PSYCHIATRY AND MEDICINE
The debate about the effects of mental health on somatic health and
somatic health on mental health is centuries old. The relationship is
summarised by the Arabic proverb “a healthy mind rests in a healthy
body”. The interrelationship between mental health and physical health
may presents in three forms: mental illness resulting in physical
disability, physical illness resulting in mental disability, or the co-
existence of mental and physical disability. Studies have shown that there
is high prevalence rate of psychiatric symptoms or disorders amongst
patients with physical illnesses and the reverse is also true. The
association of psychiatric and physical illnesses adversely affects the
outcome of these illnesses and increases the rate of morbidity. Emotions
are associated with transient and reversible physiological changes
primarily related to the autonomic nervous system. These physiological
changes normally resolve with the resolution of emotions or shortly after.
However, sustained physiological changes may result in tissue structural
damage. It is postulated that specific emotions (anxiety, anger) may result
in specific physical illnesses, and a particular type of personality is
vulnerable to a particular physical illness (stressors specificity theory of
Alexander and Dunbar). In contrast to the stressors specificity theory, it is
postulated that emotional stressors are non-specific, but some individuals
are constitutionally vulnerable to be affected (Wolf, Mahl, Selye). A
wider view postulates that biological, psychological, and sociological
factors are involved in the process (Engel). The concept of alexiythymia
was introduced by Nimiah and Sifneos. Alexithymia (a=no,
lexia=express, thymia=emotions) is the inability of the individual to
recognise and express feelings, which predispose to the development of
physical symptoms in emotionally stressful situations. The association
between emotions and physical illnesses was successively described as
psychosomatic, psychophysiological, and most recently somatoform
disorders. In summary, the interrelationship between emotional health
and physical health is not clear, but the effect of the mind on the body and
vice versa remains a matter of common sense. The mechanisms involved
in this interrelationship include physiological, hormonal, and immune
processes. Somatoform disorders are characterised by physical symptoms
suggesting medical condition,yet the symptoms are not fully explained by
the medical condition,by substance use,or by another mental disorder i.e(
for which there are no demonstrable organic findings or known
physiological mechanism).The symptoms are not intentionally produced
as are those of factitious disorders and malingering. However, there is
strong association between somatoform disorders and psychological
stressors. Somatoform disorders include somatisation disorder,
conversion disorder, body dysmorphic disorder,pain disorder and
hypochondriasis.
SOMATISATION DISORDER: Somatisation disorder is characterised
by chronic(ICD-10 at least 2 years) multiple somatic symptoms(multiple
complaints and multiple organ systems) occurring before the age of 30.It
is 5 times more common in wemen,with a life time prevalence of 2% in
wemen and 0.2 in men.5-10% of patients in general practice.
Etiology:
1-wandering womb(upward migration of uterus)-ancient Egyptian
2-intrapsychic defense: pain and suffering are deserved and use as
atonement for hostile impulses.
3-social communication:I am a person deserving care(sick role)
4-abnormal illness behaviour
5-cultural stigma of psychiatric illness
6-lateralized defects of the brain revealed by functional brain imaging
studies
Impact of somatization: in US it costs up to $ 30 billion
Clinical features:
1-pain symptoms:headache,back pain,arthralgia,rectal and abdominal
pain,dysuria,dyspareunia and dysmenorrhea.
2-bloating,nausea,vomiting,diarrhea and food sensivity(GIT).
3-amnesia,fainting,blindness,double vision,aphasia,seizure,ataxia and
paralysis(pseudoneurological symptoms)
4-sexual symptoms like decrease desire,erectile dysfunction,menorrhagia
and hyperemesis gravidum.
The history is often colourful and dramatic,presence of iatrogenic
complication,seeking multiple treaters (doctor-shop) and the relationship
with treaters is often strained.
Psychiatric comorbidity: 50% have axisI disorders like mood
disorder,anxiety disorders,substance abuse.
AxisII disorders are also very common affecting72% of patients, like
histrionic,borderline and antisocial personality disorders.
30-70% of the patients have history of childhood sexual abuse and
neglect.
This disorder was previously thought to be related to hysteria and named
Briquet syndrome (Briquet is a French physician wrote about hysteria). It
runs a chronic course and difficult to treat.
Treatment: the goal of treatment is to provide care for the patient but not
to focus on curing the disease.
The best treatment occurs in the context of a long term relationship with
an empathetic primary care provider (PCP).
The physician should be encouraged to:
1-allow the patient to maintain the sick role.
2-schedule regular follow-up appointments of a set length.
3-set the agenda of the visit.
4-do no more and no less for the somatic patient than for any other
patient.
5-set limits on contacts outside of visit time.
6-introduce psychosocial issues slowly,using stress or mind-body
language.
7-minimizing unnecessary investigation and prevent iatrogenic
complication