Broadening horizons in psychiatry and respiratory medicine
Correspondence Address: Source of Support: None, Conflict of Interest: None
Psychiatry as a discipline has significantly evolved from dealing with core psychiatric disorders to current day liaison consultation with other specialties. Patients with respiratory ailments can have co-existing psychiatric co-morbidities and psychological problems. Psychiatric patients can also have co-morbid diseases of respiratory system. Literature pertaining to the arena of psychiatry and respiratory system was reviewed and relevant studies were included. Nosology of Medically Unexplained Symptoms Functional symptoms in respiratory system include dyspnea, habit cough, laryngeal dysfunction, and hyperventilation. These symptoms are called somatic, functional, hysterical or psychogenic. The ICD 10 and DSM IV TR describe them under somatoform and dissociative disorders. [1] Neurobiology of Psychogenic Dysnoea and Hyperventillatory Syndrome Literature describes the role of neurotransmitters in panic disorder and hyperventilation. Existing studies also describe the modulation of airway responses to standard airway challenges with exercise, allergens, or pharmacological agents by psychological factors. Newer studies have are discovering physiological processes associated with psychologically induced airway responses, with vagal excitation and ventilatory influences being the most likely candidate pathways. [2] Respiratory Diseases in Psychiatric Disorders Respiratory diseases such as pneumonia and tuberculosis accounted for most deaths amongst patients with psychiatric disorders in the era of institutionalization. Despite deinstitutionalization, respiratory diseases are still continuing to be prevalent with a higher incidence of tuberculosis in patients with schizophrenia compared with the general population. Chronic obstructive pulmonary disease (COPD) has also emerged significantly among those with chronic psychiatric disorders. [3] Psychiatric Comorbidity in Respiratory Disorders Literature suggests that depression can occur during weaning from prolonged mechanical ventilation. Jubran et al, conducted a study on patients weaned from mechanical ventilation and found that depressive disorders were diagnosed in 42% of the patients. Patients with depressive disorders were more likely to experience weaning failure and death. They suggested that patients requiring mechanical ventilation were at increased risk of emotional stress. They concluded that emotional stress could negatively impact ventilator weaning and survival. [4] Moussas et al, found a significantly higher rate of anxiety and depression in patients with bronchial asthma and COPD. They concluded that probable etiology could be the chronicity and severity of pulmonary disease. Early detection and management of psychiatric disorders may improve adaptation and quality of life of these patients. [5] Miedinger et al, found that quality of life was associated with psychological distress and psychiatric disorders in individuals with occupational asthma. [6] Felker et al, conducted a cross sectional survey on patients with COPD and associated psychiatric co-morbidity. They found that at each level of COPD severity, participants with mental disorders had worse health status and dyspnea. They concluded that independent of COPD severity, comorbid mental disorders were associated with worse health status and dyspnea. They suggest that further studies are needed to determine whether patients with comorbid mental disorders could have more significant improvement in physical symptoms and functioning if providers focus more on management of psychiatric conditions. [7] Pharmacotherpaeutic Strategies for Psychogenic Dysnoea, Panic Disorder and Hyperventilation American Psychiatric Association (APA) guidelines recommend selective serotoninreuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) as the best initial pharmacotherapy choice. Tricyclic antidepressants (TCA) are effective, however, their side effects limit their wider use. SSRIs, SNRIs, and TCAs are all preferable to benzodiazepines as monotherapies for patients with co-occurring depression or substance use disorders. The benefit of more rapid response to benzodiazepines must be reasonable weighed against the potential side effects of sedation and psychological dependence. [8] Psychological Therapies for Psychogenic Dysnoea, Panic disorder and Hyperventilation APA guidelines also discuss the role of various psychotherapies available for functional disorders. Cognitive Behavior Therapy and exposure therapy are recommended for these disorders. Evidence for the use of other psychodynamic psychotherapy approaches for panic disorder is described to be limited to case reports and experience of psychodynamic psychotherapy experts. [8]
The existing literature highlights the significance of psychiatric co-morbidity in patients with respiratory diseases. Physicians should collaborate with mental health professions for early identification and management of patients with depressive and anxiety symptoms. Psychiatrist and allied mental health professionals need to be aware about respiratory diseases in patients with chronic psychiatric disorders for appropriate management. Evidence base points towards psychopharmacological and psychotherapeutic strategies for psychogenic dysnoea, panic disorder and hyperventilation. Further studies in the arena of consultation-liaison psychiatry and respiratory medicine are need.
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