Psychological factors affecting other medical conditions: Clinical features, assessment, and diagnosis
- James L Levenson, MD
James L Levenson, MD
- Professor of Psychiatry, Medicine, and Surgery
- Virginia Commonwealth University School of Medicine
Psychological factors affecting other medical conditions (PFAOMC) is a disorder that is diagnosed when a general medical condition is adversely affected by psychological or behavioral factors; the factors may precipitate or exacerbate the medical condition, interfere with treatment, or contribute to morbidity and mortality . In addition, the factors are not part of another mental disorder (eg, unipolar major depression).
Virtually all medical illnesses are potentially affected by psychological and behavioral factors (as well as social and environmental factors, such as employment status, poverty, relationships, and neighborhood). Variation in how patients respond to medical illnesses and hospitalization appears to be due at least in part to psychological factors . Hippocrates wrote that “It is more important to know what sort of person has a disease than what sort of disease a person has” .
PFAOMC emphasizes one causal direction in the interactions between mind and body, that is, the effects of psychological factors on general medical conditions. In most patients with medical conditions, there are also effects in the other direction (ie, medical illnesses affect psychological function).
This topic reviews the epidemiology, pathogenesis, clinical features, assessment, diagnosis, and differential diagnosis of PFAOMC. Management of PFAOMC is discussed separately. (See "Psychological factors affecting other medical conditions: Management".)
The prevalence of psychological factors affecting other medical conditions (PFAOMC) is not clear because the disorder describes many possible interactions between a wide range of psychological traits, states, and behaviors, and the full range of general medical diseases. The prevalence may be large:
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington 2013.
- Groves MS, Muskin PR. Psychological responses to illness. In: The American Psychiatric Publishing Textbook of Psychosomatic Medicine: Psychiatric Care of the Medically Ill, Second edition, Levenson JL. (Ed), American Psychiatric Publishing, Inc, Washington, DC 2011. p.45.
- Schindler BA. Stress, affective disorders, and immune function. Med Clin North Am 1985; 69:585.
- Osterberg L, Blaschke T. Adherence to medication. N Engl J Med 2005; 353:487.
- Serper M, Patzer RE, Reese PP, et al. Medication misuse, nonadherence, and clinical outcomes among liver transplant recipients. Liver Transpl 2015; 21:22.
- Ho PM, Bryson CL, Rumsfeld JS. Medication adherence: its importance in cardiovascular outcomes. Circulation 2009; 119:3028.
- Fava GA, Guidi J, Porcelli P, et al. A cluster analysis-derived classification of psychological distress and illness behavior in the medically ill. Psychol Med 2012; 42:401.
- Mangelli L, Fava GA, Grandi S, et al. Assessing demoralization and depression in the setting of medical disease. J Clin Psychiatry 2005; 66:391.
- Levenson JL. The somatoform disorders: 6 characters in search of an author. Psychiatr Clin North Am 2011; 34:515.
- Krantz DS, Helmers KF, Bairey CN, et al. Cardiovascular reactivity and mental stress-induced myocardial ischemia in patients with coronary artery disease. Psychosom Med 1991; 53:1.
- Gouin JP, Hantsoo L, Kiecolt-Glaser JK. Immune dysregulation and chronic stress among older adults: a review. Neuroimmunomodulation 2008; 15:251.
- Blume J, Douglas SD, Evans DL. Immune suppression and immune activation in depression. Brain Behav Immun 2011; 25:221.
- The American Psychiatric Publishing Textbook of Psychosomatic Medicine: Psychiatric Care of the Medically Ill, Second Edition, Levenson JL. (Ed), American Psychiatric Publishing, Inc, Washington, DC 2011.
- Moser DK, Riegel B, McKinley S, et al. Impact of anxiety and perceived control on in-hospital complications after acute myocardial infarction. Psychosom Med 2007; 69:10.
- Favreau H, Bacon SL, Labrecque M, Lavoie KL. Prospective impact of panic disorder and panic-anxiety on asthma control, health service use, and quality of life in adult patients with asthma over a 4-year follow-up. Psychosom Med 2014; 76:147.
- Kendzor DE, Chen M, Reininger BM, et al. The association of depression and anxiety with glycemic control among Mexican Americans with diabetes living near the U.S.-Mexico border. BMC Public Health 2014; 14:176.
- Celano CM, Millstein RA, Bedoya CA, et al. Association between anxiety and mortality in patients with coronary artery disease: A meta-analysis. Am Heart J 2015; 170:1105.
- Lichtman JH, Froelicher ES, Blumenthal JA, et al. Depression as a risk factor for poor prognosis among patients with acute coronary syndrome: systematic review and recommendations: a scientific statement from the American Heart Association. Circulation 2014; 129:1350.
- Dickens C, Cherrington A, McGowan L. Depression and health-related quality of life in people with coronary heart disease: a systematic review. Eur J Cardiovasc Nurs 2012; 11:265.
- Jonas BS, Mussolino ME. Symptoms of depression as a prospective risk factor for stroke. Psychosom Med 2000; 62:463.
- Ludman EJ, Katon W, Russo J, et al. Depression and diabetes symptom burden. Gen Hosp Psychiatry 2004; 26:430.
- Lustman PJ, Anderson RJ, Freedland KE, et al. Depression and poor glycemic control: a meta-analytic review of the literature. Diabetes Care 2000; 23:934.
- de Groot M, Anderson R, Freedland KE, et al. Association of depression and diabetes complications: a meta-analysis. Psychosom Med 2001; 63:619.
- Katon WJ, Rutter C, Simon G, et al. The association of comorbid depression with mortality in patients with type 2 diabetes. Diabetes Care 2005; 28:2668.
- Kimmel PL, Peterson RA, Weihs KL, et al. Multiple measurements of depression predict mortality in a longitudinal study of chronic hemodialysis outpatients. Kidney Int 2000; 57:2093.
- Lacson E Jr, Li NC, Guerra-Dean S, et al. Depressive symptoms associate with high mortality risk and dialysis withdrawal in incident hemodialysis patients. Nephrol Dial Transplant 2012; 27:2921.
- Lacson E Jr, Bruce L, Li NC, et al. Depressive affect and hospitalization risk in incident hemodialysis patients. Clin J Am Soc Nephrol 2014; 9:1713.
- Lopes AA, Bragg J, Young E, et al. Depression as a predictor of mortality and hospitalization among hemodialysis patients in the United States and Europe. Kidney Int 2002; 62:199.
- Fifield J, Tennen H, Reisine S, McQuillan J. Depression and the long-term risk of pain, fatigue, and disability in patients with rheumatoid arthritis. Arthritis Rheum 1998; 41:1851.
- Ang DC, Choi H, Kroenke K, Wolfe F. Comorbid depression is an independent risk factor for mortality in patients with rheumatoid arthritis. J Rheumatol 2005; 32:1013.
- Vos MS, Putter H, van Houwelingen HC, de Haes HC. Denial and social and emotional outcomes in lung cancer patients: the protective effect of denial. Lung Cancer 2011; 72:119.
- Williams AR, Olfson M, Galanter M. Assessing and improving clinical insight among patients "in denial". JAMA Psychiatry 2015; 72:303.
- Levenson JL, Mishra A, Hamer RM, Hastillo A. Denial and medical outcome in unstable angina. Psychosom Med 1989; 51:27.
- Bernstein MH, Colby SM, Bidwell LC, et al. Hostility and cigarette use: a comparison between smokers and nonsmokers in a matched sample of adolescents. Nicotine Tob Res 2014; 16:1085.
- Cougle JR, Zvolensky MJ, Hawkins KA. Delineating a relationship between problematic anger and cigarette smoking: a population-based study. Nicotine Tob Res 2013; 15:297.
- Lupis SB, Lerman M, Wolf JM. Anger responses to psychosocial stress predict heart rate and cortisol stress responses in men but not women. Psychoneuroendocrinology 2014; 49:84.
- Shin C, Kim J, Yi H, et al. Relationship between trait-anger and sleep disturbances in middle-aged men and women. J Psychosom Res 2005; 58:183.
- Gerhart JI, Sanchez Varela V, Burns JW, et al. Anger, provider responses, and pain: prospective analysis of stem cell transplant patients. Health Psychol 2015; 34:197.
- Leombruni P, Fassino S, Lavagnino L, et al. The role of anger in adherence to highly active antiretroviral treatment in patients infected with HIV. Psychother Psychosom 2009; 78:254.
- Yan LL, Liu K, Matthews KA, et al. Psychosocial factors and risk of hypertension: the Coronary Artery Risk Development in Young Adults (CARDIA) study. JAMA 2003; 290:2138.
- Lemogne C, Schuster JP, Levenstein S, et al. Hostility and the risk of peptic ulcer in the GAZEL cohort. Health Psychol 2015; 34:181.
- Burns JW, Gerhart JI, Bruehl S, et al. Anger arousal and behavioral anger regulation in everyday life among patients with chronic low back pain: Relationships to patient pain and function. Health Psychol 2015; 34:547.
- Burns JW, Bruehl S, Chont M. Anger regulation style, anger arousal and acute pain sensitivity: evidence for an endogenous opioid "triggering" model. J Behav Med 2014; 37:642.
- Chida Y, Steptoe A. The association of anger and hostility with future coronary heart disease: a meta-analytic review of prospective evidence. J Am Coll Cardiol 2009; 53:936.
- Eaker ED, Sullivan LM, Kelly-Hayes M, et al. Anger and hostility predict the development of atrial fibrillation in men in the Framingham Offspring Study. Circulation 2004; 109:1267.
- Mostofsky E, Maclure M, Tofler GH, et al. Relation of outbursts of anger and risk of acute myocardial infarction. Am J Cardiol 2013; 112:343.
- Mostofsky E, Penner EA, Mittleman MA. Outbursts of anger as a trigger of acute cardiovascular events: a systematic review and meta-analysis. Eur Heart J 2014; 35:1404.
- Penley JA, Tomaka J, Wiebe JS. The association of coping to physical and psychological health outcomes: a meta-analytic review. J Behav Med 2002; 25:551.
- Ciechanowski P, Russo J, Katon WJ, et al. Relationship styles and mortality in patients with diabetes. Diabetes Care 2010; 33:539.
- Messerli-Bürgy N, Molloy GJ, Poole L, et al. Psychological coping and recurrent major adverse cardiac events following acute coronary syndrome. Br J Psychiatry 2015; 207:256.
- Saravay SM. Interventions, outcomes, and costs. In: Psychosomatic Medicine, Blumenfield M, Strain JJ. (Eds), Lippincott Williams & Wilkins, Philadelphia, PA 2006. p.867.
- World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Version 2010. http://apps.who.int/classifications/icd10/browse/2010/en#/F54 (Accessed on October 22, 2014).
- Scher LM, Knudsen P, Leamon M. Somatic symptom and related disorders. In: The American Psychiatric Publishing Textbook of Psychiatry, Sixth Edition, Hales RE, Yudofsky SC, Roberts LW. (Eds), American Psychiatric Publishing, Washington DC 2014. p.531.
- CLINICAL FEATURES
- Type of psychological factors
- - Regression
- - Anxiety
- - Depression
- - Denial
- - Anger
- - Other
- Course of illness
- When to suspect the disorder
- Initial evaluation
- Diagnostic criteria
- DIFFERENTIAL DIAGNOSIS
- Adjustment disorder
- Conversion disorder
- Illness anxiety disorder
- Mental disorder due to another medical condition
- Somatic symptom disorder