Keywords

1 Introduction

Psychosomatic medicine dates back to the distant past, providing us to this day with the simple but innovative idea of an integrated (holistic) approach and consequent integrated provision of services to our patients.

This perception of Psychosomatic disease that arises from the teachings of ancient Greek philosophers and physicians (Christodoulou 1987) keeps influencing the practice of modern medicine to this day and is based on two basic principles:

  1. 1.

    The principle of psychogenesis

  2. 2.

    The principle of holism

The first principle refers to the importance of psychological factors in the pathogenesis of any illness and the second one, arising basically from the teachings of Socrates and Plato (Charmidis 1975) maintains that the part (the organ) cannot be restored if the whole (the body) is not treated (Christodoulou and Associates 2000).

The basic psychosomatic principles (psychogenesis and holism) are prevalent in the perception of illness and health in Modern Greece. People believe that life events play a major role in the development of both physical and mental illness and this is depicted in traditional songs, cinema, films, theater and the Mass Media. To what extent this is the result of transgenerational impact of the teachings of Socrates, Plato, and Aristotle or of the evidence arising from observation or experience remains subject to speculation.

As refers to clinical practice, most physicians do take into account psychosocial factors although this position is not subject to adherence to guidelines or systematic teaching and is consequently individualized.

The establishment of psychiatric departments in general hospitals has been a major breakthrough for the dissemination and implementation of psychosomatic principles.

The correlation of vulnerability of a body system or an organ to develop a specific disease, has been postulated long ago (Alexander and Coleman 1934). Vulnerability is associated with life events able to mobilize primary stresses as well as to break established mental defenses functioning successfully up to a point in time (Fava and Sonino 2010). The vulnerable organ can be any single one. For example, some people may have a sensitive digestive system, while others may appear to have a weaker cardiovascular system or certain skin sensitivities etc. (Holmes and Rahe 1967; Holmes and Masuda 1974).

The principles of psychosomatic medicine, its philosophy, the skills associated with it and the experience obtained from its practice have introduced the holistic approach in clinical practice, especially with reference to chronic illnesses. This is particularly important, because with the exception of infections, the most important cause of death globally are chronic illnesses (Engel 1977; Bauer et al. 2010)

Psychosomatic medicine views health and illness under a holistic bio-psycho-social vista, as opposed to the traditional medical model, which understands the disease as a result of only physiological mechanisms (Christodoulou 1987; Novack et al. 2007; WHO 2009; Patel and Prince 2010)

Since 2003, the American Board of Medical Specialties (ABMS) has established the subspecialty of Psychosomatic Medicine within the specialty of psychiatry. This is a clear recognition of the importance of Psychosomatic Medicine (Gitlin 2005).

Lipsitt (2003) has stated that Consultation Liaison (C-L) Psychiatry and Psychosomatics have common roots. These two fields actually overlap. The seed of psychosomatics is dispersed over a wide scientific area. According to Mentzos (2008), psychoanalysis in psychiatry originated mainly from the Psychosomatics approach.

Christodoulou (1987) characterized the psychosomatic approach as an ideology that infiltrates all aspects of not only disease but also health. In his view it is “a comprehensive way of looking at health and disease that contributes to avoidance of over-simplifications, scientific dogmatisms and easy solutions to complex problems”. C-L Psychiatry is one of the implementation arms of the psychosomatic approach (Christodoulou 1987)

According to Fava et al. (2005) Psychosomatic Medicine may be defined as a comprehensive interdisciplinary framework for the following:

  1. 1.

    Assessment of psychosocial factors affecting individual vulnerability, course, and outcome of any type of disease.

  2. 2.

    Holistic consideration of patient care in clinical practice

  3. 3.

    Integration of psychological therapies in the prevention, treatment, and rehabilitation of medical disease.

Lipowski (1986) postulated that C-L Psychiatry is a subspecialty of psychiatry mediating between Psychiatry and Medicine.

2 Psychosomatic Medicine in Modern Greece

In Greece, the establishment of psychiatric departments in general hospitals, within the National Health Service (NHS) in 1984 as part of the “Psychiatric Reform” gave C-L Psychiatry a great opportunity to play an important role in the holistic function of general hospitals. Psychosomatic Medicine and C-L Psychiatry influenced physicians, nurses and administrators in a variety of positive and negative ways and in spite of many difficulties arising from divergent perception of priorities (on the part of psychiatrists) and resistances (on the part of physicians) the outcome was as a whole positive and keeps improving.

At the initial phase of the reform, the integration of psychiatric units in general hospitals primarily focused on addressing purely psychiatric patients on multiple structural and operational levels, (clinical departments, emergency services, out-patients’ clinics, etc.). C-L Psychiatry was a function that was difficult to organize and implement because of the lack of trained staff, especially during the first decade. Of course, there have been, and still are to this day, a number of exceptions, but even in the best case scenarios, the situation is far from ideal.

There are, unfortunately, serious deficiencies in primary care provision, made worse by the current financial crisis (Christodoulou et al. 2012; Christodoulou and Christodoulou 2013; Christodoulou 2016). The weight is transferred to the hospitals, especially the public ones. So, inevitably, psychiatric departments of these hospitals have to deal primarily with more urgent priorities (psychiatric cases) rather than C-L cases.

In spite of these drawbacks, however, C-L Psychiatry has advanced the holistic approach in theory and in practice and to some extent has bridged the gap between Psychiatry and the other medical specialties.

There is a rather limited number of Departments offering fully developed psychosomatic services, although therapeutic and research initiatives in a number of psychiatric departments of general hospitals incorporating the principles of Psychosomatic Medicine do exist.

More specifically, in Attica, the region in Greece that includes Athens, there are currently nine psychiatric departments in General Hospitals, two University Psychiatric Departments as well as a Children’s Psychiatric Department. In Thessaly, Macedonia and Thrace, the majority of hospitals have psychiatric departments but these are not yet fully organized towards the direction of developing a fully functioning C-L service.

In Thessaloniki there are three hospitals that have developed C-L services with an approved organization chart and a Psychosomatics Unit. In Epirus there is a functioning service at the University Hospital as well as in the “Hatzikosta” General Hospital. In Crete, the General Hospital and the University Hospital have also developed C-L services.

Nationwide a total of 95 hospitals that have Psychiatric and Children’s Psychiatric Departments have developed C-L services but these do not operate in the same way, as a result of their differences in degree of service development.

On secondary and tertiary care levels C-L Psychiatry constitutes an important sector of the Psychiatric Departments in several hospitals nationwide.

C-L Psychiatry offers:

  1. (a)

    Care of patients

  2. (b)

    Training of professionals

  3. (c)

    Research

  4. (d)

    Interaction and cross-talk of C-L psychiatrists with somatic physicians.

This activity has by and large proved beneficial for both parties. Psychiatrists have learned to assess and respect priorities, to avoid the use of psychiatric jargon and to respect the time and effort of other professionals. Somatic physicians have learned to broaden their vista and thus be able to value the therapeutic importance of interaction with the patient and to become more sensitive to their psychological needs, not for reasons of good social behavior but because of the contribution of this approach to a more effective management of somatic pathology.

The Hellenic Psychiatric Association (HPA) since 5 years ago (2011) has set up an active C-L Psychiatry scientific section. The section has developed a number of notable scientific and educational activities.

So far, Psychosomatics and C-L Psychiatry have not been recognized as psychiatric subspecialties in Greece.

3 Patient Care

All parameters considered, the current state of the provided psychiatric services in General Hospitals in Greece is an obvious improvement compared to the past. Further progress is presently difficult to achieve due to financial constraints, bureaucracy and inadequate training of physicians and nurses in psychosomatic medicine and the person-centered approach which is a crucial component in the practice of psychosomatic medicine.

C-L Psychiatry can be exercised in a wide spectrum of organizational and service models:

  1. 1.

    The classical model in which a C-L team is called upon by the examining physician to offer a psychiatric consultation/evaluation.

  2. 2.

    The participatory model in which the consulting psychiatrist participates in the activities of general clinics on a regular basis.

  3. 3.

    The specialized model in which the staff of the C-L unit participates in special units such as the Special Infections Unit, Artificial Kidney Unit, etc. (Moussas 2006).

In Greece, it is the classical model that is mainly practiced.

Approximately 20–40% of patients admitted to a General Hospital appear to suffer from mental health problems, yet studies mention that only a small percentage of these patients are seen and are provided with psychological support and care. Only 7–10% of them are forwarded to C-L Services. This percentage appears to be lower in Greece, varying between 3% and 4% (Lykouras et al. 1989; Moussas et al. 2008). As previously mentioned, patients in General Hospitals are seen on the basis of the classical model. In this case, the attending physician requests consultation in writing for a patient evaluation. The evaluation is usually carried out in the presence of the attending physician.

Routine calls are related to situations such as depression, suicidal behaviour, anxiety manifestations, delirium, substance abuse, behavioral disorders, pre-existing mental disease, chronic pain, capacity assessment, legal transactions etc. (Jackson et al. 2004; Kaupp et al. 2005; Andersen et al. 2008; Abbass et al. 2009).

The clinical work conducted by C-L Psychiatrists is summarized in (Table 14.1).

Table 14.1 Clinical work conducted by C-L psychiatrists in a general hospital
Full size table

Holmes (1978) has enriched the field of psychosomatics by identifying a group of Life Events that contribute to the development of illness. The life situations presented in the Holmes & Rahe Life Events Scale and their relative importance are of course subject to the influence of cultural factors. For example, in southern European countries loss of a child would be expected to have a greater emotional charge than death of spouse or divorce. This, of course, must be verified by research.

The Interdisciplinary team of C-L Psychiatry in Greek general hospitals should consist of at least a specialist psychiatrist in the leading position, a resident psychiatrist and a psychologist.

The standard patient evaluation procedure is the following:

3.1 Procedure for the Assessment of Patients in C-L Psychiatry

  1. 1.

    Referral by the attending physician

  2. 2.

    Provision of information by the attending physician about the nature of the somatic illness causing the patient’s hospital admission.

  3. 3.

    Diagnostic Psychiatric and Psychosomatic interview and evaluation of the patient as well as request for information about the patient’s history from his/her family

  4. 4.

    Communication with the attending physician, presentation and discussion of the findings

  5. 5.

    Presentation and discussion of the patient’s case with the interdisciplinary group

  6. 6.

    Written report

  7. 7.

    Regular monitoring during the period of hospitalization.

  8. 8.

    Suggestions for the management of the patient following discharge, e.g. referral to outpatient department or to community facilities, specialized treatments (individual treatment, group therapy, family therapy, etc.)

Even by its mere existence, the interdisciplinary C-L team promotes the holistic approach in the management of the patient. The team mediates between the patient, the family, the nursing staff, the attending physician and other players. This action helps in reducing the stigma attached to mental illness by actively intervening in matters arising from differences in educational level, training, sexual orientation, culture and attitude between the various partners of the complex interaction that may arise. The participating partners in this complex interaction are psychiatrists, psychologists, social workers, priests, administrative staff, other patients, treating physicians, nursing staff and of course the patient him (her) self whose position is central in this interaction.

Many psychiatrists working in Greek general hospitals have had training in Psychoanalytic Psychotherapy, the Systemic approach, Group-Family therapy, and Cognitive-Behavioral therapy and this is certainly an asset.

The usefulness of the C-L Psychiatry team has been shown to be considerable in the case of patients who refuse treatment and insist on leaving the hospital against doctors’ advice. In such cases, the members of the C-L team assess the dynamics between the partners, especially the physician, the patient and the family. Cases of refusal of treatment refer mainly to young patients, drug users, or people who have sustained injury (Albert and Kornfeld 1973; Holden et al. 1989; Milloy et al. 2015). In Greek general hospitals this phenomenon appears quite frequently in patients with substance abuse and patients suffering from serious somatic illnesses, particularly cancer (personal observations).

On the whole, in Greece, C-L Psychiatry provides services in three basic areas.

  1. 1.

    Cooperation with the attending physician to exchange information and ideas on the psychological, psychosocial and somatic problems of the patient

  2. 2.

    Mediation/ advocacy aiming at establishment of a therapeutic alliance of the attending physician with the staff on the one hand and with the patient and the family on the other

  3. 3.

    Provision of mainly supportive psychotherapeutic interventions aiming at the enhancement of the patients’ ability to cope with the stress arising from their illness and mediation on family issues to resolve conflicts or provide psychological support, reassurance and consolation, according to the case.

The management of “Transference and Counter Transference ” situations in the therapeutic relationship is a useful tool in the hands of the physician. By applying the principles of non-interpretative intervention and using the Watzlawick principles (1967) of “interactional view”, doctors are taught a new approach towards patients and their families. The Paul Watzawick five axioms refer to communication that takes place during interaction and can be applied in the doctor-patient relationship. Emphasis is placed on the satisfaction of the spiritual needs of the patient, whenever these needs are expressed. This is an important aspect of treatment for some patients.

C-L Psychiatry, as part of a complex and multidimensional hospital system, could play an important role in improving the patients’ quality of life, reducing the days of hospitalization and promoting a holistic model of treatment. Unfortunately, the current financial crisis in Greece (Christodoulou and Christodoulou 2013) combined with bureaucratic difficulties, as well as the failure on administrative and political levels to realize its importance, act as obstacles to the further development and utilization of this special service.

To summarize, we could argue that the C-L team actually catalyzes the process of understanding the conscious and unconscious dynamics characterizing the relationship between patients and their families, physicians and the hospital staff, the C-L Psychiatry team and all the other players in this complex interaction. This process lies at the epicenter of any therapeutic attempt and facilitates or hinders treatment and the duration and quality of the patients’ hospital stay.

4 Training

Training in the field of C-L Psychiatry refers to the training of residents, psychiatrists, mental health professionals and non-psychiatric physicians.

In Greece, the period of training in C-L Psychiatry as part of the requirements for the psychiatric residency lasts 6 months. Training is carried out in general hospitals with Psychiatric Departments in the framework of a rotation system. Apart from the requirements for training in psychiatry, psychiatric trainees are required to have a good level of knowledge and skills in general medicine.

Every new trainee is supervised by a qualified psychiatrist. The entire team of trainees takes part in the ward rounds and in special meetings to resolve difficult clinical problems. They also receive training and supervision in psychopharmacology psychotherapeutic interventions and communication techniques.

The team of C-L Psychiatry participates in the training programme of the Psychiatric Department in the general hospital. There are no universal training protocols pertaining to C-L Psychiatry but in most departments training is individualized (person-centered) as “a person-centered psychiatric practice requires a person-centered psychiatric education” (Ramalho et al. 2016).

In recent years, an intense activity has been noted regarding scientific publications and books where specific chapters on C-L Psychiatry and Psychosomatic Medicine appear. Additionally, a master’s programme in C-L Psychiatry addressed to psychiatrists and other mental health professionals by the second Athens University Psychiatric Department has been available to interested candidates over the past 5 years.

The training of trainee psychologists in Psychosomatic Medicine is conducted in the public sector (NHS and Universities) or in the private sector through training in the principles of psychosomatics and psychotherapeutic approaches such as psychoanalytic, behavioral, cognitive and systemic. The role of psychologists in the general hospital is exercised through participation in the C-L therapeutic team. They work under the supervision of psychiatrists.

An important point in the training of trainees is the management of complex psychological problems and “difficult patients” like suicidal patients, patients with substance abuse comorbidity, mentally ill patients with somatic pathology, cancer patients, patients with delirium, patients coming from a different linguistic and cultural environment, patients who suffer from PTSD (as is the case with many refugees who are hosted in Greece in the last years).

5 Research

Greek Psychiatrists have always been interested in psychosomatics and have carried out research on relevant topics (e.g. Christodoulou et al. 1977, 1983; Lyketsos et al. 1982) but in recent years research has become more vigorous.

Research in the area of Psychosomatics and especially in C-L Psychiatry has undoubtedly contributed to bridging the gap between mental health professionals and somatic physicians. The involvement of mental health professionals in various research protocols has brought recognition on the part of somatic doctors and changed their attitude, which until recently was derogatory and skeptical as regards the scientific competence or general composure of mental health professionals as a whole.

Following the foundation of Psychiatric Departments in general hospitals in 1984 hundreds of presentations and round table discussions have been presented in local and International scientific congresses covering a wide spectrum of topics such as psychological problems of patients with various somatic illnesses, cognitive disorders linked with somatic illnesses, the Intensive Care Unit syndrome, hospitalized self-destructive patients, substance abusers, patients with disorders related to food intake, problems of patients in artificial kidney units, problems of patients with Ca, patients with co-existing mental and somatic illnesses, stress and depression, burn-out syndrome, problems arising from patients’ relationship with family members etc.

The participation of Health Care workers in various specialized care facilities, such as Psycho-oncology clinics, Pain Management clinics, Asthma clinics, Chronic Refractory Breathlessness clinics, Sleep Disorder clinics, Rehabilitation clinics, Stop-smoking clinics, Obesity clinics etc. has opened new communication channels with doctors focusing on these issues, thus initiating new scientific protocols for research.

The advances in Informatics and new technologies have offered the opportunity to extend C-L Psychiatry in the primary care field. For example, telepsychiatry, although still at its early stages, is a promising field for Greece, in view of the geographical distribution of the population (remote, isolated areas, including many islands).

In recent years, there has been considerable interest in psychosocial issues concerning cancer patients. Psycho-oncology deals with the psychosocial, behavioral, spiritual, and existential dimensions of cancer, with the reactions of the patients and their families and with the ways to support patients in coping with their illness. It has been recognized in many countries as a subspecialty of oncology (formally established around the mid-1970s in the United States). In Greece, it is the team of C-L Psychiatry that deals with the psychosocial aspects of cancer prevention, the management of psychological and psychiatric problems of cancer patients and their families and the provision of comfort and care to those who need it. The team also tries to raise the awareness of the somatic doctors concerning the distress of the patients and their families.

The importance attached to Psycho-oncology becomes manifest by the fact that the Hellenic Psychiatric Association has established a special psycho-oncology section and within this framework congresses, workshops and research have been carried out.

6 Publications

A number of distinguished Greek physicians and mental health workers have published dissertations, books and papers on Psychosomatic Medicine.

Among them, Marinos Geroulanos (1867–1960), Professor of Surgery at the University of Athens and Academician was one of the first physicians who fully adopted the psychosomatics theory. Professor George Lyketsos (1916–2011), Director of Dromokaition Hospital, has published a great number of papers on psychosomatics (dermatological illnesses, hypertension, peptic ulcer, bronchial asthma), psychologist Anna Potamianou has dealt with psychosomatics under a psychoanalytical view-point, Dr. Nikos Rasidakis published on psychosomatics, mainly in Greek, Professor Haralambos Ierodiakonou from the University of Thessaloniki has published mainly from a historical and psychoanalytic perspective and Dr. Gerasimos Rigatos, an oncologist and medical historian has greatly contributed to Greek and international psychosomatics literature (e.g. Rigatos and Kappou-Rigatou 1987). Peter Sifneos, a psychoanalytically oriented psychiatrist of Greek origin introduced the term “alexithymia” and extensively studied this “no words for emotions” phenomenon.

A research group of the Department of Psychiatry of Athens University at Eginition Hospital led by Prof. George Christodoulou (Christodoulou, Alevizos, Rabavilas, Kontaxakis, Trikkas and others) published extensively on psychosomatic medicine. This group produced papers on alexithymia, peptic ulcer in adults and children, the Irritable Bowel Syndrome and its connection with depression, glosodynia, diabetes mellitus etc. (e.g. Trikkas et al. 1987a, b; Christodoulou and Alevizos 1987).

A book entitled “Psychosomatic Medicine: Past and Future” Plenum Press, New York was edited in 1987 by George Christodoulou, past President of the International College of Psychosomatic Medicine who has also organized two International Congresses in Athens, the 16th European Conference on Psychosomatic Research, 6–11 September 1986 and the 15th World Congress of Psychosomatic Medicine, 16–20 April 1999.

Currently, the establishment of psychiatric units in general hospitals has provided the basis for advancement of research in Psychosomatics and C-L Psychiatry with the subsequent production of publications. Physicians from non-psychiatric specialties have also contributed to psychosomatics literature (e.g. Kosmadaki and Antoniou 2011; Karaiskos et al. 2011). Publishers have also taken the initiative to promote translations of foreign books on psychosomatics into Greek and a quick review has recorded as many as 30 such titles in the last 10 years.

Information about the practice of Psychiatry and the structure of psychiatric services in Greece can be found in a number of publications (Anagnostopoulos et al. 2009, 2016; Christodoulou et al. 2010, 2012).

7 The Future of Psychosomatic Medicine

The future of Psychosomatic Medicine in Greece depends, to a large extent, on recognition and acceptance of Psychosomatic Medicine and its implementation arm, C-L Psychiatry by professionals, decision-makers and the public. Psychosomatic Medicine must provide proof of its usefulness and this can be achieved by well-organized and reliable research that reveals its effectiveness and efficiency. It also depends on the extent to which the holistic approach acquires universal acceptance and (as a consequence of this) is integrated in the everyday practice of medicine, both in hospitals and in the community. It must be pointed out that the practice of C-L Psychiatry should not be restricted to the hospital but should be expanded to incorporate the community as well. Advocacy of psychosomatically oriented physicians addressed to decision-makers and the public is necessary in order to achieve the above goals.

8 Conclusion

Psychosomatic Medicine in Modern Greece is based on the principles of psychogenesis and holism introduced to western medicine by ancient Greek physicians and philosophers. The establishment of psychiatric departments in general hospitals in 1984 has been a major breakthrough for the implementation and dissemination of psychosomatic principles. Nationwide a total of 95 public hospitals in Greece have developed psychiatric and children’s psychiatric departments with Consultation-Liaison (C-L) services but these services operate on widely varying levels of development, efficiency and effectiveness. In this chapter, patient care, training of residents and other professionals, research and publications on psychosomatics and C-L Psychiatry are discussed as well as the achievements and drawbacks in the practice of psychosomatic medicine. It is concluded that the future of psychosomatic medicine in Greece depends to a large extent on recognition and acceptance of psychosomatic medicine and its implementation arm, C-L Psychiatry, by professionals, decision-makers and the public.