Psychosomatic renewal of health care.

Psychosomatic medicine may be defined as a comprehensive, interdisciplinary framework for: assessment of psychological factors affecting individual vulnerability as well as course and outcome of illness; biopsychosocial consideration of patient care in clinical practice; specialist interventions to integrate psychological therapies in the prevention, treatment and rehabilitation of medical disease. Current advances in the field have practical implications for medical research and practice, with particular reference to the role of lifestyle, the challenge of medically unexplained symptoms, the psychosocial needs entailed by chronic illness, the appraisal of therapy beyond pharmaceutical reductionism, and the function of the patient as a health producer. Today the field of psychosomatic medicine is scientifically rigorous, more diversified and therapeutically relevant than ever before.

Psychosomatic medicine.

Psychosomatic medicine may be defined as a comprehensive, interdisciplinary framework for: assessment of psychological factors affecting individual vulnerability as well as course and outcome of illness; biopsychosocial consideration of patient care in clinical practice; specialist interventions to integrate psychological therapies in the prevention, treatment and rehabilitation of medical disease. The aim of this review was to provide an updated definition of psychosomatic medicine, to outline its boundaries with related disciplines and to illustrate its main contributions to clinical and preventive medicine. A review of the psychosomatic literature, using both Medline and manual searches, with particular reference to articles, which could be relevant to clinical practice, was performed. Current advances in the field have practical implications for medical research and practice, with particular reference to the role of lifestyle, the challenge of medically unexplained symptoms, the psychosocial needs entailed by chronic illness, the appraisal of therapy beyond pharmaceutical reductionism, the function of the patient actively contributing to his/her health. Today, the field of psychosomatic medicine is scientifically rigorous, more diversified and therapeutically relevant than ever before.

Assessment of psychological distress in the setting of medical disease.

The biopsychosocial model of disease has recently been depicted as the basis for a renewed emphasis on the multiaxial diagnostic system of the DSM-IV. The authors challenge this stance, underscoring the clinical inadequacies of the DSM-IV in the setting of medical disease, particularly the chapters concerned with somatoform disorders and psychological factors affecting medical conditions. Diagnostic criteria which are based on the clinical insights derived from psychosomatic research in the past decades may offer new opportunities to psychosomatic medicine and consultation-liaison psychiatry. The development of the Diagnostic Criteria for Psychosomatic Research (DCPR), encompassing alexithymia, type A behavior, irritable mood, demoralization, disease phobia, thanatophobia, health anxiety, illness denial, functional somatic symptoms secondary to a psychiatric disorder, persistent somatization, conversion symptoms and anniversary reaction, is described. Preliminary results obtained with the combination of DSM and DCPR criteria appear to be promising.

Psychosomatic medicine: emerging trends and perspectives.

Developments have occurred in all aspects of psychosomatic medicine. Among factors affecting individual vulnerability to all types of disease, the following have been highlighted by recent research: recent and early life events, chronic stress and allostatic load, personality, psychological well-being, health attitudes and behavior. As to the interaction between psychological and biological factors in the course and outcome of disease, the presence of psychiatric (DSM-IV) as well as subclinical (Diagnostic Criteria for Psychosomatic Research) symptoms, illness behavior and the impact on quality of life all need to be assessed. The prevention, treatment and rehabilitation of physical illness include the consideration for psychosomatic prevention, the treatment of psychiatric morbidity and abnormal illness behavior and the use of psychotropic drugs in the medically ill. In the past 60 years, psychosomatic medicine has addressed some fundamental questions, contributing to the growth of other related disciplines, such as psychoneuroendocrinology, psychoimmunology, consultation-liaison psychiatry, behavioral medicine, health psychology and quality of life research. Psychosomatic medicine may also provide a comprehensive frame of reference for several current issues of clinical medicine (the phenomenon of somatization, the increasing occurrence of mysterious symptoms, the demand for well-being and quality of life), including its new dialogue with mind-body and alternative medicine.

Well-being therapy: conceptual and technical issues.

Well-being therapy is a short-term, well-being-enhancing psychotherapeutic strategy. It is based on Carol D. Ryff's multidimensional model of psychological well-being, encompassing environmental mastery, personal growth, purpose in life, autonomy, self-acceptance and positive relations with others. Its conceptual and technical issues are described. It may be applied as a relapse-preventive strategy in the residual phase of affective (mood and anxiety) disorders, as an additional ingredient of cognitive behavioral packages, in patients with affective disorders who failed to respond to standard pharmacological and psychotherapeutic treatments, in body image disorders and in psychosomatic medicine. The first validation studies appeared to be promising. The technique is in its preliminary stage of development and may undergo major changes in the next years. It is hoped it may herald a new trend of psychotherapy research and practice in the current symptom-oriented settings.

A simple instrument for assessing stress in clinical practice.

Methods to assess the role of stress factors in patients with medical conditions are often rather complex, require specific training, and are difficult to use in clinical practice. We attempted to develop a short index tailored to a busy clinical setting, which would be easy to use while providing adequate individual information. This index (Psychosocial Index) was largely derived from well-established instruments, such as Kellner's Screening List for Psychosocial Problems. In addition, on the basis of the patient's self-report of items, the clinician is asked to rate four dimensions of the patient's life: stress, wellbeing, psychological distress, and illness behaviour. The questionnaires of 34 female patients with functional medical disorders were first rated by an internist and afterwards, blindly, by a psychiatrist. Agreement between the two raters was excellent, as measured by the intraclass correlation coefficient. It is hoped that this Psychosocial Index may provide a new tool for psychosomatic research and practice.

Prevention of recurrent depression with cognitive behavioral therapy: preliminary findings.

BACKGROUND: Cognitive behavioral treatment (CBT) of residual symptoms after successful pharmacotherapy yielded a substantially lower relapse rate than did clinical management in patients with primary major depressive disorders. The aim of this study was to test the effectiveness of this approach in patients with recurrent depression (> or = 3 episodes of depression). METHODS: Forty patients with recurrent major depression who had been successfully treated with antidepressant drugs were randomly assigned to either CBT of residual symptoms (supplemented by lifestyle modification and well-being therapy) or clinical management. In both groups, during the 20-week experiment, antidepressant drug administration was tapered and discontinued. Residual symptoms were measured with a modified version of the Paykel Clinical Interview for Depression. Two-year follow-up was undertaken, during which no antidepressant drugs were used unless a relapse ensued. RESULTS: The CBT group had a significantly lower level of residual symptoms after discontinuation of drug therapy compared with the clinical management group. At 2-year follow-up, CBT also resulted in a lower relapse rate (25%) than did clinical management (80%). This difference attained statistical significance by survival analysis. CONCLUSIONS: These results challenge the assumption that long-term drug treatment is the only tool to prevent relapse in patients with recurrent depression. Although maintenance pharmacotherapy seems to be necessary in some patients, CBT offers a viable alternative for other patients. Amelioration of residual symptoms may reduce the risk of relapse in depressed patients by affecting the progression of residual symptoms to prodromes of relapse.

Augmented pituitary corticotropin response to a threshold dosage of human corticotropin-releasing hormone in depressives pretreated with metyrapone.

We studied pituitary corticotropin response to exogenous corticotropin-releasing hormone infusion and attempted to control for the confounding effect of variable serum cortisol levels between depressed and control subjects. If metyrapone was given during the time of day when hypothalamic pituitary adrenal activity was otherwise low, the relative increase in the corticotropin concentration was small. Pituitary response to exogenous corticotropin-releasing hormone can be defined under conditions in which the amount of glucocorticoid-mediated negative feedback present at the level of the pituitary gland is equal in all subjects. When the ambient cortisol level was equalized (and suppressed) in all subjects at the time of study with a threshold dosage of corticotropin-releasing hormone, we found an augmented response to corticotropin-releasing hormone in depressives. This raises the possibility that either increased pituitary sensitivity to corticotropin-releasing hormone or an increased intracellular pool of corticotropin is available for release in subjects with major depressive illness.

A psychosomatic outpatient clinic.

Current emphasis in clinical psychosomatic medicine is on psychiatric interventions in acute medical and surgical situations (consultation-liaison psychiatry and medical-psychiatric units). Little interest has been taken in psychosomatic interventions in chronic situations and outpatient settings. The functioning of a psychosomatic outpatient clinic (POC) is described. One-hundred consecutive referrals were analyzed. The most frequent diagnostic finding--according to DSM III criteria--was subsumed under the rubric of "psychological factors affecting physical condition," followed by affective illness, anxiety disturbances, and somatoform disorders. The results indicate that a POC may serve a specific and definable segment of patients, whose characteristics depart from the clinical populations in consultation-liaison psychiatry and medical-psychiatric units.

Recommendations for clinical studies in psychosomatic medicine.

To minimize discrepancies that may arise in clinical studies concerned with psychosomatic medicine, a set of methodologic recommendations was developed. Issues in design, sampling, collection of data and statistical inference are discussed.

The medical-psychiatric unit: a novel psychosomatic approach.

A retrospective chart review of 600 general hospital patients, of whom 200 had been admitted to a medical-psychiatric unit, 200 to a conventional psychiatric unit and 200 to medical-surgical units, and for whom psychiatric consultation had been requested, disclosed significant differences in the patient populations of these services. The data suggest that consultation psychiatry and medical-psychiatric units serve two different subgroups of patients with combined physical and psychiatric illness. A comprehensive model of clinical psychosomatic medicine encompassing consultation psychiatry, liaison psychiatry, medical-psychiatric units and after-care medical-psychiatric clinics, is proposed.

Italian validation of the Symptom Rating Test (SRT) and Symptom Questionnaire (SQ).

Two self-rating scales of psychological distress, the Symptom Rating Test (SRT) and the Symptom Questionnaire (SQ), have been validated in translations in Italy. They were administered in several studies to psychiatric patients (neurotics and depressives), matched controls, and patients suffering from various organic illnesses (dermatologic disorders, hypertension, secondary amenorrhea and patients undergoing amniocentesis). The SRT and the SQ sensitively discriminated between psychiatric patients and normals, between different levels of psychological distress in several of the somatic illnesses, and detected significant changes in the psychological status of patients participating in medical procedures such as amniocentesis. The scales were found to be useful in research in psychiatry and psychosomatic medicine. The findings suggest that the Italian translations are valid and sensitive scales of distress and can apparently be used as effectively in research as the original. They are likely to be of value in cross-cultural research in Canada. Both scales may be helpful in the psychological assessment of Italian immigrants in North America and Australia, especially in those whose English is poor.