Psychological Factors Affecting Medical Conditions Advances in Psychosomatic Medicine Vol. 28 Series Editor T.N. Wise,Falls Church, Va. Editors G.A. Fava,Bologna I. Fukunishi,Tokyo M.B. Rosenthal,Cleveland, Ohio Psychological Factors Affecting Medical Conditions A New Classification for DSM-V Volume Editors P. Porcelli,Castellana Grotte N. Sonino,Padova 3 figures and 22 tables, 2007 Basel·Freiburg·Paris·London·New York· Bangalore·Bangkok·Singapore·Tokyo·Sydney Advances in Psychosomatic Medicine Founded 1960 by F. Deutsch (Cambridge, Mass.) A. Jores (Hamburg) B. Stockvis (Leiden) Continued 1972–1982 by F. Reichsman (Brooklyn, N.Y.) Library of Congress Cataloging-in-Publication Data Psychological factors affecting medical conditions : a new classification for DSM-V / volume editors, P. Porcelli, N. Sonino. p. ; cm. – (Advances in psychosomatic medicine, ISSN 0065-3268 ; v. 28) Includes bibliographical references and indexes. ISBN-13: 978-3-8055-8331-2 (hard cover : alk. paper) 1. Medicine, Psychosomatic–Research–Methodology. 2. Sick–Psychology–Classification. 3. Diseases–Social aspects–Classification. 4. Diagnostic and statistical manual of mental disorders. I. Porcelli, P. (Piero) II. Sonino, N. (Nicoletta) III. Diagnostic and statistical manual of mental disorders. IV. Series. [DNLM: 1. Psychophysiologic Disorders–classification. 2. Psychophysiologic Disorders–diagnosis. 3. Disease–psychology. 4. Psychosomatic Medicine–methods. 5. Research. W1 AD81 v.28 2007 / WM 90 P97147 2007] RC52.P82 2007 616.08–dc22 2007025224 Bibliographic Indices. This publication is listed in bibliographic services, including Current Contents®and Index Medicus. Disclaimer. The statements, options and data contained in this publication are solely those of the individ- ual authors and contributors and not of the publisher and the editor(s). 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All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. © Copyright 2007 by S. Karger AG, P.O. Box, CH–4009 Basel (Switzerland) www.karger.com Printed in Switzerland on acid-free and non-aging paper (ISO 9706) by Reinhardt Druck, Basel ISSN 0065–3268 ISBN 978–3–8055–8331–2 Contents VII Preface 1 Development of a New Assessment Strategy in Psychosomatic Medicine: The Diagnostic Criteria for Psychosomatic Research Fabbri, S. (Bologna/Charlottesville, Va.); Fava, G.A. (Bologna/Buffalo, N.Y.); Sirri, L. (Bologna); Wise, T.N. (Baltimore, Md.) 21 Psychosocial Approach to Endocrine Disease Sonino, N. (Padova/Buffalo, N.Y.); Tomba, E. (Bologna); Fava, G.A. (Bologna/Buffalo, N.Y.) 34 Psychological Factors Affecting Functional Gastrointestinal Disorders Porcelli, P. (Castellana Grotte); Todarello, O. (Bari) 57 Psychological Factors Affecting Oncology Conditions Grassi, L.; Biancosino, B.; Marmai, L.; Rossi, E.; Sabato, S. (Ferrara) 72 Psychological Factors Affecting Cardiologic Conditions Rafanelli, C.; Roncuzzi, R.; Ottolini, F. (Bologna); Rigatelli, M. (Modena) 109 Toward a Biopsychosocial Approach to Skin Diseases Picardi, A.; Pasquini, P. (Rome) V 127 Psychological Factors Affecting Medical Conditions in Consultation-Liaison Psychiatry Bellomo, A.; Altamura, M.; Ventriglio, A. (Foggia); Rella, A.; Quartesan, R.; Elisei, S. (Perugia) 141 Psychological Factors Affecting Eating Disorders Fassino, S.; Abbate Daga, G.; Pierò, A.; Delsedime, N. (Torino) 169 Appendix 1. Diagnostic Criteria for Psychosomatic Research 174 Appendix 2. Interview for the Diagnostic Criteria for Psychosomatic Research 182 Author Index 183 Subject Index Contents VI Preface The primary goals of diagnosis are to provide clinicians with a meaningful framework that recognizes the underlying clinical condition beyond the symp- tom presentation, to facilitate communication among clinicians, and to enhance decision making to improve the patient’s health status. In any field of medicine and clinical psychology, including psychosomatic medicine, the diagnostic process can be considered as much effective as it gets closer to the top achieve- ment levels of these 3 interrelated purposes. However, a wide array of medical symptoms cannot be explained by the biomedical model and confined to the current branches of internal medicine. In turn, several health-related problems, strongly affecting daily functioning and influencing symptom presentation, cannot be fully recognized without the more comprehensive, multifactorial per- spective provided by the biopsychosocial model of health and illness. In this perspective, any illness is viewed as the common final pathway resulting from interacting systems at the cellular, tissue, organismic, interpersonal, and envi- ronmental levels, so that each of these factors has a relative weight in facilitat- ing, sustaining, or modifying the course of diseases, varying from illness to illness, from one individual to another, and even between two different episodes of the same illness in the same individual. The relationships between physical illness and psychological factors are subsumed in two chapters of the DSM-IV. One, Somatoform Disorders, is included in the main diagnostic axis I and is based on the assumptions that somatic symptoms are likely to mimic ‘real’ symptoms of medical disease while not showing any evidence of it and are not VII secondary to another psychiatric disorder. This view pertains to the concept of the excessive distance between the physical problem (inexistent or not being a plausible cause for actual symptoms) and the patient’s perception, thoughts, and behavior. The second chapter is the rubric of Psychological Factors Affecting Medical Condition (PFAMC) that requires the presence of a general medical condition and of psychological factors that adversely affect the course or treat- ment of the condition, or that increase physical or emotional risk for the patient. PFAMC are placed in the residual section of ‘other conditions that may be a focus of clinical attention’and therefore are too vague, lack specific criteria, and are not useful and not used in clinical practice. Somatoform disorders have attracted considerable criticism since their introduction in the DSM-III and the need for considerable changes in preparing the 5th edition of the DSM has been highlighted. Somatoform disorders have been criticized because they have been formulated by dichotomous thinking; they include criteria that are too restric- tive (e.g. somatization disorder) or too vague (e.g. undifferentiated somatoform disorders); they tend to overpsychologize somatic symptoms (when axis I dis- orders are present) or to underestimate somatization symptoms (when medical diagnoses are established); they underestimate the prevalence of somatization because they are limited to the more severe clinical forms; they underrecognize the dimensional nature of somatization along a continuum spectrum of degrees (severity, impairment, chronicity, comorbidity, health care utilization); they lack appropriate consideration of subsyndromal symptoms, personality and behavioral factors, and they include syndromes that are not used by physicians for the same illness (such as fibromyalgia and undifferentiated somatoform dis- order or functional abdominal pain and pain disorder), thereby producing inef- fective communication. Both Somatoform Disorders and PFAMC miss the primary goals of the diagnostic process. The debate is still ongoing, several papers and editorials have been published recently, and some proposals for DSM-V have been advanced. They range from softer (e.g. clustering of the many somatoform disorders in few categories identified by some specifiers) to harder alternatives (e.g. abolition of the rubric of somatoform disorders). On the basis of a growing body of research, this volume deals with research data and clinical views to formulate a new proposal for the DSM-V, introducing the Diagnostic Criteria for Psychosomatic Research (DCPR) in the chapter of PFAMC. The DCPR syndromes were developed about 10 years ago by an interna- tional group of investigators and are based on the recognition that a wide body of evidence that has accumulated in psychosomatic medicine relating to concepts of quality of life, stressful life events, somatization, and personality disorders has not resulted in operational tools whereby different psychosocial aspects of medical diseases can be characterized. The DCPR approach focuses on psychological char- acteristics of patients presenting symptoms across different medical disorders. Preface VIII The first chapter by Fabbri and colleagues explains the rationale for the introduction of the DCPR in the DSM-V and emphasizes their usefulness assess- ing for psychological and behavioral problems affecting the onset, the course, and the treatment of patients in the different medical settings. In the second chapter, Sonino and colleagues examine the psychological factors affecting sev- eral endocrine disorders (Cushing’s syndrome, Graves’disease, Addison’s dis- ease, primary aldosteronism, thyroid dysfunctions, hyperprolactinemia, and hyperparathyroidism). Particular attention is paid by the authors to the associa- tion between DCPR clusters and the construct of allostatic load, conceived as the chronic exposure to fluctuating or heightened neuroendocrine response resulting from repeated or chronic environmental challenge. Porcelli and Todarello’s chap- ter focuses on patients with functional gastrointestinal disorders in whom the most prevalent DCPR syndromes (alexithymia, persistent somatization, sec- ondary functional somatic symptoms, and demoralization) are consistent with the psychosocial correlates outlined in the literature as health care seeking behavior and somatosensory amplification. In the following chapter, Grassi and coworkers underscore that DSM criteria are particularly problematic in oncology because of the need to adapt them to the cancer-related life conditions, while psychological problems identified by the DCPR as health anxiety, demoraliza- tion, and alexithymia are associated with several cancer-related physical symp- toms, poor well-being and quality of life, and high health concerns. The psychological factors affecting cardiovascular disorders are reviewed by Rafanelli’s group. In this chapter, the role of ‘classic’ (stressful life events, depression, anxiety, anger, and hostility) and DCPR-related (demoralization, health anxiety, irritable mood, type A behavior, and denial) psychological factors are discussed in relation to coronary heart disease, essential hypertension, con- gestive heart failure, heart transplantation, coronary artery bypass grafting, and cardiac rehabilitation. In the subsequent chapter, Picardi and Pasquini review the psychological factors (demoralization, type A behavior, secondary somatic symptoms, irritable mood, and health anxiety) that influence dermatological conditions such as alopecia aerata, atopic dermatitis, psoriasis, and vitiligo. The skin is a sensory organ involved in socialization processes, which is responsive to various emotional stimuli, and affects an individual’s body image and self- esteem. The last two chapters are concerned with two areas closer to psychiatry. Bellomo’s group highlights findings on psychological factors in the setting of consultation-liaison psychiatry and Fassino and colleagues discuss issues of patients with eating disorders. Both conditions have important biological and psychiatric determinants involved in the presentation and the treatment of symp- toms and require a multidisciplinary approach in order to provide highly inte- grated management. Finally, two appendices report the complete list of criteria for the 12 DCPR categories and the structured interview for their assessment. Preface IX