Advances in Psychosomatic Medicine最新文献

Bariatric surgery is currently the only effective long-term treatment of morbid obesity and its related co-morbidities. Gastric bypass, adjustable gastric banding, and duodenal switch with biliopancreatic diversion are the three most common operations performed in the United States to induce sustained weight loss. Patient selection is important since compliance postoperatively leads to a successful outcome in over 80% of patients. Preoperative psychological and behavioral problems may lead to maladaptive eating habits postoperatively that defeat the purpose of the surgery. To date, we do not have a 100% reliable method of profiling patients who will fail to keep weight off for the long term. It is therefore important that patients who have preoperative psychological problems that may lead to failure to lose or keep weight off after surgery are offered postoperative counseling along with group support.

A sharp increase in bariatric surgery has resulted in spike in the population of patients seeking body-contouring procedures. Skin and soft tissue redundancy of the trunk, buttocks, breasts, upper arms, and thighs following massive weight loss is unsightly and results in medical problems such as musculoskeletal strain from increased tissue weight, intertrigo or functional limitation with walking, maintaining adequate hygiene, bowel and bladder habits and sexual activity. These elements compound the inherent psychosocial issues related to massive weight loss. Using time-tested plastic surgical techniques, several operations have been designed and perfected to address the needs of these patients. These include breast, thigh and lower body lift, abdominoplasty, face and neck lifts as well as brachioplasty or arm lift. Recognizing that there is a qualitative as well as a quantitative difference in the type and amount of tissues in postbariatric patients these techniques have been suitably refined to optimize outcomes and provide safe and durable re-contouring. Consequently, bariatric surgery and the subsequent weight loss require an additional 2-3 years commitment towards body contouring procedures. Restoring their body image through reshaping procedures is an integral part of completing the treatment of post-weight-loss patients. Strategic skills in terms of assessment of each patient, careful planning, timing, especially for patient safety and technique are fundamental for the success of these often complex and extensive procedures.

Obese patients have many physical limitations and much psychiatric burden to overcome. Several studies have shown that the prevalence of psychiatric morbidity in the obese is similar to those with normal weight. However, in obese patients seeking treatment there is an increased prevalence (40-60%) of psychiatric morbidity, most commonly depression. It is difficult to separate the effects of depression on obesity and, on the contrary, the neuroendocrine changes associated with stress and depression may cause metabolic changes that predispose and perpetuate obesity. The stigma associated with obesity causes bullying in school as well as childhood psychiatric morbidity. Prejudice is not limited to the general public but exists among health professionals too. This chapter discusses the treatment of depression in obesity and the psychiatric evaluation of the pre-bariatric surgery patient. Education of society, starting with schools and including healthcare professionals will reduce bias and stigma as well as assist this vulnerable group of patients to seek help for their obesity and the many problems that come with it. Given that by the year 2025 obesity will be the world's number one health problem with the US leading the way, it is very important that we pursue preventive measures as well as encourage research for treatments of obesity.

The psychological behaviorism theory of pain unifies biological, behavioral, and cognitive-behavioral theories of pain and facilitates development of a common vocabulary for pain research across disciplines. Pain investigation proceeds in seven interacting realms: basic biology, conditioned learning, language cognition, personality differences, pain behavior, the social environment, and emotions. Because pain is an emotional response, examining the bidirectional impact of emotion is pivotal to understanding pain. Emotion influences each of the other areas of interest and causes the impact of each factor to amplify or diminish in an additive fashion. Research based on this theory of pain has revealed the ameliorating impact on pain of (1) improving mood by engaging in pleasant sexual fantasies, (2) reducing anxiety, and (3) reducing anger through various techniques. Application of the theory to therapy improved the results of treatment of osteoarthritic pain. The psychological behaviorism theory of the placebo considers the placebo a stimulus conditioned to elicit a positive emotional response. This response is most powerful if it is elicited by conditioned language. Research based on this theory of the placebo that pain is ameliorated by a placebo suggestion and augmented by a nocebo suggestion and that pain sensitivity and pain anxiety increase susceptibility to a placebo.

Evaluating and treating patients with chronic nonmalignant pain, especially with opioid medications, often causes discomfort on the part of primary care physicians. A number of patient-, physician-, and system-related issues converge to make treating chronic pain a complex matter. Patient-related issues include an inability to define a clear anatomic cause for patients' pain, comorbid psychiatric conditions, and past and current substance abuse. Physicians lack training on the appropriate evaluation and treatment of chronic nonmalignant pain, fear creating addicts, and often face intense pharmaceutical industry pressure to prescribe medications. A paucity of practical clinical practice guidelines, controversy over the effectiveness of opioids on chronic nonmalignant pain, and concern about potential legal and regulatory ramifications add to the complexity of caring for these patients. Possible multifaceted solutions exist to minimize provider discomfort and improve their ability to treat patients appropriately. Examples include comprehensive, practical multidimensional guidelines on the evaluation and treatment of chronic nonmalignant pain, Web-based teleconferenced consultations with subspecialists, reduced pharmaceutical pressure, enhanced continuing medical education and pregraduate training, multispecialty coordinated care of patients with adequate reimbursement for such care, and physician access to state-based systems to track opioid prescriptions.