Seventeenth-century philospher Rene Descartes conceptualized the distinction between the mind and the body. He viewed the ‘mind’ as completely separable from the ‘body’ (or ‘matter’ in general). The mind was seen as the concern of organized religion, whereas the body was seen as the concern of physicians. This partitioning ushered in a separation between the so-called ‘mental’ and ‘physical’ health. This dualism has influenced the thinking of health professionals as well as lay people for a long time. However, the twentieth century has witnessed remarkable advances in the understanding of mental disorders and the brain, and there is realization of the centrality of mental health to overall health and well being. The focus has shifted in the last decade to holistic medicine.
In Ayurveda, an ancient Indian system of medicine, symptoms and diseases that could be categorized as mental thoughts or feelings are just as important as symptoms and diseases of the physical body. There can be no mental health without physical health and vice versa. The mind and the body not only influence each other – they are each other. The whole life and life style must be in harmony before one can enjoy well being.
Recent research provides evidence that stresses that affect the brain can hurt the body at the cellular and molecular level and diminish a person’s health and quality of life. Psychoneuroimmunology seeks to understand the complex communications among the brain and the immune system, and their implications for health. New molecular techniques have allowed scientists to detail links between stress and disease immunity, pinpointing changes in hormone flow and immune system cells. Recent work has demonstrated that hormones and neurotransmitters released under stress can change immune cell behaviour.
Co-occuring physical, psychological and psychiatric disorders
There is now sufficient evidence on. co-morbidity of mental and physical disorders. Several psychological factors can take a toll on cardiac health, although each factor may act at different stages through different mechanisms. Psychological risk factors for coronary disease1 can be classified in to three categories: chronic, episodic and acute based on their duration and closeness in time to coronary syndromes. Chronic psychological factors that are associated with increased risk of first heart attack include long- term stable characteristics like a hostile personality, type A behavior, or low socio-economic status. These chronic factors play an important role in early disease stages when the build up of arteryblocking plaque is beginning. Fat deposits, inflammation of the arteries and higher white blood cell counts are known to result from these psychological traits by way of the nervous system. For instance, low socio-economic status correlates with increased exposure to bacteria and viruses, to higher levels of cytokines and to elevated C-reactive protein, a marker for inflammation1.
The same pattern holds true for episodic risk factors like depression and exhaustion. Episodic mental health conditions may lead to unstable plaques. Depression with elements of immune system, like increased cytokines, lymphocytes and white blood cells, strengthens the association between depression and inflammatory markers. Acting in the short term, acute psychological risk factors can directly trigger heart attacks once disease has reached advanced stages. Outbursts of anger increase the risk of heart attack by reducing adequate blood supply to the heart plaque.
A study on association between emotional upset and cardiac arrhythmia2 showed that negative emotion was associated with increased arrhythmia. Additionally, greater negative emotion was significantly associated with increased arrhythmia among participants in a lower left ventricular ejection fraction group (LVEF). However, this relationship between negative emotion and arrhythmia was not observed among higher LVEF participants. This can be seen as contributing to a larger body of evidence suggesting that negative moods may exacerbate cardiac conditions.
A great deal of research has investigated the relationship between stress and physical health. Posttraumatic stress disorder (PTSD) and other clinically significant distress reactions are a key step in triggering the processes through which exposure affects health. These processes involve psychological , biological, behavioural mechanisms that interact to strain the body’s ability to adapt, thereby increasing the likelihood of illness. A study3 on primary care patients showed that individuals with PTSD were more likely to have a number of specific medical problems including anaemia, arthritis, asthma, back pain, diabetes, eczema, kidney disease, lung disease and ulcer.
Generalized anxiety disorder is associated with increased risk of peptic ulcer disease, odds ratio ranging from 1.3 – 5.7 with evidence of a doseresponse relationship4. Neuroticism is also associated with significantly increased risk of self reported peptic ulcer disease, odds ratio ranging from 1.03 to 2.45. The mechanism of this association remains unknown and requires further research.
There is a strong association between panic attacks and self- reported respiratory diseases such as asthma, chronic bronchitis, or emphysema and other self-reported lung diseases have also been found to associate with a significantly increased odds of panic attacks, odds ratio ranging from 1.2 to 4.2(6).
A longitudinal study among children7 showed that poor physical health predicted future depression, independent of previous depression and demographic characteristics. Similarly major depression predicted future poor physical health, independent of previous physical health and demographic characteristics. Significant relationships among specific disorders reported in the longitudinal data were limited to major depression for mental disorders and immunologically related physical disorders such as allergies and asthma.
Role of cortisol
Elevated cortisol in a subset of depressed patients is a consistent finding. A recent review8 suggests that a subset of depressed patients have subtle evidence of physical effects similar to those in patients with Cushing’s syndrome or the metabolic syndrome. Cushing’s disease is an illness associated with cortisol elevations secondary to adrenocorticotropic hormonesecreting pituitary tumours. However, the cortisol elevations in patients with major depressive disorder (MDD) may be associated with clinically significant health effects despite the absence of obvious Cushingoid features. The metabolic syndrome is a common symptom cluster that includes dysregulated insulin and glucose metabolism, abdominal obesity, hyperlipidaemia and hypertension. The metabolic syndrome is a risk factor for the development of type 2 diabetes and cardiovascular disease. This review further shows that strong data evidence exists for a relationship between elevated cortisol and depression, hippocampal atrophy, cognitive impairment, abdominal obesity, and loss of bone density. Some evidence suggests an association between depression and hypertension, peptic ulcers, and diabetes. The mechanism by which corticosteroids may exert adverse effects on the body may be different for each condition. Alterations in serotonin levels, enhanced glutamate release, or inhibition of neurogenesis may be important factors in the central nervous system (CNS) effects of corticosteroids. The corticosteroidinduced decrease in bone mineral metabolism could in part be responsible for association of depression with loss of bone density. Elevated levels of catecholamines that appear to be associated with elevated cortisol levels in depressed patients could result in hypertension. As corticosteroids have potent anti-inflammatory and immunosuppressant effects, alterations in the immune system could also play a role in some disease processes. Cortisol seems to have a complex interaction with measures of immune functioning in depressed patients, which can include cytokine-induced activation of the hypothalamuspituitary-adrenal (HPA) axis and association between cytokine and cortisol levels.
Management of co-morbidity
When physical disorders become chronic in nature, there are often psychiatric sequelae associated with them. A study of chronic childhood illness, disability, and mental and social well being revealed that children with both chronic illness and associated disability were at greater than three-fold risk for psychiatric disorders and considerable risk for social adjustment problems9. Children with chronic medical conditions, but no disability had about two-fold increase in psychiatric disorders but little increased risk for social adjustment problems. The findings suggest that physicians in the community who care for children with chronic health problems should become skilled in the recognition of existing or incipient mental health and social problems and familiar with preventive and treatment approaches that may lessen the excessive burden of psychosocial problems among those with chronic ill health. On the other side, the psychotic patients may be unable to comprehend or describe their physical symptoms adequately. Physical disorders of psychotic patients may be overlooked if clinicians are not vigilant and thorough in assessing the patient’s complaints, especially if suc\h complaints sound delusional or bizarre. There is an obvious need for further research to better understand how to manage the co-morbidity of physical and mental disorders.
In past, the mental health field often focused principally on mental illness in order to serve individuals who were most severely affected. Now there is a need to respond to intensifying interest and concerns about disease prevention and health promotion. Mental health, like the broader field of health, has to be rooted in a population-based public health model, characterized by concern for the health of a population in its entirety and by awareness of the linkage between health and physical and psychosocial environment.
References
1. Kop WJ. The integration of cardiovascular behavioral medicine and psychoncuroimmunology : New developments based on converging research fields. Brain Behav Immun 2003; 17: 233-7.
2. Carels RA, Cacciapaglia H, Perez-Benitez CI, Douglass O, Christie S, O’Brien WH. The association between emotional upset and cardiac arrhythmia during daily life. J Consult Clin Psychol 2003; 71 : 613-8.
3. Weisberg RB, Bruce SE, Machan JT, Kessler, RC, Culpepper L, Keller, MB. Nonpsychiatric illness among primary care patients with trauma histories and post-traumatic stress disorder. Psychiatr Serv 2002; 53 : 848-54.
4. Goodwill RD, Stein MB. Generalized anxiety disorder and peptic ulcer disease among adults in the United States. Psychosom Med 2002; 64 : 862-6.
5. Goodwin RD, Stein MB. Peptic ulcer disease and neuroticism in the United Slates adult population. Psychother Psychosom 2003; 72: 10-5.
6. Goodwin RD, Pine DS. Respiratory disease and panic attacks among adults in the United States. Chest 2002; 122 : 645-50.
7. Cohen P, Pine DS, Must A, Kasen S, Brook J. Prospective associations between somatic illness and mental illness from childhood to adulthood. Am J Epidemiol 1998;147:232-9.
8. Brown ES, Varghese FP, McEwen BS. Association of depression with medical illness : does cortisol play a role ? Biol Psychiatry 2004; 55: 1-9.
9. Cadman D, Boyle M, Szatmari P, Offord DR. Chronic illness, disability and mental and social well-being: findings of the Ontario Child Health Study. Pediatrics 1987: 79 : 805-13.
Narender Kumar
Division of Non-Communiable Diseases
ICMR Headquarters
New Delhi 110029, India
e-mail : [email protected]
Copyright Indian Council of Medical Research Nov 2004
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