Lecture 4: Anxiety, Depression, and Somatic Distress Flashcards
Illness and Disease
Illness
-Characterized by subjective suffering of the patient and associated behaviors
Disease
-Characterized by objective evidence of a biophysical reality (pathology) underlying the patient’s symptoms
Implications of the Biomedical Model
Biomedical model
- Illness is explained by a discernible biophysical process (i.e., pathology)
- Disease causes illness
- Health is dichotomous (sick vs. well)
Illness judged to be caused by disease
- Legitimate
- Non-voluntary
- Patient “not responsible”
The Roots of Stigma
Reality challenges the biomedical model
- ~ ¼ to ½ of outpatients suffer from MUS
- Unclear pathophysiology of anxiety and depression
Illness in the absence of disease is often perceived as:
- “Illegitimate”
- “Self-caused” (under voluntary control)
- A sociomoral problem or failure
Psychological causation model implied
- Parallel “mental health” care system
Common Terminology
Physical symptoms absent explanatory structural findings (“tissue damage” or pathology),
pathophysiologic changes,or biochemical abnormalities:
Functional Somatic Symptoms (FSS)
- Refers to a change in function rather than structure
- Reifies the symptom, but sidesteps issue of causality
Medically Unexplained Symptoms (MUS)
- Deceptively neutral term
- Risks implying that symptoms are outside the realm of
medical experience and that the problem is “undiagnosable” (“The doctors don’t what’s wrong!”)
Functional Somatic Symptoms (FSS) Relevance
- Common
- Individual and family suffering
- Functional impairment
- “Comorbid” somatic and psychiatric symptoms & disorders
- Predict future somatic and psychiatric symptoms & disorders
- Health service overuse/costs
- Risk of iatrogenic illness
Medically Unexplained Symptoms Diagnostic and Conceptual Challenges
Description at symptom level»
–Initial focus often on presenting symptom
But - most patients have multiple symptoms
–Focus often on interest of medical specialist
But - symptoms are often broader than specialist interest
–Distress considered “physical” or “mental”
But – physical symptoms commonly coexist with emotional symptoms like anxiety or depression
Description at syndrome/disorder level»_space;
Symptoms commonly overlap and cluster
Medically Unexplained Symptoms (MUS)
Deceptively neutral term
Risks implying that symptoms are outside the realm of
medical experience and that the problem is “undiagnosable” (“The doctors don’t know what’s wrong!”)
Functional Somatic Symptoms (FSS)
Refers to a change in function rather than structure
Reifies the symptom, but sidesteps issue of causality
Reify
to make (something abstract) more concrete or real.
Medically Unexplained Symptoms (MUS):
Rationale for Establishing a Diagnosis
The foundation of clinical care
Necessary communication for:
- -Clinical care
- -Education/Training
- -Research
Predict course and prognosis
Direct treatment efforts
MUS Differential Diagnosis:
A Hierarchy of Stigma?
Unrecognized physical disease
–Sometimes MUS are just that, Unexplained…
Functional somatic syndrome/disorder:
- -Real, physical, and medically unexplained
- -Non-intentional, non-voluntary
- -Typically classified by medical specialty: Irritable Bowel Syndrome (Gastroenterology), Chronic Fatigue Syndrome (Infectious Disease), Fibromyalgia (Rheumatology), Chronic pelvic pain (Obstetrics-Gynecology)
Functional somatic syndromes typically overlap:
- -With other functional somatic syndromes
- -With anxiety and depressive (“emotional” disorders)
MUS Differential Diagnosis cont…
Mental/psychiatric disorder
–“Real”, mental, and medically unexplained
–Non-intentional, non-voluntary
Somatoform (DSM IV)/Somatic Symptom (DSM5) disorders;
“Emotional” disorders (Anxiety and/or Mood Disorders)
Deliberate deception:
Intentional, voluntary enactment of illness
– Malingering
– Factitious disorder/Factitious disorder by proxy
FSSs and Emotional Disorders
Commonly Shared Characteristics
One MUS/FSS predicts another
- -Cross-sectionally and longitudinally
- -Studies are often limited by incomplete assessment
Association with anxiety and depression
- -Cross-sectionally and longitudinally
- ↑ levels of MUS associated with ↑ emotional symptoms
Association with life adversity
- -Early life adversity/trauma a risk factor
- -Concurrent life adversity a precipitant
Shared familial vulnerability
From Symptom, to Syndrome, to Disorder…
Functional Abdominal Pain (FAP) example
Functional abdominal pain (FAP) is perhaps the best studied FSS
Definition: >3 episodes of impairing abdominal pain over
a period of at least 3 months in the absence of explanatory structural or biochemical abnormalities
–No evidence of traditional disease
FAP Children:
More childhood anxiety, depression, and other somatic symptoms than controls
–Cross-sectionally and longitudinally
More FSS, anxiety/depression longitudinally
More parental anxiety/depression and other MUS/FSS
Greater exposure to life adversity
FSSs and Emotional Disorders:
Commonly Shared Characteristics: Threat sensitivity
Temperamental antecedents:
- Neuroticism, negative affect, harm avoidance
- Response to life challenge at lower thresholds: Acoustic startle, visceral hypersensitivity, immune activation
Perceptual bias for threatening stimuli
–Visceral hyperalgesia, anxiety sensitivity
Gene-environment interactions
- -Serotonin (5-HT) neurotransmission relevant to anxiety, depression, visceral pain, gut motility, and response to adversity
- Exaggerated amygdala responses linked to s/s functional polymorphism in the promoter region of the serotonin transporter gene (5HTTPR), which also moderates impact of life events on the development of depression
FSSs and Emotional Disorders
Commonly Shared Characteristics (cont.)
Support for a shared neural system for interpersonal/social distress and somatic pain
- Heightened sensitivity to pain and social interactions
- Problems down-regulating pain and interpersonal distress
- Involvement of anterior cingulate cortex (ACC) and Insula
- Relevance of amygdala and threat detection
FSSs and Emotional Disorders
Commonly Shared Characteristics: Repsonses
Similar response to coping strategies
– Passive coping:
Avoid confronting pain (avoidance, wishful thinking).
↑ levels anxiety/depression/pain.
– Accomodative coping
Accept and adjust to pain/distress.
↓ levels anxiety/depression/pain.
– Active coping
Problem focused to make pain “go away.”
↓ levels anxiety/depression but +/- pain.
Similar treatment responses
- CBT, relaxation, rehabilitative strategies
- Antidepressants
Serotonin and Threat Perception A Role Across Disorders?
95% of body’s serotonin is in gut
- 90% enterochromaffin cells
- 5% enteric neurons
- Serotonin transporter identical to that of the CNS
Role in gut sensation and motility
- Response to perceived threat
- 5-HT release with ↑ intraluminal pressure
- Stimulates 5-HT3 and 5-HT1p receptors
- Descending pain modulation pathways
GI Distress to Serotonergic Challenge:
A Risk Marker for Emotional Disorder?
??
Behavioral Inhibition:
Variation in the fear circuit?
10%-15% of Caucasian children
Shy, inhibited, cautious
- Tendency to withdraw from novelty
- No or few spontaneous comments
- No or few spontaneous smiles
Differences in stress reactivity
- ↑ Startle response
- ↑ Resting HR and ↓ HR variability
- ↑ Limbic-sympathetic arousal
Predicts future anxiety disorders
Familial and heritable -- Concordance of .5-.9 in twin pairs -- First degree relatives: ↑ Prevalence behavioral inhibition ↑ Prevalence anxiety and depression
FSSs and Emotional Disorders:
One Disorder or Many?
Separate, specific symptoms vs. Separate, specific disorders vs. A “general neurotic syndrome” where heterogeneity in the expression of symptoms reflects phenotypic variation in the manifestation of a broader syndrome
Reconceptualizing Emotional Disorders:
What Are Emotions?
Brain states associated with the perception of:
– Reward: A stimulus the organism will make an effort to
obtain»_space; APPROACH
– Punishment/threat: A stimulus the organism will make an effort to avoid»_space; AVOIDANCE
Rooted in a neural circuitry:
Inputs » Appraisal
– Natural triggers, Learned triggers
Outputs » Response
- -Mediate behaviors critical to survival
- -Generate bodily responses
Feelings are secondary
- Awareness of emotion is not a given
- Requires capacity for consciousness, which is mediated by different brain regions
Fear
Brain state(s) associated with perception of punishment/threat
Neural system to detect and respond to danger
Importance of the Amygdala:
- Central to fear circuitry
- Medial temporal lobe structure
- Almond shaped
- Anterior to hippocampus
Amygdala
Input»_space; appraisal»_space; output
Behavioral responses:
- Freezing to distal threat
- Fight/flight to immediate threat
Physiologic responses
Pain
Is Pain an Emotion?
Brain state(s) associated with perception of physical harm
Neural system (pain matrix) to detect danger that includes the amygdala -- Amygdala integrates pain with fear/anxiety
Components:
- Distress
- Avoidance behaviors
Anxiety
Brain state(s) associated with fear inappropriate to context
Components:
- Distress
- Avoidance behaviors
Functional Pain
Brain state(s) associated with perception of physical harm inappropriate to context
Components:
- Distress
- Avoidance behaviors
Management
Centrality of the Rehabilitative Approach
Encourage a rehabilitative mindset
- Avoid promises of cure
- Anticipate chronicity
- Illness as a challenge to overcome
- Emphasis on patient’s strengths and competence
Offer family guidance and support
- Balancing role as “coach” vs. “protector”
- Overcoming distress as a growth experience
- Return to function often precedes ↓ symptoms
Psychotherapeutic Management
Cognitive Behavioral Therapy (CBT)
Core features:
- Cognitive restructuring: Addresses maladaptive thinking and how to counteract it
- Behavioral Activation: Encourages return to usual routines and functioning, and Planning rewarding activities even if not feeling motivated
Associated skill building elements of CBT
- Self-management (e.g., relaxation training)
- Problem solving
Not all CBT approaches are the same
– Different manuals and emphases
Pharmacologic Management
Reasons for Excitement
Well-suited to medical settings
Limitations of psychotherapy
Data on short-term benefits and safety
Evidence that treatments successful for anxiety and depressive disorders are often helpful in patients with FSSs
Patient and family preferences
Mechanism of action?
