Psychosomatic medicine

Psychosomatic Medicine I & II

Psychosomatic Medicine I & II Fahad Alosaimi MD
Professor and consultant of
Psychiatry and Psychosomatic medicine
College of Medicine,
King Saud Medical city,
King Saud University, Riyadh

Intended Learning Objectives

• By the end of this lecture, a student should be able to:
  • Understand relevant concepts related to psychosomatic medicine which resides at the interface of physical and mental illnesses.
  • Appreciate that accurate diagnosis and treatment of depression in medically ill patients improves quality of life, enhances engagement in treatment, decreases symptom quantity and severity, and decreases cost utilization, morbidity, and mortality.
  • Acquire preliminary skills to evaluate and intervene adequately to manage somatic symptoms and related disorders.

Introduction (Psychosomatic Medicine)

• Psychosomatic medicine is the subspecialty of psychiatry whose practitioners have particular expertise in the diagnosis and treatment of psychiatric disorders and difficulties in complex medically ill patients.
• Psychosomatic medicine resides at the interface of physical and mental illness.
• Psychosomatic medicine begins long time ago with the Greeks (around 900 BCE).
• The clinical practice of psychosomatic medicine is sometimes called consultation-liaison psychiatry (CLP).
• Since 2001, Psychosomatic medicine has become a subspecialty recognized by the American Board of Medical Specialties.
• Since 2015, Psychosomatic medicine has become a subspecialty recognized by the Saudi Commission for Health Specialties.

Table of Contents

• Patient Evaluation in Psychosomatic Clinics
• Medical and Psychological Interactions
• Psychosomatic Medicine Advantages and Referrals
• Primary & Secondary psychiatric disorders

Presentations

• Depression and Medical Illnesses
• Perinatal Psychiatry
• SSD - Somatic Symptoms and Related Disorders
• IAD - Illness Anxiety Disorder
• Conversion Disorder
• PFAOMC - Psychological Factors Affecting Other Medical Conditions
• Factitious Disorder

New Concepts in the Mechanism and Etiology of Functional Neurological Disorder

• Early pre-conscious phases of motor planning are corrupted by a combination of abnormal involuntary brain-generated predictions about bodily states and interference from more emotionally oriented brain networks such as the limbic system and amygdala.

• E.G. signs such as tubular visual field loss can be explained by considering the brain as a largely “predictive” organ which makes and tests predictions about the body rather than constructing perceptions from scratch.

• In FND, it is thought that the brain prioritizes excessively strong predictions based on what the brain expects to “see” (such as “tunnel vision”) or be able to do (leg weakness) over the actual incoming sensory input.

• Previous adverse experiences are a risk factor for the development of FND.

• However, FND symptoms are often triggered by minor physical trauma or pathophysiological events such as migraine or panic attacks.

• Current models challenge outdated ones that are dependent on a dualistic separation of mind and brain.

• FND is a disorder of a dynamic, plastic brain that constantly modifies its structure and function through interactions with the environment and its interoceptive relationship with the body (Stone, Jon, 2020).

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Diagnosis

• Somatic Symptom Disorder

  • Prevalence: 6% (community) / 17% (primary care). Higher in functional disorders e.g. IBS
  • Sex: F > M
  • Age of Onset: Any age
  • Course/Prognosis: Chronic, waxes and wanes

• Illness Anxiety Disorder

  • Prevalence: 0.1% (community) / 0.75% (medical outpatient). Higher in unemployed and less educated.
  • Sex: M = F
  • Age of Onset: Adolescents
  • Course/Prognosis: Worsens with age. Prognosis: fair

• Conversion Disorder (FND)

  • Prevalence: 0.1% (community) / 5% (outpatient neurology) Incidence: 5 per 10000 per year (community). Esp. rural areas, lower SES, developing areas, and lower educational levels
  • Sex: F > M
  • Age of Onset: Late childhood – early adulthood
  • Course/Prognosis:
    • Acute or sudden: remit in about 2 weeks
    • Recur in 25%.
    • Chronic: poor prognosis

• Psychological Factors Affecting Other Medical Conditions

  • Prevalence: Not clear. Up to 30% of patients with medical conditions
  • Sex: ?
  • Age of Onset: Any age
  • Course/Prognosis: Can be acute or chronic

• Factitious Disorder

  • Prevalence: unknown, 1% of hospital cases / 6% inpatient psychiatric ward. Higher in employment in healthcare, and being unmarried
  • Sex: F > M
  • Age of Onset: Early adulthood
  • Course/Prognosis: Episodic

Future of Psychiatry

• Physical Health Inpatient Sector
• Chronic Illness
• Mental Health
• Physical Health Outpatient Sector

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Mental Health Sector

• ~10% of mental health patients
• ~98% of mental health budget
• Mental health budget is only 2% to 4% of total health budget, excluding pharmacy
• Evidence-based treatment ~50%

Mental Health Treatment in the Physical Health Sector

• ~90% of mental health patients
• ~2% of mental health budget
• ~0% actually receive any mental health treatment
• 20% to 40% of total health budget is used for physical health services in mental health patients (80% of health services used by mental health patients)
• Evidence-based treatment ~10% (in only 30% treated)

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شعرت بالكثير من الخجل من نفسي لما عرفت سيرة هذا الطبيب !!!

• https://www.youtube.com/watch?v=PQPI4quZZAA
• د. عبدالرحمن السميط

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Islamic Perspective

عن رسول الله صلى الله عليه وسلم قال:

• (من نَقَصَ عن مؤمنٍ كُرْبَةً من كُرَبِ الدنيا والآخرة، ومَن سَتَرَ عَلى مُعْصِمٍ، يُسَرُّ الله عَليه في غَضْبِه ما كان العبد في غَضَبِ الله عَزَّ وجلَّ سَرُور).

• أحبُّ الناس إلى الله أنفعهم للناس، ويدخله على مسلّم.

• (من عاد مريضًا، أو زارَ له في مرضٍ، وتبوأت من الجنة منزلاً).

• من أتى الملتزم عائداً مشى في خفَّةٍ، فإن كان غافلاً صُدِقَ عليه، فإن ألف ملكٍ حتى يمسِّه وإن كان مسائاً.

• إذا حضرتم المريض، أو الميت، فقولو: إن الملاكة يؤمنون على ما تقولون.

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Thank You

• Faalosaimi@ksu.edu.sa