Advances in Psychosomatic Medicine

Cultural psychiatry in the United Kingdom exhibits unique characteristics closely related to its history as a colonial power, its relationship with Commonwealth countries and the changing socio-demographic characteristics of its diverse population throughout the centuries. It is not surprising, therefore, that the emergence of this discipline was centred around issues of race and religion. After a brief historical review of the development of cultural psychiatry and the mention of pioneering intellectual and academic figures, as well as the evolvement of the field in organizations such as the Royal College of Psychiatrists, this chapter examines the need of a critical cultural psychiatry, more than a narrative social science distanced from the realities of clinical practice...

Since the publication of DSM-IV in 1994, neurobiologists and anthropologists have criticized the rigidity of its diagnostic criteria that appear to exclude whole classes of alternate illness presentations, as well as the lack of attention in contemporary psychiatric nosology to the role of contextual factors in the emergence and characteristics of psychopathology. Experts in culture and mental health have responded to these criticisms by revising the very process of diagnosis for DSM-5. Specifically, the DSM-5 Cultural Issues Subgroup has recommended that concepts of culture be included more prominently in several areas: an introductory chapter on Cultural Aspects of Psychiatric Diagnosis - composed of a conceptual introduction, a revised Outline for Cultural Formulation, a Cultural Formulation Interview that operationalizes this Outline, and a glossary on cultural concepts of distress - as well as material directly related to culture that is incorporated into the description of each disorder...

The current scene in the field of cultural psychiatry shows a vigorous growth, multifaceted conceptual and research developments and more relevant clinical presence. After a pertinent definition of the discipline, this chapter examines the contribution of cultural psychiatry to the etiopathogenesis of mental disorders, to the variations of clinical presentations in numerous entities, to psychiatric diagnosis and treatment and to the relatively unexplored rubric of preventive psychiatry. Advanced concepts of neurosciences and technology-based research can find a place in the realm of biocultural correlates...

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The main ethical perspective in the clinical relationship takes into consideration the vulnerability of the clinical condition before threats and risks that can undermine the integrity and dignity of the person. Psychosomatic medicine faces complex cases whose ethical problems cannot only be solved by applying top-down deontological or utilitarian approaches, principlism, which is limited mainly to easing ethical tensions, or a bottom-up approach, the casuistic model, case-based reasoning. In introducing vulnerability as the core of ethical questioning as a principle ontological priority over other principles, relational ethics refers to the appreciation of the responsibility of health professionals through which a health care professional and the patient 'together' can construct more reasonable and prudential courses of action with, for, and by the patient...

Acute and chronic illness exists in a social context. A biopsychosocial assessment should include an evaluation of the patient's social situation, the nature of the patient's interpersonal connections, and his/her family's functioning. Families can influence health by direct biological pathways, health behavior pathways, and psychophysiological pathways. There are a large number of family-based risks factors as well as many protective relational factors that influence the onset and course of illness. A family assessment is the first step in determining both the need for further intervention and the specific areas of family life that might need to be addressed...

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...

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...

The notion that personality variables can affect vulnerability to specific diseases has been widely promoted in psychosomatic medicine. Over the time, some personality patterns have been extensively studied. Among them, alexithymia, type A, and type D personality are the most relevant. However, also temperament and character has increasingly been object of studies. Alexithymia is currently recognized as a risk factor for medical, psychiatric, or behavioral problems; type A personality is recognized to increase the risk for coronary artery disease, and type D personality has been related to adverse cardiac events and cardiovascular outcomes...

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)...

The Diagnostic Criteria for Psychosomatic Research (DCPR) are a diagnostic and conceptual framework that aims to translate psychosocial variables that derived from psychosomatic research into operational tools whereby individual patients could be identified. A set of 12 syndromes was developed and grouped in the clusters of abnormal illness behavior (health anxiety, disease phobia, thanatophobia, and illness denial), somatization (functional somatic symptoms secondary to a psychiatric disorder, persistent somatization, conversion symptoms, and anniversary reaction), irritability (type A behavior, irritable mood), demoralization, and alexithymia...

Good sexual functioning is a part of overall well-being. Assessment of sexual functioning should be part of any complete psychosomatic assessment. The cornerstone of this assessment is a comprehensive clinical interview of the patient, with, if possible, collateral information obtained from the partner or another clinician. In addition, comprehensive assessment of sexual function should include a physical examination with a special focus on sexual function, laboratory testing and possibly other specialized testing and, in some cases, psychometric assessment...

Habits relevant to health include physical activities, diet, smoking, drinking and drug consumption. Despite the fact that benefits of modifying lifestyle are increasingly demonstrated in clinical and general populations, assessment of lifestyle and therapeutic lifestyle changes is neglected in practice. In this review, associations between unhealthy lifestyle and health outcomes are presented. Particular emphasis will be placed on description and discussion of the standardized assessment instruments and behavioral methods that could be used in clinical practice to measure lifestyles...

Despite the fact that there is an extensive scientific literature regarding the importance of exposure to psychosocial stressors, the assessment of such stressors is often neglected in clinical work. The present review summarizes the scientific literature on critical life changes and work-related stressors. Particular emphasis has been on somatic outcomes and physiological processes that have been shown to be affected by exposure to stressors. Although the relationships are highly complex, it could be concluded that exposure to stressors may often determine the onset of many illnesses...

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...

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...

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...

The influences of culture are present in different areas of human health, as is the case with reproductive behaviors. To have a child means to have made a responsible decision. If conception takes longer to happen, these patients require the help of doctors to stimulate the refractory body. In light of data suggesting that psychosexual symptoms may interfere with fertility, successful infertility treatment and the ability to tolerate ongoing treatment rely on paying attention to these symptoms. Infertility is not only a fault of nature, but it is also something that does not respect the established order, a fact that casts doubt on the truth of the femininity and masculinity representations prevailing in a culture...

Gonadotropin-releasing hormone agonists are underutilized in patients seeking diminution of problematic sexual drives. This chapter reviews the literature on surgical castration of sex offenders, anti-androgen use and the rationale for providing androgen deprivation therapy, rather than selective serotonin reuptake inhibitors or more conservative interventions, for patients with paraphilias and excessive sexual drive. Discussions of informed consent, side effects, contraindications and case examples are provided...

Autogynephilia is defined as a male's propensity to be sexually aroused by the thought of himself as a female. It is the paraphilia that is theorized to underlie transvestism and some forms of male-to-female (MtF) transsexualism. Autogynephilia encompasses sexual arousal with cross-dressing and cross-gender expression that does not involve women's clothing per se. The concept of autogynephilia defines a typology of MtF transsexualism and offers a theory of motivation for one type of MtF transsexualism. Autogynephilia resembles a sexual orientation in that it involves elements of idealization and attachment as well as erotic desire...