The fallacy of separating somatic and

psychological symptoms.

September 30 , 2013

St. Maarten

Erik Hoencamp

Two realities

• Split in classification and treatment of somatic or psychological symptoms.

• Leading to split between professionals, research, training curricula and financing of care.

• While

• They co-occur in many clinical situations.

• With regard to genetic vulnerability , environmental risk and protective factors they have the same etiological underpinning.

Conceptual background

• Gene * environment Interaction.

• Examples of disease/phenotype Depression<> Cardiovascular Disorders

Bipolar Disorder, Schizophrenia<> metabolic syndrome.

• Childhood Adversity as an environmental

factor

Current paradigm,

Gene*Environment Interaction

Genetic

vulnerability

environment environment

conception

Gene-

expression

Disease

phenotype

epigenetics

Gene*Environment Interaction

Genetic

vulnerability

environment environment

conception

Gene-

expression

Disease

phenotype

epigenetics

Childhood adversity Depression

Cardiovacular disorder.

Metabolic Syndrome

Psychosis

Depression & Cardiovascular disease

• Share genetic vulnerability and

environmental component.

• In clinical practice co-occur often , proper

treatment of depression enhances life

expectancy. (psychotherapy ,

antidepressants, treatment CVA)

• NB depends on definition Major

Depressive Disorder.

Schizophrenia

Bipolar disorder

Depression ??

Anxiety disorders ??

Diabetes

Hypertension

Cardiovascular

Etc.

Metabolic

syndrome both

cause and

consequence of

the disorder?

Life style

Medication

Environment

social

Migration,dicrimi

nation,etc

family psychological

physical

economic Childhood Adversity

Depression

Anxiety

Etc.

Cardiovascular

disease

Inflammatory

disease

etc

Affective

Physical

Sexual

Which has highest impact ???

Example how ACE

effects health

In this case

cardiovascular

disorders

So, related are

• Depression <>Cardiovascular Disorder.

(Genetic component)

• Schizophrenia /Bipolar Disorder<>

Metabolic syndrome. (Genetic component)

• Childhood Adversity (environmental

component)<> Depression

&Cardiovascular Disorder

Is there a common denominator

in the pathogenesis ?

• Epigenetic changes in gene expression

• Stress regulation functioning HPA-axis

• Aberrant Inflammatory processes

• Disruptive Bio-rhythms

• Microbiome ?

• Socio-economic risk and protective

factors.

Domains or levels of expression of pathology

Social , economic, political situation.

Life events risk and protective factors

Behaviour

Emotional , cognitive and physical well being .

Physical functioning and patho-fysiological processes

Structural and functional integrity of body >> vulnerability and/or acquired

disorders, disease.

Pathology is

perceived

here in the

social

context.

Pathology “ X “ and attributed causality.

Social , economic, political situation, Life events risk and protective factors

Behavior

Emotional , cognitive and physical well being .

Physical functioning and patho-fysiological processes

Structural and functional integrity of body >> vulnerability and/or acquired

disorders, disease.

Pathology is

perceived

here in the

social

context

Pathology X

Somatic Psychological

Pitfalls separating psychopathology and somatic

pathology

• Psychopathology implies that the

phenotype/disease is caused by

“psychological” factors.

• Somatic pathology implies that it is caused

by an underlying disease.

• Neither is true and leads to strange

situations what is a “ real “ disease

example whiplash , CFD, ..

What are practical the consequences

• Image : psychopathology, remains having a negative odium and easily leads to stigmatization and rejection. Religious, ideological and political factors play a role in these processes.

• Research and treatment: A fundamental change is needed and slowly in progress where somatic and psychological symptomatology and their relation are taken into account with regard to etiology and treatment.

• Training curricula should be adapted and give more background about both psychological and biological aspects of disease.

• Our own attitude : well intended we may contribute to stigmatization, by treating patients different with psychopathology leading to dependency and lack of self fulfillment and empowerment.

• Organization of health care services , Challenge to increase cost effectiveness of health care .

Thanks any questions ?