Biopsychosocial Diseases and Conditions

role of PT

- recognize complexity of condition/disorder

- provide support/patience to those afflicted

- identify when appropriate referral is needed

- submit thorough documentation of presentations

- know your boundaries!

IMPLICATIONS:

1. societal views

2. healthcare system views

3. your own views

biopsychosocial model of health

an approach to studying health and human function that focuses on importance of biological, psychological, and social (or environmental) processes

biopsychosocial (BPS) categories

1. depressive or bipolar depressive disorders

2. anxiety disorders

3. trauma-related disorders

4. personality disorders

5. psychotic disorders

6. eating disorders

7. substance abuse disorders

DSM-5

the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders

anxiety disorders

PANIC--> fight or flight is triggered

*short-lived episodes

1. panic attack

2. panic disorder

WORRY--> anticipation of misfortune/doom

*cannot shut off perceived fears & worries

3. generalized anxiety disorder (GAD)

anxiety

characteristics:

1. fear and apprehension

2. heightened physiological response

3. occurs suddenly and without warning

conditions:

- panic disorders

- panic attacks

- generalized anxiety disorder

- social and specific phobias

panic attack

short-lived, last 5-20 mins av. (<1 hr max)

- intense fear w/o trigger (no real danger)

- severe physical fight or flight response

- can occur waking up from sleep

panic disorder

reoccurring panic attacks in frequency

- usually begins in adulthood (after age 20)

- 2x as common in women

generalized anxiety disorder

severe/crippling, ongoing anxiety/worry that interferes with daily activities

*worry over countless "what if" events that they can't stop

common themes:

- health/safety of self or loved ones

- future

- $

trauma related disorders

CHARACTERISTICS:

- exposure to a traumatic or stressful event

- set-off by related-triggers (sounds, images)

1. posttraumatic stress disorder (PTSD)

2. adjustment disorders

posttraumatic stress disorder (PTSD)

recurring, intrusive recollections of an overwhelming traumatic event

*experience change in mood & cognition

**lasts for >1 month, begins 6 months after trauma

***unwanted thoughts (flashbacks) & nightmares

adjustment disorders

"overreact w/ reckless behavior"

abnormal and excessive emotional and/or behavioral reaction caused by an identifiable stressor

*symptoms show w/in 3 months after trigger and stop 6 months after trigger ends

ex. flood/fire, break-up/divorce, new job, parents fighting

normal response to stress

stress--> release of adrenaline & cortisol --> triggers endorphins

amygdala & adrenal gland --> adrenalin and norepinephrine

amygdala

What is the key to normal expression of emotions, especially fear?

endorphins

Alcohol increase ______________________ activity which therefore decreases stress and pain awareness.

amygdala

stores memory of situations to prep for similar events in future

IN PTSD--> becomes "hijacked" by stress/anxiety and reduces activity of PFC

*hippocampus and anterior cingulated cortex are smaller in those w/ PTSD

(YELLOW IN IMAGE)

prefrontal cortex (PFC)

higher reasoning, so we don't runaway with our emotions

hippocampus

stores memories

*keep fear and anxiety in check

depressive and bipolar depressive disorders

CHARACTERISTICS:

- symptoms tend to occur in cycles with normal states in between

- multiple genetic and non-genetic factors

- link btwn neural activity, endocrine system, and immune system

1. major depression (unipolar)

2. bipolar (manic-depressive)

3. seasonal affective disorder

major (unipolar) depression

MOST COMMON MENTAL HEALTH DISORDER

period of 2 weeks or longer during which there is either depressed mood or loss of interest or pleasure and at least four other symptoms with change

- wide range of behavioral and physical symptoms (can alter sleep, appetite, energy, concentration, etc.)

- may be associated with thoughts of suicide

bipolar depression (manic-depressive illness)

4 basic types with 3 components (last several days)

1. manic episodes

2. depressive episodes

3. sudden mood swings

IMPACT--> varying shifts in mood, energy, activity level may effect ability to carry out day to day tasks; erratic thoughts, sleep cycles, & behavioral patterns

INFLUENCES--> genetics, environment, altered brain chemistry & structure

manic episode

bipolar swing

- feel elated

- lots of energy

- trouble sleeping (awake >24 hrs)

- talk fast about a lot of different things (not necessarily logical)

- grandiose thoughts

- think they can do a lot of things

- do risky things

depressive episode

bipolar swing

- very sad, down, empty

- little energy

- trouble sleeping (too little or too much)

- can't enjoy anything

- trouble concentrating

- forget things

- think about death/suicide

obsessive-compulsive disorder (OCD)

subcategory of personality disorders and a condition

*hoarding is included in the O-C disorder subgroup

CHARACTERISTICS:

1. obsessions

2. compulsions

ex. germaphobe continuously wash hands, constantly check locks, specifically arrange items

obsessions

intrusive thoughts or actions which are unwanted but repeated & cause significant anxiety but must by fulfilled

ex. fear of contamination, illness, harming, self-doubting

compulsions

repetitive behaviors designed to reduce anxiety or prevent bad things from occurring

ex. checking, washing, counting

compulsive hoarding

O-C subgroup

DEFINING CHARACTERISTICS:

1. excessive accumulation of items, regardless of actual value or financial situation

2. difficulty discarding or parting with possessions because of a perceived fear if lost them & need to save them

3. inability to use the living space/rooms as intended

- items can cause distress/problems w/ everyday activities

*highly associated w/anxiety, ADHD, bipolar, depression, OCD

- often triggered by life event

- respond well to CBT

somatic symptom disorders

bodily symptoms caused or exacerbated by psychological factors

*physical symptoms are inconsistent with or cannot be fully explained by any underlying general medial or neurologic condition

1. somatic

2. illness anxiety

3. factitious disorder

4. psychogenic

5. functional neurological symptom disorder

illness anxiety disorder

a somatic disorder where person is preoccupied w/ having or getting a serious illness despite having mild or no symptoms and despite absence of physical findings

*will subject themselves through a battery of tests AND still not believe negative test results

somatic symptom disorder (SSD)

a somatic disorder where person has extreme anxiety about physical symptoms such as pain or fatigue, to the point it can interfere with daily life

*cannot work and typically lose family & friends

**preoccupied with illness for at least 6 months

1st it is believed, then somatic symptoms actually manifested

functional neurological symptom disorder (FNSD)

somatic disorder where person presents with neurological symptoms without identifiable neurological cause

ex. motor/vision/speech dysfunction, paralysis ,seizures

*dramatic and inconsistent presentation

**Hoover sign is positive

***unconscious attempt to resolve an internal psychological conflict

factitious disorder (FD)

somatic disorder where person appears ill or injured w/o external reward, to point of exaggerating symptoms, hurting self, even altering medical records

*to draw attention, sympathy, reassurance

FD imposed on another (FDIA)

somatic disorder where a person projects medical problems on another for their own attention/sympathy

*childhood trauma, depression, personality disorders, and working in the healthcare field all can be causes

psychogenic movement disorder

somatic disorder where the subconscious responds to stress and creates unwanted muscle movement such as a spasm or tremor

*cause is NOT neurogenic

**CUREABLE

malingering

illness is pretended as a way to achieve a secondary goal such as the acquisition of drugs or disability benefits

NOT RECONGINZED BY THE APA

personality disorders

1. chronic pain

2. symptom magnification syndrome

chronic pain

episode of pain that persists beyond normal healing time (3-6 months)

*lingering acute pain is typically related to anxiety

**CP associated with mental health diagnosis (commonly depression)

TREATMENT FOCUS:

- treat underlying condition

- pharmacologic support --> weaning w/ close monitoring

- CBT effective

*focus on function and want the patient CAN do

chronic pain disorder

personality disorder when magnified emotional pain manifests as unrelenting physical pain

BEHAVIORAL SYMPTOMS:

1. fear

2. isolation

3. tension

4. fatigues

*association with depression

**refer out when coping mechanisms appear impaired

symptom magnification syndrome

self-destructive, attention seeking

*symptoms reported or demonstrated which function to control the person's life

**reinforced behavioral patterns

NOT RECOGNIZED BY APA

psychotic disorder

1. schizophrenia

schizophrenia

psychotic disorder where person may hear voices, see things that aren't there, believe that others are reading or controlling their mind

*hallucinations and delusions

**onset 20-30s (earlier in males), but not typically diagnosed until mid-40s

***GENETIC LINK

COGNITIVE SYMPTOMS:

- difficulty with learning comprehension

- difficulty focusing or paying attention

- 10% die of suicide

VIOLENCE = NOT COMMON

TREATMENT:

- anti-psychotic meds (Thorazine, Haldol, Risperdal - bad side effects)

- CBT

- self-help groups

electroconvulsive therapy (ECT)

low electric brain current under anesthesia which triggers seizure

*used in the past for treatment of schizophrenic patients

**negative stigma from ECT history

eating disorders

affects both men and women and typically occurs during teens and young adults years

*usually coexists with other illnesses (depression, substance abuse, anxiety)

RISK FACTORS:

- women

- personality traits

- yo yo dieting

- family history

- social pressure

- women with DM 1

1. anorexia nervosa

2. bulimia nervosa

3. binge-eating disorder

cardiac issues

What is the #1 chronic clinical impact associated with eating disorders?

binge eating disorder

MOST COMMON EATING DISORDER

engaging in short feasts wherein they consume a large amount of calories

*NO purging afterwards and thus struggle with weight

**usually occurs due to feelings of shame and depression, lack of self-esteem or self-worth

anorexia nervosa

restricts eating intentionally

- self-purge any intake

- starvation leads to reduced cardiac function and electrolyte imbalance

*CAN BE LIFE THREATENING W/ CARDIAC ARRHYTHMIAS*

CLINICAL PRESENTATION:

- lethargy

- brittle hair/nails

- mild anemia and muscle wasting

- brain damage

- organ failure

TREATMENT:

- restore weight

- attend psych issues

bulimia nervosa

binge eating and purging several times/week or day

CLINICAL PRESENTATION:

- usually eat/purge in private

- do NOT want others to know

*chronic inflamed sore throat

*worn tooth enamel

*intestinal distress

TREATMENT:

- nutritional counseling

- CBT

disordered eating

abnormal behavior/thoughts on food/diet

muscle dysmorphia

negative body image and an obsessive desire to have a muscular physique

sleep-related eating disorder

recurrent episodes of eating or drinking after arousal from nighttime sleep w/ amnesia of episodes

substance-related disorders

21 million Americans have an addictive disorder

1. tobacco

2. alcohol

3. illicit drugs

4. prescription drugs

suicide

4th leading cause of adult death

(2nd among college students)

500,000 people attempt, 30,000 are successful

RED FLAG SIGNS:

- saying goodbye

- giving away possessions

- making final arrangements

- purchasing a gun or collecting RX drugs

WARNING SIGNS:

- mood changes

- loss of interest socially

- changes in sleep patterns

- signs of depression

RISK FACTORS:

- impulsive

- alcohol and drug abuse

QPR--> question, persuade, refer

suicide PT role

- education

- know side effects of meds

take all threats seriously

serotonin

helps to balance impulsive and aggressive behaviors

*produced during exercise (PT intervention)

mental health treatments

1. cognitive-behavior therapy (CBT)

2. exposure-based therapy

3. medications

4. transcranial magnetic stimulation (TMS)

cognitive-behavioral therapy (CBT)

MENTAL HEALTH TREATMENT

individual and/or group therapy which includes:

- reframing negative trauma-related thoughts w/ positive ones

- behavior experiments

- relaxation techniques & stress management

- role play

exposure-based therapy

MENTAL HEALTH TREATMENT

exposing the phobia or trauma through discussion or imagery

medications

MENTAL HEALTH TREATMENT

takes time to build to therapeutic dose (2-6 weeks)

*often requires numerous trial and error prescriptions

**requires persistence

transcranial magnetic stimulation (TMS)

MENTAL HEALTH TREATMENT

stimulates brain nerve cells to reduce depressive symptoms

*also found helpful for patients with anxiety and OCD

CONS: expensive, temporary fix, questionable success

implication for PT

exercise and physical activity

*benefit those with mental health conditions

**aerobic exercise releases endorphins

1. neuropeptides--> improve mood and relieve pain

2. reduces cortisol--> linked to stress and depression

3. increases serotonin--> aids w/ relaxation and sleep

when to refer for other health services