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 Table of Contents  
REVIEW ARTICLE
Year : 2017  |  Volume : 1  |  Issue : 2  |  Page : 65-70

Psychosomatic liaison service in cardiology


Department of Psychosomatic Medicine and Psychotherapy, University Medical Center of Freiburg, Freiburg, Germany

Date of Web Publication16-Nov-2017

Correspondence Address:
Kurt Fritzsche
Department of Psychosomatic Medicine and Psychotherapy, University Medical Center of Freiburg, Hauptstr 8, 79104 Freiburg
Germany
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/hm.hm_17_17

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  Abstract 


Between 30 and 50% of inpatients treated in cardiology departments have emotional or psychosomatic problems that require psychotherapeutic information, consultation, as well as emotional support. This requirement can be effectively met by a liaison service with psychotherapists who are present on a regular basis and are integrated into the ward team. The psychotherapeutic interventions applied are focused on immediate solutions, the main goal of which is an improvement of the patient's capacity to cope emotionally with heart disease and the interpersonal problems arising from it. Important components of these interventions include the therapeutic relationship, active support in coping with problems, and resource activation. Evaluation of the psychosomatic liaison service by the cardiology nursing staff and doctors reveals a high degree of satisfaction with and acceptance of the liaison service.

Keywords: Cardiology, psychosomatic consultation and liaison service, psychotherapeutic interventions


How to cite this article:
Fritzsche K. Psychosomatic liaison service in cardiology. Heart Mind 2017;1:65-70

How to cite this URL:
Fritzsche K. Psychosomatic liaison service in cardiology. Heart Mind [serial online] 2017 [cited 2019 Jul 16];1:65-70. Available from: http://www.heartmindjournal.org/text.asp?2017/1/2/65/218519




  Psychosomatic liaison service Top


In the acute hospital setting, patients frequently experience psychological and psychosomatic problems. Depending on the medical field and on the symptoms, prevalence rates for psychological disorders in need of treatment encountered in this setting vary between 10 and 50%.[1],[2] In an effort to meet this need, psychotherapeutic treatment through both consulting and liaison services has been effectively employed.[1] These distinct treatment modalities may be defined as follows:

  1. Consulting service: The patient receives inpatient psychodiagnostic and psychotherapeutic services in the standard manner
  2. Liaison service: The psychotherapists (PT) are continuously present at the hospital to provide supervisory (case discussions), improvement (team discussions), conflict resolution (e.g., patient–doctor relationship), and other services that exceed the direct treatment of the illness in scope.[10]



  Psychosomatic Disease in Cardiology Top


Approximately 30%–50% of patients in cardiology are under psychological stress.[3] This has been shown to adversely affect the course of any coronary disease.[3] In addition, in the case of myocardial infarction, in particular, patients who suffer from a depressive reaction following have a higher risk for reinfarction and increased cardiac mortality.[4],[5] Meta-analyses show that psychoeducation and psychotherapeutic intervention not only improve psychosocial well-being and quality of life but also through favorable modulation of cardiovascular risk factors, exert a positive impact on the course of the underlying somatic illness.[6],[7]


  Pilot Project Top


Two cardiology units were selected to host a pilot project designed to assess the effects of implementing a psychosomatic liaison service. Over a period of 6 months, a liaison service has been established in the units. The project, the composition of the sample, and the effect of the psychosomatic liaison service on the patients' length of stay are described elsewhere.[2] This work focuses on the content of the psychotherapeutic intervention and the evaluation of the psychosomatic liaison service from the perspective of nursing staff and physicians.

Psychotherapeutic interventions

The two liaison PT were present 3 days/week on the ward. To assess the psychotherapeutic need of treatment, all newly admitted patients received a brief diagnostic interview, during which parameters such as anxiety, depression, daily stress, social support, and coping strategies were assessed according to a standardized approach, and the need for treatment was evaluated accordingly. If there were indications of psychosocial stresses and the patient agreed, then the patient received psychotherapeutic care during his/her stay.

The psychotherapeutic interventions had the following goals:

  • Improvement in the patient's emotional well-being
  • Support in coping with the illness
  • Better cooperation between patient and the treatment team.


Contents

One-to-three meetings took place with most of the patients, depending on the length of their stay (9 days on average). [Table 1] shows the content of these meetings. The general therapeutic approach illustrated is based on the availability of the patient for three sessions; details may vary according to the nature of the psychological problem, the personality of the patient, the therapeutic approach of the PT, and additional contextual features such as length of treatment.
Table 1: Content of the psychotherapeutic sessions

Click here to view


Psychotherapeutic interventions

The psychotherapeutic interventions are structured by the following components:

  • General elements of short-term psychotherapy [8]
  • A helpful and trusting relationship [8]
  • Supportive and interactive psychotherapy [9],[10]
  • Specific elements of psychotherapeutic treatment in patients with heart disease.[11],[12],[13]


The initial session

The PT tries to provide a conversational setting for the patient that is free of anxieties, emotionally comfortable, and encouraging. To foster the formation of a narrative dialog, he lets the patient talk freely so that symptoms and psychological stresses are mentioned at the same time and without the need to ask about them explicitly. Following an open question about the current situation and his/her current symptoms, the patient can describe in detail all of the physical symptoms and experiences with the treatment, such as invasive diagnostic and therapeutic interventions. The PT explores all symptoms, their intensity, the point in time they began, and he allows the patient to demonstrate the localization of discomfort (e.g., tenderness on the sternum) and any corresponding functional limitations. In describing the symptoms, the patient often not only lists discomforts but also rather describes them in images of highly vivid intensity. The patient's language, the accompanying emotions, mimicry, and posture can all be signs that indicate repressed and unresolved conflicts and traumas.

By collecting the biopsychosocial history of the patient, the PT gains insight into the patient's past and current situation in life. In accordance with the salutogenic model, the patient's psychological and physical resources, past and current protective factors, and all conflict-solving and coping strategies applied in dealing with the illness and the stressful situation are evaluated.

Defense mechanisms such as denial, shifting, and fantasies of omnipotence are accepted as meaningful attempts by the patient to control the situation of the illness. It cannot be assumed that the patient understands psychosomatic connections and that the patient is motivated to accept psychotherapeutic treatment. Counter-transference often occurs swiftly in these patients. This can be controlled, however, if the therapist understands that these patients cannot act in any other way and that they are first and foremost hurt by the illness and are therefore in need of empathetic and active engagement by the PT.

Example:

  • PT: How did you feel emotionally when you found out about the heart disease
  • Patient: How should I have felt? It just was that way
  • PT: I could imagine, and this is what I have heard from other patients, that you must have been quite shocked at first after receiving such a diagnosis
  • Patient: Yes, that's quite true
  • PT: What did you feel? Tell me a bit more about it.


Specific interventions discuss the fear of patients that, in addition to their heart disease, they are also psychologically not well and need a psychologist. The patient is encouraged to talk about his/her worries and concerns about his/her illness. These are explained by the PT to be normal responses within the framework of dealing with the illness, and they are not questioned further.

Precise images of relationship histories and interactions become evident in the patient's description of past and current relationships with parents, friends, and partners. Has the illness changed how the patient deals with himself/herself and his/her most important attachment figures? How does the patient see himself/herself? How is he/she seen by those around him/her? These descriptions indicate any troubled interpersonal relationships, delineate habitual relationship patterns, and permit inferences about the patient's attachment behavior. Based on this information, the PT can form initial hypotheses about the structure of the patient's ego, his/her defense mechanisms, maladapted relationship patterns, attachment style, and the coping strategies he/she employs to deal with the illness.

Another goal of the initial meeting is the discovery and processing of the patient's subjective concept of the illness and treatment. For example, the following questions can be asked:

  • Do you have any idea how you developed heart disease
  • Why do you think this illness occurred now, at this point in time
  • What is your understanding of the severity of this disease
  • Which therapy do you think could be most beneficial to you
  • Do you believe you have a handle on the course of your illness?


Information about the development of heart disease, its treatment, risk factors, and their modification and information about the effects of the disease on sexuality, social relationships, work, and leisure time are not automatically provided but are described if it is determined that the patient needs this information.

Example:

  • PT: Do you have a sense of how stress can hurt your heart
  • Patient: No, but I do not believe that it is too important. I have always been restless
  • PT: There is no general answer to this question. However, research has made some discoveries over the past few years. If you would like, I can tell you something about them, and we can think together about whether one thing or another could be useful to you
  • Patient: Well, then go ahead.


Part of the conversation about the patient's understanding of the treatment also includes a clarification of the goals; the patient seeks to accomplish through the psychotherapeutic sessions. These goals should be worded as precisely as possible. For example, agreement to joint sessions with the patient's wife could be substituted for a vaguely expressed desire for better spousal relations. After the first session, the patient should feel understood, psychologically relieved, and motivated to participate in additional psychotherapeutic sessions.

Second session

The second session aims to deal with emotions and feelings in interpersonal relationships in a different way. All of the patient's descriptions, both of his current and of his past relationship experiences, are used to refine his emotional perception. Any verbal or nonverbal expressions of emotion (e.g., mimicry, posture, and clenched fists) are openly discussed. The patient should be reassured that, in addition to positive emotions, negative emotions, while accepted as subjective, are entirely acceptable. This should lead to an emotional relief. Emotions should be followed with a proposed description that does not limit the patient but that the patient can word in more detail or correct. When a feeling is described, the PT should then wait to see whether the patient agrees. Then, the patient can decide whether his feelings are in agreement with the suggestion of the PT or he can change the subject. If emotions are expressed nonverbally, they are also described as a suggestion, such as: “I am sensing that you are irritated?” or “you seem very depressed now.” One option is focusing on stressful life events, relationship problems, and aggravations in everyday life.

Example:

A patient has been re-admitted for cardiac arrhythmia with his second heart attack in 1 year. He has been on sick leave for 3 months.

  • PT: Do you have any idea what could have caused two heart attacks within such a short period
  • Patient: No clue. Stress, perhaps
  • PT: Yes, that could be. Could you tell in more detail what you mean by stress
  • Patient: Well, I had a lot of aggravations at work
  • PT: What were you angry about
  • Patient: I have a colleague who constantly picks on me
  • PT: How did you deal with it
  • Patient: Why me? What did I do wrong
  • PT: Well, I can understand your aggravation, but I ask myself whether you could find a way to defuse the conflict with your colleague. Then, perhaps you might feel less stressed and your health would be more stable. How did you feel when the colleague picked on you?


If an important event is reported by the patient with neutrality that is incongruous with its importance, then this incongruity should be addressed, as follows: “You seem very composed when you tell me about this event.” If the patient's description takes a turn that breaks with the preceding content, then this should also be addressed; doing so involves recounting the previous part of the description, and then mentioning the break: “I do not understand this unexpected step in your description.” According to the stress model, specific interventions should explain the psychophysiological connections between negative emotions and the physiological reactions that occur alongside them. The doom loop concept serves as a framework through which to understand the perpetuating interrelationship between tension, physical reaction, fear, and the succeeding increase in tension along with symptoms that is characteristic of the psychopathology of these cases.

Maladaptive illness behavior

If the patient chronically exhibits maladaptive illness behaviors, such as poor compliance with the recommendations of the physician or excessive use of medical help, the outcome of coronary heart diseases can be significantly worsened. Often, patients are fully aware of the harmfulness of their behavior but are nevertheless unable to change it. These patients may be fearful of criticism, embarrassment, and patronization, so this subject matter should be approached carefully, and the patient should be afforded the opportunity to save face. Specifically, these issues should only be dealt with during the second contact, after a trusting relationship has been established. Once the patient admits to his/her maladaptive behavior, it is important to recognize it foremost as a strategy that, for some patients, may have been the only possible way to maintain autonomy in the face of their condition.

Example:

  • PT: You have told me that you had several severe attacks of angina over the past few months. How did you deal with it
  • Patient: Well, when I could not deal with it anymore, my wife called the emergency physician, and he took me directly to the intensive care unit
  • PT: Did you try to help yourself first
  • Patient: Oh well, at first, it was not so bad, but then nothing helped anymore. Then, I used the spray
  • PT: That late
  • Patient: I figured it would cure itself
  • PT: How do you explain why you waited that long
  • Patient: When it started, I thought, I do not want to go to the hospital
  • PT: Were you so started that you kind of “forgot” to use the spray
  • Patient: Yes, something like that
  • PT: I would think that you would be interested in avoiding the hospital. We can try together to find why you could not do better.


Third session

The third session aims to integrate the partner or other close attachment figure in the conclusion of this treatment sequence. In this session, the following topics can be discussed:

  • How does the couple or the family communicate about the heart disease
  • What roles have changed due to the heart disease
  • What other changes have taken place in the relationship of the couple or within the family due to the disease
  • How does the heart disease affect the sexuality of the couple
  • What are the resources the family or couple can use to cope with the disease
  • Can the social support of the family be improved


Even if a meeting with partners or family members cannot be scheduled, these questions are discussed with the patient independently during this session.

The last session also deals with fears and hopes harbored by the patient about further treatment, interventions (such as catheter dilation or bypass surgery), and his/her occupational future. The outcome of the inpatient psychotherapeutic treatment is discussed, and if indicated, further psychotherapeutic outpatient treatment is prepared. Short-term and long-term goals are formulated together with the patient, and the ability to implement these goals is assessed.

Information about dealing with special problem areas

The patient who is reluctant to participate in psychotherapy sessions

The ambivalence of the patient is accepted and discussed in abstract terms. The setting (room, time structure) is adapted as needed to the preferences of the patient. Initially, the conversation is confined to subjects chosen by the patient.

The clinging patient

Patients who possess a basic depressive structure tend to display clinging behavior, for example, during the end of the session. While patient's neediness is accepted, the structure of the session should be maintained, and the autonomy of the patient should be promoted.

The patient who tells stories and guards his emotional stresses

The PT may be overloaded with reports about the patient's past accomplishments and come to feel rejected in his offer to provide psychotherapeutic support. The same applies here, avoid confronting the patient directly, as this will disrupt the defense mechanism. In such cases, content and emotions are picked up by mirroring using the nondirective communication method. The stories told by the patient often mask strong fears, negative experiences in relationships, and relationship desires. These can be discussed carefully later on in the course of therapy.

The pseudo-autonomous patient, who hides his desire for dependency behind megalomania

This patient associates the acceptance of help with the dependency he/she seeks to avoid. Such a patient feels compelled to maintain control over himself/herself and his/her environment. Initially, he denies any need for psychotherapeutic support but then agrees to sessions “if I can help you with it.” If the therapist accepts this constellation, then there will be many indications in the ensuing discussions about denied desires for a relationship. Initially, the patient does not discuss the disappointments and hurt he/she experienced during childhood and young adulthood. This is mostly a narcissistic issue. Therefore, the interventions serve to promote the regulation self-worth. The PT points out in an appreciative manner how difficult it must be for a person who was previously active and successful to tolerate the role of a patient. This is framed as a special accomplishment and an expression of strength.[14],[15]

The patient who is in strong denial

Denial serves to diminish or even to completely suppress any perception of harm to physical health caused by the disease. Very strong denial harbors the risk of suppressing important perceptions about how the illness is experienced and how the treatment should be understood. The patient will seem emotionally unaffected. He/she rebuffs contact and is minimally cooperative. Although this reality, conscious form of denial, referred to as “double entry bookkeeping,” can benefit from psychotherapeutic support, it presents a challenge. In these extreme cases, the therapist must understand that patient's fantasies of immortality are a mechanism of protection against suppressed fears of destruction and isolation. Control must also be maintained over possible counter-transference reactions by the PT, such as anger, rage, fear of death, and desiring the death of the patient. The emotionally acceptable therapeutic relationship and a clear orientation to current and future therapeutic goals offer the patient a helpful framework. Instead of discussing his suppressed fears and despair, it is more appropriate to ask solution-oriented questions about forms of coping:

Example:

  • PT: You reported that 3 weeks ago you suffered a heart attack, and now a bypass surgery is scheduled. How are you coping with it
  • Patient: Good. No problems. everything is like it was before
  • PT: I could imagine that you were pretty shocked initially
  • Patient: Oh, no, just a minor accident at work
  • PT: How did you manage to feel so well after such a short time?



  Evaluation Top


The results of the evaluations performed by the nursing staff and the ward physicians are shown in [Table 2].
Table 2: Evaluation

Click here to view


The psychosomatic liaison service has benefited physicians and nursing staff by assisting in the recognition of the psychological stresses of their patients and also in the treatment of emotionally difficult patients. Both professional groups strongly favor the establishment of a liaison service in place of the traditional consulting service.

Here are some comments written by the nursing staff:

“I think the psychosomatic liaison service is very worthwhile! Nurses never have the time to manage the psychological stress of patients and may not even be able to do so. The psychological training of nursing staff is certainly not sufficient to help the patient in every situation. Particularly on a unit with seriously ill patients, I find it important to have the support of psychologically trained personnel to support the patients. One requirement would definitely be that the psychosomatic liaison service is familiar with the situation on the ward, i.e., that they are knowledgeable about the symptoms of the illness, therapy, care, etc. This will support working together and make it effective.”

“In general, patients were quieter at night. They did not require nearly as much clarification before they could sleep and did not need to ask as many questions. So, no overtime, and less pills for sleeping and relaxation.”

Here are some comments written by ward physicians:

  • “The dialog helped us to better understand the psychological background of the patients. Some psychological problems expressed somatically by the patient were thus more easily recognized as such”
  • ”For me personally, this time has been a relief. I felt that there was someone with whom I could discuss my feelings and the physician–patient relationship, after which I was able to improve my relationships with my patients.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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2.
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3.
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4.
Frasure-Smith N, Lespérance F, Juneau M, Talajic M, Bourassa MG. Gender, depression, and one-year prognosis after myocardial infarction. Psychosom Med 1999;61:26-37.  Back to cited text no. 4
    
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Fritzsche K, Fritz U, Huber T, Sarai C, Beyersdorf F. Überleben mit einem künstlichen Herzen. Erfahrungen mit supportiver Psychotherapie bei einer 30-Jährigen Patientin. Psychotherapeut 2000;44:116-21.  Back to cited text no. 11
    
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Albus C, Köhle K. Krankheitsverarbeitung und Psychotherapie nach Herzinfarkt. In: Adler A, Herrmann JM, Köhle K, Langewitz W, Schonecke OW, von Uexküll T, et al., editors. Psychosomatische Medizin. 6th ed. München: Urban & Fischer; 2003. p. 879-90  Back to cited text no. 12
    
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Albus C, Wöller W, Kruse J. Die körperliche Seite nicht vernachlässigen. Patienten mit somatischen und, psychosomatischen Erkrankungen. In: Wöller W, Kruse J, editors. Tiefenpsychologisch Fundierte Psychotherapie – Basisbuch und Praxisleitfaden. Stuttgart, New York: Schattauer; 2001. p. 285-94.  Back to cited text no. 13
    
14.
Allison TG, Williams DE, Miller TD, Patten CA, Bailey KR, Squires RW, et al. Medical and economic costs of psychologic distress in patients with coronary artery disease. Mayo Clin Proc 1995;70:734-42.  Back to cited text no. 14
    
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Fritzsche K, Spahn C, Nübling M, Wirsching M. Psychosomatischer Liaisondienst am Universitätsklinikum. Bedarf und Inanspruchnahme. Nervenarzt 2007;78:1037-45.  Back to cited text no. 15
    



 
 
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