Psychosomatics 45:1-6, February 2004
© 2004 The Academy of Psychosomatic Medicine
The Changing Content of Psychosomatics: Reflection of the Growth of Consultation-Liaison Psychiatry?
Dilip Ramchandani, M.D., and
Thomas N. Wise, M.D.
Received Feb. 11, 2003, revision received Aug. 20, 2003; accepted Aug. 28, 2003. From the Department of Psychiatry, Temple University School of Medicine; and the Department of Psychiatry, INOVA Fairfax Hospital, Falls Church, Va. Address reprint requests to Dr. Ramchandani, Department of Psychiatry, Temple University School of Medicine, Jones Hall, 1316 West Ontario St., Philadelphia, PA 19140
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ABSTRACT
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Psychosomatics is the official journal of the Academy of Psychosomatic Medicine, the national organization of consultation-liaison psychiatrists. The articles published in Psychosomatics, therefore, represent an important element of the scholarship of consultation-liaison psychiatry, and the evolution of this literature should reflect the development of its knowledge base in the past 40 years. This paper analyzes the content of Psychosomatics over this period and discusses the scientific, academic, and social (including economic and political) factors that have influenced the changes in the content of the journal and, thus, the subspecialty.
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INTRODUCTION
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The Academy of Psychosomatic Medicine (APM) was an outgrowth of the American Psychosomatic Society. Seven of the APM's 10 original founders were members of the American Psychosomatic Society who felt that there was a need for a new organization with a more focused clinical agenda, since the American Psychosomatic Society was more concerned with academic scholarship and statistical modeling of nonclinical issues.1,2 The APM was interdisciplinary at its inception in 1953. Its journal, Psychosomatics, was established 7 years later. Dr. Wilfred Dorman, its first editor, was a family practitioner turned psychiatrist in private practice, with only limited ties to academic medicine.
From its beginnings as a multidisciplinary, clinically focused organization, the APM evolved into the representative organization for consultation-liaison psychiatry in the 1980s.3,4 Psychosomatic Medicine is the global term that refers to a variety of concepts, from holistic health care to biopsychosocial research to consultation-liaison work.2 Consultation-liaison psychiatry, on the other hand, is a very specific clinical endeavor that has its roots in general hospital psychiatry, psychobiology, and psychosomatic medicine.5 Grete Bibring6 identified three specific goals for consultation-liaison psychiatry in the early 1950s: 1) differentiating organic disorders from psychogenic conditions, 2) offering treatments for patients in medical settings with comorbid psychiatric conditions, and, finally, 3) encouraging self-awareness in physicians. Lipowski7–12 further outlined the specific tasks of and clinical entities seen within the field in a series of classic articles describing the function, organization, and content of consultation-liaison psychiatry. These articles formed much of the basis for contemporary consultation-liaison psychiatry, which in 2003 was designated as a subspecialty, Psychosomatic Medicine, by the American Board of Medical Subspecialties.
By investigating the changes in the content of Psychosomatics, the history of our subspecialty may be elucidated, since the journal's history has paralleled organizational changes and over the last 40 years has developed into a repository of the scholarship for consultation-liaison psychiatry. This method of historical inquiry is not new. Lipsitt13 recently studied the relationship between consultation-liaison psychiatry and traditional psychosomatic medicine by a citation analysis of papers published in Psychosomatic Medicine. Levenstein14 attempted to trace the development of the understanding of upper gastrointestinal disorders by reviewing the literature on the subject over the last 100 years.
The results of our analysis may have timely implications for consultation-liaison psychiatry as the new subspecialty begins the arduous task of establishing criteria for certification.
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METHOD
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To categorize the articles published in Psychosomatics, we examined both the content and format of the journal. The content designation considered two issues. First, the papers were sorted into those that addressed etiology, diagnosis, treatment, outcome, and education and administrative issues. Second, the papers were categorized on the basis of their theoretical or conceptual frame of reference—biological, psychopharmacological, descriptive, psychodynamic, and cognitive-behavioral. Papers that eluded such categorization were assigned to a miscellaneous group. The format of the articles was classified based upon the current groupings of submissions published in Psychosomatics—original research, case reports, literature reviews and overviews, and perspectives. Special articles were redefined into one of these categories. We independently analyzed an issue of Psychosomatics and arrived at a consensus definition of the categories described above.
In order to obtain a broad sample over time, we reviewed each of the issues of Psychosomatics from 1960 (six issues), 1980 (12 issues), and 2000 (six issues). These volume years were selected as being reflective of the early, middle, and current phases of the development of Psychosomatics. The entire analysis was completed over a 3-month period.
In order to gain a broad, but not necessarily comparable, perspective on the trends in other psychiatric journals, the content of a smaller sample of articles from The American Journal of Psychiatry and Psychosomatic Medicine was similarly tabulated and analyzed. This sample consisted of articles from the January, June, and December issues of each journal from the same volume years (1960, 1980, and 2000).
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RESULTS
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The results of the analysis (Table 1, Table 2, and Table 3) are presented without inferential statistics, since the method is primarily qualitative. Some of the categories, such as the biological and psychopharmacological frames of reference, were consolidated for the sake of simplifying the analysis. The administrative category was eliminated, since there were such few articles in that area. The following trends were identified for Psychosomatics (Table 4).
From 1960 to 2000, there was a decrease in the number of papers that addressed etiology in Psychosomatics. There was a corresponding increase in the number of papers that addressed diagnosis. There was also a substantial decrease in articles that addressed treatment and a moderate increase in papers that addressed outcome. Education was addressed infrequently throughout the three phases of Psychosomatics—a little puzzling since this was an avowed focus of the organization and the specialty in the early years. Psychosomatics saw a dramatic increase in articles that used a descriptive frame of reference and a sustained number of those with a biological conceptual frame. The number of papers using psychodynamic concepts decreased. There were very few papers that described cognitive-behavioral issues. Format analysis revealed an increased number of research reports at the cost of case reports, perspectives, and reviews over the three time periods, although there remained a moderate interest in publishing case reports.
When the smaller sample of articles from The American Journal of Psychiatry and Psychosomatic Medicine, which cater to different audiences, were subjected to a similar analysis of their content, an interesting pattern was revealed. Although The American Journal of Psychiatry saw an increase in etiological and biological subject matter, there wasn't such a dramatic increase in publication of diagnostic issues or in the descriptive focus nor was there any drop in the interest in treatment issues. Psychosomatic Medicine continued to maintain a steady balance in etiology, treatment, biological, and descriptive aspects of their scholarship (Table 4).
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DISCUSSION
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The data from this analysis mirror the evolution of consultation-liaison psychiatry. The content of the early issues of Psychosomatics (1960) reflects the agenda of the breakaway group that established the APM. Psychosomatics actually had a multidisciplinary editorial board, with members from a variety of medical specialties. Since its focus was very broad, early articles involved psychopharmacology, including ones on newly developed psychotropic medications. This might account for the preponderance of treatment articles (51%) that often had little to do with patients who had comorbid physical and psychiatric illness but more with the psychopharmacology of depression or schizophrenia. In addition, very general theoretical papers (that can perhaps be categorized as "perspective" reports in current parlance) rather than research or even case reports were published, reflecting the call for the nonpsychiatrist physician to attend to patients' emotional needs.2 Although there was a fairly even balance between descriptive, biological, and psychodynamic theoretical framework of the papers accepted for publication, a substantial number of these papers were focused on general psychiatry rather than consultation-liaison psychiatry. Only slowly did the focus upon consultation-liaison psychiatry emerge as the practicing consultation-liaison psychiatrists began to define topics that were relevant in the medical-surgical setting in which they consulted and taught.
The late 1960s and the 1970s saw an enormous growth in the emphasis on building systematized consultation-liaison activities. By 1966, it was reported that 75% of all the 202 psychiatric programs in the United States had provision for consultation-liaison services.15 NIMH established funding grants that helped generate money for training programs and consultation-liaison teams.16 It is not surprising, therefore, that the issues of Psychosomatics in 1980 doubled in frequency, although other external factors such as the marketing strategy of the new publisher may have contributed to it. There was a move away from patient-oriented focus to a consultee-oriented or even a situation-oriented one.2,17 This shift may have been consistent with the general shift in emphasis toward community psychiatry in the tumultuous 1960s. It was in this context that the new leadership of the APM shaped its convergence with consultation-liaison psychiatry (Table 5).
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TABLE 5. Salient Factors Contributing to Publication Trends From 1960 to 2000 for Articles Published in Psychosomatics
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The clamor for diagnostic rigor in psychiatry also led to the development of DSM-III in 1980.18 There was a trend toward fewer articles on treatment and more on diagnostic issues. The new APM members, often junior consultation-liaison faculty, were not very interested in theoretical psychodynamic underpinnings of patient problems because of the waning influence of psychoanalysis. Of interest is that there was also a distinct increase in the publication of case reports (39%), indicating that the consultation-liaison psychiatrists were beginning to identify common cases of interest in their workplace. The developmental phase of consultation-liaison psychiatry described by Schwab5 was thus at its zenith (Table 6).
Schwab has reviewed the history of consultation-liaison psychiatry from its early roots in the 1751 opening of the Institute of Pennsylvania Hospital to the year 1985, when NIMH withdrew all funding for training grants in consultation-liaison psychiatry. He described 1980 as a turning point when the phase of consolidation and retrenchment set in. In an attempt to define a more narrow focus and facilitate the effective organization of APM as representative of consultation-liaison psychiatry, nonphysicians were excluded from APM membership in the early 1990s. A less charitable view may attribute this to a desire to preserve a shrinking domain and fear of unfair financial competition. Many of the new members did not have an overlapping link with the American Psychosomatic Society. The headlong rush into diagnostic empiricism continued unabated with the advent of DSM-III-R and DSM-IV. Even as consultation-liaison psychiatry has matured into a body of knowledge that allowed for an interest in publications on outcome (17%) and a transformation of the format into largely research reports (a full 55% in 2000), there were some disturbing trends. The papers suggest decreasing focus on etiology and treatment. A majority of the literature addresses diagnostic issues. Descriptive literature, too, takes the lion's share (62% in 2000). This overrepresentation may reflect the current empirical focus of consultation-liaison psychiatry that emphasizes the need to develop reliability of the cohorts to be treated by consultation-liaison psychiatrists. The previous concerns with etiologic theorizing are less apparent. Furthermore, the treatment literature focuses on reporting pharmacological side effects and case reports of effective treatments. From such single case reports, hypotheses are generated that may be studied in a more experimental manner in the future.
The selective emphasis on diagnosis and description to the detriment of addressing etiology and treatment may be a reflection of the complexity of psychiatric diagnosis and treatment in the context of comorbid medical illness. On the other hand, it may be self-preservative in nature in that having given up on the intractable or complex issues of etiology and treatment, the consultation-liaison psychiatrists are merely coasting along. Were Rosenbaum and McCarty prescient in reporting that consultation-liaison psychiatry in the 1990s had largely been reduced to triage and psychopharmacology?19 The economics of medicine in the form of increased hospitalization costs and reduced reimbursement have no doubt led to an exclusive focus on reducing length of stay of hospitalized patients so that early discharge takes precedence over all regard to psychosocial aspects of patient care. It is ironic, nonetheless, that a historical analysis of Psychosomatics suggests that even as consultation-liaison psychiatry is moving forward as a formal subspecialty, it is also struggling to maintain a foothold on the ever receding slope of the basic tenets of psychosomatic medicine.
There is room, however, for hope. The methodology of the journal papers has matured as reflected in the equitable balance between research and case reports on one hand and continued publication of smaller numbers of perspectives and reviews. Consultation-liaison psychiatry continues to play an increasingly indispensable role in the "operational group" of a general hospital setting, although it is a little different from what was envisioned by the pioneers of psychosomatic medicine.20,21 The "liaison" component of the function of a consultation-liaison psychiatrist, for example, has changed in that the "in depth" relationship with medical colleagues developed by Billings22 has yielded to a "broader" relationship with the hospital milieu.20 As the APM begins to ponder on how to establish standards, competencies, curricula, and examinations, serious consideration needs to be given to the idea of taking advantage of the body of knowledge that the American Psychosomatic Society has accumulated and continues to develop. It is time, perhaps, to consider a return to a closer academic collaboration with the American Psychosomatic Society, with its continuing focus on etiology and treatment. Combining the strengths of these two organizations may lead to the development of a specialty that is truly unique in its position on the interface of psychiatry with medicine.23
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REFERENCES
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- Lipowski ZJ: Review of consultation psychiatry and psychosomatic medicine, III: theoretical issues. Psychosom Med 1968; 30:395–422[Abstract/Free Full Text]
- Wise TN: Presidential address: a tale of two societies. Psychosom Med 1995; 57:303–309[Abstract/Free Full Text]
- Webb WL: A new challenge for the Academy of Psychosomatic Medicine. Psychosomatics 1988; 29:148–152[Free Full Text]
- Wise TN: Thomas P Hackett (1928–1988): an appreciation. Psychosomatics 1988; 29:147[Free Full Text]
- Schwab JJ: Consultation-liaison psychiatry: an historical overview. Psychosomatics 1989; 30:245–254[Abstract/Free Full Text]
- Bibring GL: Psychiatry and medical practice in a general hospital. N Engl J Med 1956; 254:366–372
- Wittkower ED, Lipowski ZJ: Recent developments in psychosomatic medicine. Psychosom Med 1966; 28:722–737[Abstract/Free Full Text]
- Lipowski ZJ: Psychiatric consultations in medical and surgical outpatient clinics. Can Psychiatr Assoc J 1969; 14:239–345[Medline]
- Lipowski ZJ: Consultation-liaison psychiatry in general hospital. Compr Psychiatry 1971; 12:461–465[CrossRef][Medline]
- Lipowski ZJ: Consultation-liaison services in general hospitals. Psychother Psychosom 1972–1973; 21:232–234
- Lipowski ZJ: Consultation-liaison psychiatry: an overview. Am J Psychiatry 1974; 131:623–630[Abstract/Free Full Text]
- Lipowski ZJ: Liaison psychiatry: referral patterns and their stability over time. Am J Psychiatry 1981; 138:1608–1611[Abstract/Free Full Text]
- Lipsitt DR: Consultation-liaison psychiatry and psychosomatic medicine: the company they keep. Psychosom Med 2001; 63:896–909[Abstract/Free Full Text]
- Levenstein S: Bellyaching in these pages: upper gastrointestinal disorders in psychosomatic medicine. Psychosom Med 2002; 64:767–772[Abstract/Free Full Text]
- Mendel WM: Psychiatric consultation education—1966. Am J Psychiatry 1966; 123:150–155[Abstract/Free Full Text]
- Eaton JS Jr: Consultation-liaison psychiatry: unfinished business (editorial). Psychosomatics 1986; 27:323–324[Free Full Text]
- Balint M: The Doctor, His Patient, and the Illness. New York, International Universities Press, 1957
- American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 3rd ed (DSM-III). Washington, DC, APA, 1981
- Rosenbaum M, McCarty T: The relationship of psychosomatic medicine to consultation-liaison psychiatry. Psychosomatics 1994; 35:569–573[Abstract/Free Full Text]
- Ramchandani D, Lamdan RM, O'Dowd MA, Boland R, Hails K, Ball S, Schindler BA: What, why, and how of consultation-liaison psychiatry: an analysis of the consultation process in the 1990s at five urban teaching hospitals. Psychosomatics 1997; 38:349–355[Abstract/Free Full Text]
- Meyer E. Mendelsohn M: Psychiatric consultations with patients on medical and surgical wards: patterns and processes. Psychiatry 1961; 24:427–431
- Billings EG: The psychiatric liaison department of the University of Colorado School and Hospitals. Am J Psychiatry 1929; 85:403–410
- Pardes H: Symposium introduction: research at the interface of medicine and psychiatry. Gen Hosp Psychiatry 1983; 5:79–81
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ABSTRACT
INTRODUCTION
