The DSM-5 has always faced criticism over the term “psychological factors affecting other medical conditions” because the clinical application was always unclear. The simplest way to define this term might be the presence of psychological or behavioral factors that adversely affect an organic medical condition in a patient with confirmed medical illness other than a mental disorder. These psychological factors should show a positive temporal relationship with disease’s exacerbations or delayed recovery.
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Epidemiology

The exact prevalence of psychological factors that are clearly affecting patients with medical conditions is unknown but is believed to be higher than the prevalence of other somatic disorders.

Children are more likely to develop certain psychological tendencies against a medical condition that is chronic and severe. Additionally, adults might choose to ignore certain life-threatening symptoms such as acute chest pain in a high-risk patient for coronary artery disease either because they are in denial or because they have comorbid depression.

It is important to differentiate between the presence of a psychological reason behind delayed treatment and cultural differences. Some patients with certain medical illnesses might first choose to perform certain spiritual activities hoping the symptoms might improve before they seek medical attention. Therefore, certain behaviors that arise from beliefs should not be mistaken for a psychological issue that is adversely affecting a given medical condition.

Clinical Presentation of Psychological Factors Affecting Other Medical Conditions

Patients should have a medical symptom or condition in addition to certain psychological or behavioral factors that are adversely affecting their medical condition for this diagnosis to be made. Examples of these behaviors include an intentionally delayed presentation to the emergency department in a patient with acute coronary syndrome or poor adherence to prescribed medications.

The described behaviors should constitute an additional health risk to the patient’s current medical condition. This increased risk might be attributed to the effects of these risky behaviors on the disease’s pathophysiology and should be associated with symptoms’ precipitation or exacerbation.

The severity of the behavior should be also assessed in the patient. The behavior might pose mild but increased medical risk, clearly aggravate the current medical condition, be severe and result in hospitalization or be extreme. An example of an extreme psychological factor that might affect a medical condition is ignoring heart attack symptoms in a patient who is aware of the condition.

Diagnostic Criteria for Psychological Factors Affecting Other Medical Conditions

To confirm the presence of psychological factors that are adversely affecting a patient with an established medical condition, one can either use the DSM-5 criteria or the Diagnostic Criteria for Psychosomatic Research. DSM-5 criteria are stricter and might miss some cases but are more widely accepted by psychiatrists.

The DSM-5 criteria of psychological factors affecting other medical conditions include the following:

  1. The established presence of a medical condition in the patient.
  2. The presence of certain psychological or behavioral factors that are clearly and adversely affecting the patient’s medical condition.
  3. These behaviors should not be better explained by panic disorder, major depressive disorder, or other mental disorders.

When the presence of psychological factors affecting a medical condition in a patient is confirmed, it is important to note the severity of these factors. The severity should be classified based on the degree of risk the behavior might have on the patient’s condition. The severity of the behavior can be mild, moderate, severe or extreme.

The most common psychological factors include abnormal coping styles, denial of symptoms, poor adherence to medical treatment, maladaptive health behaviors. Patients might stop taking their medicines because they are in denial, because they want to achieve other goals such as losing weight in a diabetic patient who is on insulin, or because they are having problems coping with the illness.

The effects of such psychological factors on the patient’s health might be immediate, subacute or chronic. For instance, severe sadness and grieving might cause Takostubo cardiomyopathy. On the other hand, prolonged anxiety about a trivial medical condition might be associated with an increased risk of hypertension in the future.

Certain psychological factors might be also associated with recurrent exacerbations of a medical condition. For instance, anxiety induced asthma might be prominent in a child who is newly diagnosed with asthma.

The different psychological factors we described might have a direct effect on diseases with clear pathophysiology mechanisms such as diabetes, might exacerbate functional syndromes such as migraines, or might cause idiopathic symptoms in the patient. Non-specific abdominal pain is common in children and might be caused by some psychological factors.

Mental Disorder Due to Medical Condition

It is important to differentiate between the mere presence of psychological factors in a patient with a medical condition and having a medical condition that is known to “cause” abnormal behaviors and mental illness. For instance, Cushing syndrome has been associated with psychosis. Systemic lupus erythematosus can cause mild psychiatric abnormalities related to mood disorders or might cause psychosis.

Seizure’s disorders should be excluded reliably as they can cause certain abnormal behaviors that might be interrupted as psychogenic. Somatic symptom disorder should be also excluded in patients with medical conditions as one recent study has found that patients with a recent myocardial infarction are more likely to suffer from somatic symptom disorder compared to the general population.

Illness anxiety disorder is a condition that is characterized by severe anxiety that is distressing to the patient and causes him or her significant impairment in daily function. The anxiety should be about having a certain medical condition that is not present.

Treatment of Psychological Factors Affecting Other Medical Conditions

Patients should be counseled about how psychological factors might affect their condition. Cognitive behavioral therapy might be useful in such patients and the aim should be about understanding why the patient is showing such behavior and focus on changing the patient’s beliefs and ideas about his or her condition.

Medical treatment of anxiety in a patient with hypertension or asthma is reasonable. For instance, the use of beta-blockers in an anxious patient who also has hypertension is good for two reasons: 1. It lowers the patient’s blood pressure, 2. It decreases the anxiety symptoms of the patient which might have a long-term effect on his or her hypertension.

Patients who show signs of failed coping with their illness should be offered group therapy. When the patient meets other people with a similar or same condition, he or she will have a better understanding of the condition and this can help with coping.

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