Management of psychological factors affecting the patient’s med-ical condition should be tailored both to the particular psycholog-ical factor of relevance and to the medical outcome of concern. Some general guidelines, however, can be helpful. The physician, whether in primary care or a specialty, should not ignore appar-ent psychiatric illness. Unfortunately, this occurs all too often because of discomfort, stigma, lack of training, or disinterest. Referring the patient to a mental health specialist for evaluation is certainly better than ignoring the psychological problem but should not be regarded as “disposing” of it, because the physician must still attend to its potential impact on the patient’s medical illness. Similarly, psychiatrists and other mental health practitio-ners should not ignore coincident medical disease and should not assume that referral to a nonpsychiatric physician absolves them of all responsibility for the patient’s medical problem.
If the patient has a treatable Axis I disorder, treatment for it should be provided. Whereas this is obviously justified on the basis of providing relief from the Axis I disorder, psychiatric treatment is further supported by the myriad ways in which the psychiatric disorder may currently or in future adversely affect the medical illness. The same psychopharmacological and psy-chotherapeutic treatments used for Axis I mental disorders are normally appropriate when an affected medical condition is also present. However, even well-established psychiatric treatments supported by randomized controlled trials have seldom been validated in the medically ill, who are typically excluded from the controlled trials. Thus, psychiatric treatments may not always be directly generalizable to, and often must be modified for, the medically ill.
When prescribing psychiatric medications for patients with significant medical comorbidity, the psychiatrist should keep in mind potential adverse effects on impaired organ systems (e.g., anticholinergic exacerbation of postoperative ileus; tricyclic antidepressant causing completion of heart block), changes in pharmacokinetics (absorption, protein binding, metabolism and excretion) and drug–drug interactions. Psychotherapy may also require modification in patients with comorbid medical illness, including greater flexibility regarding the length and frequency of appointments, and deviations from standard therapeutic ab-stinence and neutrality. Psychotherapists treating patients with PFAMC should usually be much more active in communicating with other health care professionals caring for the patient (with the patient’s consent) than is usually the case in psychotherapy.
If the patient has an Axis II personality disorder or other prominent personality or coping style, the psychiatrist should modify the patient’s treatment accordingly, which is usually more easily accomplished than trying to change the patient’s personality. For example, patients who tend to be paranoid or mistrustful should receive more careful explanations, particu-larly before invasive or anxiety-provoking procedures. With nar-cissistic patients, the psychiatrist should avoid relating in ways that may seem excessively paternalistic or authoritarian to the patient. With some dependent patients, it may be advisable to be more directive, without overdoing it and fostering excessive dependency.
In some instances, psychiatric symptoms not meeting the thresh-old for an Axis I diagnosis will respond positively to the same treatments used for the analogous Axis I psychiatric disorder, with appropriate modifications as noted before. There is not a great amount of treatment research on subsyndromal psychiatric symptoms, and even less in patients with comorbid medical ill-ness, so this area of practice remains less evidence-based. Some psychiatric symptoms affecting a medical condition may be ame-nable to stress management and other behavioral techniques as well as appropriate reassurance.
Any intervention directed by the psychiatrist at a par-ticular patient’s psychological symptoms or behavior should be grounded in exploratory discussion with the patient. Interven-tions without such grounding tend to seem at best superficial and artificial and at worst are entirely off the mark. For example, if the psychiatrist wrongly presumes to know why a particular patient seems anxious without asking, the patient is likely to feel misunderstood. Facile, nonspecific reassurance can undermine the physician–patient relationship because the patient is likely to feel that the psychiatrist is out of touch with and not really interested in the patient’s experience. It is especially important with depressed patients that psychiatrists avoid premature or unrealistic reassurance or an overly cheerful attitude; this tends to alienate depressed patients, who feel that their psychiatrist is insensitive and either does not understand or does not want to hear about their sadness. Physicians should provide specific and realistic reassurance, emphasize on a constructive treatment plan and mobilize the patient’s support system.
As with Axis II disorders affecting a medical condition, psychia-trists should be aware of the personality style’s effects on the phy-sician–patient relationship and modify management better to fit the patient. For example, with type A “time urgent” patients, psy-chiatrists may need to be more sensitive to issues of appointment scheduling and waiting times. Group therapy interventions can enhance active coping with serious medical illnesses like can-cer, heart disease and renal failure but to date have usually been designed to be broadly generalizable rather than targeted to one particular trait or style (with the exception of type A behavior).
Another general guideline is not to attack or interfere with a patient’s defensive style unless the defense is having an adverse impact on the medical illness or its management. Psychiatrists are particularly tempted to intervene when the defense is dramatic, breaks with reality, or makes the psychiatrist uncomfortable.
For example, denial is a defense mechanism that reduces anxiety and conflict by blocking conscious awareness of thoughts, feelings, or facts that an individual cannot face. Denial is com-mon in the medically ill but varies in its timing, strength and adaptive value. Some patients are aware of what is wrong with them but consciously suppress this knowledge by avoiding think-ing about or discussing it. Others cope with the threat of being overwhelmed by their illness by unconsciously repressing it and thereby remain unaware of their illness. Marked denial, in which the patient emphatically refuses to accept the existence or sig-nificance of obvious symptoms and signs of the disease, may be seen by the psychiatrist as an indication that the patient is “crazy” because the patient seems impervious to rational persuasion. In the absence of signs of another major psychiatric disorder (e.g., paranoid delusions), such denial is not often a sign of psychosis but rather represents a defense against overwhelming fear.
The adaptive value of denial may vary, depending on the nature or stage of illness. When a patient’s denial does not preclude cooperation with treatment, the psychiatrist should leave it alone. The psychiatrist does have an ethical and professional obligation to ensure that the patient has been informed about the illness and treatment. After that, if the patient accepts treatment but persists with an irrationally optimistic outlook, the psychiatrist should re-spect the patient’s need to use denial to cope. For some, the denial is fragile, and the psychiatrist must decide whether the defense should be supported and strengthened, or if the patient had better give up the denial to discuss fears directly and receive reassur-ance from the psychiatrist. The psychiatrist should not support denial by giving the patient false information, but rather encour-age hope and optimism. When denial is extreme, patients may refuse vital treatment or threaten to leave against medical advice. Here, the psychiatrist must try to help reduce denial but not bydirectly assaulting the patient’s defenses. Because such desper-ate denial of reality usually reflects intense underlying anxiety, trying to scare the patient into cooperation will intensify denial and the impulse to flight. A better strategy for the psychiatrist is to avoid directly challenging the patient’s claims while simulta-neously reinforcing concern for the patient and maximizing the patient’s sense of control.
This is an area of research with many promising approaches. To achieve smoking cessation, bupropion, nicotine replace-ment, behavioral therapies and other pharmacological strate-gies all warrant consideration. Behavioral strategies are also useful in promoting better dietary practices, sleep hygiene, safe sex and exercise. For some patients, change can be achieved ef-ficiently through support groups, whereas others change more effectively through a one-to-one relationship with a health care professional.
Biofeedback, relaxation techniques, hypnosis and other stress management interventions have been helpful in reducing stress-induced exacerbations of medical illness including cardiac, gas-trointestinal, headache and other symptoms. Pharmacological in-terventions have also been useful (e.g., the widespread practice of prescribing benzodiazepines during acute myocardial infarction to prevent stress-induced increase in myocardial work).
The primary focus is on those effects for which there is reasonable evidence from controlled studies. Space considerations preclude inclusion of all valuable studies and all medical disorders.
Most of the early research suffers from serious method-ological flaws, including use of small biased samples, limited or no statistical analysis, poor (if any) controls and retrospective designs subject to recall and other biases. This early work gener-ated excitement and interest in psychosomatic medicine but also produced ideas that in retrospect were intellectually appealing but erroneous and simplistic regarding the special designation of certain diseases as psychosomatic.
Later research has shown improvements in methodology, but problems in design and interpretation continue. Several stud-ies that seem to show significant effects of psychological factors on medical disease are inconclusive because of nonequivalence in groups at baseline either in medical disease severity or in treat-ments received (many studies do not even monitor this possibil-ity). Some studies fail to attend to important potential confound-ing factors such as smoking or diet. A number of studies measure too many psychological variables and then overly emphasize the few “discovered” positive associations in the published results. Failure to standardize measures of initial psychological factors and measures of medical outcome has also been frequent. Despite these and other critiques, a large and growing body of disease-specific research is illuminating the full range of PFAMC.