Organic Diseases and Psychosomatic Approach

*Psychosomatic Medicine*

2020]

[12] Winn AM, Edelman R, Merchasin C, Monson E, Women Survivors. Buddhist Project Sunshine Phase 2 Final Report. A 3-month Initiative to Bring Healing Light to Sexualized Violence at the Core of the Shambhala Buddhist Community [Internet]. 2018. Available from: andreamwinn.com/project\_sunshine/ Buddhist\_Project\_Sunshine\_Phase\_2\_ Final\_Report.pdf [Accessed: 01 June

[13] Dockler L, Mueller J. Introduction to the special issue on institutional and betrayal trauma. Journal of Aggression, Maltreatment and Trauma. 2017;**26, 1**: 1-2. DOI: 10.1080/10926771.2016.1263707

[14] Jung CG. Die Beziehungen zwischen dem Ich und dem Unbewußten. 2nd ed. Dt. Taschenbuch-Verlag: München; 2014

[15] Gentile K. Assembling justice: Reviving nonhuman subjectivities to examine institutional betrayal around sexual misconduct. Journal of the American Psychoanalytic Association. 2018;**66**(4):647-678. DOI:

10.1177/0003065118797138

**46**

**Chapter 3**

**Abstract**

way of thinking of people.

syndrome

**1. Introduction**

syndromes [1].

the diagnosis is made.

**49**

Psychosomatic Approach to

*and Ignacio Jáuregui-Lobera*

Fibromyalgia Syndrome: Medical,

Psychological, and Social Aspects

Management of patients who describe chronic pain all over the body, associated with a range of symptoms as sleep disturbance, overwhelming fatigue, alteration in mood, or psychological distress that worsens the quality of life, is often complex and challenging. This syndrome has been named by terms such as "neurasthenia," "fibrositis," and "fibromyalgia". At the present time, fibromyalgia is considered the most common central sensitivity syndrome, affecting over 5% of the population, being often observed in people with rheumatic conditions. While typically presenting in middle-aged women, fibromyalgia can affect both sexes at any age. The causes of fibromyalgia remain unknown. Significant research findings have focused on dysfunction of central pain processing, with defects in the ascending and descending pain pathways leading to increased pain perception. There are two methods used in the diagnosis of fibromyalgia: *criteria-based diagnosis* and *clinical diagnosis.* Although fibromyalgia defies definitively efficacious management, much evidence underlies the importance of treating the psychological factors that affect pain management process. The primary purpose of this paper is to provide a psychosomatic approach to fibromyalgia from three points of view of processing: the viewpoint of the medical profession, the position of the psychologist, and finally the

*José Vicente Martínez-Quiñones, Mar Martínez Gamarra*

**Keywords:** fibromyalgia, psychosomatic, chronic pain, central sensitivity

Under conditions of psychological dysregulation or disease, pain can lose its

As doctors, we often take care of patients who describe chronic pain all over the body, which is associated with a range of other symptoms including poor sleep, fatigue, and depression. This complex of symptoms is sometimes referred to as *functional somatic syndrome*, part of a *somatization disorder*, *idiopathic pain disorder*,

By reason of that, it is not unusual for patients to see at least four physicians before

physiological role and take on an aberrant course, resulting in chronic pain

or *psychosomatic syndrome*, dismissing the true suffering of the patients [2].

#### **Chapter 3**

## Psychosomatic Approach to Fibromyalgia Syndrome: Medical, Psychological, and Social Aspects

*José Vicente Martínez-Quiñones, Mar Martínez Gamarra and Ignacio Jáuregui-Lobera*

#### **Abstract**

Management of patients who describe chronic pain all over the body, associated with a range of symptoms as sleep disturbance, overwhelming fatigue, alteration in mood, or psychological distress that worsens the quality of life, is often complex and challenging. This syndrome has been named by terms such as "neurasthenia," "fibrositis," and "fibromyalgia". At the present time, fibromyalgia is considered the most common central sensitivity syndrome, affecting over 5% of the population, being often observed in people with rheumatic conditions. While typically presenting in middle-aged women, fibromyalgia can affect both sexes at any age. The causes of fibromyalgia remain unknown. Significant research findings have focused on dysfunction of central pain processing, with defects in the ascending and descending pain pathways leading to increased pain perception. There are two methods used in the diagnosis of fibromyalgia: *criteria-based diagnosis* and *clinical diagnosis.* Although fibromyalgia defies definitively efficacious management, much evidence underlies the importance of treating the psychological factors that affect pain management process. The primary purpose of this paper is to provide a psychosomatic approach to fibromyalgia from three points of view of processing: the viewpoint of the medical profession, the position of the psychologist, and finally the way of thinking of people.

**Keywords:** fibromyalgia, psychosomatic, chronic pain, central sensitivity syndrome

#### **1. Introduction**

Under conditions of psychological dysregulation or disease, pain can lose its physiological role and take on an aberrant course, resulting in chronic pain syndromes [1].

As doctors, we often take care of patients who describe chronic pain all over the body, which is associated with a range of other symptoms including poor sleep, fatigue, and depression. This complex of symptoms is sometimes referred to as *functional somatic syndrome*, part of a *somatization disorder*, *idiopathic pain disorder*, or *psychosomatic syndrome*, dismissing the true suffering of the patients [2]. By reason of that, it is not unusual for patients to see at least four physicians before the diagnosis is made.

At the present time, we know that fibromyalgia (FM) is a nonprogressive and nondegenerative syndrome with a spectrum of symptoms that most commonly include generalized chronic pain. It affects 0.4–8.8% of the general population worldwide, with a global mean prevalence of 2.7%, with women outnumbering men by an average of 3:1 [3].

C. The pain is not better accounted for by another chronic pain condition.

*Psychosomatic Approach to Fibromyalgia Syndrome: Medical, Psychological, and Social Aspects*

In addition to the direct physical suffering that patients experience, the biopsychosocial nature of chronic pain affects their social lives, ability to work, and psychological well-being. People with FM often reported dismissive

substantial negative impact on patients, who are already distressed [18].

attitudes from others, such as disbelief, stigmatization, lack of acceptance by their relatives, and friends, and doctors may consider them as *lazy* or *attention seeking* people, with their symptoms *all in their head* [2]. Such disdainfulness can have a

Furthermore, patients have an increased lifetime prevalence of many psychological

The primary purpose of this paper is to provide an approach to FM from three points of view of processing: the viewpoint of the medical profession, the position

CWP is obviously a distinct entity.

*DOI: http://dx.doi.org/10.5772/intechopen.91768*

of the psychologist, and finally, social aspects.

a. Diagnostic criteria of FM

c. What causes FM? Predisposing factors

i. Other central sensitivity syndromes

iii. Nonpsychiatric: rheumatology

1.The medical profession:

b. Pathogenesis

d. Comorbidities:

ii. Psychiatric

2.The position of the psychologist:

a. Psychosomatic disease?

b. Emotional dysregulation

i. Our experience

3. Social aspects. Impact at three levels:

a. Family

b. Labor

**51**

c. Health system

c. Address the psychological in FM:

ii. The main topics from a psychological point of view

disorders.

This definition seems to define a CWP as a disease or disorder. Neither FM nor

FM is defined as a central sensitization syndrome characterized by chronic extensive "centralized pain." Central sensitization, as well, is defined as the process of becoming susceptible to a given stimulus that previously had no effect or significance (i.e., pressure, light, medication, temperature) [4]. This increased central responsiveness causes hyperalgesia, allodynia, and pain across multiple spinal segments, leading to chronic widespread pain [2].

Although FM is commonly classified as "functional," because its etiology, pathogenesis, and symptoms are not completely explained, rheumatologists, pain specialists, and increasingly primary care providers are gaining confidence in making this diagnosis and initiating treatment [5].

Historically, its definition and content have changed repeatedly in the more than 100 years of its existence. Different terms have been proposed by the medical science [6–14], which summarizes the lack of understanding of this argumentative condition, which has evolved from a regional pain disorder to a multiple symptoms disorder [15] (**Table 1**).

Nowadays the ICD-11 considers FM to be a form of chronic widespread pain (CWP) [16, 17], besides it considers CWP a form of chronic primary pain (MG30.0) and is present when:

	- 1.Emotional distress due to pain is present.

2.The pain interferes with daily life activities and social participation.


#### **Table 1.** *Fibromyalgia-like conditions.*

*Psychosomatic Approach to Fibromyalgia Syndrome: Medical, Psychological, and Social Aspects DOI: http://dx.doi.org/10.5772/intechopen.91768*

C. The pain is not better accounted for by another chronic pain condition.

This definition seems to define a CWP as a disease or disorder. Neither FM nor CWP is obviously a distinct entity.

In addition to the direct physical suffering that patients experience, the biopsychosocial nature of chronic pain affects their social lives, ability to work, and psychological well-being. People with FM often reported dismissive attitudes from others, such as disbelief, stigmatization, lack of acceptance by their relatives, and friends, and doctors may consider them as *lazy* or *attention seeking* people, with their symptoms *all in their head* [2]. Such disdainfulness can have a substantial negative impact on patients, who are already distressed [18]. Furthermore, patients have an increased lifetime prevalence of many psychological disorders.

The primary purpose of this paper is to provide an approach to FM from three points of view of processing: the viewpoint of the medical profession, the position of the psychologist, and finally, social aspects.

1.The medical profession:

At the present time, we know that fibromyalgia (FM) is a nonprogressive and nondegenerative syndrome with a spectrum of symptoms that most commonly include generalized chronic pain. It affects 0.4–8.8% of the general population worldwide, with a global mean prevalence of 2.7%, with women outnumbering

FM is defined as a central sensitization syndrome characterized by chronic extensive "centralized pain." Central sensitization, as well, is defined as the process of becoming susceptible to a given stimulus that previously had no effect or significance (i.e., pressure, light, medication, temperature) [4]. This increased central responsiveness causes hyperalgesia, allodynia, and pain across multiple spinal

Although FM is commonly classified as "functional," because its etiology, pathogenesis, and symptoms are not completely explained, rheumatologists, pain specialists, and increasingly primary care providers are gaining confidence in making

Historically, its definition and content have changed repeatedly in the more than

Nowadays the ICD-11 considers FM to be a form of chronic widespread pain

A.Chronic pain (persistent or recurrent pain for longer than 3 months) is present in at least three body quadrants plus the axial skeleton (4 of 5 regions).

2.The pain interferes with daily life activities and social participation.

*Fibrositis* Inflammation of white fibrous tissue wherever situated (panniculitis, interstitial

*Burn out* Represents the total depletion of one's physical and mental resources [12]

number of painful musculoskeletal body locations or sites [13, 14]

Pathological entity in which there is a functional nervous dysfunction manifested by marked fatigability and irritability affecting various organs and functions without any demonstrable pathological tissue changes [6]. This term was abandoned in the

neuritis, myositis, bursitis, capsulitis, etc.). In this sense these terms merely indicate the position of the fibrous tissue which is implicated. Tenders point needed.

A pain variable that would identify potential FM patients. It represents a categorical designation of musculoskeletal body pain defined by the location, distribution, and

Medical condition characterized by symptom clusters that include pathological fatigue and malaise that is worse after exertion, cognitive dysfunction, immune dysfunction, unrefreshing sleep, pain, autonomic dysfunction, neuroendocrine, and

100 years of its existence. Different terms have been proposed by the medical science [6–14], which summarizes the lack of understanding of this argumentative condition, which has evolved from a regional pain disorder to a multiple symptoms

(CWP) [16, 17], besides it considers CWP a form of chronic primary pain

B. The pain is associated with at least one of the following:

1.Emotional distress due to pain is present.

Widespread aching. Fatigue [7–9]

immune symptoms [10, 11]

men by an average of 3:1 [3].

*Psychosomatic Medicine*

disorder [15] (**Table 1**).

(MG30.0) and is present when:

**Disorders Features**

1930s

*Neurasthenia Nervous exhaustion*

*Chronic fatigue syndrome Myalgic encephalomyelitis*

*Chronic widespread pain (CWP)*

*Fibromyalgia-like conditions.*

**Table 1.**

**50**

segments, leading to chronic widespread pain [2].

this diagnosis and initiating treatment [5].

	- i. Other central sensitivity syndromes
	- ii. Psychiatric
	- iii. Nonpsychiatric: rheumatology
	- a. Psychosomatic disease?
	- b. Emotional dysregulation
	- c. Address the psychological in FM:
		- i. Our experience
		- ii. The main topics from a psychological point of view
	- a. Family
	- b. Labor
	- c. Health system

#### **2. The medical profession**

#### **2.1 Diagnostic criteria of fibromyalgia**

Diagnosing FM is quite challenging because there is an absence of a univocal identified biological cause [19].

Although two methods are used in the diagnosis, criteria-based and clinical one, FM remains a controversial interpretation, with some studies suggesting that FM is overdiagnosed and other reporting that community physicians have limited knowledge of FM diagnosis and criteria:

#### *2.1.1 Criteria-based diagnosis*

FM became officially established by formal criteria in 1990 [20], after which a multiplicity of symptoms became a central component of the illness. Nowadays there is evidence in support of FM as a dimensional or continuum disorder [21, 22] which is included in the international list of diseases of the World Health Organization [17] (**Table 2**).

In 2016, the widespread pain criterion was reinstalled; thus FM diagnosis requires:


Classification criteria may help guide a diagnosis but are primarily useful for research and epidemiological studies.

#### *2.1.2 Clinical diagnosis*

It is based on the physician/patient relationship. FM, because of symptoms' intensities (pervasive fatigue, abdominal cramps, headaches, disturbed sleep, muscle spasms, stiffness, tenderness, reduced physical, social and cognitive functioning, depressed mood, anxiety, and irritability), constitutes a heterogeneous disorder in which "chronic widespread pain" is dominant [23–28]. Moreover, FM differs from the "chronic widespread pain" by its inclusion of non-pain symptoms, including severity measures of fatigue, unrefreshed sleep, cognitive problems, and somatic symptoms [29].

Quantitative sensory testing should be undertaken to determine if augmented response is present or absent, using pressure, pinprick, cold, heat, vibration, electricity, ischemia, and chemical (capsaicin, hypertonic saline) stimuli. Patients should be tested for allodynia (using cotton swab, brush, Von Frey filaments), temporal summation, conditioned pain modulation, and nociceptive flexion reflex. All common conditions, like depression or FM, are caught in the dilemma of

Given the high incidence of chronic pain, it is fundamental to understand basic processes underlying this kind of suffering: repeated stimulation of the centripetal

disease versus illness state (of health) versus trait (characteristic feature

**Criteria stablished Clarification**

*Psychosomatic Approach to Fibromyalgia Syndrome: Medical, Psychological, and Social Aspects*

CWP: Simultaneous pain in the axial skeleton, in the left and the right side of the body, and above and

Tender point positive: the subject must state that the

SSS: the sum of the severity of the three symptoms plus the extent (severity) of somatic symptoms in

"It does not require a tender point examination"

• WPI ≥ 7/19 and SS score ≥ 5/12 *or* WPI between

• Symptoms have been present at a similar level for

• The patient does not have a disorder that would otherwise sufficiently explain the pain WPI: In how many areas has the patient had pain?

For the each of these three symptoms, indicate the level of severity over the past week using the

0 = no problem; 1 = slight or mild problems; generally mild or intermittent; 2 = moderate; considerable problems; often present and/or at a moderate level; 3 = severe: pervasive, continuous, life-disturbing

The SS score is the sum of the severity of the three symptoms plus the sum of the number of the following symptoms occurring during the previous 6 months: headaches, pain or cramps in lower abdomen, and depression (0–3). The final score is

below the waist, for at least 3 months "Digital palpation" should be performed with an

WPI: areas with pain over the last week

3–6/19 and SS score ≥ 9/12.

Score will be between 0 and 19

at least 3 months

approximate force of 4 Kg

palpation was painful

general

SS score:

problems

between 0 and 12

following scale:

Chronic widespread pain

Pain in 11 of 18 *tender point* sites on "digital palpation"

Widespread pain index

Symptom severity scale

Widespread pain index

Lt. Upper *Leg* Rt. Lower

Symptom severity (SS)

*Waking unrefreshed Cognitive symptom*

*Fibromyalgia criteria according to the American College of Rheumatology.*

*Waking unrefreshed Cognitive symptom*

Left *Shoulder* Right Lt. Upper *Arm* Rt. Lower

(CWP) +

*DOI: http://dx.doi.org/10.5772/intechopen.91768*

(WPI) +

(SSS): *Fatigue*

(WPI):

Lt. *Hip* Rt.

Lt. *Jaw* Rt. *Chest Abdomen Upper Back Lower*

*Neck* +

score: *Fatigue*

distinguishing a particular human being).

**2.2 Pathogenesis**

**53**

**Table 2.**

**American College of Rheumatology**

Wolfe et al. [20]

Wolfe et al. [21]

Wolfe et al. [22]

**(ACR)**

1990

2010

2011

Common manifestations in FM are *hyperalgesia* (excessive sensitivity to a normally painful stimulus, such as pressure), *allodynia* (painful sensation to a normally non-painful stimulus, e.g., touch and massage), expansion of the receptive field (pain beyond the area of peripheral nerve supply), prolonged electrophysiological discharge, an after-stimulus unpleasant quality of the pain (e.g., burning, throbbing, tingling, or numbness), and referred pain across multiple spinal segments, leading to chronic widespread pain [20]. The number of pain sites is strongly correlated with somatic and psychological symptom burden in the general population. An example of making a record of the pain sites is by the "Michigan body map" [30] (**Figure 1**)*.*


*Psychosomatic Approach to Fibromyalgia Syndrome: Medical, Psychological, and Social Aspects DOI: http://dx.doi.org/10.5772/intechopen.91768*

#### **Table 2.**

**2. The medical profession**

*Psychosomatic Medicine*

identified biological cause [19].

*2.1.1 Criteria-based diagnosis*

Organization [17] (**Table 2**).

requires:

**2.1 Diagnostic criteria of fibromyalgia**

knowledge of FM diagnosis and criteria:

WPI of 4–6 and an SSS score ≥9

research and epidemiological studies.

*2.1.2 Clinical diagnosis*

symptoms [29].

map" [30] (**Figure 1**)*.*

**52**

• Symptoms of at least 3 months of duration

Diagnosing FM is quite challenging because there is an absence of a univocal

Although two methods are used in the diagnosis, criteria-based and clinical one, FM remains a controversial interpretation, with some studies suggesting that FM is overdiagnosed and other reporting that community physicians have limited

FM became officially established by formal criteria in 1990 [20], after which a multiplicity of symptoms became a central component of the illness. Nowadays there is evidence in support of FM as a dimensional or continuum disorder [21, 22]

which is included in the international list of diseases of the World Health

• Presence of widespread pain (pain in four or five body regions)

In 2016, the widespread pain criterion was reinstalled; thus FM diagnosis

• Widespread pain index (WPI) ≥ 7 and symptom severity scale (SSS) ≥ 5 or a

Classification criteria may help guide a diagnosis but are primarily useful for

It is based on the physician/patient relationship. FM, because of symptoms' intensities (pervasive fatigue, abdominal cramps, headaches, disturbed sleep, muscle spasms, stiffness, tenderness, reduced physical, social and cognitive functioning, depressed mood, anxiety, and irritability), constitutes a heterogeneous disorder in which "chronic widespread pain" is dominant [23–28]. Moreover, FM differs from the "chronic widespread pain" by its inclusion of non-pain symptoms, including severity measures of fatigue, unrefreshed sleep, cognitive problems, and somatic

Common manifestations in FM are *hyperalgesia* (excessive sensitivity to a normally painful stimulus, such as pressure), *allodynia* (painful sensation to a normally non-painful stimulus, e.g., touch and massage), expansion of the receptive field (pain beyond the area of peripheral nerve supply), prolonged electrophysiological discharge, an after-stimulus unpleasant quality of the pain (e.g., burning, throbbing, tingling, or numbness), and referred pain across multiple spinal segments, leading to chronic widespread pain [20]. The number of pain sites is strongly correlated with somatic and psychological symptom burden in the general population. An example of making a record of the pain sites is by the "Michigan body

*Fibromyalgia criteria according to the American College of Rheumatology.*

Quantitative sensory testing should be undertaken to determine if augmented response is present or absent, using pressure, pinprick, cold, heat, vibration, electricity, ischemia, and chemical (capsaicin, hypertonic saline) stimuli. Patients should be tested for allodynia (using cotton swab, brush, Von Frey filaments), temporal summation, conditioned pain modulation, and nociceptive flexion reflex.

All common conditions, like depression or FM, are caught in the dilemma of disease versus illness state (of health) versus trait (characteristic feature distinguishing a particular human being).

#### **2.2 Pathogenesis**

Given the high incidence of chronic pain, it is fundamental to understand basic processes underlying this kind of suffering: repeated stimulation of the centripetal

**Figure 1.**

*The Michigan Body Map. ©2015 Regents of the University of Michigan (https://medicine.umich.edu/sites/defa ult/files/content/downloads/MBM%202016.pdf ).*

nerves overtime causes changes to the way the pain signals are processed, leading to a pathophysiological state where the nervous system is sensitized and the perception of pain becomes heighten.

Both the peripheral and the central nervous system can become sensitize to pain signals in response to injury or inflammation nociceptors. The periphery can become more sensitive to painful stimuli, a process called "peripheral sensitization." These sensitize nociceptors and then send additional pain signals to the CNS which can lead to the overstimulation of the CNS.

neuroendocrine processes and vascular permeability. These processes encompass the phenomenon of neuro-inflammation, in which stress and other psychological

*neurotransmitters: Substance P (SP), nerve growth factor (NGF), calcitonin gene-related peptide, vasoactive intestinal peptide, glutamate (GLUT), aspartate, and brain-derived neurotrophic factor. These chemicals cause a barrage of impulses at the synapse that now hyperexcite the postsynaptic receptors: neurokinin1 (NK1), N-methyl-D-aspartate (NMDA), metabotropic glutamate, tyrosine kinase B (TrK-B), and protein kinase gamma. Activation of these receptors results in a remarkable physiologic change in the postsynaptic nerve cells, including membrane changes, intracellular influx of calcium, protein kinase activation, and expression of protein c-fos (marker for neuronal activity following peripheral stimulation). These changes cause an intensification of hyperexcitability of the second-order neurons, giving rise to hypersensitivity to various peripheral stimuli. "*Central sensitivity*": perturbation in the central processing of sensory information that*

*Psychosomatic Approach to Fibromyalgia Syndrome: Medical, Psychological, and Social Aspects*

*DOI: http://dx.doi.org/10.5772/intechopen.91768*

Abnormal sensory and pain processing is the key factor in the pathophysiology

There is evidence for excessive pain-related neuronal activity at multiple levels of the central nervous system, structural and functional changes in the brain by imaging studies, and impaired function of normal descending inhibitory

Several factors, such as genetic predisposition or alteration in the expression of several genes (epigenetic mechanisms), deficiencies in neurotransmitter levels, biochemical changes in the body, endocrine dysfunction, certain types of infections (e.g., Epstein-Barr virus, Lyme disease, Q fever, viral hepatitis), mood states, sociocultural environment (early-life stress or adversity), psychological trauma, and past experiences in general (e.g., childhood or sexual abuse), have been proposed as explanatory mechanisms of patients'subjective experience of central

factors induce these neural responses to amplify the pain perception.

*Physiological pathways of pain. The activated C fibers express, at their nerve terminals, several*

sensitivity and subcortical nociceptive transmission [28, 36–43].

**2.3 What causes fibromyalgia? Predisposing factors**

*amplifies the response of the central nervous system to a peripheral input.*

mechanisms [29].

**55**

**Figure 2.**

of FM [35], and in addition, sensitization heightens the perception of pain.

"Central sensitization" is a proposed physiological phenomenon in which dysregulation in the central nervous system (imbalance between pain transmission and pain inhibition) causes neuronal dysregulation and hyperexcitability, resulting in hypersensitivity to both noxious and non-noxious stimuli and the perpetuation of pain [31] (**Figure 2**).

Central sensitization has been proposed as the root etiology for "central sensitivity syndromes" (CSS), which refer to a group of medically indistinct disorders for which no organic cause can be found. A number of authors state that the CSS symptoms are not medically explicable and are psychiatric, psychological, or psychosocial in nature [32–34]. Therefore, people with FM suffer from abnormalities in the central pain processing, what implies a lower threshold for interpreting sensory information as noxious, in addition to an increased excitation's mechanism or reduced inhibition's ones. This plays an important role in the development and maintenance of chronic pain.

On the other hand, some aberrations of the peripheral nervous system, as an antidromal axonal reflex of C fibers in response to a stimulus, may initialize

*Psychosomatic Approach to Fibromyalgia Syndrome: Medical, Psychological, and Social Aspects DOI: http://dx.doi.org/10.5772/intechopen.91768*

#### **Figure 2.**

nerves overtime causes changes to the way the pain signals are processed, leading to a pathophysiological state where the nervous system is sensitized and the

*The Michigan Body Map. ©2015 Regents of the University of Michigan (https://medicine.umich.edu/sites/defa*

signals in response to injury or inflammation nociceptors. The periphery can become more sensitive to painful stimuli, a process called "peripheral sensitization." These sensitize nociceptors and then send additional pain signals to the CNS which

"Central sensitization" is a proposed physiological phenomenon in which dysregulation in the central nervous system (imbalance between pain transmission and pain inhibition) causes neuronal dysregulation and hyperexcitability, resulting in hypersensitivity to both noxious and non-noxious stimuli and the perpetuation

Central sensitization has been proposed as the root etiology for "central sensitivity syndromes" (CSS), which refer to a group of medically indistinct disorders for which no organic cause can be found. A number of authors state that the CSS symptoms are not medically explicable and are psychiatric, psychological, or psychosocial in nature [32–34]. Therefore, people with FM suffer from abnormalities in the central pain processing, what implies a lower threshold for interpreting sensory information as noxious, in addition to an increased excitation's mechanism or reduced inhibition's ones. This plays an important role in the development and

On the other hand, some aberrations of the peripheral nervous system, as an antidromal axonal reflex of C fibers in response to a stimulus, may initialize

Both the peripheral and the central nervous system can become sensitize to pain

perception of pain becomes heighten.

*ult/files/content/downloads/MBM%202016.pdf ).*

of pain [31] (**Figure 2**).

**Figure 1.**

*Psychosomatic Medicine*

maintenance of chronic pain.

**54**

can lead to the overstimulation of the CNS.

*Physiological pathways of pain. The activated C fibers express, at their nerve terminals, several neurotransmitters: Substance P (SP), nerve growth factor (NGF), calcitonin gene-related peptide, vasoactive intestinal peptide, glutamate (GLUT), aspartate, and brain-derived neurotrophic factor. These chemicals cause a barrage of impulses at the synapse that now hyperexcite the postsynaptic receptors: neurokinin1 (NK1), N-methyl-D-aspartate (NMDA), metabotropic glutamate, tyrosine kinase B (TrK-B), and protein kinase gamma. Activation of these receptors results in a remarkable physiologic change in the postsynaptic nerve cells, including membrane changes, intracellular influx of calcium, protein kinase activation, and expression of protein c-fos (marker for neuronal activity following peripheral stimulation). These changes cause an intensification of hyperexcitability of the second-order neurons, giving rise to hypersensitivity to various peripheral stimuli. "*Central sensitivity*": perturbation in the central processing of sensory information that amplifies the response of the central nervous system to a peripheral input.*

neuroendocrine processes and vascular permeability. These processes encompass the phenomenon of neuro-inflammation, in which stress and other psychological factors induce these neural responses to amplify the pain perception.

Abnormal sensory and pain processing is the key factor in the pathophysiology of FM [35], and in addition, sensitization heightens the perception of pain.

#### **2.3 What causes fibromyalgia? Predisposing factors**

There is evidence for excessive pain-related neuronal activity at multiple levels of the central nervous system, structural and functional changes in the brain by imaging studies, and impaired function of normal descending inhibitory mechanisms [29].

Several factors, such as genetic predisposition or alteration in the expression of several genes (epigenetic mechanisms), deficiencies in neurotransmitter levels, biochemical changes in the body, endocrine dysfunction, certain types of infections (e.g., Epstein-Barr virus, Lyme disease, Q fever, viral hepatitis), mood states, sociocultural environment (early-life stress or adversity), psychological trauma, and past experiences in general (e.g., childhood or sexual abuse), have been proposed as explanatory mechanisms of patients'subjective experience of central sensitivity and subcortical nociceptive transmission [28, 36–43].

Genes associated with increased or decreased frequency of chronic pain states or pain sensitivity regulate the breakdown or binding of pain sensitivity-modulating neurotransmitters and other inflammatory pathways. Candidate genes implicated in FM include those controlling serotonin mechanisms, dopamine receptors, as well as metabolism of catecholamines [44, 45].

*2.4.3 Nonpsychiatric: rheumatology*

*DOI: http://dx.doi.org/10.5772/intechopen.91768*

and spondyloarthritis

**3.1 Psychosomatic disease**

abuse, etc.

• Muscle disorders and myalgias

**3. The position of the psychologist**

following [52]:

pain

repercussions:

meanings.

**57**

• *The pain takes hold of me*

• *I lost something*

It is said that non-arthritic rheumatism frequently covers anxiety states. The musculoskeletal pain or fatigue associated with other disorders may mimic those of FM and vice versa. Additionally, there are many similar disorders, which are not exclusive of FM, and will overlap concomitantly. The broad categories are the

*Psychosomatic Approach to Fibromyalgia Syndrome: Medical, Psychological, and Social Aspects*

• Inflammatory and autoimmune disorders, including rheumatoid arthritis, systemic lupus erythematosus, Sjögren's syndrome, polymyalgia rheumatica,

• Myofascial pain syndrome, temporomandibular joint dysfunction, lower back

a. Physical (inactivity, disability) that leads the person to a sick and invalid role

b. Psychological, resulting in emotional disturbances, vulnerability to substance

c. Social, such as tendencies towards isolation, interpersonal conflicts, etc.

sive demand for assistance, conflicts with professionals, etc.

Sometimes pain becomes the center of life for the patients, leading to a succes-

Regarding the psychological point of view, pain has been approached from the theories of traits, psychodynamic thesis, behaviorism, neuropsychology, etc., since the cognitive perspective is one of the most relevant today, specifically the study of beliefs and internal language of the patients. Along with this, the study of the different styles in the locus of control is relevant and, from the constructivist perspective, the study of the meanings and the analysis of the narrations of pain by the patients. The study of personality traits and their link with pain would be the most basic psychological approach. The study of coping styles would be in an intermediate place. Finally, the most elaborate approach would be the study of

It is interesting to make it clear that among the very different styles of coping with pain (avoidance, ignoring, reinterpreting, giving self-instructions, etc.), the most negative, the one that makes the pain worse, is the catastrophic style. In the well-known constructivist perspective, authors such as Walker, Holloway, and Sofaer [53] studied five sequential themes in the experience of pain:

FM, as a paradigm of psychosomatic disorders, would have different

A recent review confirmed the key role of neurobiological substrates, including the hypothalamic-pituitary-adrenal (HPA) axis, monoaminergic, opioidergic, endocannabinoid, and immune systems, as well as some epigenetic mechanisms, in the association of early-life psychological stress and the risk of chronic pain in later life [40]. Early psychological trauma can alter the HPA axis response, which may result in the dysfunction of peripheral and spinal dorsal horn neurons, excitatory amino acids, and central neuropeptides that can lead to abnormal nociceptive input to the brain when there is no actual painful stimulus, resulting in a central sensitization syndrome [46, 47]. Similarly, many people with FM exposed to early abuse have anxiety, depression, and post-traumatic stress disorder [2].

Patients with FM appear to have specific gut microbiome alterations that differ from their healthy peers. Recently Clos-García et al. have found an alteration in glutamate metabolism (possible molecular biomarker) connecting the gut microbiome with the brain through the enteric nervous system. This alteration has been associated with psychiatric and gastrointestinal disorders [48].

Finally, there is no scientific support for the idea that physical trauma (e.g., motor vehicle accidents) causes FM [49].

#### **2.4 Comorbidities**

#### *2.4.1 Other central sensitivity syndromes*

Pain, fatigue and other distressing sensations, occurring in the absence of clinically obvious pathology are common health problems in medical practice. Such experiences are never uniform, yet symptoms often present together in stereotypically recognizable ways. Several criteria were suggested for classification of a disease as a member of the CSS group: (a) the presence of CS; (b) the absence of an underlying disease (primary conditions), and (c) mutual associations between the disorders.

Recently, Yunus proposed a number of ailments included in the list of CSS family: irritable bowel syndrome, primary (dysfunctional) dyspepsia, tension-type headache, migraine, myofascial pain syndrome, myofascial temporomandibular disorder, primary chronic neck pain, primary low back pain, restless legs syndrome, periodic limb movement disorder, and endometriosis, among others [42].

Because of the mutual associations between the disorders, the differential diagnosis of FM is difficult.

#### *2.4.2 Psychiatric*

Patients relate too many symptoms, and the symptoms appear too severe and too unusual, and the patients too healthy compared with patients with other pain disorders [15].

A recent clinical review summarized that 62% of FM patients showed major depressive disorder, 11% bipolar disorder, 29% panic disorder, and 29% social phobia [50].

Mental disorders, especially mood disorders, have been associated with a negative impact on pain, fatigue, sleep, physical functioning, and quality of life in FM [51].

*Psychosomatic Approach to Fibromyalgia Syndrome: Medical, Psychological, and Social Aspects DOI: http://dx.doi.org/10.5772/intechopen.91768*

#### *2.4.3 Nonpsychiatric: rheumatology*

Genes associated with increased or decreased frequency of chronic pain states or pain sensitivity regulate the breakdown or binding of pain sensitivity-modulating neurotransmitters and other inflammatory pathways. Candidate genes implicated in FM include those controlling serotonin mechanisms, dopamine receptors, as well

A recent review confirmed the key role of neurobiological substrates, including

Patients with FM appear to have specific gut microbiome alterations that differ from their healthy peers. Recently Clos-García et al. have found an alteration in glutamate metabolism (possible molecular biomarker) connecting the gut

microbiome with the brain through the enteric nervous system. This alteration has

Finally, there is no scientific support for the idea that physical trauma (e.g.,

Pain, fatigue and other distressing sensations, occurring in the absence of clinically obvious pathology are common health problems in medical practice. Such experiences are never uniform, yet symptoms often present together in stereotypically recognizable ways. Several criteria were suggested for classification of a disease as a member of the CSS group: (a) the presence of CS; (b) the absence of an underlying disease (primary conditions), and (c) mutual associations between the

Recently, Yunus proposed a number of ailments included in the list of CSS family: irritable bowel syndrome, primary (dysfunctional) dyspepsia, tension-type headache, migraine, myofascial pain syndrome, myofascial temporomandibular disorder, primary chronic neck pain, primary low back pain, restless legs syndrome,

Patients relate too many symptoms, and the symptoms appear too severe and too unusual, and the patients too healthy compared with patients with other pain

A recent clinical review summarized that 62% of FM patients showed major depressive disorder, 11% bipolar disorder, 29% panic disorder, and 29% social

Mental disorders, especially mood disorders, have been associated with a negative impact on pain, fatigue, sleep, physical functioning, and quality of life

periodic limb movement disorder, and endometriosis, among others [42]. Because of the mutual associations between the disorders, the differential

the hypothalamic-pituitary-adrenal (HPA) axis, monoaminergic, opioidergic, endocannabinoid, and immune systems, as well as some epigenetic mechanisms, in the association of early-life psychological stress and the risk of chronic pain in later life [40]. Early psychological trauma can alter the HPA axis response, which may result in the dysfunction of peripheral and spinal dorsal horn neurons, excitatory amino acids, and central neuropeptides that can lead to abnormal nociceptive input to the brain when there is no actual painful stimulus, resulting in a central sensitization syndrome [46, 47]. Similarly, many people with FM exposed to early abuse

have anxiety, depression, and post-traumatic stress disorder [2].

been associated with psychiatric and gastrointestinal disorders [48].

as metabolism of catecholamines [44, 45].

*Psychosomatic Medicine*

motor vehicle accidents) causes FM [49].

*2.4.1 Other central sensitivity syndromes*

**2.4 Comorbidities**

disorders.

diagnosis of FM is difficult.

*2.4.2 Psychiatric*

disorders [15].

phobia [50].

in FM [51].

**56**

It is said that non-arthritic rheumatism frequently covers anxiety states. The musculoskeletal pain or fatigue associated with other disorders may mimic those of FM and vice versa. Additionally, there are many similar disorders, which are not exclusive of FM, and will overlap concomitantly. The broad categories are the following [52]:


#### **3. The position of the psychologist**

#### **3.1 Psychosomatic disease**

FM, as a paradigm of psychosomatic disorders, would have different repercussions:


Sometimes pain becomes the center of life for the patients, leading to a successive demand for assistance, conflicts with professionals, etc.

Regarding the psychological point of view, pain has been approached from the theories of traits, psychodynamic thesis, behaviorism, neuropsychology, etc., since the cognitive perspective is one of the most relevant today, specifically the study of beliefs and internal language of the patients. Along with this, the study of the different styles in the locus of control is relevant and, from the constructivist perspective, the study of the meanings and the analysis of the narrations of pain by the patients. The study of personality traits and their link with pain would be the most basic psychological approach. The study of coping styles would be in an intermediate place. Finally, the most elaborate approach would be the study of meanings.

It is interesting to make it clear that among the very different styles of coping with pain (avoidance, ignoring, reinterpreting, giving self-instructions, etc.), the most negative, the one that makes the pain worse, is the catastrophic style.

In the well-known constructivist perspective, authors such as Walker, Holloway, and Sofaer [53] studied five sequential themes in the experience of pain:


#### **3.2 Emotional dysregulation**

In the psychosomatic field, stress has been a very studied element with respect to FM. When scales or questionnaires are applied, the stress scores in FM patients are higher than in the control groups. In addition, patients who score higher also show several psychological disorders. It has been postulated that chronic stress (but not acute stress) would contribute to the FM symptoms. It has also been noticed that specific situations of intense stress correlate with post-traumatic stress disorder and FM. Finally, among the patients with FM, a higher prevalence of experiences of victimization (abuse and sexual abuse), throughout the life, is detected. The intensity of the traumatic event correlates, in these cases, with pain and sleep disturbances.

meeting the expectations of others; (c) when the support person is too demanding; and (d) when there is a sort of contagion of the stress from some

Beyond works with quantitative methodology, we will focus this section on qualitative research. This way of approaching knowledge is interpretive. It would be the interpretative study of a particular problem in which the researcher is responsible for the production of meaning. Many times, we reach statistically significant results that are absolutely useless, that do not discover anything, and that do not tell us anything that we did not know from our conversations with patients, and that, simply, we did not care to measure in order to know. In a different way, qualitative methods study intersubjective meanings located and constructed rather than supposed objective facts. Observation and interview would be prioritized over the experiment and the standardized questionnaires. In the understanding of the meanings, one works with the narrative, being storytelling a good tool for it. The laws of physical objects imply that there is no history, which is something impossible for the person. Faced with paradigmatic, objectivist thinking, without a position on itself, narrative thinking poses positions depending on the context. The data is not the central element, but where the data comes from, the person is the starting point, the private representation of the person about the world or its disorder, the way the person lives reality. The subject is therefore interesting: how the person builds the own context and makes history. The narrative is the element to reach that meaning sought. It is a story, a story ordered in some way. The narratives are unique, individual, unrepeatable, and have an author. They provide, finally, a

*Psychosomatic Approach to Fibromyalgia Syndrome: Medical, Psychological, and Social Aspects*

In order to research the experience of pain and its different repercussions in women diagnosed with FM, we performed individual in-depth interviews in a total of 15 patients. It is a semi-structured interview with some guide points but giving the patients the opportunity of a broad expression of their experiences. This way we tried to know the ideas that patients had about the disease but, above all, their experiences. The interviews lasted 50–60 min, were recorded in audio, and subsequently, transcribed with the collaboration of two psychologists. After the transcription, an analysis of the interviews was developed. For this purpose, in the clinical field, the methodology proposed by Weber for the analysis of content has been used [56]. It involves the following stages: (a) identifying common themes in the responses of patients and classifying them semantically, by their meaning; (b) grouping the themes of common meaning into categories; and (c) analyzing the frequency of each of the topics by watching its presence depending on the number

Our patients had a mean age of 45 years (ranged 36–59), all of them were women and married. Regarding their training level, 46.46% had primary studies (7 out of 15), and the rest were divided between degree or diploma (26.66%) and professional training or baccalaureate (26.66%). Besides, 40% were housewives (6 out of 15), and the rest worked in extra domestic tasks (26.66% as administrative assistants, 13.33% as operators, one of them as a secondary school teacher, another

**3.3 Address the psychological factors in fibromyalgia**

members to others [55].

*DOI: http://dx.doi.org/10.5772/intechopen.91768*

meaning.

of patients.

**59**

**3.5 Our sample**

**3.4 Our experience**

Linked to this, it is worth noting the issue of social support, which is an issue usually over-mentioned by FM patients. Social support has three main functions:


The tendency to consider the first function as the most important is not correct. The key would be to give support based on the type of need that arises. Giving emotional support when the problem is strictly material, for example, may be tender, but it will not be effective. It must be noted that social support would lead to stress. Social relations imply obligations, and in turn, tensions can be derived from them. In short, stress can emerge. In fact, Helgeson [54], among others, points out that negative social interactions predict health- and well-being-related problems more than the positive ones do.

The differences between men and women in social support have not been studied much, although it is a simple fact that men and women differ in the way they participate in social relations. In this regard, it is necessary to mention something about gender roles. The traditional masculine role is associated with activity, the search for independence, competitiveness, objectives, assertiveness, selfconfidence, etc., and within this role, it may be more difficult to seek and achieve social support. The role of women has been associated with expressiveness, emotions, intimacy, more ability to recognize difficulties (and with it to ask for help), cooperation, empathy, etc., thus giving and receiving social support seem to be easier tasks.

The association between social support, stress, and health has been studied without conclusive results due to serious methodological errors. Perhaps it would point out that the negative part of the social relations that we have already indicated is more relevant in the case of women. Why is it? Women tend to be a source of support more frequently and are more involved in socio-family networks. Belle already pointed out how support networks can create psychological distress: (a) for a lack of respect or disapproval of others; (b) for revealing confidences or not

meeting the expectations of others; (c) when the support person is too demanding; and (d) when there is a sort of contagion of the stress from some members to others [55].

#### **3.3 Address the psychological factors in fibromyalgia**

Beyond works with quantitative methodology, we will focus this section on qualitative research. This way of approaching knowledge is interpretive. It would be the interpretative study of a particular problem in which the researcher is responsible for the production of meaning. Many times, we reach statistically significant results that are absolutely useless, that do not discover anything, and that do not tell us anything that we did not know from our conversations with patients, and that, simply, we did not care to measure in order to know. In a different way, qualitative methods study intersubjective meanings located and constructed rather than supposed objective facts. Observation and interview would be prioritized over the experiment and the standardized questionnaires. In the understanding of the meanings, one works with the narrative, being storytelling a good tool for it. The laws of physical objects imply that there is no history, which is something impossible for the person. Faced with paradigmatic, objectivist thinking, without a position on itself, narrative thinking poses positions depending on the context. The data is not the central element, but where the data comes from, the person is the starting point, the private representation of the person about the world or its disorder, the way the person lives reality. The subject is therefore interesting: how the person builds the own context and makes history. The narrative is the element to reach that meaning sought. It is a story, a story ordered in some way. The narratives are unique, individual, unrepeatable, and have an author. They provide, finally, a meaning.

#### **3.4 Our experience**

• *I feel lost in the system*

*Psychosomatic Medicine*

**3.2 Emotional dysregulation**

bances.

function.

more than the positive ones do.

easier tasks.

**58**

• *They do not understand me*

• *My situation is unacceptable, inexplicable, speechless*

c. Informative: advice, guide, education, etc.

In the psychosomatic field, stress has been a very studied element with respect to FM. When scales or questionnaires are applied, the stress scores in FM patients are higher than in the control groups. In addition, patients who score higher also show several psychological disorders. It has been postulated that chronic stress (but not acute stress) would contribute to the FM symptoms. It has also been noticed that specific situations of intense stress correlate with post-traumatic stress disorder and FM. Finally, among the patients with FM, a higher prevalence of experiences of victimization (abuse and sexual abuse), throughout the life, is detected. The intensity of the traumatic event correlates, in these cases, with pain and sleep distur-

Linked to this, it is worth noting the issue of social support, which is an issue usually over-mentioned by FM patients. Social support has three main functions:

a. Affective-emotional: intimacy, attachment, care, concern for the other, etc.

b. Material: provision of material assistance, assistance, etc., is an instrumental

The tendency to consider the first function as the most important is not correct.

The differences between men and women in social support have not been studied much, although it is a simple fact that men and women differ in the way they participate in social relations. In this regard, it is necessary to mention something about gender roles. The traditional masculine role is associated with activity, the search for independence, competitiveness, objectives, assertiveness, self-

confidence, etc., and within this role, it may be more difficult to seek and achieve social support. The role of women has been associated with expressiveness, emotions, intimacy, more ability to recognize difficulties (and with it to ask for help), cooperation, empathy, etc., thus giving and receiving social support seem to be

The association between social support, stress, and health has been studied without conclusive results due to serious methodological errors. Perhaps it would point out that the negative part of the social relations that we have already indicated is more relevant in the case of women. Why is it? Women tend to be a source of support more frequently and are more involved in socio-family networks. Belle already pointed out how support networks can create psychological distress: (a) for a lack of respect or disapproval of others; (b) for revealing confidences or not

The key would be to give support based on the type of need that arises. Giving emotional support when the problem is strictly material, for example, may be tender, but it will not be effective. It must be noted that social support would lead to stress. Social relations imply obligations, and in turn, tensions can be derived from them. In short, stress can emerge. In fact, Helgeson [54], among others, points out that negative social interactions predict health- and well-being-related problems

In order to research the experience of pain and its different repercussions in women diagnosed with FM, we performed individual in-depth interviews in a total of 15 patients. It is a semi-structured interview with some guide points but giving the patients the opportunity of a broad expression of their experiences. This way we tried to know the ideas that patients had about the disease but, above all, their experiences. The interviews lasted 50–60 min, were recorded in audio, and subsequently, transcribed with the collaboration of two psychologists. After the transcription, an analysis of the interviews was developed. For this purpose, in the clinical field, the methodology proposed by Weber for the analysis of content has been used [56]. It involves the following stages: (a) identifying common themes in the responses of patients and classifying them semantically, by their meaning; (b) grouping the themes of common meaning into categories; and (c) analyzing the frequency of each of the topics by watching its presence depending on the number of patients.

#### **3.5 Our sample**

Our patients had a mean age of 45 years (ranged 36–59), all of them were women and married. Regarding their training level, 46.46% had primary studies (7 out of 15), and the rest were divided between degree or diploma (26.66%) and professional training or baccalaureate (26.66%). Besides, 40% were housewives (6 out of 15), and the rest worked in extra domestic tasks (26.66% as administrative assistants, 13.33% as operators, one of them as a secondary school teacher, another

as clerk, and one as head of section in the regional administration). Those who had extra domestic works said that they had in charge the housework with some help from their couples. Eight of the patients had two sons and daughters and seven of them only one son or daughter. In three cases (20%), in addition to the couple and the children, other family members lived at home and they needed care.

*doctor … he has the consultation in … and he made several medical checks, he gave*

*Psychosomatic Approach to Fibromyalgia Syndrome: Medical, Psychological, and Social Aspects*

*Patient D: …The first symptoms were that I complained about my legs and I was said I had a column deviation; when I was 25 it hurts me a lot … well with 25 … no, with 23, my neck started to hurt me a lot and doctors told me that it was a cervical problem and they gave me laser … well, I felt better, but pain remains, I always had pain and I continued with my medications … I was bearing pain, it*

FM is a disease with clear female predominance. Stress seems to be a highlighted element in its origin, especially chronic stress. Regarding social support, it is essential to mention that, in order to make it appropriate, the type of support (material, emotional, informative) must be in accordance with the needs that arise. Giving material support, when emotional support is necessary, is simply inefficient. We also said that social support can usually involve stress. Social relationships entail, for example, obligations from which tensions and stress may arise. It is also necessary to remember here that the traditional feminine role is associated with the expression

In our patients we observe how they work mostly away from home, they bear the burden of homework, and in addition, one out of five not only takes care of their husbands and children but is in charge of some other relatives. And it is striking that 40% of these patients do not perceive any help to face their pain. *They work inside, they work outside, they take care of everyone, they have pain, and they have no help*. This is the reality of some women we interviewed. Chronic stress and FM? It does not seem to fit any doubt. And regarding the health of women, there is a chilling fact: patients usually take several drugs for more than 5 years, continuously, without a diagnosis of certainty. Some patients interviewed told us that the feeling that was seizing them on their pilgrimage from doctor to doctor was that they were labeled as hysterical or a merely storyteller and that they just told them to take a pain reliever

Some husbands, ratifying such clinical impressions, exclaim on more than one occasion: "Again, with your pain!" And since the traditional female role is designed to take care and not so much to receive care from others, to understand and not so much to be understood, in many cases it is hardly expected that, when a woman feels pain, the husband will give an adequate care. The trigger elements of pain are usually psychic tensions. There is nothing to add to it, chronic stress seems evident. Along with it there are thoughts of resignation not exempt of accompanying feelings of guilt. The random attribution of pain seems to be part of that female role of taking on loads ("this pain has also touched me!"). The feeling of guiltiness is strange. Facing pain limits the woman life, which prevents her to have a satisfying sex life, which keeps her at home, and which prevents her from performing her tasks. She feels guilty: guilty for not attending to her relatives and spoiling their vacations and guilty because she does not have sexual relations as often as she would wish and for not being able to enjoy them, for not having a clean house, etc. What makes her feel so guilty if it's not the assumption of a traditional role? We

*me medications … until I went to another doctor who finally diagnosed*

From a psychological point of view, topics such as "personality and fibromyalgia," "emotional dysregulation," and "fibromyalgia as a psychosomatic disease (labeled as negative connotations)" would be the most relevant aspects to

*fibromyalgia …*

of emotions and empathy.

when they had pain.

**61**

leave the answer for your own reflection [57].

*was easy when I was 23, but now …*

*DOI: http://dx.doi.org/10.5772/intechopen.91768*

deep into the patients' thoughts, feelings, and behaviors.

#### **3.6 The main topics from a psychological point of view**

As main concerns, patients referred the following:


At this point, our focus was the personal history of pain. In this regard, it is worth noting some narratives of our patients:

*Patient A: I was attended by several orthopedists and some of them gave me medication to the pain … the problem is that when one has … does not reach 30 years old and begins with continuous muscle contractures and without having a logical cause, well … even while playing sports in those moments, well, you get annoyed, don't you? And then you go to one and the other, you even go to the neurosurgeon that the only thing he found was a minimal dehydration in … a … dorsal intervertebral disk … and … I think then it was progressively studied in case they found neck calcifications, they corrected them, they sent me to the rehabilitators …*

*Patient B: … It was mostly because of the birth of my daughter, well with … my daughter is already 10 years old, perhaps was the upbringing of the girl and also my father was diagnosed with a retinal detachment from the second eye because I had already had one and had lost the other eye … this brought me a lot of tension buildup …*

*Patient C: …When I was diagnosed with fibromyalgia I was suffering from pain for months, the pain started in the feet and hands, I had no strength in the hands, they became inflamed but I thought the housewives … I thought it was from the mop, scrub … always a blame for cleaning … I said to me "today I'm more tired of cleaning," "today for …" … always blame until my husband told me to go to the*

*Psychosomatic Approach to Fibromyalgia Syndrome: Medical, Psychological, and Social Aspects DOI: http://dx.doi.org/10.5772/intechopen.91768*

*doctor … he has the consultation in … and he made several medical checks, he gave me medications … until I went to another doctor who finally diagnosed fibromyalgia …*

*Patient D: …The first symptoms were that I complained about my legs and I was said I had a column deviation; when I was 25 it hurts me a lot … well with 25 … no, with 23, my neck started to hurt me a lot and doctors told me that it was a cervical problem and they gave me laser … well, I felt better, but pain remains, I always had pain and I continued with my medications … I was bearing pain, it was easy when I was 23, but now …*

From a psychological point of view, topics such as "personality and fibromyalgia," "emotional dysregulation," and "fibromyalgia as a psychosomatic disease (labeled as negative connotations)" would be the most relevant aspects to deep into the patients' thoughts, feelings, and behaviors.

FM is a disease with clear female predominance. Stress seems to be a highlighted element in its origin, especially chronic stress. Regarding social support, it is essential to mention that, in order to make it appropriate, the type of support (material, emotional, informative) must be in accordance with the needs that arise. Giving material support, when emotional support is necessary, is simply inefficient. We also said that social support can usually involve stress. Social relationships entail, for example, obligations from which tensions and stress may arise. It is also necessary to remember here that the traditional feminine role is associated with the expression of emotions and empathy.

In our patients we observe how they work mostly away from home, they bear the burden of homework, and in addition, one out of five not only takes care of their husbands and children but is in charge of some other relatives. And it is striking that 40% of these patients do not perceive any help to face their pain. *They work inside, they work outside, they take care of everyone, they have pain, and they have no help*. This is the reality of some women we interviewed. Chronic stress and FM? It does not seem to fit any doubt. And regarding the health of women, there is a chilling fact: patients usually take several drugs for more than 5 years, continuously, without a diagnosis of certainty. Some patients interviewed told us that the feeling that was seizing them on their pilgrimage from doctor to doctor was that they were labeled as hysterical or a merely storyteller and that they just told them to take a pain reliever when they had pain.

Some husbands, ratifying such clinical impressions, exclaim on more than one occasion: "Again, with your pain!" And since the traditional female role is designed to take care and not so much to receive care from others, to understand and not so much to be understood, in many cases it is hardly expected that, when a woman feels pain, the husband will give an adequate care. The trigger elements of pain are usually psychic tensions. There is nothing to add to it, chronic stress seems evident. Along with it there are thoughts of resignation not exempt of accompanying feelings of guilt. The random attribution of pain seems to be part of that female role of taking on loads ("this pain has also touched me!"). The feeling of guiltiness is strange. Facing pain limits the woman life, which prevents her to have a satisfying sex life, which keeps her at home, and which prevents her from performing her tasks. She feels guilty: guilty for not attending to her relatives and spoiling their vacations and guilty because she does not have sexual relations as often as she would wish and for not being able to enjoy them, for not having a clean house, etc. What makes her feel so guilty if it's not the assumption of a traditional role? We leave the answer for your own reflection [57].

as clerk, and one as head of section in the regional administration). Those who had extra domestic works said that they had in charge the housework with some help from their couples. Eight of the patients had two sons and daughters and seven of them only one son or daughter. In three cases (20%), in addition to the couple and

a. The personal history of pain: time elapsed since the pain started, professionals consulted, treatments performed, time elapsed since the diagnosis of FM,

b. The pain today: description (intensity, frequency, and duration) and

d. Feelings regarding pain: emotions that arise when facing pain

g. Support against pain: what help do you have to deal with pain.

c. Thoughts regarding pain: what is attributed to, how to control it, what is

f. Repercussions of pain in daily life: functional impact on the patient (how pain

At this point, our focus was the personal history of pain. In this regard, it is

*Patient A: I was attended by several orthopedists and some of them gave me medication to the pain … the problem is that when one has … does not reach 30 years old and begins with continuous muscle contractures and without having a logical cause, well … even while playing sports in those moments, well, you get annoyed, don't you? And then you go to one and the other, you even go to the neurosurgeon that the only thing he found was a minimal dehydration in … a … dorsal intervertebral disk … and … I think then it was progressively studied in case they found neck calcifications,*

*Patient B: … It was mostly because of the birth of my daughter, well with … my daughter is already 10 years old, perhaps was the upbringing of the girl and also my father was diagnosed with a retinal detachment from the second eye because I had already had one and had lost the other eye … this brought me a lot of tension*

*Patient C: …When I was diagnosed with fibromyalgia I was suffering from pain for months, the pain started in the feet and hands, I had no strength in the hands, they became inflamed but I thought the housewives … I thought it was from the mop, scrub … always a blame for cleaning … I said to me "today I'm more tired of cleaning," "today for …" … always blame until my husband told me to go to the*

the children, other family members lived at home and they needed care.

**3.6 The main topics from a psychological point of view**

As main concerns, patients referred the following:

treatment; what precipitates, worsens, or relieves

e. Behaviors as responses to pain: how the pain is faced

limits life), impact on the family, social impact

*they corrected them, they sent me to the rehabilitators …*

biographical aspects at the onset of pain

thought when the pain appears

*Psychosomatic Medicine*

worth noting some narratives of our patients:

*buildup …*

**60**

#### **4. Social aspects**

By the time patients get to the FM treatment program at different health institutions, they typically have tried all the approved drugs for the disorder and are tired of the pain, the fatigue, the depression, and the skepticism. Many patients have been told for years (by friends, by family, by clinicians) that their symptoms are imaginary or that they are lazy or drug-seeking.

**5. About treatments**

*DOI: http://dx.doi.org/10.5772/intechopen.91768*

**5.1 Psychoactive drugs**

are going to revise the different treatment options.

through controlled clinical trials in FM are [59, 60]:

recommendations of psychoactive drugs.

• **Gamma-aminobutyric acid (GABA) analog**

of pain in patients with FM [61].

and stress-related responses [66–68].

**5.2 Nonpharmacological options**

**63**

the patient. It is therefore highly recommended.

There is increasing recognition that multidisciplinary treatment models that address physical symptoms of the disease, as well as behavioral and psychological components, are effective, although total removal of symptoms is almost never achieved. The goal is improvement in health-related quality of life, function, and symptom burden. Patients should also know that symptoms will never kill them. The first step should be to address concerns, such as sleep or mood disorders. We

*Psychosomatic Approach to Fibromyalgia Syndrome: Medical, Psychological, and Social Aspects*

"Being on the hunt for the magic pill": drugs don't work very well with FM.

• **Antidepressants.** The three main antidepressants that have been studied

◦ *Amitriptyline*. It reduces pain and fatigue, improves sleep, and produces a global feeling of improvement from the perspective of both the doctor and

◦ *Duloxetine*. It also reduces pain and improves sleep and mood and quality of life and functional capacity, so it is also equally recommended.

◦ *Fluoxetine*. Its evidence on pain, sleep, and fatigue in FM patients is controversial, and it seems to be effective for depressive symptoms and functional limitation. I would not currently be at the forefront of the

◦ *Pregabalin.* It was the first drug to be approved by the US FDA in 2007. Pregabalin reduces pain and improves sleep and quality of life, so it can be recommended for the treatment of these symptoms in patients with FM. It must be noted that a recent study comparing the efficacy of Duloxetine and Pregabalin concludes a higher efficacy of duloxetine for the treatment

• **Other pharmacotherapies**, like opioids (e.g., tramadol), dopamine agonist (e.g., ropinirole, pramipexole, or rotigotine), cannabinoids (e.g., Nabilone), or sodium oxybate, do not seem to support its use for treating FM [62–65].

• **Exercise**. Exercise is known to be beneficial for overall health. Incorporation of some physical exercise with strengthening and stretching program as a part of FM treatment shows significant effects in reducing pain and related FM symptoms. Recent evidence suggests that exercise may regulate the immune-

• **Transcranial stimulation***.* Two types of noninvasive brain stimulation methods have been used to treat the cognitive and affective disorders [69]:

Above and beyond the specific impact on health, from a social perspective, FM contemplates an impact at three levels: (a) family, (b) labor, and (c) about the health system.

In the **family environment**, patients point to the existence of family imbalances, putting at risk the maintenance and quality of their relationships in that context. It seems that there are at least four aspects to highlight:


In the **work context**, fibromyalgia is an important cause of work hour lost. In Spain, for example, people with fibromyalgia have an annual average of 21 days of work lost, and approximately one third of patients (depending on their jobs) already have a disability pension before they reach the retirement age (in other diseases this figure is around 9–10%). And, in summary, the percentage of temporary leave and the number of sick leave days is 3–4 times higher than in the case of other workers. In addition, it is known that the occupational impact of fibromyalgia seems to be strongly influenced by psychopathological comorbidity (especially anxiety and depression).

The **impact on the health system** refers to the amount of resources that these patients use, with the consequent economic cost. The positive part is arriving at a diagnosis as soon as possible, these costs decrease as it stops the pilgrimage of patients in search of evidence that clarifies their health problem. Patients with fibromyalgia visit the primary care physician at an average of 8–13 times a year, with almost €1,000 annual cost for such visits, about €500 for testing, and another €1,500 for "nonmedical" therapies (e.g., physiotherapy or massages). We must add about €500 per year for the use of different medications.

Storytelling, as an instrument of communication in health context, can be used to create a story as a way to share or receive information as well as a way for us to understand our own lives and those of others around us [58]. In this case, one of the signatories (MG) has composed a narrative to make fibro**mya**lgia visible. **Mya**, the chief character of the play, wishes us to transmit the emotions and feelings of the people who bear patiently the illness. Sometimes, the lack of understanding or the disregard of those around them for the different aspect of their lives doesn't help them to make progress. Various conditions affecting fibromyalgia patients have been depicted in this story. A great help for patients would be an overall consideration of clinicians, relatives, friends, and coworkers. Let us go to the story: and who is **Mya** (see Appendix 1)?

*Psychosomatic Approach to Fibromyalgia Syndrome: Medical, Psychological, and Social Aspects DOI: http://dx.doi.org/10.5772/intechopen.91768*

#### **5. About treatments**

**4. Social aspects**

*Psychosomatic Medicine*

health system.

By the time patients get to the FM treatment program at different health institutions, they typically have tried all the approved drugs for the disorder and are tired of the pain, the fatigue, the depression, and the skepticism. Many patients have been told for years (by friends, by family, by clinicians) that their symptoms

Above and beyond the specific impact on health, from a social perspective, FM contemplates an impact at three levels: (a) family, (b) labor, and (c) about the

In the **family environment**, patients point to the existence of family imbalances, putting at risk the maintenance and quality of their relationships in that context. It

a. A certain family disruption from the psycho-affective point of view (before

b. Family loads secondary to fibromyalgia (change of roles in family

d. Patterns of family behavior directly related to fibromyalgia and its

In the **work context**, fibromyalgia is an important cause of work hour lost. In Spain, for example, people with fibromyalgia have an annual average of 21 days of work lost, and approximately one third of patients (depending on their jobs) already have a disability pension before they reach the retirement age (in other diseases this figure is around 9–10%). And, in summary, the percentage of temporary leave and the number of sick leave days is 3–4 times higher than in the case of other workers. In addition, it is known that the occupational impact of fibromyalgia seems to be strongly influenced by psychopathological comorbidity (especially

The **impact on the health system** refers to the amount of resources that these patients use, with the consequent economic cost. The positive part is arriving at a diagnosis as soon as possible, these costs decrease as it stops the pilgrimage of patients in search of evidence that clarifies their health problem. Patients with fibromyalgia visit the primary care physician at an average of 8–13 times a year, with almost €1,000 annual cost for such visits, about €500 for testing, and another €1,500 for "nonmedical" therapies (e.g., physiotherapy or massages). We must add

Storytelling, as an instrument of communication in health context, can be used to create a story as a way to share or receive information as well as a way for us to understand our own lives and those of others around us [58]. In this case, one of the signatories (MG) has composed a narrative to make fibro**mya**lgia visible. **Mya**, the chief character of the play, wishes us to transmit the emotions and feelings of the people who bear patiently the illness. Sometimes, the lack of understanding or the disregard of those around them for the different aspect of their lives doesn't help them to make progress. Various conditions affecting fibromyalgia patients have been depicted in this story. A great help for patients would be an overall consideration of clinicians, relatives, friends, and coworkers. Let us go to the story: and who

components, redistribution of tasks, loss of role, etc.)

about €500 per year for the use of different medications.

are imaginary or that they are lazy or drug-seeking.

seems that there are at least four aspects to highlight:

or after the onset of the disease)

c. Family economic losses

repercussions

anxiety and depression).

is **Mya** (see Appendix 1)?

**62**

There is increasing recognition that multidisciplinary treatment models that address physical symptoms of the disease, as well as behavioral and psychological components, are effective, although total removal of symptoms is almost never achieved. The goal is improvement in health-related quality of life, function, and symptom burden. Patients should also know that symptoms will never kill them. The first step should be to address concerns, such as sleep or mood disorders. We are going to revise the different treatment options.

#### **5.1 Psychoactive drugs**

"Being on the hunt for the magic pill": drugs don't work very well with FM.

	- *Amitriptyline*. It reduces pain and fatigue, improves sleep, and produces a global feeling of improvement from the perspective of both the doctor and the patient. It is therefore highly recommended.
	- *Duloxetine*. It also reduces pain and improves sleep and mood and quality of life and functional capacity, so it is also equally recommended.
	- *Fluoxetine*. Its evidence on pain, sleep, and fatigue in FM patients is controversial, and it seems to be effective for depressive symptoms and functional limitation. I would not currently be at the forefront of the recommendations of psychoactive drugs.

#### • **Gamma-aminobutyric acid (GABA) analog**


#### **5.2 Nonpharmacological options**


transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS). TMS sends a brief electrical current from an electromagnetic coil that is placed against the patient's scalp, creating a regional magnetic field that affects neural activity. tDCS sends a weak electrical current through a pair of electrodes placed on the scalp in the region of interest. The current is considered to help modulate the neural activity, possibly in a polarity specific way [70, 71]. It appears that both TMS and tDCS may modulate mood, but the effects on pain may be marginal.

At the moment, the museum officials have not made authorized statements. At 7:30 pm, the director called a press conference at the headquarters of the feelings (25 Transcendence St.), to make the first manifestations of what happened.

*Psychosomatic Approach to Fibromyalgia Syndrome: Medical, Psychological, and Social Aspects*

**Mya** reads the news and decides to go to the museum. She cannot accept another

The H.G. Wells Museum is a building without defined forms. A weird-speaking drone with fraudulent voice announces: "free admission." There is a large uneven corridor where three rooms are placed on the right side and one more on the left.

**Mya** enters into the first of the rooms in the right: "*The Room of the White Coats.*" Although *Painting One* greets her kindly, it can only spend 5 minutes because there are too many visitors. It examines her quickly and recommends talking to *Painting Two*. Then, the latter gives her some futuristic capsules and asks her to come back at another time. Finally, a whisper leads her to *Painting three*, which tells her that it has

She comes out very confused, and stays absorbed in the middle of "*The Family Room,*" right next to the caution tape that the *Art Police* had put to cordon off the scene. She hears peaceful voices. Being suspended in the air, the *legless chairs* tell her that they are almost no longer visited or accompanied. At the beginning of the opening of the museum, it was the most frequented room, but now they are not important to them or simply do not know how to look at them. On the ceiling of this lugubrious room there is a *Deco Lamp* that looks at the walls with the complicity of the years. From a distance it seems to say: "I already knew that sooner or later it would happen." The always silent *Deco Lamp* addresses the intrigued **Mya** sharing its thoughts: "They have never watched us, they don't care, people come and go, they look at us but they don't see us. They extract what we have inside but they give us nothing back. The one who hung us performed his function. The one who repairs us, from time to time, also believes that he has fulfilled his duty. But now, that doesn't care." And the *Sculpture of Pain* was she left to her fate by a wrong way or did she abandon her privileged place in the museum because of misunderstanding

Curiosity leads her to the "*Just in Time Room,*" where the *Mosaics* are in continuous synchronized motion and almost silent. They ignore her. They prefer not to have eye contact with her. They have lost the habit. They do not recognize visitors because they are missing too much. Their complaints and regrets bore them. They

Once she visited the rooms on the right of the corridor, she went to the left side, to the "*Not Near Room.*" Those who were next to the stolen sculpture. And since their disappearance they have not even asked again. *Sculptures with no eyes* look her up and down, without any empathy. She prefers to think they have not seen her. She listens to a secure voice, which comes from the *Spokesman of the Council of Emotions*, who starts the meeting. It is necessary to face the fact of theft and start making decisions. Find out who has been the guilty before it is judged by the *Court*

After 5 hours, the members of the council were still trying to assess what could have happened with the sculpture. The clues confused them. The *Query Painting* had not manifested yet. Its strokes made a slight movement. Everyone else looked paying more attention than on other occasions, but they didn't understand why the

**Mya**, as she did not know anything about it, felt a greater curiosity for the painting. She waited just to see what it was doing. Its images were as clocks with

something for pain. It scares her because she hadn't explained anything.

*Myalgia*

A reward is offered to all those who care about visibility.

day of tiredness and fatigue.

*DOI: http://dx.doi.org/10.5772/intechopen.91768*

What do they hide?

and loneliness?

*of Righteousness*.

**65**

picture wasn't able to talk.

don't feel they are part of the team.

#### • **Psychological and behavioral modalities**

### ◦ **Psychological treatment**

There is great evidence of the effectiveness of cognitive behavioral therapy on pain control, physical discomfort, and mood in patients with FM [72]. Similarly, behavioral therapy has shown efficacy in reducing the number of medical visits.

Other treatments, such as relaxation techniques, used in isolation for the sole purpose of controlling pain, have not proven effective. On the other hand, despite some positive results, there is no scientific evidence to recommend hypnosis and other forms of therapy.

In any case, it seems that the best option is the use of "multicomponent therapies," specifically those based on the combination of physical exercise, cognitive behavioral intervention strategies, and drugs. They have proven effective in managing pain and improving the quality of life and physical capacity of patients.

### ◦ **Alternative therapies**

Today there is no scientific evidence on the effectiveness of certain treatments, at least for being recommended: acupuncture, homeopathy, ozone therapy, dietary supplements, Qi-Gong, Reiki, or Taichi [73].

Finally, the beneficial effect of chiropractic treatment and massage in the treatment of FM has not been sufficiently demonstrated, and therefore, its use is not recommended.

#### **Appendix 1**

**And who is Mya?** "El entusiasta" www.elentusiasta.es

The H.G. Wells Museum *Second day of the fatigue, Sunday. In the twenty-first century*

News: and where's Mya?

Yesterday, the *Sculpture* of Pain was stolen, a fifteenth-century masterpiece, highly valued by the *Experts of Life*. It belongs to the stage of the Spanish flamboyant gothic. It's an alabaster sculpture made by Sebastián de la Esperanza. It symbolizes medieval culture; the accompanying book personifies Wisdom.

It was transferred in March 1999, from the Cathedral of Sigüenza to the recently opened H.G. Wells Museum.

The *Commissioner of Righteousness* has asked to cooperate with the country's officials to investigate the clues in depth.

This morning, the main authorities of the emotions, have established the action plan and the resources they will provide to clarify the events that occurred.

#### *Psychosomatic Approach to Fibromyalgia Syndrome: Medical, Psychological, and Social Aspects DOI: http://dx.doi.org/10.5772/intechopen.91768*

At the moment, the museum officials have not made authorized statements. At 7:30 pm, the director called a press conference at the headquarters of the feelings (25 Transcendence St.), to make the first manifestations of what happened.

A reward is offered to all those who care about visibility.

#### *Myalgia*

**Mya** reads the news and decides to go to the museum. She cannot accept another day of tiredness and fatigue.

The H.G. Wells Museum is a building without defined forms. A weird-speaking drone with fraudulent voice announces: "free admission." There is a large uneven corridor where three rooms are placed on the right side and one more on the left.

What do they hide?

transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS). TMS sends a brief electrical current from an

but the effects on pain may be marginal.

• **Psychological and behavioral modalities**

◦ **Psychological treatment**

other forms of therapy.

*Psychosomatic Medicine*

◦ **Alternative therapies**

recommended.

**Appendix 1**

**64**

**And who is Mya?** "El entusiasta" www.elentusiasta.es

News: and where's Mya?

opened H.G. Wells Museum.

officials to investigate the clues in depth.

supplements, Qi-Gong, Reiki, or Taichi [73].

electromagnetic coil that is placed against the patient's scalp, creating a regional magnetic field that affects neural activity. tDCS sends a weak electrical current through a pair of electrodes placed on the scalp in the region of interest. The current is considered to help modulate the neural activity, possibly in a polarity specific way [70, 71]. It appears that both TMS and tDCS may modulate mood,

There is great evidence of the effectiveness of cognitive behavioral therapy on pain control, physical discomfort, and mood in patients with FM [72]. Similarly, behavioral therapy has shown efficacy in reducing the number of medical visits. Other treatments, such as relaxation techniques, used in isolation for the sole purpose of controlling pain, have not proven effective. On the other hand, despite some positive results, there is no scientific evidence to recommend hypnosis and

In any case, it seems that the best option is the use of "multicomponent therapies," specifically those based on the combination of physical exercise, cognitive behavioral intervention strategies, and drugs. They have proven effective in managing pain and improving the quality of life and physical capacity of patients.

Today there is no scientific evidence on the effectiveness of certain treatments, at least for being recommended: acupuncture, homeopathy, ozone therapy, dietary

Finally, the beneficial effect of chiropractic treatment and massage in the treatment of FM has not been sufficiently demonstrated, and therefore, its use is not

Yesterday, the *Sculpture* of Pain was stolen, a fifteenth-century masterpiece, highly valued by the *Experts of Life*. It belongs to the stage of the Spanish flamboyant gothic. It's an alabaster sculpture made by Sebastián de la Esperanza. It symbol-

It was transferred in March 1999, from the Cathedral of Sigüenza to the recently

This morning, the main authorities of the emotions, have established the action

The *Commissioner of Righteousness* has asked to cooperate with the country's

plan and the resources they will provide to clarify the events that occurred.

izes medieval culture; the accompanying book personifies Wisdom.

The H.G. Wells Museum

*Second day of the fatigue, Sunday. In the twenty-first century*

**Mya** enters into the first of the rooms in the right: "*The Room of the White Coats.*" Although *Painting One* greets her kindly, it can only spend 5 minutes because there are too many visitors. It examines her quickly and recommends talking to *Painting Two*. Then, the latter gives her some futuristic capsules and asks her to come back at another time. Finally, a whisper leads her to *Painting three*, which tells her that it has something for pain. It scares her because she hadn't explained anything.

She comes out very confused, and stays absorbed in the middle of "*The Family Room,*" right next to the caution tape that the *Art Police* had put to cordon off the scene. She hears peaceful voices. Being suspended in the air, the *legless chairs* tell her that they are almost no longer visited or accompanied. At the beginning of the opening of the museum, it was the most frequented room, but now they are not important to them or simply do not know how to look at them. On the ceiling of this lugubrious room there is a *Deco Lamp* that looks at the walls with the complicity of the years. From a distance it seems to say: "I already knew that sooner or later it would happen." The always silent *Deco Lamp* addresses the intrigued **Mya** sharing its thoughts: "They have never watched us, they don't care, people come and go, they look at us but they don't see us. They extract what we have inside but they give us nothing back. The one who hung us performed his function. The one who repairs us, from time to time, also believes that he has fulfilled his duty. But now, that doesn't care." And the *Sculpture of Pain* was she left to her fate by a wrong way or did she abandon her privileged place in the museum because of misunderstanding and loneliness?

Curiosity leads her to the "*Just in Time Room,*" where the *Mosaics* are in continuous synchronized motion and almost silent. They ignore her. They prefer not to have eye contact with her. They have lost the habit. They do not recognize visitors because they are missing too much. Their complaints and regrets bore them. They don't feel they are part of the team.

Once she visited the rooms on the right of the corridor, she went to the left side, to the "*Not Near Room.*" Those who were next to the stolen sculpture. And since their disappearance they have not even asked again. *Sculptures with no eyes* look her up and down, without any empathy. She prefers to think they have not seen her. She listens to a secure voice, which comes from the *Spokesman of the Council of Emotions*, who starts the meeting. It is necessary to face the fact of theft and start making decisions. Find out who has been the guilty before it is judged by the *Court of Righteousness*.

After 5 hours, the members of the council were still trying to assess what could have happened with the sculpture. The clues confused them. The *Query Painting* had not manifested yet. Its strokes made a slight movement. Everyone else looked paying more attention than on other occasions, but they didn't understand why the picture wasn't able to talk.

**Mya**, as she did not know anything about it, felt a greater curiosity for the painting. She waited just to see what it was doing. Its images were as clocks with

#### *Psychosomatic Medicine*

distorted shapes and its light was different from the rest. Would it know who was the guilty of the disappearance? What were the reasons of its differences? Would it be able to reach others with harmony? What a different museum! All its elements express those they feel and hear! She exclaimed.

**References**

[1] Kuner R, Flor H. Neural circuits of chronic pain. Neuroscience. 2018;**387**:1-3

*DOI: http://dx.doi.org/10.5772/intechopen.91768*

A prospective study of 1520 patients. The Journal of Rheumatology. 1985;**12**:

[11] Bested AC, Marshall LM. Review of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: an evidence-based approach to diagnosis and management by clinicians. Reviews on Environmental Health. 2015;**30**(4):223-249

[12] Kissling W, Mendel R, Förstl H. The burn-out syndrome: prevalence, symptoms, differential diagnosis and treatment. Deutsche Medizinische Wochenschrift. 2014;**139**(50):2587-2596

[13] Benjamin S, Morris S, McBeth J, Macfarlane GJ, Silman AJ. The

2000;**43**:561-567

2001;**40**:95-101

2019;**160**:28-37

association between chronic widespread pain and mental disorder: A populationbased study. Arthritis and Rheumatism.

[14] McBeth J, Macfarlane GJ, Hunt IM, Silman AJ. Risk factors for persistent chronic widespread pain: a communitybased study. Rheumatology (Oxford).

[15] Wolfe F, Walitt B. Culture, science

[16] Nicholas M, Vlaeyen JW, Rief W, Barke A, Aziz Q, Benoliel R, et al. The IASP classification of chronic pain for ICD-11: Chronic primary pain. Pain.

[17] Treede R-D, Rief W, Barke A, Aziz Q, Bennett MI, Benoliel R, et al. Chronic pain as a symptom or a disease: The IASP Classification of Chronic Pain for the International Classification of Diseases (ICD-11). Pain. 2019;**160**:19-27

[18] Kool MB, Geenen R. Loneliness in patients with rheumatic diseases: The significance of invalidation and lack of

and the changing nature of fibromyalgia. Nature Reviews Rheumatology. 2013;**9**(12):751-755

1164-1168

*Psychosomatic Approach to Fibromyalgia Syndrome: Medical, Psychological, and Social Aspects*

[2] Sancassiani F, Machado S, Ruggiero V, Cacace E, Carmassi C, Gesi C, et al. The management of fibromyalgia from a

[3] Branco JC, Bannwarth B, Failde I, Abello Carbonell J, Blotman F, Spaeth M, et al. Prevalence of fibromyalgia: A survey in five European countries. Seminars in Arthritis and Rheumatism.

[4] Sumpton J, Moulin D. Fibromyalgia. In: Biller J, Ferro JM, editors. Handbook of Clinical Neurology, Vol. 119 (3rd series). Neurologic Aspects of Systemic Disease; Part I. Elsevier BV; 2014.

[5] Bennett R, Friend R, Marcus D, Bernstein C, Han BK, Yachoui R, et al.

fibromyalgia: validation of the modified 2010 preliminary ACR criteria and the development of alternative criteria. Arthritis Care and Research. 2014;**66**

[6] Burton AR. Neurasthenia. Journal of the National Medical Association. 1925;

[7] Gowers WR. A lecture on lumbago: its lessons and analogues. BMJ. 1904;**1**:

[8] Fletcher E. Fibrositis. Postgraduate Medical Journal. 1937;**13**(143):324-329

[9] Smythe HA, Moldofsky H. Two contributions to understanding of the fibrositis syndrome. Bulletin on the Rheumatic Diseases. 1977;**28**:928-931

[10] Wolfe F, Cathey MA. The epidemiology of tenders points:

Criteria for the diagnosis of

psychosomatic perspective: An overview. International Review of Psychiatry. 2017;**29**(5):473-488

2010;**39**(6):448-453

pp. 513-524

(9):1364-1373

**17**(1):16-18

117-121

**67**

Suddenly, several coordinated voices arise:


Everyone directed their forms to *Painting Seven*, which looked at the ground for a few seconds and shouted with no-voice: "Please, let's change something about our past!"

From this moment on, they understood why the *Pain* with their *Sculpture* had decided to leave.

#### **Author details**

José Vicente Martínez-Quiñones<sup>1</sup> \*, Mar Martínez Gamarra<sup>2</sup> and Ignacio Jáuregui-Lobera<sup>3</sup>

1 Department of Neurosurgery, Mutua de Accidentes de Zaragoza, Zaragoza, Spain

2 Storytelling Spanish Association (ASEST), Zaragoza, Spain

3 Department of Molecular Biology and Biochemical Engineering, University of Pablo de Olavide of Seville, Seville, Spain

\*Address all correspondence to: jvmartinez@maz.es

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Psychosomatic Approach to Fibromyalgia Syndrome: Medical, Psychological, and Social Aspects DOI: http://dx.doi.org/10.5772/intechopen.91768*

#### **References**

distorted shapes and its light was different from the rest. Would it know who was the guilty of the disappearance? What were the reasons of its differences? Would it be able to reach others with harmony? What a different museum! All its elements

• *Painting Two*: "We were drawn to remember the decay of those who live

Everyone directed their forms to *Painting Seven*, which looked at the ground for a few seconds and shouted with no-voice: "Please, let's change something about

From this moment on, they understood why the *Pain* with their *Sculpture* had

\*, Mar Martínez Gamarra<sup>2</sup>

1 Department of Neurosurgery, Mutua de Accidentes de Zaragoza, Zaragoza, Spain

3 Department of Molecular Biology and Biochemical Engineering, University of

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

2 Storytelling Spanish Association (ASEST), Zaragoza, Spain

• *Sculpture Eight*: "We were built to remember that principles exist."

• *Mosaic Fifteen*: "We were just to remember that the senses exist."

• *Frame Ten*: "We were to remember the transcendence."

express those they feel and hear! She exclaimed. Suddenly, several coordinated voices arise:

depending on something or someone."

our past!"

decided to leave.

*Psychosomatic Medicine*

**Author details**

**66**

José Vicente Martínez-Quiñones<sup>1</sup>

Pablo de Olavide of Seville, Seville, Spain

provided the original work is properly cited.

\*Address all correspondence to: jvmartinez@maz.es

and Ignacio Jáuregui-Lobera<sup>3</sup>

[1] Kuner R, Flor H. Neural circuits of chronic pain. Neuroscience. 2018;**387**:1-3

[2] Sancassiani F, Machado S, Ruggiero V, Cacace E, Carmassi C, Gesi C, et al. The management of fibromyalgia from a psychosomatic perspective: An overview. International Review of Psychiatry. 2017;**29**(5):473-488

[3] Branco JC, Bannwarth B, Failde I, Abello Carbonell J, Blotman F, Spaeth M, et al. Prevalence of fibromyalgia: A survey in five European countries. Seminars in Arthritis and Rheumatism. 2010;**39**(6):448-453

[4] Sumpton J, Moulin D. Fibromyalgia. In: Biller J, Ferro JM, editors. Handbook of Clinical Neurology, Vol. 119 (3rd series). Neurologic Aspects of Systemic Disease; Part I. Elsevier BV; 2014. pp. 513-524

[5] Bennett R, Friend R, Marcus D, Bernstein C, Han BK, Yachoui R, et al. Criteria for the diagnosis of fibromyalgia: validation of the modified 2010 preliminary ACR criteria and the development of alternative criteria. Arthritis Care and Research. 2014;**66** (9):1364-1373

[6] Burton AR. Neurasthenia. Journal of the National Medical Association. 1925; **17**(1):16-18

[7] Gowers WR. A lecture on lumbago: its lessons and analogues. BMJ. 1904;**1**: 117-121

[8] Fletcher E. Fibrositis. Postgraduate Medical Journal. 1937;**13**(143):324-329

[9] Smythe HA, Moldofsky H. Two contributions to understanding of the fibrositis syndrome. Bulletin on the Rheumatic Diseases. 1977;**28**:928-931

[10] Wolfe F, Cathey MA. The epidemiology of tenders points: A prospective study of 1520 patients. The Journal of Rheumatology. 1985;**12**: 1164-1168

[11] Bested AC, Marshall LM. Review of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: an evidence-based approach to diagnosis and management by clinicians. Reviews on Environmental Health. 2015;**30**(4):223-249

[12] Kissling W, Mendel R, Förstl H. The burn-out syndrome: prevalence, symptoms, differential diagnosis and treatment. Deutsche Medizinische Wochenschrift. 2014;**139**(50):2587-2596

[13] Benjamin S, Morris S, McBeth J, Macfarlane GJ, Silman AJ. The association between chronic widespread pain and mental disorder: A populationbased study. Arthritis and Rheumatism. 2000;**43**:561-567

[14] McBeth J, Macfarlane GJ, Hunt IM, Silman AJ. Risk factors for persistent chronic widespread pain: a communitybased study. Rheumatology (Oxford). 2001;**40**:95-101

[15] Wolfe F, Walitt B. Culture, science and the changing nature of fibromyalgia. Nature Reviews Rheumatology. 2013;**9**(12):751-755

[16] Nicholas M, Vlaeyen JW, Rief W, Barke A, Aziz Q, Benoliel R, et al. The IASP classification of chronic pain for ICD-11: Chronic primary pain. Pain. 2019;**160**:28-37

[17] Treede R-D, Rief W, Barke A, Aziz Q, Bennett MI, Benoliel R, et al. Chronic pain as a symptom or a disease: The IASP Classification of Chronic Pain for the International Classification of Diseases (ICD-11). Pain. 2019;**160**:19-27

[18] Kool MB, Geenen R. Loneliness in patients with rheumatic diseases: The significance of invalidation and lack of social support. The Journal of Psychology. 2012;**146**:229-241

[19] Adams LM, Turk DC. Psychosocial factors and central sensitivity syndromes. Current Rheumatology Reviews. 2015;**11**:96-108

[20] Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis and Rheumatism. 1990;**33**(2): 160-172

[21] Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Katz RS, Mease P, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care & Research (Hoboken). 2010;**62**(5): 600-610

[22] Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Häuser W, Katz RS, et al. Fibromyalgia criteria and severity scales for clinical and epidemiological studies: A modification of the ACR Preliminary Diagnostic Criteria for Fibromyalgia. The Journal of Rheumatology. 2011;**38**(6):1113-1122

[23] Crawford BK, Piault EC, Lai C, Bennett RM. Assessing fibromyalgiarelated fatigue: content validity and psychometric performance of the Fatigue Visual Analog Scale in adult patients with fibromyalgia. Clinical and Experimental Rheumatology. 2011;**29**(6 Suppl 69):S34-S43

[24] Bennett RM. Clinical manifestations and diagnosis of fibromyalgia. Rheumatic Diseases Clinics of North America. 2009;**35**(2):215-232

[25] Bennett RM, Jones J, Turk DC, Russell IJ, Matallana L. An internet survey of 2,596 people with fibromyalgia. BMC Musculoskeletal Disorders. 2007;**8**:27

[26] Turk DC, Adams LM. Using a biopsychosocial perspective in the treatment of fibromyalgia patients. Pain Management. 2016;**6**(4):357-369

[35] McCarberg BH. Clinical overview of fibromyalgia. American Journal of Therapeutics. 2012;**19**(5):357-368

*DOI: http://dx.doi.org/10.5772/intechopen.91768*

[44] Ablin J, Neumann L, Buskila D. Pathogenesis of fibromyalgia— a review. Joint, Bone, Spine. 2008;**75**(3):

[45] Limer KL, Nicholl BI, Thomson W,

[46] Beggs S. Long-term consequences of neonatal injury. Canadian Journal of Psychology. 2015;**60**:176-180

[47] Schwaller F, Fitzgerald M. The consequences of pain in early life: Injury-induced plasticity in developing pain pathways. The European Journal of

Neuroscience. 2014;**39**:344-352

[48] Clos-Garcia M, Andrés-Marin N, Fernández-Eulate G, Abecia L, Lavín JL, van Liempd S, et al. Gut microbiome and serum metabolome analyses identify molecular biomarkers and altered glutamate metabolism in fibromyalgia. eBioMedicine. 2019;**46**:

[49] Wolfe F, Häuser W, Walitt BT, Katz RS, Rasker JJ, Russell AS. Fibromyalgia and physical trauma: The concepts we invent. The Journal of Rheumatology.

[50] Palagini L, Carmassi C, Conversano C, Gesi C, Bazzichi L, Giacomelli C, et al. Transdiagnostic factors across fibromyalgia and mental disorders: Sleep disturbances may play a key role.

Experimental Rheumatology. 2016;**34**:

[51] Plazier M, Ost J, Stassijns G, De RD, Vanneste S. Pain characteristics in fibromyalgia: Understanding the multiple dimensions of pain. Clinical Rheumatology. 2015;**34**:775-783

[52] Chinn S, Cadwell W, Gritsenko K. Fibromyalgia pathogenesis and

A clinical review. Clinical and

Mcbeth J. Exploring the genetic susceptibility of chronic widespread pain: The tender points in genetic association studies. Rheumatology.

2008;**47**(5):572-577

273-279

*Psychosomatic Approach to Fibromyalgia Syndrome: Medical, Psychological, and Social Aspects*

499-511

S140-S144

2014;**41**(9):1737-1745

[36] Fitzcharles MA, Yunus MB. The clinical concept of fibromyalgia as a changing paradigm in the past 20 years. Pain Research and Treatment. 2012;

[37] Buskila D, Atzeni F, Sarzi-Puttini P. Etiology of fibromyalgia: the possible role

Autoimmunity Reviews. 2008;**8**(1):41-43

[38] Arnold LM, Hudson JI, Hess EV, et al. Family study of fibromyalgia. Arthritis and Rheumatism. 2004;**50**(3):

[39] Holliday KL, McBeth J. Recent advances in the understanding of genetic susceptibility to chronic pain and somatic symptoms. Current Rheumatology Reports. 2011;**13**(6):521-527

[40] Burke NN, Finn DP, McGuire BE, Roche M. Psychological stress in early life as a predisposing factor for the development of chronic pain: Clinical

neurobiological mechanisms. Journal of Neuroscience Research. 2017;**95**(6):

[41] Scarinci IC, McDonald-Haile J, Bradley LA, Richter JE. Altered pain perception and psychosocial features among women with gastrointestinal disorders and history of abuse: a preliminary model. The American Journal of Medicine. 1994 Aug;**97**(2):

[42] Yunus MB. Editorial Review: An update on central sensitivity syndromes

psychobiology. Current Rheumatology

Epigenetics of early child development. Frontiers in Psychiatry. 2011;**2**:16

and the issues of nosology and

[43] Murgatroyd C, Spengler D.

Reviews. 2015;**11**:70-85

and preclinical evidence and

of infection and vaccination.

**2012**:184835

944-952

1257-1270

108-118

**69**

[27] Wilson HD, Robinson JP, Turk DC. Toward the identification of symptom patterns in people with fibromyalgia. Arthritis and Rheumatism. 2009;**61**(4): 527-534

[28] Wolfe F, Brähler E, Häuser W. Fibromyalgia prevalence, somatic symptom reporting, and the dimensionality of polisymptomatic distress: Results from a survey of the general population. Arthritis Care and Research. 2013;**65**(5):777-785

[29] Meeus M, Nijs J. Central sensitization: a biopsychosocial explanation for chronic widespread pain in patients with fibromyalgia and chronic fatigue syndrome. Clinical Rheumatology. 2007;**26**(4):465-473

[30] Brummett CM, Bakshi RR, Goesling J, Leung D, Moser SE, Zollars JW, et al. Preliminary validation of the Michigan Body Map. Pain. 2016;**157**(6):1205-1212

[31] Neblett R, Cohen H, Choi Y, Hartzell MM, Williams M, Mayer TG, et al. The Central Sensitization Inventory (CSI): establishing clinically significant values for identifying central sensitivity syndromes in an outpatient chronic pain sample. The Journal of Pain. 2013;**14**(5):438-445

[32] Kroenke K. Physical symptom disorder: a simpler diagnostic category for somatization-spectrum conditions. Journal of Psychosomatic Research. 2006;**60**:335-339

[33] Rubin JJ. Psychosomatic pain: new insights and management strategies. Southern Medical Journal. 2005;**98**: 1099-1110

[34] Ehrlich GE. Pain is real; fibromyalgia isn't. The Journal of Rheumatology. 2003;**30**:1666-1667 *Psychosomatic Approach to Fibromyalgia Syndrome: Medical, Psychological, and Social Aspects DOI: http://dx.doi.org/10.5772/intechopen.91768*

[35] McCarberg BH. Clinical overview of fibromyalgia. American Journal of Therapeutics. 2012;**19**(5):357-368

social support. The Journal of Psychology. 2012;**146**:229-241

*Psychosomatic Medicine*

factors and central sensitivity syndromes. Current Rheumatology

Reviews. 2015;**11**:96-108

160-172

600-610

[19] Adams LM, Turk DC. Psychosocial

[26] Turk DC, Adams LM. Using a biopsychosocial perspective in the treatment of fibromyalgia patients. Pain

Management. 2016;**6**(4):357-369

[28] Wolfe F, Brähler E, Häuser W. Fibromyalgia prevalence, somatic symptom reporting, and the dimensionality of polisymptomatic distress: Results from a survey of the general population. Arthritis Care and

Research. 2013;**65**(5):777-785

[29] Meeus M, Nijs J. Central sensitization: a biopsychosocial

explanation for chronic widespread pain in patients with fibromyalgia and chronic fatigue syndrome. Clinical Rheumatology. 2007;**26**(4):465-473

[30] Brummett CM, Bakshi RR, Goesling J, Leung D, Moser SE, Zollars JW, et al. Preliminary validation of the Michigan Body Map. Pain. 2016;**157**(6):1205-1212

[31] Neblett R, Cohen H, Choi Y, Hartzell MM, Williams M, Mayer TG, et al. The Central Sensitization

Pain. 2013;**14**(5):438-445

2006;**60**:335-339

1099-1110

Inventory (CSI): establishing clinically significant values for identifying central sensitivity syndromes in an outpatient chronic pain sample. The Journal of

[32] Kroenke K. Physical symptom disorder: a simpler diagnostic category for somatization-spectrum conditions. Journal of Psychosomatic Research.

[33] Rubin JJ. Psychosomatic pain: new insights and management strategies. Southern Medical Journal. 2005;**98**:

[34] Ehrlich GE. Pain is real; fibromyalgia isn't. The Journal of Rheumatology. 2003;**30**:1666-1667

527-534

[27] Wilson HD, Robinson JP, Turk DC. Toward the identification of symptom patterns in people with fibromyalgia. Arthritis and Rheumatism. 2009;**61**(4):

[20] Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis and Rheumatism. 1990;**33**(2):

[21] Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Katz RS, Mease P, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care & Research (Hoboken). 2010;**62**(5):

[22] Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Häuser W, Katz RS, et al. Fibromyalgia criteria and severity scales for clinical and epidemiological studies: A modification of the ACR Preliminary Diagnostic Criteria for Fibromyalgia. The Journal of

Rheumatology. 2011;**38**(6):1113-1122

[23] Crawford BK, Piault EC, Lai C, Bennett RM. Assessing fibromyalgiarelated fatigue: content validity and psychometric performance of the Fatigue Visual Analog Scale in adult patients with fibromyalgia. Clinical and Experimental Rheumatology. 2011;**29**(6

[24] Bennett RM. Clinical manifestations

and diagnosis of fibromyalgia. Rheumatic Diseases Clinics of North

America. 2009;**35**(2):215-232

[25] Bennett RM, Jones J, Turk DC, Russell IJ, Matallana L. An internet survey of 2,596 people with

fibromyalgia. BMC Musculoskeletal

Suppl 69):S34-S43

Disorders. 2007;**8**:27

**68**

[36] Fitzcharles MA, Yunus MB. The clinical concept of fibromyalgia as a changing paradigm in the past 20 years. Pain Research and Treatment. 2012; **2012**:184835

[37] Buskila D, Atzeni F, Sarzi-Puttini P. Etiology of fibromyalgia: the possible role of infection and vaccination. Autoimmunity Reviews. 2008;**8**(1):41-43

[38] Arnold LM, Hudson JI, Hess EV, et al. Family study of fibromyalgia. Arthritis and Rheumatism. 2004;**50**(3): 944-952

[39] Holliday KL, McBeth J. Recent advances in the understanding of genetic susceptibility to chronic pain and somatic symptoms. Current Rheumatology Reports. 2011;**13**(6):521-527

[40] Burke NN, Finn DP, McGuire BE, Roche M. Psychological stress in early life as a predisposing factor for the development of chronic pain: Clinical and preclinical evidence and neurobiological mechanisms. Journal of Neuroscience Research. 2017;**95**(6): 1257-1270

[41] Scarinci IC, McDonald-Haile J, Bradley LA, Richter JE. Altered pain perception and psychosocial features among women with gastrointestinal disorders and history of abuse: a preliminary model. The American Journal of Medicine. 1994 Aug;**97**(2): 108-118

[42] Yunus MB. Editorial Review: An update on central sensitivity syndromes and the issues of nosology and psychobiology. Current Rheumatology Reviews. 2015;**11**:70-85

[43] Murgatroyd C, Spengler D. Epigenetics of early child development. Frontiers in Psychiatry. 2011;**2**:16

[44] Ablin J, Neumann L, Buskila D. Pathogenesis of fibromyalgia— a review. Joint, Bone, Spine. 2008;**75**(3): 273-279

[45] Limer KL, Nicholl BI, Thomson W, Mcbeth J. Exploring the genetic susceptibility of chronic widespread pain: The tender points in genetic association studies. Rheumatology. 2008;**47**(5):572-577

[46] Beggs S. Long-term consequences of neonatal injury. Canadian Journal of Psychology. 2015;**60**:176-180

[47] Schwaller F, Fitzgerald M. The consequences of pain in early life: Injury-induced plasticity in developing pain pathways. The European Journal of Neuroscience. 2014;**39**:344-352

[48] Clos-Garcia M, Andrés-Marin N, Fernández-Eulate G, Abecia L, Lavín JL, van Liempd S, et al. Gut microbiome and serum metabolome analyses identify molecular biomarkers and altered glutamate metabolism in fibromyalgia. eBioMedicine. 2019;**46**: 499-511

[49] Wolfe F, Häuser W, Walitt BT, Katz RS, Rasker JJ, Russell AS. Fibromyalgia and physical trauma: The concepts we invent. The Journal of Rheumatology. 2014;**41**(9):1737-1745

[50] Palagini L, Carmassi C, Conversano C, Gesi C, Bazzichi L, Giacomelli C, et al. Transdiagnostic factors across fibromyalgia and mental disorders: Sleep disturbances may play a key role. A clinical review. Clinical and Experimental Rheumatology. 2016;**34**: S140-S144

[51] Plazier M, Ost J, Stassijns G, De RD, Vanneste S. Pain characteristics in fibromyalgia: Understanding the multiple dimensions of pain. Clinical Rheumatology. 2015;**34**:775-783

[52] Chinn S, Cadwell W, Gritsenko K. Fibromyalgia pathogenesis and

treatment options update. Current Pain and Headache Reports. 2016;**20**:25-35

[53] Walker J, Holloway I, Sofaer B. In the system: Patients' experiences of chronic back pain. Pain. 1999;**80**: 621-628

[54] Helgeson VS. Two important distinctions in social support: Kind of support and perceived versus received. Journal of Applied Social Psychology. 1993;**23**:825-845

[55] Belle D. Gender differences in the social moderators of stress. In: Barnett RC, Biener L, Baruch GK, editors. Gender and Stress. Nueva York: Free Press; 1987. pp. 257-277

[56] Weber RP. Basic Content Analysis. Newbury Park, CA: Sage Publications; 1990

[57] Jáuregui-Lobera I. Cuestiones de género. Zaragoza: Libros Certeza; 2007

[58] Jáuregui-Lobera I, Martínez-Gamarra M, Montes-Martínez M, Martínez-Quiñones JV. Storytelling as instrument of communication in health contexts. Journal of Negative and No Positive Results. 2020;**5**

[59] Okifuji A, Gao J, Bokat C, Hare BD. Management of fibromyalgia syndrome in 2016. Pain Management. 2016;**6**(4): 383-400

[60] Government of Spain. Fibromyalgia. Madrid (Spain): Ministry of Health, Social Policy and Equality; 2011

[61] Bidari A, Moazen-Zadeh E, Ghavidel-Parsa B, Rahmani S, Hosseini S, Hassankhani A. Comparing duloxetine and pregabalin for treatment of pain and depression in women with fibromyalgia: an open-label randomized clinical trial. DARU. 2019;**27**:149-158

[62] Bennett RM, Kamin M, Karim R, Rosenthal N. Tramadol and acetaminophen combination tablets in the treatment of fibromyalgia pain: A double blind, randomized, placebocontrolled study. The American Journal of Medicine. 2003;**114**(7):537-545

[70] Galhardoni R, Correia GS, Araujo H, et al. Repetitive transcranial magnetic stimulation in chronic pain: A review of the literature. Archives of Physical Medicine and Rehabilitation. 2015;**96**(4

*DOI: http://dx.doi.org/10.5772/intechopen.91768*

*Psychosomatic Approach to Fibromyalgia Syndrome: Medical, Psychological, and Social Aspects*

[71] Boyer L, Dousset A, Roussel P, et al. rTMS in fibromyalgia: A randomized trial evaluating QoL and its brain metabolic substrate. Neurology. 2014;**82**

[72] Bernardy K, Klose P, Welsch P, Häuser W. Efficacy, acceptability and

psychological therapies for fibromyalgia syndrome: A systematic review and meta-analysis of randomized controlled trials. European Journal of Pain. 2019;**23**

[73] Lauche R, Cramer H, Häuser W, Dobos G, Langhorst J. A Systematic overview of reviews for complementary

and alternative therapies in the treatment of the fibromyalgia syndrome. Evidence-based Complementary and Alternative Medicine. 2015;**2015**:610615

safety of Internet-delivered

suppl):S156-S172

(14):1231-1238

(1):3-14

**71**

[63] Holman AJ, Myers RR. A randomized, double-blind, placebocontrolled trial of pramipexole, a dopamine agonist, in patients with fibromyalgia receiving concomitant medications. Arthritis and Rheumatism. 2005;**52**(8):2495-2505

[64] Skrabek RQ, Galimova L, Ethans K, Perry D. Nabilone for the treatment of pain in fibromyalgia. The Journal of Pain. 2008;**9**(2):164-173

[65] Scharf MB, Baumann M, Berkowitz DV. The effects of sodium oxybate on clinical symptoms and sleep patterns in patients with fibromyalgia. The Journal of Rheumatology. 2003;**30**(5): 1070-1074

[66] Kelley GA, Kelley KS, Jones DL. Efficacy and effectiveness of exercise on tender points in adults with fibromyalgia: A meta-analysis of randomized controlled trials. Art. 2011; **2011**:125485

[67] Busch AJ, Webber SC, Brachaniec M, et al. Exercise therapy for fibromyalgia. Current Pain and Headache Reports. 2011;**15**(5):358-367

[68] Mist SD, Firestone KA, Jones KD. Complementary and alternative exercise for fibromyalgia: A meta-analysis. Journal of Pain Research. 2013;**6**: 247-260

[69] Jáuregui Lobera I, Martínez Quiñones JV. Neuromodulation in eating disorders and obesity: A promising way of treatment? Neuropsychiatric Disease and Treatment. 2018;**14**:2817-2835

*Psychosomatic Approach to Fibromyalgia Syndrome: Medical, Psychological, and Social Aspects DOI: http://dx.doi.org/10.5772/intechopen.91768*

[70] Galhardoni R, Correia GS, Araujo H, et al. Repetitive transcranial magnetic stimulation in chronic pain: A review of the literature. Archives of Physical Medicine and Rehabilitation. 2015;**96**(4 suppl):S156-S172

treatment options update. Current Pain and Headache Reports. 2016;**20**:25-35

[62] Bennett RM, Kamin M, Karim R,

acetaminophen combination tablets in the treatment of fibromyalgia pain: A double blind, randomized, placebocontrolled study. The American Journal of Medicine. 2003;**114**(7):537-545

[64] Skrabek RQ, Galimova L, Ethans K, Perry D. Nabilone for the treatment of pain in fibromyalgia. The Journal of

[65] Scharf MB, Baumann M, Berkowitz DV. The effects of sodium oxybate on clinical symptoms and sleep patterns in patients with fibromyalgia. The Journal of Rheumatology. 2003;**30**(5):

[66] Kelley GA, Kelley KS, Jones DL. Efficacy and effectiveness of exercise on

[67] Busch AJ, Webber SC, Brachaniec

[68] Mist SD, Firestone KA, Jones KD. Complementary and alternative exercise for fibromyalgia: A meta-analysis. Journal of Pain Research. 2013;**6**:

[69] Jáuregui Lobera I, Martínez Quiñones JV. Neuromodulation in eating disorders and obesity: A promising way of treatment? Neuropsychiatric Disease and Treatment. 2018;**14**:2817-2835

tender points in adults with fibromyalgia: A meta-analysis of randomized controlled trials. Art. 2011;

M, et al. Exercise therapy for fibromyalgia. Current Pain and Headache Reports. 2011;**15**(5):358-367

Rosenthal N. Tramadol and

[63] Holman AJ, Myers RR. A randomized, double-blind, placebocontrolled trial of pramipexole, a dopamine agonist, in patients with fibromyalgia receiving concomitant medications. Arthritis and Rheumatism.

2005;**52**(8):2495-2505

Pain. 2008;**9**(2):164-173

1070-1074

**2011**:125485

247-260

[53] Walker J, Holloway I, Sofaer B. In the system: Patients' experiences of chronic back pain. Pain. 1999;**80**:

[54] Helgeson VS. Two important distinctions in social support: Kind of support and perceived versus received. Journal of Applied Social Psychology.

[55] Belle D. Gender differences in the social moderators of stress. In: Barnett RC, Biener L, Baruch GK, editors. Gender and Stress. Nueva York: Free

[56] Weber RP. Basic Content Analysis. Newbury Park, CA: Sage Publications;

[57] Jáuregui-Lobera I. Cuestiones de género. Zaragoza: Libros Certeza; 2007

[59] Okifuji A, Gao J, Bokat C, Hare BD. Management of fibromyalgia syndrome in 2016. Pain Management. 2016;**6**(4):

Fibromyalgia. Madrid (Spain): Ministry of Health, Social Policy and Equality;

Ghavidel-Parsa B, Rahmani S, Hosseini

duloxetine and pregabalin for treatment of pain and depression in women with fibromyalgia: an open-label randomized clinical trial. DARU. 2019;**27**:149-158

[58] Jáuregui-Lobera I, Martínez-Gamarra M, Montes-Martínez M, Martínez-Quiñones JV. Storytelling as instrument of communication in health contexts. Journal of Negative and No

Positive Results. 2020;**5**

[60] Government of Spain.

[61] Bidari A, Moazen-Zadeh E,

S, Hassankhani A. Comparing

621-628

1990

383-400

2011

**70**

1993;**23**:825-845

*Psychosomatic Medicine*

Press; 1987. pp. 257-277

[71] Boyer L, Dousset A, Roussel P, et al. rTMS in fibromyalgia: A randomized trial evaluating QoL and its brain metabolic substrate. Neurology. 2014;**82** (14):1231-1238

[72] Bernardy K, Klose P, Welsch P, Häuser W. Efficacy, acceptability and safety of Internet-delivered psychological therapies for fibromyalgia syndrome: A systematic review and meta-analysis of randomized controlled trials. European Journal of Pain. 2019;**23** (1):3-14

[73] Lauche R, Cramer H, Häuser W, Dobos G, Langhorst J. A Systematic overview of reviews for complementary and alternative therapies in the treatment of the fibromyalgia syndrome. Evidence-based Complementary and Alternative Medicine. 2015;**2015**:610615

**73**

**Chapter 4**

**Abstract**

terminal illness

**1. Introduction**

Palliative Care

*and Ignacio Jauregi Lobera*

*through their words that are the symptoms".*

Psychosomatic Medicine and

*Manuel Mejías-Estévez, Rocio Dominguez Álvarez* 

beginning and help to the quality of life of terminally ill patients.

**Keywords:** palliative care, physical factors, quality of life, medical discipline,

The first great historical relationship between both disciplines is referenced by the Paracelsus himself who could inspire centuries later the great Professor Sigmund Freud, since he was the promater of psychotherapy as a science: psychoanalysis, as a part of the birth of medicine itself psychosomatic (MP). This conclusion is understood when reading Dr. Freud's own words about his own condition, that of an oncological disease for 26 years, caused by his smoking habit, of a squamous cell carcinoma of the palate and jaw, which led him to numerous interventions surgical and painful conditions [2, 3]. Although the breaking news pointed to morphine overdose as the immediate cause of death, the fundamental cause was that terminal tumor, which turned off the light of genius in London on 23 September 1939. If palliative care, a later discipline, had been able to intervene, they would have allowed relief from his suffering, from the symptoms that tormented

him, and, consequently, a dignified, natural and not accelerated death.

*"In psychosomatic diseases the body takes the voice so that the emotions tell stories* 

Psychosomatic medicine (MP) and palliative care are disciplines with history and both are based in the scientific world. Although the psychosomatic diagnosis is exclusionary, it can help palliative care to be more effective. The influence of the psychosomatic in the palliative exists. According to all the bibliography available in the electronic databases, psychosomatic medicine is a biopsychosocial model related to both physical and psychosocial factors, which helps improve the care of patients with advanced cancer in palliative care (improved survival, quality of life, reduces the burden on caregivers). It helps analyze and address psychiatric disorders, as well as in the control of complex symptoms such as life-threatening anxiety, depression or delirium. Therefore, both medical disciplines are related from the

*Mejias [1]*

#### **Chapter 4**

## Psychosomatic Medicine and Palliative Care

*Manuel Mejías-Estévez, Rocio Dominguez Álvarez and Ignacio Jauregi Lobera*

> *"In psychosomatic diseases the body takes the voice so that the emotions tell stories through their words that are the symptoms".*

> > *Mejias [1]*

#### **Abstract**

Psychosomatic medicine (MP) and palliative care are disciplines with history and both are based in the scientific world. Although the psychosomatic diagnosis is exclusionary, it can help palliative care to be more effective. The influence of the psychosomatic in the palliative exists. According to all the bibliography available in the electronic databases, psychosomatic medicine is a biopsychosocial model related to both physical and psychosocial factors, which helps improve the care of patients with advanced cancer in palliative care (improved survival, quality of life, reduces the burden on caregivers). It helps analyze and address psychiatric disorders, as well as in the control of complex symptoms such as life-threatening anxiety, depression or delirium. Therefore, both medical disciplines are related from the beginning and help to the quality of life of terminally ill patients.

**Keywords:** palliative care, physical factors, quality of life, medical discipline, terminal illness

#### **1. Introduction**

The first great historical relationship between both disciplines is referenced by the Paracelsus himself who could inspire centuries later the great Professor Sigmund Freud, since he was the promater of psychotherapy as a science: psychoanalysis, as a part of the birth of medicine itself psychosomatic (MP). This conclusion is understood when reading Dr. Freud's own words about his own condition, that of an oncological disease for 26 years, caused by his smoking habit, of a squamous cell carcinoma of the palate and jaw, which led him to numerous interventions surgical and painful conditions [2, 3]. Although the breaking news pointed to morphine overdose as the immediate cause of death, the fundamental cause was that terminal tumor, which turned off the light of genius in London on 23 September 1939. If palliative care, a later discipline, had been able to intervene, they would have allowed relief from his suffering, from the symptoms that tormented him, and, consequently, a dignified, natural and not accelerated death.

**Psychosomatic medicine (PM)**, coined in 1818 by Heinroth, sought to relate psychosocial variables to psychophysiological changes. Although the first great evolution came from psychoanalysis, from 1965 this orientation changed towards other explanatory theoretical models based on the temporal and evolutionary analysis of the underlying disorder, somatic syndrome, pathogenesis, conflict, neurosis, personality, reliability of the signs, gains (primary and secondary) …, and thus reach from psychosomatic factors (alexithymia, demoralization, irritability, behavior A), to psychosomatic diseases (according to the Chicago school, chronic with outbreaks) such as high blood pressure, bronchial asthma, peptic ulcer, ulcerative colitis, rheumatoid arthritis, thyrotoxicosis, neurodermatitis.

This medicine "is not a specialty but rather a point of view that applies to all aspects of Medicine and Surgery. It does not mean studying the body less; it means studying the psyche more. It is a reaffirmation of the old principle that the mind and body are one, that they function as interactive and interdependent organs, a principle that has always guided the intelligent practical physician. As a science, psychosomatic medicine aims to discover the precise nature of the relationship between emotions and bodily function. Research in this field is based on the convergence of modern physiological research, as developed by laboratory science and animal experimentation, as well as the discoveries of psychoanalysis, as previously mentioned, both dynamic developments in medicine [4]. It is established from the 1960s of the twentieth century as a multifactorial biopsychosocial model for all disease processes and not only for a group of diseases [5, 6].

The American Board of Medical Specialties recognizes it as the subspecialty of Psychiatry that is dedicated to the diagnosis, treatment and prevention of psychiatric morbidity in medical patients, through psychiatric counseling and the training of health professionals, especially in the hospital context [7]. However, in essence, psychosomatic medicine is multidisciplinary for the evaluation of psychosocial factors involved in individual vulnerability within the disease, holistic clinical care and the integration of psychological interventions with therapeutic, preventive and rehabilitative functions of medical diseases [8].

There are various theories that guide the psychosomatic model in our times, highlighting the complexity of the reality of the problems and the need for an interdisciplinary and multidisciplinary vision. Although it is a way of understanding medicine referring to the concept of disease, it is usually associated in a restricted way with a group of diseases that are variable but superimposable according to many tendencies to the somatoform disorders of DSM-IV-TR, the result of the influence of American origins, where it is equated with the somatopsychic, defined as a psychic alteration that causes organic symptoms through the somatic nervous system (mainly vegetative). The DSM-V criteria for the diagnosis of disorders with somatic symptoms continue to be incomplete because they do not take into account disease behaviors, such as denial of disease or experimental avoidance, which can be very important in the effect on quality of life of patients, for example, in pain, or in palliative care [5, 9].

Circumscribing the psychosomatic as a psychological disorder that generates a physical effect, causing some consequence in the body, although practical, would limit our analysis, since psychosomatic medicine as an integrative science, always tries to overcome itself, fleeing from partial or reductionist visions for integrate the manifestations of the biological, psychological, social world in the understanding of the human being, that is, the support of the good doctor or health professional, whose objective is to help the sick person, integrating the humanistic essence. Possibly for this reason, Laín Entralgo, already defined it as *"an orientation of Medicine that is characterized by including in each medical act and in each clinical judgment, the consideration of unconscious emotions that contribute to each patient configuring a sick person in a situation different"*.

**75**

• Cancer.

• Advanced chronic heart disease.

• Advanced chronic kidney failure.

• Advanced lung disease.

○ Dementia.

• Advanced liver failure (liver cirrhosis).

• Chronic neurological disease. Highlight:

○ Advanced chronic cerebrovascular disease.

○ Motor neuron disease: amyotrophic lateral sclerosis (ALS).

*Psychosomatic Medicine and Palliative Care DOI: http://dx.doi.org/10.5772/intechopen.93154*

**Palliative care (PC)** is a relatively new field with which a good part of the health system professionals are not familiar, despite its importance. Callahan reminds us in a paradigmatic article in the New England Journal of Medicine, that the main goals of today's medicine are not only to diagnose and treat diseases, but also, and equally important, to help die in peace. The English word "care" has its root in the goth term "Kara", which means to grieve, suffer, cry out in pain. The one who really cares must join the other person in his suffering (caring is assisting). Paliar derives from "pallium" (from the Latin "under the Canopy") which means mitigating the violence of certain diseases by making them more bearable. Palliative care is to attend, with the intention of making the

Palliative care or "Hospice" care, as they were called from their origin in the fifth century, since they were carried out in hospices, led to the great modern movement in the United Kingdom in the 1960s–1970s of the twentieth century with Cicely Saunders as main figure and after expand to the rest of Europe, North America. The Hospice concept refers more to the physical structure of an organization, and PC would be a special type of care designed to provide well-being and support to patients and their families, in the final stages of a terminal illness (currently called advanced disease). Palliative Medicine from its first steps highlights two important aspects of medical ethics: respect for the weak and evicted, and recognition of the finite nature of curative medicine. Emphasize that palliative care offers the most basic of the concept of caring, covering the needs of the patient and their family regardless of where they are being cared for or the evolutionary stage of the underlying disease. They affirm life considering death as a normal biological process, that is, the final part of the life process (biography of the subject). Therefore, they seek to preserve the best possible quality of life to the end without accelerating or delaying death. This improvement in the quality of life of patients and their families is achieved by facing the many problems associated with a fatal disease through the prevention and relief of suffering, identifying early, assessing and using adequate treatments for pain and other physical, psychological, social and spritual problems. Its application, when necessary, ranges from the diagnosis of the disease to the death of the patient,

patient's coexistence with their disease more comfortable.

continuing with the care of the family in mourning [10, 11].

instrument, which basically includes the following diseases [12–15]:

Determining which diseases are subsidiary to PC is complex, although it is currently based on the well-known McNamara list, the recommendations of the National Hospice Organization (NHO) of 1996 and the NECPAL CCOMS-ICO©

#### *Psychosomatic Medicine and Palliative Care DOI: http://dx.doi.org/10.5772/intechopen.93154*

*Psychosomatic Medicine*

**Psychosomatic medicine (PM)**, coined in 1818 by Heinroth, sought to relate psychosocial variables to psychophysiological changes. Although the first great evolution came from psychoanalysis, from 1965 this orientation changed towards other explanatory theoretical models based on the temporal and evolutionary analysis of the underlying disorder, somatic syndrome, pathogenesis, conflict, neurosis, personality, reliability of the signs, gains (primary and secondary) …, and thus reach from psychosomatic factors (alexithymia, demoralization, irritability, behavior A), to psychosomatic diseases (according to the Chicago school, chronic with outbreaks) such as high blood pressure, bronchial asthma, peptic ulcer, ulcer-

This medicine "is not a specialty but rather a point of view that applies to all aspects of Medicine and Surgery. It does not mean studying the body less; it means studying the psyche more. It is a reaffirmation of the old principle that the mind and body are one, that they function as interactive and interdependent organs, a principle that has always guided the intelligent practical physician. As a science, psychosomatic medicine aims to discover the precise nature of the relationship between emotions and bodily function. Research in this field is based on the convergence of modern physiological research, as developed by laboratory science and animal experimentation, as well as the discoveries of psychoanalysis, as previously mentioned, both dynamic developments in medicine [4]. It is established from the 1960s of the twentieth century as a multifactorial biopsychosocial model for all

The American Board of Medical Specialties recognizes it as the subspecialty of Psychiatry that is dedicated to the diagnosis, treatment and prevention of psychiatric morbidity in medical patients, through psychiatric counseling and the training of health professionals, especially in the hospital context [7]. However, in essence, psychosomatic medicine is multidisciplinary for the evaluation of psychosocial factors involved in individual vulnerability within the disease, holistic clinical care and the integration of psychological interventions with therapeutic, preventive and

There are various theories that guide the psychosomatic model in our times, highlighting the complexity of the reality of the problems and the need for an interdisciplinary and multidisciplinary vision. Although it is a way of understanding medicine referring to the concept of disease, it is usually associated in a restricted way with a group of diseases that are variable but superimposable according to many tendencies to the somatoform disorders of DSM-IV-TR, the result of the influence of American origins, where it is equated with the somatopsychic, defined as a psychic alteration that causes organic symptoms through the somatic nervous system (mainly vegetative). The DSM-V criteria for the diagnosis of disorders with somatic symptoms continue to be incomplete because they do not take into account disease behaviors, such as denial of disease or experimental avoidance, which can be very important in the effect on quality of life of patients, for example, in pain, or in palliative care [5, 9]. Circumscribing the psychosomatic as a psychological disorder that generates a physical effect, causing some consequence in the body, although practical, would limit our analysis, since psychosomatic medicine as an integrative science, always tries to overcome itself, fleeing from partial or reductionist visions for integrate the manifestations of the biological, psychological, social world in the understanding of the human being, that is, the support of the good doctor or health professional, whose objective is to help the sick person, integrating the humanistic essence. Possibly for this reason, Laín Entralgo, already defined it as *"an orientation of Medicine that is characterized by including in each medical act and in each clinical judgment, the consideration of unconscious emotions that contribute to each patient configuring a sick person in a* 

ative colitis, rheumatoid arthritis, thyrotoxicosis, neurodermatitis.

disease processes and not only for a group of diseases [5, 6].

rehabilitative functions of medical diseases [8].

**74**

*situation different"*.

**Palliative care (PC)** is a relatively new field with which a good part of the health system professionals are not familiar, despite its importance. Callahan reminds us in a paradigmatic article in the New England Journal of Medicine, that the main goals of today's medicine are not only to diagnose and treat diseases, but also, and equally important, to help die in peace. The English word "care" has its root in the goth term "Kara", which means to grieve, suffer, cry out in pain. The one who really cares must join the other person in his suffering (caring is assisting). Paliar derives from "pallium" (from the Latin "under the Canopy") which means mitigating the violence of certain diseases by making them more bearable. Palliative care is to attend, with the intention of making the patient's coexistence with their disease more comfortable.

Palliative care or "Hospice" care, as they were called from their origin in the fifth century, since they were carried out in hospices, led to the great modern movement in the United Kingdom in the 1960s–1970s of the twentieth century with Cicely Saunders as main figure and after expand to the rest of Europe, North America. The Hospice concept refers more to the physical structure of an organization, and PC would be a special type of care designed to provide well-being and support to patients and their families, in the final stages of a terminal illness (currently called advanced disease). Palliative Medicine from its first steps highlights two important aspects of medical ethics: respect for the weak and evicted, and recognition of the finite nature of curative medicine.

Emphasize that palliative care offers the most basic of the concept of caring, covering the needs of the patient and their family regardless of where they are being cared for or the evolutionary stage of the underlying disease. They affirm life considering death as a normal biological process, that is, the final part of the life process (biography of the subject). Therefore, they seek to preserve the best possible quality of life to the end without accelerating or delaying death. This improvement in the quality of life of patients and their families is achieved by facing the many problems associated with a fatal disease through the prevention and relief of suffering, identifying early, assessing and using adequate treatments for pain and other physical, psychological, social and spritual problems. Its application, when necessary, ranges from the diagnosis of the disease to the death of the patient, continuing with the care of the family in mourning [10, 11].

Determining which diseases are subsidiary to PC is complex, although it is currently based on the well-known McNamara list, the recommendations of the National Hospice Organization (NHO) of 1996 and the NECPAL CCOMS-ICO© instrument, which basically includes the following diseases [12–15]:

	- Advanced chronic cerebrovascular disease.
	- Motor neuron disease: amyotrophic lateral sclerosis (ALS).
	- Dementia.

It is estimated that the need for PC varies between 50 and 90% of patients who die, being higher during the last year of life. In absolute numbers, cases of nononcology are much more frequent, although the complexity of the cancer is usually greater, which explains at least in part that the scientific experience and clinical practice of tumor-related PC is greater. All health professionals must possess basic knowledge to care for these individuals and families, and in the most complex cases, it is when the Specific Palliative Care Teams or Units must intervene.

A disease is terminal if it has the following criteria:


So what criteria can we use to establish terminality or advanced disease?. Two types of criteria [1]:

	- a.Advanced age.
	- b.Comorbidity versus vulnerability.
	- c.Well-documented disease progression that has generated an increasing need for healthcare. It is established according to:
		- i.Clinical criteria.
			- Independently include advanced cognitive decline.
		- ii.Lab tests.
	- iii.Supplementary tests.
	- d.Emergencies or hospital admissions in the last 6 months, associated with:

**77**

*Psychosomatic Medicine and Palliative Care DOI: http://dx.doi.org/10.5772/intechopen.93154*

ii.Serum albumin <2.5 g/dl.

b.No cancer:

2.Specific to the disease. Two subgroups:

i.Advanced organic insufficiencies.

normal life, such as cystic fibrosis.

ability, such as cerebral palsy.

e.Nutritional impairment or malnutrition:

i.Weight loss >10% in the last 6 months.

a.Cancer: They are mainly based on the histology and staging of the tumor.

ii.Advanced degenerative diseases of the central nervous system.

3.Diseases with premature death with long periods of treatment to promote a

4.Non-progressive irreversible diseases, which cause great disability and vulner-

There is an instrument that helps to identify advanced terminal disease and the need for PC, which is the NECPAL CCOMS-ICO© instrument for the identification of people in a situation of advanced or terminal chronic disease (oncological or non-oncological) and need for care palliative in Health and Social Services. Its application is aimed at the subsidiary diseases of PC referred to above. Thanks to it, it is possible to detect at a certain moment if the person with an advanced disease requires palliative care, that is, to have quality of life and comfort as a fundamental objective, without ruling out other curative therapeutic measures provided for the clinical and evolutionary state of the subject. Such care is normally welcomed by conventional health resources, and in the most difficult or complex cases, a

The question in its three aspects: *how much do I have left to live*?*; How much does* 

*my loved one have left?; how much does my patient have left?*. These are constant questions when faced with a terminal illness in the final phase of life. But this issue is also fundamental for the health professional, since life estimation is fundamental for clinical decision-making and for the proper management of therapies, including communicative ones, such as giving bad news. The possible answer would be made

2.Estimation of life prognosis. There is no single standard method for this due to its complexity. From the study of a multitude of variables, especially in the terminal cancer patient, a multitude of prognostic indices have been designed

In the case of children, terminality is grouped into four groups:

2.Progressive diseases without cure such as muscular dystrophy.

1.Serious potentially curable diseases, such as cancer.

Specialized Palliative Care Team will intervene [13, 16, 17].

as three questions to answer reflected in **Figure 1** [1, 18, 19]:

1.Presence of terminal illness.


*Psychosomatic Medicine and Palliative Care DOI: http://dx.doi.org/10.5772/intechopen.93154*

	- i.Weight loss >10% in the last 6 months.
	- ii.Serum albumin <2.5 g/dl.
	- a.Cancer: They are mainly based on the histology and staging of the tumor.

b.No cancer:

*Psychosomatic Medicine*

• Advanced AIDS.

○ Advanced Parkinson's disease.

○ Advanced Huntington's disease.

○ Advanced Alzheimer's disease.

• Geriatric patient with advanced frailty.

It is estimated that the need for PC varies between 50 and 90% of patients who die, being higher during the last year of life. In absolute numbers, cases of nononcology are much more frequent, although the complexity of the cancer is usually greater, which explains at least in part that the scientific experience and clinical practice of tumor-related PC is greater. All health professionals must possess basic knowledge to care for these individuals and families, and in the most complex cases,

1.Advanced and incurable and progressive disease, without reasonable possibilities of response to its specific treatment, and with a limited prognosis for life.

3.Great emotional impact on patients, families and professionals, which gener-

So what criteria can we use to establish terminality or advanced disease?. Two

c.Well-documented disease progression that has generated an increasing need

d.Emergencies or hospital admissions in the last 6 months, associated with:

it is when the Specific Palliative Care Teams or Units must intervene.

2.Presence of intense and changing multifactorial symptoms.

A disease is terminal if it has the following criteria:

○ Persistent vegetative states.

ates a great demand for care.

types of criteria [1]:

a.Advanced age.

i.Clinical criteria.

iii.Supplementary tests.

i.Recent functional impairment.

ii.Lab tests.

1.General.

4.Implicit or explicit presence of death.

b.Comorbidity versus vulnerability.

for healthcare. It is established according to:

• Independently include advanced cognitive decline.

ii.Dependency for at least three basic activities of daily life.

**76**


In the case of children, terminality is grouped into four groups:


There is an instrument that helps to identify advanced terminal disease and the need for PC, which is the NECPAL CCOMS-ICO© instrument for the identification of people in a situation of advanced or terminal chronic disease (oncological or non-oncological) and need for care palliative in Health and Social Services. Its application is aimed at the subsidiary diseases of PC referred to above. Thanks to it, it is possible to detect at a certain moment if the person with an advanced disease requires palliative care, that is, to have quality of life and comfort as a fundamental objective, without ruling out other curative therapeutic measures provided for the clinical and evolutionary state of the subject. Such care is normally welcomed by conventional health resources, and in the most difficult or complex cases, a Specialized Palliative Care Team will intervene [13, 16, 17].

The question in its three aspects: *how much do I have left to live*?*; How much does my loved one have left?; how much does my patient have left?*. These are constant questions when faced with a terminal illness in the final phase of life. But this issue is also fundamental for the health professional, since life estimation is fundamental for clinical decision-making and for the proper management of therapies, including communicative ones, such as giving bad news. The possible answer would be made as three questions to answer reflected in **Figure 1** [1, 18, 19]:


**Figure 1.**

*Algorithm for the management of terminal illness, prognosis and last days of life (authorized by the author [1]).*

based on laboratory tests, functional status, symptoms, signs and subjective clinical impression of the prognosis. The vital prognosis in non-oncological disease is more difficult to determine, so the need for palliative care will be given by the presence of organic failure and irreversible progressive deterioration with unrelieved suffering. It will be based on the analysis of the functionality of the patient, clinical estimation of the expert professional, present symptoms and laboratory analysis.

3.The third question is the culmination of the person's end of life, in which death comes progressively (as opposed to sudden death). It is the situation of the last days of life or state of pre-agony or agony, which indicates that death is next (between hours and a few days). It would be the last stage of a terminal illness known as the End of Life Phase (FFV). Therefore, it is a phase that precedes death when it occurs gradually (hours, days) with signs that begin with severe asthenia associated with bedriddenness, loss of interest in the surroundings, development of a semi-comatose state, intake limited to liquids or small sips (including total dysphagia), with the inability to take oral medication, it is establishing a very short life prognosis. The treatment is supportive, aimed at intensifying comfort and reducing suffering as much as possible, given that symptoms that cause discomfort to the dying person are frequent, for which fortunately we have effective medications, usually administered subcutaneously (more frequent at home) or intravenous (most often used in hospitals). In the necessary cases, palliative sedation will be applied in order to control the refractory symptoms and alleviate the suffering of the patient.

The great contributions of Palliative Care to Medicine are [1, 10, 19–22]:


**79**

Oncology [28].

*Psychosomatic Medicine and Palliative Care DOI: http://dx.doi.org/10.5772/intechopen.93154*

delirium and depression.

region [23, 24].

control delirium associate [25].

tion of the real state of the patient [11, 26].

3.To confront the symptoms from a practical and decisive point of view so that their control allows helping the patient to have the greatest possible wellbeing, regardless of the evolutionary stage of their disease. It is common to confuse pain (*"Unpleasant sensory and emotional experience, associated with actual or potential tissue damage, or described in terms of such damage",* defined in 1979 by the International Association for the study of pain or IASP) and suffering (grief). In Palliative Care there are 56 definitions of suffering, showing that although there are deficiencies in its definition, its relevance in the deep personal anguish it causes, especially in the last year of life, makes the person more vulnerable. Its most frequent causes are pain, dyspnea,

4.Communication and emotional coping skills (especially for bad news, trustworthy therapeutic relationship acquisition or emotional ventilation).

**Psycho-oncology** (term that is related to Psychosomatic Medicine and Palliative Care) studies the impact of cancer on the psychological function of patients and their families. It arises, among other influences, from the PM as a need to respond to the needs of the cancer patient, from which the PC has tried to benefit. Its evolution has been possible thanks to the sustained advancement of multiple disciplines such as Oncology (Medical and Radiotherapy), Epidemiology, Surgery, Immunology, Genetics, Endocrinology, Sociology and Bioethics, among others, providing updated assistance protocols comprehensive for terminally ill patients in the Palliative Care Units. This development has clearly contributed to the development of the psychological and psychiatric aspects linked to cancer. Thus, as we have reiterated, it contributes to a better quality of life for cancer patients from the initial impact of the diagnosis. Adjustment disorders, related major depressive disorder, and acute confusional syndrome (delirium) are common. There are effective treatment protocols for such adapted pathologies in each

Psychosomatic physicians can play an important role in the field of cancer treatment through psycho-oncological activities such as psychological support after receiving bad news, before and/or after surgery and in chemotherapy cycles to

Within the biopsychosocial framework and from the knowledge coming from the Psycho-oncology and the PC, one of the great problems is addressed which is the *Pact or Conspiracy of Silence*. This is usually defined as an agreement, implicit or explicit, between family members, relatives and health professionals, to hide or distort information about the patient's diagnostic, prognostic and/or therapeutic situation, in order to avoid the suffering of facing the end of your own life. This information deficit is regarding not only the diagnosis, but also and above all the prognosis. Only between 15 and 21% of people at the end of their lives know their diagnosis and prognosis, being the most important factor when communicating the diagnosis the fear of negative repercussions that may result from the communica-

The idea behind this chapter is that PM and PC are related disciplines. I am pleased to find, albeit to a much lesser extent than we would like, that there is an attempt to verify this interrelation. For example, in Romania, how life experiences imprint the possible relationship of somatic effects in terminal diseases, especially cancer [27] or as a professional paradigm of life, represented in Dr. Arthur H. Schmale, who advocated the relationship between PC, PM, and Psychosocial

#### *Psychosomatic Medicine and Palliative Care DOI: http://dx.doi.org/10.5772/intechopen.93154*

*Psychosomatic Medicine*

laboratory analysis.

**Figure 1.**

of the patient.

based on laboratory tests, functional status, symptoms, signs and subjective clinical impression of the prognosis. The vital prognosis in non-oncological disease is more difficult to determine, so the need for palliative care will be given by the presence of organic failure and irreversible progressive deterioration with unrelieved suffering. It will be based on the analysis of the functionality of the patient, clinical estimation of the expert professional, present symptoms and

*Algorithm for the management of terminal illness, prognosis and last days of life (authorized by the author [1]).*

3.The third question is the culmination of the person's end of life, in which death comes progressively (as opposed to sudden death). It is the situation of the last days of life or state of pre-agony or agony, which indicates that death is next (between hours and a few days). It would be the last stage of a terminal illness known as the End of Life Phase (FFV). Therefore, it is a phase that precedes death when it occurs gradually (hours, days) with signs that begin with severe asthenia associated with bedriddenness, loss of interest in the surroundings, development of a semi-comatose state, intake limited to liquids or small sips (including total dysphagia), with the inability to take oral medication, it is establishing a very short life prognosis. The treatment is supportive, aimed at intensifying comfort and reducing suffering as much as possible, given that symptoms that cause discomfort to the dying person are frequent, for which fortunately we have effective medications, usually administered subcutaneously (more frequent at home) or intravenous (most often used in hospitals). In the necessary cases, palliative sedation will be applied in order to control the refractory symptoms and alleviate the suffering

The great contributions of Palliative Care to Medicine are [1, 10, 19–22]:

2.Give quality of life to life, helping the patient and the family in their suffering.

1.Accept death as a biological and natural process.

**78**


**Psycho-oncology** (term that is related to Psychosomatic Medicine and Palliative Care) studies the impact of cancer on the psychological function of patients and their families. It arises, among other influences, from the PM as a need to respond to the needs of the cancer patient, from which the PC has tried to benefit. Its evolution has been possible thanks to the sustained advancement of multiple disciplines such as Oncology (Medical and Radiotherapy), Epidemiology, Surgery, Immunology, Genetics, Endocrinology, Sociology and Bioethics, among others, providing updated assistance protocols comprehensive for terminally ill patients in the Palliative Care Units. This development has clearly contributed to the development of the psychological and psychiatric aspects linked to cancer. Thus, as we have reiterated, it contributes to a better quality of life for cancer patients from the initial impact of the diagnosis. Adjustment disorders, related major depressive disorder, and acute confusional syndrome (delirium) are common. There are effective treatment protocols for such adapted pathologies in each region [23, 24].

Psychosomatic physicians can play an important role in the field of cancer treatment through psycho-oncological activities such as psychological support after receiving bad news, before and/or after surgery and in chemotherapy cycles to control delirium associate [25].

Within the biopsychosocial framework and from the knowledge coming from the Psycho-oncology and the PC, one of the great problems is addressed which is the *Pact or Conspiracy of Silence*. This is usually defined as an agreement, implicit or explicit, between family members, relatives and health professionals, to hide or distort information about the patient's diagnostic, prognostic and/or therapeutic situation, in order to avoid the suffering of facing the end of your own life. This information deficit is regarding not only the diagnosis, but also and above all the prognosis. Only between 15 and 21% of people at the end of their lives know their diagnosis and prognosis, being the most important factor when communicating the diagnosis the fear of negative repercussions that may result from the communication of the real state of the patient [11, 26].

The idea behind this chapter is that PM and PC are related disciplines. I am pleased to find, albeit to a much lesser extent than we would like, that there is an attempt to verify this interrelation. For example, in Romania, how life experiences imprint the possible relationship of somatic effects in terminal diseases, especially cancer [27] or as a professional paradigm of life, represented in Dr. Arthur H. Schmale, who advocated the relationship between PC, PM, and Psychosocial Oncology [28].

### **2. Relationship study (PM and PC)**

The first known article that related both concepts in an indirect way was van der Valk [29], since he commented on the psychological aspects of palliative treatment of malignant tumors with a small psychosomatic veneer. In that same year, H. Zalce in the medical journal Gaceta de México, spoke in a shallow way when referring to the scarce training of doctors in the therapeutic management of advanced cancer. Geriatrician Dr. A. Verwoerdt, from the Southern American Medical Association, began to relate a little more, almost unintentionally, the importance of both, in reference to palliative care in the communication process, especially the bad news, becoming from the early 70s, a promoter of Counseling and of the psychological stress responses of physical illnesses, that is, he traveled from palliative to Psychosomatic Medicine, to finish the last third of his career focusing on study of sexual behavior [30–32].

It is in May 1965, when the German B. Staehelin, deals specifically with Psychosomatic Medicine (PM) and Palliative Care (CP) in a German magazine [33]. It showed that an adequate psychosomatic approach helped physicians to better treat patients with advanced cancer, subsidiaries of Palliative Care (PC).

The relevant aspects of this research that show the concern of Psychosomatic Medicine in Palliative Care and its interrelation, contain the following eight thematic pillars (summarized in **Table 1**):


Psychosomatic medicine deals with relevant aspects in improving the survival of cancer patients. An aging population, advances in diagnosis and treatment, have led to a rapidly growing population of people affected by cancer. People live longer after a cancer diagnosis, tolerating more advanced and even aggressive treatments more and better than in times past. In the evolution of tumors, there is an impact on the quality of life, with a psychological repercussion, where Psychiatry, Psychology, Psychotherapy, Mental Health Services, in short, provide tools to all professionals (doctors, nurses, social workers, physiotherapists, psychologists, trained volunteers, etc.), who have contact with these patients and their families, many medical specialties: Medical Oncology, Radiation Oncology, Internal Medicine, Primary Care, Psychiatry, Pediatric, Emergency Medicine, other medical and/or surgical specialties (Cardiology, Dermatology, Endocrine, Nephrology, Pulmonology, Neurology, Rheumatology, Gynecology, General, Digestive, Cardiovascular, Neurosurgery, Traumatology, Maxillofacial, Otorhinolaryngology, Ophthalmology, Urology). Therefore, the increase in life expectancy in cancer has increased interest for its impact on psychosocial problems and quality of life, rather than just focusing on longevity [37].

Psychiatry has been collaborating more and more with the above all hospitable services of palliative care, although there is much to improve because it is not a general trend [36].

**81**

*Psychosomatic Medicine and Palliative Care DOI: http://dx.doi.org/10.5772/intechopen.93154*

2. Improved care in PC (especially

3. Analysis of psychiatric disorders in

5. Symptom control (especially in

6. Psychotherapy to patients and family (basic concepts)

terminal cancer)

cancer patients in PC

advanced cancer)

**Thematic area Relevant ideas** Featured authors

• Decreased load • Improved survival • Impact on quality of life • Psychiatry (area of work to be

developed)

• Early detection • Specific derivation • Psychosocial suffering • Psychosocial interview

• Disorders:

○ Delirium

4. Bad news communication • Kübler-Ross phases

7. Psychotherapeutic interventions • Emotional Support

○ Adaptive (anxiety, depression)

• Denial, anger, negotiation, depres-

• Cancer as a stressful life event • Impaired quality of life • Fatigue by compassion of professionals • Depression in cancer • Anorexia in cancer

• Psychosomatic symptoms

sion, acceptance

• Anxiety before death • Chronic pain

• Psychoeducation • Cognitive-behavioral (self-regulation) • Individual ○ Mindfulness ○ Counseling

○ Others • Group • Specific

○ Meditation and hypnosis

• Life distress

[35]

[33] [35] [36] [37]

[38] [39] [37] [40]

[41] [37]

[42] [37] [43] [44] [45]

[46] [47] [48] [49] [50]

[51] [52] [37] [53] [54]

1. Biopsychosocial model • Psychosocial support [34]

*Psychosomatic Medicine and Palliative Care DOI: http://dx.doi.org/10.5772/intechopen.93154*

*Psychosomatic Medicine*

sexual behavior [30–32].

matic pillars (summarized in **Table 1**):

**2. Relationship study (PM and PC)**

The first known article that related both concepts in an indirect way was van der Valk [29], since he commented on the psychological aspects of palliative treatment of malignant tumors with a small psychosomatic veneer. In that same year, H. Zalce in the medical journal Gaceta de México, spoke in a shallow way when referring to the scarce training of doctors in the therapeutic management of advanced cancer. Geriatrician Dr. A. Verwoerdt, from the Southern American Medical Association, began to relate a little more, almost unintentionally, the importance of both, in reference to palliative care in the communication process, especially the bad news, becoming from the early 70s, a promoter of Counseling and of the psychological stress responses of physical illnesses, that is, he traveled from palliative to Psychosomatic Medicine, to finish the last third of his career focusing on study of

It is in May 1965, when the German B. Staehelin, deals specifically with Psychosomatic Medicine (PM) and Palliative Care (CP) in a German magazine [33]. It showed that an adequate psychosomatic approach helped physicians to better

The relevant aspects of this research that show the concern of Psychosomatic Medicine in Palliative Care and its interrelation, contain the following eight the-

1.Psychosomatic medicine is based on a biopsychosocial model related to physical and psychosocial factors, with many similar points of view in General Medicine, Psychosomatic Medicine and Palliative Care [35]. Thus, the PM also

2.Psychosomatic medicine helps physicians to improve the care of patients with advanced cancer in palliative care [33], to get better the satisfaction of their own illness and at the same time helps to reduce the overload of professionals

Psychosomatic medicine deals with relevant aspects in improving the survival of cancer patients. An aging population, advances in diagnosis and treatment, have led to a rapidly growing population of people affected by cancer. People live longer after a cancer diagnosis, tolerating more advanced and even aggressive treatments more and better than in times past. In the evolution of tumors, there is an impact on the quality of life, with a psychological repercussion, where Psychiatry, Psychology, Psychotherapy, Mental Health Services, in short, provide tools to all professionals (doctors, nurses, social workers, physiotherapists, psychologists, trained volunteers, etc.), who have contact with these patients and their families, many medical specialties: Medical Oncology, Radiation Oncology, Internal Medicine, Primary Care, Psychiatry, Pediatric, Emergency Medicine, other medical and/or surgical specialties (Cardiology, Dermatology, Endocrine, Nephrology, Pulmonology, Neurology, Rheumatology, Gynecology, General, Digestive, Cardiovascular, Neurosurgery, Traumatology, Maxillofacial, Otorhinolaryngology, Ophthalmology, Urology). Therefore, the increase in life expectancy in cancer has increased interest for its impact on psychosocial

problems and quality of life, rather than just focusing on longevity [37].

Psychiatry has been collaborating more and more with the above all hospitable services of palliative care, although there is much to improve because it is not a

treat patients with advanced cancer, subsidiaries of Palliative Care (PC).

helps cancer survivors as psychosocial support services [34].

in palliative care that cares for patients and their families [35].

**80**

general trend [36].



**Table 1.**

*Thematic summary of Psychosomatic Medicine in Palliative Care.*

3.The psychosomatic spectrum analyzes psychiatric disorders in cancer patients and very sensitively when they are also subsidiaries of palliative care. A double operational advantage is provided: teaching professionals to detect the most common problems in order to address them and specifically refer experts (psychiatrists, physiotherapists, psychologists,…) when it'd been necessary [37, 38].

A fundamental question is to measure the presence of mental disorders. There are many different variables that act as factors on individual vulnerability (for example, life events, chronic stress, well-being and health attitudes) and the psychosocial correlates of medical illness (for example, psychiatric disorders, psychological symptoms, disease behavior, quality of life,…), which are possibly involved not only in classic psychiatric disorders, but more broadly in psychosocial suffering in cancer and in Palliative Care. There are many studies, so we summarize the highlights of this analysis [37–40]:

	- Adaptive disorder (68%) with depressed and/or anxious mood. It's a response to a vital stressor that produces harmful interference in the social role. It requires a follow-up to differentiate it from depressive or anxiety disorders.
	- Others (10–34%): major depression, anxiety disorders, delirium or acute confusional syndrome (more frequent in the last days of life).

**83**

to acceptance.

*Psychosomatic Medicine and Palliative Care DOI: http://dx.doi.org/10.5772/intechopen.93154*

phenomenology stands out [37, 41]:

• In specific types of cancer, for example prostate cancer, depression is more

4.People diagnosed with cancer, their families and close friends experience normalized responses, such as those derived from the impact as bad news of having a tumor (knowledge of diagnosis and/or prognosis), initially described by Elizabeth Kübler-Ross in 1969, in the following phases where psychosomatic

• *Denial (Phase I)*. It's an isolation phase as a defense mechanism against the perception of the disease and its consequences. The information received produces an emotional impact, which requires progressive and usually adaptive elaboration. Therefore, if it's maintained throughout the disease process, it becomes a difficult pathology to treat. The most convenient attitude on the part of professionals is respect, trying to combat it with patience and delicacy, without reinforcing denial with lies. Communication skills are essential.

• *Fury or anger (Phase II)*. It's characterized by outrage and the fight against the inevitable, looking for guilty people. Anger is a feeling that appears at the perception of injustice due to illness. It's important that this fury directed at oneself, the family for not having cared for the patient, friends, work environment, superior forces (like God), but especially towards the health workers, the doctor who did not detect the pathology, the tests that took time to carry out, the medication that was not effective,... It's essential to know that this is not a personal attack, so the professional should not judge or participate in the

• *Negotiation (looking for a pact: Phase III).* It's a pact that faces reality but looks for the possibility of improvement, cure or even miracle. Pacts are made with a supreme being (in our culture it would be God), others and oneself. The attitude towards this phase will have to be formed by tolerance, respect, without prejudices. The patient can seek relief in other complementary or less conventional therapies, so an integrative and communicative medicine should be promoted. Dialog is specially important to face this phase.

• *Depression (Phase IV)*. The disease progresses and cannot escape from reality, adopting different attitudes: crying, sadness, indifference, isolation,... Although it's a very hard phase for the family and the health workers, it can be an adaptive mechanism and the beginning of acceptance. That is why we must maximize communication skills, knowing how to be active listening,

• *Acceptance (Phase V).* After the depression phase, the inevitability progression of the disease and the physical-psychological exhaustion, can reach a degree of acceptance of reality, entering a state of serenity, tranquility and inner peace that's always recommended, although not always possible. Spiritual needs take on greater importance at this time, and farewells are

These phases do not always appear all of them nor do they have to be consecutive. Each person has a phase rhythm, so that for example one person can be angry (Phase II) throughout the disease process and another can come directly

managing silences and promoting emotional expression.

important to close life cycles and unfinished situations.

frequent in the elderly and anxiety in young adults.

confrontation. Self-blame involves extra suffering.

*Psychosomatic Medicine*

necessary [37, 38].

**Table 1.**

enhancer.

most frequent are:

summarize the highlights of this analysis [37–40]:

3.The psychosomatic spectrum analyzes psychiatric disorders in cancer patients and very sensitively when they are also subsidiaries of palliative care. A double operational advantage is provided: teaching professionals to detect the most common problems in order to address them and specifically refer experts (psychiatrists, physiotherapists, psychologists,…) when it'd been

**Thematic area Relevant ideas** Featured authors

• Caregivers (overload) • Anxiety about death and relationships

• Assessment and perception of health care received • Place of exitus • Attention to grief

[55] [49] [56] [57] [58] [59] [50] [50] [60] [61] [62]

• Pediatric PC

8. Others aspects of interest • Non-cancer PC

*Thematic summary of Psychosomatic Medicine in Palliative Care.*

A fundamental question is to measure the presence of mental disorders. There are many different variables that act as factors on individual vulnerability (for example, life events, chronic stress, well-being and health attitudes) and the psychosocial correlates of medical illness (for example, psychiatric disorders, psychological symptoms, disease behavior, quality of life,…), which are possibly involved not only in classic psychiatric disorders, but more broadly in psychosocial suffering in cancer and in Palliative Care. There are many studies, so we

• The specific psychosocial interview with diagnostic criteria for psychosomatic research (known as Diagnostic Criteria for Psychosomatic Research or DCPR) represents a way to detect and evaluate emotional distress, anxiety, depression, wrong coping, dysfunctional attachment and other dimensions psychosocial. Intercultural problems, such as language, ethnicity, race, and religion, are also discussed as possible factors influencing perception of the disease in patients and families (another important aspects may be survival

mechanisms and the psychological response to cancer diagnosis).

• Psychiatric disorders can be found in up to 47% of cancer patients. In some cases they are direct responses to this disease, in others it acts as a trigger or

• Psychiatric disorders depend mainly on individual factors. In cancer the

○ Adaptive disorder (68%) with depressed and/or anxious mood. It's a response to a vital stressor that produces harmful interference in the social role. It requires a follow-up to differentiate it from depressive or anxiety disorders.

○ Others (10–34%): major depression, anxiety disorders, delirium or acute

confusional syndrome (more frequent in the last days of life).

**82**

	- *Denial (Phase I)*. It's an isolation phase as a defense mechanism against the perception of the disease and its consequences. The information received produces an emotional impact, which requires progressive and usually adaptive elaboration. Therefore, if it's maintained throughout the disease process, it becomes a difficult pathology to treat. The most convenient attitude on the part of professionals is respect, trying to combat it with patience and delicacy, without reinforcing denial with lies. Communication skills are essential.
	- *Fury or anger (Phase II)*. It's characterized by outrage and the fight against the inevitable, looking for guilty people. Anger is a feeling that appears at the perception of injustice due to illness. It's important that this fury directed at oneself, the family for not having cared for the patient, friends, work environment, superior forces (like God), but especially towards the health workers, the doctor who did not detect the pathology, the tests that took time to carry out, the medication that was not effective,... It's essential to know that this is not a personal attack, so the professional should not judge or participate in the confrontation. Self-blame involves extra suffering.
	- *Negotiation (looking for a pact: Phase III).* It's a pact that faces reality but looks for the possibility of improvement, cure or even miracle. Pacts are made with a supreme being (in our culture it would be God), others and oneself. The attitude towards this phase will have to be formed by tolerance, respect, without prejudices. The patient can seek relief in other complementary or less conventional therapies, so an integrative and communicative medicine should be promoted. Dialog is specially important to face this phase.
	- *Depression (Phase IV)*. The disease progresses and cannot escape from reality, adopting different attitudes: crying, sadness, indifference, isolation,... Although it's a very hard phase for the family and the health workers, it can be an adaptive mechanism and the beginning of acceptance. That is why we must maximize communication skills, knowing how to be active listening, managing silences and promoting emotional expression.
	- *Acceptance (Phase V).* After the depression phase, the inevitability progression of the disease and the physical-psychological exhaustion, can reach a degree of acceptance of reality, entering a state of serenity, tranquility and inner peace that's always recommended, although not always possible. Spiritual needs take on greater importance at this time, and farewells are important to close life cycles and unfinished situations.

These phases do not always appear all of them nor do they have to be consecutive. Each person has a phase rhythm, so that for example one person can be angry (Phase II) throughout the disease process and another can come directly to acceptance.

	- In the process of oncological disease, psychological or vital anguish (valued through emotional reactions, physical restrictions, communication deficits, negative social reactions, pain and gastrointestinal symptoms) has a prominent psychosomatic role, the origin of which emanates from the four main actors involved in the palliative disease process [37, 42]:
		- Patient.
		- Family.
		- Health professionals.
		- Society and culture.

Understanding these factors allows professionals involved in cancer to better assess the patient and adapt therapies in a more personalized way, also helping their families, because cancer is a stressful life event (SLE), tumor pathology involves a change of life throughout the family, especially when the patient is a child, in addition to developmental problems and cognitive disorders, behavioral changes (including schooling), financial difficulties... Young adults fight especially for the changes that the disease implies in the work and in their social or personal relationships. The elderly focus on the challenge of aging and cancer.

Therefore, the psychological and social care of cancer patients is part of quality medical care, and training professionals in diagnostic (test, questionnaires...) and therapeutic techniques (psychotherapy, pharmacology...) are priority needs.


6.The PM investigates relevant aspects of psychotherapy in Palliative Care.

• It's common for the family to hide both what they know and their negative emotions (anxiety, fear, sadness ...) to the cancer patient's dying [49]. It's shown that this process also influences caregivers [50].

**85**

*Psychosomatic Medicine and Palliative Care DOI: http://dx.doi.org/10.5772/intechopen.93154*

therapies [37, 51–54]:

hope.

• The presence of chronic pain in general (whether oncological or non-oncological), and particularly in terminal illnesses, should benefit from psychological therapies applied, both for seniors, adults and children [46–48].

7.The types of recommended psychotherapeutic interventions that have shown improvement in the quality of life, anxiety and distress of cancer patients are short-term therapies, aimed at supporting and helping in their anxiety and stress crises. Obviously, these therapies often require psychotropic drugs to control symptoms, especially anxiety, depression, negative thoughts, conduct disorders, etc. Therefore, the following are included as types of recommended

• Emotional *support to the patient and caregivers* (essential treatment). Through like-minded thinking (empathy), a comprehensive and integrative vision of personal life can be provided, transferring a coherent, real and meaningful

• *Psychoeducation.* It can be carried out by other members of the health team,

• *Cognitive and behavioral therapies,* especially self-regulation (for example, relaxation exercises, distraction tools, rehearsal of dreaded events, suggestion ...). They are especially effective in pain, fatigue and post-chemotherapy emetic

○ Mindfulness: effective technique especially for anxiety and depression. It's popular on PC because is widely used in professionals' self-care. It's a person-centered therapy, based on meditation and compassion, to reduce

○ Counseling: therapy that helps especially in the existential crisis of a tumor, especially if it's advanced. It's about guiding and advising from empathetic listening to be able to handle negative thoughts and the emotions that are generated. It's a therapy frequently followed in PC, applicable

○ Meditation and hypnosis: neuropsychobiological management of stress and anxiety, although it has also been used for difficult pain, nausea and

○ Others: psychotherapy focused on meaning, therapy for preserving

group therapy for caregirvers of patiente with long survival.

• *Specific treatment implemented by specialists in Mental Health Systems* (Psychotherapy, Psychopharmacology, other interventions such as psychological support, among others...). This type of intervention is formally requested in appropriate situations where patients face challenges, especially

• *Group psychotherapy*. Its objective is to educate, guide and reduce social isolation. Couples and family therapy are included. A very important example is

and helps to know the disease, its natural evolution...

syndrome, especially if they are done preventively.

anxiety and strengthen resilience and motivation.

to patients, family and health personnel.

vomiting.

dignity ...

• *Individual psychotherapy*. Are included:

*Psychosomatic Medicine*

symptoms to treat.

○ Patient.

○ Family.

aging and cancer.

priority needs.

work environment in general [37].

loss of quality [44].

○ Health professionals.

○ Society and culture.

5.The importance of recognizing and addressing symptoms is the principle on which PC are based. PM brings its vision to some of the more complex

actors involved in the palliative disease process [37, 42]:

• In the process of oncological disease, psychological or vital anguish (valued through emotional reactions, physical restrictions, communication deficits, negative social reactions, pain and gastrointestinal symptoms) has a prominent psychosomatic role, the origin of which emanates from the four main

Understanding these factors allows professionals involved in cancer to better assess the patient and adapt therapies in a more personalized way, also helping their families, because cancer is a stressful life event (SLE), tumor pathology involves a change of life throughout the family, especially when the patient is a child, in addition to developmental problems and cognitive disorders, behavioral changes (including schooling), financial difficulties... Young adults fight especially for the changes that the disease implies in the work and in their social or personal relationships. The elderly focus on the challenge of

Therefore, the psychological and social care of cancer patients is part of quality medical care, and training professionals in diagnostic (test, questionnaires...) and therapeutic techniques (psychotherapy, pharmacology...) are

• Burnout and compassion fatigue of health professionals who care for cancer patients can have two major problems for themselves: professional and personal damage and the negative repercussion on patient care and on the

• Depression in cancer patients is a frequent symptom. PM tries to study its relationship with age, where it seems that there is an inverse relationship, improving depression with increasing age or senescence [43]. Likewise, it has helped to show the negative impact of depression on cancer, measured by quality-adjusted life year. That is, if depression exists, life is shorter and with

• Anorexia is one of the most frequent symptoms in patients with terminal cancer. It's characterized by a lack of appetite, where treatment is very

• It's common for the family to hide both what they know and their negative emotions (anxiety, fear, sadness ...) to the cancer patient's dying [49]. It's

limited, especially with corticotherapy and antiestrogens [45].

shown that this process also influences caregivers [50].

6.The PM investigates relevant aspects of psychotherapy in Palliative Care.

**84**

	- Emotional *support to the patient and caregivers* (essential treatment). Through like-minded thinking (empathy), a comprehensive and integrative vision of personal life can be provided, transferring a coherent, real and meaningful hope.
	- *Psychoeducation.* It can be carried out by other members of the health team, and helps to know the disease, its natural evolution...
	- *Cognitive and behavioral therapies,* especially self-regulation (for example, relaxation exercises, distraction tools, rehearsal of dreaded events, suggestion ...). They are especially effective in pain, fatigue and post-chemotherapy emetic syndrome, especially if they are done preventively.
	- *Individual psychotherapy*. Are included:
		- Mindfulness: effective technique especially for anxiety and depression. It's popular on PC because is widely used in professionals' self-care. It's a person-centered therapy, based on meditation and compassion, to reduce anxiety and strengthen resilience and motivation.
		- Counseling: therapy that helps especially in the existential crisis of a tumor, especially if it's advanced. It's about guiding and advising from empathetic listening to be able to handle negative thoughts and the emotions that are generated. It's a therapy frequently followed in PC, applicable to patients, family and health personnel.
		- Meditation and hypnosis: neuropsychobiological management of stress and anxiety, although it has also been used for difficult pain, nausea and vomiting.
		- Others: psychotherapy focused on meaning, therapy for preserving dignity ...
	- *Group psychotherapy*. Its objective is to educate, guide and reduce social isolation. Couples and family therapy are included. A very important example is group therapy for caregirvers of patiente with long survival.
	- *Specific treatment implemented by specialists in Mental Health Systems* (Psychotherapy, Psychopharmacology, other interventions such as psychological support, among others...). This type of intervention is formally requested in appropriate situations where patients face challenges, especially

during active cancer treatment, survival, and in the worst case, end of life. However, there are disparities in criteria regarding these assumptions given that in clinical practice the cases are not always the same. Therefore, psychosomatic medicine tries to emphasize what are the most frequent stages in palliative care, in order to provide the best care for patients with severe cancer.

	- Palliative care in non-cancer patients, such as Phase IV and V advanced chronic kidney disease (end-stage renal disease). The stress of hemodialysis has a negative impact on the mental health of the patients. Spiritual wellbeing can be a great predictor of mental health, psychological distress, sleep disturbance, and psychosomatic complaints [63].
		- Palliative care in the pediatric age. Pathological behaviors produce symptoms, functional deterioration and difficulty in therapeutic coping. For this reason, integrated models of behavioral health care have been implemented to promote resilience (adaptability of a living being against a disturbing agent or an adverse state or situation) in: Oncology, PC, pain, Neuropsychiatry, Cystic Fibrosis and Transplants. This psychosomatic treatment helps the child comprehensively and effectively and reduces costs derived from tests and hospitalizations of pathologies such as asthma [58].
		- Caregivers and family. Throughout the chapter, we have emphasized the importance of the role of the family. We highlight the following studies:
			- a.In relatives of patients with cerebral malignancy, it's found that financial support in most cases does not exist, and that there is an increased risk of psychosomatic problems such as anxiety or depression. Caregivers worsen care overload, quality of life and mental state [55].
			- b.Caregiver burden is often a difficulty in increasing family satisfaction in end-of-life care at home. A caregiver burden-centered home care model could improve end-of-life experiences for patients and family caregivers [59].
			- c.Death anxiety can produce negative emotions that hinder the search for meaning in family members and in dying patients themselves with advanced or metastatic cancer. A study qualitative to highlight on these aspects investigated the relationship of a couple of patients diagnosed with melanoma along 6 months, revealing how the image of the relationship and its nature changed in a complex way, especially in aspects of care patterns, closeness, distance regulation and the communication process between each couple. Thus, 50% of the patients and their partners hid negative emotions to avoid worries in the other person (this phenomenon i more frequent in Latin and South American cultures). And yet in those who did not hide these emotions, changes continued to appear in the relationship. Using a scale such as the Death and Dying Distress Scale (DADDS) in the sessions, it was shown in this work how the score depended on the knowledge and reflective capacity of one's own death. Consequently, when anxiety is very high, high-intensity emotions dominate and hinder the search for meaning in their death

**87**

**3. Conclusions**

been accepted internationally in PC.

cachexia, among others.

*Psychosomatic Medicine and Palliative Care DOI: http://dx.doi.org/10.5772/intechopen.93154*

> process. On the contrary, if anxiety is low, there is more psychological preparation for death without the need to reflect on it. It's shown that this process influences both patients and their caregivers [49, 50, 56].

d.The majority of caregivers who lose loved ones in PC Units are satisfied with the behavior of doctors in the face of death, integrating professionalism and friendliness, being these factors most commonly associated

e.The place of exitus can have an effect on the grief of caregivers, where generally the quality of death is better at home or in Hospice compared to acute care hospitals. The most frequent causes of hospital admission are pain and dyspnea because they are the ones that generate the most

stress in the whole family, including the dying sick [50, 57].

the quality of life of the dying person's death [61, 62].

1.In the last 15 years, there has been an increase in electronic literature on PM and PC (especially scientific books and papers). Even so, there is "a lot of bibliographic noise" as in any search for information (large number of duplications, documents unrelated to search criteria, etc.), that make analysis of the relationship more difficult, in this case than usual of both medical disciplines. This is mainly due to the fact that the close relationship with the PM has not

2.Currently, the psychosomatic diagnosis is by exclusion, largely because

organic substrate of many diseases understood today as "mental".

more and more in all areas of research in Medicine.

Evidence-Based Medicine is based on the need to explain the existence of a palpable or visible substrate of the disease. It's probable that functional imaging tests (nuclear magnetic resonance imaging and others), will demonstrate the

3.Mental illness is one of the most striking complications in terminal illnesses, which could have the same or greater prognostic impact than the tumor stage, the leukocyte formula, the presence of symptoms such as delirium, dyspnea or

4.The influence of the psychosomatic world is objectified in the increase of electronic scientific resources in recent years. It's striking how from the oriental culture, mainly from Japan, the largest studies in reference to both disciplines of knowledge have come in last years, although this phenomenon is increasing

5.There is an influence of the PM on the PC, reflected to a lesser extent than the real one in the scientific literature, where Palliative Care in general as a

f. Family grief care is a reflection of the continuity of care before and after the death of the patient. After death (usually months and more in couples), depression, insufficient social support and decreased physical activity are frequent. Fluent communication, especially before death, helps reduce depression and complicated grief, improving coping and

with caregivers'satisfaction health care [60].

*Psychosomatic Medicine*

but important, which would be:

caregivers [59].

during active cancer treatment, survival, and in the worst case, end of life. However, there are disparities in criteria regarding these assumptions given that in clinical practice the cases are not always the same. Therefore, psychosomatic medicine tries to emphasize what are the most frequent stages in palliative care, in order to provide the best care for patients with severe cancer.

8.The PM has been concerned with other topics of interest in PC, less recognized

• Palliative care in non-cancer patients, such as Phase IV and V advanced chronic kidney disease (end-stage renal disease). The stress of hemodialysis has a negative impact on the mental health of the patients. Spiritual wellbeing can be a great predictor of mental health, psychological distress, sleep

○ Palliative care in the pediatric age. Pathological behaviors produce

symptoms, functional deterioration and difficulty in therapeutic coping. For this reason, integrated models of behavioral health care have been implemented to promote resilience (adaptability of a living being against a disturbing agent or an adverse state or situation) in: Oncology, PC, pain, Neuropsychiatry, Cystic Fibrosis and Transplants. This psychosomatic treatment helps the child comprehensively and effectively and reduces costs derived from tests and hospitalizations of pathologies such as asthma [58].

○ Caregivers and family. Throughout the chapter, we have emphasized the importance of the role of the family. We highlight the following studies:

worsen care overload, quality of life and mental state [55].

a.In relatives of patients with cerebral malignancy, it's found that financial support in most cases does not exist, and that there is an increased risk of psychosomatic problems such as anxiety or depression. Caregivers

b.Caregiver burden is often a difficulty in increasing family satisfaction in end-of-life care at home. A caregiver burden-centered home care model could improve end-of-life experiences for patients and family

c.Death anxiety can produce negative emotions that hinder the search for meaning in family members and in dying patients themselves with advanced or metastatic cancer. A study qualitative to highlight on these aspects investigated the relationship of a couple of patients diagnosed with melanoma along 6 months, revealing how the image of the relationship and its nature changed in a complex way, especially in aspects of care patterns, closeness, distance regulation and the communication process between each couple. Thus, 50% of the patients and their partners hid negative emotions to avoid worries in the other person (this phenomenon i more frequent in Latin and South American cultures). And yet in those who did not hide these emotions, changes continued to appear in the relationship. Using a scale such as the Death and Dying Distress Scale (DADDS) in the sessions, it was shown in this work how the score depended on the knowledge and reflective capacity of one's own death. Consequently, when anxiety is very high, high-intensity emotions dominate and hinder the search for meaning in their death

disturbance, and psychosomatic complaints [63].

**86**

process. On the contrary, if anxiety is low, there is more psychological preparation for death without the need to reflect on it. It's shown that this process influences both patients and their caregivers [49, 50, 56].


### **3. Conclusions**


discipline has not recognized this contribution. In the most professional in PC the PM is applied, although its deep association is unknown. Many aspects collected in the research in this chapter support the experience of palliative care professionals (the suffering of patients and relatives, the concern to protect the other from the disease and its consequences ...). More research is needed to help patients, families and healthcare professionals.


#### **Note**

This chapter is based on research awarded "In Memoriam Juan Rof Carballo" by the Royal Academy of Medicine and Surgery of Cadiz (Spain), at the titled "Psychosomatic Medicine and Palliative Care in the scientific literature", whose author was Mejias MD.

### **Author details**

Manuel Mejías-Estévez1,2,3\*, Rocio Dominguez Álvarez4 and Ignacio Jauregi Lobera5

1 Primary Care District of Seville, Clinic Historical Round, Seville, Spain

2 University of Pablo de Olavide, Seville, Spain

3 Training and Research Department of the Sant Ángela Institute (ISA) for Chronic Disease and Palliative Care, Seville, Spain

4 Internal Medicine Unit, Virgen Macarena University Hospital, Seville, Spain

5 Department of Molecular Biology and Biochemical Engineering, University of Pablo de Olavide of Seville, Seville, Spain

\*Address all correspondence to: drmjme@hotmail.com

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**89**

*Psychosomatic Medicine and Palliative Care DOI: http://dx.doi.org/10.5772/intechopen.93154*

[1] Mejías MJ. Practical Guide to Home Management of Pain and Other Symptoms. 2nd ed. Editorial Sanaidea; primary care. Panamericana Editorial.

[12] Esteban M et al. Care complexity in end-of-life care: Criteria and levels of intervention in community health care.

[13] Gómez X et al. Instrument for the Identification of People in Situation of Advanced Chronic Disease and Need for Palliative Care in Health and Social Services. Qualy Observatory, WHO Collaborating Center for Public Palliative Care Programs (CCOMS-ICO), Institut Català d'Oncologia; 2011

[14] Pastrana T et al. A matter of definition–Key elements identified in a discourse analysis of definition of palliative care. Palliative Medicine.

[15] McNamara B, Rosenwax L, Holman DC. A method for defining and estimating the palliative care population. Journal of Pain and

Symptom Management. 2006;**32**(1):5-12

[17] Iwase S et al. Assessment of cancerrelated fatigue, pain, and quality of life in cancer patients at palliative care team referral: A multicenter observational study (JORTC PAL-09). 2015;**10**(8):e0134022. DOI: 10.1371/

[18] Beller E et al. Palliative pharmacological sedation for terminally ill adults. Cochrane Database of Systematic Reviews. 2015;**1**:Art. No.: CD010206. DOI: 10.1002/14651858.CD010206

[19] Boston P, Bruce A, Schreiber R. Existential suffering in the palliative

[16] Mayo. White Paper on Quality Standards and Palliative Care Standards of the European Society for Palliative Care. Madrid: Spanish Society for

2008;**22**:222-232

Palliative Care; 2012

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[2] Rosin U. Palliative psychosomatic medicine. Therapeutische Umschau.

[3] Senn HJ. Paracelsus, scientific

after! Supportive Care in Cancer.

research and supportive care—500 years

[4] Weiss E, English OE. Psychosomatic medicine. In: The Clinical Application of Psychopathology to General Medical Problems, w.b. Saunders Co. 2nd ed. Philadelphia and London; 1949

[5] Sirri L, Fava GA. Diagnostic criteria for psychosomatic research and somatic symptom disorders. International Review of Psychiatry. 2013;**25**:19-30

[6] Engel GL. The need for a new medical model: A challenge for biomedicine. Science. 1977;**196**:129-136

[7] Lipowski ZJ. Current trends in consultation-liaison psychiatry. Canaidan Journal of Psychiatry.

[8] Berrocal C, Fava GA, Sonino N. Contributions of psychosomatic medicine to clinical and preventive medicine. Annals of Psychology.

[9] Bernini O et al. The psychometric properties of the CPAQ in Italian patients with chronic pain. Journal of Health Psychology. 2010;**5**:1-10

[10] Gawande A. Quantity and quality of life: Duties of care in life-limiting illness. JAMA. 2016;**315**(3):267-269. DOI: 10.1001/jama.2015.19206

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1983;**28**:329-338

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*Psychosomatic Medicine and Palliative Care DOI: http://dx.doi.org/10.5772/intechopen.93154*

#### **References**

*Psychosomatic Medicine*

**Author details**

author was Mejias MD.

**Note**

Manuel Mejías-Estévez1,2,3\*, Rocio Dominguez Álvarez4

2 University of Pablo de Olavide, Seville, Spain

Disease and Palliative Care, Seville, Spain

Pablo de Olavide of Seville, Seville, Spain

provided the original work is properly cited.

\*Address all correspondence to: drmjme@hotmail.com

1 Primary Care District of Seville, Clinic Historical Round, Seville, Spain

3 Training and Research Department of the Sant Ángela Institute (ISA) for Chronic

discipline has not recognized this contribution. In the most professional in PC the PM is applied, although its deep association is unknown. Many aspects collected in the research in this chapter support the experience of palliative care professionals (the suffering of patients and relatives, the concern to protect the other from the disease and its consequences ...). More research is needed to

6.The PM provides insight in Psychiatry for specific disorders, but also, in its

7.To reach the soul of a person (understood as the essence that defines each person against the rest), according to their nature, the health professional must know how to be a psychotherapist. Because this way you will be able to treat from the symptoms of the body, the emotions or from the thought. Although these three structures are the great summary of what a human being can explain, the reality is always more complicated, where good human relations would be a great bridge with the person who suffers to help them.

This chapter is based on research awarded "In Memoriam Juan Rof Carballo" by the Royal Academy of Medicine and Surgery of Cadiz (Spain), at the titled "Psychosomatic Medicine and Palliative Care in the scientific literature", whose

breadth, it can be useful for any discipline such as cancer or PC.

help patients, families and healthcare professionals.

4 Internal Medicine Unit, Virgen Macarena University Hospital, Seville, Spain

5 Department of Molecular Biology and Biochemical Engineering, University of

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

and Ignacio Jauregi Lobera5

**88**

[1] Mejías MJ. Practical Guide to Home Management of Pain and Other Symptoms. 2nd ed. Editorial Sanaidea; 2016. ISBN: 978-84-617-5641-4

[2] Rosin U. Palliative psychosomatic medicine. Therapeutische Umschau. 2001;**58**(7):449-452

[3] Senn HJ. Paracelsus, scientific research and supportive care—500 years after! Supportive Care in Cancer. 1993;**1**(5):230-232

[4] Weiss E, English OE. Psychosomatic medicine. In: The Clinical Application of Psychopathology to General Medical Problems, w.b. Saunders Co. 2nd ed. Philadelphia and London; 1949

[5] Sirri L, Fava GA. Diagnostic criteria for psychosomatic research and somatic symptom disorders. International Review of Psychiatry. 2013;**25**:19-30

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Macmilan Co. 1969

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*Psychosomatic Medicine and Palliative Care DOI: http://dx.doi.org/10.5772/intechopen.93154*

*Psychosomatic Medicine*

care setting: An integrated literature review. Journal of Pain and Symptom Management. 2016;**41**(3):604-618

[28] Quill T, Holland J, Arthur H, Schmale MD. 14 March 1924-17 March 1993. Psycho-Oncology. 1994;**3**(1):77-78

[29] van der Valk JM. Psychological aspects in the palliative treatment of malignant tumors. Jaar Kankeronderz Kankerbestrijd. 1964;**14**:231-237

[30] Verwoerdt A. Communication with the fatally ill. Southern Medical Journal.

[31] Verwoerdt A. Communication with the fatally ill. CA: A Cancer Journal for

[32] Verwoerdt A. The physician's role in retirement counseling. Gerontologist.

[33] Staehelein B. Some psychiatric and psychosomatic aspects of palliative treatment of advanced cancer. Therapeutische Umschau.

[34] Matsui T, Tanimukai H. The use of psychosocial support services among Japanese breast cancer survivors. Japanese Journal of Clinical Oncology.

1964;**57**:787-795

1970;**10**(1):22-26

1965;**22**:218-222

2017, 2017;**47**(8):743-748

2010;**37**(2):359-362

2015;**65**:299-314

[35] Matsuoka H et al. The role of psychosomatic medicine doctors in palliative care medicine: Two case reports. Gan To Kagaku Ryoho.

[36] Ogawa A et al. Availability of psychiatric consultation-liaison services as an integral component of palliative care programs at Japanese cancer hospitals. Japanese Journal of Clinical

[37] Mehta RD, Roth AJ. Psychiatric considerations in the oncology setting. CA: A Cancer Journal for Clinicians.

[38] Zabora J et al. The prevalence of psychological distress by cancer site. Psychooncology. 2001;**10**:19-28

Oncology. 2012;**42**(1):42-52

Clinicians. 1965;**15**:105-111

[20] Balaguer A et al. An International Consensus Definition of the wish to hasten death and its related factors. PLoS One. 2016;**11**(1):e0146184. DOI:

10.1371/journal.pone.0146184

Cancer. 3rd ed. Generalitat de Catalunya, Departament de Salut, Institut Català d'Oncologia, Editorial

Focus S.C; 2013

2017;**28**:450-459

2001;**7**(6):458-471

Disponible en: BASE

2008;**5**(1):53-69

[21] Porta J, Gómez X, Tuca A, et al. Symptom Control Manual in

Patients with Advanced and Terminal

[22] Anneser J et al. Needs, expectations, and concerns of medical students regarding end-of-life issues before the introduction of a mandatory undergraduate palliative care curriculum. Journal of Palliative Medicine. 2014;**17**(11):1201-1205

[23] Rojas O, Fuentes C, Robert V.

Psycho-oncology in the general hospital. Approaches in cancer and depression. Las Condes Clinic Medical Magazine.

[24] Holland JC. Improving the human side of cancer care: Psycho-oncology's contribution. The Cancer Journal.

[25] Originals. The significance of a specific psycho-oncology outpatient service for cancer patients run by psychosomatic medical doctors. 2011.

[26] De Lugo M, Coca M. The pact of silence in the relatives of terminal cancer patients. Psycho-oncology.

[27] Macarie G, Filipescu R, Voichita A. Framing the cancer patients' life experiences and attitudes: A

psychosomatic approach. Postmodern

Openings. 2013;**4**(1):103-116

**90**

[39] Rayner L et al. The clinical epidemiology of depression in palliative care and the predictive value of somatic symptoms: Cross-sectional survey with four-week follow-up. Palliative Medicine. 2011;**25**(3):229-241

[40] Grassi L et al. Psychosocial screening and assessment in oncology and palliative care settings. Frontiers in Psychology. 2015;**5**

[41] Kübler-Ross E. On death and dying. Macmilan Co. 1969

[42] Fischbeck S et al. Assessing somatic, psychosocial, and spiritual distress of patients with advanced cancer: Development of the Advanced Cancer Patients' Distress Scale. American Journal of Hospice and Palliative Care. 2013;**30**(4):339-346

[43] Wada S et al. The Association between depressive symptoms and age in cancer patients: A multicenter cross-sectional study. Journal of Pain and Symptom Management. 2015;**50**(6):768-777

[44] Fujisawa D et al. Impact of depression on health utility value in cancer patients. Psychooncology. 2016;**25**(5):491-495

[45] Matsuo N et al. Predictors of responses to corticosteroids for anorexia in advanced cancer patients: A multicenter prospective observational study. Supportive Care in Cancer. 2017;**25**(1):41-50

[46] Virizuela JA, Escobar Y, Casinello J, Borrega P. Treatment of cancer pain: Spanish Society of Medical Oncology (SEOM) recommendations for clinical practice. Clinical and Translational Oncology. 2012;**14**(7):499-504

[47] Eccleston C et al. Psychological therapies (through the internet) for the treatment of chronic pain in adults. Cochrane Database of Systematic

Reviews. 2014;**2**:Art. No.: CD010152. DOI: 10.1002/14651858.CD010152

[48] Fisher E et al. Psychological (remote) therapies for the treatment of chronic and recurrent pain in children and adolescents. Cochrane Database of Systematic Reviews. 2015;**3**:Art. No.: CD011118. DOI: 10.1002/14651858. CD011118

[49] Drabe N et al. When cancer cannot be cured: A qualitative study on relationship changes in couples facing advanced melanoma. Palliative & Supportive Care. 2016:1-12

[50] Hatano Y et al. The relationship between cancer patients' place of death and bereaved caregivers' mental health status. Psycho-Oncology. 2017

[51] Iglesias A. Hypnosis and existential psychotherapy with end-stage terminally ill patients. American Journal of Clinical Hypnosis. 2004;**46**(3):201-213

[52] Ayers T. A partnership in like-minded thinking-generating hopefulness in persons with cancer. Med Health Care Philos. 2007;**10**(1):65-80

[53] Satsangi A, Brugnoli M. Anxiety and psychosomatic symptoms in palliative care: From neuropsychobiological response to stress, to symptoms' management with clinical hypnosis and meditative states. Annals of Palliative Medicine. 2017

[54] Orellana-Ríos CL et al. Mindfulness and compassion-oriented practices at work reduce distress and enhance self-care of palliative care teams: A mixed-method evaluation of an "on the job" program. BMC Palliative Care. 2017;**17**(1):3

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**93**

Section 3

Psychopathology
