Psychosomatic Medicine
Everyone knows or has heard of somebody who became medically ill after a stressful experience. The medical student who always seems to have a cold during exam week, or the elderly man who, 6 months after the death of his wife, is diagnosed with a rapidly metastasizing cancer, are familiar situations. Although these examples and the folk wisdom of many cultures suggest that people under psychological stress are likely to become ill, it is only in the past few decades that medical research has provided compelling evidence of this psyche (mind) and soma (body) relationship.
Physicians must be aware of the close association between the mind and body in all aspects of medical practice. Not only are stressed people more likely to become medically ill, but medical illnesses or their treatments can themselves lead to or exacerbate psychological symptoms. As such, the psychological symptoms displayed by a patient can sometimes be the first indication of a serious medical illness.
• PSYCHOLOGICAL FACTORS THAT AFFECT MEDICAL CONDITIONS
A variety of psychological factors are likely to affect the course or treatment of an individual’s medical condition. These factors include psychiatric illnesses, such as depression, and poor health behaviors, such as smoking. They also include stressrelated physiological responses and maladaptive personality traits and coping styles. Descriptions and clinical examples of these factors are given in Table 25-1.
Depression and medical illness
Depression affects both the body and the brain. It has been associated with a variety of physical changes, some of which have medical consequences (McEwen, 2000). For example, the risk in depressed patients of death after a myocardial infarction (MI) is higher than in nondepressed patients and is equivalent to that of patients with a history of previous MI or of left ventricular dysfunction (Frasure-Smith et al., 1993). Depressed patients are also more likely to develop diabetes, osteoporosis, and stroke (Krishnan et al., 2002).
Stress
In physics, the term “stress” refers to forces that are brought against an object in equilibrium. In psychiatry, stress refers to life events, or stressors, that have the force to alter the expected course of an individual’s goals, employment, relationships, and health.
Stressful life events
It is obvious that events such as September 11 are extreme psychological stressors (Galea et al., 2002). However, even “ordinary” life events cause stress, some more than others. Several schemes have been devised to quantify such stress. According to research by Holmes and Rahe (1967), life events have positions in a hierarchy called the Social Readjustment Rating Scale. The position of an event in the hierarchy is determined by its power to cause a person to alter or readjust his or her life. For example, the event with the highest score, death of a spouse (100 points), requires the most readjustment and thus represents the highest level of stress for an individual. Stressful life events also include positive occurrences. Interestingly, promotion and demotion at work provide equal amounts of stress (Table 25-2).
Holmes and Rahe suggested that the more life adjustments patients need to make, the higher their risk for medical and psychiatric illness. Eighty percent of patients who accumulated a score of 300 points or more in 1 year developed an illness in the following year. Because not all of the patients with high scores became ill, factors noted earlier, such as
personality and coping styles, affect the relationship between life stress and illness.
personality and coping styles, affect the relationship between life stress and illness.
table 25.1 PSYCHOLOGICAL FACTORS AFFECTING THE COURSE OR TREATMENT OF A MEDICAL CONDITION* | |||||||||||||||||||||
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Effects of stress on physiological function
In 1976, Hans Selye described the general adaptation syndrome—homeostatic mechanisms that the body uses in response to social stress. These mechanisms include neuroendocrine responses. For example, an immediate effect of stress is to increase secretion of catecholamines such as epinephrine. This increase can exacerbate cardiovascular disorders such as congestive heart failure, cardiac arrhythmias, and hypertension, and pain disorders such as migraine headache. A later effect of stress is increased secretion of cortisol, which can lead to altered immune system activity and decreased ability to resist infection or cancer (see later text).
Stress and immune system function
Studies in the field of psychoneuroimmunology (PNI) have further characterized the relationship between stress and immune system function (Solomon, 2000; Wong, 2002). A major tenet of PNI is that external stress leads to stimulation of the hypothalamus, which in turn leads to the release of corticotropin-releasing factor (CRF). The
release of CRF results in rapid release of adrenocorticotropic hormone (ACTH), which prompts the release of corticosteroids (e.g., cortisol) that modify immune responses.
release of CRF results in rapid release of adrenocorticotropic hormone (ACTH), which prompts the release of corticosteroids (e.g., cortisol) that modify immune responses.
table 25.2 MAGNITUDE OF STRESS ASSOCIATED WITH SELECTED LIFE EVENTS ACCORDING TO THE HOLMES AND RAHE SOCIAL READJUSTMENT RATING SCALE | ||||||||||
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In PNI studies, measures of alterations in immune responses include decreased lymphocyte response to mitogens and antigens and impaired function of natural killer cells (Schleifer et al., 1983; Stein et al., 1987). It is of interest that medical students show decreased natural killer cell cytotoxicity and decreased cell-mediated immunity before and during examination periods (Vitaliano et al., 1988).
case 25.1
THE PATIENT
A 65-year-old man is brought to the hospital after collapsing in a local restaurant. The patient is unable to move his right arm or leg and is having difficulty speaking. The history, obtained from his son, reveals that aside from mild hypertension, the patient’s health had been good until the previous year. During that year, both the patient’s wife and his older brother died. After his wife’s death, the patient retired from his job and moved to a different city. The move entailed taking out a mortgage on an apartment. During the move, the patient fell and fractured his hip and was hospitalized for 6 weeks. Neurological examination and neuroimaging studies indicate that this patient has had a left-hemisphere stroke.
COMMENT
According to the Holmes and Rahe scale, many of the social experiences this man had in the past year placed him at high risk for physical illness in the present year. These experiences include the death of two close family members—his wife (100 points) and brother (63 points)—as well as retirement (45 points), moving (20 points), and assuming a large debt (31 points). The fall and subsequent hospitalization (53 points) led to an accumulation of 312 points, well above the 300-point cutoff for risk of physical illness devised by Holmes and Rahe.
MANAGEMENT
Supportive physiological measures along with treatment to prevent another stroke should be provided to the patient. Psychological counseling can help this patient deal with the stressors in his life, as well as this serious new stressor, i.e., the loss of his own physical health (53 points).
Use of stress-reduction techniques to treat physical illness
The idea that life stress can affect the course of physical illness implies that patients can improve the outcome of their illnesses if they successfully reduce their life stress. Although psychologically empowering, this belief also implies that the patient is responsible if the illness worsens. The latter perception can lead to disappointment, guilt, and depression if the stress-reduction strategy fails. The authors of a study in lung cancer patients which failed to show a difference in survival between those who were optimistic and those who were not (Schofield, 2004) suggested that “encouraging patients to ‘be positive’ may only add to the burden of having cancer.”
Evidence exists both for and against the notion that behavioral stress-reduction strategies improve the outcome of illness. In an often-cited study, 86 women terminally ill with breast cancer who received standard cancer treatment and also participated in a supportive peer group lived longer than a group of women who received only standard treatment (Spiegel et al., 1981). However, in more recent studies (Goodwin et al., 2001; Spiegel et al., 2007), there was no significant increase in median survival time for those in support groups compared with those in control groups. Although differences between groups were generally not significant, a subset of women with estrogen-receptor (ER) negative (but not with ER positive) breast cancer in the 2007 study showed life-lengthening effects of support groups. This suggests that hormonal factors may interact with stress-reduction efforts.
• MEDICAL CONDITIONS ASSOCIATED WITH PSYCHOLOGICAL SYMPTOMS
The social problems caused by medical illness often result in psychological difficulties. For example, a self-employed carpenter who is unable to work because of a bone infection becomes anxious and depressed because he cannot pay his bills. When these psychiatric symptoms lead to behavioral problems such as alcohol abuse or failure to take his medications, the patient’s physical condition deteriorates, and his recovery is delayed.
Common psychological complaints in medically ill patients include depression, anxiety, and disorientation (sometimes, as a result of delirium [see Chapter 14]). Behavioral symptoms can also be caused directly by medications. Often, the treating physician can manage a patient’s psychological problems by talking with the patient and helping to organize and activate his or her social support systems. Specific psychotropic medications, such as antianxiety agents and antidepressants, also can help. For severe stress-induced psychiatric problems such as brief psychotic disorder (see Chapter 12), a multidisciplinary approach, including a consultation-liaison psychiatrist who specializes in psychiatric symptoms in medical patients, may be needed.
Certain patient populations are more likely to be psychologically stressed than others. These populations include hospitalized patients, especially surgical patients, and those who are being treated in the intensive care unit (ICU) or coronary care unit (CCU). Patients with AIDS, patients on renal dialysis, and patients who have chronic pain are also at high risk for psychological stress and symptoms.
Surgical patients
Surgery is a stressful experience for anyone. However, some patients are at even greater psychological and medical risk for the effects of stress than others. These patients include those who believe that they will not survive surgery and patients who do not admit that they are worried before surgery. To reduce the risk for these patients, the doctor should encourage them to talk about their fears and address these fears as honestly as possible (see Chapter 24). Education beforehand about what to expect during and after the procedure in terms of mechanical support, pain relief, and other measures can also improve the outcome for surgical patients.
Patients undergoing renal dialysis
Patients on renal dialysis are at increased risk for psychological problems, such as depression. Among the reasons for this risk is the daunting recognition by these patients that they are dependent on other people and on machines for life itself. Psychological and medical risk for dialysis patients can be reduced through the establishment of good communication between the doctor and patient, as well as the use of in-home dialysis units. Such units are less likely to disrupt the patient’s life than hospital-based treatment.
Patients in ICUs or CCUs
Because of the disorienting nature of the ICU or CCU environment and the life-threatening characteristics of their illnesses, patients treated in these units are at increased risk for psychiatric symptoms, particularly delirium, or “ICU psychosis.” Several steps can be taken to decrease this risk. First, enhancing sensory and social input by encouraging the patient to talk and to have
visitors and by providing orienting environmental cues, such as windows and clocks, can be helpful. The patient should also be able to maintain as much control as possible over his or her environment (e.g., adjusting the lighting level and self-administering pain medication).
visitors and by providing orienting environmental cues, such as windows and clocks, can be helpful. The patient should also be able to maintain as much control as possible over his or her environment (e.g., adjusting the lighting level and self-administering pain medication).
Patients with AIDS
Individuals who are HIV-positive or have AIDS must deal with a particular combination of psychological stressors. Not only do they have a fatal illness, but they may also experience guilt over how they contracted the illness (e.g., sex with multiple partners, intravenous drug use) or the possibility of having infected others. These patients must also deal with complex, painful and often costly treatment regimens. In addition, if the patients are addicted to substances, they must undergo uncomfortable withdrawal from the drug. AIDS patients also often contend with fear of contagion from family, friends, and even medical personnel. Patients with a homosexual orientation who are HIV-positive may be burdened further by the need to reveal their sexual orientation to others (i.e., to “come out”). Medical and psychological counseling, peer support groups, reassurance from the physician that the patient will not be abandoned, and psychoactive medication for specific symptoms can reduce medical and psychological risk for these patients.
• PATIENTS WITH CHRONIC PAIN
Chronic pain, often defined as pain lasting at least 6 months, is commonly reported by patients. Chronic pain is associated primarily with physical factors but is often influenced by psychosocial factors. For example, the ability of a person to tolerate pain is decreased by depression, anxiety, and life stress in adulthood and by physical and sexual abuse in childhood.
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