**4. Conclusion**

*New Insights into Systemic Sclerosis*

(family, society, and community), personality, emotional incompetence, etc. The question remains: Who is responsible for the treatment and resolution of these factors? The physician? Physiotherapist? Psychologist? Gynecologist? Sexologist? Occupational therapist? Social worker? Or some other healthcare professional? In the BPS model of treatment, the answer is clear—interdisciplinary cooperation which is very demanding but beneficial. And if there is no interdisciplinary cooperation, all of these factors (because these patients usually have them) fall into the care of one expert, who can experience a burnout or ignorance syndrome from exhaustion and great exertion and misunderstanding of all the components.

Unfortunately, the current concept of medicine addresses most of the patients (let alone patients with a rare and incurable disease like SSc) as an object from a biomedical point of view, assuming the linear relationship between the pathophysiology of the disease, its course, the patient's involvement, and disability, whose usual means of treatment are insufficiently effective. This is also the case if healing does not take place in a multidisciplinary team and the psychosocial factors affecting the ability of patients with SSc to face their disease are neglected and underestimated due to the idea that they belong to other professionals competent in this area. In addition, possible somatized psychosocial problems caused by this disease in SSc patients, who respect a physician who performs a social role for them which equals the position of God, strengthen this biomedical model most of the time. On the other hand, the psychosocial model assumes that the interdependence between the bio-, psycho-, and social variables is rather complex and therefore the SSc can be understood as a significant predictor of a mental condition. This is how we can say that such an integrated BPS model of SSc includes both the effects that contribute to the progression of the disease but also the influences involved in the disease behavior. However, none of the processes is linear but

involves circular cycle and feedback with a repeating process over time [47–49].

From my own experience, I can point out that during the diagnosis process and subsequent treatment, the patient with SSc suffers from several stages of disease acceptance: from shock upon diagnosis, detection of its prognosis on inadequate web sites, anxiety states at the time of first physical symptoms and increased follow-up, inappropriate expectation of the results of further examinations to a depressive state of varying intensity. Another response is deciding whether to undergo treatment at all if there is no universal effective drug, and the drugs used to suppress the symptoms of the disease have many other undesirable and potentially toxic effects on the body. Consequently, some even experience maladaptation, refusal of treatment, and accompanying deep depression with suicidal thoughts. Nevertheless, the patient is constantly confronted with the reality of decreased life expectancy (70% of SSc patients survive for 10 years), the fear of pain, change in appearance, functional limitation, dependence on another person, loneliness, lack of social support, cessation of many activities, fear of treatment side effects, death, etc. Cognitive assessment of threats created by stressors and other possible sources has a central role in the effects of stressors on psychosocial and somatic outcomes. In a 2014 study, where a personalized approach was used for modeling biopsychosocial features in relation to SSc-associated pain, the results indicated that psychosocial functioning is the basis for understanding the pain in this population, and physicians should apply the holistic approach and, if appropriate, recommend

And such a complex BPS model in SSc patients offers a comprehensive approach to diagnosis and treatment of its manifestations, including pain that mostly leads to suffering. However, suffering through somatization can also create pain, influenced by cognitive and emotional factors. This means that for a SSc patient, social and psychological impairment as a result of painful experience can be as difficult as

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somatic injury.

pain management in specialized centers [49].

In conclusion, we can say that without the need to investigate EBM, an individual complex of biopsychosocial factors influences the onset, progression, treatment, and survival of SSc patients. In addition, besides the biological factors, the psychological and social factors play a significant role in negatively affecting the quality of life of patients with SSc and their interpersonal relationships, disruption and change of their personality and behavior, and coping with the illness. Since the illness and the consequences of treatment are reflected and manifested not only at the somatic level but also at psychological (emotional) and social levels, we should consider all these components in the treatment and approach in a multidisciplinary fashion. Since fatigue is one of the most prevalent symptoms which is adversely affecting the SSc patients, future research should investigate whether such a disease-associated depressive condition negatively promotes fatigue or whether effective pain management could reduce fatigue or explore other possible causes of fatigue and then find adequate strategies for its effective management. In any case, anyone involved in the treatment of SSc patients should have that twenty-first century holistic approach, take a proper medical history, and listen to patients' own opinions about their quality of health, which could help to spread the knowledge about psychosomatic correlations of the disease and adequate modification of the therapy for the patient. Nevertheless, proper education and awareness of the patient's illness is essential in managing the illness according to the best practice available.
