Contributions to Psychology and Medicine – Serie

Behavioral medicine has blossomed as an area of systematic investiga­ tion during the past 10-20 years. Throughout its steady growth, there have been increasing interest and specialization in the study of neuro­ psychological and behavioral aspects of diabetes. This book attempts to capture and report exciting new developments in the study of both insulin-dependent (Type I) and non-insulin-dependent (Type II) dia­ betes mellitus. Accordingly, it is divided into two major sections. Physiological aspects of each disease, which differ significantly in pathophysiology and course, are discussed in separate medical over­ views that introduce each major section. These overviews are written by Drs. Tsalikian and Zimmerman, leading medical researchers in insulin­ and non-insulin-dependent diabetes, respectively. Each section also contains chapters describing neuropsychological and cognitive disease correlates, psychosocial patterns of adjustment, and treatment adher­ ence issues. Psychological aspects of insulin-dependent diabetes have been studied more extensively than non-insulin-dependent diabetes, perhaps because it is more often associated with graver medical compli­ cations. Therefore, there is a larger body of research to review and the first section has been divided into chapters on cognitive disease se­ quelae in populations of children and adults, separately. In his chapter, Dr. Ryan discusses developmental factors related to the unique sensi­ tivity of the brain to metabolic derangement. Dr. Holmes reviews studies of adults with diabetes and the cognitive correlates of both acute and chronic blood glucose disruption. Developmental disease is­ sues are further covered in Dr.

Individual Differences, Stress, and Health Psychology presents recent research on how individual differences lead to the variety of reactions people display to stressors. These reactions are considered particularly in their relation to health and illness. Distinguished international researchers in health psychology speculate on the future of the field and its application to developing treatments or changes in lifestyles that may prevent or alleviate such disorders as cancer, coronary heart disease, hypertension, and post-traumatic stress syndrome. The volume makes a significant contribution to the study of the relation between stress and health processes.

Prospects of Heart Surgery: Psychological Adjustment to Coronary Bypass Grafting reports on a study of how patients and their spouses adjusted to the prospect, and then to the outcome, of coronary graft surgery. The focus upon patients' social relationships rather than upon individuals reveals that the way people bear their illness, and adapt to symptom removal, is part of a wider adjustment involving both the spouse and other individuals. The book offers, as one of its main contributions, a social-psychological approach to the study of illness in general. It sets out a new methodology which might be applied in a number of illness contexts. Using both qualitative and quantitative analyses, Prospects of Heart Surgery describes differences between smooth and problematic approaches to surgery as well as variations in the experience of rehabilitation afterwards.

Decision making is the physician's major activity. Every day, in doctors' offices throughout the world, patients describe their symptoms and com­ plaints while doctors perform examinations, order tests, and, on the basis of these data, decide what is wrong and what should be done. Although the process may appear routine-even to the physicians in­ volved-each step in the sequence requires skilled clinical judgment. Physicians must decide: which symptoms are important, whether any laboratory tests should be done, how the various items of clinical data should be combined, and, finally, which of several treatments (including doing nothing) is indicated. Although much of the information used in clinical decision making is objective, the physician's values (a belief that pain relief is more important than potential addiction to pain-killing drugs, for example) and subjectivity are as much a part of the clinical process as the objective findings of laboratory tests. In recent years, both physicians and psychologists have come to realize that patient management decisions are not only subjective but also prob­ abilistic (although this is not always acknowledged overtly). When doc­ tors argue that an operation is fairly safe because it has a mortality rate of only 1 %, they are at least implicitly admitting that the outcome of their decision is based on probability.

The pattern of childhood illness has changed significantly during this century. Many frightening conditions such as polio and tuberculosis have essentially been eradicated. Other conditions that were once fatal have now achieved the status of chronic disorders, for example, leukemia, cancer, and cystic fibrosis. Technological advances which have resulted in the medical treatment of these conditions have, however, created a gamut of psychological problems for the children and their families. Recognition of these problems has lagged behind other advances in pediatric medicine. The emergence of a specialist area of pediatric psychology (Wright, 1975) has largely been responsible for the mushrooming of research in the area. In much early work, the emphasis was on the impact of chronic illness on children and their families. Reactions at times of greatest trauma, especially diagnosis or death, were particularly well documented. Issues relating to day-to-day aspects of child care, involving questions of discipline or protectiveness, have received much less attention. As far as the sick child is concerned, there has been much investigation of academic and intellectual development, as well as of personality changes that might accompany illness.

Physical illness cannot be effectively treated other than in the context of the psychological factors with which it is associated. The body may have the disease, but it is the patient who is ill. Research psychologists from a number of different backgrounds have, in the past few decades, turned increasingly to the study of physical illness, and there is now an extensive literature on preventive behaviors, the role of stress in the etiology of illness, the patient's reactions to illness and its treatment, and the physician-patient relationship. At the same time practicing clinical psychologists have extended their concern beyond the treatment of speci­ fically psychiatric disorders, to include also the psychological care of people experiencing distress through illness or injury. Traditionally, these patients have tended to fall through the net, unless their distress is so great that it assumes the proportion of a psychiatric disorder that can then be treated in its own right. Because the physical disorder is the primary one, its existence has detracted from the salience of the very real emotional disturbance to which it can give rise. Moreover, emotional reactions in this setting, being the norm, seems to have been regarded as not meriting special attention and care. This situation is chang­ ing, and it is not just psychologists or psychiatrists who are responsible for the shift in attitudes. Within general medicine itself, there is now a renewed empha­ sis on the care of the whole patient and not just the disease.

A Woman With Cancer Deborah came to University Hospital when she was 25. She was the mainstay of a young farming family. Her husband, Merle, was now farming his family land, working hard to keep financially solvent during these difficult f;lrming days. They had four children: Carolyn, 4 months; Michael, 17 months; John, 4 years; and Susie, 5 years. There was nothing special about this woman or her circumstances; she was like every woman who had ordinary daily chores and responsibilities, people in her life about whom she cared and who cared for her, worries, goals, dreams, and her life before her. Deborah's 4-week postpartum checkup and Pap smear were normal; however, six weeks later she had heavy, irregular bleeding. To Deborah this symptom picture did not seem to fit the pattern of her other preg­ nancies, and so she returned to her doctor. A large lesion was found on the posterior cervix and biopsies of the tissue revealed moderately dif­ ferentiated adenocarcinoma of the cervix. Referral to the University Hospital 60 miles away confirmed the diagnosis. Further tumor workup, which included a pelvic ultrasound, bladder cystoscopy, sigmoidoscopy, and chest x-ray, was normal, although the IVP was notable for nonvi­ sualization of the right ureter, thought to be secondary to an enlarged lymph node.

In the spring of 1982, we began our collaboration while on sabbatical in Jerusa­ lem. Working together at Hadassah Medical Center, we discovered that we had overlapping and complementary interests. The wonderful surroundings com­ bined with a warm friendship nourished the development of this book. E. G. S:s interest in neuropsychology, cognitive function, and diagnostic clas­ sification and A. A R:s interest in the development of normal sexual behavior, incest and its consequences for psychopathology, and psychoanalytic thought provided a broad perspective on the field of somatoform disorders. For E. G. S. , Lawrence A. Lockman, a faculty member in pediatric neurology at the Univer­ sity of Minnesota who has a great interest in these cases, was particularly helpful. Many of the ideas on case management came from his admonitions to the house staff on rounds regarding proper management of patients and families. When we began to write the book in the fall of 1984, two students of E. G. S:s became involved. Norman Cohen, then a post doc, was very interested in pain and biofeedback, having worked extensively in the Pain Clinic at the University of Minnesota Hospitals. He was seeing many of the children in the clinic who required biofeedback and was especially interested in those with headache. He agreed to write the chapter on headache.

The Psychology of the Dentist-Patient Relationship acquaints dentists with the underlying interpersonal dynamics of their professional work. The author has reviewed the dental and psychological literature about the behavior of dentists and their patients, and used this evidence to evaluate critically the various theoretical models of the dentist-patient relationship. A major aim of this book is to show how the application of soundly based psychological theory and practice can improve patient management, reduce the stress of practicing dentistry, and contribute to the design of effective community dental health campaigns.

Assessing Chronic Pain offers a unique approach to the evaluation and assessment of treatment for chronic pain patients. Rather than adhering to the criteria of any one discipline's approach to treating chronic pain, whether that of anesthesia, physical therapy, psychiatry or psychology, the editors overview a range of disciplines, and focus on the integration of those approaches to achieve what they term a "handbook", rather than a textbook, for the assessment of chronic pain from a multidisciplinary perspective. Issues confronting clinicians have been compounded by procedural problems and assessment indecision, but in Assessing Chronic Pain, Drs. Camic and Brown create a framework to guide specialists in all fields in approaching the patient suffering from chronic, non-malignant pain.

How do individuals conceive illness and symptoms? Do theirconceptions conflict with the physician's views of theirillness, and what happens if they do? This book thoroughlyexplores the field of disease representation, describes anddiscusses lay illness models in a variety of social, histo-rical and cultural contexts.