Assessment and Diagnosis
The 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.
Let us 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.
PFAMC can 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.
PFAMC can 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.
When a 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.
To 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 psychological status.
PFAMC has descriptive names for subcategories described as follows.
If the 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.
Patients 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.
This may 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.
Many 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.
Examples 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.
There are 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.