25 - Psychological treatments in liaison psychiatry

Summary

The use of psychological treatments for patients presenting with physical health problems has a long history. A Persian physician used exploratory psychotherapy over 1200 years ago to successfully treat a patient's psoriasis, by linking it to conflict with his father (Shafi ' Shafi, 1979). Alexander (1950) was one of the great pioneers of psychosomatic medicine of the 20^th century. Although he recognised that the aetiology of disease was multifactorial, he speculated that in a number of diseases (including hypertension, rheumatoid arthritis, peptic ulcer and asthma) psychological factors might be of aetiological importance. The notion that psychological factors may be relevant to either the genesis or the progression of physical illness persists. We now know that there is a strong association between most chronic diseases and psychiatric disorder, especially depression (Katon ' Sullivan, 1990). Increasing awareness of this has led to an upsurge in the literature assessing psychological interventions in this area.

Even though only a minority of patients with physical illnesses meet criteria for psychiatric disorder, psychologically determined consequences of physical illness are common, clinically significant and potentially treatable. Indeed, it has been argued that psychological skills are essential in the management of all physical disorders (Mayou, 2005). Psychological treatments are not only useful for patients who have psychiatric disorder in addition to physical illness but are also beneficial in patients without psychiatric disorder who have difficulties arising from problematic illness beliefs, illness behaviour or adjustment to illness. Not infrequently these distinctions overlap, such as non-epileptic attacks in a patient who has epilepsy, or breathlessness secondary to panic attacks in a patient with asthma.

Psychological therapy has been particularly neglected in older patients, who are most at risk of physical illness and often require longer periods of treatment. However, there is no evidence that they do not respond to psychological treatment and many may benefit (Evans, 2007). The focus of this chapter is on psychological treatments for patients who are physically ill and those who present with medically unexplained symptoms.