Psychosomatic Medicine and Evidence-Based Surgery:Reflections and Perspectives

She-Ying Chen,Elaina Y Chen

1Healthcare Administration and former Assoc.Provost at Pace University,New York,USA.2University of Rochester Medical Center,New York,USA.

Abstract This article reflects on the need for psychosomatic medicine research in the field of surgery by complementing psychological/psychiatrist approaches with a physician’s (particularly surgeon’s) point of view.Focusing on esthetic/cosmetic surgery,a broader notion of “psychosomatic surgery” is also used regarding plastic surgery as well as examples of vascular and general surgery.Relevant literature reviews are utilized to gain a more comprehensive bio-psycho-social perspective.By providing a deeper understanding in the specialty areas,it makes a case for evidence-based practice by shedding light on psychosomatic medicine research on surgery in the United States with cross-cultural implications.

Keywords:Psychosomatic medicine,Evidence-based practice,Esthetic,Cosmetic,Plastic,Vascular Surgery;Physical and mental health;Healthcare services

Introduction

In the eyes of psychologists and psychiatrists,the relationship between emotion and disease has long been fascinating [1].They see physical illness as a consequence of mental distress (including the role of the nervous system in disease).While psychosomatic medicine is said to have fallen in and out of favor repeatedly over the past centuries,"we are currently witnessing exciting and challenging times for psychosomatic research" [2].The key question they dealt with in psychosomatic research has since remained to be:"do psychiatric disorders cause or contribute to physical disease such as heart disease,diabetes and asthma? ...a second question is:does timely and optimum treatment of the psychiatric disorders prevent,arrest or roll back the progression of physical disease?" Later,the impact of cognition and emotion (not only psychiatric illness) on general and physical health became an important line of investigation,which even went beyond and helped to expand psychosomatic medicine with a new interest in positive psychology.Subsequently,the impact of such“positive emotional states” as equanimity,level-headedness,and congruence are highlighted[3].

While psychosomatic research has not yet lived up to its full promise along the line of psychological/psychiatrist thinking,this article will approach the topic from a physician’s (particularly surgeon’s) point of view.It reflects on the need for psychosomatic medicine research in the domain of surgery by complementing the psychological and psychiatrist perspectives.In this pursuit,all sorts of psychosocial factors and impacts may be considered whether as causes or consequences (equally emphasized here) of surgical procedures and associated issues[4].

Our article attempts to make a case for evidence-based practice in selected subfields of surgery (with some general reasoning) by shedding light on psychosomatic medicine research (broadly defined) in the United States as well as its cross-cultural implications.Genest,a retired plastic surgeon,used the term "psychosomatic surgery" to designate esthetic surgery and clearly indicate the psychological problems inherent in every case [5].Though,it’s noted that about 80% of the author’s practice was reconstructive surgery.Our discussion here will also focus on esthetic (or cosmetic) surgery while the full range of plastic surgery will be taken into account as needed.Cosmetic surgery focuses on enhancing appearance while reconstructive plastic surgery emphasizes on repairing defects to reconstruct a normal function and appearance.The two are closely connected and the terms are sometime used interchangeably although cosmetic surgery and plastic surgery are not exactly the same.To further expand and enrich the discussion on the psychosomatic dimensions of surgery practice,we shall also examine a few important perspectives regarding psychosocial factors,or so-called “social determinants of health”[6]a focal concern of social medicine and public health[7].

Evidence-Based Psychosomatic Medicine:the Case of Plastic Surgery

In many disciplines and professions,“aesthetic” is considered a more complete approach than “cosmetic”while the latter is sometimes deemed more commercialized [8].In the past,cosmetic surgery recipients were patients,not consumers,but that has changed [9].According to a review conducted by Harth and Hermes [10] an increasing demand and use of doctor/medical services by healthy individuals resulted in a drastic change to cosmetic dermatology.While cosmetic surgery was mainly regarded as an eccentric intervention for the rich and famous in the 1980s,nowadays it has become available to lower income people and is aggressively marketed as a necessary and ordinary procedure.

In a sense,plastic surgery (particularly esthetic surgery) would easily make a case for psychosomatic medicine due to its cosmetic nature and intimate psychological grounds.That is probably why Genest used the term "psychosomatic surgery" first to refer to esthetic surgery and clearly indicate the psychological problems inherent in every case.“Psychosomatic surgery”is totally different from “psychosurgery”.The latter refers to a type of surgical ablation of brain tissue(first introduced as a treatment for severe mental illness by Egas Moniz in 1936,who won the Nobel Prize in Medicine in 1949),in order to alter affective or cognitive states caused by mental illness.In the early times when no satisfactory pharmacological treatment options were available,psychiatric neurosurgery was used to cure schizophrenia,depression,criminal behavior,and some other mental illnesses.After the introduction of antipsychotic drugs in 1954 the role of surgery has declined,though psychosurgery with less invasive techniques is still used nowadays for treatment of brain disorders with known pathophysiology (e.g.,Parkinson’s disease,epilepsy,and obsessive-compulsive disorder)[11].

In most (if not all) cases,the request for cosmetic surgery by patients is emotionally or psychosocially motivated.Patients with psychological disturbances would even push aside potential risks/complications or disregard side effects (including interactions of the procedures).Subjective deficiencies of appearance,feelings of inferiority,and social anxieties are some possible factors in somatizing disorders [12].Sometimes major emotional disorders,such as body dysmorphic disorder,personality disorder or polysurgical addiction,remain undiscovered but should be excluded in any patient receiving cosmetic procedures.Harth and Hermes made such a suggestion and labeled these issues accordingly as“psychosomatic disturbances”in cosmetic surgery.

Honigman,Phillips and Castle went further with another review on psychosocial outcomes of cosmetic surgery to address whether elective cosmetic procedures affect psychological well-being and psychosocial functioning [13].The 37 relevant studies of varying cosmetic procedures they identified at the turn of the 21st century show that patients appeared generally satisfied with the outcomes of their procedures,though some exhibited transient and some others exhibited longer-lasting psychological disturbances.Factors associated with poor psychosocial outcomes included being young (i.e.,the younger,the worse),being male (worse than female),having unrealistic expectations of the procedures,previous unsatisfactory cosmetic surgery,minimal deformity,body dysmorphic disorder,motivation based on relationship issues,and a history of depression,anxiety,or personality disorder.While most people appeared satisfied with the outcomes of cosmetic surgical procedures,some were not,and attempts should be made to screen for such individuals in cosmetic surgery settings.

More recently,Herpertz,Kessler and Jongen provided an overview of the status with recent developments of the reciprocal effects between plastic surgery and psychosocial functioning by focusing on bariatric surgery [14].It’s noted that (especially in cases of class II and III obesity)bariatric surgery is the only means to reduce bodyweight significantly and permanently,though they carry with them the associated risk factors of metabolic,cardiovascular,and oncological diseases.With regard to psychosocial and psychosomatic aspects of obesity surgery,studies over the past decade provided a huge amount of essential research data to support evidence-based practice.Although the results were partly contradictory and highly dependent on the duration of follow-up,it’s evident that bariatric surgery might convey an elevated risk for a minority of patients.Yet,identifying these patients before surgery had been insufficient.Fortunately,psychiatric management of bariatric surgery patients has been available via psychological and psychopharmacological treatments,with certain desired impact on postoperative mental health and weight outcomes[15].

A more detailed literature review of existing research results regarding plastic surgery and its various subfields is not intended for this mainly reflective piece.However,from the viewpoint of psychosomatic surgery,it’s safe to say that plastic(particularly esthetic/cosmetic) surgery is no longer a mere set of surgical procedures.Even the psychosocial dimensions are now emphasized and related research interests have continued to increase with regard to Castle and colleagues’ original question:Does cosmetic surgery improve psychosocial wellbeing?[13].Such a question may also become more and more important for reconstructive surgery.Yet the way the question is asked differs from a typical psychosomatic research interest.It calls for more research and empirical evidence with a broader scope.In reality,identifying those at-risk patients before surgery is difficult and we may have to continue relying on psychiatric management of surgery patients.However,a keen awareness raised by such research endeavor should help to promote psychosomatic medicine research as well as evidence-based professional practice in the fields of plastic/esthetic/cosmetic surgery.

Evidence-Based Psychosomatic Medicine:the Case of Vascular Surgery

As shown in the above,psychosomatic medicine research is very helpful and even necessary for achieving more desired outcomes of plastic surgery,particularly esthetic/cosmetic surgery which is often psychologically motivated.Other subfields of surgery may be quite different.Let us take a look at vascular surgery,for example.Unlike the subfield of esthetic/cosmetic surgery where the request for surgery by patients is often emotionally or psychosocially motivated,a diagnosis of vascular disease may be rather frightening to the patients who are not in a position to determine whether a surgical procedure is necessary or desirable."Psychosomatic surgery",therefore,might not appear to be very promising in this subfield at first glance.

Although a vascular surgery is seldom (if at all)requested by patients as emotionally or psychosocially motivated as in the case of esthetic/cosmetic surgery,attention has long been paid to the psychosomatic aspects/processes in various types of vascular disease[17].Reviews of psychosomatic aspects of cardiovascular disease,for example,have revealed significant psychological and behavioral issues [18,19].The issues have to do with physical activity,smoking cessation,behavior and cholesterol,depression and heart disease,etc.Other important psychosomatic aspects in the prevention,treatment,and rehabilitation of cardiac disease include:psychiatric risk factors for coronary artery disease,pharmacotherapy of depression,and treatment of hostility,stress and Type A behavior.

In the field of surgery,research has revealed that certain types of major vascular surgeries,for example abdominal aortic aneurysm (AAA) repair,which are often followed by psychiatric symptoms and disorders.Specifically,open AAA repair surgery is found prospectively linked to the development of psychiatric morbidity,and history of depression elevates risk [20].Cortisol measures before surgery are associated with current and future psychological functioning,suggesting potential neurobiological mechanisms that may contribute to vulnerability.These results can help identify surgical patients at risk and point to potential targets for risk reduction interventions.

Suciu and Cristescu provided a comprehensive review by focusing on the subfield of cardiovascular diseases (CVD) [21],which had become a major concern of World Health Organization (WHO) as the No.1 cause of deaths,generating the greatest economic burden worldwide through morbidity,disability,and poor quality of life.Nowadays,the psychic field and the vulnerability of individual mental level to stress are an important link in the development of mental illness,CVD (included in the group of psychosomatic disorders),and also of interrelationship between them.Therefore,it is important to address both the interrelationship of psychosocial factors with CVD and the mark of this bidirectional link on the quality of life of the patients.This will help surgeons with an understanding of the homeostasis-stress-pathology paradigm,the role of stress as a psychosocial factor in the multifactorial etiology of CVD,implications of mental disorders in the pathogenesis of CVD,and strategies for improving therapeutic adherence and the quality of life of these patients.

Thanks to a continued,growing interest in the psychosomatic aspects of vascular disease,some psychiatrists began to see “vascular psychiatry” as a new specialty[22].With regard to vascular surgery,the Journal of Psychosomatic Research recently published a fresh study on patients with serious mental illness(SMI),which is very timely since post-operative outcomes following vascular surgery have so far received little investigation in this subpopulation [23].The retrospective observational study used data gathered by South London and Maudsley NHS Foundation Trust,and 30-day emergency hospital readmissions using odds ratios for people with SMI 152 patients with diagnoses of schizophrenia,schizoaffective disorder,and bipolar disorder were compared with the general population (8,821 catchment residents without any mental health conditions).The study found that people with active SMI symptoms were more likely to be admitted to hospital via emergency route,more likely to stay longer in the hospital for vascular surgery,and more likely to be readmitted to hospital via emergency route within 30 days.People with SMI who had major open vascular surgery and peripheral endovascular surgery more likely had worse post-operative outcomes.The study thus highlights the risks faced by people with SMI following vascular surgery and suggests tailored guidelines and policies based on the identification of pre-operative risk factors,allowing for focused post-vascular surgery care to minimize adverse outcomes.In general,such research efforts have shown great promise for evidence-based psychosomatic medicine in the field of vascular surgery.

Evidence-Based Psychosomatic Surgery:Theoretical Perspectives

The term "psychosomatic surgery" used in a broad sense suggests that any kind of surgery may be viewed in a psychosomatic medicine perspective.In other words,psychological and behavioral (oftentimes also social) issues are inherent in all kinds of surgery(including general surgery),justifying a general need for the services of psychologists and psychiatrists [24].This,however,not only requires more empirical studies to cover the entire field of surgery but also a theoretical understanding of important psychosocial factors including,for example,utilization patterns of healthcare services by diverse groups of surgery recipients.In theory,the utilization patterns of healthcare services are a product of social construction,historical accumulation,and interaction among social,cultural,and psychological aspects [25].Thus,in order to gain a fuller understanding we have to look at patients’ perceptions of health and examine the stressors and resources that affect their health and utilization of healthcare services.For this purpose,it is necessary to scrutinize health and health-related concepts in a particular culture,as well as the role immigration experience plays and its interaction with the mainstream society.Such analysis will help to contextualize our understanding and interpretation of the different patterns of healthcare service utilization based on empirical evidence.

Drawing on the first author’s previous teamwork[25],several theoretical perspectives will be reviewed and introduced below,which are useful for providing a larger context for the study of psychosomatic surgery(broadly conceived).The major viewpoints include a feminist perspective,a cultural perspective,a political and social change perspective,and some other theories and speculations that will contribute to a more comprehensive bio-psycho-social understanding.Taken altogether,such perspectives will help to show that utilization of general/plastic/esthetic surgery is not only a function of the patient/client/consumer,but also of the healthcare services,gender and racial issues,political context,and social-cultural circumstances.

Feminist Perspective

“Psychosomatic surgery” in its narrow sense (i.e.,esthetic/cosmetic surgery) is a highly gendered topic.Both women and men are seeking plastic surgery as well as non-invasive cosmetic treatments.Yet the American Society of Plastic Surgeons (2018) revealed from its annual plastic surgery statistics that women constantly accounted for about 92% of all cosmetic procedures whereas only 8% or so was attributable to men [26].To translate into actual numbers (in 2014,for instance):13.6 million total cosmetic procedures were performed for women,while 1.3 million total cosmetic procedures were recorded for men in the United States.

Why is there such an extreme gender difference/imbalance? The feminist perspective may provide some unique clues by emphasizing women’s social status which is often disadvantaged.The various disadvantages can be traced to women’s powerlessness in a male-dominated society.The feminist perspective argues that women suffer from a minority status (i.e.,being female) and experience more psychological conflicts and stress in male-dominated cultures.As a coping strategy or unconsciously,some women may choose cosmetic surgery in the hope to increase self-confidence and attractiveness in a sexist society.Also,there is ample evidence in the research literature,based on both feminist and mainstream social science studies,suggesting that women are more vulnerable to mental disorders because of their low-income or poverty status [27],family and social violence against them as women,and high demands stemming from women’s multiple roles [28].In some racial/ethnic communities,women might suffer from triple jeopardy(i.e.,being female,being minority,and being in male-dominated ethnic culture),which could have made them experience even more stress and conflicts[29].

The feminist perspective is very insightful in understanding the psychosomatic processes,particularly concerning esthetic/cosmetic surgery.It also calls for the study of a wide range of subjects from the analysis of makeover television shows,cosmetic surgery websites,public health system,cosmetic surgeons,and the ethnic side of cosmetic surgery,to discussion of breast reduction and augmentation surgeries.Methodologically,from the social science perspective,both discursive construction and deconstruction (or problematization) of the concept of cosmetic surgery are instrumental.The same is also true for questioning a divide between cosmetic and reconstructive surgery[30].

Cultural Perspective

Cultural factors play a big part in cosmetic surgery[31,32] especially stigmatization as part of the consideration.While the numbers of cosmetic procedures continue to climb worldwide,cosmetic surgery continues to be plagued by negative stigmatization [33].Recently,Alotaibi conducted a systematic literature review (among a total of 1,515 abstracts reviewed,94 were identified for full-text review)on demographic and cultural differences in the acceptance and pursuit of cosmetic surgery [34].In addition to reaffirming women comprising roughly 90%of all the recipients,the pursuit of beauty through cosmetic surgery is seen culturally as a universal phenomenon.Though,different countries,races,and cultures differ in how cosmetic surgery is perceived,and in the aesthetic goals of those choosing to have it.In culturally diverse societies like the United States,non-Hispanic Whites continue to dominate among cosmetic surgery recipients,though the proportion of other races is rising rapidly (thanks to the role played by social media).After revealing these trends,Alotaibi’s literature review concludes that surgeons need to consider demographic and cultural differences of the cosmetic patients in order to understand their aesthetic goals and expectations.

Differences between countries and cultures are particularly notable for beautification and transformation.With respect to the former,whereas Western patients generally prioritize their lips and the reshaping of cheeks,Asian patients tend to focus on facial slimming,and nose,cheek,and chin definition.Asian patients also are the most likely to pursue transformation,for instance,as exhibited by certain terms within the South Korean language specific to such changes to enhance marital or occupational success[35].

As for psychological/psychiatric management,the notorious underutilization of mental health services by Asian American populations has been most striking and should first be noted.And the most popular explanation of the issue is from a cultural perspective[25].This perspective points out important differences among various cultures in terms of fundamental values,forms of expression,perceptions of mental illness,and patterns of help seeking [36].In a diverse and multicultural society like the United States,such cultural issues may be attributable to people’s immigration statuses,which in turn may have significant effects on their mental health and illness.For instance,voluntary immigrants to the United States may tend to be positively selected from their sending countries in terms of human capital (mental and physical)and socioeconomic status,which may reduce their chances of becoming mentally ill.These may serve as some research notes for further exploring the cultural dimension with regard to psychosomatic surgery and associated mental health services.

Political or Social Change Perspective

The political or social change perspective on mental health brings about a wide range of logical arguments[37,38].This perspective holds a critical view of traditional mental health practice,public attitudes,research methods,and intervention techniques.Based on a different set of assumptions,it directs the study of psychological problems of individuals to broader issues facing the community and society.The reality of economic disadvantage,social stress,community disorganization,and racism not only causes psychological/psychiatric problems among disadvantaged groups,but also presents a barrier to their getting professional help.In a literature review of psychological studies of oppressed groups (including Chinese Americans),Howard showed that many people in those groups see their world as hostile,often manifest symptoms of depression,and may suffer from a sense of alienation,self-negation,and ambivalence about personal identity[39].

It is important to note that cultural issues always operate under certain social conditions.Cultural values and the social structure always mutually influence,constantly adopt and adjust,and may also conflict with each other.From the political perspective,social action is viewed as a vehicle for psychological health,and social change is deemed as a necessary precondition for personal change[40].

There is a less radical but more popular approach under the political or social change perspective,which puts emphasis on policy-making and mental health service delivery.Underutilization of healthcare services does not necessarily mean lack of needs or problems,but rather an indication that healthcare services may not respond very well to the needs of certain populations (e.g.,Asian Americans) [41].Policy-wise,Sure&Morishima(1982)pointed out that the Center for Minority Mental Health Programs in the National Institute of Mental Health gave primary consideration to Black,Latino,and American Indian groups [42].Reflecting a systemic issue in the policy provision,Asian Americans were the only minority group that was not given priority in terms of research funding and mental health service delivery.Later,our previous teamwork provided evidence that the situation has been improved since the 1980s [25],thanks to the efforts of Asian American mental health researchers and practitioners.Other research studies also indicated an improvement of mental health service delivery over time in certain areas (e.g.,ethnic match and cultural competency training) [43,44].However,there is still a long way to go to achieve racial and social equity in the provision of mental health services.

In general,healthcare advocacy is an important tool in the physician/surgeon’s arsenal that stands the potential to improve both patient care and the profession [45].However,many physicians feel that they lack the leverage and knowledge to advocate on behalf of themselves,their practices,their patients,and their profession.Yet,as a matter of fact,surgeons are uniquely positioned to advocate based on their clinical acumen,personal experience with patient care,and their position in the healthcare ecosystem value chain.Mullens and colleagues discussed recent advocacy efforts related to plastic surgery,and efforts that are on the horizon to provide some context to the relevance of advocacy related to the practice of surgery.The purpose is to empower surgeons to step into the policy advocacy arena for the betterment of their patients and the professional practice of plastic surgery[46].

The Bio-Psycho-Social Perspective

The feminist,cultural,and political/social change perspectives reviewed and introduced in the above are instrumental to achieving a deeper understanding of the need for psychosomatic research in the specialty fields of surgery.Yet,more insights can be obtained from available research literature that contributes to a more comprehensive bio-psycho-social perspective regarding evidence-based practice.As such research interest grows in surgery-related healthcare services,we may also get some tips from the lessons learned in other fields of health and mental health services.Taking alcohol abuse issue for instance,previous studies revealed that Asian Americans tended to have lower rates of alcohol abuse than some other racial/ethnic groups.On the other hand,clinical studies also demonstrated that Asian subjects were more sensitive to alcohol than non-Asian subjects,besides the influences of psychological and social factors.Therefore,lower rates of alcohol abuse found in certain Asian cultures might have a physiological base,and thus enriching our understanding with a more comprehensive bio-psycho-social perspective that may also be applicable to the study of reaction patterns to surgical procedures.Also,cross-national comparative studies are needed since different nations have different patterns of alcohol consumption which may be more complicated than some simple rates can clearly differentiate or evaluate.The same may be true when we introduce a broader context for psychosomatic research in surgery.

With regard to the psychosocial aspects of mental illness,theories of stress and coping along with the role of socioeconomic status have helped to expand our knowledge in terms of the development of social psychiatry and social medicine[47].On the other hand,unlike the stress theory emphasizing that social conditions may cause mental illness,some other approaches such as selection and drift theories argue that mental illnesses cause low social status through a selecting or drifting process.Our previous teamwork also presented empirical evidence that socioeconomic status would not only affect the onset,development,and prognosis of mental illnesses,but also might have an effect on help-seeking and service-receiving[25].In particular,mental patients in the lower socioeconomic classes were less likely to go to private clinics but more likely to receive severe diagnoses when first seen by healthcare professionals,and more likely to be involuntarily hospitalized.Lower class status might also cause mental disorders through environmental and individual factors;conversely,mental disorders could cause lower socioeconomic status.At an even higher level of theoretical reasoning,the former is associated with the conflict theory while the latter more associated with the functional theory in sociology.All these ideas and insights would help us achieve a more comprehensive understanding via the bio-psycho-social lens when studying a variety of health service issues in surgical practice.

Conclusion and Discussion

The main issue/problem addressed in this article is the potential need for psychosomatic medicine research in the field of surgery,which is getting attention but still largely remains to be resolved.We would argue that the need does not only exist but also is very promising,particularly from a surgeon’s point of view.Focusing on esthetic/cosmetic surgery and with a broader notion of “psychosomatic surgery” in this field,psychosomatic medicine research does appear to be highly relevant even with regard to vascular surgery.With the theoretical and research perspectives derived from relevant literature reviews as the guidance,a deeper understanding in the specialty areas will make a good case for evidence-based practice by shedding light on psychosomatic medicine research about surgery in the United States with cross-cultural implications.

Our discussions have focused on esthetic/cosmetic surgery as well as other examples based on literature reviews and our own experiences and observations.In terms of future research directions,this would help to open a door to further and broader inquiry.For instance,in order to maximize the practical impact on this field,we should also consider potential administrative issues in the clinical settings involving broader psychosocial factors.

Utilization of surgery and associated psychological/psychiatric services is a complex issue.As Abe-Kim et al.described with regard to mental health services,help-seeking decisions are made not only at the individual level;they could be made by patients themselves,their families,or other social agents (in the case of involuntary admissions) [48].Similarly,individual decisions in seeking/accepting surgery are made within a social context and subject to certain limits,or both choices and constraints.Hence,the perceptions,values,and beliefs of the patients/recipients and their socioeconomic status and social support systems,and also their English language proficiency,may all affect their help seeking and services utilization [25].Consequently,the social construct of surgery as well as mental health services utilization involves multiple dimensions and levels of facts that require a systematic understanding of potential practical issues.

A further suggestion to more comprehensive“psychosomatic surgery” research is that more insights are needed under a comprehensive bio-psycho-social perspective.This includes theories on stress,coping,and the role of social support as well as selection and drift theories that provide a causal link between mental illnesses and low socioeconomic status.Issues of gender and race should also be heeded [49].The implications for healthcare (particularly surgery)practice are that the best service providers will not only possess good surgery skills but also a keen understanding of psychological factors/processes inherent in various kinds of surgery.In addition,higher standards are needed regarding clinicians’ cultural competence in providing surgery and related mental health services,with also a keen awareness of gender,political,and social issues involved that may affect the patients’ help-seeking,stress-coping,as well as other decision-making behavior situated within particular cultures.Such an understanding will help to foster a stronger commitment to empowering the patients in obtaining services and maintaining their physical,mental,and social health before,during,and after various kinds of surgical procedures.