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Curs Psihosomatica

partea I
Dr Alexandra Mihailescu
Medic specialist psihiatru
Asistent univ. Catedra de Psihologie Medicala
Istoric
Istoric
1. Foarte demult.
Corp____Minte


Spirit
2. Grecia antica
Corp Minte
3. Evul mediu
Corp____Minte


Spirit
4. Vederi contemporane
Corp Minte
Comportament social
Gandirea magica/ supranaturala;
Cauza bolii era:
Vrajitoria
Incalcarea unui taboo social
Posesia supranaturala
Pierderea sufletului
Tratament
Confesiunea
Impacarea cu zeii
Inlaturarea spiritului rau
Trepanatia
Grecii Hippocrates
(460-377 B.C.)
Originea ideii ca boala este un proces
natural
Teoria umorilor
Ideea ca boala apare cand cele 4 fluide ale
corpului sunt in dezechilibru
Cele 4 fluide sunt sangele, bila neagra, bila
galbena si saliva
Tipuri de personalitate
Hippocrates - Tratamente
Temperament Umoarea Boala Tratament
Flegmatic Saliva Raceli,
dureri de
cap
Bai calde,
mancare
calda
Sangvin Sange Angina,
epilepsie
Sangerare
Melancolic Bila
neagra
Ulcere,
hepatita
Bai calde
Coleric Bila
galbena
Stomac,
icter
Sangerare,
dieta lichida
Evolutia ideii de boala
Patologia legata de anatomie
Boala era legata de schimbari anatomice in organe
(sec 18)
Patologia legata de tesut
Tesuturi specifice ale unui organ pot sa fie bolnave, in
timp ce altele sa ramana sanatoase (sf sec 18)
Patologia legata de celule
Viata este originara din celule, deci celulele trebuie
cercetate pentru semnele bolii (sec 19)
Evolutia ideii de boala
Teoria germenilor
Particule nevazute din aer (bacterii) pot cauza boala.
Pilula magica
Un medicament specific poate fi gasit pentru fiecare
boala care sa readuca persoana la starea de sanatate.
Modelul Biopsihosocial
Minte, Corp, si mediu interactioneaya in determinarea
bolii.
Istoric
1. Foarte demult.
Corp____Minte


Spirit
2. Grecia antica
Corp Minte
3. Evul mediu
Corp____Minte


Spirit
4. Vederi contemporane
Corp Minte
Comportament social
Medicina Psihosomatica
Freud (1856-1939)

Cannon (1932)

Dunbar (1930)

Alexander (1940s 1950s)
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cauza organica cauza neexplicata
Incidenta pe 3 ani a celor mai frecevente simptome
in practica medicului generalist
Modelul biopsihosocial al bolii
Biologie
Variabilitate genetica
Anatomie
Fiziologie
Patogeni
Germeni
Toxine
Factori de risc comportamentali
Dieta
Exercitiu fizic
Fumat
Sex protejat
Purtarea centurii de siguranta
Social
Familia
Societatea
Prieteni, etc.
Modelul Biopsihosocial
Componenta psihologica
Comportament (adoptare si mentinere)
Emotii (sentimente)
Cognitii (ganduri, credinte, si atitudiini)
Personalitate moduri caracteristice de a
gandi si de a simti
Elemente de definiie ale concepiei
psihosomatice (Iamandescu 1999)
Concepie holistic (integrativ) - unitatea dintre SOMA i
PSIHIC, modulat sociocultural
modelul bio-psiho-social (Engel)
Bazat pe observaii clinice (continuate de cercetri
epidemiologice), rezultate experimentale psiho-fiziologice,
neuro-endocrinologice i imunologice, etc.
Includerea influenei mediului social asupra bolii (mediat prin
psihicul bolnavului) (Von Uexkuell, def. BPS)
Reliefarea, la bolnavii psihosomatici, a unei duble vulnerabiliti
la stres: psihic i de organ
Impunerea stresului psihic ca factor de risc major n
patogenez i, adesea, sumativ cu ali factori organo-specifici"
Includerea stilului de via, ca factor cu posibil implicare
etiopatogenic.
Utilizarea psihoterapiei i, facultativ, a medicaiei psihotrope
(ca adjuvant)

Concepia psihosomatic are drept corespondent n practica medical o atitudine teoretici terapeutic de
considerare global a bolnavului, nu numai din punct de vedere somatic, psihic i social (Buddeberg i
colab.). Susinem astfel definirea Psihosomaticii de ctre Buddeberg i colab. ca pe o disciplin tiinific ce are
ca obiect studierea relaiilor ce exist ntre factorii biologici, psihologici i sociali care intervin n explicarea
sntii i bolii, avnd drept corolar diagnostic i terapeutic, acea abordare holistic (global) a bolnavului, mai
sus menionat. n interiorul acestei sfere se cuprind n mod consistent tulburrile psihosomatice (TPS) i bolile
psihosomatice (BPS) dar i o parte component mai mic sau mai mare din celelalte boli fr participare
etiologic major a stresului psihic dar care creeaz premisele unui stres psihic secundar, adeseori mai important
dect boala propriu-zis (de exemplu, tulburrile psihice la bolnavii SIDA, sau problemele generate de o fractur
imobilizat ntr-un aparat gipsat). De fapt, cea mai mare parte a psihosomaticii actuale este concentrat n vastul
capitol al problemelor psihologice ale evoluiei bolilor severe ca i ale recuperrii bolnavilor cronici. Participarea
factorilor psiho-sociali n etiopatogenia multifactorial a BPS nu exclude interaciunea lor cu factorii de risc i
organospecifici, interesul nostru pentru factorii psihologici fiind bine asemnat, de ctre Fritzsche, cu jocul
actorilor aflai episodic n prim plan dar a cror participare la aciunea piesei este strns legat de cea a celorlali
participani rmai n umbr.
Psihosomatica general se ocupa n special cu concepia psihosomatic i termenii ei fundamentali (tulburrile
psihosomatice, somatoforme, somatopsihice i bolile psihosomatice), precum i cu interrelaiile acestora n
dinamica i interaciunea lor cu factorii etiologici multipli ai bolilor somatice.
n cadrul Psihosomaticii generale trebuie studiate, de asemenea, modalitile generale de abordare
psihosomatic a tuturor bolnavilor, dar mai ales a celor psihosomatici, conform cu problemele psiho-sociale ale
acestora. Corolarul acestor demersuri diagnostice l constituie stabilirea unor principii de terapie pentru
bolnavii psihosomatici, incluznd - alturi de tratamentul bolii de baz i de medicaia psihotrop
adjuvant, i terapia psihologic, ncepnd cu psihoterapia suportiv (acordat de ctre medicii nepsihiatri, de
la medicii de familie, pn la chirurgi) i culminnd, cu forme de psihoterapie special (aplicat de psihologi i
psihiatri).
n schimb, psihosomatica aplicat reprezint o abordare prin prisma concepiei psihosomatice a unor grupe
de boli psihosomatice aparinnd diferitelor specialiti. Reprezinta o aplicare a concepiei psihosomatice la o
serie de specialiti medicale i chirurgicale (tabelul 3) unificat prin ponderea major a factorului psihosocial,
fie n etiopatogenia lor, fie n consecinele negative ale acestor boli asupra psihicului bolnavilor afectai prin recul
somatopsihic, manifestat, n special, prin alterarea calitiii vieii (QOL).
Psiho-neuroimunologia (R. Ader-1981), Psihodermatologia (Koblenyer-1992 i Panconesi 2002), Psiho-oncologia,
Psihosomatica ginecologic, Psihoneuroalergologia (Iamandescu 1998), Neuro-gastro-enterologia (Dumitracu i
Nedelcu)i Psihoreumatologia. De asemenea exist o arie de patologie cu sindroame pluriorganice precum
tulburrile somatoforme (revendicat n egal msur de psihiatri i psihologi) i o serie de boli, nc discutabile
sub raport etiopatogenetic dar cu o participare important a factorului psihologic precum fibromialgia i sindromul
oboselii cronice. De asemenea, fr a li se desemna inc un nume specific, o serie de alte specialiti medicale,
ca de exemplu bolile infecioase, cuprind n domeniul lor o serie de boli psihosomatice importante precum
tuberculoza sau chiar SIDA (cu referire la impactul somato-psihic al bolii).
Un loc important l ocup cercetarea tiinific a interrelaiilor ntre psihic i corp axat, n special, pe
psihofiziologia neuro-endocrino-imunologic i pe utilizarea metodelor specifice epidemiologiei, psihologiei clinice,
sociologiei i altor tiine asociate.
Modalitile abordrii psihosomatice a
bolnavilor
1. Colaborarea n echip (psiholog i psihiatru) sau abordarea holistic de ctre medicul
specializat n Psihosomatic;
2. Importana factorului psihologic ca parte a etiologiei multiple = Identificarea tuturor
triggerilor ai simptomelor alergice i izolarea factorului declanator psihologic;
3. Relevarea trsturilor de personalitate i biografici ai bolnavului, stabilind o relaie
terapeutic optim;
4. Informarea despre cauza, efecte, durata i evoluia bolii;
5. Evaluarea calitii vieii (QOL);
6. Compliana terapeutic versus
medicaie
stil de via nou
7. Consilierea
comportamental (factorii de risc)
viaa social, familial i profesional
8. Psihoterapia suportiv sau special, aplicat de specialiti diferii i/sau medicaia
psihotrop
9. Educarea pacientului - asigur o complian terapeutic bun.
Contributii importante ale
psihologiei pentru pastrarea starii
de sanatate a individului
A creat tehnici folositoare pentru a schimba
comportamentele care determina sanatatea si
boala.
Mentine individul sanatos mai curand decat sa
astepte sa-l trateze doar cand este bolnav.
Istoric lung de dezvoltarea a unor masuri
sigure si valide pentru a evalua factorii legati
de sanatate.
A contribuit la o fundamentare solida a
metodelor stiintifice pentru studierea acestor
comportamente.

Stress and the cardiovascular system
The incidence of major depression is ~20% after MI;
cardiovascular mortality is tripled in this group (15%)
compared to nondepressed patients (5%) in the next 6 months.
Risk equals that of poor left ventricular function.

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Is it magic? The mind-body connection
Autonomic nervous system

Sympathetic innervation (red)
Parasympathetic (blue)

Regulates physiology to
prepare for short-term vs. long-
term projects
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Total
volume
(x1000
ml/min)
Brain Heart Muscle Skin Kidney Viscera
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At rest Sympathetic activation
Blood flow changes with sympathetic activation
Is it magic? The mind-body connection
CRH
ACTH
cortisol
Short-term effect of cortisol
Glucose release from liver and
muscles

Long-term effects
Immune changes
Loss of muscle and bone mass
Loss of insulin sensitivity
Hippocampus neuronal death
Stress
Sympathetic activation
Cortisol release
among others
Hypertension
Immunosuppression
Insulin resistance
among others
Clinical health
ACE INHIBITORS
BETA-BLOCKERS
STRESS MANAGEMENT
Relieving stress: Relaxation techniques
Forms of relaxation practice include progressive muscle
relaxation, autogenic relaxation, stretch-based relaxation, the
relaxation response, meditation, some kinds of yoga and other
exercises coming from Eastern traditions (e.g., tai chi)

Relaxation is often used in treatments for anxiety as a way for
patients to control sympathetic activation and to provide a
coping strategy

Biofeedback involves direct visual or aural feedback regarding
physiological states and can target muscle tension, skin
temperature, or vasoconstriction (e.g., of the temporal artery)
Relieving stress: Relaxation techniques
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Pre Post 4 weeks 6 months
Relaxation effectively treated generalized anxiety disorder
in 45 patients. 44% achieved recovery levels of trait anxiety
post-treatment, 50% at 4 weeks post-treatment, and 53% at 6
months post-treatment
Relieving stress: Exercise
Typical prescription in most studies is 20-30 minutes of exercise,
usually aerobic, 3-4 times weekly

Physiological effects of exercise are diverse and include
improvement in cardiac function and insulin sensitivity

Psychological effects of exercise are potentially robust and include
decreases in stress and depression (mean 7 points on the Beck
Depression Inventory)

Potential biological mechanisms for psychological effects include
increased endorphins and NE in the brain (NE is also increased by
tricyclic antidepressants such as amitryptaline); potential social
effects include increased social contact in exercise groups
Relieving stress: Exercise
Exercise was equally effective as SSRI medication (sertraline)
in alleviating depression in 156 adults > 50 years old with major
depressive disorder after 16 weeks of treatment, although
medication had a somewhat larger response in the first 8 weeks
Relieving stress: Cognitive-behavioral therapy
Stress management therapies usually have several targets
of action within the biopsychosocial model

Social: Provide social support from group therapies;
maximize support from existing social networks; teach
assertion as a coping skill to resolve conflict

Psycho: Teach adaptive interpretation of stressful events
challenge rather than threat; encourage active engagement
rather than passive avoidance

Bio: Teach relaxation, self-hypnosis, healthy behavior
Relieving stress: Cognitive-behavioral therapy
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Depression (control) Anxiety (control)
Depression (CBSM) Anxiety (CBSM)
Stress management decreased depressive and anxious
responses to positive HIV serostatus notification in 47 gay
men who attended group sessions twice weekly for 5 weeks
before blood draw, while waiting for notification, and 5 weeks
afterward. Change is from 1 week before to 1 after notification.
Evidence: Benign headache
Relaxation training (such as progressive muscle relaxation),
EMG biofeedback from frontal or forehead sites, and thermal
biofeedback are now well accepted in the larger headache
treatment community . . . They are a typical part of the
armamentarium of comprehensive headache centers or clinics
. . . These treatments are clearly superior to headache
monitoring while on a waiting list.

Progressive muscle relaxation or EMG biofeedback are
typically attempted first for tension headache because they
focus on muscle tension, whereas autogenic relaxation or
thermal biofeedback are typically attempted first for migraine
headache because they focus on vasodilation.
Issues with the Evidence: Benign headache
The placebo effect may be responsible for some of the effects;
similarly, the gain in coping efficacy may be responsible.
Several treatments, however, have been shown to be more
effective than placebo.

Combination treatments may be more effective than pure
treatments. Relaxation, biofeedback, and cognitive therapy
can be combined in any configuration.

In trials that compared behavioral treatments with medications
(propanolol, diazepam, amitryptaline), behavioral treatments
seem generally as effective as medications.
Evidence: Hypertension
Blood pressure (SBP or DBP) biofeedback, thermal
biofeedback, stress management, meditation, various forms of
relaxation, and autogenic training have all been used in
controlled trials to decrease blood pressure. Single component
interventions show little effect, but combination therapies on
average decrease SBP 13.5 mm Hg, and DBP 3.4 mm Hg.
As with headache treatments, relaxation, biofeedback, and
cognitive-behavioral approaches are combined.

Other behavioral remedies include exercise, which is effective
at reducing blood pressure mostly to the extent that it reduces
weight. Weight loss of 15-20 pounds typically reduces SBP
by 6-10 mm Hg and DBP by 3-7 mm Hg.
Issues with the Evidence: Hypertension
Even small reductions in blood pressure may have large
clinical effects. Reduction in DBP of 5-6 mm Hg resulted in
42% decrease in stroke, 14% decrease in heart disease, and
21% decrease in vascular mortality in drug trials; mean
reduction of only 2 mm Hg lowers stroke risk by 15% and
heart disease risk by 6%.

Behavioral interventions may reduce or eliminate the need
for drug therapy in some patients.

There are few randomized, controlled trials in this area, and
more methodologically rigorous research is needed.
Evidence and Issues: Immune function
If stress suppresses immunity, can interventions improve it?

Stress management in general has no effect, but very few
studies actually enrolled stressed populations. Those studies
found increases in immune cell functions and helper T cell
counts.

Relaxation has few effects on the immune system, but it does
reliably increase salivary IgA. Again, very few studies
actually enrolled stressed populations.

Hypnotic suggestion to increase or decrease immune
reactions is effective only for decreases and only for
suggestible people.
Evidence: Chronic disease
Several studies with HIV and cancer suggest that stress
management interventions may benefit physiological
functioning and prolong life:

Cognitive-behavioral stress management
Michael Antoni and colleagues, University of Miami
HIV
Breast cancer

Cognitive-behavioral therapy
Fawzy Fawzy and colleagues, UCLA
Malignant melanoma
CBSM with HIV:
Effects on immunity
In addition to buffering the
psychological impact of
HIV notification, CBSM
buffered negative
immunological changes;
these changes may be
prognostic in HIV.
CBSM with Breast
Cancer: Effects on
cortisol
CBSM reduced serum
cortisol; this changes may
be prognostic in cancer, as
dysregulated cortisol
predicts breast cancer
survival.

This effect was most
pronounced in women who
found some benefit in their
cancer experience during
the group.
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CBSM Control
Baseline Post
CBT with Malignant
Melanoma: Effects
on recurrence and
survival
CBT reduced rates of
cancer recurrence and
death 5-6 years after
participating in a 6-week
structured intervention.

This effect was most
pronounced in people who
increased the amount of
active coping with cancer
stresses.
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CBT Control
Recurrence
Cancer death

Personality and Hypertension,
The effect of Hypertension Awareness
(Irvine et al. 1989)
Hypertension Study
Personality
Study
2nd BP
Screen
Matched
Normotensive
Mean DBP>= 90 mmHg
Hypertensive
5th BP Screen
5 months
4th BP Screen
4 months
DBP < 105
3rd BP Screen
3 months
Personality
Study
2nd BP Screen
2-3 weeks later
DBP >= 90 but
< 115 mmHg
1st BP Screen
Personality and Hypertension:
Effect of Hypertension
Awareness
Variable Group 1
Aware
Hyper-
tensive
Group 2

Normo-
tensive
Group 3
Unaware
Hyper-
tensive
Group 4

Normo-
tensive
% Male 75 75 89 89
Age
Mean*
(SD)

46.2
(9.2)

46.2
(8.2)

46.4
(8.3)

45.8
(8.0)
SBP/DB
P
Mean*
(SD)
135.1/
93.9
(9.2/5.1)
118.7/
76.3
(11.5/5.5)
135.8/
93.8
(8.2/3.4)
118.5/
75.7
(10.3/4.8)
Personality and Hypertension:
Effect of Hypertension
Awareness
Variable Group 1
Aware
Hyper-
tensive
Group 2

Normo-
tensive
Group 3
Unaware
Hyper-
tensive
Group 4

Normo-
tensive
Neuro-
ticism
Mean*
(SD)

12.0
(5.3)

9.3
(5.3)

9.7
(4.8)

9.5
(4.6)
Type A
Mean*
(SD)

0.79
(8.5)

-3.0
(9.4)

-2.0
(9.4)

-2.6
(8.2)
* Group 1 > Group 2 & Group 3 (p < 0.01)
Personality and Hypertension:
Effect of Hypertension Awareness
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Neuroticism
Aware Hyper
Normot
Unaware Hyper
Normot
Aware hypertensive > normotensive & unaware hypertensive,
P < 0.001
Personality and Hypertension:
Conclusion
Do hypertensives have a different
personality than those with normal blood
pressure?
No, because the unaware hypertensives did
not differ from the normotensives.
Why did the aware and unaware
hypertensives differ?
Possible explanations?
Personality and Hypertension:
Conclusion
Awareness of hypertension status
confounds assessment of the
association between personality
characteristics and hypertension.

Due to hypertension labeling effect; or
Due to self-selection bias
Longitudinal Design
To gather data on the course of health or
disease over time (e.g., progression of
multiple sclerosis).
Advantage is that you can see the time
course of the disease or behaviour (e.g.,
smoking cessation over time).
Disadvantage is it is costly and still subject to
bias
Experimental Designs
Examines differences between
experimentally manipulated groups (e.g.,
one group gets a certain drug and the
other gets a placebo).
Advantage is that you can determine
causality.
Disadvantage is cost and many variables
cannot be experimentally manipulated (e.g.,
smoke exposure over time).