Psychosomatic Practice in Gastroenterology

Diversity of Psychosomatic Models for GE

There are three main models of psychosomatic medicine [6^, 16^, 17]: (1) a branch or subspecialty of psychiatric medicine, nearly the same as consultation-liaison psychiatry (CLP); (2) a branch of medicine, a primary discipline independent of psychiatry, internal medicine, or surgery; and (3) a method or a practice model of holistic medicine to treat patients in various medical specialties including psychiatry. The respective models may be defined as a comprehensive, interdisciplinary framework for: (1) assessment of psychosocial factors affecting individual vulnerability to and the course and outcome of any type of disease; (2) holistic consideration of patient care in clinical practice; and (3) integration of psychological therapies in the prevention, treatment, and rehabilitation of medical disease [16^, 18]. The models refer to taking biological, psychological, and social factors into consideration in a comprehensive and integrative way in the process of diagnosis and treatment of medical conditions [6^, 19]. In China, psychosomatic medicine is still mainly used in CLP, even though recently it has become more and more popular in the medical setting [20^, 21].

The psychosomatic practice model of GE has three main connotations or forms:

1. Biomedicine-oriented PSGE tends to explore the relationship between the brain and the GI tract by means of scientific technology such as neuro-GE; this form connotes “brain-body” medicine instead of “mind-body” medicine, since the brain itself is part of the body

2. Psychiatry-oriented PSGE, in the narrow sense, is essentially the same as CLP; in this model, functional GI symptoms are simply regarded as unrecognized or missed somatic symptoms of mental disorders

3. Holistic medicine-oriented PSGE; in this model, the synergistic effects of biological, social, and psychological factors are comprehensively considered in the process of interviewing, assessment, diagnosis, treatment, and rehabilitation; it is strongly suggested that nonpsychiatric specialists such as gastroenterologists practice this model after short formal training in medical psychology, psychiatry, and psychosomatic assessment

Integration of Psychosomatic Assessment into GE

The GI symptoms of almost 60% of patients cannot be explained with the conventional disease-centered model of GE, which has not yet included unexplained symptoms of organic GI diseases such as the so-called residual symptoms of IBD [7^, 8]. Biological assessment is inadequate to meet the needs of current clinical practice, and systematic psychosomatic assessment can provide a solution and will be a vital step in bringing about the transition of the biopsychosocial model from theory to operational clinical practice [22]. The two levels of functional analysis by Emmelkamp [22], the DCPR by Fava and Sonino [13] and Fava et al. [14], and the clinimetric approach introduced by Feinstein [23] may greatly improve the clinical process in shared decision-making and self-management, increasing the motivation for psychotherapy and psychoactive medication when really needed. These assessment tools related to nonbiological variables actually are the basis of the holistic psychosomatic model. There will be ample opportunity for its application in the medical setting [24] including GE.

Psychosomatic Interventions for FGIDs

It is not easy for patients with FGIDs to accept psychological or even psychiatric attributions and related interventions for their symptoms. The key to solving this problem is to improve compliance with or the motivation for psychosomatic interventions [25]. It is not feasible – or is even wrong – for a clinician to attribute those unexplained GI symptoms to “no disease.” In the conventional model, typical conversations often occurring between physicians and patients could be along the lines of: “You can go back home now, since you have no disease!” from the physician’s side, and “Now what shall I do, doctor? I have a really uncomfortable feeling in my stomach!” from the patient’s side.

Understanding, explaining, and treating “functional symptoms” from the perspective of psychiatry undoubtedly is a move forward in GE practice. The Rome Foundation for Functional Gastrointestinal Disorders put forward the basic framework and principles of psychological and psychoactive medicinal interventions for patients with FGIDs [26]. A meta-analysis by Ford et al. [27] showed that psychotherapy and antidepressants were effective in improving the symptoms of IBS. However, if clinicians simply attribute “functional symptoms” to psychiatric disorders such as anxiety or depressive disorders, they go from one extreme of a “no-disease” attribution to another extreme which we call “jump reattribution” [15].

Psychiatry-oriented models for functional GI symptoms tend to make physicians pay more attention to antidepressants and less to psychological intervention. The psychosocial backgrounds of patients are complicated and various, but there is one thing they have in common, which is an irrational understanding or interpretation of the symptoms by themselves. It is unimaginable for a patient with GI symptoms to first see a psychologist or even a psychiatrist. Hence, in order to solve any psychological problems of patients with FGIDs, we should first of all solve the GI-related psychological problems, that is, specific recognition of a link between GI diseases and symptoms. After this, it will be possible to extend any psychological intervention to include more general aspects. Based on the above views, a symptom-centered, stepped reattribution model has gradually developed and achieved good clinical outcomes [15^, 28^, 29] with reference to classic cognitive behavioral therapy (CBT) and the core content of the reattribution model proposed by Fink et al. [30]. The specified steps and implications are presented in Table 2.

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It is not so hard to see that the model is also suitable for the management of medically unexplained symptoms in other specialties apart from GE. Second-step reattribution seems to be very effective in that patients’ general well-being recovers further when it is combined with Buddhism or a more operational therapy implementing Buddhist thought, such as the well-being therapy (WBT) developed by Fava [31], whose Chinese version (xin fu gan liao fa,) is available now [32]. CBT, WBT, and Buddhism basically share a common idea that is all about adjusting or changing people’s views or attitudes towards the world, life events, and health. CBT tends to help patients recognize and correct any negative aspects or perceptions of ill-being, while WBT and Buddhism tend to teach people to find out more about or experience the positive aspects of life or well-being perceptions. As a supplement to CBT or even independently, Buddhism and WBT are bound to find broad application in the management of FGIDs, especially in late stages of treatment; we had satisfying outcomes in several cases in our practice.

Case Report

Mr. Cai, a 35-year-old IT engineer, was a patient with complex FGIDs. In the course of seeking medical treatment, during 3 years he had visited gastroenterologists countless times and also cardiologists several times. He had been diagnosed with chronic superficial gastritis, inflammatory polyps in the gastric antrum by endoscopy with intestinal metaplasia, and mild atypical hyperplasia pathologically. Helicobacter pylori detection in his stomach had been positive one time. He had also visited various psychiatrists and had been diagnosed with anxiety disorder, depressive disorder, and somatoform disorder at different times. However, none of the treatments had worked well, and he had rejected psychotherapy and psychoactive medication from his psychiatrists.

He visited me 2 years ago. In the first interview, we discussed his various somatic symptoms without using any psychological terminology and assigned him the homework to describe his symptoms in detail and accurately with his own IT technique. He brought it back at his next visit. We discussed the homework and made a first-step symptom reattribution to disease phobia (gastric cancer and heart attack) according to the DCPR, as well as positively too his ambitious way of working. He agreed with the reattribution and accepted medical treatment with a proton pump inhibitor and a very low dose of a selective serotonin reuptake inhibitor (SSRI). Three weeks later, his symptoms had relieved significantly. He continued low-dose SSRI treatment without the proton pump inhibitor till the end of 3 months. Then the dose of the SSRI was gradually decreased, and he accepted psychotherapy consisting of 4 sessions of CBT and 4 sessions mixed with Buddhism. He discontinued medication at the end of 6 months. He came again at the end of 11 months with a self-assigned homework report. Follow-up for another year showed that he was well and kept practicing Zen (sitting meditation) following my suggestion.

Psychosomatic Rehabilitation for “Organic” GI Diseases

The comprehensive psychosomatic model has great potential for application in the rehabilitation of patients with chronic “organic” diseases in many medical specialties such as cardiology [33], pneumology, rheumatology, neurology, and endocrinology. Sonino and Fava [34^, 35] defined rehabilitation as the sum of activities required to ensure that patients have the best physical, mental, and social conditions for progressing towards an optimal state of health.

Even though the results of their biomedical evaluation may show good recovery, the quality of life (e.g., lack of well-being, demoralization, and difficulties fulfilling personal and family responsibilities) of many patients may still by impaired for reasons that cannot be explained with the original internal disease [34^, 35]. The same applies to GE. For example, some patients with IBD tend to have residual symptoms or “psychiatric morbidity” (particularly depression and anxiety) even when their organic lesions are reduced and the inflammation is inactive and under satisfying control with standard biological treatment [8]. There is a need for filling the gap between “hard” pathological data and “soft” psychosocial aspects [35]. Hence, it is necessary to introduce the concept of psychosomatic rehabilitation in GE.

In a preliminary clinical investigation conducted recently [8], a psychosomatic practice model improved coexisting functional symptoms that could not be explained by ulcerative colitis itself. In that study, 60 patients with biologically qualified ulcerative colitis were randomly divided into a conventional intervention group and a comprehensive psychosomatic intervention group, with 30 patients in each group. Patients’ self-reported efficacy in terms of GI symptoms and global well-being, as well as results from the Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS), were compared at the beginning and at the end 4 weeks after treatment to evaluate the outcome. The results showed that the residual symptoms had relieved, global well-being was improved, and the SAS and SDS scores were reduced in the comprehensive psychosomatic intervention group to a significant degree. Comprehensive psychosomatic care may potentially improve the rehabilitation of patients with IBD.

The scope of rehabilitation is very wide and heterogeneous. Generally, in practice, much more effort has been exerted on the “hard” data of pathology than on the “soft” psychosocial aspects. The soft part of rehabilitation should include patients’ disease-specific concerns and general psychological aspects. For any particular disease, psychosomatic intervention should focus on the particular psychological aspects first. For instance, in patients with IBD-IBS, specific psychological concerns include an irrational cognition of their gut, irrational food avoidance, recurrence and complications of IBD, and colon cancer phobia. Physicians should help patients to expose any irrational cognition of their gut and instruct them to do some cognition-related dietary training to overcome food avoidance and cultivate gut-specific perceptions of well-being. Then, the psychological intervention should be extended to general aspects of social functioning and daily life events. Thus, a comprehensive psychosomatic evaluation is needed for rehabilitation with particular diseases before any specified intervention. For IBD patients, for example, an evaluation should include at least four dimensions: (1) mucosal healing assessed by endoscopy; (2) the activity level of inflammation assessed with a scale such as the ulcerative colitis activity index [36]; (3) symptoms; and (4) psychological well-being assessed with the DCPR [13].