Kk&s Ch.28 Psychosomatic Medicine

Front 1

In the 1920s, ?(1875–1945) conducted the first systematic study of the relation of stress to disease. He demonstrated that stimulation of the autonomic nervous system, particularly the sympathetic system, readied the organism for the “fight or flight” response characterized by hypertension, tachycardia, and increased cardiac output.

Back 1

Walter Cannon

Front 2

Hans Selye (1907–1982) developed a model of stress that he called the general adaptation syndrome. It consisted of three phases:

Back 2

(1) the alarm reaction;
(2) the stage of resistance, in which adaptation is ideally achieved; and

(3) the stage of exhaustion, in which acquired adaptation or resistance may be lost

Front 3

Endocrine response to stress?

Back 3

CRF is secreted from the hypothalamus into the hypophysial-pituitary-portal system. CRF acts at the anterior pituitary to trigger release of adrenocorticotropic hormone (ACTH). Once ACTH is released, it acts at the adrenal cortex to stimulate the synthesis and release of glucocorticoids.

Front 4

Glucocorticoids themselves have myriad effects within the body, but their actions can be summarized in the short term as

Back 4

promoting energy use,
increasing cardiovascular activity (in the service of the “flight or fight” response), and

inhibiting functions such as growth, reproduction, and immunity.

Front 5

Immune response to stress?

Back 5

CRF stimulates NE release
NE can activate immune system so get release of ctyokines
ctyokines can lead to further release CRF

Front 6

Top 5 Life event stressors?

Back 6

1. Death of spouse
2. Divorce
3. Separation
4. Jail/detention
5. Family member death
6. Major Illness
7. Marriage
8. Fired
9. Marital reconciliation
10. Retirement
11. Family member health change
12. Pregancy
13. Sexual difficulties
14. New family member
13. Major business readjustment

Front 7

An individual with a coronary personality is a ??? person who is predisposed to coronary artery disease.

Back 7

hard-driving, competitive, aggressive

Front 8

Meyer Friedman and Ray Rosenman first defined two types: (1) type ?—similar to the coronary personality—and (2) type? personalities—calm, relaxed, and not susceptible to coronary disease (See discussion below).

Back 8

A

B

Front 9

According to psychoanalytic theory, the choice of the afflicted region by stress is determined by unconscious factors, a concept known as

Back 9

somatic compliance.

Front 10

Organ system most linked with psychiatric disorders or functional status?

Back 10

GI

Front 11

In the esophagus, acute stress (increases or decreses) resting tone of the upper esophageal sphincter and (increases or decreases) contraction amplitude in the distal esophagus.

Back 11

increases both

Front 12

In the stomach, acute stress induces (increased or decreased) antral motor activity, potentially producing functional nausea and vomiting.

Back 12

decreased

Front 13

Acute stress impact on:
small intestine migrating motor function
: increased or decreased

Back 13

decreased/reduced

Front 14

Acute stress impact on large intestine

myoelectrical and motility activity can be (increased or decreased) under acute stress.

Back 14

increased

Front 15

? disorders ranked highest in a study of psychiatric comorbidity in functional esophageal spasm, being present in 67 percent of subjects referred to a GI motility laboratory for testing.

Most common specific ds?

Back 15

Anxiety
GAD

Front 16

Psychiatric ds associated to peptic ulcer disease

Back 16

No consensus exists on specific psychiatric disorders being related to peptic ulcer disease.

Front 17

Psychiatric ds associated with ulcerative colitis

Back 17

Some workers have reported an increased prevalence of dependent personalities in these patients. No generalizations about psychological mechanisms for ulcerative colitis can be made, however.

Front 18

Crohn's disease and associated psychiatric ds?

Back 18

Panic Ds
study of psychiatric symptoms in patients with Crohn's disease before the onset of symptoms found high rates (23 percent) of preexisting panic disorder compared with control subjects and subjects with ulcerative colitis

Front 19

List 2 disorders, 4 factors that have been evaluated as risk factors for the development and expression of coronary disease

Back 19

Depression, anxiety, type A behavior, hostility, anger, and acute mental stress

Front 20

??? have been shown to have significant relationships with each of these individual psychological factors, and some investigators have proposed these latter characteristics as more promising indices of psychological risk.

Back 20

Negative affect in general, low socioeconomic status, and low social support

Front 21

Strongest psych factor associated with coronary disease?

Back 21

depression

Front 22

Severe depression 6 months after coronary artery bypass graft (CABG) surgery, or persistence of even moderate depression symptoms beginning before surgery at 6-month postoperative follow-up, predicts increased risk of death over ?-year follow-up

Back 22

5

Front 23

The relationship between Type A behavior pattern characterized by ? and CAD found the type A pattern to be associated with a nearly twofold increased risk of incident MI and CAD-related mortality

What has helped decrease this risk?

Back 23

easily aroused anger,
impatience,
aggression,
competitive striving, and
time urgency (type A)

Group therapy for Type A's

Front 24

Key factor in Type A associated with CAD?

Back 24

hostility

Front 25

Is submissiveness in women protective against CAD risk?

Back 25

Yes

Front 26

Does psychosocial tx on rehab from CAD help?

Back 26

Yes

Patients having psychosocial treatment had greater reductions in emotional distress, systolic blood pressure, heart rate, and blood cholesterol level than comparison subjects.

Patients who did not receive psychosocial intervention had 70 percent greater mortality and 84 percent higher cardiac recurrent event rates during 2 years of follow-up

Front 27

High anxiety symptom levels are associated with a ? of risk of sudden cardiac death.

Back 27

tripling

Front 28

wo studies have demonstrated that, in addition to depression, a high level of anxiety symptoms raises the risk of further coronary events in patients after MI by ? times that for nonanxious comparison patients.

Back 28

2 to 5

Front 29

Mood disorders are common in transplant recipients, in part because of chronic ? therapy.

Back 29

prednisone

Front 30

Personality profiles associated with essential hypertension include persons who

Back 30

have a general readiness to be aggressive, which they try to control, albeit unsuccessfully.

Front 31

p to 30 percent of persons with asthma meet the criteria for

Back 31

panic disorder or agoraphobia.

Front 32

Certain personality traits in patients with asthma are associated with greater use of corticosteroids and bronchodilators and longer hospitalizations than would be predicted from pulmonary function alone. These traits include

Back 32

intense fear,
emotional lability,
sensitivity to rejection, and
lack of persistence in difficult situations.

Front 33

Family members of patients with severe asthma tend to have higher than predicted prevalence rates of

Back 33

mood disorders, posttraumatic stress disorder, substance use, and antisocial personality disorder.

Front 34

Tx of hyperventilation

Back 34

increase PC02
with paper bag or holding breath

Front 35

COPD associated with what psych ds?

Back 35

Panic Ds
8 to 24 % with COPD have panic ds (versus 1.5 percent of general prev)

Front 36

mania like sx seen in what GMC?

Back 36

hyperthyroidism or Graves

Front 37

Hyperthyroidism ... what type of antipsycotic to use?

Back 37

For patients with psychotic symptoms, medium-potency antipsychotics are preferable to low-potency drugs, because the latter can worsen tachycardia.

Front 38

high TSH + depressive sx + psychotic (AH, paranoia) sx:
dx + tx?

Back 38

hypothyroidism

Psychotropic agents should be given at low doses initially, because the reduced metabolic rate of patients with hypothyroidism may reduce breakdown and result in higher concentrations of medications in blood, as in the following case.

Front 39

Can DM onset be associated with psychological factors?

Back 39

sudden onset is often associated with emotional stress, which disturbs the homeostatic balance in persons who are predisposed to the disorder.

Psychological factors that seem significant are those provoking feelings of frustration, loneliness, and dejectio

Front 40

In patients with known diabetes, ? can produce some violence and confusion

Back 40

ketoacidosis

Front 41

? (often occurring when a patient with diabetes drinks alcohol) can produce severe anxiety states, confusion, and disturbed behavior

Back 41

hypoglycemia

Front 42

Cushing's psychiatric sx?

Back 42

Psychiatric symptoms are common and vary from severe depression to elation with or without evidence of psychotic features.

Front 43

Psychiatric symptoms are myriad. Most patients experience fatigue and approximately 75 percent report depressed mood. Of these, approximately 60 percent experience moderate or severe depression.

Dx?

Back 43

Hypercortisolism

Front 44

Depressive symptoms occur more commonly in ? patients than in (sex?) patients with Cushing's syndrome

Back 44

Depressive symptoms occur more commonly in female patients than in male patients with Cushing's syndrome

Front 45

Severity of psychiatric sx associated with Cushing's varies by?

Back 45

plasma cortisol
and ACTH levels

Front 46

What factor significantly increases chances of manic/psychotic sx in cortisolism ds?

Back 46

Manic and psychotic symptoms occur much less frequently than depression, at a rate of approximately 3 to 8 percent of patients, but rising to as high as 40 percent in patients with adrenal carcinomas.

Front 47

The psychiatric disturbances in prednisone-treated patients tend to appear within the first ? weeks of treatment and occur more commonly in (sex) than in (sex).

Back 47

The psychiatric disturbances in prednisone-treated patients tend to appear within the first 2 weeks of treatment and occur more commonly in women than in men.

Front 48

The withdrawal of steroids can also produce psychiatric disturbances, particularly
others

perisist as long as?

Back 48

depression, weakness, anorexia, and arthralgia
Other steroid-induced withdrawal symptoms include emotional lability, memory impairment, and delirium

8 weeks after corticosteroid withdrawal

Front 49

Patients presenting with mood lability or depression in association with muscle weakness,
obesity, diabetes,
easy bruising,
cutaneous striae,
acne,
hypertension

and in women
hirsutism, oligomenorrhea/amenorrhea benefit from
what kind of evaluation?

Back 49

endocrinological

Front 50

Prolactin production: inhibited by, increased by?

Back 50

inhibited by dopamine
block dopmaine increases prolactin

Front 51

Normal concentration of prolactin in men,
women
and when is concentration at peak?

Back 51

Normal concentrations
5 to 25 ng/mL in women and
5 to 15 ng/mL in men

fluctuate during the day, peaking during sleep.

Front 52

What can increase prolactin besides antipsychotics

Back 52

exercise,
stress

Front 53

Which antipsychotic not increase prolactin

Back 53

clozapine
olanzapine

Front 54

Relationship between thyroid and prolactin?

Back 54

Hypothyroidism raises prolactin concentration because thyrotropin-releasing hormone (TRH) stimulates prolactin release.

Front 55

Traumatic childhood experiences, such as separation from parents or living with an alcoholic father, have been reported to predispose to (hypo or hyper)prolactinemia

Back 55

hyper

Front 56

Stressful life events are also associated with galactorrhea
True or False?

Back 56

Stressful life events are also associated with galactorrhea, even in the absence of increased prolactin concentrations

Front 57

Low prolactin associated with
increased or decreased
libido

Back 57

decrased

Front 58

Eczema/atopic dermatitis associated with what psych ds?

Back 58

Patients with atopic dermatitis tend to be more anxious and depressed than clinical and disease-free control groups. Anxiety or depression exacerbates atopic dermatitis by eliciting scratching behavior, and depressive symptoms appear to amplify the itch perception.

Front 59

Atopic dermitis

In families that encouraged independence, children had (more, less) severe symptoms
parental overprotectiveness (increased, reduced) scratching

Back 59

In families that encouraged independence, children had less severe symptoms, whereas parental overprotectiveness reinforced scratching

Front 60

Psoriasis and psych ds?

Back 60

Controlled studies have found that patients with psoriasis have high levels of anxiety and depression and significant comorbidity with a wide array of personality disorders including
schizoid,
avoidant,
passive-aggressive, and
obsessive-compulsive personality disorders

Front 61

Depression is comorbid with rheumatoid arthritis in about ?percent of individuals.

Back 61

20

Front 62

Individuals with rheumatoid arthritis and depression commonly demonstrate poorer functional status, and they report more of the following: ??? than do patients with similar objective measures of arthritic activity without depression.

Back 62

painful joints, pronounced experience of pain,
health care use,
bed days, and inability to work

Front 63

Fibromylagia
more with women or men?

Back 63

women

Front 64

Fibromyalgia
exclude what?
associated with what psych ds?

Back 64

The diagnosis is made after excluding rheumatic disease or hypothyroidism

Depression

Front 65

recurrent unilateral headaches, with or without related visual and gastrointestinal disturbances (e.g., nausea, vomiting, and photophobia)

type of headache?

Back 65

migraine

Front 66

Migraines can be precipitated by cycling ?,

Back 66

estrogen
which may account for their higher prevalence in women.

Front 67

They are unilateral, occur up to eight times a day, and are associated with miosis, ptosis, and diaphoresis.

Back 67

cluster headaches

Front 68

Migraines and cluster headaches are best treated with ?

Back 68

during the prodromal period with ergotamine tartrate (Cafergot) and analgesics.

Sumatriptan (Imitrex) is indicated for the short-term treatment of migraine and can abort attacks.

Front 69

The scalp may be tender to the touch and, in contrast to a migraine, the headache is usually bilateral and not associated with prodromata, nausea, or vomiting

Back 69

Tension Headache

Front 70

Tension headaches are frequently associated with anxiety and depression and occur to some degree in about ? percent of persons during periods of emotional stress.

Back 70

80

Front 71

Cognitive-behavioral therapy approaches to stress management have three major aims:

Back 71

(1) to help individuals become more aware of their own cognitive appraisals of stressful events,

(2) to educate individuals about how their appraisals of stressful events can influence negative emotional and behavioral responses and to help them reconceptualize their abilities to alter these appraisals, and

(3) to teach individuals how to develop and maintain the use of a variety of effective cognitive and behavioral stress management skills.

Front 72

Five skills form the core of almost all stress-management programs:

Back 72

self-observation (diary)
cognitive restructuring (realistic vs disortions)
relaxation training (e.g. PMR)
time management, and
problem-solving

Front 73

Progressive Muscle Relaxation is what type of behaviour therapy?

Back 73

systematic desenstization

Front 74

Biofeedback and related techniques have been useful in ?

Back 74

tension headaches, migraine headaches, and Raynaud's disease

Front 75

Time management approach

Back 75

Have pts create life categories (family, exercise, leisure)
Diary life and compare to desired % of time in each category