide will be Indian. It is due to exposures to chemicals and other environmental substances that also have a profound impact on cardiac health.Physical disorders are present in at least 50% psychiatric patients. They are underdiagnosed, misdiagnosed or suboptimally treated. Cardiac symptoms frequently associate with psychological symptoms / disorders. <br />3<br />
  4. 4. Concepts of Psychosomatic Medicine:<br />Psychosomatic medicine is an area of scientific investigation concerned with the relation between psychological factors and physiological phenomena in general and disease pathogenesisin particular.<br /> Integrates mind and body into a psychobiological unit; to study psychological and biological processes as dynamic interacting systems.<br /> It emphasizes the unity of mind and bodyand the interaction between them. <br />4<br />
  5. 5. Concepts of Psychosomatic Medicine contd…<br />The concepts of psychosomatic medicine also influenced the field of behavioral medicine which integrates the behavioral sciences and the biomedical approach to the prevention, diagnosis, and treatment of diseases.<br />Psychosomatic concepts have contributed greatly to those approaches of medical care.<br /> A holistic approach to medicine.<br />5<br />
  6. 6. Concepts of Psychosomatic Medicine contd…<br />Biomedical Model:<br />The application of biological science to maintain health and treating disease.<br />Engel (1977) proposed a major change in our fundamental model of health care.<br />The new model continues the emphasis on biological knowledgebut also encompasses the utilization of psychosocial knowledge.<br />“Biopsychosocial Model”<br />6<br />
  7. 7. Stress Theory<br />Stress can be described as a circumstance that disturbs, or is likely to disturb, the normal physiological or psychological functioning of a person.<br /> The body reacts to stress in this sense defined as anything (real, symbolic, or imagined) that by 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. <br />7<br />
  8. 8. THE STRESS MODEL<br />A psychosomatic framework.<br />Two major facets of stress response.<br /> This concept was given by Robert P. Liberman<br />“Fight or Flight”response is mediated by hypothalamus, the sympathetic nervous system, and the adrenal medulla.<br />If chronic, this response can have serious health consequences.<br />The hypothalamus, pituitary gland, the adrenal cortex mediate the second facet.<br />8<br />
  9. 9. Neurotransmitter Responses to Stress<br />Stressors activate noradrenergic systems in the brain and cause release of catecholamines from the autonomic nervous system.<br />Stressors also activate serotonergic systems in the brain, as evidenced by increased serotonin turnover.<br />Stress also increases dopaminergicneurotransmission in mesocorticalpathways. <br />9<br />
  10. 10. Endocrine Responses to Stress<br />CRF( secreted from the hypothalamus).<br />CRF acts at the anterior pituitary to trigger release of ACTH.<br />ACTH acts at the adrenal cortex to stimulate the synthesis and release of glucocorticoids.<br />Promote energy use, increase cardiovascular activity, and inhibit functions such as growth, reproduction, and immunity.<br />10<br />
  11. 11. Immune Response to Stress<br />Inhibition of immune functioning by glucocorticoids.<br />Stress can also cause immune activation through a variety of pathways including the release of humoral immune factors (cytokines) such as interleukin-1 (IL-1) and IL-6. <br />These cytokines can themselves cause further release of CRF, which serves to increase glucocorticoid effects and thereby self-limit the immune activation. <br />11<br />
  12. 12. Immune Response to Stress contd…<br />High level of Cortisol results in suppression of immunity which can cause susceptibility to infections and possibly also in many types of cancer.<br />Changes in the immune system in response to stress are now very well established.<br />12<br />
  13. 13. Immune Response to Stress contd…<br />Immune suppression in response to stress occurs even after removal of the adrenal gland !!.<br />There appears to be an alternative path, other than through the adrenals, for the brain to influence the immune response.<br />Psychoneuroimmunology<br />13<br />
  14. 14. 14<br />STRESS<br />DEPRESSION<br />Depressive mood<br /> Insomnia<br />↓ Pleasure<br />↓ Appetite<br />↓ Libido<br />HYPOTHALAMUS<br />CRH<br />ANTERIOR PITUITARY<br />ENDOTHELIUM & BLOOD VESSEL<br /><ul><li>↑ Platelet activity
  15. 15. Vasoconstriction</li></ul>ACTH<br />ADRENAL GLAND<br />Immune System<br />Increased secretion of<br /><ul><li>TNFα
  16. 16. IL-1
  17. 17. IL-6</li></ul> HEART<br /><ul><li>Myocardial ischemia
  18. 18. Ventricular arrhythmia</li></ul>CATECHOLAMINE<br />CORTISOL<br />Adrenal sympathetic hyperactivity <br />
  19. 19. 15<br />
  20. 20. Psychiatric Disorders in Heart Disease<br />16<br />
  21. 21. Behavioral risk factors for cardiovascular disease<br />17<br />
  22. 22. Psychiatric consequences of cardiovascular diseases<br />Depression<br />Anxiety<br />Heart Disease<br />Cognitive Impairment<br />18<br />
  24. 24. Congestive Heart Failure
  25. 25. Mitral valve prolapse
  26. 26. Automatic implantation cardiovascular defibrillator
  27. 27. Supraventricular tachycardia</li></ul>19<br />
  28. 28. I.Depression:<br /><ul><li>Depression in Coronary Heart Disease</li></ul>Point prevalence of depression in CAD = 15-20%(Shapiro et al 1997)<br />Most patients presents with MDD & half of these with minor depression found to have MDD at 1 year follow up.<br /> Associated with increased rate of mortality.<br /> Healthy individuals who suffer from depression are at higher risk of developing heart attacks & strokes later in life (Glassman et al 2006)<br />Most of the time it is under recognized & untreated.<br />SADHART( Sertraline antidepressant heart attack randomized trial) <br /> Rx with sertraline in MI> placebo<br /> ENRICHED (Enhancing recovery in Coronary Heart Disease)<br /> CBT in post MI improves depression but not mortality<br /> Rx with SSRI definitely lowers mortality.<br />20<br />
  29. 29. Depression contd….<br /><ul><li>Depression in Congestive Heart Failure</li></ul>Point prevalence of depression in CHF = 15% (Faris et al 2002)<br /> Mortality is 36% in depressed in 5 years against 16% non depressed. <br /> REMATCH trial <br />Study comparing left ventricular assist device implantation + medical therapy in end stage CHF patients<br /> Mean baseline Beck Depression Inventory score > 16 with 2/3 had score above 10<br />21<br />
  30. 30. How depression causes CAD ?<br />Psycho physiological mechanism include <br />Platelet dysfunction<br />2. Autonomic dysfunction<br />3. Abnormalities of inflammation <br />22<br />
  31. 31. 1. Platelet Dysfunction:<br />A. In depression : ↑ circulating βthromboglobulin+ Platelet factor 4<br /> Increase likelihood of thrombus formation<br /> Release of serotonin stored in Platelet<br />Platelet Aggregation<br /> SSRI<br /> Thrombosis <br />23<br />
  32. 32. How depression causes CAD ? Contd…<br />2) Cardiac autonomic control<br /> ↑ Sympathetic activation<br /> Suppression of vagal tone<br /> Propensity for cardiac arrhythmias<br />3) Inflammation (Libby et al 2002)<br />In CAD - ↑ inflammatory cytokines- interleukin- 6 (IL-6), TNF-α& C-Reactive Protein <br />In Depression - ↑ IL-6 & CRP<br />24<br />
  33. 33. II Anxiety Disorder:<br /><ul><li>Anxiety in CAD:</li></ul>Seen in 5-10% with chronic heart disease (Sullivan et al 2000) <br /> Many patients with coronary disease have a family history of death of the parent of same sex as a result of the same illness.<br /> This history often associated with the conscious fantasy that the patient’s death at the age at which the parent died is inevitable leading to considerable vigilance, avoidance & other anxiety behavior. <br />25<br />
  34. 34. II Anxiety Disorder contd..<br /><ul><li>Anxiety in Congestive Heart Failure:</li></ul>Lack of studies regarding the incidence of anxiety in CHF<br /> Survey of ambulatory dilated cardiomyopathy outpatient shows anxiety symptoms are higher than population norms suggesting a substantial prevalence of anxiety disorder. <br /><ul><li> Anxiety & Mitral valve Prolapse:</li></ul> 5-20% or more patients with panic disorder have mitral valve prolapse (Dager et al 1986).<br /> Patient may be asymptomatic or may experience occasional palpitations or fluttering sensation in the precordium.<br /> Gives rise catastrophic cognition that stimulate panic attack in predisposed individuals (Barlow 1988)<br />26<br />
  35. 35. Anxiety Disorder contd….<br /><ul><li>Anxiety & Automatic Implantable cardiovarer- Defribilators (A.I.C.D) :
  36. 36. A.I.C.D. : reduced mortality of malignant </li></ul> ventricular arrhythmias.<br /><ul><li> Unpleasant feeling of defibrillation </li></ul> - “kicked in the chest”<br /> - iatrogenic anxiety<br /> - 50% incidence viz. adjustment disorder, major depression and panic disorder.<br /><ul><li> Most patients report satisfaction.
  37. 37. It mortality .</li></ul>27<br />
  38. 38. Anxiety Disorder contd….<br /><ul><li>Anxiety & Supraventricular Tachycardia:</li></ul>Occurs in young and middle aged adults.<br />Experience symptoms of shortness of breath, chest discomfort and apprehension.<br />Those symptoms overlap with those of generalized anxiety symptoms and panic attack.<br />ECG -> QRS complex < 120 mesec. <br />28<br />
  40. 40. Vascular dementia
  41. 41. Adverse Psychiatric side affect by cardiac drugs
  42. 42. Cardiac neurosis
  43. 43. Sexual dysfunction
  44. 44. Acute Mental Stress
  45. 45. Sleep Apnea</li></ul>29<br />
  46. 46. Delirium:<br /> It is a clinical syndrome of fluctuating global cognitive impairment associated with behavioral abnormalities.<br /> Acute heart failure<br />↓ Cardiac output<br /> Cerebral anoxia<br /> Delirium<br />30<br />
  47. 47. Vascular dementia:<br />Dementia due to chronic cerebrovascular disease is 2nd / 3rd most common cause of dementia in elderly(Alzeimer’s Dementia and dementia with Lewy bodies). <br /> Prolonged hypertension & atherosclerosis can lead to acute onset dementia.<br />31<br />
  48. 48. 32<br />
  49. 49. Sexual Dysfunction<br />It occurs after the onset of heart disease as a <br /> consequence of :–<br /><ul><li>Physical factors : medication, co-morbid medical conditions (Peripheral vascular disease, D.M.), low cardiac output.
  50. 50. Psychological : anxiety ,depression, fear of inducing heart disease
  51. 51. Coital angina 5% cases. </li></ul>33<br />
  52. 52. Cardiac Neurosis<br />An anxiety reaction characterized by quick fatigue, shortness of breath, rapid heart beat, dizziness, and other cardiac symptoms, but not caused by disease of the heart.<br /> Clinging to symptoms to escape from intolerable life stream<br />Also called effort syndrome, irritable heart, neurocirculatory asthenia, soldier's heart.<br />34<br />
  53. 53. Acute Mental Stress:<br /> Cardiovascular mortality rises 1 month after death of a loved one.<br /> Sudden cardiac death occurs following disaster<br /> (Leor et al 1996)<br />Following 9/11 incidence similar findings were reported (Qureshi et al 2003)<br />Such stressors increases heart rate, blood pressure, myocardial oxygen demands with sympathetic vasospasm which ultimately causes ischemia.<br />20-30% of acute coronary events are due to acute mental stress. (Muller 1994)<br />35<br />
  54. 54. Sleep Apnea:<br />Associated with hypertension & CHF (Bradley & Floras 2003a, 2003b) <br />Prevalence 11-37% <br />Results in hypoxia, elevated intrathoracic pressure , sympathetic nervous system activation with increase in heart rate, blood pressure<br />Heart failure, ischemic event & arrhythmias <br />36<br />
  55. 55. SPECIAL ISSUES :<br /><ul><li>Cardiac side effects of Psychiatric drugs
  56. 56. Chest pain/palpitation
  57. 57. Heart transplantation
  58. 58. Hypertension
  59. 59. Left ventricular Assist Device</li></ul>37<br />
  60. 60. 38<br />
  61. 61. Chest Pain<br /> Typical anginal chest pain occurs on exertion or eating, - dull pressure like pain.<br /> cardiac pain often radiates to one arm, both arms or neck / jaw.<br /><ul><li>Anginal pain may last for 2-10 minutes
  62. 62. Often aggravated by emotional stress/activity.
  63. 63. Atypical -> symptoms of panic attack</li></ul>39<br />
  64. 64. Heart Transplantation<br />A heart transplant removes a damaged or diseased heart and replaces it with a healthy one. <br />The healthy heart comes from a donor who has died. <br />It is the last resort for people with heart failure when all other treatments have failed. <br />Heart transplants are now the third most common organ transplant operation in the U.S.<br /> Expected 5 yrs survival by 75%<br />Psychiatric complication following surgery fairly common – Depression.<br />40<br />
  65. 65. Hypertension <br />Systolic ≥ 140 mm Hg, diastolic ≥ 90 mm Hg <br />Transient ↑ B.P. -> pain & anxiety<br />10 % HTN due to secondary cause (obesity, alcohol, renovascular)<br />Relationship between HTN and psychological <br /> factors – subject of controversy with mixed findings <br /> Increased prevalence panic disorder in patients with HTN<br />Chronic HTN long term neurocognitive impairment <br /> ↑ risk of dementia.<br />41<br />
  66. 66. Battery-operated, mechanical pump-type device that's surgically implanted. <br /> Maintains the pumping ability of a heart that can't effectively work on its own.<br />Replaces heart transplantation (due to shortage of donor)<br />Post operation delirium is common side effect<br />42<br />Left Ventricular Assist Device<br />
  67. 67. Normal ECG:<br />43<br />
  68. 68. Normal ECG:<br />44<br />
  69. 69. ECG changes in Myocardial infarction<br />45<br />
  70. 70. Torsade de pointes:<br />46<br />
  71. 71. Diagnostic Issues<br />47<br />
  72. 72. Brief Psychometric Screening<br />Non-recognition of emotional distress is pervasive in cardiac settings due to denial and somatic presentation (e.g., chest pain, palpitations, fatigue and presyncope, also poor sleep). Therefore, simple screening tools are necessary.<br />Measures of Emotional Distress are confounded and non-independent in predicting outcomes. Therefore, a single screening tool is sufficient.<br />
  73. 73. 49<br />Source: Dammen et al 1999<br />
  74. 74. Management<br />50<br />
  75. 75. Consultation Liaison Psychiatry<br />The subspecialty of psychiatry that incorporates clinical service, teaching, and research at the borderland of psychiatry and medicine.<br />CL psychiatrist MUST have an extensive clinical understanding of physical/neurological disorders and their relation to abnormal illness behavior.<br />Liaison refers to interactionswith nonpsychiatrist physicians for teaching psychosocial aspects of medical care.<br /> CL psychiatrist MUST have knowledge of psychotherapeutic and psychopharmacological interventions<br />
  76. 76. Consultation Liaison Psychiatry contd….<br />Liaison model is based on an early detection strategy to identify potential problems.<br /> Liaison psychiatrist may participate in ward rounds and team meetings while addressing the behavioural issues.<br />Educationof nonpsychiatric physicians and health professionals about medical and psychiatric issues related to a patient’s illness.<br /> Liaison services lead to heightened sensitivity by medical staff, which result in earlier detection and more cost-effectivemanagement of patients with psychiatric problems.<br />
  77. 77. Psychotherapy and behavior modification<br />Psychopharmacological<br />C. Stress management & health education programme<br />53<br />Treatment:<br />
  78. 78. A. PSYCHOTHERAPY<br /><ul><li>C.B.T.: aimed at ameliorating the symptoms of anxiety & depression associated with concern for heart disease -
  79. 79. survival, social role, relationship, limitation.
  80. 80. Denial & nonadherence to therapy.
  81. 81. Individual & group therapy.
  82. 82. Interpersonal psychotherapy
  83. 83. focuses on present day interpersonal problem linked to depressed mood.</li></ul>54<br />
  84. 84. B. Behavior Modification<br />Psychosocial :- smoking, diet, alcohol, physical activities.<br /> Personality traits & behavior pattern<br />Type A Personality: Highly, ambitious & aggressive, anger / suppressed<br />Type B Personality: calm, non-aggressive <br />55<br />
  85. 85. Behavior Modification contd…<br />Psychobehavioral <br />Compliance to smoking cessation, <br /> Pill-taking<br /> Exercise<br /> Glucose control <br />56<br />
  86. 86. Emotional Distress<br />Predicts Noncompliance to:<br />Smoking Cessation/Relapse Avoidance (Hall et al. 1998)<br />Exercise (Stetson et al., 1997)<br />Pill-Taking (Carney et al., 1995)<br />Glucose Control (de Groot et al., 2001)<br />
  87. 87. B. PHARMACOTHERAPY<br />Antidepressant <br />TCA – Orthostatic hypotension, <br /> conduction delay <br /> – Prolongation of QT QRS interval <br /> SSRI – Less or no side effect<br /> Sertraline : cardiac friendly<br />58<br />
  88. 88. 2. Antipsychotic<br />Haloperidol: In acute psychotic symptoms in post operative delirium.<br /> Typical antipsychotic – Orthostatic hypotention, QT prolongation.<br /> CPZ – causes α adrenergic blocking effect.<br /> Olanzapine, Risperidone & Quetiapine: Less QT prolongation.<br /> Ziprasidone: prolongs QT interval with risk of sudden death.<br />59<br />
  89. 89. ANXIOLYTICS<br /> Benzodiazepine :<br /> - Have no specific cardiac effect<br /> - Reduction of anxiety tend to reduce sympathetic nervous system activation<br /> Slow heart rate, reduce myocardial work & irritability <br />Lorazepam – 1/M or 1/V route<br />Buspiron<br /> STIMULANTS<br />Indication : Pronounced apathy, fatigue & psychomotor slowing<br /> Dextroamphetamine & Methylphenidate: safe<br /> Dose: 5-30 mg/day<br /> LITHIUM<br /> - Sinus node dysfunction & sinus arrest<br /> - Avoid in acute congestive heart failure, renal failure, patient on Thiazide & salt restricted diet<br />60<br />
  90. 90. Other mood stabilizer<br /> Safe : Valproic acid, Lamotrigine<br /> Cholinesterase Inhibitor <br /> Indication: Comorbid dementia + Heart disease<br />Drugs: Donapezil, Rivastigmic & Galentamine<br />Side effects: bradycardia or heart block<br /> NMDA Receptor Antagonist<br /> Indication: Comorbid dementia + Heart disease<br />Drug: Mementine<br /> Side effects: hypertension.<br />61<br />
  91. 91. Electro Convulsive Therapy:<br />Initial response : ↑ Sympathetic discharge :<br /> tachycardia, hypertension <br /> Later response : Parasymphathetic reflex response . <br /> May evoke myocardial ischemia, in elderly person<br />Safe: IHD, CHF<br />62<br />
  92. 92. C. Stress management & health education programme<br /> Ways to Prevent Stress<br />Avoid common daily annoyances that cause stress<br />Make a “to-do” list – this can aid in avoiding procrastination.<br />Don’t make decisions at the last minute – plan ahead. Last minute decision-making can cause lots of stress.<br />Keep your social and academic commitments within limits. <br />63<br />
  93. 93. Ways to Prevent Stress contd…<br />Exercise is great in preventing stress. You could begin by walking, which requires no special equipment, and is a good way to start incorporating aerobic exercise into your daily routine.<br />Take a 2-hour break – walk around campus, sit by one of the ponds (water is very soothing), talk with a friend about what’s troubling you, make sure you are getting enough sleep!<br />64<br />
  94. 94. Take Home Message<br />Cardiac morbidity in Psychiatric disorders or Psychiatric morbidity in Cardiac illness are not uncommon. <br />Confusion may arise due to overlap of symptoms of heart disease and cardiac disorder.<br />Early detection of psychiatric symptoms more so of depression and anxiety in cardiac patients entails stability of the disease and improve quality of life.<br />Physician in general and cardiologists in particular should be made aware of various psychosocial factors and presence of anxiety and depression among their cardiac patients<br />65<br />
  95. 95. Contd…..<br /><ul><li>Psychiatrists should also focus special attention to rule out cardiac symptoms particularly in the risk groups.</li></ul>Sertraline is the safe antidepressant, while Lorazapam, Buspirone; and Haloperidol, Olazepine, Risperidone, Quetipine are safe anxiolytic and antipsychotic agents respectively.<br />Psychotherapy and behaviour modification and health education are always complementary to pharmacotherapy.<br />66<br />
  96. 96. Conclusion<br /> Psychological factors are important <br /> consideration in CAD. These factors often remain under diagnosed & untreated. They lead to increased morbidity & mortality. Management of these factors will not only reduce morbidity & mortality but also lead to better quality of life.<br />67<br />
  97. 97. Bibliography:<br /> Essentials of Psychosomatic Medicine , Levenson, P 423-39, American Psychiatric Publishing Textbook.<br /> Psychosomatic Medicine, Blumenfield & Strain, P 109-19, Lippincott Williams & Wilkins.<br /> Psychological Co-relates in cardiovascular diseases, Deka Dr. kamala,P 18-22, 5th Mid Term CME-2009, IPS- Assam State branch.<br /> Psychiatry & Cardiovascular disease-a brief review, Bhagabati Dr. Dipesh & Das Dr. Syamanta P 24-35, Psychiatric Updates, IPS- Assam State Branch.<br /> Web:<br /> -<br /> -<br /> -<br /> -<br />68<br />
  98. 98. Acknowledgement:<br />Prof. P.K. Choudhary: <br /> “Cardiac Manifestation in Psychiatric Disorders - An approach to diagnosis and management”, 5th Mid Term CME -2009, Morigaon, IPS- Assam State Brach.<br />69<br />
  99. 99. Thank you<br />70<br />