New Ways of Integrating Psychiatry and Medicine

Psychiatric Times

April Bonus Edition 2005

Vol. XXII

Issue 5

Imagine sitting down for dinner with a colleague who enthusiastically starts discussing the latest developments in the following areas:

• The effects of stress reduction on health
• The hypothalamic-pituitary adrenal (HPA) axis and stress
• The effect of massage therapy on the immune system of breast cancer patients
• The role of frontal lobe subcortical circuits in neuropsychiatric disorders
• The pharmacotherapy of somatoform disorders
• Psychological problems in patients with multiple sclerosis
• The connection between stress and cardiovascular disease
• The physiological correlates of burnout

The notion of a psychiatrist with such broad-ranging biopsychosocial knowledge is becoming increasingly plausible, given recent developments in the field of psychosomatic medicine. (Indeed, all the topics listed above were covered in the Journal of Psychosomatic Research within the past few years.) As Paula T. Trzepacz, M.D., president of the Academy of Psychosomatic Medicine (APM), recently put it, "I cannot recall a more exciting time for this organization" (Trzepacz, 2005b). Trzepacz pointed to the recent decision of American Board of Psychiatry and the Neurology (ABPN) to make psychosomatic medicine a "bona fide subspecialty of psychiatry," with its own subspecialty board examination. Furthermore, the American Psychiatric Association has just established a Council on Psychosomatic Medicine, chaired by Phil Muskin, M.D. To top things off, the theme of this year's APA Annual Meeting is "Psychosomatic Medicine: Integrating Psychiatry and Medicine."

This flurry of recent developments, however, belies the long history of psychosomatic medicine. Indeed, the APM just celebrated its 50th anniversary as an organization for consultation-liaison (C-L) psychiatry.

A Brief History

The earliest attempts in the United States to integrate psychiatry and medicine may be traced to the efforts of Benjamin Rush (1745-1813) at the Pennsylvania Hospital ( Lipowski, 1996). Amid all the "mind-body" controversies still brewing today, it is enlightening to recall Rush's words, in 1811 (cited in Lipowski, 1996):

Man is said to be a compound of soul and body. However proper this language may be in religion, it is not so in medicine. [Man] is, in the eye of a physician, a single and indivisible being.

The term psychosomatic was first used by the German physician Johann Christian Heinroth in 1818, when discussing causes of insomnia, and the term psychosomatic medicine is thought to have been introduced by Felix Deutsch, M.D., around 1922 ( Gitlin et al., 2004). As Lipsitt (2000) has pointed out, the roots of psychosomatic medicine in the United States "were distinctly psychoanalytic and psychodynamic" as a number of Sigmund Freud's students began to apply their theories to a variety of physical disorders. (Freud himself always maintained the hope that biological and psychological concepts would someday be integrated.)

The 1920s also saw the emergence of general hospital psychiatric units in the United States, such as the one at Henry Ford Hospital in Detroit. Indeed, the origins of C-L psychiatry can be seen in precisely this convergence of psychosomatic medicine and the general hospital psychiatric unit (Lipowski, 1996). The field was moved forward in the 1930s, with the founding of the journal Psychosomatic Medicine by Helen Flanders Dunbar, M.D., Ph.D. By the 1950s, C-L units were found in many U.S. hospitals. The 1960s saw the emergence of some outpatient psychiatric clinics that included social workers and psychologists on the treatment team; for example, the Integration Clinic founded by Don Lipsitt, M.D., at Beth Israel Hospital in Boston (Lipsitt D, personal communication, March 2005).

One of the leaders in the field, Donald S. Kornfeld, M.D., has summarized the numerous contributions of C-L psychiatry to the practice of medicine over the past 50 years (Kornfeld, 2002). Among many others, Kornfeld pointed to the areas of C-L research in the Table. Kornfeld also noted the immense contributions of the biopsychosocial model of George Engel, M.D., to the overall humanization of patient management.

As Gitlin et al. (2004) noted, the growth of C-L and psychosomatic medicine organizations and programs has been dramatic in the past 50 years. As of 2001, there were 32 C-L fellowship programs registered with the APM and 48 combined residencies (e.g., psychiatry combined with internal medicine, family practice, pediatrics or neurology). This trend in residency training points to the increasing integration of psychiatry with primary care medicine.

Within the past few years, the name of the field was changed from C-L psychiatry to psychosomatic medicine for a variety of reasons and after extensive discussion within the APM, APA and ABPN.

Recent Research Advances

The full scope of psychosomatic medicine research over the past decade could easily fill a textbook. Here is a focus on a few recent advances.

Hypothalamic-pituitary-adrenal axis. Abnormalities of the HPA axis have been found in a number of neuropsychiatric disorders, including depression, posttraumatic stress disorder (Yehuda et al., 1995) and chronic stress. The neuroendocrine response to the chronic stress may lead to damage in limbic and mesiotemporal structures (Arborelius et al., 1999; Bremner, 1999). This damage, in turn, could exacerbate congenital tendencies toward affective instability and contribute to the development of affective or even Axis II (personality) disorders (Duman et al., 2000).

Schatzberg et al. (2000) have focused on HPA abnormalities in patients with psychotic depression. These patients tend to show higher levels of 24-hour urinary free cortisol, higher rates of dexamethasone non-suppression and high post-dexamethasone cortisol levels. The researchers have hypothesized that glucocorticoid-induced decreases in dopamine function may underlie cognitive deficits in these patients--due, perhaps, to prefrontal cortical damage.

Psychoneuroimmunology. Kiecolt-Glaser et al. (2002) have reviewed the burgeoning research on psychological modulation of immune function, concluding, "Immune modulation by psychosocial stressors or interventions can lead to actual health changes, with the strongest direct evidence ... in infectious disease and wound healing." Furthermore, they concluded that an entire spectrum of diseases--ranging from cardiovascular disease to osteoporosis to Alzheimer's disease--may be influenced by chemicals called pro-inflammatory cytokines, such as interleukin-6. Importantly for psychiatrists, depression and distress appear to enhance production of these injurious substances (Kiecolt-Glaser et al., 2002).

Pathological emotional states and cardiac morbidity. Harnett (2001) has reviewed the literature linking depression and other pathological emotions to altered cardiac function. For example, extensive epidemiologic research suggests that depression is associated with the development of ischemic heart disease (Glassman and Shapiro, 1998). For individuals with pre-existing cardiovascular disease, these researchers found depression was even more closely associated with adverse cardiac outcome, including enhanced cardiac mortality. These associations persist after controlling for the morbid effects of smoking and other medical and social risk factors. Panic disorder and other anxious states may also contribute to cardiac morbidity (Tucker et al., 1997). Moreover, as Katon et al. (1988) have shown, many patients with chest pain and normal coronary angiograms suffer from panic disorder.

Brain circuitry and emotion. The growing interest in "behavioral neurology" and neuropsychiatry is integrally related to recent discoveries in brain structure and function. Mesulam (2000), for example, has suggested that our brains respond to the world via three intricately connected neural systems: the limbic system, the prefrontal cortex and the paralimbic system. As Mesulam puts it, " Paralimbic areas [of the brain] play an important role in linking cognition with visceral states and emotion." The paralimbic regions of the frontal lobes participate in "binding thoughts, memories, and experiences with corresponding visceral and emotional states." Indeed, damage to these mediating structures "interferes with the ability of emotion and visceral state to guide behavior, especially in ... ambiguous situations" (Mesulam, 2000). Many C-L psychiatrists working with stroke patients have observed these deficits firsthand.

New Challenges and Directions

As exciting a time as this is for the APM, then President-Elect Trzepacz (2005a) noted some significant challenges facing the organization. "C-L services are small, and clinical consultations are unpredictably timed, thereby offering a limited and fluctuating pool of potential subjects," Trzepacz observed. Furthermore, "For residents or junior investigators ... it is often a difficult task to find a seasoned C-L research mentor; and, as in other areas of care, the teaching burden often leaves limited time to pursue research." Given these realities, Trzepacz and Donald Rosenstein, M.D.--scientific program chair for the 2005 APM annual meeting--have advocated, "A new paradigm in psychosomatic medicine research- multicenter research trials." The idea is to "develop a national consortium of C-L research sites across the country" (Trzepacz, 2005a).

The APM is far from the only organization feeling its oats in the area of psychosomatic medicine. The American Neuropsychiatric Association (ANPA) is at the forefront of integrating traditional psychiatry and neurology. According to the ANPA Web site (<www.anpaonline.org>), the organization is dedicated to "understanding the links between neuroscience and behavior, and to developing effective diagnosis and treatment for patients with neuropsychiatric disorders." In March 2004, a joint application from ANPA and the Society for Behavioral and Cognitive Neurology was submitted to the United Council for Neurologic Subspecialties. On June 30, 2004, behavioral neurology and neuropsychiatry was approved as a single subspecialty. At the 15th Annual Meeting of ANPA (Feb. 21-24, 2004), a two-day symposium focused on "The Neuropsychiatry of Modularity: Cognition, Emotion, and the Interactive Brain." Pre-meeting workshops reviewed the neuropsychiatry of epilepsy, including surgery, pseudoseizures and psychosis.

Recently, plans were announced to develop "a network of AIDS Psychiatrists and an Organization of AIDS Psychiatry" (Cohen, 2005). Cohen explained, "There are many psychiatrists who are devoting their professional lives to providing care for persons with HIV and AIDS ... there is a need for a national organization to provide networking and support." In November 2004, the APM agreed to establish a new special section of AIDS psychiatry.

Finally, the integration of psychiatry with primary care is proceeding apace. In June 2004, several agencies within the U.S. Department of Health and Human Services coordinated a conference titled "Complexities of Co-Occurring Conditions: Harnessing Services Research to Improve Care for Mental, Substance Use, and Medical/Physical Disorders." One of the main findings of the conference was that for patients with co-occurring depression and medical illness, a systems-based response--integrating medical and behavioral health interventions--results in improved outcome.

Conclusion

This is, indeed, an exciting and challenging time for the integration of psychiatry and medicine. As Lipsitt (2000) has suggested, "Psychiatry's next hurdle in keeping the study of the mind in medicine may be its response to the perturbations of managed care, managed competition, and other products of emerging health care reform." It will certainly take diligence and determination to ensure that we "close the gap" between psyche and soma.

Acknowledgments

The author wishes to thank Wayne Katon, M.D., and Don Lipsitt, M.D., for their helpful comments on the scope and content of this paper.

Dr. Pies is clinical professor of psychiatry at Tufts University. His most recent books include Creeping Thyme, a collection of poetry (Brandylane Publishing); Zimmerman's Tefillin, a short story collection (PublishAmerica); and Handbook of Essential Psychopharmacology, 2nd edition, forthcoming from American Psychiatric Publishing.

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