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Integrative dimensions of primary medical care.

INTRODUCTION

Every science, every specialization, every discipline, and every profession should have a specific object of study and a methodology. The basic principles of the primary health care are: equitable distribution, involvement of community, focus on preventive activities, and appropriate technology. In general, the physician is the first instance of the patient's itinerary. For him, the patient becomes a topic of medical research and practise, but also a rational and social being, with spiritual life and concerns for own health. Regardless of the condition, knowing the patient's psychology becomes compulsory.

The physician, as a fine psychologist, will build a close interhuman relationship with the patient, to the benefit of the latter. The physician's affective openness to the patient is "the keystone of medical psychology", aiming at humanizing the medical action. Always in somatic illnesses and very frequently in mental ones, the motivational mechanism and the psychological processes, as well as the affected organism, become the object of analysing the own" self" (1,2). Thus, besides the somatic and mental symptoms directly determined by the illness, mental changes appear, generated by the conscience of the ill person, reflecting the subject's positioning towards somatic and mental aggression, depending on the nature and severity of the illness, evolution, but mostly by the patient's premorbid personality and life experiences. Mental illnesses are a real problem of public health across the world. It is vital that psychiatrists and other experts in mental health work closely with primary assistance services (3).

Psychiatric pathology and all aspects related to altered mental health became mostly the attribute of the young generation, rather than the old generation. It is necessary to develop a system based on multidisciplinary approaches concerning early detection of mental illnesses.

A cooperation between the specialists in primary medicine and the ones in mental health could help especially the youth, who are more exposed to various mental disorders.

FAMILY PHYSICIAN AND PSYCHIATRIC PATHOLOGY

A family physician must know well the symptoms of various conditions, which are object of activity of other specializations. This is necessary so that after the examination, the physician can refer patients to a certain specialization. During his dialogue with other specialists, the family physician must be as close as possible to the correct diagnosis. Estimating the diagnosis should involve the knowledge of diagnosis criteria and performing an accurate differential diagnosis. A superficial and rigid anamnesis, based on closed questions, leads to lack of revealing relevant information in diagnosing and treating patients. The right attitude is to use stages of gathering information: patient centred anamnesis, physician centred anamnesis, and a balanced interview, which underlines the importance of presenting social circumstances, psychiatric medical antecedents, reactivity and adaptation in various stages of development (4).

The personality traits outlined in adolescence are determinant in an individual's way to react to an illness, and later they define his/her way to take social and family responsibilities and to adapt to his/her workplace. Anamnesis is fundamental in outlining the personality profile, revealing traits like: egocentrism, immaturity, histrionic behaviour or scrupulousness, resistance, modesty, and adaptability. Observation completes the information collected by anamnesis, and nonverbal communication unveilsthe patient's attitudes and reactions while exposing the subjective accusations. Masking anxiety, bursting into crying, correlated to body pos ture/facial expressions can trigger the detection of stressors related to the evolution of the illness. The primary assistance physician's clinical experience and therapeutic skills help circumscribe mental conflicts and decelerate their somatisation (5). Multidisciplinary consultation with the psychiatrist and the psychologist avoid excessive guidance of the patient and configurates the use of recommendations (6). Often, an apparently healthy patient has an acute sufferance or even a chronic illness; most frequently, the physician eyewitnesses the patient's transition from health to illness. Approaching the illness as a medical theory that treats the pathological and physiological sides of the patients, from the perspective of their adaptation to the environment leads to psychosomatic conception, having as an object of study the pathologic impact of psychological factors upon the functions of various organs and systems (7), reconsidering the aetiology of the illness.

Reconsidering anamnesis by re-evaluating the biography of life conditions leads to the goal of psychosomatic medicine to create a pathography, understanding illness not as an accident, but in relation with the patient's past.

PSYCHOSOMATIC MEDICINE

Psychosomatic conception has the main essential features:--holistic conception involving the unity between the soma and the psyche;--neuro-endocrinological, based on clinical observations and psychophysiological experimental results;--reconsiders the influence of the social environment upon the illness;--psychosomatic patients' vulnerabil ity to stress;--psychic stress as a major or summative risk factor in the pathogenesis of the illness (8).

In medical practice, the psychosomatic approach is proved relevant considering the following premises: acute or chronic psychological stress is found in 35% of the symptomatology; illness itself is a source of stress. The psychic factor aggravates the evolution of the illness; as a resistance to therapy factor, and it may generate the onset of other illnesses. Psychotherapy underpins the therapeutic effect (9).

Psychosomatic medicine aims at developing and perfecting the diagnosis method and the appropriate treatment, adapted to unique needs of the patients.

Integrative psychosomatic treatment is based on psycho-somatoform theory, recognizing the involvement of memory, communication systems of the human body, conscious and unconscious, without which life cannot exist. The main mutual systems, inter-and intracommunicational, are: vegetative nervous system and endocrine system. Every disorder permanently activates all the systems of the body. Affective states have an organic echo, while emotions determine changes of the cardiovascular apparatus, secretion of the glands, and digestive system. A repetitive emotion can cause serious illnesses. An illness can be the result of energetic exhaustion of the body or of a severe communication disorder among different systems of an event that the body perceives as stressful, with somatic manifestations (inflammation, high blood pressure, immunosuppression, and hyperlipemia) or psychological (anxiety, depression, and emotional instability) (10). Psychosomatic illnesses are organic illnesses appeared in an individual with a certain type of personality determined by complexity, etiopathologic factors among which the psychogenic factor is very important, and they are conditioned by the pre-existence of a territory which is vulnerable to psychological stress. In the genesis of the psychosomatic illness there are exaggerated or chronic excitations of the central and vegetative nervous system which lead to disbalances of homeostasis. The onset of a psychosomatic illness is determined by the personality type of the patients who is exposed to the action of the psychological stress, type of constitution and last, but not least, the field of minimal resistance of the body.

The way of preventing and limiting the distress in primary assistance implies building empathic relationship, of physician-patient communication, beneficial for finalizing the therapeutic act, reducing the circumstantial and iatrogenic stress, produced by the impact with the medical team; patient centred anamnesis, afterwards balanced, then physiciancentred, developed in a relaxed environment, using supportive verbal/nonverbal communication techniques (11). Meanwhile, the impact of psychological stress on the onset of the illness is evaluated and the patient's psychological assessment is done (intellectual, social, emotional, behavioural); diagnosis aims at outlining the personality type; elucidation of the implication of psychological stress in determining symptomatology; context of the appearance of symptomatology (physiologic, biographic); supportive psychotherapy by favouring the verbalization of the sufferance and initiation of the plain psychotherapy (12).

The professional relationship between physician and patient lays explicitly on a technicalprofessional level (observation, anamnesis, objective examination, investigation, and therapeutic indications), but also on a psychological level (emotional, moral). The psychosomatic model implies the physician's intervention during patient's exposure, allowing the patient to describe his/her sufferance in detail. The model encourages exposure of personal problems, allowing an emotional catharsis by revealing the patient's worries and thus identifying the psycho-behavioural risk factors.

For a family physician, the psychosomatic approach facilitates the overall knowledge of patient's problems. Most of the patients as a first contact with the family physician stay under his/her therapy for a long period, facilitating the access to the patient's biography and intimacy; there is an emotional relationship physician-patient, aiming at promoting sanogenesis (5).

Implications of psychosomatic conception of medical thinking consist in reshaping behaviours that generate somatic illnesses, establishing the weight of psychic stress in genesis and aggravation of the illness and designing antistress conducts.

Medical profession is a means to serve people with abnegation, to know them profoundly, without reservations and prejudices. During the medical deed, in addition to knowing the somatic-physiological phenomena that are disturbed by the illness, one must look for their impact on a subjective level, experienced by patients (13).

Analysing the subjectivity of a person implies mutuality and affective communion, comprehension, a dimension of medical psychology which will study the illness in human existence, whose individuality emphasizes the manifestation of the illness on physical and psychological level (14).

The investigated patient must benefit in the end from a medical diagnosis and a psychological one, establishing the extent of organic deterioration, but also theidentification of the psychological and social distress of the patient, individualising the assistance act, because internal factors make that the same external conditions have different impacts upon individuals.

The relationship between the physician and the patient is the fundamental problem of the medical psychology, expanding the sphere of knowledge and the action beyond the psychological changed triggered by illness, advancing to an integrative vision that sees the patient in relation with his social, professional, and family environment (15).

ACKNOWLEDGEMENTS AND DISCLOSURES

The authors state that they are no declared conflicts of interest regarding this paper

REFERENCES

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(10.) Kroenke K, Spitzer RL, Williams JB, Linzer M, Hahn SR, deGruy FV, Brody D. Physical symptoms in primary care: predictors of psychiatric disorders and functional impairment. Arch Fam Med, 1994; 3(9):744-779.

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Luana Andreea Macovei, Irina Dobrin, Vasile Chirifa, Elena Rezus

Luana Andreea Macovei--Assistant Professor, MD, PhD, "Grigore T. Popa" University of Medicine and Pharmacy, Department of Rheumatology. Rehabilitation, Physical Medicine and Balneology

Irina Dobrin--Assistant Professor, MD, PhD, "Grigore T. Popa" University of Medicine and Pharmacy, Department of Psychiatry

Vasile Chirifa--Academician, MD, PhD, "Socola" Institute of Psychiatry

Elena Rezus--Associate Professor, MD, PhD, "Grigore T. Popa" University of Medicine and Pharmacy, Department of Rheumatology. Rehabilitation, Physical Medicine and Balneology

Correspondence:

Vasile Chirifa, Honorary Member of Academy, MD, PhD, senior psychiatrist, professor, "Socola" Institute of Psychiatry, Bucium 36 road, 700282, Iasi, Romania, vasile.chirita@yahoo.com

Submission: 02 apr 2018

Acceptance: 22 may 2018
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Author:Macovei, Luana Andreea; Dobrin, Irina; Chirifa, Vasile; Rezus, Elena
Publication:Bulletin of Integrative Psychiatry
Article Type:Report
Date:Jun 1, 2018
Words:2068
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