Dennis H. Novack, MD

Practitioners understand thewholeness and unity of their patients.Instead of being consideredisolated organ systems or enzymecycles, patients are understood as coherententities composed of coordinatedand interrelated processes and systems.This fundamental understanding guidesinvestigative and clinical care approachesin psychosomatic medicine.As an integrative science, psychosomaticresearch investigates multilevelinteractions that contribute to health andillness

--which include genetic susceptibility,biologic insults, early childhoodexperiences, socioeconomicstatus, personality, acute and chronicstressors, and social networks--andtheir combined effects on physiologicfunctioning. Committees of the NationalResearch Council and the Institute ofMedicine have recently publishedcomprehensive reviews of this science.

With its clinical approach, psychosomaticmedicine includes social,psychological, behavioral, physiologic,and medical parameters in its evaluationand treatment of patients. Comorbidpsychiatric conditions areaccounted for--not excluded. Forexample, the anxiety disorder thatcomplicates the care of the asthmaticpatient is addressed and integrated intothe overall care plan. In its inclusiveness,this approach provides the mostcomprehensive model for understandingand intervening in patients' care.

Psychosomatic medicine is the coreperspective not only for psychiatristswho also provide primary care or workin general medical settings but for allpsychiatrists who are dedicated to thecare of the whole patient. With theAmerican Board of Medical Specialties'recent specialty designation ofPsychosomatic Medicine for psychiatristswho care for the medically ill,many of these practitioners will takethe lead in applying this approach toclinical care and medical education.

Psychosomatic medicine investigationtargets phenomena that traditionallyhave been studied in isolation. To illustratethis approach, the 

 (page6) shows the central interaction of variousaspects of the patient while recognizingthat there is a broad range ofinteractive possibilities. Each interactivedomain contains illustrative examples,without intending to be exhaustive.

With an extensive set of potentialresearch possibilities, the followingareas of study are among the mostpromising, both now and in the foreseeablefuture, and exemplify the vitalityof the field.

The expansive growth of neuroscienceinvestigation has had an impact onmany fields, including that of psychosomaticmedicine. Areas of researchactivity include social neuroscience,emotion and autonomic regulation, andthe neurobiology of depression.

Emotions--their arousal, regulation,and physiologic effects--are an area ofstudy with great potential importancefor psychosomatic medicine researchand with promising value and applicabilityfor clinical psychiatry. Emotionsand their neural substrate may prove tobe a key mediator of psychophysiologicprocesses. Various techniques, such as functional brain imaging in conjunctionwith physiologic measures, arebeing used to investigate the linksbetween emotion, internal bodilyresponses, and behavior.

 Both positiveand negative emotional states andprocesses are being investigated fortheir influence on health behaviors andoutcomes.

 An improved understandingof emotional states and their impactmay provide a basis for more effectiveinterventions for a range of psychiatricand medical conditions.

Psychoneuroimmunology has beenanother area of growing investigation.

Progress in this area accelerated dramaticallyin the 1990s and 2000s. Psychiatricsymptoms and syndromes,personality features, and stressors havebeen studied in their association withimmune function. Some of the strongestevidence to date indicates that stressand negative emotions appear capableof increasing the risk of initiation andprolongation of infectious disease andof retarding wound healing.

With inflammation implicated as animportant pathogenic process acrossnumerous systemic disorders, the doorto future studies of various diseases hasbeen opened wide by studies that demonstratethe impact of depression and distresson proinflammatory cytokines.

Future intervention studies will attemptto modify immune functions with methodsthat include longer clinical trials witholder and sicker participants.

Compelling findings from the study ofthe relationship between depression andheart disease continue to emerge. Thepsychiatrist evaluating and treating thedepressed middle-aged or elderly patientmust account for the substantial epidemiologicevidence that warns of anincreased risk of adverse cardiac events.A dose-response relationship has beenshown to exist between the severity ofdepressive symptoms and the risk ofadverse cardiac events.

 Even relativelymild symptoms and other negativepsychological states have been associatedwith cardiovascular disturbance.

Growing evidence indicates that notonly depression but also social variablessuch as low socioeconomic status, poorsocial support, and chronic stress arestrongly linked to coronary artery disease.

 This evidence is a powerfulimpetus to provide timely and effectivetreatment for depressive symptoms,given the presumed added benefit ofreduced cardiac risk.

With the increasing confirmation ofthe relationship between depression andcardiovascular disease, interventionstudies have begun to investigate thetreatment of depression in cardiacpatients. In theory, treatment of depressionshould alter its negative effects onthe incidence of cardiac events and thecourse of heart disease.

The Sertraline AntiDepressant HeartAttack Trial found that sertraline(Zoloft) could be used by cardiacpatients without substantial safetyconcerns.

 Drug efficacy on measuresof the severity of depression was somewhatdisappointing in the entire sample,although more encouraging in patientswith severe or recurrent depression.The difference in the incidence of majorcardiac events between the treated andplacebo groups did not reach statisticalsignificance but favored the interventiongroup. The Myocardial INfarctionand Depression-Intervention Trial, nowin progress, is a 3-armed trial comparing2 antidepressants with placebo inthe treatment of depressed patientsfollowing myocardial infarction.

In addition to drug treatment studies,the federal government funded thefirst large trial of a cognitive-behavioraltreatment for depressed cardiacpatients--Enhancing Recovery inCoronary Heart Disease.

 Althoughdepression was confirmed as an independentrisk factor for postmyocardialinfarction mortality, effective treatmentof depression failed to reduce the cardiacrisk. Future studies will continue to grapplewith the challenge of understandingand intervening to reduce depressionand its impact on heart disease.

While biopsychosocial research continuesto proliferate, the educational challenge remains daunting. Medical educationin the United States remainspredominantly biomedical in itsperspective. A recent survey of USmedical school curricula found thatmost schools fail to teach adequatelymany topics that would convey theknowledge and skills necessary to carryout comprehensive patient assessmentand treatment.

 Examples of such skillsinclude behavioral treatments for thepsychosocial elements that complicateillnesses such as diabetes mellitus andpulmonary and renal disease, and alternativetreatments such as biofeedbackand relaxation exercises.

Maladaptive health behaviorscontinue to be a significant barrier tohealth promotion. Nevertheless, medicalschool curricula remain grossly deficientin teaching the next generation ofphysicians counseling skills that couldhelp patients modify risk factors ormaladaptive health behaviors.

With strong encouragement fromthe leadership of the American PsychosomaticSociety and other organizations,the Office of Behavioral andSocial Sciences Research (OBSSR) atthe NIH asked the Institute of Medicineto undertake a study of behavioral andsocial science teaching in the undergraduatemedical curriculum. Resultsof this study, Improving MedicalEducation: Enhancing the Behavioral and Social Science Content of MedicalSchool Curricula, were reported inMarch 2004.

Noting that demographicand other factors are increasing theimportance of behavioral and socialelements of health and health care, thestudy found that there is inadequateinformation to characterize satisfactorilythe content of behavioral/socialscience curricula, teaching techniques,and evaluation methods in US medicalschools. The study offered a number of recommendations:


Establish a national behavioral/socialscience database.

Develop an integrated behavioraland social science curriculum thatcontinues through the 4 years ofmedical school, with an emphasis onthe inclusion of 26 behavioral/socialscience topics in 6 domains (

Offer career and curriculum developmentawards supported by theNIH or foundations.

Develop sufficient coverage of behavioral/social science content on the USMedical Licensing Examinationadministered by the National Boardof Medical Examiners.

The Institute of Medicine report hasthrown down the gauntlet for educationalchange. As a result, the OBSSRhas followed with a request for applicationsfor career development awards.

To promote development of coursesand curricula to increase medicalstudents' knowledge of and skills inthe behavioral and social sciencesrelated to health, with possible educationalapplication for postgraduatephysicians, faculty, and practicingphysicians.

To disseminate curricular and othereducational materials to othermedical and health care professionalschools.

To promote research and careers inbehavioral/social science in medicalschools.

As of October 2005, nine medicalschools were funded via this initiativefor a project period of up to 5 years.

Currently we are in the midst of unprecedentedattempts to place behavioral andsocial sciences at the core of physicianeducation. New and revised behavioraland psychosomatic medicine texts andother educational materials are beingdeveloped to reflect the imperatives setout by the Institute of Medicine report.There are growing opportunities for thepsychiatrist to design, implement, andevaluate education initiatives. Psychiatrists,as traditional leaders in holisticcare, bring the commitment andexperience needed to make a significantlasting contribution to the futuredirection of medical education.

Dr Ochitill is director of the psychiatric consultationservice at San Francisco GeneralHospital and clinical professor of psychiatryat the University of California, San Francisco,School of Medicine. He is co-chair of the professionaleducation committee of the AmericanPsychosomatic Society. Dr Ochitill has noconflicts to disclose regarding the subjectmatter of this article.

Dr Novack is director of clinical skills teachingand assessment, professor of medicine, andassociate dean of medical education at DrexelUniversity, College of Medicine, Philadelphia.He is past president of the American PsychosomaticSociety. Dr Novack has no conflictsto disclose regarding the subject matterof this article.

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Articles

Practitioners understand the wholeness and unity of their patients. Instead of being considered isolated organ systems or enzyme cycles, patients are understood as coherent entities composed of coordinated and interrelated processes and systems. This fundamental understanding guidesinvestigative and clinical care approaches in psychosomatic medicine.

Dennis H. Novack, MD

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Progress and Promise: Research and Education in Psychosomatic Medicine