Psychosomatic medicine

Medically Unexplained Symptoms (MUS)Bio-psycho-social model

Stress and healthPositive psychology

Psychosomatic medicine

• coronary heart disease• hypertenstion• diabetes• bronchial athma• infertility• morbus Crohn• colitis ulcerosa• cancer• functional aphonia• stuttering

• headaches• fatigue• skin problems• lower back pain• sleep problems • obesity and weight

management• unhealthy behaviours

related to stress (alcohol, nicotine, overeating

• eating disorders

??

Medically unexplained symptoms (MUS)

• Symptoms for which the treating physician, other healthcare providers, and research scientists have found no medical cause.

• cause(s) for given symptoms are uncertain, • A task force of the US

National Institutes of Health states, "Medically unexplained syndromes (MUS) present the most common problems in medicine."

Medically unexplained symptoms in primary care

• 14 common physical symptoms are responsible for almost half of all primary care visits.

• Only about 10–15% of these symptoms are found to be caused by an organic illness over a 1-yr period.

• An increasing number of medically unexplained symptoms over a patient's lifetime correlate linearly with the number of anxiety and depressive disorders experienced, the score on the personality dimension of neuroticism, and the degree of functional impairment.

Katon et al., 1998

What is psychosomatics?

• „Psycho“: mental reaction to our current life situation

• „Somatic“: how body reacts to our current situation

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Examples ?

Sayings and Proverbs• A good laugh and a long sleep are the best cures in the doctor's

book. ~Irish Proverb

• The root of all health is in the brain. The trunk of it is in emotion. The branches and leaves are the body. The flower of health blooms when all parts work together. ~Kurdish Saying

• When the head aches, all the body is the worse. ~English Proverb

• To avoid sickness eat less; to prolong life worry less. ~Chu Hui Weng

Patients with psychosomatic problems:

• 7 years on average; changing doctors, requiring repeated check-ups

• Before accepting the fact that problems are result of their own upbrining, reactivity to problems, readiness to solve problems, personality traits, worcoholism,…;

• Diseases of civilization tend to be more frequent• Psychotherapy and psychosomatic medicine is not taught at

the academic medicine at all; bio-psycho-social model is not taught

• As a result people search for healers

Medicine in 21st century:„Tools“ and/or „Talking?“

Tools and equipment medicine;„academic medicine“ Talking medicine

Bio-psycho-social model

Biomedical model Psychosocial model

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Bio-psycho-social model

• a conceptual model that assumes that psychological and social factors must also be included along with the biologic in understanding a person's medical illness or disorder.

Bio-psycho-social model: Integrated approach to human behaviour, disease and

healthcare

Biological factors

Social factorsPsychological factors

Engel, 1977

Occupational stressStigma

Family environmentLife EventsPersonality traits

MotivationOptimism

GenesDrugsGerms

Bio-psycho-social model

• The biological system: deals with anatomical, structural and molecular substrate of disease and the effects on the paitent´s biological functioning

• Psychological system: deals with effects of psychodynamic factors like motivation, personality, optimism, on the experience of and reaction to illness

• Social system: examines the cultural, environmental and familial influences on the expression and experience of the illness

Study of the relationship between sudden deaths and psychological factors: Background

• 170 sudden deaths over 6 years• Serious illness or even death might be

associated with psychological stress or trauma.

Engel, 1971

Study of the relationship between sudden deaths and psychological factors: Triggers

• the impact of the collapse or death of a close person;

• during acute grief; • on threat of loss of a close person; • during mourning or on an anniversary; • on loss of status or self-esteem; • personal danger or threat of injury; • after the danger is over; • reunion, triumph, or happy ending.

Engel, 1971

Study of the relationship between sudden deaths and psychological factors. Conclusion

• Common to all is that they involve events impossible for the victims to ignore and to which their response is overwhelming excitation or giving up, or both.

• this combination provokes neurovegetative responses, involving both the flight-fight and conservation-withdrawal systems, conducive to lethal cardiac events, particularly in individuals with preexisting cardiovascular disease; other modes of death, however, were also noted.

• Better understanding of the potentially lethal life situations and identification of individuals at risk may lead to the development of practical prophylactic measures.

Engel, 1971

Suggest practical prophylactic measures (???)

Effects of Bereavement on Physical and mental health – a study of the medical records of widows

• The medical records kept before and after the bereavement of 44 unselected London widows

• In widows under the age of 65 the consultation rate for psychiatric symptoms more than trebled during the first six months after bereavement. The increase was greatest during the first six months.

• The amount of sedation prescribed to widows under the age of 65 was seven times greater during the 18 months after bereavement than it had been during the control period, not for widows over the age of 65.

• The consultation rate for non-psychiatric symptoms increased by nearly a half in both older and younger widows. This change in the consultation rate was most pronounced in the subgroup diagnosed " osteoarthritis," which increased by one and a half times after bereavement.

Parkes, 1964

Effects of Bereavement on Physical and mental health – a study of the medical records of widows:

Conclusion

„Grief is a syndrome which commonly causes the

widow to seek help from her general practitioner.

As yet little attention has been paid to it in the medical curriculum.“

Parkes, 1964

Life events andlife stress, 1967

The Social readjustment Rating Scale

Scoring the Life Change Index

„The body is a finely instrument that does not like surprises. Any sudden change stimuli which affectsThe body, or the rreordening of important Routines that tho body become used to, Can couse needless stress, throuwingYour whole physical being into turmoil.

Life Change Units and likelihood of illness in near future:

300+: about 80%150-299: about 50%Less than 150: about 30%

Occupational StressorsSan Fransico Bus Drivers, Heart Attacks and hypertension

Occupational stressors: Bus driving and hypertension

41.5% of the transit workers had hypertension compared to 27.6% for all the 214,413 workers studied.

Stage of Disease Physiology Affective Cognitive

Normotensive/youth (genetic/familial risk)

All normal possible hyper-reactivity to lab stress, Mild elevation in SBP Opioid dysregulation

Anger? Reduced pain sensitivity

Subtle spatial attention, short term memory deficit

Borderline/Pre-hypertensive

BP >119/79 <140/90 with predominance of elevated DBP, sympathetic activation High cardiac output Baroreceptor adjustment; hyper reactivity to lab stress

Interpersonal difficulty Pain insensitivity Less awareness negative affect, positive affect?

 

Early Hypertension(40–60yrs)

BP >140/90 High TPR Salt/diet sensitive Renin/angiotensin Aldosterone Sympathetic Structural/function brain changes Hyperreactivity

Above with transition to greater negative affect with inhibition of the expression of intense angry cognitive and emotive reactions

Mild deficits executive attention, working memory

Late Hypertension(60+ yrs)

Same BP or isolated systolic hypertension? maintenance of altered regulatory system

Continued high negative affect and expression of negative affect?; awareness of BP status may invert relationship

Deficits not as clear relative to age matched; Related to Alzheimer's Disease

Study of the natural history of hypertension. Biological and psychological factors

Jennings and Heim, 2011

Biological, psychological and social factors influence:

• the prevention,• causes, • Presentation, • management • and outcome of the diseases

Stress

Neurocognitive Impairment +

Dopamine dysregulation

Early warning signs

Relapse

Antipsychotic medicationCognitive rehabilitation

PsychoeducationITAREPS

De-stigmatization Family psychoeducation

Social Skills trainingAssisted working

Bio-psycho-social model and schizophrenia management

Family Environment and Schizophrenia outcome„Patients have families“

• Schizophrenogenic mother (Fromm-Reichmann, 1949)

• Family influence is an etiology factor, not a method for recovery (Palo Alto Mental Research Institute, 1950)

• Double bind theory: deviance in communication = schizophrenogenic communication (Bateson, 1956)

Henry Richardson,

1948

Pharmacological revolution in psychiatry:Deinstitutionalization!

Pilgrim State Hospital, USA, 1954: 13 875 patients

Family Environment and Schizophrenia outcome

• Interpersonal atmosphere in a household influences the course of the illness

(Brown, 1966)

• High Expressed Emotions, (HEE) as a trigger of relapse: hostility, emotional over-involvement and critical comments

(Vaughn a Leff, 1976)

Patients at home, relatives need

information

Information

Communication skills

Problem management

Relatives:↓anxiety, expectations, self-blaming

↑communication skills

Patients:↓ anxiety, hopelessness↑ treatment adherence

Environment:↓stress

↓relapse risk

InformationIllness management

Problem management

Family psychoeducation and relapse prevention

Stress and health

Psychology• Anxiety• Anger, rage• Apathy, depression• Cognitive dysfunction

Physiology• ↑ metabolism• ↑ heart rate• ↑ blood pressure• ↑ breathing • ↑ muscle tone• ↑ endorphins and ACTH

Fight of flight

Hans Selye, 1907-1982Canadian physician and medical teacher, born in Austria

General Adaptation Syndrome.

“The absence of stress is death. Only the dead has no stress.“

Posttraumatic Stress Disorder

Burn-out syndrome

• result of long-term occupational stress• long-term exhaustion and diminished interest

in work• about 90% of burned out workers meet

diagnostic criteria for depression, suggesting that burnout may be a depressive syndrome rather than a new or distinct entity

Interventions

Relaxation techniquesPositive psychology

How does it work?

Positive psychological attributes promote health

HopeSelf-efficacyOptimismResiliency

Biological correlates of happiness over the working day. a: mean salivary cortisol averaged during the working day in relation to hapinessb: Mean heart rate averaged during the working day in relation to happiness in men (black bars) and women (hatched bars).

Steptoe et al., 2005

Positive psychology interventions and cardiac health

• Positive psychological attributes--especially optimism--may be independently associated with superior cardiac outcomes.

• Positive attributes appear to be associated with increased participation in cardiac health behaviors (e.g., healthy eating, physical activity) linked to beneficial outcomes;

• Data linking positive psychological states and biomarkers of cardiac health (e.g., inflammatory markers) is mixed but suggests a potential association.

• Positive psychological interventions have consistently been associated with improved well-being and reduced depressive symptoms, though there have been few such studies in the medically ill.

Dubois et al., 2012

Positive psychology interventions

Integrating positive psychology in practice

• Three good things. Every evening, write down three good things that happened that day and think about why they happened.

• Gratitude visit. Write a letter to someone explaining why you feel grateful for something they’ve done or said. Read the letter to the recipient, either in person or over the phone.

• Reverse the focus from negative to positive. Shift attention to more positive aspects of life.

1) take a mental spotlight each night and scan over the events of the day, thinking about what went right.

2) compile “I did it” lists instead of only writing down what needs to be done.

Integrating positive psychology in practice

Develop a language of strength. • Talk or identify more positive qualities and personal strengths.• Just as an athlete exercises certain muscles to become

stronger, the theory is that people who use their strengths regularly will function better in life: identify one top strength and then use it at least once a day.

Build strategies that foster hope. • reduce the scope of the problem by breaking it down into

components that can be tackled one at a time.

5 mm rule

„Turn that frown upside

down“