Advances in Psychosomatic Medicine最新文献

The measures of disease status alone are insufficient to describe the burden of illness or one's attitudes toward illness and life. The subjective health status including psychological resources and well-being is as valid as that of the clinician when it comes to evaluating outcomes. The aim of this chapter is to provide a theoretical framework for the assessment of psychological well-being and positive functioning and to review the literature supporting the influence of these positive dimensions on illness development and health protection. We selected the assessment tools such as Kellner's Symptom Questionnaire, Antonovsky's Sense of Coherence, Ryff's Psychological Well-Being Scales and Psychosocial Index that we found most helpful in clinical and psychosomatic practice and that displayed clinimetric properties of sensitivity in research.

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.

The psychosomatic interview is a patient-focused dialogue between physician and patient. It differs from the traditional disease-focused encounter in that the psychosomatic approach includes the biological, psychological, and sociocultural domains irrespective of the patients initial complaint, whether somatic or psychological. The process of dyadic interaction and the techniques of open questions are reviewed. Specific issues such as the alexithymic patient and breaking bad news are challenges in such communications. Organizing the data into the perspectives of diseases, dimensions, behaviors, and life stories allows the clinician to best understand their patients within a psychosomatic milieu.

In this review on rating scales for anxiety and depression, only instruments considered to be quantifiable, analogue to the measurement of hypertension in the medical setting, have been selected. The clinimetric method for validating these rating scales is the item response theory model in which the individual items are rank ordered on the dimensions of anxiety or depression, resulting in their total score being a sufficient statistic. The measurement of anxiety and mood on their respective dimensions of severity implies that we can speak of primary and secondary anxiety or depression in the same way as we speak about primary hypertension (without a medical explanation) and secondary hypertension (when caused be various medical conditions). Both clinician-rated scales and patient-rated questionnaires are discussed. The Clinical Interview for Depression and Related Syndromes (CIDRS) is included in the appendix as this CIDRS covers many of the rating scales measuring mood and anxiety.

The term illness behavior was introduced by Mechanic and Volkart to describe the individuals' different ways to respond to their own health status. Pilowsky's concept of abnormal illness behavior encompasses several clinical conditions characterized by a maladaptive mode of experiencing, perceiving, evaluating and responding to one's own health status. The concept of somatization was criticized because it implies the presence of psychological distress or an underlying psychiatric disturbance when an organic cause for somatic symptoms is not found. Thus, more atheoretical terms , such as functional somatic symptoms and medically unexplained symptoms, were introduced. Both Kellner's Symptom Questionnaire and Derogatis' Symptom Checklist-90 include a scale for somatic symptoms, and other questionnaires were specifically designed to measure their frequency and severity. Kellner's Illness Attitude Scales appear to be the gold standard for the measurement of the hypochondriacal spectrum, which includes several clinical conditions, such as nosophobia, thanatophobia and health anxiety. The assessment of illness denial should consider that a certain degree of denial may sometimes prevent patients from overwhelming psychological distress resulting from life-threatening or stigmatized diseases. Denial may concern both physical and psychiatric symptoms. Specific instruments are available for both types of denial. The cognitive and emotional representations developed by subjects when they have to cope with an illness or a perceived health threat are subsumed under the concept of illness perception and may be assessed by the Brief Illness Perception Questionnaire.

Childhood adversity increases risk of psychological and physical disorders. The comprehensive psychosomatic assessment of an individual's vulnerability to illness includes the evaluation of early life events, especially exposure to physical, emotional, sexual abuse and neglect. Many self-report and observer-rated instruments are now available to aid this evaluation and increase its validity. The authors review the features and limitations of published tools, and recommend which to choose for clinical and research purposes.

Female orgasmic disorder (FOD) is defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision, as a persistent or recurrent delay in, or absence of, orgasm following a 'normal' sexual excitement phase. FOD is a common problem affecting sexual function in a substantial proportion of women. Studies suggest that it is prevalent in 11-41% of women worldwide and can have a tremendous impact on the individual's quality of life, relational satisfaction and general well-being. The etiology of FOD tends to be multifactorial as it relates to genetics, medical conditions, medications, alcohol and drug use, other sexual dysfunctions, mental illness, life stressors, communication deficits and relationship issues. It is critical that sexual functioning in patients is assessed frequently through interview and/or validated questionnaires to aid in treatment strategy and/or referral. Currently, there are no approved medications to treat FOD. However, there are medications and psychological treatments that have shown promise in either treating FOD or thwarting the side effects of medications that can cause FOD. This chapter discusses the epidemiology and etiology of FOD and provides a comprehensive critical review of the literature on assessment and treatment of FOD.

Chronic opioid therapy for patients with chronic noncancer pain has become controversial, given the rising prevalence of opioid abuse. The prevailing literature suggests that the rate of addiction in chronic noncancer pain patients exposed to opioid therapy is relatively low, especially in those patients without significant concomitant psychiatric disorders and personal and family history of addiction. However, the escalating rate of misuse of prescription opioids has resulted in many clinicians caring for these patients to be more judicious in prescribing opioids. Accurately diagnos ing addiction in chronic pain patients receiving opioids is complex. Managing the patient with pain and co-occurring opioid abuse is equally challenging. Diagnostic issues, current guidelines for the appropriate use of opioids in the chronic pain population and risk stratification models are examined. Pharmacologic and nonpharmacologic treatment strategies for the patient with pain and opioid addiction are reviewed.

Ketamine is an N-methyl-D-aspartate receptor antagonist that has been in clinical use in the USA for over 30 years. Its ability to provide profound analgesia and amnesia while maintaining spontaneous respiration makes it an ideal medication for procedure-related pain and trauma. In the chronic pain arena, its use continues to evolve. There is strong evidence to support its short-term use for neuropathic and nociceptive pain, and conflicting evidence for preemptive analgesia. Its potential ability to prevent 'windup' and, possibly, 'reboot' aberrant neurologic pathways in neuropathic and central pain states has generated intense interest. However, the long-term use of ketamine for chronic neuropathic pain is limited by its side effect profile, and is largely anecdotal. More research is needed to better ascertain its long-term efficacy and side effects, to determine the ideal candidates for sustained treatment and to develop means of exploiting the antinociceptive properties of ketamine while minimizing the adverse effects.