Diagnosis and Management of Psychosomatic Disease

Dr. Cokorda Bagus Jaya Lesmana, MD, PhD
Department of Psychiatry, Udayana University, Denpasar, Indonesia
Introduction
Throughout life one faces many problems. Some people can handle most of them well,
while others find it difficult to cope successfully. Experiencing and dealing with problems may
make one a stronger individual, or in certain cases may negatively influence thought,
behaviour, and emotions and potentially result in mental illness. Although the unconscious
mind always tries to resolve these problems, the individual may still be unhappy and out of
balance, albeit still psychologically functional. Problems can have genetic, organic,
experiential, psychological, or a combination of these causes.
Past traumas can act as pathological triggers, resulting in the above causes entering
dysfunctional or psychopathological states. Should one follow the current psychobiological
evidence-based approaches, one would, arguably, conclude that psychology, and in particular
personality, begins developing through proto-experiences in the womb, as soon as the foetal
nervous system is formed. These proto-experiences influence and shape the biological
foundations of thought, emotion, feeling, behaviour, response to stimulation, and adaptation to
new situations. Should these proto-experiences be traumatic, they will contribute to the
dysfunctional dispositions of the psychobiological systems, and subsequently increase the
individual’s vulnerability to stress and their ability to successfully cope with problems later in
life.
Somatic symptoms are common in the general population and they are prevalent in
different medical conditions such as cancer or coronary heart disease and in the context of
mental disorders, e.g. somatoform disorders, anxiety disorders, and depression. Because
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somatic symptoms are related to impaired functioning, decreased health related quality of life,
increased health care service use and psychological distress, the assessment of somatic
symptom burden is essential in evidence based patient care and research.
Moreover, in epidemiology, multiple somatic symptoms reliably predict
psychopathology and healthcare use in population-based studies (Creed et al., 2012).
Consequently, the introduction of the new DSM-5 category ‘somatic symptom disorder’ (SSD)
is generally seen as a major change in the fields of public mental health and psychiatry. For
these reasons, in the current APA psychiatric diagnostic system (the fifth edition, or DSM-5),
the “medically unexplained” requirement was abandoned, as was the syllable “form” in
“somatoform.” DSM-5 introduced “somatic symptom and related disorders” to characterize the
spectrum of psychiatric distress based on somatic symptoms. Similar to the older term
“psychiatric overlay,” the new definition focuses on the emotional and psychological reactions
to somatic symptoms rather than on their etiology (van Geelen et al., 2015).
At present, the research evidence that has accumulated in psychosomatic medicine
offers unprecedented opportunities for the identification and treatment of medical problems.
Treatment focuses on memory and the unconscious mind, and considers the effects of proto-
experiences on the (dys)functional psychological development of the individual. Using a
biopsychospirit-sociocultural approach may improve final outcomes and quality of life
(Lesmana et al., 2009).
Psychosomatic medicine cuts across many specialties and is concerned with assessment of
psychosocial variables in the setting of medical disease. It has developed methods that provide
clinical information that is likely to increase diagnostic sharpness and yield better targeted
therapeutic approaches in all fields of medicine, including psychiatry (Sirri & Fava, 2013).
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Psychosomatic medicine has become in the US a subspecialty recognized by the
American Board of Medical Specialties. This has led to identifying psychosomatic medicine
with consultation-liaison psychiatry, a subspecialty of psychiatry concerned with diagnosis,
treatment, and prevention of psychiatric morbidity in the medical patient in the form of
psychiatric consultations, liaison and teaching for nonpsychiatric health workers, especially in
the general hospital. Consultation liaison psychiatry is clearly within the field of psychiatry;
its setting is the medical or surgical clinic or ward, and its focus is the comorbid state of patients
with medical disorders. Psychosomatic medicine is, by definition, multidisciplinary. It is not
confined to psychiatry, but may concern any other field of medicine. Not surprisingly, in
countries such as Germany and Japan, psychosomatic activities have achieved an independent
status and are often closely related to internal medicine. In the US, family medicine endorses a
comprehensive psychosocial approach as integral to their training and practice. Interestingly,
the general psychosomatic approach has resulted in a number of subdisciplines within their
own areas of application: psychooncology, psychonephrology, psychoneuroendocrinology,
psychoimmunology, psychodermatology and others. Such sub-disciplines have developed
clinical services, scientific societies and medical journals. The psychosomatic approach has
resulted in important developments also in the psychiatric field, subsumed under the rubric of
psychological medicine (Lokko et al., 2016; Yoshiuchi, 2016).
Today the life expectancy in Western countries is much higher and most of clinical
activities are concentrated on chronic disease or non-disease specific complaints (McGinnis,
2016). ‘The changed spectrum of health conditions, the complex interplay of biological and
nonbiological factors, the aging population, and the inter individual variability in health
priorities render medical care that is centred primarily on the diagnosis and treatment of
individual diseases at best out of date and at worst harmful. A primary focus on disease, given
the changed health needs of patients, inadvertently leads to under treatment, overtreatment, or
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mistreatment’. Disease-specific guidelines provide very limited indicators for patients with
multiple conditions. The goal of treatment should be the attainment of individual goals, and the
identification and treatment of all modifiable biological and non biological factors.
But how should we assess these nonbiological variables? In clinical medicine there is
the tendency to rely exclusively on ‘hard data’, preferably expressed in the dimensional
numbers of laboratory measurements, excluding ‘soft information’ such as impairments and
well-being. This soft information can now, however, be reliably assessed by clinical rating
scales and indexes which have been validated and used in psychosomatic research and practice.
It is not that certain disorders lack an explanation; it is our assessment that is inadequate in
most of the clinical encounters, since it does not reflect a global psychosomatic approach
(Bauer et al., 2011).
All physicians in all fields of medicine should utilize the psychosomatic approach in
medical interviewing. The psychosomatic interview properly managed should prevent
premature closure of diagnostic considerations and ensure consideration of biological
psychological and sociocultural factors. No matter what the presenting complaint, whether a
medically unexplained complaint or a presurgical evaluation for oncologic surgery, the patient
exists in a milieu of emotional reactions, biological vulnerability and a social network
composed of health care providers and whatever support system is available. It is imperative
that the physician document and understand the salient factors in these domains and conduct
interviews utilizing a psychosomatic approach, whatever the complaint might be. Utilizing the
techniques of open-ended questions, observing nonverbal behaviors, and considering the
perspectives of diseases, dimensions, behaviors, and life stories, the physician will gather a
more complete picture of the patient (Rafanelli & Ruini, 2012). Better care will follow.
One of the main criticisms against the use of the traditional psychiatric classification
with medical patients is the misleading assumption of the organic versus functional dichotomy
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claiming that the presence of an organic cause, as well as a hierarchical higher-order psychiatric
disorder such as major depression or panic disorder, subsumes psychological disturbances and,
vice versa, the absence of an organic cause strongly indicates the presence of a psychological
or psychiatric reason (Fava et al., 2012).
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 (Barbosa,
2012). 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 (Fava et al., 2012).
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. A psychiatric consultant
can relieve some of this frustration by clarifying the diagnosis and providing guidance on ways
to improve the patient’s functioning and relationship with the medical team.
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Management
There have been major transformations in health care needs in the past decades. Chronic
disease is now the principal cause of disability and use of health services consumes almost 80%
of health expenditures. Yet, current health care is still conceptualized in terms of acute care
perceived as a product processing, with the patients as a customer, who can, at best, select
among the services that are offered. In health care the product is clearly health and the patients
is one of the producers, not just a customer. As a result ‘optimally efficient health production
depends on a general shift of patients from their traditional roles as passive or adversarial
consumers to become producers of health jointly with their health professionals’ (Wholey et
al., 2014).
The exponential spending on preventive medication justified by the potential long-term
benefits to a small segment of the population is now being challenged, whereas the benefits of
modifying lifestyle by population-based measures are increasingly demonstrated and are in
keeping with the biopsychosocial model. Medically unexplained symptoms occur in up to 30–
40% of medical patients and increase medical utilization and costs. The traditional medical
specialties, based mostly on organ systems (e.g. cardiology, gastroenterology), appear to be
more and more inadequate in dealing with symptoms and problems which cut across organ
system subdivisions. The need for a holistic approach is underscored by the implementation of
interdisciplinary services. In the UK, the establishment of psychological treatment centers
within the National Health System for providing psychotherapy to patients with anxiety and
depressive disorders is an unprecedented opportunity of integration of different treatments
(Lousada et al., 2015). The need to include consideration of functioning in daily life,
productivity, performance of social roles, intellectual capacity, emotional stability and well-
being, has emerged as a crucial part of clinical investigation and patient care. These aspects
have become particularly important in chronic diseases, where cure cannot take place, and also
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extend over family caregivers of chronically ill patients and health providers. Patients have
become increasingly aware of these issues. The commercial success of books on
complementary and mind-body medicine exemplifies the receptivity of the general public to
messages of well-being pursuit by alternative medical practices. Psychosomatic interventions
may respond to these emerging needs within the established medical system and may play an
important role in supporting the healing process (Au et al., 2016; Becker et al., 2016).
The goal of treatment planning is to find with the patient a treatment strategy that
combines the patient’s willingness with medical necessity to the greatest extent possible
(shared decision making). What we know of compliance is sobering. In family practice, only
33 % of the patients take their medications correctly. So, it is highly relevant whether the
patient can or will follow the treatment at all.
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 (Wortman et al., 2016). 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,
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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 (Ballard et al., 2016).
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 (Song & Ward, 2015).
Given the diagnostic challenges discussed above, it is often prudent for the choice of
treatment to be guided by the symptoms of concern, especially when the aetiology is
ambiguous. It is also worth noting that most efficacy studies for psychiatric medications
exclude patients with comorbid medical conditions. While the treatment options are the same
as in a behavioral health setting, you will need to pay much more attention to medication side
effects, drug-drug interactions, altered metabolism, and absorption.
Summary
identification and treatment of medical problems. Treatment focuses on memory and the
unconscious mind, and considers the effects of proto-experiences on the (dys)functional
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