Book Review
Psychosocial Aspects
Psychosocial Treatment for Medical Conditions: Principles and Techniques. Leon A Schein, Harold S Bernard, Henry I Spitz, Philip R Muskin, editors. New York: Brunner–Routledge; 2003. 456 p. US$59.95.
Reviewer
rating*: Good
Review by: Alex Adsett, MD, FRCPC
Hamilton, Ontario
Why another book on psychosocial aspects of medicine in this age of exciting rapid developments in biotechnology? It is this current fascination with the biology of the biopsychosocial health care model that makes this book relevant. Moreover, time pressures on physicians allow them less time to talk with patients and to build a therapeutic doctor– patient relationship. Along with increased biotechnology, we have seen an amazing increase in patients turning to alternative medicine, perhaps partly because the average primary care physician spends 7 minutes with each patient, while the average alternative practitioner spends 30 minutes.
This book’s goal is to help the reader gain a comprehensive and integrated understanding of both the biomedical knowledge and the psychosocial aspects of various medical disorders, a goal that is achieved by a multidisciplinary group of authors. The editors consist of 2 psychologists and 2 psychiatrists. Each chapter is written by at least 2 authors, the total of whom comprise 7 psychologists, 7 psychiatrists, 1 professor of nursing, and 7 clinical medicine specialists. In the preface, the editors indicate that the book is directed to a wide range of health care providers, including psychiatrists, psychologists, social workers, and nurses.
The introductory chapters review research findings for such important clinical issues as treatment adherence, delay in seeking medical aid, and the value of patient participation in treatment decisions. This section also presents evidence showing that environmental and work factors and lifestyle and social supports significantly influence illness and disease. The authors discuss theoretical models that help clarify health behaviour, including a patient’s locus of control and health beliefs and the transtheoretical model of stages of change. The editors recognize the complexity of medically unexplained symptoms and somatization and the need for an evolving interactional view as more research is done on this group of difficult patients.
Chapters 3 through 10 present psychosocial considerations in women’s health and in various common medical disorders, such as cancer, cardiovascular or renal disease, gastrointestinal disorders, endocrine disorders, neurological illness, and infectious diseases. Each chapter provides basic medical information about the disease in that body system, including symptoms, treatments, effects, prognoses, usual psychosocial responses of the patient and family, and long-term sequelae. Many physicians will find the summaries of medical disease unnecessary, and sometimes, more medical information than a reader wants to know is provided. In this case, it is sufficient to skim the information, though for some, the information might be useful.
Following the basic medical description, each chapter presents a section labelled Psychological Sequelae. For example, a patient who develops diabetes is described as often experiencing a profound sense of sadness and loss, mood swings, anger, and lowered self- esteem. Studies show that psychosocial factors affect blood sugar indirectly by patient compliance and directly by neuroendocrine effects. Blood sugar levels, in turn, may affect emotional state. Cognitive-behavioural therapy (CBT) has been shown to improve coping, treatment compliance, and control of blood glucose.
The authors present an interesting historical review of our understanding of peptic ulcer that illustrates how many physicians tend to think in a simplistic linear fashion rather than appreciating complex multifactorial etiology. Clearly, peptic ulcer is not primarily a psychosomatic disorder, as psychiatry has maintained in the past. However, H. pylori infection—now in vogue—cannot be considered a sufficient cause either; by age 70 years, over 50% of the population has been exposed to H. pylori, and not all cases of peptic ulcer have H. pylori infection.
The chapter on infectious diseases provides abundant medical knowledge and focuses on HIV, chronic fatigue syndrome (CFS), and Lyme disease—a group of disorders that exemplify the growing complexity of our understanding of host–pathogen interactions. The controversial disorder, CFS, is handled in a thoughtful manner emphasizing that this is a clinical syndrome with a significant prevalence and morbidity but with unknown etiology. The authors outline theories of etiology, including psychiatric etiologies, and the sparse evidence supporting them. They note how the lack of objective medical findings to explain CFS has detrimental effects on the patient’s relationship with family and friends and with the physician, as well as on the patient’s sense of self. Current treatment consists of CBT and a graded program of rehabilitation, but the authors provide no evidence to support treatment efficacy.
It was refreshing to see a chapter on women’s health, but the chapter was disappointing in that it provided extensive medical coverage but a limited discussion of psychosocial issues and research on psychosocial treatment in women.
The final 2 chapters specifically relate to the book’s title, Psychosocial Treatments. The authors summarize the principles of psychoeducation, relaxation and stress management, supportive therapy, CBT, and psychodynamic psychotherapy delivered to the individual, the couple or family, and the group. They point out that most medical patients view their psychosocial problems as arising from their physical illness. The patient’s goal is to learn to cope with the changes and losses in their lives.
In summary, this book is well written and free from errors, and in most instances, it provides reasonably up-to-date references for its statements, at times including contradictory studies. However, there is no attempt to assess the various studies’ level of evidence. The editors acknowledge that research in this field is still relatively new and that much knowledge thus far consists of hypotheses in need of refinement.
The book is much more than its title suggests, as it provides a wealth of studies on the relation between medical illness and psychosocial factors. This knowledge helps psychiatrists to understand patients’ experiences and responses and supplies a map for psychiatric treatment.
I recommend the book to consultation-liaison psychiatrists and to those with psychosomatic interests, as well as to nurses, social workers, and psychologists who work with medical patients. The book might also be valuable to psychiatrists who want to refresh their medical knowledge and to primary care physicians who want to expand their understanding of psychosocial issues.
The price is slightly high for the value of the book.
*Reviewer
Rating Scale/ Échelle d’évaluation du réviseur
Excellent / Excellent
Very Good / Très bon
Good / Bon
Fair / Passable
Not recommended / Pas recommandé
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