01 - 13.1 Introduction and Overview

13.1 Introduction and Overview

Psychosomatic Medicine 13.1 Introduction and Overview Psychosomatic medicine has been a specific area of concern within the field of psychiatry for more than 50 years. The term psychosomatic is derived from the Greek words psyche (soul) and soma (body). The term literally refers to how the mind affects the body. Unfortunately, it has come to be used, at least by the lay public, to describe an individual with medical complaints that have no physical cause and are “all in your head.” In part due to this misconceptualization, the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM), in 1980, deleted the nosological term psychophysiological (or psychosomatic) disorders and replaced it with psychological factors affecting physical conditions (see Section 13.5), nor has the term reappeared in subsequent editions, including the latest edition (DSM-5). Nonetheless, the term continues to be used by researchers and is in the title of major journals in the field (e.g., Psychosomatic Medicine, Psychosomatics, and Journal of Psychosomatic Research). It is also used by the two major national organizations in the field (the Academy of Psychosomatic Medicine and the American Psychosomatic Society) as well as international organizations (e.g., the European Association for Consultation Liaison Psychiatry and Psychosomatics). In 2003 the American Board of Medical Specialties and the American Board of Psychiatry and Neurology approved the specialty of psychosomatic medicine. That decision recognized the importance of the field and also brought the term psychosomatic back into common use. HISTORY As Edward Shorter discusses in detail in his summary of the history of psychosomatic illness, ways of presenting illness vary over history, because patients unconsciously select symptoms that are thought to represent true somatic illnesses. As a result, psychosomatic presentations have varied over the course of recent history. Prior to 1800, physicians did not conduct clinical evaluations and could not distinguish somatic from psychogenic illness. As a result, the diagnoses of hysteria and hypochondriasis could easily be made in the presence of true medical illnesses and did not suggest any specific disease presentations. Sigmund Freud was the principal theoretician to bring psyche and soma together. He demonstrated the importance of the emotions in producing mental disturbances and somatic disorders. His early psychoanalytic formulations detailed the role of psychic determinism in somatic conversion reactions. Using Freud’s insight, a number of

workers in the early decades of the 20th century tried to expand the understanding of the interrelationship of psyche and soma. The influence on adult organ tissue of various unresolved pregenital impulses was proposed by Karl Abraham in 1927, the application of the idea of conversion reaction to organs under the control of the autonomic nervous systems was described by Sándor Ferenczi in 1926, and the attaching of a symbolic meaning to fever and hemorrhage was suggested by Georg Groddeck in 1929. In the 20th century, somatization symptoms changed from predominantly neurologic (e.g., hysterical paralysis) to other symptoms such as fatigue and chronic pain. Edward Shorter attributes this change to three causes: (1) improvements in medical diagnostic techniques made it easier to rule out organic causes for neurologic disease; (2) the central nervous system (CNS) paradigm faded; and (3) social roles changed (e.g., the disappearance of the historical notion that “weak” women would be expected to have fainting spells and paralysis). Although hysterical neurologic symptoms have remained relatively less common in the 21st century, CNS explanations of chronic pain and fatigue are gaining prominence. For example, functional brain research has demonstrated brain dysfunction and possibly genetic contributions among some individuals with fibromyalgia and chronic fatigue syndrome. Those syndromes, while still thought by some to represent somatization variants, are currently established medical diagnoses. The major conceptual trends in the history of psychosomatic medicine are outlined in Table 13.1-1. Table 13.1-1 Major Conceptual Trends in the History of Psychosomatic Medicine

CURRENT TRENDS The practice of psychosomatic medicine has evolved considerably since its early clinical origins and has come to focus on psychiatric illnesses that occur in the setting of physical health care. In large part this evolution has occurred as a result of the increased complexity of medicine, the increased understanding of the relationship of medical illness to psychiatric illness, and the greater appreciation of mind and body as one. A key outcome of this has been the granting of subspecialty status for psychosomatic medicine. Clinical care is now delivered in a variety of health care settings and utilizes an ever expanding set of diagnostic tools, as well as many effective somatic and psychotherapeutic interventions. Research in the area has progressed to include a

greater understanding of the relationship between chronic medical conditions and psychiatric disorders and has examined the pathophysiologic relationships, the epidemiology of comorbid medical and psychiatric disorders, and the role specific interventions play in physiologic, clinical, and economic outcomes (Table 13.1-2). Table 13.1-2 Summary of Clinical Problems in Psychosomatic Medicine Psychiatric morbidity is very common in patients with medical conditions, with a prevalence ranging from 20 to 67 percent, depending on the illness. Patients in the general hospital have the highest rate of psychiatric disorders when compared with community samples or patients in ambulatory primary care. For example, compared with community samples, depressive disorders in the general hospital are more than twice as common, and substance abuse is two to three times as common. Delirium occurs in 18 percent of patients. Similarly, increased rates are seen in primary and long-term care. Psychiatric morbidity has serious effects on medically ill patients and is often a risk factor for their medical conditions. It is well established that depression is both a risk factor and a poor prognostic indicator in coronary artery disease. Psychiatric illness

worsens cardiac morbidity and mortality in patients with a history of myocardial infarction, diminishes glycemic control in patients with diabetes, and decreases return to functioning in patients experiencing a stroke. Depressive and anxiety disorders compound the disability associated with stroke. In the context of neurodegenerative disease such as Parkinson’s or Alzheimer’s, depression, psychosis, and behavioral disturbances are significant predictors of functional decline, institutionalization, and caregiver burden. Hospitalized patients with delirium are significantly less likely to improve in function compared with patients without delirium. Delirium is associated with worse outcomes after surgery, even after controlling for severity of medical illness. In addition, depression and other mental disorders significantly impact quality of life and the ability of patients to adhere to treatment regimens (e.g., in patients with diabetes mellitus). Psychiatric disorders are linked to nonadherence with antiretroviral therapy, adversely affecting the survival of human immunodeficiency virus (HIV)- infected patients. Psychiatric disorders worsen the prognosis and quality of life of cancer patients. Psychiatric disorders are also linked to nonadherence with safe sex guidelines and with use of sterile needles in HIV-infected injection drug users, thus having major public health implications. EVALUATION PROCESS IN PSYCHOSOMATIC MEDICINE Psychiatric assessment in the medical setting includes a standard psychiatric assessment as well as a particular focus on the medical history and context of physical health care. In addition to obtaining a complete psychiatric history, including past history, family history, developmental history, and a review of systems, the medical history and current treatment should be reviewed and documented. A full mental status examination, including a cognitive examination, should be completed, and components of a neurologic and physical examination may be indicated depending on the nature of the presenting problem. Another important objective of the psychiatric evaluation is to gain an understanding of the patient’s experience of his or her illness. In many cases, this becomes the central focus for both the psychiatric assessment and interventions. It is often helpful to develop an understanding of the patient’s developmental and personal history as well as key dynamic conflicts, which in turn may help to make the patient’s experience with illness more comprehensible. Such an evaluation can include use of the concepts of stress, personality traits, coping strategies, and defense mechanisms. Observations and hypotheses that are developed can help to guide a patient’s psychotherapy aimed at diminishing distress and may also be helpful for the primary medical team in their interactions with the patient. Finally, a full report synthesizing the information should be completed and include specific recommendations for additional evaluations and intervention. Ideally, the report should be accompanied by a discussion with the referring physician. TREATMENTS USED IN PSYCHOSOMATIC MEDICINE

A host of interventions have been successfully utilized in psychosomatic medicine. Specific consideration must be given to medical illness and treatments when making recommendations for psychotropic medications. Psychotherapy also plays an important role in psychosomatic medicine and may vary in its structure and outcomes as compared with therapy that occurs in a mental health practice. Psychopharmacologic recommendations need to consider several important factors. In addition to targeting a patient’s active symptoms, considering the history of illness and treatments, and weighing the particular side-effect profile of a particular medication, there are several other factors that must be considered that relate to the patient’s medical illness and treatment. It is critical to evaluate potential drug–drug interactions and contraindications to the use of potential psychotropic agents. Because the majority of psychotropic medications used are metabolized in the liver, awareness of liver function is important. General appreciation of side effects, such as weight gain, risk of development of diabetes, and cardiovascular risk, must be considered in the choice of medications. In addition, it is also important to incorporate knowledge of recent data that outline effectiveness and specific risks involved for patients with co-occurring psychiatric and physical disorders. For example, a greater understanding of the side effects of antipsychotic medications has raised concerns about the use of these medications in patients with dementia. The use of psychosocial interventions also requires adaptation when used in this population. The methods and the goals of psychosocial interventions used in the medically ill are often determined by the consideration of disease onset, etiology, course, prognosis, treatment, and understanding of the nature of the presenting psychiatric symptoms in addition to an understanding of the patient’s existing coping skills and social support networks. However, there are ample data that psychosocial interventions are effective in addressing a series of identified problems and that such interventions in many cases are associated with a variety of positive clinical outcomes. REFERENCES Ader R, ed. Psychoneuroimmunology. 4th ed. New York: Elsevier; 2007. Alexander F. Psychosomatic Medicine: Its Principles and Application. New York: Norton; 1950. Cannon WB. The Wisdom of the Body. New York: Norton; 1932. Chaturvedi SK, Desai G. Measurement and assessment of somatic symptoms. Int Rev Psychiatry. 2013;25(1):31–40. Escobar J. Somatoform disorders. In: Sadock BJ, Sadock VA, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Vol. 1. Philadelphia: Lippincott William & Wilkins; 2009:1927. Fava GA, Sonino N. The clinical domains of psychosomatic medicine. J Clin Psychiatry. 2005;66:849–858. Goodwin RD, Olfson M, Shea S, Lantigua RA, Carrasquilo O, Gameroff MJ, Weissman MM. Asthma and mental disorders in primary care. Gen Hosp Psychiatry. 2004;25:479–483. Hamilton JC, Eger M, Razzak S, Feldman MD, Hallmark N, Cheek S. Somatoform, factitious, and related diagnoses in the National Hospital Discharge Survey: Addressing the proposed DSM-5 revision. Psychosomatics. 2013;54(2):142–148. Kaplan HI. History of psychosomatic medicine. In: Sadock BJ, Sadock VA, eds: Kaplan and Sadock’s Comprehensive Textbook of Psychiatry. 8th ed. Philadelphia: Lippincott Williams & Wilkins; 2005:2105.