+

Psychosomati
c Medicine

Michelle Marie M. Marinas,

M.D.
Department of Psychiatry
DLSHSI – College of Medicine
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Psychological Factors Affecting
Medical Condition
 Two Basic Assumptions of Psychosomatic
Medicine:
1. There is unity of mind and body (mind-body
medicine)
2. Psychological factors must be taken into
account when considering all disease states

 In DSM-IV-TR
 Psychological Factors Affecting Medical
Conditions
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Psychological Factors affecting
Medical Condition
 Physical disorders caused by emotional or
psychological factors

 Mental or emotional disorders caused of aggravated by

physical illness

Exclusions:
1. Classic mental d/o’s that have physical symptoms as
part of the disorder (eg., Conversion Disorder)
2. Somatization disorder
3. Hypochondriasis
4. Physical complaints associated with mental d/o’s
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DSM-IV-TR Diagnostic Criteria

A. A GMC (coded on Axis III) is present

B. Psychological Factors adversely affect the
GMC:
1. Factors have influenced the course of the
GMC as shown by temporal association
between psychological factors and
development or exacerbation of, or
delayed recovery from, the GMC
2. Factors interfere with treatment of GMC
3. Factors constitute additional health risks
for the individual
4. Stress-related physiological responses
precipitate or exacerbate symptoms of
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If more than one factor is
present, choose the most
prominent…
Mental Disorder affecting GMC
 Psychological symptoms affecting GMC
 Personality traits or coping style affecting
GMC
 Maladaptive health behaviors affecting GMC
 Stress-related physiological response affecting
GMC
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STRESS THEORY
 A circumstance that disturbs, or is likely to disturb,
the normal physiological or psychological
functioning of a person.
 Walter Cannon: first systematic study on the
relation of stress to disease
 Harold Wolff: physiology of GI tract correlate with
emotional states
 Hans Selye: General adaptation syndrome (3
phases)
 Alarm reaction
 Stage of resistance
 Stage of exhaustion
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Stress
 Neurotransmitter Responses to Stress
 Activate noradrenergic systems in the brain (locus
ceruleus) release catecholamines from ANS
 Activate serotonergic systems increased serotonin
turnover

 Endocrine Responses to Stress

Corticotropin Releasing Factor (CRF)

Acts at anterior pituitary

Release of ACTH

Synthesis and release of glucocorticoids (fight or flight)
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Stress
 Immune Response to Stress
 Inhibition of immune functioning by
glucocorticoids
 Also, immune activation by other pathways
 Also, profound immune activation by release of
cytokines, which increase glucocorticoid effects
 Life Events
 Life situation or event, favorable or unfavorable,
often occurring by chance, generates challenges
to which the person must adequately respond
 Holmes and Rahe Social Readjustment Scale:
 200 or more life-change units increases risk
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Stress
 Specific vs. Nonspecific Stress Factors
 Specific personalities and conflicts – certain
psychosomatic diseases
 Meyer Friedman and Ray Rosenman – personality
types
 Type A – coronary personality
 Type B
 Franz Alexander- unconscious conflicts and
specific diseases
 Peptic ulcer – dependency needs
 Essential HPN – hostile impulses from which
they feel guilty
 Asthma – separation anxiety
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SPECIFIC ORGAN SYSTEMS
Gastrointestinal System
 Functional GI Disorders
 Anxiety can produce disturbances in GI function
through central control mechanism or humoral effects
(release of catecholamines)
 Vagus modulated by limbic system (emotions-gut
pathway)
 Functional dysphagia, IBS, functional diarrhea

 Peptic Ulcer Disease

 Increased gastric acid secretion associated with
psychological stress
 Higher vulnerability to H. pylori

 Ulcerative Colitis
 No generalizations about psychological mechanisms
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Cardiovascular System
 Associated with depression
 Severe depression after CABG – increased risk of
death
 Type A behavior pattern, anger, hostility
 Physiologic processes: reduced parasympathetic
modulation of HR, increased circulation of
catecholamines, increased coronary calcification,
increased lipid levels
 Stress Management
 Cardiac arrhythmias and sudden cardiac death
 Acute emotions can stimulate arrythmias
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 Heart Transplantation
 Stages of adaptation elicit anxiety,
depression, etc.
 Mood disorders

 Hypertension

 Vasovagal syncope
 Specific psychological triggers still
unidentified
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Respiratory System
 Asthma
 Dependency needs
 Greater use of corticosteroids, longer
hospitalizations
 Personality traits: intense fear, emotional
lability, sensitivity to rejection, lack of
persistence in difficult situations
 Hyperventilation syndrome

 Chronic Obstructive Pulmonary Disease (COPD)

 Panic and anxiety disorders are co-morbidities
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Endocrine System
 Hyperthyroidism
 Nervousness, insomnia, lability of mood,
dysphoria
 Pressured speech
 Short attention span, impaired recent memory,
exaggerated startle response
 Visual hallucinations, paranoid ideation, delirium

 Hypothyroidism
 Depressed mood, apathy, impaired memory
 Auditory hallucinations and paranoia (myxedema
madness)
 Diabetes mellitus
 Dietary control - depression
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Adrenal Disorders
 Cushing’s Syndrome
 Adrenocortical hyperfunction from excessive
secretion of ACTH or adrenal pathology (tumor)
 Severe depression to elation

 Clinical features of Cushing’s

 Hypercortisolism
 Fatigue, depressed mood

 Emotional lability, irritability, decreased libido,

anxiety
 Social withdrawal

 Hyperprolactinemia
 Traumatic childhood experiences predispose to
hyperprolactinemia
 Sexual dysfunctions: erectile disorder and
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Skin Disorders
 Atopic dermatitis (atopic eczema or neurodermatitis)
 Anxiety, depression

 Exacerbate atopic dermatitis by scratching behavior

 Depressive symptoms amplified itching behavior

 Psoriasis
 Lead to stress, which triggers psoriasis

 Cosmetic disfigurement and social stigma

 Psychogenic excoriation (psychogenic pruritus)

 Lesions caused by scratching or picking in response
to an itch
 Resembles OCD: impulsive, ritualistic, repetitive,
tension reducing
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 Localized pruritus
 Pruritus ani
 Pruritus vulvae

 Hyperhidrosis
 States of fear, rage and tension
 Increased sweat secretion on the palms, soles
and axillae
 Anxiety phenomenon mediated by the ANS

 Urticaria
 Stressful life events and urticaria
 Stress – secretion of neuropeptides - vasodilation
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Musculoskeletal system
 Co-morbid psychiatric symptoms may be
 result of patient’s psychological response to the
loss and discomfort imposed by the disease
 effect of disease process on CNS

 Rheumatoid Arthritis – chronic musculoskeletal

pain from inflammation of the joints
 depression

 Systemic Lupus Erythematosus

 Recurrent episodes of destructive inflammation
of several organs
 Highly unpredictable, incapacitating, potentially
disfiguring
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 Low back pain

 Excruciating pain, restricted movement, paresthesias,
weakness or numbness
 Accompanied by fear, panic and anxiety
 Oftentimes debilitating

 Fibromyalgia
 Pain and stiffness of the soft tissues such as muscles,
ligaments and tendons
 “trigger points”: local areas of tenderness
 Cervical and thoracic areas most commonly affected
 Fatigue, anxiety, insomnia
 Present in chronic fatigue syndrome and depressive d/o
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Headaches
 Psychological stress exacerbates headache,
whether primary cause is physical or psychological
 Migraine (Vascular) and Cluster Headaches
 Functional disturbance in cranial circulation
 Stress is al precipitant at times
 Overly controlled perfectionists, unable to
suppress anger
 Tension (Muscle Contraction) Headaches
 Emotional stress  prolonged contraction of
head and neck muscles  constrict blood
vessels
 Dull, aching pain, tightening band
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Treatment
 Good MD-patient relationship
 Aaron Lazare’s Negotiating Strategies:
1. Direct education
2. Third party intervention
3. Exploration of options
4. Provision of sample treatment
5. Control sharing
6. Concession making
7. Empathic confrontation –”what would you do if
you were in my place?”
8. Standard setting
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Stress management and
relaxation therapy
 Stress management training
1. Self-observation
• Daily diary format

• How they respond to stress/ challenges each day

• Stressful events that precipitate signs/ symptoms

2. Cognitive restructuring
• awareness of maladaptive thoughts, beliefs and
expectations
3. Relaxation training – hypnosis, biofeedback

4. Time management
5. Problem-solving
• Applying solutions to problem situations
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Consultation-Liaison Psychiatry
 Study, practice and teaching of the relation between
medical and psychiatric disorders

 Psychiatrists serve as consultants to colleagues or

other mental health professionals

 CL psychiatrists are part of the medical team

 Knowledge of psychiatric diagnosis + awareness of

medical illnesses with psychiatric symptoms

 Purpose of the diagnosis:

 Identify mental disorders and psychological responses to
physical illness
 Patient’s personality features
 Patient’s coping techniques
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Common CL problems
 Suicide attempt or threat

 Depression

 Agitation

 Hallucinations

 Sleep Disorder

 Confusion

 Noncompliance or Refusal to Consent to Procedure

 No organic basis for symptoms

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CL Psychiatry in special
situations
 Intensive Care Units

 Hemodialysis Units

 Surgical Units

 Transplantation Issues

 PSYCHO-ONCOLOGY
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Medical Conditions that present
with psychiatric symptoms
 Hyperthyroidism – irritability, pressured speech,
psychosis

 Hypothyroidism - depression

 Hypoglycemia – anxiety, confusion, agitation

 Hyperglycemia – anxiety, agitation, delirium

 Brain neoplasms – personality changes

 Frontal lobe tumor – mood changes, impaired judgment

 Occipital lobe tumor – aura, visual hallucinations

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 Temporal lobe tumor – olfactory hallucinations

 AIDS – progressive dementia, depression, psychosis

 Hyponatremia – confusion, lethargy, personality

changes

 Pancreatic Ca – depression, lethargy, anhedonia

 Multiple sclerosis – anxiety, euphoria, mania

 Hepatic encephalopathy – euphoria, disinhibition,

psychosis, depression

 Pheochromocytoma – anxiety

 Wilson’s disease – mood disturbances, delusions,

hallucinations
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Mental Disorders due to a GMC
 Delirium
 Short-term confusion and changes in cognition
 Four sub-categories: GMC, substance-induced, multiple
causes, NOS

 Dementia
 Impairment in memory, judgment, orientation and
cognition

 Amnestic Disorder
 Memory impairment or forgetfulness
 3 sub-categories:
 caused by medical condition (hypoxia)
 Caused by toxin or medication
 NOS
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Delirium
 Acute onset of fluctuating cognitive impairment and a
disturbance of consciousness

 Syndrome, not a disease, many causes

 Hallmark symptom: impairment of consciousness, in

association with global impairments of cognitive
functioning

 Sudden onset, brief and fluctuating course, rapid

improvement when causative factor is identified

 10-30% of medically ill exhibit delirium

 Poor prognostic sign – high mortality rate for patients

who exhibit delirium while in the hospital
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DSM-IV-TR diagnostic criteria
 Delirium due to a GMC

 Substance Intoxication Delirium

 Substance Withdrawal Delirium

 Delirium NOS
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Core features of Delirium
 Altered consciousness – decreased level

 Altered attention – diminished ability to focus, sustain

or shift attention

 Impairment in cognitive function – disorientation and

decreased memory

 Relatively rapid onset – hours to days

 Brief duration – days to weeks

 Marked, unpredictable fluctuations in severity

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Course and Prognosis
 Recede over 3-7 days after removal of causative factor

 Some symptoms may take up to two weeks

 Recall of the patient is characteristically spotty (“bad

dream”)

 Associated with high mortality rate due to the serious

nature of associated medical conditions
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Dementia

 Progressive impairment of cognitive functions occurring

in clear consciousness

 Global impairment of intellect

 Other mental functions can be affected: mood,

personality, judgment, social behavior

 Decline in functioning

 5% prevalence in general population

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Dementia
 Dementia of the Alzheimer’s type
 Diagnosed when other causes have been
excluded
 Hallmark: amyloid deposits
 Classic pathognomonic microscopic findings:
neurofibrillary tangles, senile plaques, neuronal
loss, synaptic loss
 Hypoactivity of acetylcholine and norepinephrine
 Parietal-temporal distribution

 Vascular Dementia
 Multi-infarct dementia
 Pre-existing hypertension or cardiovascular risk
factors
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Dementia
 Pick’s Disease
 Fronto-temporal atrophy
 Pick’s bodies in post-mortem specimens
 Behavioral and personality changes early on
 Otherwise, similar to Alzheimer’s

 Lewy Body Disease

 Similar to Alzheimer’s, with hallucinations, parkinsonian
features and EPS

 Huntington’s Disease

 Parkinson’s Disease

 HIV-related Dementia

 Head trauma related dementia – punch-drunk syndrome (in

boxers)
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Psychiatric and Neurological
Changes
 Personality

 Hallucinations and Delusions

 Mood

 Cognitive Change

 Catastrophic reaction

 Sundowner syndrome – drowsiness, confusion, ataxia,

accidental falls
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Mental Disorders Due to a GMC

 Mood Disorder due to GMC

 Secondary mood disorders
 Prominent mood alteration due to direct physiological effect
of a specific medical illness or agent
 Affect both sexes equally
 Psychological symptoms and somatic symptoms
 Specifiers: with depressive features, with major depressive-
like episode, with manic features, with mixed features
 Eg., Depression secondary to hypothyroidism
 Treatment: treat underlying medical disorder;
antidepressant/ mood stabilizers may help
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Mental Disorder due to GMC

 Psychotic Disorder due to a GMC

 any cerebral or systemic disease
 Two subtypes: with delusions; with hallucinations
 Differentiate from primary psychosis, mood disorder with
psychotic features and delirium
 Treatment: removal of causative factor and antipsychotics

 Anxiety Disorder due to a GMC

 Product of medication, intoxication or withdrawal
 Most common: withdrawal from sedative-hypnotics, alcohol
 Usually fluctuates in direct relation to the course of the
provoking factor
 Treatment: Benzodiazepines
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Mental Disorder due to a GMC
 Sleep Disorder due to a GMC
 Hypersomnia
 Insomnia
 Parasomnia
 Circadian rhythm sleep disorders – BPO’s

 Sexual dysfunction due to a GMC

 Etiology: medications, substances of abuse, local disease
processes that affect primary or secondary sex organs,
systemic disease processes

 Mental D/O due to a GMC NOS

 Catatonia due to a GMC: mutism, negativism, echolalia
 Personality changes due to a GMC: labile type, aggressive
type, apathetic type, paranoid type, other, combined,
unspecified
 Treatment: mood stabilizer, psychostimulant,
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Mental Disorder due to a GMC
SPECIFIC DISORDERS
 Epilepsy
 Main psychiatric problem is personality change
 Temporal lobe seizures

 Religosity, heightened experience of emotions,

changes in sexual behavior
 Viscosity in personality: noticeable in conversation –
slow, replete with details, circumstantial
 Hypergraphia, pathognomonic for complex partial
seizures

 Brain Tumors
 Colloid cyst: not tumor, but can exert pressure on
sturctures within diencephalon
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Mental Disorder due to a GMC
 Head Trauma
 Major symptoms: cognitive impairment and
behavioral sequelae
 Post-traumatic amnesia: 6 to 12-month period of
recovery, afterwhich residuals
 Decreased speed in information processing,
decreased attention, increased distractibility, deficits
in problem-solving, some language disabilities
 Treatment: low-dose psychotropics due to
susceptibility to side effects

 Demyelinating Disorders
 Multiple Sclerosis – cognitive impairments and
behavioral
 Amyotrophic Lateral Sclerosis
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Mental Disorder due to a GMC
 Infectious Diseases
 Herpes simplex encephalitis – frontal and
temporal lobes: anosmia, olfactory
hallucinations, personality changes
 Rabies encephalitis - hydrophobia
 Neurosyphylis – general paresis:
development of poor judgment, personality
changes, decreased care of self, irritability
 penicillin
 Chronic meningitis – memory impairment,
confusion
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Mental Disorder due to a GMC
 Subacute Sclerosing Panencephalitis – usu.
follows measles
 Lyme Disease – bull’s eye rash, impaired
cognitive functioning and mood changes
 Prion Disease
 Creutzfeld-Jakob Disease – cognitive
impairment, aphasia, apraxia
 Kuru
 Gertsmann-Straussler-Scheinker –
neurodegenerative syndrome of ataxia,
chorea and cognitive decline
 Fatal Familial Insomnia – insomnia and ANS
dysfunction, death within a year
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Mental Disorder due to a GMC
 Immune Disorders
 AIDS
 SLE
 50% show neuropsychiatric symptoms
 Depression, insomnia, labile mood, nervousness,
confusion

 Endocrine Disorders
 Thyroid disorders
 Hyperthyroidism – confusion, anxiety, agitated syndrome
 Hypothyroidism – myxedema madness
 Parathyroid disorders – hyper and hypocalcemia: delirium
 Adrenal disorders – Addison’s (adrenocortical insufficiency),
Cushing’s
 Pituitary disorders – psychiatric symptoms (Sheehan’s
syndrome)
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Mental Disorder due to a GMC
 Metabolic Disorders
 Hepatic encephalopathy – alterations in consciousness,
changes in memory, personality
 Uremic encephalopathy – alterations in memory,
consciousness and orientation
 Hypoglycemic encephalopathy – feelings of hunger,
apprehension, restlessness; then, confusion, disorientation
and hallucinations
 Diabetic ketoacidosis – chronic dementia
 Acute Intermittent Porphyria
 Disorders in heme synthesis
 Result in excessive accumulation of porphyrins
 Triad of symptoms:
1. acute, colicky abdominal pain
2. Motor polyneuropathy
3. psychosis
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Mental Disorder due to a GMC
 Nutritional Disorders (Deficiency)
 Niacin – pellagra (alcohol abuse, vegetarian diet,
starvation)
 5 D’s: dermatitis, diarrhea, delirium, dementia,
death
 Thiamine

 beri-beri, Wernicke-Korsakoff syndrome

 Apathy, depression, irritability, nervousness, poor
concentration
 Cobalamin

 Failure of gastric mucosal cells to secrete intrinsic

factor in secretion of B12 in the ileum
 Pernicious anemia – depression

 Megaloblastic madness – with paranoid features

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Mental Disorder due to a GMC
 Toxins
 Mercury – mad hatter syndrome: depression, irritability,
psychosis
 Manganese – manganese madness
 Emotional lability, pathological laughter, nightmares,
hallucinations, compulsive and impulsive acts
 Lead
 200mg/ L – severe lead encephalopathy
 Dizziness, clumsiness, ataxia, irritability, restlessness,
insomnia
 IV disodium edetate for 5 days
 Arsenic
 Prolonged exposure to Arsenic from herbicides or drinking
water
 Skin pigmentation, GI symptoms, characteristic garlic
odor of breath, generalized sensory/ motor loss
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Neuropsychiatric
Aspects of HIV
Infection and AIDS

Michelle Marie M. Marinas,

M.D.
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Specific Psychiatric Conditions

 AIDS dementia
 AIDS mania
 Increased rates of MDD
 Psychiatric consequences of CNS
injuries
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 HIV is a retrovirus related to human l T-cell

leukemia viruses
 HIV-1: causative agent for most HIV infections
 Transmission after single exposure is relatively
low, but depends on viral load of contact person
 Anal sex
 Vaginal sex
 Needles
 In utero

 Can develop into AIDS in 8-11 years

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 Virus primarily targets T4 (CD4) helper
lymphocytes

to which virus binds

injects RNA into lymphocyte

Reverse transcriptase
RNA  DNA

Incorporated into host genome

Translated, transcribed
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Diagnosis
 Serum testing
 Conventional: blood test – 3 to 10 days
 Rapid test: oral swab – 20 minutes
 Positive
 Negative – not exposed, not infected, or exposed but not
yet developed antibodies (less than a year)

 Counseling – pre and post testing

 Confidentiality – exception is to notify partners or at

risk individuals, laws vary in different states

 CLINICAL FEATURES
 Non-neurologic factors – flu-like symptoms
 Neurologic Factors – HIV mild neurocognitive disorder, HIV-
associated dementia
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Psychiatric Syndromes
 HIV-associated Dementia – direct pathophysiologic
consequence of HIV

 Mild Neurocognitive disorder – aka HIV encephalopathy;

impaired cognitive functioning, mild form

 Delirium

 Anxiety disorder – GAD, PTSD, OCD

 Adustment disorder – 5 to 20% of patients

 Depressive disorder – 4 to 40% of patients

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Psychiatric Syndromes
 Mania – most commonly in late-stage disease

 Substance Abuse – IV users

 Suicide – risk factors:

 Friends who died from AIDS
 Recent notification of HIV seropositivity
 Relapses
 Difficult social issues (homosexuality)
 Inadequate social and financial support
 Dementia or delirium

 Psychotic Disorder – late stage

 Worried well – seronegative but anxious

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Treatment
 Preventionis primary approach
 Treatment/ prevention complicated by
complex societal values
 Complete sexual history, sexual orientation

 Pharmacotherapy
 Reverse transcriptase inhibitors
 Protease inhibitors
 Fusion inhibitors
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Treatment
 Psychotherapy
 Approaches – help deal with feelings of guilt
 Therapist-Related Issues –
countertransference issues and burnout
 Involvement of Significant Others – deal with
partner’s feelings of anger or guilt
 Partner Notification – recommendations for
voluntary and involuntary interventions
+Thank you and Good luck on
your quiz.
+
1 to 4: Name 3 disorders affected or
exacerbated by psychological factors

5 to 7: Name 3 mental disorders due to a

general medical condition

8. Is the study, practice and teaching of the

relation between medical and psychiatric
disorders

9. Name one medical disorder with psychiatric

symptoms

10. Identify one CL issue

BONUS: Identify a CL unit