ICL 1.2: Psychological Factors Effecting Medical Conditions

Question 1

what is psychosomatic medicine?

Answer 1

the study, practice and teaching of the relationships between medical and psychiatric disorders

Question 2

what is Consultation-Liaison Psychiatry?

Answer 2

when someone is experiencing a medical condition but also has a psychiatric disorder

Question 3

what is an affective disturbance?

Answer 3

a disturbance in mood in which the person may be anxious, depressed, chronically angry etc. – a psychiatric diagnosis is not required!!

through various pathways, this affective disturbance then links to a physical disorder or illness behavior –> there are biological, behavioral, cognitive and social pathways

it can also go backwards where a physical disorder or illness behavior can effect a person’s mood, emotions, feelings and affect

Question 4

what is the DSM5 criteria for an affective disorder?

Answer 4

1. person must have a medical condition or validated symptoms
2. effects on the medical condition are not better explained by another mental disorder – so if someone has anxiety or depression it doesn’t count
3. psych factors adversely affect the medical condition but are not necessarily linked by cause and effect
4. no specific duration or frequency required

Question 5

what types of psychological factors affect medical conditions?

Answer 5

1. emotional symptoms: like when anxiety worsens asthma
2. personality traits: type A behavior is linked to heart disease
3. maladaptive health behaviors: stress eating of carbohydrates when stressed in someone who has diabetes
4. ineffective coping style: avoidant coping like when someone has irregular monitoring of blood pressure and hypertension to avoid knowing how their health is doing

Question 6

which specifies indicate how quickly a physician will have to intervene? how serious of an effect is this affective disturbance having on the medical condition?

Answer 6

mild = increases medical risk like inactivity

moderate = aggravates medical condition like stress eating which increases blood glucose in a DM2 patient

severe = results in hospital stay or ER visit

extreme = life threatening psychological factor like ignoring symptoms of heart attack

so the degree of risk is assessed by the physician and then the physician asses the patient’s health belief model; so why are they thinking or doing these things without realizing that it’s worsening their condition or just taking their chances and not paying attention to it

then the doctor asses what stage of change they’re in to try and modify these risk factors; this is the next step in intervention

Question 7

what are the effects of stress on the immune system?

Answer 7

1. people studied examination stress in medical students

they found that the immune system was depressed around the time of examination and actually lasted for about a week after –> there was inhibition of T cell responses and slower wound healing!

2. then they studied marital stress and the immune system

marriages with little distress confers benefit; psychological and physiological on immune function

distressed marriages: cellular immunity declines over 2 years; less robust immune response to viral and bacterial infection

3. finally, they looked at caregiver stress

greater “burden” associated with social isolation, financial stress, lack of choice which resulted in poorer physical and mental health

Question 8

how does caregiver stress effect the immune system?

Answer 8

acute and chronic stress increases pro-inflammatory cytokines, specifically interleukin 6 (IL-6) when they are NOT needed which increases risk for heart disease

then when the immune response is actually needed, the immune system won’t respond if they person is under stress!!

interventions for caregivers: respite, support group, treatment for depression as needed

Question 9

what are migraines?

Answer 9

pain is moderate to severe, unilateral, due to hyper-excitability of the brain

food types, alcohol, stress, caffeine, disruptions in sleep schedule, weather changes are factors

commonly comorbid with depression!!

so if you consider the various pathways for what’s causing this headache, a biological pathway could be a food choice or effects of alcohol; a behavioral pathway would be changes in sleep schedule; emotional pathway would be depression; cognitive pathway would be someone who is a perfectionist

Question 10

using the biopsychosocial model, how would you treat someone’s headache?

Answer 10

it depends on which pathway is causing the headache!

1. eliminate food triggers (nuts, alcohol, chocolate) so then the prescription you write would be for preventive and “rescue’ medication for migraine
2. stress management: thermal biofeedback, relaxation
3. treat depression with CBT and medication if appropriate

Question 11

what is bereavement?

Answer 11

sadness, varying in severity resulting from the loss of a loved one or other losses

most people improve significantly in months, resolve in one year –> all cultures have different processes of grieving and they have rituals that allow them to grieve and work themselves through the loss

normal reaction to loss seen in all age groups

Question 12

what things can cause grief?

Answer 12

1. changes in physical health or body part
2. loss of independence
3. change in social role in family
4. loss of youthful body image – aging
5. loss of a person

Question 13

what are the normal reactions to grief?

Answer 13

2. emotion: sad, angry, guilt, yearning, anxious
3. cognitive: disbelieving, confused, visions, depersonalization
4. physical: chest tightness, pain, dry mouth, weakness, noise sensitive, loss of appetite
5. behavior: insomnia, withdrawal, crying
6. spiritual: seeking comfort or faith crisis

people may present for medical care because short term, these can be extreme even if they’re not technically meeting criteria for PTSD, acute stress disorder or complicated grief disorder so the physician does have a role in grief!

Question 14

what is the role of the physician in the normal bereavement process?

Answer 14

1. Encourage and normalize grieving within cultural framework
2. suggest support groups
3. anticipate anniversary events
4. follow up to assess resolution of grieving process

Question 15

what are the risk factors/predictors for grief disorder? aka complex bereavement disorder

Answer 15

1. multiple recent or unresolved past losses
2. history of mood or anxiety disorders
3. minimal social support
4. deficient coping skills
5. relationship with the deceased was ambivalent, guilty or overly dependent
6. socially negated loss, socially unspeakable loss, stoicism, guilt

so for diagnosis, it has to be related to loss of a person! however, with general grief, it can be caused by many other things

Question 16

what is a socially negated loss?

Answer 16

grief not recognized by society

ex. miscarriage, loss of family pet

“oh you can get pregnant again” or “it was just a cat”

Question 17

what is a social unspeakable loss?

Answer 17

conspiracy of silence

things that people do not reveal

ex. suicide, abortion

Question 18

what is stoicism?

Answer 18

inhibited expression of grief

in certain cultures, grief is internalized and not expressed openly so people believe they have to be stoic even though they’re suffering greatly

Question 19

what is guilt?

Answer 19

belief that loss was preventable

Question 20

what is delayed grief?

Answer 20

minimal grief at the time of first loss but excessive grief years later to a minor loss

Question 21

what is masked grief?

Answer 21

vague somatic symptoms like pain, insomnia instead of identifying the actual emotional loss

Question 22

what is ambiguous grief?

Answer 22

loss of a person who has disappeared physically or psychologically so there’s no resolution

Question 23

what is persistent complex bereavement disorder?

Answer 23

the patient experienced the death of someone with whom a close relationship was shared but the reaction is out of proportion to cultural, religious or age appropriate norms

12 months since the loss but:

1. marked functional impairment remains
2. physical deterioration: weight loss, worsening of medical condition
   examples: exaggerated grief (over reactions not culturally sanctioned)

Question 24

what are the symptoms of persistent complex bereavement disorder?

Answer 24

1. reactive distress to the death like disbelief or numbness, bitterness or anger, self blame
2. identity/social disruption: desire to die, feeling alone, detached, belief that life has no meaning, confusion about a role, part of their self died
3. one of the following up to a year after the loss:
4. yearning, longing for the deceased
5. intense sorrow and emotional pain
6. preoccupation with the deceased
7. preoccupation with the circumstances of the death; ruminating about the details

Question 25

how do physicians treat persistent complex bereavement disorder?

Answer 25

1. educate about factors that may be delaying resolution like going after the feelings of guilt and self blame and providing them information about the person’s death
2. consider medical management of insomnia, anxiety, depression, suicide risk
3. refer to support group
4. refer for psychotherapy
5. follow up*** make sure you schedule another appointment!!

Question 26

when you’re acting as a physician, what do you need to be aware of when you’re acting as a grief counselor?

Answer 26

1. unfinished grief after one’s own losses
2. personal feared losses
3. focus on what the physician can control, but recognize that there are always questions and things that you yourself struggle to resolve

Question 27

what are some of the interventions that can be done through cognitive behavioral therapy for people who have complex bereavement disorder?

Answer 27

1. address negative cognitions and learn to counter
2. offer breathing and other relaxation skills
3. consider mindfulness
4. include exposure intervention for memories of the death