psychosomatic illness in psychiatric nursing

1. PSYCHOLOGICAL
FACTORS AFFECTING
MEDICAL CONDITIONS
PRESENTED BY:-
PRIYANKA MARWAHA

2. INTRODUCTION
• Psychological factors can influence physical health either
indirectly, by changing behaviors that affect our health,
such as eating, sleeping and socializing, or directly, by
producing changes in our hormones and/or heart rate.
Additionally, the mind can interact with the benefits of a
medicine, reducing the effectiveness of a certain drug or
worsening the negative symptoms associated with certain
medical conditions.
• Psychosomatic (psychophysiological) medicine has been a
specific area of study within the field of psychiatry for
more than 75 years. It is informed by two basic
assumptions: There is a unity of mind and body (reflected
in the term mind-body medicine); and psychological
factors must be taken into account when considering all
disease states.

3. CONT...
• Concepts derived from the field of psychosomatic
medicine influenced both the emergence of
complementary and alternative medicine (CAM), which
relies heavily on examining psychological factors in the
maintenance of health, and the field of holistic
medicine with its emphasis on examining and treating
the whole patient, not just his or her disease or
disorder.
• The concepts of psychosomatic medicine also influenced
the field of behavioral medicine, which integrates the
behavioral sciences and the biomedical approach to the
prevention, diagnosis, and treatment of disease.
Psychosomatic concepts have contributed greatly to
those approaches to medical care.

4. DEFINITION
• A group of ailments in which emotional stress is a contributing factor to physical problems involving an organ
system under involuntary control.
Bimla kapoor 1994

5. CONT..
• Disorders in which psychic elements are significant in initiating alteration in chemical,
physiological or structure of the individual resulting in physical symptoms.
Sreevani R

6. PSYCHOLOGICAL BIOLOGICAL
SOCIAL PERSONALITY
ETIOLOGICAL FACTORS

7. PSYCHE-SOMA INTERACTION
• Mind–body interactions have long been
a focus of interest, both in health and in
disease. Psychiatric illness and medical
disease frequently coexist.
• A more modern approach has been to
recognize that all medical illnesses are
potentially affected by many different
factors in the biological, psychological,
and social realms.

8. DSM-IV- TR CRITERIA FOR PSYCHOLOGICAL FACTORS
AFFECTING GENERAL MEDICAL CONDITION
• A general medical condition (coded on Axis III) is present.
• Psychological factors adversely affect the general medical condition in one of the
following ways:
• the factors have influenced the course of the general medical condition as shown by
a close temporal association between the psychological factors and the development
or exacerbation of, or delayed recovery from, the general medical condition
• the factors interfere with the treatment of the general medical condition
• the factors constitute additional health risks for the individual
• stress-related physiological responses precipitate or exacerbate symptoms of the
general medical condition
•

9. CONT..
• These psychological factors include:
• Mental disorders (e.g., Major Depressive Disorder)
• Psychological symptoms (e.g., depressed mood or anxiety)
• Personality traits or coping style (e.g., denial of need for
medical care)
• Maladaptive health behaviors (e.g., smoking or overeating)
• Stress-related physiological responses (e.g., tension
headaches)
• Other unspecified psychological factors (e.g., interpersonal
or cultural factors)

10. ASTHMA
• Asthma affects between 3-5 per cent of the population.
The three hallmarks of the disease are airway
inflammation, airway hyper-responsiveness, and a
partially reversible airway obstruction.
Definition
• Asthma is a disorder of the bronchial airways
characterized by inflammation of the mucosal lining of
the bronchial tree and spasm of the bronchial smooth
muscles, which caused narrow airways and air
trapping.
Epidemiology
• It affects 22 million Americans, including
approximately 9 million children younger than age 18
(Centers for Disease Control [CDC], 2007). Asthma
may occur at any age, although it is more common in
individuals younger than 40 years of age.

11. PREDISPOSING FACTORS
• Biological Influences
• Allergies
• Psychosocial influences
Induced by emotional stress.
Individuals with asthma are characterized as having excessive
dependency needs
Personality characteristics, including fears, emotional lability, increased
anxiety, and depression.

12. SIGNS AND SYMPTOMS
Asthma is characterized by episodes of bronchial constriction
resulting in
• Dyspnoea
• Wheezing
• Productive cough
• Restlessness,
• Eosinophilia
• Expiration is prolonged
• Breathing reflects use of accessory muscles.
• Tachypnea, nasal flaring are common.
• The individual is usually diaphoretic and quite apprehensive, with
total attention focused on his or her breathing.

13. TREATMENT MODALITIES
• Bronchodilators
• Beta-adrenergic agonists such as
albuterol, metaproterenol.
• Oral administration of Theophylline
and other Methylxanthines are also
used, but it produces more side effect
than inhalers.
• Corticosteriods

14. PSYCHO THERAPY
• Psycho therapist
focuses on attitudes
and emotions and
helping the client to
progress with the
separation-
individuation process.

15. CANCER
• Many health professionals and lay people believe that
psychological factors play a major role in cancer onset
and progression. The media have promoted popular
ideas of overcoming cancer through “mind over body.”
Definition
• Cancer is a malignant neoplasm in which the basic
structure and activity of the cells have become
deranged, usually because of changes in the DNA.
• These mutated cells grow widely and rapidly and lose
their similarity to the original cells. The malignant cells
spread to other areas by invading surrounding tissues
and by entering the blood and lymphatic system.

16. EPIDEMIOLOGY
• Cancer is the second leading cause of death in the United
States. However, 5-year survival rates have increased as a
result of early diagnosis and treatment and the
improvement of treatment modalities for most cancers.
The largest number of deaths from cancer in both men
and women is attributed to cancer of the lung (American
Cancer Society [ACS], 2007).

17. PREDISPOSING FACTORS
Biological influences:
• Hereditary factors
• Certain cancers, such as those of the stomach, breast, colon, kidney, uterus,
and lung tend to occur in a familial pattern. Continuous irritation also
predispose individuals to certain types of cancer. e.g: chronic exposure to sun
is thought to predispose to melanoma.
• Environmental factors
• Exposure to occupational or environmental carcinogens leads to specific
cancers. Examples include cigarette smoke, aniline dye, radium, arsenic,
chromate, uranium, and asbestos. Various drugs such as immunosuppressive
agents, diethylstilbestrol, oral contraceptives, cytotoxic agents, and
radioisotopes may also predispose individuals to specific cancer.

18. PSYCHOSOCIAL INFLUENCES
• Cancer is also known as “nice guy’s disease”. It is more common among people
with type C personality.
Type C personality characteristics include;
• Suppress anger and hostility to an extreme
• Express a calm
• Commonly feels depressed and in despair
• Has low self-esteem, low self-worth
• Put others’ needs before his or her own
• Has a tendency towards self-pity
• Sets unrealistic standards and is inflexible in the enforcement of these standards

19. SIGNS AND SYMPTOMS
Early warning signs of cancer include:
• Thickening or lump in the breast or any
other part of the body
• Obvious change in a wart or mole
• A sore that doesn’t heal
• Nagging cough or hoarseness
• Changes in bowel or bladder habits
• Indigestion or difficulty swallowing
• Unexplained changes in weight
• Unusual bleeding or discharge

20. LATE STAGE CANCER SYMPTOMS INCLUDE:
• Anaemia,
• Infection
• Thrombocytopenia
• Cachexia
• Weakness
• Weight loss
• Dyspnoea
• Ascites
• Pleural effusion

21. TREATMENT
1) Surgery
2) Radiation therapy
3) Chemotherapy
4) Psychotherapy

22. PSYCHOTHERAPY
It is helpful to cancer prone individual with type C
personality. The individual must learn to express the
feelings and emotions that have been suppressed. Some
studies indicate a decrease in mortality rate in cancer
patients who experience a reduction of anxiety, depression,
and traumatic stress (Levenson, 2003).

23. 5) PSYCHOSOCIAL INTERVENTION AND CANCER OUTCOME
• A number of studies have shown improvement in the quality of life
in cancer patients receiving group therapy, including improved
mood and vigor, decreased pain, and better adjustment (Trijsburg
et al. 1992 , Andersen 1992 , Fawzy et al. 1993 , Spiegel et al.
1981 , Goodwin et al. 2001).
• The possibility that a psychological intervention might improve
longevity in metastatic breast cancer patients was exciting,
supported initially by some studies (e.g., Spiegel et al. 1989 ,
Cunningham et al. 1998 ), but not by the definitive replication
study (Goodwin et al. 2001) as well as some others. Thus the
evidence to date suggests that patients with cancer can be told
that group therapy contributes to living better, not necessarily
longer.

24. 6) AUTOGENIC RELAXATION AND MENTAL IMAGERY
• Simonton and Simonton reported positive results with autogenic
relaxation and mental imagery in the role of adjunct therapy for
clients with malignant disease.

25. C) CORONARY HEART DISEASE
Introduction
Coronary heart disease is also called coronary artery disease or ischemic heart
disease. The presence of major depressive disorder in a patient with cardiac
disease has a significant impact on morbidity and mortality. Carney et al. found
that major depressive disorder was the best single predictor of myocardial
infarction, angioplasty, and death during the 12 months following cardiac
catheterization. Patients with a history of myocardial infarction and major
depressive disorder are five times more likely to die within 6 months of
discharge than non-depressed patients following infarction.

26. PREDISPOSING FACTORS
Hereditary factors
Environmental factors
Psychosocial factors

27. CHARACTERISTICS OF TYPE A PERSONALITY INCLUDE:
• Having easily aroused hostility that is usually kept under control but flares up
unexpectedly, often when others would consider it as unwanted.
• Being very aggressive, very ambitious, concentrating almost exclusively on his/her
career.
• Having no time for hobbies, and during any leisure time, feeling guilty just
relaxing as if wasting time.
• Seldom feeling satisfied with accomplishments; always feeling must do more.
• Measuring achievements in numbers produced and money earned
• Continually struggling to achieve and feeling there is never enough time
• Appearing to be very extroverted and social; often dominating conversation;
having an outgoing personality but often concealing a deep seated insecurity about
one’s own worth.
• Experiencing driving ambition and the need to win.

28. CONT…
According to Denollet, (1997) CHD is associated with type D
personality (distressed personality). Individuals with type D
personality have a tendency to experience negative emotions such
as anger, anxiety, depression, worry, and hopelessness and the
inability to express feelings in social situations.

29. SIGNS AND SYMPTOMS
• Myocardial ischemia. Myocardial ischaemia often leads to myocardial infarction. Acute
myocardial infarction can develop at rest or with normal activity, and can be the first clinical
manifestation of coronary heart disease.
• Angina pectoris can occur spontaneously in relation to increased myocardial oxygen demand.
Characteristics of pain associated with angina include squeezing, burning, pressing, chocking,
aching or bursting pressure. The discomfort of angina lasts for 2 to 5 minutes, sometimes as
long as 15minutes and rarely as long as 30 minutes.
• Pain associated with myocardial infarction is similar to that experienced in angina, but lasts
longer than 15 to 30 minutes. Symptoms include nausea, vomiting, diaphoresis, syncope,
palpitation, dyspnoea. Up to one third of people experiencing MI will not experience chest
pain. This phenomenon is more prevalent among elderly population, in women, and in clients
with diabetes.

30. TREATMENT
• Surgical interventions with CABG
• Percutaneous transluminal coronary angioplasty (PTCA)
• Intervention with chemotherapeutic agents is common in the treatment of
CHD. Vasodilators, beta-adrenergic blocking agents (e.g., propranolol) and
calcium channel blockers (e.g., verapamil, diltiazem) to treat angina and
hypertension; and antihyperlipidemic agents (e.g., simvastatin, atorvastatin,
gemfibrozil) to lower serum lipid levels are commonly prescribed.
• A combination of education, interpersonal counselling, and behavioural
modifications have been showed positive outcomes in reduction of type A
behaviours.

31. PEPTIC ULCER
• Peptic ulcer disease occurs when the balance
between stomach acid and mucosal defence factors
is disrupted. Peptic ulcers are an erosion of
mucosal wall in the esophagus, stomach,
duodenum, or jejunum. Deeper lesions may
penetrate the mucosal layer and extend into the
muscular layers of intestinal wall.
Epidemiology
• Peptic ulcers occur four times more frequently in
men than in women. The disease occurs in
approximately 10 percent of the population, and
peak ages have been identified as 40 to 60 years.

32. PREDISPOSING FACTORS
• Biological influences
• Environmental factors
• Psychological influences
There is an increased gastric secretion and motility in the presence
of hostility, resentment, and frustration (Karren et al., 2002). Ulcer
prone individuals tend to have an unhealthy attachment to others,
they are dependent by nature, and they perceive that they have few
people on whom they can depend in times of crisis. They are
excessive worriers and pessimists. Anxiety and depression are
common among ulcer prone individuals.
•

33. SIGNS AND SYMPTOMS
• Pain is the characteristic clinical manifestation of peptic ulcer disease.
• It is usually experienced in the upper abdomen near the midline, and may radiate to
the back, sternum, or lower abdomen.
• Pain is usually worse when the stomach is empty and gastric secretions are high.
• Food or antacid medications often relieve the pain
Treatment modalities
• The focus of treatment for peptic ulcer is to alleviate symptoms, promote healing, and
prevent complications or recurrence

34. MANAGEMENT
Pharmacological interventions
• Antacids
• Antisecretory agents
• Histamine H2 antagonists
• Proton pump inhibitors
• Anticholinergics
• Cytoprotective agents
• Antibiotics and anti-infectives to treat H. pylori
infection.
Dietary management

35. CONT….
Surgical interventions
• Gastrectomy
• Vagotomy
• Pyloroplasty
Psychotherapy
• Psychotherapy with ulcer clients focuses on troublesome conflicts such as passivity,
dependency, aggression, anger, and frustration. It has been beneficial with ulcer clients
whose personality characteristics, ego strength, and coping mechanisms favour increased
vulnerability to stress.
• Peptic ulcer clients should be screened for anxiety characteristics.
• CBT can help patients feel a greater sense of mastery over feared calamities and less helpless
and overwhelmed. Clinicians also should identify depression, overuse of NSAIDs, alcohol
abuse, smoking, job stress, and other psychosocial factors that may aggravate peptic ulcer for
appropriate therapeutic intervention. (Levenson 2003)

36. ESSENTIAL HYPERTENSION
Definition
• It is the persistent evaluation of blood pressure for which there is no apparent
cause or associated underlying disease (Fanning & Lewis,2003). It is a major
cause of cerebrovascular accident (Stroke), cardiac disease, and renal failure.
Epidemiological statistics
• Approximately 30% of the adult population in the United States is
hypertensive. (American Heart Association, 2005). Because hypertension is
often asymptomatic it is estimated that 30% of persons with hypertension do
not know they have it.
• The disorder is more common in men than in women and is twice as
prevalent in the African American population as it is in the white population.

37. PREDISPOSING FACTORS
• Biological influences
• Physiological influences
• Environmental factors
• Psychosocial influences
• Karren and associates (2002)
report on studies that suggest
there is a correlation between
suppressed anger and
hypertension.
• Some psychoanalyst believes this
may be associated with childhood
rearing that forbade expression of
angry feelings. Several studies
showed consistent results of a
significant relationship between
suppressed anger and elevated
blood pressure.

38. SIGNS AND SYMPTOMS
• Most commonly hypertension produces no
symptoms, particularly in the early stages. When
symptoms do occur, they may include
• headache
• Vertigo
• Flushed face
• Spontaneous nosebleed
• Blurred vision.
• Chronic progressive hypertension may reveal signs
and symptoms associated with specific organ system
damage.

39. TREATMENT
• Dietary modification
• Weight reduction and sodium restriction.
• Decrease the intake of caffeine, alcohol, saturated fats.
• Environmental factors
Individuals with hypertension should not smoke.
• Physical exercise
• Increased physical activity (e.g: 30 to 45 minutes of brisk walking
three to five times a week) has been shown to lower blood pressure
in some patients.

40. MIGRAINE (VASCULAR) AND CLUSTER HEADACHES
• Migraine (vascular) headache is a disorder characterized
by recurrent unilateral headaches, with or without
related visual and gastrointestinal disturbances (e.g.,
nausea, vomiting, and photophobia).

41. PREDISPOSING FACTORS
Biological Influence
• Functional disturbance in the cranial circulation.
• Can be precipitated by cycling estrogen, which may
account for their higher prevalence in women.
• Some foods, beverages and drugs individuals like caffeine,
chocolate, cheese, vinegar, organ meats, alcoholic
beverages, etc can precipitate migraine in certain.

42. CONT…
Psychological influences
• Stress is also a precipitant, and many persons with
migraine are overly controlled, perfectionists, and unable
to suppress anger. Cluster headaches are related to
migraines.
• They are unilateral, occur up to eight times a day.

43. TREATMENT
• Migraines and cluster headaches are best treated during the
prodromal period with ergotamine tartrate (Cafergot) and
analgesics.
• Prophylactic administration of propranolol or verapamil
(Isoptin) is useful when the headaches are frequent.
• Sumatriptan (Imitrex) is indicated for the short-term
treatment of migraine and can abort attacks. SSRIs are also
useful for prophylaxis.
• Psychotherapy to diminish the effects of conflict and stress
and certain behavioral techniques (e.g., biofeedback) have been
reported to be useful.

44. CONT…
Pharmacotherapy
• Pharmacological intervention may be
with a diuretic, beta-blocker, calcium
channel blocker, or angiotensin
converting enzyme (ACE) inhibitor.
Supportive psychotherapy
• Supportive psychotherapy, during
which the individual is encouraged to
express honest feelings, particularly
anger, may also be helpful.

45. RELAXATION THERAPY
• Rhythmic breathing
• Deep breathing
• Visualized breathing
• Progressive muscle relaxation
• Relax to music
• Mental imagery relaxation

46. POSITIVE STATEMENTS TO BE PRACTISED
• Let go of things, i cannot control
• I am healthy, vital and strong
• All my need are met
• I am completely and utterly safe
• Everyday in every way i am getting stronger

47. CONT..
• Hypnosis
• Biofeedback
• Cognitive behavior therapy

48. RHEUMATOID ARTHRITIS
Definition
• Rheumatoid arthritis is a disease characterized by
chronic musculoskeletal pain arising from inflammation
of the joints. The disorder's significant causative factors
are hereditary, allergic, immunological, and
psychological.

49. PREDISPOSING FACTORS
Biological influences:
• Heredity appears to be influential in the predisposition to
rheumatoid arthritis .The serum protein rheumatoid factor is
found in at least half of people with rheumatoid arthritis and
frequently in their close relatives .Rheumatoid arthritis affects
people with a family history of the disease two to three times
more often than the rest of the population
• An additional theory postulates that rheumatoid arthritis may be
the result of a dysfunctional immune mechanism initiated by an
infectious process although the causative agent is yet to be
identified

50. PSYCHOLOGICAL INFLUENCES:
• Rheumatoid arthritis clients are postulated to be self sacrificing
,anxious, unassertive, inhibited and perfectionistic with an
inherent inability to express anger .Female rheumatoid clients are
described as nervous ,tense, worried ,moody and depressed and
typically had mothers whom they felt rejected them and fathers
who were unduly strict .
• Stress can predispose patients to rheumatoid arthritis and other
autoimmune diseases by immune suppression.
• Depression is comorbid with rheumatoid arthritis in about 20
percent of individuals. Individuals with rheumatoid arthritis and
depression commonly demonstrate poorer functional status, and
they report more of the following: painful joints, pronounced
experience of pain, health care use, bed days, and inability to
work than do patients with similar objective measures of
arthritic activity without depression.

51. TREATMENT:
• Pharmacological Treatment:
• Psychotropic agents may be of use in some patients. Sleep,
which is often disrupted by pain, can be assisted by the
combination of a nonsteroidal anti-inflammatory drug (NSAID)
and trazodone (Desyrel) or mirtazapine (Remeron), with
appropriate cautionary advice regarding orthostatic
hypotension.
• Tricyclic drugs exert mild anti-inflammatory effects
independent of their mood-altering benefit; however,
anticholinergic effects (prominent among the tricyclic drugs
and also present with some serotonergic agents) can aggravate
dry oral and ocular membranes in some patients with the
disorder.

52. SURGICAL TREATMENT:
• Various surgical treatments are available for clients with rheumatoid
arthritis.
• Synovectomy is performed to relieve pain and maintain muscle and
joint balance .Joint fusion may provide stability to a joint and decrease
deformity .
• Spinal fusion may be necessary to treat subluxation.
• Total joint replacement is performed to restore motion to a joint and
function to the muscles ,ligaments and other soft tissue structures that
control a joint.

53. THERAPIES
• Relaxation therapy
• Biofeedback
• Cognitive behavior therapy
• Coping skills training

54. PSYCHOLOGICAL TREATMENT:
• Psychotherapy and prompt recognition and treatment of
psychiatric morbidity may help clients cope and adapt to this
condition. A client’s initial reaction to the diagnosis of rheumatoid
arthritis depends on the degree of incapacity at the time and the
immediate threat to his or her lifestyle.
• Depression may need to be treated separately .
• Clients should be encouraged to function as independently as
possible.
• The focus on cure should be deflected to a focus on control of the
disease and prevention of disability

55. ULCERATIVE COLITIS
• Ulcerative colitis is an inflammatory bowel disease affecting
primarily the large intestine.
• The cause of ulcerative colitis is unknown.
• The predominant symptom of ulcerative colitis is bloody
diarrhea. Extracolonic manifestations can include uveitis,
iritis, skin diseases, and primary sclerosing cholangitis.

56. PREDISPOSING FACTORS
Biological Influences:
• A genetic factor may be involved in the development
because individuals who have a family member with
ulcerative colitis are at greater risk than the general
population.
• The possibility that ulcerative colitis may be an
autoimmune disease has generated a great deal of
research interest .High rates of anticolon antibodies
are found in relatives of ulceratives colitis clients.

57. PSYCHOSOCIAL INFLUENCES:
• Predominance of obsessive compulsive traits. They
are neat ,orderly ,punctual and have difficulty
expressing anger.
• A pathological mother child relationship resulting
in feelings of helplessness and hopelessness has also
been implicated .
• Stressful life events or psychological trauma.
• The altered immune status that accompanies
psychological stress may be an influencing factor
in predisposed individuals.

58. TREATMENT:
Nutritional Therapy
• A low residue diet is initiated and advanced as tolerated with
one food added at a time. Milk may be a problem for some
clients.
• Total parenteral nutrition may be necessary.
Pharmacological Treatment
• Sulfasalazine which appears to have both anti-inflammatory
and antimicrobial properities.
• Severe forms of the disease are treated with corticosteroids
eg hydrocortisone, prednisone, prednisolone.
• Antibiotics eg metronidazole, ciprofloxacin may be
administered when an infectious process is present.

59. PSYCHOLOGICAL SUPPORT
• Psychological support may help to decrease
the frequency of these attacks by helping the
individual to recognize the stressors that
precipitate exacerbations and identify more
adaptive ways of coping .
• Feels a lack of control over his or her life .
• Psychological support may help the client
cope with feelings of insecurity
,dependency, and depression .It is extremely
important that the individual express
feelings of repressed or suppressed anger
and hostility.

60. THERAPIES
• Psychoanalytic psychohterapy
• Relaxation therapy
• Cognitive behavior therapy
1.Individual CBT
2.Group CBT

61. TREATMENT OF PSYCHOSOMATIC DISORDERS
• A major role of psychiatrists and other physicians working with patients with
psychosomatic disorders is mobilizing the patient to change behavior in ways that
optimize the process of healing. This may require a general change in lifestyle (e.g.,
taking vacations) or a more specific behavioral change (e.g., giving up smoking).
Whether or not this occurs depends in large measure on the quality of the
relationship between doctor and patient.
• Failure of the physician to establish good rapport accounts for much of the
ineffectiveness in getting patients to change.
• Ideally, both physician and patient collaborate and decide on a course of action. At
times this may resemble a negotiation in which doctor and patient discuss various
options and reach a compromise about an agreed-on goal. Aaron Lazare described
specific negotiating strategies to achieve behavioral changes:

62. CONT…
• Direct education
Explain the problem, goals, and methods to achieve goals. Education must be geared to the patient's
socioeconomic level and cultural traditions. If the patient has questions, they should be answered frankly.
Explanations in keeping with the patient's capacity to understand should be given. Such factors as
intelligence, sophistication in regard to personality reactions, and degree and type of illness should influence
the vocabulary and content of the physician's response. Every effort should be made to convey to belligerent
patients both understanding and tolerance for their feelings.
• Third-party intervention
Family members, friends, and other clinicians can provide support and encourage the patient to follow a
course of action. This may occur in a group setting, which is especially effective in motivating patients who
have substance abuse problems to obtain treatment (called an intervention).
• Exploration of options.
There may be alternative methods for achieving a desired goal. For example, quitting smoking can be done
with support groups, nicotine patches or gum, psychotropic drugs

63. CONT…
• Provision of sample treatment
If a patient fears a particular course of action or considers
change impossible, a treatment trial can be implemented. The
patient always may opt out of the prescribed program.
• Control sharing.
Some patients resent any approach that appears to be
authoritarian. They may wish to set the pace of a withdrawal
program or titrate their medication depending on adverse
effects.

64. CONT..
• Concession making
The clinician may grant the patient something that he or
she wants (e.g., medication) as a bargaining chip to get the
patient to comply with advice.
• Empathic confrontation
Patients who resist change may do so because of fear or
other uncomfortable emotions of which they are unaware.
The doctor can try to step into the patients' shoes• in an
effort to raise their level of awareness. Doctors should be
prepared to answer the patient's question

65. CONT…
• Standard setting
Guidelines or standards (sometimes called milestones)
should be set to evaluate the progress of an agreed-upon
program (e.g., the loss of 1 pound of weight every 2 weeks to
achieve a weight loss of 10 pounds in 20 weeks).
• In rare cases in which negotiations break down and an
impasse is reached it may be necessary to threaten to
terminate the relationship

66. STRESS MANAGEMENT
• Self-observation
• Cognitive restructuring
• Relaxation training
• Time management
• Problem-solving.

67. RELAXATION TRAINING
• JPMR
• Benson relaxation therapy
• Hypnosis
• Biofeedback

68. TIME MANAGEMENT
They may be asked to list the important areas in their lives
and, then, asked to provide two time estimates:
(1) the amount of time they currently spend engaging in these
activities and
(2) the amount of time they would like to spend engaging in
these activities.
Frequently, a substantial difference is seen in the time
individuals would like to spend on important activities and
the amount of time they actually spend on such activities.
With awareness of this difference comes increased motivation
to make changes.

69. PROBLEM SOLVNIG
• The final step is problem-solving in which patients basically try to
apply the best solution to the problem situation and then review
their progress with the therapist.

70. NURSING MANAGEMENT

71. ASTHMA
• Ineffective airway clearance related to bronchospasm, ineffective cough, excessive
mucus production, tenacious secretions, and fatigue.
• Anxiety related to difficulty breathing, perceived or actual loss of control, and fear
of suffocation.
• Activity intolerance related to difficulty breathing, perceived or actual loss of
control, and fear of suffocation.

72. CANCER
• Fear related to pain and perceived actual threat of death.
• Anticipatory grieving related to perceived actual threat of death.
• Disturbed body image related to drug side effect.

73. CORONARY ARTERY DISEASE
• Pain related to myocardial ischemia and decreased myocardial oxygen
supply.
• Fear related to perceived actual threat of death, pain, possible life style
changes.
• Activity intolerance related to fatigue secondary to decreased cardiac
output and poor lung and tissue perfusion

74. PEPTIC ULCER
• Pain related to increased gastric secretions, decreased mucosal protection, and
ingestion of gastric irritants.
• Ineffective therapeutic regimen management related to lack of knowledge of long-
term management of peptic ulcer disease and consequences of not following
treatment plan and unwillingness to modify life style.

75. Migraine Headache
• Pain
• Ineffective role performance
• Rheumatoid Arthritis
• Pain
• Self care deficit
• Activity intolerance

76. ULCERATIVE COLITIS
• Pain related to erosion of mucosal lining
• Risk for imbalanced nutrition less than body requirements

77. SOME NURSING DIAGNOSES COMMON TO THE GENERAL
CATEGORY OF PSYCHOLOGICAL FACTORS AFFECTING
MEDICAL CONDITION INCLUDE:
• Ineffective coping related to repressed anxiety and inadequate coping methods,
evidenced by initiation or exacerbation of physical illness.
• Deficient knowledge related to psychological factors affecting medical condition,
evidenced by statements such as “I don’t know why the doctor put me on the
psychiatric unit. I have a physical problem.”
• Low self-esteem related to unmet dependency needs, evidenced by self-negating
verbalizations and demanding sick-role behaviors.
• Ineffective role performance related to physical illness accompanied by real or
perceived disabling symptoms, evidenced by changes in usual patterns of
responsibility.

78. THE FOLLOWING CRITERIA MAY BE USED FOR
MEASUREMENT OF OUTCOMES IN THE CARE OF
THE CLIENT WITH A PSYCHO PHYSIOLOGICAL
DISORDER:
The client:
• Denies pain or other physical complaint.
• Demonstrates the ability to perform more adaptive coping strategies in the face of
stressful situations.
• Verbalizes stressful situations that have led to or worsened physical symptoms in
the past.
• Verbalizes a plan to cope with stressful situations in an effort to prevent
exacerbation of physical symptoms.
• Performs activities of daily living independently.

79. NURSING PLANNING/IMPLEMENTATION
Ineffective coping related to repressed anxiety and inadequate coping methods.
• Perform thorough physical assessment.
• Monitor laboratory values, vital signs, intake and output, and other assessments.
• Help the client to set goals and identify the best way he or she can achieve those goals
based on his or her believes.
• Assist the client in problem solving
• Encourage client to discuss current life situations that he or she perceives as stressful and
feelings associated with each.
• As client becomes able to discuss feelings more openly, discuss about the relation between
feelings and physical symptoms.
• Teach adaptive coping strategies that can be used for stressful situations.
• Help the client to identify support system within his community for the expression of
feelings.

80. CONT..
Knowledge deficit related to psychological factors affecting medical conditions.
• Assess the client’s level of knowledge regarding effects of psychological problems on the body.
• Assess client’s level of anxiety and readiness to learn.
• Discuss physical examination and laboratory tests that have been conducted.
• Explore client’s feelings and fears. Be supportive.
• Encourage client to maintain two diaries; one for recording physical symptoms and the othe for stressful
situations.
• Help the client to identify the benefit for being in sick role.
• Provide instruction in assertive technique.
• Discuss adaptive methods of stress management such as relaxation technique, physical exercise,
meditation, breathing exercise and autogenic.

81. CONCLUSION:
• Medical Conditions Due To Psychological Factors could be very confusing and difficult to diagnose and
therefore could hamper the care needed and provided to the patient. In order for the health care
provider and team to make the diagnosis of PFAMC, either the factors must have influenced the course
of the medical condition, interfered with its treatment, contributed to health risks, or physiologically
aggravated the medical condition. It is the responsibility of a psychiatric nurse to have a sound
knowledge in assessing and identified the illness in ordr to provide a complete holistic and unbiased
care to the patient.