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Psychosomatic Medicine
Aws Khasawneh, MD.
Overview:
* Psychosomatic medicine is an area of scientific
investigation concerned with the relation between
psychological factors and physiological phenomena
in general and disease pathogenesis in particular.
* Integrates mind and body into a psychobiological
unit; to study psychological and biological
processes as dynamic interacting systems.
* It emphasizes the unity of mind and body and the
interaction between them.
* A holistic approach to medicine.
Stress theory: Definitions
Stress: a state of disturbed equilibrium
Stressor: the life events that do the disturbance
Stress response: the physiological and
psychological responses that seek to diminish the
impact of stressor and restore equilibrium/
homeostasis.
Types of Stressors
Environmental
 Physiological
 Emotional
(psycho-social)

Measuring Stress

Stress can be measured in three
different ways:
◦ Paper-and-pencil scales
◦ Interviews
◦ Physiological measurements
Social Readjustment Rating Scale
(SRRS)

The Social Readjustment Rating Scale
(SRRS) was developed in 1967 by
Thomas Holmes and Richard Rahe.

In many ways, their work was
influenced by earlier work by Adolph
Meyer.
Adolph Meyer
(1866-1950)

In the 1930s, Meyer proposed
that life events were related to
health
◦ These events need not be negative,
bizarre, or catastrophic; they must
simply be interpreted as important
life changes, requiring some degree
of coping
 e.g., marriage, moving to new city,
changing jobs, death in family
◦ Although he noted the effects these
life changes had on patients with
diseases, he did not document his
findings with empirical research

Thomas Holmes and Richard Rahe
constructed a social readjustment rating
scale and asked hundreds of people to
rank the relative degree of adjustment
required by changing life events.

Holmes and Rahe listed 43 life events
associated with varying amounts of
disruption and stress in average
people’s lives





Events with high scores require people to
make the most social readjustment in their
lives.
The need for social readjustment is directly
correlated with increased risk of medical and
psychiatric illness.
Score of 300+( in a given year): At high risk of
illness.80%
Score of 150-299: Risk of illness is moderate
(reduced by 30% from the above risk).
Score <150: Only have a slight risk of illness.
Life Change Units and Disease
90
%
80
d
i
s
e
a
s
e
i
n
70
y
e
a
r
s
60
50
40
30
20
10
2
0
0
100
200
Life Change Units
people with disease
Holmes and Rahe 1967
300
RESPONSE TO STRESS
The response to any stressor by individual
is buffered by:
1. the accuracy of the appraisal
2. adequacy of resources and social support
3. maturity of coping behavior
THE STRESS MODEL
Two major facets of stress response.
1-“Fight or Flight” response is mediated by
hypothalamus, the sympathetic nervous
system, and the adrenal medulla.
If chronic, this response can have serious health
consequences.
2-The hypothalamus, pituitary gland, the adrenal cortex
mediate the second facet.
15
Comer, Abnormal Psychology, 7e
Neurotransmitter Responses to
Stress
-Stressors activate noradrenergic systems
in the brain and cause release of
catecholamines from the autonomic nervous
system.
-Stressors also activate serotonergic
systems in the brain, as evidenced by
increased serotonin turnover.
-Stress also increases dopaminergic
neurotransmission in mesoprefrontal
pathways.
Endocrine Responses to Stress
CRF is secreted from the hypothalamus.
CRF acts at the anterior pituitary to trigger
release of ACTH.
ACTH acts at the adrenal cortex to stimulate the
synthesis and release of glucocorticoids.
Promote energy use, increase cardiovascular
activity, and inhibit functions such as growth,
reproduction, and immunity.
Immune Response to Stress
Inhibition of immune functioning by glucocorticoids.
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 IL6.
These cytokines can themselves cause further release of
CRF, which in theory serves to increase glucocorticoid
effects and thereby self-limit the immune activation.
High level of Cortisol results in suppression of immunity
which can cause susceptibility to infections and possibly
also in many types of cancer.
Changes in the immune system in response to stress
are now very well established.
Psychological factors adversely affect the
general medical condition in one of the
following ways:
(1)
Ex:
the factors have influenced the course of the
general medical condition as shown by a close
temporal association between the psychological
factors and the development or exacerbation of,
or delayed recovery from, the general medical
condition.
Psychological symptoms affecting medical condition (e.g., depressive
symptoms delaying recovery from surgery; anxiety exacerbating
asthma). : Maladaptive Personality traits or coping style e.g.
hostile, pressured behavior contributing to cardiovascular
disease, type A personality)
(2) the factors interfere with the treatment of the
general medical condition.
Ex: pathological denial of the need for surgery in a patient with
cancer,
(3) the factors constitute additional health risks for the
individual.
Ex: Maladaptive health behaviors:
1.
2.
3.
4.
5.
6.
Tobacco
Poor diet/ lack of exercise
Excess Alcohol
Risky Sexual Behavior
Homicides & Physical Abuse
Unintentional Injuries
(4) stress-related physiological responses precipitate
or exacerbate symptoms of a general medical
condition.
Ex: stress-related exacerbations of ulcer, hypertension,
arrhythmia, or tension headache
Other relationships


Medical conditions that can present with
psychiatric symptoms. Ex: neurological
illnesses , neoplasm, endocrine disturbances
and viral illnesses can present with depression
Psychotropic and non-psychotropic
medications can produce psychiatric
symptoms. Ex: antihistamine, steroids,
antiparkinson, antihypertensive ,
analgesics…etc
Psychological stress in hospitalized
patients

Psychological problems are common among
hospitalized patients.

Usually these problems have a negative
impact on the patient’s physical problem

Treating physician should manage to handle
these problem utilizing the social support
system, and psychotropic medications.

In sever psychiatric problem CL
Psychiatrists have to be involved in
management.
Examples of psychiatric problems in
hospitalized patients:


Delirium: disorientation, anxiety , sleep
disturbance, psychotic symptoms. Elderly
patient are at grater risk, patients undergo
cardiac or orthopedic surgery, those being
treated in ICU or CCU. And renal dialysis
patients.
Surgical patients: those who believe that they
won’t survive surgery and those who do not
admit that they are worried before surgery,
are at greatest psychological and medical risk
Patients with chronic pain
Chronic pain: pain lasting at least 6
months.
 It’s associated with physical factors,
psychological factors or both.
 Psychological factors such as
depression, anxiety, physical and sexual
abuse can decrease tolerance to pain/
decrease pain threshold.
 Chronic pain results in depression.

Treating pain



Analgesics: specially in pain induced by
physical illness, patient controlled analgesia,
nerve block procedures.
Antidepressants: TCA, SSRI, specially in
patient with arthritis, facial pain and headache.
Mechanism 1-direct stimulation of inhibitory
pain pathway 2- indirect by improving
depression symptoms.
Behavioral, cognitive psychotherapy:
biofeedback, hypnosis, meditation and
relaxation training
Psychological stressors in AIDS
patients
Having a fatal illness
 Guilt feelings about how they got infected
(multiple sex partners, IV drug use)
 Guilt feelings about possibly infecting other.
 Being met with fear of contagion from medical
staff, family and friends.
 Homosexual patients may compelled to come
out to others.
 Depression is the most common psychiatric
diagnosis in HIV +ve patients.
