Pulmonary medicine Psychiatric aspects COPD Asthma

1. PSYCHIATRICPSYCHIATRIC
ASPECTS OFASPECTS OF
COMMON LUNGCOMMON LUNG
DISEASESDISEASES
BY
WAHEED SHOUMAN
PROFESSOR
CHEST MEDICINE
ZAGAZIG UNIVERSITY

2. To see plague in my
hospital is better
than a psychiatrist
The beginning

3. Keep in mind that:
“You are treating
‘patients’‘patients’ with lung
disease notnot lunglung
diseasedisease””

4. SMOKINGSMOKING

5. OnethousandOnethousand
Americans stopsmokingAmericans stopsmoking
everyday–everyday–
bydyingbydying

6. AddictionAddiction
“It is a chronic relapsing
disease characterized by
compulsive drug-seeking and
abuse and by long-lasting
chemical changes in the
brain”.
• It is a disease affected by
genetic, psychosocial and
environmental factors

7. Criteria for SubstanceCriteria for Substance
DependenceDependence
A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as
manifested by three (or more) of the following, occurring at any time in the same 12-month
period:
1. tolerance, as defined by either of the following:
1. a need for markedly increased amounts of the substance to achieve intoxication or desired effect
2. markedly diminished effect with continued use of the same amount of the substance
2. withdrawal, as manifested by either of the following:
1. the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets
for Withdrawal from the specific substances)
2. the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
3. the substance is often taken in larger amounts or over a longer period than was intended
4. there is a persistent desire or unsuccessful efforts to cut down or control substance use
5. a great deal of time is spent in activities necessary to obtain the substance (e.g., visiting
multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or
recover from its effects
6. important social, occupational, or recreational activities are given up or reduced because of
substance use
7. the substance use is continued despite knowledge of having a persistent or recurrent
physical or psychological problem that is likely to have been caused or exacerbated by the
substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or
continued drinking despite recognition that an ulcer was made worse by alcohol
consumption)

8. Criteria for SubstanceCriteria for Substance
AbuseAbuse
• A maladaptive pattern of substance use leading to clinically
significant impairment or distress, as manifested by one (or
more) of the following, occurring within a 12-month period:
1. recurrent substance use resulting in a failure to fulfill major role
obligations at work, school, or home (e.g., repeated absences or poor
work performance related to substance use; substance-related
absences, suspensions, or expulsions from school; neglect of children
or household)
2. recurrent substance use in situations in which it is physically
hazardous (e.g., driving an automobile or operating a machine when
impaired by substance use)
3. recurrent substance-related legal problems (e.g., arrests for
substance-related disorderly conduct)
4. continued substance use despite having persistent or recurrent social
or interpersonal problems caused or exacerbated by the effects of the
substance (e.g., arguments with spouse about consequences of
intoxication, physical fights)
• The symptoms have never met the criteria for Substance

9. Criteria for SubstanceCriteria for Substance
WithdrawalWithdrawal
1. The development of a substance-
specific syndrome due to the
cessation of (or reduction in)
substance use that has been heavy
and prolonged.
2. The substance-specific syndrome
causes clinically significant distress
or impairment in social,
occupational, or other important
areas of functioning.
3. The symptoms are not due to a
general medical condition and are

10. NicotineNicotine
• Nicotine dependence is more
intense in cigarette smokers
than other forms of tobacco
smoking habits
• This is related to its rapid effect,
higher frequency and higher
reinforcement.
• 80%-90% of regular smokers have
nicotine dependence
• Nicotine withdrawal symptoms
include desire to sweets and
impaired performance of tasks
requiring vigilance

11. Features of nicotine dependenceFeatures of nicotine dependence
which predict greater difficultywhich predict greater difficulty
in quitting smoking:in quitting smoking:
1. Smoking soon after waking
2. Smoking when ill
3. Difficulty refraining smoking
4. Reporting that first cigarette of
the day to be the most difficult
to give up
5. Smoking more in the morning
than afternoon
6. Number of cigarettes per day
and pack.year

12. Withdrawal symptoms of
nicotine include:
• Slowing of EEG
• Decreased catecholamines
• Decreased cortisol level
• Decreased BMR
• REM changes
• Impaired neuropsychiatric
testings

13. • Nicotine dependence is more
common in mental disorders as
scizophrenia “55%-90%”
• Mood, anxiety and other
substance-related are more
common in smokers
• Smoking increases the
metabolism of many drugs used
in mental illnesses
• This is related to other
components of tobacco rather
than nicotine

14. BRONCHIABRONCHIA
L ASTHMAL ASTHMA

15. William Osler in 1898 stated
that:
“Asthma is a
disease of ‘all
in the patients
mind’”

16. The psychiatric view ofThe psychiatric view of
asthma in the recentasthma in the recent
years:years:
• Asthma, anxiety and depression
are all syndromes that emerges
as a consequence of
dysregulation of physiologically
critical biochemical pathways.
• These pathways are regulated by
net work of families of genes
rather than one gene
• Hence, they may show some

19. Psychiatric disorders andPsychiatric disorders and
asthma:asthma:
1. Psychiatric disorders may
contribute to etiology, course or
clinical expression of asthma
2. Asthma may contribute to
emergence of depression and
anxiety
3. Poor mental health may affect
the capacity of asthmatics to
cope with their illness

20. 3 RISK FACTORS PREDICT3 RISK FACTORS PREDICT
ASTHMA IN GENETICALLYASTHMA IN GENETICALLY
VULNERABLE CHILDREN:VULNERABLE CHILDREN:
1. ATOPIC VULNERABILITY
2. EARLY EMOTIONAL STRESS
3. EARLY RECURRENT
RESPIRATORY INFECTIOS
• WHEN THE 3 FACTORS ARE
COMBINED, 50% OF THEM
DEVOLOP BRONCHIAL ASTHMA.

21. UncontrolledUncontrolled
asthmatics haveasthmatics have
more:more:
• Denial
• Panic-fear
• Inappropriate coping skills
• More non compliance with
treatment

22. Depression and asthma:Depression and asthma:
• 50% of cases
• Higher than any other medical
disease except RA
• Younger asthmatics have higher
depressive symptoms
• Depressed asthmatics utilize more
health resources
• They are more prone to sudden death
due to asthma
• They improve with TCA and
citalopram

26. Mechanisms and risks for panic-Mechanisms and risks for panic-
anxiety in asthmatics:anxiety in asthmatics:
• Dyspnea-fear theory
• Suffocation false alarm theory
• Drugs “steroids, β-agonists and
theophylline”
• Shared genetic influence
• Common environmental risk factors
“smoking, low-socioeconomic status
and stressful life events”
• Selection biases in studies

28. Two types of panic inTwo types of panic in
asthmatics:asthmatics:
1. Panic-fear in response to
asthma “illness-specific”
2. High generalized panic fear

29. Treatment of panic and anxietyTreatment of panic and anxiety
in asthma:in asthma:
• Anxiolytics, not established
• Anti-depressants, may be of
help, need more studies
• Cognitive behavioral therapy
“CBT”. The best approach “the
way you thinkthink affects the way
you feelfeel and the way you
behavebehave”

30. COPDCOPD
• Depression 40%
• Anxiety 15%-35%
• Depressed COPD patients have:
1. More admissions
2. More re-admissions
3. Longer hospital stays
4. Early addictive smoking
5. Impede smoking cessation
6. Decreased exercise tolerance
7. Treatment non-compliance
8. Decreased QOL

31. • Schizophrenic patients seem to
be more likely to have COPD
attributed to:attributed to:
SmokingSmoking “90%” which is used a
self-medication as nicotine
stimulate CNS cholinergic
receptors which improve
negative symptoms of
schizophrenia

32. Chronic hypoxemia disturbs
the synthesis, release and
replenishment of nor-
adrenergic and
dopaminergic neuro-
transmitters in the brain
leading to depression

33. Treatment:Treatment:
• TCA effectively decrease depression
in COPD patients
• SSRI “sertraline, fluoxetine and
paroxetine” are better and safe, but
need further evaluation
• Buspirone is effective and COPD-
anxiety patients
• CBT is effective
• Pulmonary rehabilitation programs
are effective (short-lived)
• Anti-depressants need 4-6 weeks for
their cellular changes, hence long-
term studies are needed

35. ICU and ARDS
• Depression in 40%-60%
• PTSD: characterized by:
1.Hyper-arousal
2.Persistent avoidance
3.Persistent re-experience
• PTSD is present in 100% of
ARDS patients at discharge
and 50% after 8 years

36. Causes of psychiatric problems in
ARDS patients:
1. The primary insult
2. Hypoxemia (damage
hippocampus)
3. Hypotension
4. Glucose dysregulation
5. Long-term MV
6. Sedation and drug withdrawal

37. Psychiatric aspects of weaningPsychiatric aspects of weaning
failure:failure:
1. Delirium
2. Anxiety
3. Depression
4. Agitation
5. Residual or deficient sedation
6. Loss of independence
7. Loss of communication
8. Frightening nightmare
9. Non-restorative sleep (the average time
of sleep in ICU on MV is 1.8h/24 hours)

39. Cystic fibrosisCystic fibrosis
The same like general
population
IPFIPF
Slightly and non-significantly
higher than general
population

40. Primary pulmonaryPrimary pulmonary
hypertensionhypertension
• Early,Early, they may be
misdiagnosed as having panic
disorder
• One thirdOne third has depression
• One quarterOne quarter has anxiety and
panic
• 4-6 times4-6 times greater than
general population
• ProportionalProportional to the NYHA

41. SarcoidosisSarcoidosis
• Depression in 60%
• More in females
• More with neurosarcoidosis

42. SteroidsSteroids
• Mood disturbances: mania,
hypomania, mood liability and
depression
• Cognitive changes
• More frequent in the 1st
two weeks of
therapy
• Dose-dependent (40-80mg 5%,
>80mg/day 18%-19%)
• Improve with lithium, anti-
convulsants and anti-psychotics
• Very less common, but occur, with
inhaled steroids

43. VCDSVCDS
• Vocal cords adduct during
inspiration, but may occur with
expiration as well
• IdiopathicIdiopathic
• More in females
• 5% of US Olympic athletics
• 15% of US Army with exert ional
dyspnea
• 35%-55% coexist with true
asthma

45. Treatment of VCDS:Treatment of VCDS:
• Reassurance
• Relaxation techniques
• Vocal cord paralysis with botulin
toxin
• Speech therapy (the best line of
treatment)

46. Psychogenic cough ticsPsychogenic cough tics
• Dry repetitive and honking, from the
throat
• Chronic cough without any
physiological cause
• Diagnosis of exclusion
• No specific diagnostic criteria
• 3%-10% of chronic cough of
unknown cause
• Doesn’t occur during sleep
• Treatment:Treatment:
Reassurance, suggestion therapy,

47. Sighing dyspneaSighing dyspnea
•Prevalence is unknown
•Female sex
•Anxiety is principal
•Episodes may last hours
•No change in respiratory
rate
• TreatmentTreatment
Reassurance and relaxation
techniques

48. The endThe end
The greatest mistake in the treatmentThe greatest mistake in the treatment
of diseases is that there are physiciansof diseases is that there are physicians
for the body and physicians for thefor the body and physicians for the
soul, although the two cannot besoul, although the two cannot be
separated. ~Platoseparated. ~Plato
Body and soul cannot be separated forBody and soul cannot be separated for
purposes of treatment, for they arepurposes of treatment, for they are
one and indivisible. Sick minds mustone and indivisible. Sick minds must
be healed as well as sick bodies. ~C.be healed as well as sick bodies. ~C.
Jeff MillerJeff Miller