Learning Objectives
- Describe how psychological factors affecting other medical conditions presents.
- List and describe the most common types of psychophysiological disorders.
- Describe treatment options for psychological factors affecting other medical conditions.
Although previously known as psychosomatic disorders, the DSM-5-TR has identified physical illnesses that are caused or exacerbated by biopsychosocial factors as psychological factors affecting other medical conditions. This disorder is different than all the previously mentioned somatic related disorders as the primary focus of the disorder is not the mental disorder, but rather the physical disorder. Psychological or behavioral factors adversely affect the medical condition by, “…influencing its course or treatment, by constituting an additional well-established health risk factor, or by influencing the underlying pathophysiology to precipitate or exacerbate symptoms or to necessitate medical attention” (APA, 2022, pg. 365). It is believed that a lack of positive coping strategies, psychological distress, or maladaptive health behaviors exacerbate these physical symptoms (McGeary, Harzell, McGeary, & Gatchel, 2016).
Psychophysiological Disorders
The most common types of psychophysiological disorders are headaches (migraines and tension), gastrointestinal (ulcer and irritable bowel), insomnia, and cardiovascular-related disorders (coronary heart disease and hypertension). We will briefly review these disorders and discuss the associated psychological features believed to exacerbate symptoms.
8.6.1.1. Headaches. Among the most common types of headaches are migraines and tension headaches (Williamson, 1981). Migraine headaches are often more severe and are explained by a throbbing pain localized to one side of the head, frequently accompanied by nausea, vomiting, sensitivity to light, and vertigo. It is believed that migraines are caused by the blood vessels in the brain narrowing, thus reducing the blood flow to various parts of the brain, followed by the same vessels later expanding, thus rapidly changing the blood flow. It is estimated that 23 million people in the U.S. alone suffer from migraines (Williamson, Barker, Veron-Guidry, 1994).
Tension headaches are often described as a dull, constant ache localized to one part of the head or neck; however, it can co-occur in multiple places at one time. Unlike migraines, nausea, vomiting, and sensitivity to light do not often occur with tension headaches. Tension headaches, as well as migraines, are believed to be primarily caused by stress as they are in response to sustained muscle contraction that is often exhibited by those under extreme stress or emotion (Williamson, Barker, Veron-Guidry, 1994). In efforts to reduce the frequency and intensity of both migraines and tension headaches, individuals have found relief in relaxation techniques, as well as the use of biofeedback training to help encourage the relaxation of muscles.
8.6.1.2. Gastrointestinal. Among the two most common types of gastrointestinal psychophysiological disorders are ulcers and irritable bowel syndrome (IBS). Ulcers, or painful sores in the stomach lining, occur when mucus from digestive juices are reduced, allowing digestive acids to burn a hole into the stomach lining. Among the most common type of ulcers are peptic ulcers, which are caused by the bacteria H. pylori (Sung, Kuipers, El-Serag, 2009). While there is evidence to support the involvement of stress in the development of dyspeptic symptoms, the evidence linking stress and peptic ulcers is slowly growing. (Purdy, 2013). Researchers believe that while H. pylori must be present for a peptic ulcer to develop, increased stress levels may impact the amount of digestive acid present in the stomach lining, thus increasing the frequency and intensity of symptoms (Sung, Kuipers, El-Serag, 2009).
IBS is a chronic, functional disorder of the gastrointestinal tract. Common symptoms of IBS include abdominal pain and extreme bowel habits (diarrhea or constipation). It affects up to a quarter of the population and is responsible for nearly half of all referrals to gastroenterologists (Sandler, 1990).
Because IBS is a functional disorder, there are no known structural, chemical, or physiological abnormalities responsible for the symptoms. However, there is conclusive evidence that IBS symptoms are related to psychological distress, particularly in those with anxiety or depression. Although more research is needed to pinpoint the timing between the onset of IBS and psychological disorders, preliminary evidence suggests that psychological distress is present before IBS symptoms. Therefore, IBS may be best explained as a somatic expression of associated psychological problems (Sykes, Blanchard, Lackner, Keefer, & Krasner, 2003).
8.6.1.3. Insomnia. Insomnia, the difficulty falling or staying asleep, occurs in more than one-third of the U.S. population, with approximately 10% of patients reporting chronic insomnia (Perlis & Gehrman, 2013). While exact pathways of chronic psychophysiological insomnia are unclear, there is evidence of some biopsychosocial factors that may predispose an individual to develop insomnia such as anxiety, depression, and overactive arousal systems (Trauer et al., 2015). Part of the difficulty with insomnia is the fact that these psychological symptoms can impact one’s ability to fall asleep; however, we also know that lack of adequate sleep also predisposes individuals to increased psychological distress. Due to this cyclic nature of psychological distress and insomnia, intervention for both sleep issues as well as psychological issues is vital to managing symptoms.
8.6.1.4. Cardiovascular. Heart disease has been the leading cause of death in the United States for the past several decades. Costs related to disability, medical procedures, and societal burdens are estimated to be $444 billion a year (Purdy, 2013). With this large financial burden, there have been considerable efforts to identify risk and protective factors in predicting cardiovascular mortality.
Researchers have identified that depression is a predictor of early-onset coronary heart disease (Ketterer, Knysk, Khanal, & Hudson, 2006). More specifically, there is a five-fold increase of depression in those with coronary heart disease than the general population (Ketterer, Knysk, Khanal, & Hudson, 2006). Additionally, anxiety and anger have also been identified as an early predictor of cardiac events, suggesting psychological interventions aimed at reducing anxiety and establishing positive coping strategies for anger management may be effective in reducing future cardiac events (Ketterer, Knysk, Khanal, & Hudson, 2006).
8.6.1.5. Hypertension. Also called or chronically elevated blood pressure, is also found to be affected by psychological factors. More specifically, constant stress, anxiety, and depression have all been found to impact the likelihood of a cardiac event due to their impact on vasoconstriction (Purdy, 2013). Elevated inflammatory markers such as C-reactive protein, which is indicative of plaque instability, has been found in chronically depressed individuals, thus predisposing them to potential heart attacks (Ketterer, Knysk, Khanal, & Hudson, 2006).
Treatments for Psychological Factors Affecting Other Medical Conditions
As more information regarding contributing factors to psychophysiological disorders is discovered, more psychological treatment approaches have been developed and applied to these medical problems. The most common types of treatments include relaxation training, biofeedback, hypnosis, traditional CBT treatments, group therapy, as well as a combination of the previous treatments.
8.6.2.1. Relaxation training. Relaxation training essentially teaches individuals how to relax their muscles on command. While relaxation is used in combination with other psychological interventions to reduce anxiety (as seen in PTSD and various anxiety disorders), it has also been shown to be effective in treating physical symptoms such as headaches, chronic pain, as well as pain related to specific causes (e.g., injection sites, side effects of medications; McKenna et al., 2015).
8.6.2.2. Biofeedback. Biofeedback is a unique psychological treatment in which an individual is connected to a machine (usually a computer) that allows for continuous monitoring of involuntary physiological reactions. Measurements that can be obtained are heart rate, galvanic skin response, respiration, muscle tension, and body temperature, to name a few.
There are a few different ways in which biofeedback can be administered. The first is clinician-led. The clinician will actively guide the patient through a relaxation monologue, encouraging the patient to relax muscles associated near the pain region (or within the entire body). While going through the monologue, the clinician is provided with real-time feedback about the patient’s physiological response. Research studies have routinely supported the use of biofeedback, particularly for those with pain and headaches that have not been responsive to pharmacological interventions (McKenna et al., 2015).
Another option of biofeedback is through computer programs developed by psychologists. The most common, a program called Wild Devine (now Unyte) is an integrative relaxation program that encourages the use of breathing techniques while simultaneously measuring the patient’s physiological responses. This type of programming is especially helpful for younger patients as there are various “games” the child can play that requires the awareness and control of their thoughts, feelings, and emotions.
8.6.2.3. Hypnosis. Hypnosis, which some argue is just an extreme sense of relaxation, has been effective in reducing pain and managing anxiety symptoms associated with medical procedures (Lang et al., 2000). Through extensive training, an individual can learn to engage in self-hypnosis or obtain recorded hypnosis monologues to assist with the management of physiological symptoms outside of hypnosis sessions. While additional research is still needed within the field of hypnosis, studies have indicated that hypnosis is effective in not only treating chronic pain, but also assists with a reduction in anxiety, improved sleep, and improved overall quality of life (Jensen et al., 2006).
8.6.2.4. Group Therapy. Group therapy is another effective treatment option for individuals with psychological distress related to physical disorders. These groups not only aim to reduce the negative emotions associated with chronic illnesses, but they also provide support from other group members that are experiencing the same physical and psychological symptoms. These groups are typically CBT based and utilize cognitive and behavioral strategies in a group setting to encourage acceptance of disease while also addressing maladaptive coping strategies.
Key Takeaways
You should have learned the following in this section:
- Psychological factors affecting other medical conditions has as its primary focus the physical disorder, and not the mental disorder.
- The most common types of psychophysiological disorders include headaches to include migraines and tension, gastrointestinal to include ulcers and IBS, insomnia, coronary heart disease, and hypertension.
- Common treatments for these other medical conditions include relaxation training, biofeedback, hypnosis, traditional CBT treatments, and group therapy.
Review Questions
- What are the most common types of psychophysiological disorders?
- Discuss the differences between the different types of headaches.
- What is the difference between ulcers and irritable bowel syndrome?
- What are the identified predictors to coronary heart disease and other cardiac events?
- What are the most effective treatment options for psychophysiological disorders?
Module Recap
In Module 8, we discussed somatic disorders in terms of their clinical presentation, epidemiology, comorbidity, etiology, and treatment options. Somatic disorders included somatic symptom disorder, illness anxiety disorder, functional neurological symptom (conversion) disorder , and factitious disorder. We also discussed psychological factors affecting other medication conditions in relation to their clinical presentation, common types of psychophysiological disorders, and treatment.
