JOSEPH N. DiGIACOMO, M.D. HAROLD ROSEN, M.D.

Psychosomatic disorders: Psychotropic medications Psychiatric consultation in the management of the patient with psychosomatic disorders often occurs during a deterioration in the patient's clinical course. It is the task of the consultant to use the tools at his disposal to help the patient move toward more adaptive functioning. Often supportive care and brief psychotherapy are sufficient in creating this momentum. If this intervention does not suffice, the use of psychotropic drugs is indicated. Several specific symptom complexes are discussed and recommendations for management are outlined.

ABSTRACT:

The comprehensive management of the patient with a psychosomatic disorder often includes the use of psychotropic medication. The manner in which this is done is often crucial to the success of the treatment. The almost infinite variety of emotional responses to psychosomatic illness and the complexity of drug interactions make it impossible to construct a "cook-

book" approach. Despite these difficulties, however, it is possible to formulate a set of general principles for the use of psychotropic medication in the patient with a psychosomatic illness. Perhaps the single most important principle in the use of psychotropic medication is to avoid administering any until a thorough psychologic evaluation has been

From the Third Weiss-English Symposium. Philadelphia, October 29, 1977. Dr. DiGiacomo is associate prOfessor of psychiatry at the University of Pennsylvania School of Medicine and chief ofpsychiatry at the Veterans Administration Hospital. Philadelphia. Dr. Rosen is assistant clinical prOfessor of psychiatry at the University ofPennsylvania School of Medicine and assistant chiefofpsychiatry at the Veterans Administration Hospital. Reprint requests to Dr. DiGiacomo, VA Hospital, Philadelphia, PA 19104.

FEBRUARY 1979 • VOL 20 • NO 2

accomplished. Frequently the support, concern, and understanding communicated over the course of four to six brief interviews are suf-. ficient to obviate the need for psychotropic medication.

Ca•• 1 A patient with severe asthma lost almost half of his body weight because of inability to eat. Parenteral hyperalimentation and systemic steroids were ineffective in checking the downhill course. When a cardiac arrhythmia began to further complicate treatment, the patient requested psychiatric consultation. On examination the patient appeared severely ill. When the psychiatrist expressed some concern about what he could offer. the patient replied. "Wait Doc, I want to tell you something. I think this is all psychological.·· When the psychiatrist continued to question this assessment. the patient became increasingly insistent. The psychiatrist indicated the patient could not be treated on the psychiatric ward while he was receiving high doses of steroid medication and parenteral feedings, and the patient then asked if he could be transferred if the intravenous feeding and

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steroids were no longer necessary. In a somewhat disbelieving manner the psychiatrist agreed to the transfer if these terms could be met. Over the next ten days the patient was visited daily, and at the end of two weeks he no longer required parenteral feeding and was receiving very small doses of steroids. He was transferred according to the agreement. Following transfer, the patient continued to gain weight and began to become aware of the environmental stresses that had preceded his hospitalization. With help in modifying these stresses, and six-year follow-up in group therapy, the patient has had no major recurrences.

If, as- in this case, the patient displays significant improvement during the course of evaluation, medication can be withheld. Psychotherapeutic techniques can then be uscd as the primary treatment modality with the geals of the therapy determined by the personality structure and needs of the patient in question. If improvement does not occur, the data provided by the evaluation provide the foundation for the choice of medication, and brief supportive psychotherapy can continue as an important adjunct to the pharmacologic treatment. Hospitalization The second form of treatment intervention that should be considered before deciding on the use of psychotropic medications is brief hospitalization. Removing the patient from the stress of his environment and providing him with a brief period of rest and nurture are often sufficient to halt the progressive deterioration in the patient's functioning. Once momentum toward more adaptive functioning is established, the need for additional medication may be eliminated. FEBRUARY 1979· VOL 20 • NO 2

If there is no evidence of clinical improvement after an extensive psychiatric evaluation done in conjunction with supportive psychotherapy, and if brief hospitalization is impractical or unsuccessful, the use of medication may be indicated. Despite the multiplicity of psychologic responses to physical illness, certain symptom constellations occur repeatedly. The following sections will describe several patterns of response and discuss the type of medication we found most effective.

Severe, persistent anxiety Although psychophysiologic symptoms serve, in many instances, to bind anxiety and thus prevent it from reaching conscious awareness, these defensive mechanisms are not always successful. When anxiety overwhelms the psychophysiologic defenses and erupts into consciousness, a variety of cognitive functions such as attention, concentration, learning, and memory may be disrupted. Learning based on verbal interactions, as in psychotherapy, becomes difficult if not impossible, and medication to reduce this nonproductive anxiety is indicated. The choice between the benzodiazepine group of "minor" tranquilizers and the use of low-dose neuroleptics depends largely on the degree to which psychotic mechanisms such as projection, externalization, delusions, and hallucinations are used to control the anxiety. Psychologic tests such as the MMPI may be useful to provide confirmatory data. If psychotic mechanisms appear to be present, the use of low-dose neuroleptic therapy is recommended. If a degree of sedation seems beneficial, thioridazine 25 to 100 mg is effective. Haloperidol 2 to 4 mg per day

is somewhat less sedating but equally effective. The patient should be seen regularly after the initiation of drug therapy and the dosage modified as necessary. Since there may be a week's interval before maximum therapeutic effect occurs, dosage changes should be initiated in a conservative manner. The goal of treatment is not the complete elimination of anxiety. The patient should be informed that he will continue to have some anxiety in response to the stress produced by his illness and his inability to exert full control over the decisions regarding his care. Attempts to medicate away all anxiety are often unrealistic and result in the use of doses of medication that carry a high risk of adverse effects. Slurred speech, a look of detachment, and akinesia may result; and an unwarranted dependence on medication may be initiated. These effects are both unnecessary and socially aversive. If the patient appears to be a "zombie," and/or intoxicated, social supports in his environment may be withdrawn, leaving the patient without the help he requires to find adaptive solutions to his problems. Affect block A significant number of patients with psychosomatic illnesses appear unable to feel any powerful emotion. 1 Not infrequently, these patients state that they feel nothing except a small amount of anxiety. This lack of response may be most apparent in a group setting when all other group members are able to express intense emotional responses to a shared event. Although blocking of affect may have an adaptive function, as in a cardiac patient who witnesses a cardiac arrest, such inability to re101

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spond emotionally may worsen a psychosomatic illness. When inhibition of affect is habitual in a patient with a psychosomatic disorder, a psychotherapeutic approach alone may be unrewarding. The difficulties inherent in affect block are clearly demonstrated in the following example.

In such situations, small doses of a neuroleptic may be helpful in reducing anxiety and thus increase the patient's tolerance for the release of strong emotion. As these feelings become articulated, an understanding of the patient's conflicts can be developed and eventually worked through.

Case 2 A 30-year-old woman with a long history of asthma and severe affect block had become part of a structured group-therapy program. During one of the sessions, most of the patients became visibly annoyed in response to a provocative statement made by the group therapist. The patient with asthma, however, appeared totally unperturbed. When asked to describ~ their feelings, the other group members began to associate to situations in which they had felt oppressed and controlled by an authority figure. Almost all were able to express some annoyance. The asthmatic woman, however, despite repeated questioning, maintained that she felt only a slight degree of anxiety. Over the ensuing weeks the group, with the exception of the asthmatic patient, worked in a cohesive manner and became able to express feelings of annoyance and anger with less difficulty. She continued to report only the feeling of diffuse anxiety. Finally, she behaved in an angry fashion, raising her voice, and acknOWledged feeling full of rage. In response to the group's questions regarding her angry feelings, she stated, "You didn't do me a favor. I felt very unpleasant and I'd rather be anxious than angry."

Depression The occurrence of severe depression, with impairment of sleep and appetite and loss of the will to live, in conjunction with a severe psychosomatic disorder presents a challenging treatment situation. Although the feelings of hopelessness, worthlessness, and helplessness may be communicated directly, it is Also common to find behavioral rather than verbal attempts to communicate these unpleasant affects. Alcohol use, for example, is often an attempt to self-medicate, as is the abuse of sedative-hypnotics. Impulsive pleasure-seeking behavior, such as spending sprees, increase in masturbatory activity, promiscuity, and job changes, may be another way of relieving the patient's dysphoria. Irritability and explosive outbursts of anger may be yet another important manifestation. When the expression of depressive feelings is behavioral rather than verbal, it is crucial to attempt to establish a relationship between the behavior and the underlying affect, and initiate treatment for the depression. Although use of the tricyclic antidepressants may be effective, it is also important to integrate the antidepressants into the total medical management of the p~ychosomatic disorder. Remember that the anticholinergic properties of the antidepressants may cause excessive drying of the mucus in the bron-

A small dose of a major tranquilizer was prescribed with the intent of allowing the woman to experience her anger without an intense and disorganizing degree of anxiety. The fear of this intense dysphoric state appeared to act as a block against any strong emotion. 102

chial tree of a patient with asthma and may thus aggravate the condition. In patients with peptic ulcer, the use of antidepressants with strong anticholinergic properties may reduce gastric acidity and decrease the need for other anticholinergic medications. If evidence of anxiety, agitation, impulsive pleasure seeking, or sleep disorder continues after a three- to four-week trial of a therapeutic dose of tricyclic antidepressants, it is often helpful to add a major tranquilizer to the regimen. Again, neuroleptics should be initiated in small doses and increased very gradually until the desired control of symptoms is achieved. Severe persistent pain Although severe, persistent pain unexplained by existing organic pathology is not one of the "classic" psychosomatic disorders, this problem warrants discussion because of its frequency and the distress it can cause both patient and physician. When first seen, the patient with pain evokes immediate and sustained attention. Physical examinations, tests, and consultations are all palpable evidence of the physician's concern and desire to help. If no source for the pain is found or the pain does not respond to standard treatment, there is often a rapid and dramatic shift itl the doctor-patient relationship. The physician may become increasingly frustrated and annoyed with the patient. He forgets or cancels appointments. Complaints of increased pain evoke direct or indirect statements concerning lack of "will power" or even malingering. Finally the psychiatrist is called in to help, often with the covert intent of determining if the pain is "real" or "imaginary." PSYCHOSOMATICS

In many ways this is an "impossible consultation."2 The patient feels hurt, rejected, and angry. He may view the psychiatrist as a detective who will attempt to prove that he is mentally ill and that his physical perceptions, therefore, are not real. Collaborative attempts to ameliorate the pain and the associated emotional responses are difficult to achieve. In these situations it is important to assure the patient that his pain is real and not "in his head." The patient is accurately reporting his sensory experiences, but the peremptory nature of the pain may prevent him from reporting other aspects of his internal world such as feelings of depression, worthlessness, anxiety, and need for care. It is important at this juncture to express willingness to participate in the patient's care and to initiate brief supportive visits and tricyclic antidepressants. In our experience these drugs not only reduce the intensity of depression in many of these individuals, but also increase pain tolerance and make it easier to sleep. With the use of these drugs the addicting potential of the narcotic analgesics is avoided and the therapist continues to participate actively in the patient's care. Family involvement in the treatment plan must begin before antidepressants are employed. The family must be taught to avoid reinforcing the patient's pain as a mechanism of communication within the family. Both the patient and the family must accept the possibility that the patient may always have some pain; treatment should be aimed at helping the patient function despite the pain.

Angina pectoris Perhaps the most challenging and urgent of the variants of persistent. FEBRUARY 1979· VOL 20 • NO 2

pain is the problem of unresponsive angina pectoris. Clearly, strong emotion exerts powerful effects on the heart, and these effects may be magnified in an already diseased heart. We have had the opportunity to evaluate several patients with angina pectoris who have had recurrent angina at rest or with minimal exertion. Several of these admissions were at the request of the patient's cardiologist, who felt that there was a "supratentorial" element to the angina. Case 3 A psychiatric evaluation was requested for a 50-year-old man to explore the possibility that psychologic responses to his complicated cardiac problems were preventing effective rehabilitation. The patient, who had had three previous myocardial infarctions over the past several years, was experiencing 10 to 12 attacks of angina per day. He had been unable to work for the past two years, and had limited his activity to sitting in a chair. His wife was finally forced to leave her job to care for her husband. Medications at the time of evaluation were digoxin 0.25 mg q.i.d., propranolol 80 mg q.i.d., quinidine 200 mg !.i.d., furosemide 120 mg q.i.d., triamterene 100 mg b.i.d., nitroglycerin ointment, isosorbide dinitrate 20 mg q.i.d., and diazepam 10 mg q.i.d. In the initial psychiatric interview, the patient complained of feeling overwhelmed by unexpressed anger and hatred and crying spells. He described feeling "fragile." The patient was an obese white man who appeared depressed and displayed a strained, contained quality in his ability to relate to the interviewer. He was alternately tearful and explosively angry. His thought content revealed preoccupation with either suicide or homicide. The physical examination was negative and the ECG revealed an old infarct pattern.

The patient's clinical presentation remained the same for the first two weeks on the inpatient psychiatric unit except for occasional increases in irritability and demands for medication when diazepam was discontinued. At the end of the second week he was participating in milieu, occupational, individual, and couples therapy. In the last three weeks of hospitalization his anginal attacks subsided with his maintenance on cardiac medications. Because of his cardiac status the patient was the only person on the ward allowed in bed during the day. As he joined the ward community he insisted that he would not be a "VIP" and requested permission to walk to the canteen. At the time of discharge, he was able to walk about the hospital with the other patients without experiencing angina or any marked shortness of breath. During the hospital stay, strong situational factors were uncovered, and he was helped to deal effectively with his depressed and angry feelings without the use of any psychotropic drugs. Three months later, he requested readmission because he felt "a depression coming on." His chest pain was again becoming frequent, and his exercise tolerance had decreased. He was discharged one month later, again with marked improvement both in his anginal pain and exercise tolerance. He felt at discharge that he could now cope with his situational stresses. He has been followed for 18 months in a group consisting of medically ill middle-aged men and has essentially maintained his improvement.

Admission to the psychiatric ward may be associated with a marked decrease in the incidence of angina and an increase in exercise tolerance. During the first week or two on the ward, patients seem extremely sensitive to tensions in the environment. These tensions seem to be internalized and can become an additional factor in precipitating 103

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an attack of angina or an arrhythmia. As the patients become acclimated to the community and participate in the resolution of conflicts in an active verbal fashion, the frequency of anginal attacks may be reduced significantly. It is not unusual to see these patients increase their exercise tolerance five- to tenfold within a month. Certain patients, however, show no significant change in the frequency of angina or exercise tolerance even after several weeks 011 the psychiatric ward. Most of them are markedly anxious about their heart disease and they often appear agitated. One of them commented, "I was afraid I wasn't going to wake

up when I felt my heart skip a beat, and thought I'd die in bed." The ward personnel become understandably concerned if the patient looks ashen and expresses a concern that he may suddenly die. In such patients we have avoided the use of the minor tranquilizers and have treated the underlying depression related to the prolonged and chronic nature of the heart disease with a tricyclic antidepressant such as doxepin. Low doses of neuroleptics such as haloperidol or thioridazine 10 to 100 mg b.i.d. can also be used if anxiety Or arrhythmias such as premature ventricular contractions are prominent. The minor prolongation of the QT in-

tervals produced by thioridazine in low doses may be similar to the antiarrhythmic effect of quinidine. Although the decrease in episodes of angina may not be dramatic in this group, these patients are able to become functioning members of their ward. They become less anxious about their angina, increase their compliance with the therapeutic regimen, and become more amenable to educative efforts on the part of their physicians. 0 REFERENCES 1. Sffneos P: Alexithymia. Psycho/her Psychosom 22:255-262.1973. 2. Hollender M. Hersh SP: Impossible consul1alion made possible. Arch Gen Psychia/r 23:343-345. 1970.

Case Reports PSYCHOSOMATICS has recently introduced a new department for the presentation of Case Reports. Submissions are invited of reports of provocative or interesting clinical experiences in psychosomatio medicine-particularly those that suggest improved therapies or raise pertinent Questions about currently used therapies. Cohtributions should include a brief introduction, followed by a description' of one or two cases, a short statement of their significance, and suggestions for further study. They should not exceed 1,200 words. Attach a short list of references, cited by number in the text of the report.

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Submit two copies to: Wilfred Dodman, M.D. Editor in Chief Psychosomatics 1921 Newkirk Avenue Brooklyn, NY 11226

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Psychosomatic disorders: psychotropic medications.

JOSEPH N. DiGIACOMO, M.D. HAROLD ROSEN, M.D. Psychosomatic disorders: Psychotropic medications Psychiatric consultation in the management of the pati...
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