Psychosomatic Medicine: a New Psychiatric Subspecialty in the U.S. Focused on the Interface Between Psychiatry and Medicine

Eur. J. Psychiat. Vol. 20, N.° 3, (165-171) 2006

Key words: Psychosomatic medicine, Subspecial- ty, Liaison psychiatry.

Psychosomatic medicine: A new psychiatric subspecialty in the U.S. focused on the interface between psychiatry and medicine

Constantine G. Lyketsos, MD, MHS*, Frits J. Huyse, MD, PhD**, David F. Gitlin, MD***, James L. Levenson, MD**** * Division of Geriatric Psychiatry and Neuropsychiatry, Department of Psychiatry and Behavioral Sciences, School of Medicine, The Johns Hopkins University ** Department of Internal, Medicine, University Medical Center Groningen, Groningen, The Netherlands *** Department of Psychiatry, Brigham and Women’s Hospital, Harvard University Medical School, Boston, Massachusetts **** Department of Psychiatry, School of Medicine, Virginia Commonwealth University, Richmond, Virginia USA

ABSTRACT – Background and Objectives: In the past, Psychosomatic Medicine (PM) has had ambiguous connotations, and there have been many other names for this specialized fields, including Consultation-Liaison Psychiatry. The objective of this report is to briefly review the background, the history and current status of PM, which recently was recognized in the U.S. a psychiatric subspecialty. Methods: Historical review and review of the literature. Results: PM has a rich history. Psychoanalysts and psychophysiologists pioneered the study of mind-body interactions, and crucial events in the development include the funding of PM units in several U.S. teaching hospitals by the Rockefeller Foundation, and the training grants and a research development program funded by the National Institute of Mental Health. By the 1980s, all psychiatry residency programs were requiered to provide substancial clinical experience in the field, and as of 2005 there were 32 fellowship programs in the Academy of Psychosomatic Medicine's (APM) directory. In 2001, The Acad- emy of Psychosomatic Medicine (APM) applied for the recognition of PM as a subspecialty of psychiatry, and formal approval was granted by the American Board of Medical Specialties (ABMS) in March 2003. 166 C. LYKETSOS ET AL.

The foundation of PM is a specialized body of scientific knowledge regarding psychiatric aspects of medical illness. This has been articulated in contemporary textbooks, journals and regular scientificic meetings of national and international societies A cadre of scholars and researchers has emerged, and important contributions have occurred. A major goal of the PM field is to improve the psychiatric care of patients with complex medical conditions. There are a number of obstacles and challenges ahead in pursuing optimal integration of PM services into existing service delivery systems of care, but anticipated expansion of accredited fellowship programs in PM will hopefully help address this short- fall. In the past 20 years an international PM network has developed with increasing scientific exchanges, and the US paradigm is regarded as important for the development of PM as a subspecialty internationally. Conclusion: Formal recognition as a subspecialty in the U.S. has and will strengthen PM and will enhance its growth internationally.

Received 19 November 2005 Accepted 1 February 2006

Introduction other’s management; those with psychiatric disorders that are the direct consequence of a primary medical condition or its treatment, In the past, Psychosomatic Medicine (PM) such as delirium, dementia or other sec- has had ambiguous connotations, alternative- ondary mental disorders (formerly known as ly “psychogenic” or “holistic,” but it is the “organic” disorders); those with complex ill- latter meaning that has characterized its ness behavior such as “somatoform” and emergence as a contemporary scientific and functional disorders; and, patients with acute clinical discipline1. PM is the newest psychi- psychopathology admitted to medical-surgi- atric subspecialty approved by the American cal units, such as after attempted suicide. Board of Medical Specialties. There have Many of these patients have multiple med- been many other names for this specialized ical, psychiatric, functional, and/or substance field, including Consultation-Liaison psychi- abuse disorders, thus are best thought of as atry2, medical-surgical psychiatry, psycho- the psychiatric counterpart of the multimor- logical medicine, or psychiatric care of the bid frail elderly seen by geriatricians. complex medically ill. The name chosen for PM psychiatrists have been trained to the field was intended to reflect the field’s deliver services in the general health care history, its focus on the interface between sector working with the complex medically psychiatry and other areas of medicine, and ill. They have been known as consultation- the patient population it serves. PM psychia- liaison psychiatrists practitioners. They trists have special expertise in the diagnosis may work as hospital-based consultation- and treatment of psychiatric conditions in liaison psychiatrists, on medical-psychi- complex medically ill patients3. Working atric inpatient units4, and in settings in closely with physicians in primary care and which mental health services are integrated other specialties, its practitioners treat and with primary care or medical specialties. study four general groups of patients, some- Thus the field’s name reflects the fact that times referred to as the “complex medically it exists at the interface of psychiatry and ill”: those with co-morbid psychiatric and medicine and focuses on the interaction general medical illnesses complicating each between medical conditions and psychi- PSYCHOSOMATIC MEDICINE: A NEW PSYCHIATRIC SUBSPECIALTY IN THE U.S... 167 atric disorders. The rest of this article is Board of Psychiatry and Neurology (ABPN) devoted to a brief discussion of the history for the recognition of "Psychosomatic Medi- and current status of PM. cine” as a subspecialty of psychiatry, choos- ing to return to the name for the field imbed- ded in its history, its journals, and its national organizations7. Formal approval History was granted by the American Psychiatric Association, the ABPN, the Residency Review Commission (RRC) of the Accredi- PM has a rich history. The term "psycho- tation Committee for Graduate Medical somatic” was introduced by Johann Hein- Education (ACGME), and eventually the roth in 1818, and “psychosomatic medicine" American Board of Medical Specialties by Felix Deutsch around 19225. Psychoana- (ABMS), the latter in March 2003. The first lysts and psychophysiologists pioneered the certifying examination was administered in study of mind-body interactions from very June 2005 to almost 500 psychiatrists. As of different vantage points, each contributing to August 2005, the ACGME has accredited 16 the growth of PM as a clinical and scholarly fellowship-training programs in PM. field. The modern history of the field per- haps starts with the Rockefeller Founda- An impediment to the field’s growth has tion’s funding of PM units in several U.S. been the split between general medical and teaching hospitals in 1935. The National mental healthcare, with major adverse Institute of Mental Health made it a priority effects on quality of medical service delivery 8 to foster the growth of consultation-liaison and patient oriented care . This split is psychiatry, the name of the field at the time, reflected in disparities and disintegration in through training grants (circa 1975) and a the reimbursement of patient care (carve research development program (circa 1985). outs, lack of parity in coverage) and funding mechanisms in silos that do not promote The integration of consultation-liaison cross-disease research and therefore require psychiatry into the core of psychiatric resi- special attention for the further growth of dency training began in the 1960s at indi- PM. vidual institutions. By the 1980s, all psychiatry residency programs were required to provide substantial clinical experience in the field. In the U.S., subspecialty fellow- Psychosomatic medicine as a ship training in PM has been available for scholarly discipline over 25 years, with over 1,000 psychiatrists educated in this subspecialty. As of 2005, there were 32 fellowship programs in the The foundation of PM is a specialized Academy of Psychosomatic Medicine’s body of scientific knowledge regarding psy- (APM) directory. In the last national survey chiatric aspects of medical illness. This has of U.S. psychiatrists’ practices, well over been articulated in half a dozen contempo- 2,500 psychiatrists were practicing in this rary textbooks, about a dozen active jour- field6. nals, and the regular scientific meetings of a dozen national and international societies2. In 2001, The Academy of Psychosomatic A major new textbook for the field has Medicine (APM) applied to the American recently been published and is being widely 168 C. LYKETSOS ET AL. used9. A cadre of scholars and researchers atric illness on medical morbidity is sub- has emerged involved in a wide spectrum of stantial. For example, depression has been investigations looking at the medical ill- associated with increased risk of recur- ness-psychiatry interface. Important contri- rence and mortality from myocardial butions have occurred in the interface infarction2, increased risk of stroke in between psychiatry and HIV-AIDS, cancer, hypertensive patients2,worse glycemic transplantation, cardiology, neurology, control in diabetic patients2, and increased endocrinology, pulmonary, renal and GI dis- functional dependency in Alzheimer eases, obstetrics-gynecology, and geriatric patients2. In fact, psychiatric morbidity in medicine. many medical disorders has been shown to be a potent risk factor for increased med- Epidemiologic research has repeatedly ical morbidity and disability. Unfortunate- documented a substantial clustering of ly, many studies demonstrate that poten- medical and psychiatric morbidity, espe- tially treatable psychiatric disorders in the cially in the complex medically ill. This complex medically ill are typically under- co-morbidity leads to increased mortality, diagnosed and under-treated2, 6,8. morbidity, loss of quality of life and excess utilization of health care services through Early empirical efforts to treat psychiatric several psychosocial and biological mech- morbidity in the medically ill have been fol- anisms, among them non-compliance and lowed by intervention trials focused on lack of interdisciplinary communication. reducing their associated impact on medical Studies in the 1980s and 90s identified the illness such as in cardiac and diabetes extent and nature of psychiatric morbidity patients2. In these studies the psychiatric associated with the most common diseases, condition is treated, while its effects on and its effects on outcomes such as mortal- medical outcomes, compliance with treat- ity, morbidity, quality of life and excess ment for the medical condition, and quality health care utilization2. These studies established the high prevalence rates of a of life are assessed. Similar trials are under- broad range of psychiatric disorders in way for patients with unexplained symp- medical illnesses as well as less common, toms and related “functional” syndromes. or newly recognized psychopathologic conditions. Similar studies examined psy- Research has also begun to explore the chiatric morbidity in patients with abnor- complex mechanisms involved in the devel- mal illness behavior such as unexplained opment of psychiatric morbidity in the med- physical complaints and functional disor- ically ill, including genetic, neurochemical, ders. Inpatients in general hospitals have behavioral or social factors, the latter the highest rates of psychiatric disorders including the way health care is delivered. followed by medical outpatients2. Com- Examples include the relationship between pared to community samples, depressive the location of stroke and major depression, disorders in the general hospital are 2-5 the role of childhood sexual abuse in chron- times as common, substance abuse 2 to 3 ic pain and illness behavior, interferon- times as common, and somatoform disor- induced depression, causal pathways to ders more than 10 times as common2. delirium, and barriers to care for blood- Delirium occurs in almost a fifth of elderly borne diseases among patients with serious medical inpatients2. The impact of psychi- mental illness2,10. PSYCHOSOMATIC MEDICINE: A NEW PSYCHIATRIC SUBSPECIALTY IN THE U.S... 169

The clinical practice of grams to identify and initiate treatment for Psychosomatic Medicine: psychiatric disorders, there is potential for models for service delivery great improvement in both psychiatric and medical outcomes2. There are a number of obstacles and chal- A major goal of the PM field is to lenges ahead in pursuing optimal integra- improve the psychiatric care of patients tion of PM services into existing service with complex medical conditions. Physi- delivery systems of care. Most PM psychia- cians in primary care or internal medicine trists are on psychiatric consultation services, provide the great majority of the psychi- rarely found outside teaching hospitals, and atric care for these patients. These patients their services are reactive, typically emergent are encountered in general or chronic care or urgent. Optimal care for patients with hospitals, in home healthcare settings, in complex medical illnesses such as cancer or the offices of primary care or specialist AIDS, or for those patients being considered physicians, and in many other health care for transplant or gastric bypass, calls for environments, such as rehabilitation units, close working relationships with the primary nursing homes, and assisted living facili- physicians as well as easy access to specialties. The higher concentration of patients ized psychiatric expertise. Psychiatric liai- with psychiatric disorders in the general son, in which psychiatrists are integrated hospital and in primary care provides a members of a specialized care team, is a critical opportunity, working closely with more advanced model, with greater ability to team members in other medical specialties, provide early detection and prevention10. to identify and treat this important group of However, such services are usually limited patients both to reduce their emotional suf- to larger teaching and specialty hospitals. fering and improve their medical out- Thus, there is an overall shortage of PM comes. Patients who pass through these psychiatrists in the U.S., and they are not portals need recognition, appropriate diag- evenly distributed, but anticipated expan- nosis, initiation of treatment, and referral sion of accredited fellowship programs in for the follow-up psychiatric care they PM will hopefully help address this short- 11 would otherwise fail to receive . Failures fall. to identify, evaluate, diagnose, treat, or achieve symptom resolution results in pre- ventable adverse outcomes. A major cause of the failure to identify and treat psychi- Psychosomatic Medicine’s atric disorders in the medical setting is the Interface with other medical absence of on-site or ready access to psychiatric expertise. PM subspecialists deliv- disciplines er emergency services for attempted suicide and serious behavioral disturbances; Training of other medical specialists:PM consults for medical generalists and spe- psychiatrists often take part in the training of cialists, and most critically, integrated ser- non-psychiatric residents, particularly in vices for patients with psychiatric disor- internal medicine, family practice, pediatrics, ders and complex medical illness. When an obstetrics/gynecology, and neurology. They active PM service is integrated with the play a significant role in teaching about psy- medical/surgical staff in collaborative pro- chiatric disorders at annual meetings of the 170 C. LYKETSOS ET AL.

American College of Physicians, the Society ity of consultations in the general hospital, for General Internal Medicine, the American specialists in PM are primarily internists Association for Family Practice, the Ameri- who treat patients with depression or abnor- can College of Obstetrics and Gynecology, mal illness behavior in specialized PM and others. An important aspect is the com- departments with a primary focus on psy- bined training of psychiatrists and other med- chotherapy. German patients with “organic” ical specialists, in “medicine-psychiatry” psychosis, substance abuse, or attempted inpatient units, collaborative care outpatient suicide are treated by general psychiatrists. clinics, or in other integrated service delivery Although German psychiatrists provide approaches. hospital consultations, this is not a subspecialty within their field. Participation in medical center ethics committees: PM psychiatrists play leading roles on medical center ethics committees, contributing specialized expertise regarding Conclusion end of life decisions, capacity/competency, involuntary treatment, boundary violations, and other doctor-patient relationship prob- PM has evolved from its beginnings in lems. PM psychiatrists have served as chairs psychophysiology and psychoanalysis to of hospital ethics committees far out of pro- become a subspecialty of psychiatry devot- portion to their numbers (Academy of Psy- ed to psychiatric care of the complex med- chosomatic Medicine Task Force on Ethics, ically ill through consultation and integra- unpublished data). tion with the rest of medicine. The future aims of the PM field include: • Collaboration with other medical specialties and disciplines to develop integrated International developments care for the complex medically ill thus over- coming the burden of fragmentation in the In the past 20 years an international PM existing service delivery system; network has developed with increasing sci- • Development of combined training pro- entific exchanges. The US paradigm is grams for medical specialists in integrated regarded as important for the development care on psychiatry-medicine units and other of PM as a subspecialty internationally. In types of integrated service delivery; Australia, the United Kingdom and Japan formal criteria for sub-specialty status in • Development, funding, and evaluation PM have recently been established. In of new collaborative research models in Turkey it is in process of evaluation. In psychopathology and complex medical ill- other countries subspecialty status is a more nesses; distant prospect. For instance, in Spain PM • Changes in health care insurance and is a rotation in the basic psychiatric special- financing to overcome the current disinte- ty training, whereas in the Netherlands gration and disparities between mental under the influence of the US develop- health and general health care. ments, such a rotation has become a realistic possibility. It is important to know that in Formal recognition as a subspecialty in the Germany, where psychiatrists do the major- U.S. has and will strengthen PM and will PSYCHOSOMATIC MEDICINE: A NEW PSYCHIATRIC SUBSPECIALTY IN THE U.S... 171 enhance its growth internationally. The certi- 6. Dorwart RA, Chartock LR, Dial T, Fenton W, Knes- fication of more psychiatrists with expertise per D, Koran LM, et al. A national study of psychiatrists' professional activities. Am J Psychiatry 1992; 149: 1499- in PM will help address the unmet psychi- 1505. atric needs of the medically ill, improve the quality of education and training both in psy- 7. Lyketsos, CG, Levenson JL, with the Academy of Psy- chiatry and in other areas of medicine, pro- chosomatic Medicine (APM) Task Force for Subspecializa- tion. Proposal for recognition of “Psychosomatic Medicine” mote integrative research, and improve the as a psychiatric subspecialty. Academy of Psychosomatic medical outcomes of this complex patient Medicine, July 2001. population. Progress in PM and its contributions to care are endangered by existing splits 8. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Committee on and fragmentation in health care delivery and Quality of Health Care in America. Washington DC: financing. National Academy Press; 2001.

9. Levenson JL (Editor). Textbook of Psychosomatic Medicine. Washington DC: American Psychiatric Press Inc; 2004. References 10. Rosenberg S, Brunette M, Oxman T, Marsh B, Dietrich A, Mueser K, Drake R, Torrey W, Vidaver R.The 1. Lipowski ZJ. What does the word "psychosomatic" STIRR model of best practices for blood-borne diseases really mean? A historical and semantic inquiry. Psychosom among clients with serious mental illness. Psychiatr Serv Med 1984; 46: 153-171. 2004; 55(6): 660-664. 2. Kornfeld DS. Consultation-Liaison psychiatry: con- 11. Huyse FJ. From consultation to complexity of care tributions to medical practice. Am J Psychiatry 2002; 159: prediction and health service needs assessment. J Psycho- 1964-1972. somatic Res 1997; 43: 233-240. 3. Gitlin DF, Levenson JL, Lyketsos CG. Psychosomat- ic Medicine: A New Psychiatric Subspecialty. Academic Address for correspondence: Psychiatry 2004; 28: 4-11. Constantine G. Lyketsos, MD, MHS Professor of Psychiatry 4. Kishi Y, Kathol RG. Integrating medical and psychi- 550 North Broadway, Suite 308 atric treatment in an inpatient medical setting. The type IV Baltimore, MD 21207 program. Psychosomatics 1999; 40(4): 345-355. 410-955-6158 (tel) 5. Lipsitt DR. Consultation-liaison psychiatry and psy- 410-614-8042 (fax) chosomatic medicine: the company they keep. Psychosom [email protected] Med 2001; 63: 896-909. USA