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Presidential Address: Academy of Psychosomatic Medicine Tucson, AZ November 2006

The new name of our subspecialty, "Psychosomatic Medicine," challenges our field to rethink its identity and to rethink how our new name may affect who we are and what we do. In this presentation, I will suggest that the name "Psychosomatic Medicine" tells us where we came from and may also help us to determine where we are going.

The way our new name was selected is of some interest. In the first application for subspecialty status, in 1991, the American Board of Psychiatry and Neurology (ABPN) objected to the name "consultation–liaison" as too generic and descriptive of activities of general psychiatric practice. With some soul-searching, the Academy discussed various alternatives. A 1993 survey reported that "medical psychiatry" was the clear preference of 210 respondents for the name of our field, whereas "psychosomatic medicine" placed fifth.¹

With the second subspecialty application, the Academy decided proactively to avoid any potential impediment to approval and delegated the choice of name to the ABPN. The ABPN chose "Psychosomatic Medicine."

In this presentation, I will suggest that the name "Psychosomatic Medicine" is a defining part of our heritage, and, with a new definition of its meaning, it can lead us to an exciting future. It can also help define our relationship with the American Psychosomatic Society (APS), with which we share the name "psychosomatic," and reinvigorate our collaboration with them and, perhaps, other, allied organizations. For this heuristic purpose, I will review certain elements of the two societies’ interwoven histories. The older of the two, the American Psychosomatic Society, will be examined first, followed by the Academy. Their development and historical relationship will be examined. And from this review, future directions for the general field of psychosomatic medicine and for our new subspecialty, Psychosomatic Medicine, will be suggested.

Psychosomatic medicine antedated "consultation–liaison ("C–L") by more than a century.² Johann Christian Heinroth was the first to use the word "psychosomatic," in 1818, and the term "psychosomatic medicine" was coined by Felix Deutsch in 1922.²

The American Psychosomatic Society was formed as a research organization comprising participants in the journal "Psychosomatic Medicine," which Flanders Dunbar established in 1939. In fact, the organization, which was established 4 years after the journal was inaugurated, was originally named "The American Society for Research in Psychosomatic Problems." Three years after that, in 1946, the organization was renamed the American Psychosomatic Society (APS).^2,3 On its website, the mission statement of the APS says that the understanding of the interrelationships among biological, psychological, social, and behavioral factors in human health and disease will contribute to education and improved healthcare.

Early psychosomatic approaches were characterized by concept-driven research, and tended to focus on how psychological states or traits affected, or caused, physical illness. This emphasis tended to neglect the comorbid relationship between psychiatric disorders and physical disorders and their impact on each other.

Several conceptual approaches came into prominence and subsequently receded. These included personality types, propounded by Dunbar, Rosenman, and Friedman;^2,4 regression to earlier psychosexual stages of maturation, a concept espoused by Deutsch, Grinker, and Schur;^5,6 and Alexander’s specificity theory, in which certain disorders were posited to be caused by specific psychodynamic conflicts.⁷ These were described by him and his Chicago coworkers, and informally referred to as the "Holy Seven;" these included asthma, hypertension, ulcerative colitis, Graves’ disease, rheumatoid arthritis, peptic ulcer, and neurodermatitis.

Engel, Knapp, and Nemetz, and Weissman then demonstrated the lack of specificity of underlying conflicts in ulcerative colitis, asthma, and peptic ulcer,⁶ which gave rise to nonspecificity formulations by Engel, Green, and Schmale’s "hopeless/helpless, giving up/given up" syndrome as a state, rather than a conflict, that gave rise to a variety of physical illnesses, and Hans Selye’s elaboration of stress and Holmes and Rahe’s life-stressor scores.⁶ More recently, Engel developed the "biopsychosocial model," which took the biomedical model to task and proposed levels of complexity to understand how social, mental, and physical factors interacted to produce physical illness.⁸

But by 1977, Weiner⁶ observed that not only was there a lack of clarity about the psychological states that contributed to physical disease, but that the "holy grail" of psychosomatic-medicine theories, the transducer mechanisms by which emotions cause or affect somatic disease, remained elusive. Furthermore, he described a cloud of demoralization that had descended over the field. "[T]hose of us who subscribe... to psychosomatic concepts have found it difficult to convince medical and scientific colleagues of the validity of the assertion that psychosocial factors play a part in the etiology and pathogenesis of certain diseases."⁶ In other words, an important element of the mission of the Society—contributing to the education of caregivers and improving health care—was not being achieved. Weiner explained that the failure of early psychosomatic studies to explain the role of emotions in physical disorders, was due in part to the failure to understand the multiple etiologies behind a given physical disorder. As one example, psychosomatic theories conceived of peptic ulcer as a singular disorder, whereas, at the time of Weiner’s review, 29 different forms of the disease had been distinguished.

So, by the late 1970s and early 1980s, confusion and demoralization began to set in,⁹ and "[S]ucceeding presidents of the APS frequently expressed gloom about the future of the Society, or appeared to feel a deep need to reassure themselves and the members that matters were not as desperate as they seemed."³ For example, Marvin Stein, in his presidential address, stated, "[T]he general field of psychosomatic medicine has not made the progress expected of it,"³ and Stanford Friedman, in 1988, proclaimed, "[T]he very term "psychosomatic" has lost meaning. No longer can we talk about "psychosomatic illnesses," but must acknowledge that most, if not all, disease is potentially influenced by psychological factors." He believed that the future of the organization was in "[T]eaching the current knowledge and concepts linking behavior and disease, especially as related to health and illness,"³ despite the failure to accomplish this goal up until then.

As the 1980s drew to a close, the Society was experiencing a confusion of its identity and its aims and objectives, declaring all of medicine as psychosomatic at the same time it was feeling marginalized.³ Perhaps spurred by an attempt to reverse this perceived decline, the Society arranged for the "Great Debate" at its annual meeting in Monterey in 2001. Drs. Relman and Angell, former editors of The New England Journal of Medicine, were invited to evaluate the evidence that psychosocial interventions could improve clinical outcomes in organic disease, exclusive of any changes they might induce in health-related behaviors such as diet, exercise, smoking cessation, and treatment compliance.

These two esteemed representatives of the medical establishment concluded that the research data were not persuasive.¹⁰ Five years later, Drs. Freedland, Miller, and Sheps, recalling their reactions, felt "It struck a deep chord [that] our research was not being taken seriously... by the medical mainstream. After the closing arguments, the audience might have wanted to go down to the beach and drown itself en masse."

On later reflection, they revised their assessment. The conclusions, although disappointing, were not a reason for despair.¹¹ After all, the Society was noted for its excellent and well-attended meetings, its members’ high quality and volume of research, and the excellent reputation of its journal. Also, there had been a shift in the focus of research toward the psychosomatic interactions between comorbid psychiatric disorders and medical diseases, rather than the impact of affects and emotional states on physical states, a change that might promote a better dialogue with general medicine.

What about the development of consultation–liaison psychiatry? The term "psychiatric consultation" was first used during the early 1900s, and "Psychiatric Liaison" was introduced by Billings, who ran the first formal Consultation–Liaison Service, in the 1930s.² The Academy of Psychosomatic Medicine was established in 1953, with 10 founding members, 7 of whom were also members of the American Psychosomatic Society. Three of the 10 were psychiatrists.¹² The journal of the Academy was established 7 years later, in 1960, and was initially run out of Wilfred Dorfman’s home.¹²

In the early years of C–L, psychiatrists utilized liaison teaching of psychosomatic concepts to gain credibility on the medical floors, in part because of the scant clinical knowledge-base. It was also practiced as an end in itself. Liaison teaching was formalized as a component of the C–L field in the 1970s, as one of the criteria for applying for C–L teaching grants offered by the Psychiatry Education Branch of NIMH, under James Eaton.¹³ However, the liaison teaching model began to fall out of favor in the face of persisting resistance by medical staff and the impediments it created in fostering state-of-the-art clinical treatment and research.¹⁴ It came to be seen as a demeaning, "hat-in-hand" approach that begged for acceptance on the medical floors. Just as Psychosomatic Medicine practitioners failed to convince the medical establishment of the virtues of their theories, the failures that C–L psychiatrists encountered in their attempts to change the practices of general-medical physicians through their liaison efforts demoralized the field and even led to the suggestion to abandon efforts to develop consultation–liaison psychiatry as a formal subspecialty.¹⁵

In the late 1980s, this tension emerged in an APA meeting that came to be known as the "C-versus-L Debate." Robert Pasnau was the moderator, with Tom Wise and Tom Hackett against a major role for liaison psychiatry and James Strain and Harold Pincus in favor. But, by the end of the 1980s, and into the ’90s, liaison teaching and liaison psychiatry, in general, were on the wane.¹⁶ "Liaison" came to be seen a means to consultation,¹⁴ and not as an end in itself, as it "morphed" into models of integrated care or was rejected for models of pure consultation services.¹⁷ As C–L de-emphasized liaison teaching of psychosomatic concepts, a major bond between C–L and Psychosomatic Medicine was lost.

Beginning in the 1970s, but more so in the ’80s, C–L members felt increasingly marginalized by the lack of C–L content in programs at the annual meetings of the American Psychosomatic Society and an underrepresentation of C–L-related articles in Psychosomatic Medicine.^3,18,19 Consultation–liaison psychiatrists were sensitive to a series of unmet needs: advocacy for their clinical role, the importance of pursuing formal subspecialty status for the field, and securing an academic forum in which to present research, clinical, and educational activities, and foster communication within the field.

As a counterpoint, the American Psychosomatic Society began to feel a growing divergence of identity and alienation from C–L Psychiatry. Bernard Engel voiced the concern that C–L might mistakenly be perceived as all there was to Psychosomatic Medicine.^3,18,19 Both sides were increasingly recognizing different needs despite shared areas of interest.

Donald Oken suggested that although C–L Psychiatry was a subspecialty of psychiatry, it was informed by psychosomatic concepts. He believed that "Psychosomatic Medicine and C–L practice are intimately interrelated and mutually reinforcing."²⁰ William Webb, a member of the American Psychosomatic Society, although recognizing this interrelationship, suggested, in 1988, that the Academy of Psychosomatic Medicine refocus its mission to address the needs of C–L Psychiatry.

In 1991, during Troy Thompson’s presidency, the APM restructured itself as the National Organization of Consultation–Liaison Psychiatry.¹² The articulated mission of the Academy states that it "represents psychiatrists dedicated to the advancement of medical science, education, and health care for persons with comorbid psychiatric and general-medical conditions..."

After 1991, C–L research became newly energized and focused on psychiatric disorders that were comorbid with medical disorders, examining the impact of comorbidity on outcomes, such as length of stay, utilization of medical resources, and costs, as well as functional impairment and quality of life. Patterns of underrecognition and undertreatment of psychiatric disorders in the medical setting were identified, and the importance of recognizing interactions between general-medical and psychiatric drugs was emphasized. The research data gathered served as a powerful base for advocating the importance of C–L Services.¹⁷

During the 1980s, the demand for "consults" began to increase as hospital populations were aging and patients presented with more complex medical and psychiatric comorbidities. For example, the C–L service at The Long Island Jewish Medical Center had a progressive rise in the number of annual consults, from 400, in 1988, to over 2000, in 2006. This increased demand for consultations implied a greater acceptance of the value of C–L services and a willingness of medical colleagues to collaborate with C–L psychiatrists around patient care, and it helped to mitigate the earlier feelings of alienation and demoralization that had permeated the field.

Ironically, this growing demand, combined with growing pressures to generate revenues, eroded academic teaching and staff research time and became a new source of demoralization. As Maurice Steinberg noted in his address at the Society of Liaison Psychiatry Awards Dinner in 2003, paraphrasing Kingsbury, "Practitioners of ... psychosomatic medicine may well be lost in thought while... C–L psychiatrists are lost in action."

In the interim, some major changes were taking place within and between the APS and the APM. Before the Academy became the National Organization of C–L Psychiatry, in 1991, the American Psychosomatic Society had 650 members,³ of whom 65% were psychiatrists. Forty percent of these psychiatrists also held joint membership in the Academy (Shapiro P: Personal communication, 2006). After the Academy reorganized, in 1991, the American Psychosomatic Society lost 65% of its psychiatrists, with membership dropping from 479, in 1989, to 164, in 2005. At the time of this talk, as the overall membership rose from 650 to 850, psychiatrist members had dropped to 19%. It became more and more evident that the differences in aims and missions between the two organizations were now being reflected in the make-up of their members.

Should this divergence be a source of concern or an opportunity for the two societies to benefit from each other’s growing, but divergent, expertise in a related field by collaborating around joint initiatives? To explore the possibilities, Maurice Steinberg, Richard Lane, Peter Shapiro, and I met informally over dinner at the Annual Meeting of the Academy, in Albuquerque, NM, in 2005. We realized that the theme planned for the 2006 meeting of the APM, "Defining the Scope of Psychosomatic Medicine," might be a felicitous venue to involve the APS in discussing this issue in a Presidential Symposium and by encouraging participation in other aspects of the meeting, as well.

On July 8th, Peter Shapiro invited available leaders from the APS and APM to meet at his home in Fieldston, NY, to discuss these issues in greater detail. Invited by the host were Bill Lovallo, Matt Muldoon, Shari Waldstein, Bill Breitbart, Maurice Steinberg, Dave Gitlin, and I. The group reached a consensus that certain areas offered opportunities for collaboration for the mutual benefit of both societies. Among those areas suggested were increasing the opportunities for presentation at each other’s annual meetings, website listings and chat rooms for areas of mutual research interests, and the invitation by Shari Waldstein to members of the Academy to participate in the creation of a planned textbook of psychosomatic medicine for medical students, which the APS was undertaking and which she was editing.

Before these meetings, collaborative efforts had already begun, with a joint submission for an R-13 grant. The NIH had determined a need to address "an absence of a strategic research focus to address the epidemiology, pathogenesis, and interventions and dissemination related to... physical and mental comorbidities." Carol Alter, as the Principal Investigator, along with co-investigators from the APM and APS, brought together the combined areas of expertise of the two societies, and submitted a grant application. The grant request outlined three areas of comorbidity to address: depression and cardiovascular disease, depression and diabetes, and depression and other mental disorders and cancer. The first attempt was not funded, and plans were made to reapply, pursuing funding from the NIH Road Map Initiative and seeking other venues for collaborative grant funding.

These collaborative initiatives raised a broader but related question about the new name of our subspecialty. How does the term "Psychosomatic Medicine" define the research, teaching, and clinical scope of our subspecialty, and does it clarify or confuse the similarities and differences between the Academy and other organizations, such as the American Psychosomatic Society? I would suggest a definition of Psychosomatic Medicine whose scope is broad enough to encompass the existing activities of organizations and specialties in the field, while implicitly acknowledging overlapping areas of interest that can serve as an impetus for fruitful collaboration.¹² It would also embrace some of the ground-breaking research being carried out in other disciplines, which are not generally associated with the field of psychosomatic medicine. I would propose the following definition: "Psychosomatic Medicine is a scientific and medical field whose practitioners engage in activities of research, teaching, and treatment that focus on the mechanisms and impact of the bidirectional interactions of psychiatric disorders and the emotions with medical disorders and their physical symptoms."

New answers about psychosomatic "transducers," the mechanisms by which mental and physical disorders affect each other, are beginning to emerge through basic research, using technology never dreamed of by the early pioneers investigating mind–body relationships. Some of these research efforts carried out by investigators in other disciplines are revisiting and deepening our understanding of areas such as the autonomic nervous system (ANS), previously identified by earlier psychosomatic researchers as crucial to the understanding of mind–body interactions. Some examples are the growing understanding about the interaction between the ANS and a variety of cytokines that implement immune responses,²¹ influence reactions to stress, and play an important but as-yet undefined role in the relationship between depression and medical disorders, such as cardiovascular disease, stroke, diabetes, and osteoporosis. Other areas include the exciting fields of genomics and the field of neuro-imaging.

The data from research in these areas may suggest that not all associations found between mental and physical disorders are due to cause-and-effect relationships, but may be epiphenomena due to genetic pleiotropy. For example, some genes or combinations of genes may predispose given individuals to both mental and physical illness, such as depression and heart disease. Investigation into cause-and-effect relationships between mental and physical illness, therefore, requires objectivity and neutrality, absent of a fervor to prove the impact of the emotions on physical illness. While awaiting answers provided by basic research, epidemiologic studies and randomized, controlled intervention treatment trials must go forward. We can let the data gathered from research speak for themselves. Great debates about the pertinence of psychosomatic medicine belong to our past, not our future.

Advances in research from within our own ranks and from other psychosomatic researchers will inform the clinical practice of our subspecialty of Psychosomatic Medicine. Collaborative initiatives between and among other psychosomatic specialists and organizations, as well as other disciplines, will be essential in advancing the broader field of psychosomatic medicine. The Academy of Psychosomatic Medicine, while remaining true to its mission, and by acting as an umbrella organization to encourage collaborative initiatives with related organizations and other disciplines, can help to lead the exciting new advances in the field.

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