Psychosomatic medicine Medically Unexplained Symptoms (MUS) Bio-psycho-social model Stress and health Positive 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 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 + 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 Genes Drugs Germs Biological factors Personality traits Motivation Optimism Psychological factors Occupational stress Stigma Family environment Life Events Social factors Engel, 1977 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 conservationwithdrawal 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. Suggest practical prophylactic measures (???) Engel, 1971 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 and life 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 affects The body, or the rreordening of important Routines that tho body become used to, Can couse needless stress, throuwing Your 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 Stressors San 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. Study of the natural history of hypertension. Biological and psychological factors Stage of Disease Physiology Affective Cognitive Normotensive/youth (genetic/familial risk) All normal possible hyperreactivity to lab stress, Anger? Reduced pain Mild elevation in SBP sensitivity Opioid dysregulation Borderline/Prehypertensive 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 Subtle spatial attention, short term memory deficit Jennings and Heim, 2011 Biological, psychological and social factors influence: • • • • • the prevention, causes, Presentation, management and outcome of the diseases Bio-psycho-social model and schizophrenia management Stress Neurocognitive Impairment + Dopamine dysregulation Early warning signs Relapse De-stigmatization Family psychoeducation Social Skills training Assisted working Antipsychotic medication Cognitive rehabilitation Psychoeducation ITAREPS Family Environment and Schizophrenia outcome „Patients have families“ Henry • 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) Richardson, 1948 Pilgrim State Hospital, USA, 1954: 13 875 patients Pharmacological revolution in psychiatry: Deinstitutionalization! 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 overinvolvement and critical comments (Vaughn a Leff, 1976) Patients at home, relatives need information Family psychoeducation and relapse prevention Relatives: ↓anxiety, expectations, self-blaming ↑communication skills Environment: ↓stress ↓relapse risk Patients: ↓ anxiety, hopelessness ↑ treatment adherence Stress and health Psychology • Anxiety • Anger, rage • Apathy, depression • Cognitive dysfunction Fight of flight Physiology • ↑ metabolism • ↑ heart rate • ↑ blood pressure • ↑ breathing • ↑ muscle tone • ↑ endorphins and ACTH Hans Selye, 1907-1982 Canadian 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 techniques Positive psychology How does it work? Positive psychological attributes promote health Hope Self-efficacy Optimism Resiliency Biological correlates of happiness over the working day. a: mean salivary cortisol averaged during the working day in relation to hapiness b: 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“