Professional Documents
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Psychosomati
c Medicine
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
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
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
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
Hypercortisolism
Fatigue, depressed mood
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
Psoriasis
Lead to stress, which triggers psoriasis
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
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
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
Depression
Agitation
Hallucinations
Sleep Disorder
Confusion
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
Pheochromocytoma – anxiety
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
Delirium NOS
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Core features of Delirium
Altered consciousness – decreased level
Decline in functioning
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
Huntington’s Disease
Parkinson’s Disease
HIV-related Dementia
Mood
Cognitive Change
Catastrophic reaction
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
AIDS dementia
AIDS mania
Increased rates of MDD
Psychiatric consequences of CNS
injuries
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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
Delirium
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.
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1 to 4: Name 3 disorders affected or
exacerbated by psychological factors