Mgmcri psychiatry bulletin mind & medicine 2013 1 1

MIND & MEDICINE

Vo l u m e 1 Issue 1

Quarterly bulletin of the Department of Psychiatry

July-September

MAHATMA GANDHI MEDICAL COLLEGE & RESEARCH INSTITUTE ● PONDICHERRY ● INDIA

2013

“From the brain, & from the brain alone, arise our pleasures, joys, laughter & jokes, as well as our sorrows, pains, griefs & tears. Through it, we think, see, hear, & distinguish the ugly from the beautiful, the bad from the good, the pleasant from the unpleasant…”

- Hippocrates, 5th century BC

EDITORS Dr. Sivaprakash B Dr. Abu Backer S ASSOCIATE EDITORS Dr. Eswaran S Dr. Sukanto Sarkar Dr. Vinodh Kumar J

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MIND & MEDICINE ● 2013 ● Volume 1 ● Issue 1 Dr. Donald Black & Dr. Nancy Andreasen, University of Iowa College of Medicine, USA, have made impressive & fascinating statements about the brain, mental health & Psychiatry, in their popular “Introductory Textbook Of Psychiatry” (5th edition, 2011). A few excerpts are provided here:

Our ability to think, to feel emotions, and to relate to other people in normal ways depend on the activity of this complex organ. The disturbances in thought, emotion, and behavior that we observe in the mentally ill also are ultimately due to aberrations in the brain.

PSYCHIATRY is one of the most exciting disciplines within medicine. Psychiatrists are specialists who work with a very interesting organ the brain. The brain is intrinsically fascinating because it controls nearly all aspects of functioning within the rest of the body as well as the way people interact with and relate to one another.

The drive of modern psychiatry is to develop a comprehensive understanding of normal brain function at levels that range from mind to molecule and to determine how aberrations in these normal functions (produced either endogenously through genetic coding or exogenously through environmental influences) lead to the development of symptoms of mental illnesses.

All of our emotions, thoughts, beliefs, and behaviors arise from the workings of that furrowed and folded chunk of tissue that is so carefully protected inside our skulls. The human brain has created and invented the myriad achievements that surround us every day skyscrapers, computers, complex economic markets, advances in medical science ranging from vaccines to antibiotics to magnetic resonance scanners, an understanding of quantum mechanics and chaos theory, and art, music, and literature. These achievements have been accomplished because the human brain is one of the most complex systems in the universe. Composed of more than 100 billion neurons (more nerve cells than the stars in the Milky Way), the brain expands its communicating and thinking power by multiplying connectivity through an average of 1,000 - 10,000 synapses per nerve cell!

The synapses are “plastic” in that they remodel themselves continuously in response to changes in their environment and the inputs that they receive.

The brain is composed of feedback loops and circuits composed of multiple neurons, further expanding the fine-tuning and thinking capacities.

Psychiatry has rapidly advanced in recent years through the burgeoning of neuroscience, which has provided psychiatrists with the tools by which they can understand brain anatomy, chemistry, and physiology, thereby gradually developing a scientific base that will permit them to understand human emotion and behavior and to develop methods for treating abnormalities in these domains.

As psychiatry evolves into a relatively high-powered science, it remains a very clinical and human branch within medicine. The clinician working in psychiatry must spend time with his or her patients and learn about them as human beings as well as individuals who have illnesses or problems.

Mental illnesses are among the most clinically important diseases from which human beings suffer.

In 1996, two investigators at Harvard University, working in collaboration with the World Health Organization, published a pivotal book titled “The Global Burden of Disease”. This book provided the first objective summary of the costs of various types of illness to society throughout the world.

One head-turning fact is the cost exacted by mental illnesses. For example, unipolar major depression is the costliest illness in the world.

Furthermore, four mental illnesses are among the top 10 diseases affecting people between ages 15 and 44 years: depression, alcohol misuse, bipolar disorder, and schizophrenia. Because self-inflicted injuries are also a consequence of mental illness, 5 of the 10 leading causes of disability in the world are attributable to psychiatric disorders.

The message is clear: Doctors can no longer afford to ignore mental illnesses.

Department of Psychiatry

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MGMCRI ● Pondicherry 607402

MIND & MEDICINE ● 2013 ● Volume 1 ● Issue 1

Why do matters of the mind matter? - Mental health & physical disease The magnitude of mental-physical comorbidity (Cowen et al, 2012): People with chronic physical conditions have a greater probability of developing mental disorders such as depression. 1/3rd of people attending medical & surgical outpatient clinics have a psychiatric disorder. Half of these have depressive & anxiety disorders. 20% of medical & surgical inpatients have a comorbid depressive or anxiety disorder. Psychiatric disorder is present in 1/3rd of patients with serious acute, recurrent, or progressive medical conditions.

The clinical implications of psychological factors (Cowen et al, 2012): Comorbid mental disorder can affect the impact & outcome of medical conditions. Psychiatric comorbidity results in lower adherence to treatment, lower quality of life, increase in disability & mortality, & higher health costs.

Psychosomatic medicine seeks to advance the scientific understanding & multidisciplinary integration of biological, psychological, social factors in human health & disease, & incorporate this understanding into health care (Lane & Wager, 2009). The mind, a product of the brain, influences physical health through three brain-body information transfer systems, namely, the autonomic nervous system (ANS), neuroendocrine pathways & neuroimmune pathways, & the health behavior pathway (eating sensibly, adequate sleep, regular exercise, avoiding smoking, treatment compliance etc.). For example, depression is associated with deranged autonomic regulation of cardiac function (ANS pathway), cortisol dysregulation (neuroendocrine pathway), & increased level of IL-6 & CRP (neuroimmune pathway) (Shapiro, 2005). Mental illness affects health behavior too.

Physical illness makes detection of mental health problems more difficult. Patients & doctors tend to focus on physical symptoms, during consultations. Comorbid mental disorders & stress are often under-recognized. The PHQ-9 Depression Scale, General Health Questionnaire, Hospital Anxiety & Depression Scale & the Perceived Stress Scale are simple & popular screening measures that facilitate the mental health screening of patients with chronic medical conditions. There is evidence for benefits of collaborative care in which medical & psychiatric treatment are coordinated, especially in chronic medical conditions (Cowen et al, 2012). Antidepressant treatment is efficacious in patients with comorbid depression & chronic medical illness, & improves their overall medical outcomes. (WHO, 2003). Cognitive-behavioral therapy for people with co-morbid long-term medical conditions improves treatment adherence, adjustment & coping, & quality of life (Naylor et al, 2012).

Physical & mental comorbidity is common, & has serious implications for overall outcome. Comorbid mental disorders are often under-recognized & not treated. Negative emotions / chronic stress have deleterious effects on health. Addressing stress & mental health issues of patients with physical disease can improve quality of care.

Mental health screening of patients with chronic medical conditions such as diabetes mellitus & coronary artery disease can detect psychological problems. Mental health care & stress management strategies need to be integrated with physical health care to achieve holistic care & improve health outcomes.

References Cowen, P., Harrison, P.J., Burns, T., 2012. Shorter Oxford textbook of psychiatry. Oxford University Press, Oxford; New York.

Lane, R.D., Wager, T.D., 2009. The new field of Brain-Body Medicine: what have we learned & where are we headed? Neuroimage 47, 781-4.

Naylor, C., et al., 2012. Long-term conditions & mental health : the cost of co-morbidities. King’s Fund, London.

Shapiro, P.A., 2005. Heart disease. In: Levenson, J.L. (ed.) Essentials of psychosomatic medicine. American Psychiatric Pub., Washington, DC; pp. 423-444.

World Health Organization, 2003. Investing in mental health.

Department of Psychiatry

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MIND & MEDICINE ● 2013 ● Volume 1 ● Issue 1

Case report Mr. S, a 42-year-old married male, was referred to us in July 2013, for evaluation of several “medically unexplained physical symptoms”. The patient had suffered from myriad somatic symptoms for 10 years. These included abdominal discomfort & a dull, diffuse pain over the left jaw. His descriptions of these symptoms were vague & inconsistent. He had relentlessly consulted several specialists over the years, including neurologists, orthopedic surgeons, dental surgeons & otorhinolaryngologists. He had spent a large sum of money on several costly investigations & treatment procedures. A series of investigations done in the past, including USG of abdomen, UGI endoscopy, MRI of the spine and brain, & a sialogram, were non-contributory. Various diagnostic possibilities such as trigeminal neuralgia, Frey’s syndrome and Sjogren’s syndrome had been documented in the past, by his doctors. He had undergone 2 surgical procedures, including a tooth extraction, and had diligently followed various prescriptions. However, there had never been a significant remission of symptoms. He had consistently shown excessive somatic preoccupation, and had often believed that he was being neglected by his physicians, and had been reluctant to accept any reassurance. His family members reported that he had always been dull, lethargic, & that his somatic symptoms occupied centre stage in all spheres of his life, resulting in significant impairment in socio-occupational and interpersonal domains.

We admitted this patient and a thorough examination was conducted, followed by referrals to the Departments of Orthopedic Surgery, General Medicine, and Otorhinolaryngology. Recommended investigations were done, which revealed disc degeneration at C6-C7 level, and an oro-antral fistula. However, it was opined that the pattern & severity of his symptoms could not be adequately explained by these findings.

In accordance with the WHO-ICD classification, diagnoses of Undifferentiated Somatoform Disorder (F45.1) & Dysthymia (F34.1) were made. Appropriate psychopharmacological intervention was initiated, along with mental health education & cognitive-behavioural therapy. On follow-up, he reports improvement in symptoms & has currently resumed his work. It is apparent that early detection of mental health problems & a timely referral to mental health services could have significantly curtailed the magnitude of financial burden & the suffering experienced by Mr. S & his family over a decade.

Somatoform disorders are characterized by multiple somatic symptoms that cannot be fully explained by a physical disorder, & are associated with distress & impairment that are in excess of what would be expected from the history, physical examination & laboratory findings. Somatoform disorders are quite common. Up to 30% of primary care patients present with unexplained symptoms, & a substantial proportion of them have a somatoform disorder. Dysthymia is a chronic depression of mood that usually begins early in adult life and lasts for several years, sometimes indefinitely. A combination of genetic, psychosocial & neurobiological factors play a role in the etiology of somatoform disorder & dysthymia. Neurophysiological dysfunction in the attention process has been demonstrated in somatoform disorder, which may be explained by a reduced corticofugal inhibition in the diencephalon & the brainstem of afferent bodily stimuli, resulting in insufficient filtering of irrelevant bodily stimuli. A dysfunction of the secondary somatosensory area in the brain, & a hypersensitivity of the limbic system towards bodily stimuli may be involved.

Bibliography Black DW, Andreasen NC. Introductory textbook of psychiatry. 5th ed. Washington, DC: American Psychiatric Publishing; 2011.

Fink P. Somatization disorder and related disorders. In: Gelder MG, Andreasen NC, Lopez-Ibor Jr JJ, Geddes JR, editors. New Oxford textbook of psychiatry. 2nd ed. Vol. 2. New York: Oxford University Press; 2009. p. 999-1011.

Sadock BJ, Sadock VA. Kaplan and Sadock’s synopsis of psychiatry. 10th ed. Philadelphia: Lippincott Williams & Wilkins; 2007.

World Health Organization. The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. Geneva: World Health Organization; 1992.

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