Psychosomaticslecture

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HistoryofpsychosomaticsIFromtheverybeginningofthemedicineitwas

dividedbytheparadigmaticdualism:medicineoforgansvs.medicineoffunctions

Primitivemedicine:shamanicmedicine,CentralAmerica‘sLadynos;�  TheideaexpressedinOldTestament,thatbodyhealthisinseparablefromthehealtofsoul(BookofJob)�  Plato:“...partcannotbehealthyiftheunityisnothealthy”(Charmides)�  ErasistratusfromAlexandria(IIIB.C.)diagnosed„incurable“diseaseofthesonofthekingofSyriawhichwasduetotheloveofthefathersnewwifeStratonike,andhewascured(!);

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HistoryofpsychosomaticsIIInthemedievalIslamicworldthePersianpsychologist-physiciansAhmedibnSahlal-Balkhi(d.934)andHalyAbbas(d.994)developedanearlymodelofillnessthatemphasizedtheinteractionofthemindandthebody.Theyproposedthatapatient'sphysiologyandpsychologycaninfluenceoneanother.

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HistoryofpsychosomaticsIII�  RenéDescartes(1596–1650,France)–oneofmaintheoreticiansof„dualism“,whodividedphenomenainttwocathegories-“resextensa”and“rescogitans”(however,originallystatingitwillnotapplyformedicine)�  BaruchSpinoza(1632–1677,theNetherlands)thought,thateveryeventinthepsychehasitsparalleleventinthebody–“ideoplasia”�  G.W.Leibnitz(1646–1716,Germany)thought,thatthereisnointerconnectionbetweenbodyandsoul,butpredestinedcoordinationoftheeventsinbothrealms–„aharmony“

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Historyofpsychosomatics

�  J.C.Heinroth(1773–1843,Germany)–theauthoroftheterm„psychosomatics“(1818),usedtodescribethedevelopmentofinsomnia

�  H.Maudsley(1835–1918,UK)–“Ifemotionsarenotexpressedbytheexternalsignsortheworkoftheorganism,theyinfluenceourorgansanddamageitsfunctions;[e.g.]sadnessisbestexpressedthroughtearsandlament...”(1876)

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HistoryofpsychosomaticsV�  S.Freud‘spsychoanalysiswasatheoreticalbackgroundforthedevelopmentofpsychoso-maticsinthe1sthalfoftheXXcentury.Mostprominentauthorsofthisperiodwere:◦ F.Dunbar(handbookin1948)◦ F.Alexander(handbookin1950)◦ F.Deutsch(handbookin1953)

�  Essentialparadigmofallthesetheorieswasaconceptofintrapsychicconflictanditsinfluenceonthepathologyoftheorgansystems.

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HistoryofpsychosomaticsAfterWWIImaincenterofthedevelopmentof

psychosomatics becameNorth America and Europe(esp. Germany). Until now in many Germanuniversities clinics of psychosomatic medicine areactive (sometimes combined with psychotherapy),andmanypsychosomaticdepartmentsorwardsareoperatinginNHCS(e.g.,inKur‘s).MaintheoreticiansoftheendofXXcentury:�  Th.vonUexküll,M.vonRad(Germany)�  P. Sifneos, J. C. Nemiah, M. Freedman, R.Rosenman,T.Holmes,R.Rahe(USA)�  Z.Lipowsky(Canada)

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Maintheoreticalparadigmsofpsychosomatics

1.  Personality–specificparadigmofpsy-chosomatics

2.  Event–specificparadigmofpsychoso-matics

3.  Unspecificparadigmofpsychosomatics

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Personality–specificparadigmofpsychosomatics

�  S.Freud:“Somaticsymptomsmaybeproducedbypsychologicalcauses”

Thisgeneralstatementwasinterpretedbyseveralauthorsinaspecificways:�  F.Dunbar–lookingforarelationshipbetweenspecificpersonalitytypesandrespectivediseases;�  F.Alexander–connectedspecificintrapersonalconflicts(betweenaggressionandthedependencyneed)inspecialsituationswithspecificpsychosomaticreactions:

◦  DominanceoftheSympatheticnervoussystemincaseoftherepressionofaggression(hypertension)◦  DominanceoftheParasympatheticnervoussystemincaseoftherepressionofdependencyneeds(rheumatoidarthritis,ulcer)

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ConceptofPsychosomatics

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InSF AcSF

AcPF InPF

Personalityspecificpsychosomatics

Aleksithymia(a-lexis-thymos)isaconceptofarelationbetweenunexpressedemotionsinlanguageofthesubjects(contentanalysis)andpsychosomaticdiseases:�  Healthysubject�  Neuroticpatients�  PsychosomaticpatientsP.E.SifneosandJ.Nemiah(1972-1973),

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2,5X

TypeAbehaviour(TAB)TABfoundbyM.FriedmanirR.H.Rosenmanin1959

m.ResearchprojectwascarriedintheInstituteofHeart,Lungs,andBloodofChicago,included3460healthymen49–54yearsofage.Itwasafirstprospectivestudyinafieldofpsychosomatics.TwotypesofbehaviorswerefoundconnectedwithCHDandlabeledA/B.EssentialfeaturesofTAB:

1.  Constanttimerestrain1.  “Steppingupon”theendofthesentence2.  Inabilitytodrive„atthetail“3.  Rushtomakeallpossiblejobs

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TypeAbehaviour(TAB)2.Aggressiontowardslife:

•  Loud,overpowering,anddecisivespeech•  Inabilitytoloseatanysituation•  Inabilitytovaluedonejobs•  Attemptstodomoreandmore

3.Thisproducesaconstantstresssituation:1.  PeriorbitalhyperpigmentationHypophysisACTH(+TTH) pigment

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TypeAbehaviour(TAB)ImpactofTABoncoronaryheartdisease:

�  TABdemonstratingsubjectsmaketo98,5%ofthosewithCHDandMI;�  Innateformsmakeonlyabout20%ofcases,therest–conditionedTAB�  TABcanbemodified,andaftermodificationtheriskofasecondMIdecreasessubstantially(intheexperimentalgroupMIhappened45%lessduring4yearsfollow-upafterfirstMI,andevenamonghealthycontrolstheincidenceofMIwassignificantlylower,thaninthepopulation)�  TABmodificationispossibleonlybyPTmeans

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TypeAbehaviour(TAB)ProblemsindiagnosticsofTAB:

�  Onlyapartofsymptomscanbediagnosedusingtests(only17of35canbediagnosedbypsychologicinstruments)�  Behaviouralsymptoms(18)canbediagnosedonlyafterspecializedtraining�  Absolutemajority(85%)ofcardiologistsdemontrateTABthemselves(Blankenhornetal.,1981)

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Event-connectedpsychosomatics� Vietnamwar(1959[1964-USA]–1975)veteransfromUSA(19–22m.)after12monthsinjunglehadscleroticchangesintheiraortas,resemblingthesameas55–60yearsoldinanordinarylifeconditions.� Thelossofaspouse–increasesarisktodieinconsecutive6months(mainlyforheartattack)2x,comparedtothesameagesubjectwhohasn’tlostthespouse.

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Event-connectedpsychosomatics�  Processofmourninganditspsychosomaticconsequences.�  Stages:◦  Denialandaggression◦  Acceptanceanddepression(frequentpaindisorders):

�  Vague(non-specific)�  Identificatory(intheorganorsystem,wherethediseaseofthedeceasedwaslocalized

◦  ReadaptationAgriefwhichisnotcompletedincreasesthe

riskofpsychosomaticdisorderssignificantly!18

Nonspecificconceptofpsychosomatics

�  Stress(generaladaptationsyndrom)conceptwasintroducedbyHansSelyein1936.�  In1975hedivideditintoeustress(whichincreasesaresistanceofthesubject)andadistress(whencompensationmechanismsareexhausted,anddis-adaptationstarts).Extentofstressdependson:◦  Experienceofchange(inexternalorinternalreality)◦  Personalexpectations◦  Copingmechanisms

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Stresscurve

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Physiologyofthestress

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StressResponse

OptimalPositiveStress

FlightEscapeStressor

FightConfrontStressor

FreezeSurrenderto

Stressor

Intensity and duration of stressor

Ability to mediate stressor

High

High Low

Low

The Stress Response Continuum

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Socialreadaptationscale�  T.HolmesirR.Rahein1967proposedthescaleformeasuringlifechanges(LCU)aftertheevaluationoftheimpactofdifferentlifeeventsonthesomatichealthof>5000in-andout-patientscasehistories.Itwasdemonstarted,thatforbothchildrenandadults,whocollectedinapreviousyearLCU‘s:

>300–highriskofdisease299÷150–moderateriskofdisease≤149–lowriskofdisease

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LCUscaleforadultsLIFECHANGEUNITS

EVENTIMPACT

[]DEATHOFSPOUSE100

[]DIVORCE73

[]MARITALSEPARATION65

[]JAILTERM63

[]DEATHOFCLOSEFAMILYMEMBER63

[]PERSONALINJURYORILLNESS53

[]MARRIAGE50

[]LOSSOFJOB47

[]MARITALRECONCILIATION45

[]RETIREMENT45

[]CHANGEINHEALTHOFFAMILYMEMBER44

[]PREGNANCY40

[]SEXDIFFICULTIES39

[]GAINOFNEWFAMILYMEMBER39

[]BUSINESSREADJUSTMENT39

[]CHANGEINFINANCIALSTATE38

[]DEATHOFCLOSEFRIEND37

[]CHANGETODIFFERENTLINEOFWORK36

[]CHANGEINNUMBEROFARGUMENTSWITHSPOUSE35

[]DEBTOFMORETHAN$10,00031

[]TROUBLEWITHIN-LAWS29

[]OUTSTANDINGPERSONALACHIEVEMENT28

[]SPOUSEBEGINSORSTOPSWORK26

[]BEGINORENDSCHOOL26

[]REVISIONOFPERSONALHABITS24

[]TROUBLEWITHBOSS23

[]CHANGEINWORKHOURSORCONDITIONS20

[]CHANGEINRESIDENCE20

[]CHANGEINSCHOOLS20

[]CHANGEINRECREATION19

[]CHANGEINCHURCHACTIVITIES19

[]CHANGEINSOCIALACTIVITIES19

[]DEBTOFLESSTHAN$10,00017

[]CHANGEINSLEEPINGHABITS16

[]CHANGEINNUMBEROFFAMILYGET-TOGETHERS15

[]CHANGEINEATINGHABITS15

[]VACATION13

[]CHRISTMAS12

[]MINORVIOLATIONSOFTHELAW11

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MediatingStressThe amount of stress we experience in a given situation is mediated by our perception of how prepared we are to effectively confront it. Sapolsky (2004) has argued that the amount of stress experienced is determined by two psychological factors:

CONTROL PREDICTABILITY

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MediatingStressCONTROL: The feeling that one is in control of the situation buffers the individual against stress. EX: A well-trained and well-armed police officer feels a relatively high degree of control most of the time, and thus they experience less stress than a civilian would in a similar situation. PREDICTABILITY: Being familiar with a crisis-producing situation, including the potential outcomes, also provides a buffer against stress. EX: As a result of training and experience, a police officer knows what to expect most of the time when entering a crisis situation. This high level of predictability increases control and reduces stress.

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MediatingStressLOCUS OF CONTROL (Rotter, 1954, 1990) A person can have either an INTERNAL or EXTERNAL locus of control. Those with an internal orientation believe they are in control of their own destiny, regardless of the circumstances. Those with an external orientation believe their fate is determined by external forces, and that they have little control over their circumstances. Self-efficacy is the belief one has in their ability to achieve a successful outcome. High self-efficacy leads to a high level of confidence. Thus the following…

Internal locus + Self-efficacy = Control

Experience + Training = Predictability

Control + Predictability = Reduced levels of stress 28

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MediatingStressLOCUS OF CONTROL (Rotter, 1954, 1990)

Assertive

Helpless

Confident

Cautious

Doubting

Indecisive

Low

High

Abi

lity

to m

edia

te th

e st

ress

or

High

Low

Leve

l of

stre

ss e

xper

ienc

e

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MediatingStress

WHAT DOES IT ALL MEAN? 1.  It is important that those agencies tasked with

crisis response focus their hiring and recruiting efforts on individuals who demonstrate an INTERNAL orientation.

2. Repetitive and realistic training is critical to increasing a sense of control and predictability in those who respond to crisis.

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