Psychosomatics

• psychosomatic medicine  the

study of the interactions between
psychological processes and
physiological states
Classification of psychosomatic
disorders
• Psychosomatic disorder: characterized
by physical symptoms and demonstrable
structural or physiological changes in
which emotional factors are believed to
play a major etiologic role (gastric ulcer,
bronchial asthma)
• Somatoform disorder is a mental
disorder characterized by physical
symptoms that mimic physical disease or
injury for which there is no identifiable
physical cause.
Somatoform disorders (DSM-IV):
• Conversion disorder
• Somatization disorder
• Hypochondriasis
• Body dysmorphic disorder
• Pain disorder
• Undifferentiated somatoform disorder
- only one unexplained symptom is
required for at least 6 months.
• Patients with these complaints
represent one of the major groups of
patients with abnormal health care
use, increased sick leave days, and
early retirement.
• Former diagnoses (e.g., hysteria,
neurasthenia, functional syndromes,
and psychosomatic complaints) were
stigmatizing, unreliable, and rarely
used even in psychiatry.
• Conversion disorder: motor symptoms
• Loss of speech or aphonia may be
accompanied by much writing by the
patient. The patient cannot whisper, but
can cough loudly
• absence of organic disease or
disproportionately small disease compared
with the complaint
• proof that the patient can do things which
he or she considers cannot be done
• a psychological aetiology for the
complaint, i.e. psychological evidence in
proportion to the problem
• Astasia–abasia is a difficulty in
standing and walking even though all
leg movements are normal when the
patient is sitting or lying down. A
classical sketch by Charcot shows a
patient standing on tiptoes with
crossed legs and a little help from
the examiner.
• Paralyses may affect one or more
limbs, or one side of the face. They
may occur with contractures.
• Hysterical tremor is a repeated
movement of a voluntary type. It
ceases if the patient can be
persuaded to perform some other
movement with the same limb.
• Abnormal movements such as
facial tics, blepharospasm,
dyskinesia including tardive
dyskinesias, and Tourette's
syndrome were often thought to be
psychological in origin.
• Seizures occur only in the presence
of an audience or when one is close
at hand. They may be precipitated by
stress, but more often seem to occur
in response to the social setting.
• Hyperventilation Anxious patients
may hyperventilate, particularly in
response to phobias of small spaces,
tunnels, etc. They feel short of
breath and overbreathe.
• Dizziness is a subjective feeling of
unsteadiness. In vertigo the patient
feels that the environment is
rotating.
• Globus hystericus Difficulty in
swallowing or ‘globus' has
traditionally been called hysterical.
Reflux oesophagitis, and elevated
resting pressures in the
cricopharyngeal sphincter has been
identified in patients with gastric
reflux.
Conversion disorder: sensory symptoms
• Blindness or blurring of vision or difficulty
in reading or changes in visual fields
• Visual hallucinations - well-formed
visual hallucinations, usually of people, are
frequently regarded as hysterical (after
the exclusion of drug hallucinatory states)
• Deafness is quite rare in psychiatric
practice but was common among soldiers
exposed to blast injury, and was then
often associated with hysterical paralysis
or blindness.
• Peripheral nerve sensory loss
may involve half the entire body
from top to toe or from right to left.
It may affect the whole of a limb,
and characteristically has a glove or
stocking distribution on the arms or
legs, or both.
• Dissociative disorder
• Stupor is marked by a profound
diminution or absence of voluntary
movement, but normal responsiveness to
external stimuli such as light, noise, and
touch. The condition has to be
distinguished from physical disorders
affecting the midbrain particularly, and
catatonia and severe depression.
• Amnesia there is a loss of knowledge of
personal identity with preservation of
other information, often including complex
learned information or skills.
• Fugue is sudden unexpected travel
away from home or a customary
place of work. There is also inability
to recall their personal past history.
Sometimes a partial or completely
new identity is assumed. The
memory for some recent traumatic
or stressful event may be lost,
although these matters are
discovered when other informants
become available.
• Dissociative identity disorder is the
presence of two or more distinct identities,
or personality states, each with its own
pattern of perceiving, relating to, and
thinking about the environment and self.
At least two of these identities or
personality states must recurrently take
control of the person's behaviour. There
should also be inability to recall important
personal information that is too extensive
to be explained by ordinary forgetfulness.
 Somatization disorder
• the patient presents multiple physical complaints
suggesting a physical disease that cannot be
adequately explained on the basis of organic
pathology or any known pathophysiological
mechanism
• The most frequent symptoms are non-specific in
character and of low diagnostic value (fatigue,
nausea, pain, dizziness, and palpitations)
• there may be a striking discrepancy between the
patient's subjective complaints and behaviour (a
patient may smile, walk, and move normally
when reporting severe intolerable pain in muscles
and joints).
 Differential diagnosis
• In malingering, the patient feigns
illness with a conscious motivation to
avoid responsibility or to gain an
advantage. In factitious disorder,
the symptoms are intentionally
produced and the patient may self-
inflict or induce diseases and lesions.
• In somatoform disorders, both the
symptom-producing behaviour and
the motive are unconscious.
 Aetiology of Somatization disorder

• family transmission may be due to

sociocultural learning
• In the classical psychodynamic drive
theory, it’s a reaction to the
repression of unacceptable wishes or
instinctual impulses and internal
psychic conflicts
• According to the theory of self-psychology,
in a defence against the feeling of
emptiness the individual becomes directed
on the outside world and on physical
stimuli.
• Individuals with alexithymia have a poorly
developed language of emotions, and it
has been suggested that instead they
might respond with bodily symptoms.
• The cognitive theory - the patients'
misinterpretation of benign symptoms and
normal physical sensations
• Biological factors
• A neurophysiological dysfunction in
the attention process (reduced
corticofugal inhibition in the
diencephalon and the brainstem of
afferent bodily stimuli, resulting in
insufficient filtering of irrelevant
bodily stimuli).
• A dysfunction of the secondary
somatosensory area in the brain, a
hypersensitivity of the limbic system
towards bodily stimuli
• Hypochondriasis is a preoccupation
with the fear that one has, or may
develop, serious disease despite
evidence to the contrary. It affects
between 2 and 7 % of patients
attending general medical clinics
Hypochondriacal disorders
• triad of disease conviction,
• functional impairment,
• and refusal to accept appropriate
reassurance.
Somatoform pain disorder is persistent
pain without clear medical
explanation.(ICD-10)
• psychological factors are judged to
have an important role in the onset,
severity, exacerbation, or
maintenance of the pain (DSM-IV).
• pain symptoms are strongly
associated with anxiety and
depressive disorders
 Psychological aspects of neurological
diseases
• Stroke - During the first 2 years after
stroke two-thirds of patients are
likely to experience symptoms of
depression
–Anxiety About 25% of patients
–Emotionalism (irresistible
crying or laughing) during 1
year after stroke
• Parkinson's disease
• – Depression, dysthymia
- ‘levodopa psychosis' occurs

in 20 % of patients
- Visual hallucinations in clear
consciousness, with or
without delusions (fully
formed images of people or
animals, non-threatening,
and stereotyped).
 Tuberculosis
• often develops in patients who previously
had alcoholism or intravenous drug abuse,
or in the chronic mentally ill.
• emotional lability and depression could be
related to the feeling of invalidity that
accompanies the illness, and its social
stigma.
• the preventive treatment of those in
contact with the patient can trigger
feelings of guilt.
 Viral encephalitis
• the complications that appear after
the acute episode - anxiety and
depressive syndromes, personality
change, and dementia.
• In the early years of life,
encephalitides may be followed by
behavioural disorders
 Lyme disease
• difficulties involving memory,
orientation, and calculation
• violent and impulsive behaviour,
labile affect, and depression.
• catatonic syndromes
• chronic dementia, encephalopathy
with alterations in sleep, affect, and
memory.
 Brucellosis
• depressive or anxious syndromes
 Psychological aspects of surgery

• Preoperative stage
Anxiety is a risk factor for adverse
medical events and persistent
anxiety following surgery
is managed with education,
reassurance, and self-guided
relaxation techniques
- benzodiazepines to assist in reducing
anxiety and to allow adequate sleep
• Severe personality disorders
• These patients may have unrealistic
expectations about their surgical care
and the outcome of the surgery and
may either be unreasonably
demanding and/or may create
divisions amongst the treatment
team. The psychiatric consultant may
need to serve as an advocate for
these individuals.
Postoperative complications
• Agitation
• Delirium occurs in about 15 % of
patients undergoing general surgery,
especially, cardiac or transplant
surgery or hip replacement
• inadequate pain management
contributes to distress, agitation,
sleep disturbance, anxiety, mood
symptoms, and to behavioural
disorders
• Sleep disorders are related to the
sleeping environment, daytime
sleeping related to prolonged bed
rest, lack of intellectual and social
stimulation, and reduced circadian
cues
• Cognitive impairment is a common
short-term and long-term
complication of major surgery,
particularly in those with advanced
age.
• Adjustment disorders occur in the
longer term following disfiguring
surgeries (for example, facial
surgery, amputations, ostomies) or
which require complicated post-
operative regimens (such as organ
transplantation).
• phases of Normal psychological
response to cancer diagnosis
1. initial denial - the person doubts the
diagnosis and questions that it may be a
mistake
2. an acute turmoil phase - 1 to 2 weeks -
intrusive thoughts about death and disease,
poor concentration, irritability, anxious and
depressed mood, anorexia, and insomnia.
Some actually have weight loss related to
the anorexia, which they attribute to cancer
progression. They may have motor
restlessness, and inability to carry out daily
activities owing to preoccupation with
concerns for the future.
3. a period of adaptation -the acute
turmoil symptoms begin to diminish
and the reality of illness becomes
more tolerable. Hope returns with
beginning a treatment plan and a
clear course of action to deal with
the disease.
 Psychological aspects of
oncological diseases
• Depression, suicidal thoughts and
attempts– are more often in
pancreatic cancer
• – must have adequate pain control
• - support groups
• - medications – SSRIs (citalopram,
fluoxetine, paroxetine, sertraline)
 Psychological aspects of
oncological diseases
• Anxiety
• -adequate information about the illness or
treatment
• Individual and group therapies
• relaxation techniques
• Benzodiazepines, neuroleptics (e.g.
haloperidol, methotrimeprazine,
thioridazine, chlorpromazine),
antihistamines (e.g. hydroxyzine), and
tricyclic antidepressants (imipramine and
clomipramine)
 Psychological aspects in
gynaecology and obstetrics
• Infertility
• the wish for children dominates everything.
• self-reproach over sexual indiscretions, abortions,
contraception, or venereal disease.
• the envy of fertile couples: contacts with other
people's children, family celebrations, and
pregnancies in relatives and friends become crises.
• the fear that the spouse will desert to a fertile
partner
• The psychological reaction unfolds over years.
When treatment begins, there is a cycle of
optimism and hope, with a build-up of tension
towards the end of the cycle, followed by
disappointment and despair.
 Surrogate motherhood
• A woman contracts with a couple to
be inseminated (artificially or
naturally) with the husband's semen,
and to surrender the child to the
genetic father and adoptive mother.
The surrogate provides both oocyte
and womb, and is a substitute
spouse
• The wife is the genetic mother,
donating a fertilized oocyte to the
surrogate gestational mother.
 Pseudocyesis

• a firm belief in the pregnancy, usually lasting

until the onset of a false labour at 9 months, after
which the disorder usually resolves
• amenorrhoea
• morning sickness
• enlargement of the breasts and nipples, and even
a discharge of colostrum
• abdominal enlargement, caused by muscular
contraction, tympanites, fat, or pathological
lesions, but without effacement of the navel
• an illusion of fetal movements
• enlargement of the uterus to the size of a 6-week
pregnancy.
The psychological basis is
• an intense desire for children,
especially in older childless women.
• In some cases, a guilty fear of
pregnancy; this may lead to
attempts at abortion by women who
are not pregnant
 Sterilization
• Regret after sterilization
• Younger women or those with fewer children:
• Those sterilized at parturition: it is often difficult to
make a balanced judgement at this moment.
• Those under external pressure.
• Those who are mentally retarded.
• Those sterilized for medical reasons such as inherited
disorders: medical advances (e.g. amniocentesis) have
sometimes provided an alternative solution to
sterilization.
• Those sterilized in the course of a psychiatric illness:
this often impairs judgement and, after recovery,
decisions may be regretted.
• Those who seek sterilization in a context of marital
disharmony.
• Those with religious scruples.
 Hysterectomy
• psychological effects on feminine
identity.
• In younger women, the loss of
fertility
 menstruation
• 20 and 30 per cent of women suffered a mood
disorder before or during the menses—usually
irritability or depression, occasionally euphoria.
• deviant behaviour, including nymphomania, food
cravings, binge drinking, pathological lying,
shoplifting, and firesetting, as well as suicide,
violence, homicide, morbid jealousy, and
admission to mental hospital.
• a number of other nervous diseases is associated
with menstruation, including epilepsy, migraine,
and hypersomnia.
 pregnancy
• Denial of pregnancy is common in the
early stages, especially in women who are
pregnant accidentally or for the first time;
in a few, it continues until delivery.
• must distinguish between: unnoticed
pregnancy, deliberate concealment, and
dissociative denial.
• The late discovery of an unwelcome
pregnancy carries a small risk of suicide.
• Prenatal attachment
• The mother ‘bonds' to the unborn
child in a way analogous to the
formation of the mother–infant
relationship after birth
• In some mothers the fetus is viewed
as an intrusion whose movements
annoy or distract the mother and
disturb her sleep. Touching the
abdomen and identifying fetal body
parts, or telling stories about the
baby's future life are suggested.
• When a mother deeply resents her
pregnancy, she may try to harm the
fetus.
• self-induced abortion.
 Miscarriage
• 40 % of all conceptions
• An ectopic pregnancy is gynaecologically more
serious, but it has the same psychological effects.
• resemble post-traumatic stress disorder, with
perseverative and intrusive re-experiencing
(‘flashbacks') and nightmares.
• sense of failure, guilt, and anger.
• depressive episodes at the time of the expected
delivery, anniversary reactions, and an increased
risk of postpartum emotional disorder after a
later normal delivery, including a pathological
fear of death.
 Grief after infant loss
• Honesty and openness in communication the
parents' guilt should not be reinforced by the medical
team's refusal to accept responsibility. Staff should
not to be defensive. After a stillbirth, most mothers
prefer to be segregated in a single room and
discharged early. One or more interviews with the
consultant obstetrician are indicated. Hypnotics may
help mothers troubled by insomnia. The doctor should
be alert for secondary depression.
• All parents want to know why the baby died The
necropsy can help, but parents should be warned that
often no explanation is found.
• The mother will often be helped by seeing and
holding the dead baby A photograph should be
taken and kept. Others keep a memento such as a
lock of hair. The dignity of naming and a burial
ceremony is helpful.
• The bereaved mother needs to share her
distress A sensitive and sympathetic person, with
the time and interest to listen can help her to
grieve and accept her loss. This support will often
come from husband, family, and friends. Self-help
groups and voluntary agencies are invaluable for
some mothers.
• The next pregnancy No doctrinaire advice can be
given about the timing of the next pregnancy,
which is a personal decision. Increased anxiety
during pregnancy can be expected.
• The grieving sibling The routine and rhythm of
family life should be disturbed as little as possible.
The parents should not be afraid to show their
emotions. It is important to reassure the children:
they are not responsible and will not lose the love
of the parents; neither they nor their parents are
in danger of death.
 postpartum period
• Physical exhaustion This can be
coupled with the painful sequelae of
pelvic trauma.
• Breast feeding Although this has
many advantages, it is often difficult
to establish.
• Insomnia Sleep deprivation is a
cause of irritability, and should be
borne in mind when mothers present
‘at the end of their tether'.
• Recovery of normal figure and
attractiveness This may be threatened
by weight gain and stretch marks.
• Loss of libido Episiotomy and vaginal
trauma often cause dyspareunia;
nevertheless sexual relations are usually
resumed within 1 to 3 months, though
reduced in frequency, and with a delayed
return of orgasm. For this and other
reasons (e.g. jealousy) the marriage may
come under strain.
• Social privation The loss of employment,
income, and leisure, as well as
confinement to the house and boredom,
are all contributory factors.
 Mother–infant relationship disorders

• Lack of emotional response – the baby does

not seem to be her own.
• Rejection of the infant The mother regrets the
pregnancy and expresses hostility to the baby.
Some mothers try to escape, leaving home for
long periods or repeatedly or have the secret
wish that the baby ‘disappear'—be stolen, or die.
• Pathological anger The infant's demands make
the mother feel tense and angry, and provoke
aggressive impulses, which may lead to
avoidance, neglect, and assaults.