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
