diagnosis of PFAMC differs from most other psychiatric di-agnoses in its focus
on the interaction between the mental and medical realms. As noted, the
criteria require more than that the patient have both a medical illness and
contemporaneous psycho-logical factors, because their coexistence does not
always include significant interactions between them. To make the diagnosis of
PFAMC, either the factors must have influenced the course of the medical
condition, interfered with its treatment, contrib-uted to health risks, or
physiologically aggravated the medical condition.
consider each of these four ways of making the diagnosis of PFAMC in more
detail. The psychological factor’s influence on the course of a general medical
condition can be inferred from a close temporal relationship between the factor
and the development or exacerbation of the medical condition (or delayed
recovery). For example, a 45-year-old male executive re-ports symptoms sounding
like typical angina, but occurring only on weekends. Further questioning
reveals that he is depressed over deterioration in his marriage. During the
week he works late and has limited contact with his family but he spends the
week-end at home. The symptoms began after he and his wife started arguing
every weekend. The temporal link between onset and recurrence of angina and
marital arguments supports a diagnosis of PFAMC.
be diagnosed when the psychological factor interferes with treatment including
not seeking medical care, not following up, nonadherence to prescribed drugs or
other treat-ment, or maladaptive modifications in treatment made by the
pa-tient or family. The executive with angina rejected his physician’s
recommendations for further assessment and treatment. He said, “I do get upset
at home but I feel just fine at the office, so there couldn’t be anything
really wrong with me”. The patient is able to acknowledge marital discord, but
the defense of denial clouds his perception of his physical health and blocks
appropriate medical care. This is another form of PFAMC.
also be diagnosed when the psychological factor contributes to health risks,
exemplified by the executive increasing his smoking and drinking despite his
physician’s warnings. (“It’s the only way I can cope with my wife.”) Finally,
PFAMC is an appropriate diagnosis when there are stress-related physiological
responses precipitating or exacerbating symptoms of the medical condition. The
same man observes that angina is most likely to occur after marital arguments
during which he be-comes irate, yells, slams doors and throws things.
patient’s medical illness is faring worse than ex-pected and not responding
well to standard treatment, physicians should and often do consider whether a
psychological factor maybe responsible for the poorer than expected outcome.
This is a far from trivial task. To ignore the possibility of PFAMC may miss
the crucial barrier to the patient’s recovery. On the other hand, premature or
facile attribution to psychological factors may lead the physician to overlook
medical or social explanations for “treatment-resistant disease” and unfairly
blame the patient, with resultant further deterioration in health outcomes and
the physi-cian–patient relationship.
illustrate, a common clinical problem is the brittle dia-betic adolescent with
labile blood glucose levels and frequent episodes of ketoacidosis and
hypoglycemia, despite vigorous attempts by the physician to improve diabetic
management and glucose control. The considerable difficulty in controlling such
patients’ diabetes is often attributed to adolescents’ dislike of lifestyle
restrictions, their tendency to act out and rebel against authority figures,
their denial of vulnerability, their ambivalence about their need for
nurturance and their wish to be “normal”. There are many adolescent (and some
adult) diabetic patients for whom these psychological issues do play an
important role in undermining diabetes management through noncompliance
re-garding medication, diet, visits to the physician, substance use and
activity limitations. However, psychological factors do not always account for
brittleness and are sometimes incorrectly suspected. It has been demonstrated
that much of the difficulty in achieving stable glucose control in adolescent
diabetics is the result of the dramatically labile patterns of hormone
secretion (cortisol, growth hormone) typical of adolescence, independent of
descriptive names for subcategories described as follows.
patient has a mental disorder meeting criteria for an Axis I or Axis II
diagnosis, the diagnostic name is mental disorder affecting medical condition,
with the particular medical condi-tion specified. In addition to coding PFAMC,
the specific mental disorder is also coded on Axis I or Axis II. Examples
include major depressive disorder that reduces energy and compliance in a
hemodialysis patient; panic disorder that makes an asthmatic patient
hypersensitive to dyspnea; and schizophrenia in a patient with recurrent
ventricular tachycardia who refuses placement of an automatic implantable
defibrillator because he fears it will control his mind.
who have psychological symptoms that do not meet the threshold for an Axis I
diagnosis may still experience important effects on their medical illness, and
the diagnosis would be psy-chological symptoms affecting a medical condition.
Examples include anxiety that aggravates irritable bowel syndrome; de-pressed
mood that hinders recovery from hip replacement sur-gery; and anger that
interferes with rehabilitation after spinal cord injury.
include personality traits or coping styles that do not meet criteria for an
Axis II disorder and other patterns of re-sponse considered to be maladaptive
because they may pose a risk for particular medical illnesses. An example is
the competi-tive hostility component of the type A behavior pattern, and its
impact on coronary artery disease. Maladaptive personality traits or coping
styles are particularly likely to interfere with the phy-sician–patient
relationship as well as the patient’s relationships with other caregivers.
maladaptive health behaviors have significant effects on the course and treatment
of many medical conditions. Examples include sedentary lifestyle, smoking,
abuse of alcohol or other substances, and unsafe sexual practices. If the
maladaptive be-haviors can be better accounted for by an Axis I or Axis II
dis-order, the first subcategory (mental disorder affecting a medical
condition) should be used instead.
of stress-related physiological responses affecting a medical condition include
the precipitation by psychological stress of angina, cardiac arrhythmia,
migraine, or attack of coli-tis in medically vulnerable individuals. In such
cases, stress is not the cause of the illness or symptoms; the patient has a
medi-cal condition that etiologically accounts for the symptoms (e.g., coronary
artery disease, migraine, or ulcerative colitis), and the stressor instead
represents a precipitating or aggravating factor.
other psychological phenomena that may not fit within one of these
subcategories. An interpersonal example is mari-tal dysfunction. A cultural
example is the extreme discomfort women from some cultures may experience being
alone with a male physician, even while they are fully dressed. A religious
example is a Jehovah’s Witness who ambivalently refuses blood transfusion.
These fall under the residual category of other or unspecified psychological
factors affecting a medical condition.