Clinical Interviewing: An Essential but Neglected Method of Medicine.

Clinical interviewing is the basic method to understand how a person feels and what are the presenting complaints, obtain medical history, evaluate personal attitudes and behavior related to health and disease, give the patient information about diagnosis, prognosis, and treatment, and establish a bond between patient and physician that is crucial for shared decision making and self-management. However, the value of this basic skill is threatened by time pressures and emphasis on technology. Current health care trends privilege expensive tests and procedures and tag the time devoted to interaction with the patient as lacking cost-effectiveness. Instead, the time spent to inquire about problems and life setting may actually help to avoid further testing, procedures, and referrals. Moreover, the dialogue between patient and physician is an essential instrument to increase patient's motivation to engage in healthy behavior. The aim of this paper was to provide an overview of clinical interviewing and its optimal use in relation to style, flow and hypothesis testing, clinical domains, modifications according to settings and goals, and teaching. This review points to the primacy of interviewing in the clinical process. The quality of interviewing determines the quality of data that are collected and, eventually, of assessment and treatment. Thus, interviewing deserves more attention in educational training and more space in clinical encounters than it is currently receiving.

Key psychosocial issues in medical care.

OBJECTIVE: The aim of this review is to illustrate an innovative framework for assessing the psychosocial aspects of medical disorders within the biopsychosocial model. It is based on clinimetrics, the science of clinical measurements. It may overcome the limitations of DSM-5 in identifying highly individualized responses at the experiential, behavioral, and interpersonal levels. METHOD: A critical review of the clinimetric formulations of the biopsychosocial model in the setting of medical disease was performed. References were identified through searches from PubMed for English articles on human subjects published from January 1982 to October 2023. RESULTS: Clinimetric methods of classification have been found to deserve special attention in four major areas: allostatic load (the cumulative cost of fluctuating and heightened neural or neuroendocrine responses to environmental stressors); health attitudes and behavior; persistent somatization; demoralization and irritable mood. This type of assessment, integrated with traditional psychiatric nosography, may disclose pathophysiological links and provide clinical characterizations that demarcate major prognostic and therapeutic differences among patients who otherwise seem deceptively similar because they have the same medical diagnosis. It may be of value in a number of medical situations, such as: high level of disability or compromised quality of life in relation to what is expected by disease status; delayed or partial recovery; insufficient participation in self-management and/or rehabilitation; failure to resume healthy role after convalescence; unhealthy lifestyle; high attendance of medical facilities disproportionate to detectable disease; lack of treatment adherence; illness denial. CONCLUSIONS: The clinimetric approach to the assessment of key psychosocial variables may lead to unique individual profiles, that take into account both biology and biography. It may offer new opportunities for integrating psychosocial and medical perspectives.

Allostatic Load and Endocrine Disorders.

The building of life stress, well expressed by the concept of allostatic load, plays an important part in all phases of endocrine illness. Allostatic load refers to the cumulative burden of both stressful life events and chronic stress. When environmental challenges exceed the individual ability to cope, allostatic overload ensues. Assessment of allostatic load/overload by clinical measurements including indices and rating scales, in addition to biomarkers, offers a characterization of the person's psychosocial environment that is missing from current formulations. Consideration of allostatic load in endocrinology may shed light on a number of clinical issues: interpretation of abnormal hormone values that lack explanations; coping with the various phases of illness; maladaptive illness behavior; response to treatment; presence of residual symptoms; health-damaging lifestyle habits. Addressing allostatic load calls for innovative models of endocrine outpatients with multidisciplinary organization of care, extended time for the interview, focus on rehabilitation. We provide an overview on the mechanisms of allostatic load, how it can be assessed, its potential role in endocrine disturbances, and how its consideration may lead to a needed innovation in patient care.

Benzodiazepines: it's time to return to the evidence.

SUMMARY: We propose that discussions of benzodiazepines in the current psychiatric literature have become negatively biased and have strayed from the scientific evidence base. We advocate returning to the evidence in discussing benzodiazepines and adhering to clear definitions and conceptual rigour in commentary about them.

Allostatic Load and Its Impact on Health: A Systematic Review.

INTRODUCTION: Allostatic load refers to the cumulative burden of chronic stress and life events. It involves the interaction of different physiological systems at varying degrees of activity. When environmental challenges exceed the individual ability to cope, then allostatic overload ensues. Allostatic load is identified by the use of biomarkers and clinical criteria. OBJECTIVE: To summarize the current knowledge on allostatic load and overload and its clinical implications based on a systematic review of the literature. METHODS: PubMed, PsycINFO, Web of Science, and the Cochrane Library were searched from inception to December 2019. A manual search of the literature was also performed, and reference lists of the retrieved articles were examined.We considered only studies in which allostatic load or overload were adequately described and assessed in either clinical or non-clinical adult populations. RESULTS: A total of 267 original investigations were included. They encompassed general population studies, as well as clinical studies on consequences of allostatic load/overload on both physical and mental health across a variety of settings. CONCLUSIONS: The findings indicate that allostatic load and overload are associated with poorer health outcomes. Assessment of allostatic load provides support to the understanding of psychosocial determinants of health and lifestyle medicine. An integrated approach that includes both biological markers and clinimetric criteria is recommended.

Clinimetric Criteria for Patient-Reported Outcome Measures.

Patient-reported outcome measures (PROMs) are self-rated scales and indices developed to improve the detection of the patients' subjective experience. Given that a considerable number of PROMs are available, it is important to evaluate their validity and usefulness in a specific research or clinical setting. Published guidelines, based on psychometric criteria, do not fit in with the complexity of clinical challenges, because of their quest for homogeneity of components and inadequate attention to sensitivity. Psychometric theory has stifled the field and led to the routine use of scales widely accepted yet with a history of poor performance. Clinimetrics, the science of clinical measurements, may provide a more suitable conceptual and methodological framework. The aims of this paper are to outline the major limitations of the psychometric model and to provide criteria for clinimetric patient-reported outcome measures (CLIPROMs). The characteristics related to reliability, sensitivity, validity, and clinical utility of instruments are critically reviewed, with particular reference to the differences between clinimetric and psychometric approaches. Of note is the fact that PROMs, rating scales, and indices developed according to psychometric criteria may display relevant clinimetric properties. The present paper underpins the importance of the clini-metric methodology in choosing the appropriate PROMs. CLIPROM criteria may also guide the development of new indices and the validation of existing PROMs to be employed in clinical settings.

A Trial Integrating Different Methods to Assess Psychosocial Problems in Primary Care.

BACKGROUND: A number of studies have documented psychosocial problems, psychiatric morbidity and impaired quality of life in primary care patients. OBJECTIVE: The aim of this trial was to test the usefulness of the joint use of different diagnostic interviews and self-rated questionnaires. METHODS: Two hundred consecutive patients in a primary care practice in Italy underwent the Structured Clinical Interview for DSM-5 and the Semi-Structured Interview for the Diagnostic Criteria for Psychosomatic Research (DCPR) in its recently revised form. As self-rated evaluations, the PsychoSocial Index, the Short-Form Health Survey and the Illness Attitude Scales were administered. RESULTS: There were 46 patients (23%) with at least 1 DSM-5 diagnosis. Eighty-eight patients (44%) had at least 1 DCPR diagnosis, mainly maladaptive illness behavior (26.5%), allostatic overload (15.5%) and demoralization (15%). There were 47 (23.5%) patients who had a DCPR diagnosis only; 5 subjects (2.5%) had a DSM diagnosis only. Patients with DCPR syndromes displayed significantly higher self-rated levels of stress, psychological distress and maladaptive illness behavior and significantly lower levels of quality of life and well-being than patients with no diagnoses. CONCLUSIONS: In a busy clinical setting, a simple self-rated questionnaire such as the PsychoSocial Index may afford a useful tool to unveil patient current distress. The DCPR can provide clinical information for a substantial number of patients who do not satisfy DSM-5 classification criteria and yet present with psychosocial problems, as measured by self-rated scales. The DCPR may improve the assessment and treatment plan of primary care psychologists or consulting psychiatrists.

Current Psychosomatic Practice.

Psychosomatic research has advanced over the past decades in dealing with complex biopsychosocial phenomena and may provide new effective modalities of patient care. Among psychosocial variables affecting individual vulnerability, course, and outcome of any medical disease, the role of chronic stress (allostatic load/overload) has emerged as a crucial factor. Assessment strategies include the Diagnostic Criteria for Psychosomatic Research. They are presented here in an updated version based on insights derived from studies carried out so far and encompass allostatic overload, type A behavior, alexithymia, the spectrum of maladaptive illness behavior, demoralization, irritable mood, and somatic symptoms secondary to a psychiatric disorder. Macroanalysis is a helpful tool for identifying the relationships between biological and psychosocial variables and the individual targets for medical intervention. The personalized and holistic approach to the patient includes integration of medical and psychological therapies in all phases of illness. In this respect, the development of a new psychotherapeutic modality, Well-Being Therapy, seems to be promising. The growth of subspecialties, such as psychooncology and psychodermatology, drives towards the multidisciplinary organization of health care to overcome artificial boundaries. There have been major transformations in health care needs in the past decades. From psychosomatic medicine, a land of innovative hypotheses and trends, many indications for changes in the current practice of medicine are now at hand. The aim of this critical review is to outline current and potential clinical applications of psychosomatic methods.

Use of the Psychosocial Index: A Sensitive Tool in Research and Practice.

BACKGROUND: The Psychosocial Index (PSI) is a self-rating scale based on clinimetric principles that is simple to use in a busy clinical setting. It can be integrated by observer-rated clinical judgment, providing a first-line, comprehensive assessment of stress, well-being, distress, illness behavior, and quality of life. By calculation of scores, it can be used for conventional psychological measurements. Its clinical applications and clinimetric properties are reviewed. The present version of the PSI has been slightly revised. In addition, a modified version for use in adolescents and young adults (PSI-Young; PSI-Y) is also included. METHODS: Articles that involved the use of the PSI were identified by searching the Web of Science database from 1998 to February 2016 and by a manual search of the literature. RESULTS: A total of 20 studies reporting results from the use of PSI were included. The PSI has been employed in various clinical populations in different countries and showed high sensitivity. It significantly discriminated varying degrees of psychosocial impairment in different populations. When subjects were identified by categorical criteria (presence of allostatic overload, psychosomatic syndromes, psychiatric disorders), the PSI scores were significantly different across subgroups. CONCLUSIONS: In clinical practice, scanning the list of symptoms allows clinicians to assess rapidly which symptoms and problems are perceived as most troublesome. In research settings, the use of scores makes the PSI a valid and sensitive tool in differentiating levels of psychosocial variables among groups.

The Psychosomatic Practice.

There is increasing awareness of the limitations of the disease oriented approach in medical care. The primary goal of psychosomatic medicine is to correct this inadequacy by incorporation of innovative operational strategies into clinical practice. Psychosomatic practice can be recognized by 2 distinctive features: the holistic approach to patient management (encompassing psychosocial factors) and the clinical model of reasoning (which reflects a multifactorial frame of reference). A basic psychosomatic assumption is the consideration of patients as partners in managing disease. The partnership paradigm includes collaborative care (a patient-physician relationship in which physicians and patients make health decisions together) and implementation of self-management (a plan that provides patients with problem-solving skills to enhance their self-efficacy). Pointing to strategies that focus on individual needs may improve patient quality of life and final outcomes.

Mood and anxiety disorders as early manifestations of medical illness: a systematic review.

BACKGROUND: Affective disturbances involving alterations of mood, anxiety and irritability may be early symptoms of medical illnesses. The aim of this paper was to provide a systematic review of the literature with qualitative data synthesis. METHODS: MEDLINE, PsycINFO, EMBASE, Cochrane, and ISI Web of Science were systematically searched from inception to February 2014. Search terms were 'prodrome/early symptom', combined using the Boolean 'AND' operator with 'anxiety/depression/mania/hypomania/irritability/irritable mood/hostility', combined with the Boolean 'AND' operator with 'medical illness/medical disorder'. PRISMA guidelines were followed. RESULTS: A total of 21 studies met the inclusion criteria and were analyzed. Depression was found to be the most common affective prodrome of medical disorders and was consistently reported in Cushing's syndrome, hypothyroidism, hyperparathyroidism, pancreatic and lung cancer, myocardial infarction, Wilson's disease, and AIDS. Mania, anxiety and irritability were less frequent. CONCLUSIONS: Physicians may not pursue medical workup of cases that appear to be psychiatric in nature. They should be alerted that disturbances in mood, anxiety and irritability may antedate the appearance of a medical disorder.

The unifying concept of illness behavior.

The concept of illness behavior was introduced to indicate the ways in which given symptoms may be perceived, evaluated and acted upon at an individual level. Illness behavior may vary greatly according to illness-related, patient-related and doctor-related variables and their complex interactions. In the past decades, important lines of research have been concerned with illness perception, frequent attendance at medical facilities, health care-seeking behavior, treatment-seeking behavior, delay in seeking treatment, and treatment adherence. They have, however, mostly investigated single aspects separately. In this concise review, we suggest that the concept of illness behavior may provide a unifying framework and useful insights to observations and findings that would otherwise remain scattered and unrelated in the medical literature. The wide range of expressions of illness behavior is likely to affect the presentation of any disease and its identification, course and treatment. Assessing illness behavior and devising appropriate responses by health care providers may contribute to the improvement of final outcomes.

Understanding Health Attitudes and Behavior.

Individual attitudes and behavior related to health and disease are major components of clinical encounters. These factors shape lifestyle, presentation of symptoms, access to patient care, interactions between patients and physicians, adherence to medical advice, and response to treatment. Health attitudes and behavior may range from anxiety and worry about illness to various forms of denial, such as delay of seeking care and lack of adherence to treatment. When attitudes result in health-damaging behavior, they may be particularly difficult to understand and become a source of frustration to both physicians and patients. Devising appropriate responses by health care providers may contribute to improving final outcomes and decrease health care costs. In particular, health behavior is likely to play a major role in the process of convalescence, in self-management of chronic conditions, in determining a state of recovery, and whenever a rehabilitation process is involved. Understanding the spectrum of health attitudes and behavior is also crucial for motivating people to make beneficial changes (lifestyle medicine), as well as for implementing safety procedures in the community.

Anniversary reactions in medical patients.

The aim of this study was to explore the prevalence and characteristics of anniversary reactions (somatic symptoms occurring at the anniversary of specific events) in a large sample of 1498 medical patients from different medical settings who underwent the Structured Clinical Interview for DSM-IV (SCID) and the Structured Interview for Diagnostic Criteria for Psychosomatic Research (DCPR), which provide definition of anniversary reactions. In 54 (3.6%) of the 1498 patients for whom anniversary reaction was identified, 61.1% had a concurrent DSM-IV diagnosis. Other syndromes related to somatization, abnormal illness behavior, irritable mood, demoralization, and alexithymia were present in 9 of 10 cases. Symptoms of the conversion syndrome were found in 6 (0.4%) patients with the SCID and in 67 (4.5%) patients with the DCPR, 20% of whom also had anniversary reaction. The results should alert physicians to enquire about the timing of symptoms in relation to meaningful personal events.

Principles of psychosomatic assessment.

There is increasing awareness of the limitations of disease as the primary focus of medical care. It is not that certain disorders lack an organic explanation, but that our assessment is inadequate in most clinical encounters. The primary goal of psychosomatic medicine is to correct this inadequacy by incorporation of its operational strategies into clinical practice. At present, the research evidence which has accumulated in psychosomatic medicine offers unprecedented opportunities for the identification and treatment of medical problems. Taking full advantage of clinimetric methods (such as with the use of Emmelkamp's two levels of functional analysis and the Diagnostic Criteria for Psychosomatic Research) may greatly improve the clinical process, including shared-decision making and self-management. Endorsement of the psychosomatic perspective may better clarify the pathophysiological links and mechanisms underlying symptom presentation. Pointing to individually targeted methods may improve final outcomes and quality of life.