^SS^^^^k,
Psychosomatic medicine in a general hospital: some
dilemmas
John G. Flannery, mb, frcp[c]
"Psychosomatic medicine" is a men¬ tal set used by those physicians who be¬ lieve "that all illness depends on a multiplicity of factors involving the somatic and psychological processes of the in¬ dividual in relationship to the environ¬ ment".1 This concept differs greatly from earlier, simplistic views such as those of Deutsch and colleagues,2 who, using a cause-and-effect model, saw all physical illness as conversion, resulting from unconscious conflict. Today the "environment" that Kimball1 referred to in his definition may be the uncon¬ scious mind or equally it may be the attitudes of physicians and nurses toward the patient, attitudes that can subtly generate a functional symptom, or a remission of organic disease, or an apparently coincidental depression. Indeed, "environment" in psychosoma¬ tic medicine now has the expanded, inclusive meaning that it has in ecology. The physician who holds this multipolar view of illness together with en¬ vironment will consider recorded his¬ tory as only a partial explanation of the patient's distress. He will remember the observation of Henry3 that physi¬ cians do not attend to everything a patient says as they seek specific configurations in the history, symptoms and physical signs in order to make a diagnosis; and, conversely, that their communications to the patient, based on the abstraction they have formed, may be frightening or incomprehensible.4 Thus, the observations, both recorded and unrecorded, are grist to From the department of of Toronto
psychiatry, University
Reprint requests to: Dr. J.G. Flannery, Coordinator, consultation and liaison service, Toronto General Hospital, Toronto, ON M5G 1L7
the mill of the "psychosomatic physi¬ as valid as anyone else's, or he may cian". He sifts through the history, make referrals indifferently to a social notes the trivial, spontaneous and seem¬ worker, psychiatrist, psychologist or the ingly irrelevant things a patient does chaplain, often doing what seems at the and says both during the interview and time to be most expedient. But since at other times, observes the spoken and psychosomatic concepts are not fully unspoken feelings of his medical and integrated into medical thinking and then begins to medical literature, many physicians do nursing colleagues understand the relevance of the present not understand the psychosomatic ap¬ illness to the patient's life situation. The proach or appreciate what it can offer psychosomatic physician's goal is to them that they do not already know. enable the patient's physician and nurse Thus, the failure to be recognized as an expert is a consequence of (a) the to understand the patient. However, the medical team does not assumption that others already believe always find the data thus gathered this to be so and (b) a failure to define helpful. It would be facile to term this and publicize psychosomatic expertise. The belief, already implied, that any a "resistance" (i.e., that awareness of the meaning of the report would cause physician can practise psychosomatic anxiety or depression, and to ward off medicine also has its consequences: these unpleasant effects they ignore it, specialized psychosomatic services are not considered essential or even im¬ or complain they cannot follow it, or deny its import, and so on). This may portant; physicians may decide to teach be true, but often only in part. A more psychiatry themselves, for instance, to consistent explanation is that the psy¬ general practice residents; social service chosomatic physician, usually a psy¬ (an arm of psychosomatic work) may chiatrist, is not considered an expert by be cut back without consultation if the the medical team, and he resists this budget is overrun; the psychosomatic perception of him he wards off the physician is seldom asked to attend blow to his self-esteem. major teaching rounds; and entire pro¬ This point requires elaboration. jects, such as pain clinics and acupunc¬ There is, indeed, a field of psychosoma¬ ture clinics, are set up without any tic expertise, attested to by careful re¬ apparent reference to psychosomatic search and numerous publications, but medicine, so that projects may proceed it seems to be largely unapplied. To along simplistic stimulus-response lines, the average physician it is a remote the staff responsible for them often endeavour, because it does not affect being unaware of the research and his everyday work, he may not be fam¬ theoretical contributions of psychoso¬ iliar with the results of research, and matic workers such as Engel5 and he probably does not read the psycho¬ Szasz.6'7 How much does this failure to be somatic journals. Therefore he does not seen as an expert really matter? In see the psychosomatic physician as an expert in his own right. The conse¬ terms of research, probably not much quences are interesting: the referring in view of the advances in medicine and physician in many hospitals may believe the eventual acceptance of the psycho¬ that his own opinion of a patient is somatic physician through his col.
CMA JOURNAL/APRIL 17, 1976/VOL. 114 665
leagues' good will. This process of ac- procedures. Of these, Schiffer12 has ceptance is well described by Lipow- pointed out the unconscious meanings sky;8 and the psychosomatic physician of many routine investigations, which can still do his research, write his papers are often not apparent to the physicians and have his psychosomatic colleagues using them. Adventitious human sufread them. But one cannot be so com- fering frequently confronts the psychoplacent about the effects on patient somatic physician: Kiibler-Ross13 has ilcare. To the psychosomatic physician luminated brilliantly this dark side of more and more patients appear to hospital life in her studies of the dying need this care and understanding, be- patient, who must carry out the most cause today sophisticated treatment of solitary and private of all human acts a relatively straightforward cause-and- in a public institution, and the suffering effect problem may result in a much of those who care for him, which may more complex disorder, so that a multi- even lead them to deny that he is there plicity of processes begins to take effect at all. Further, since adventitious sufin the patient. For example, a man with fering in hospital is so difficult to depolycystic kidneys and progressive renal fine precisely, many referrals for psyfailure has thirst, polyuria and drowsi- chiatric consultation are vague. The ness, and these can be adequately con- physicians and nursing staff often feel ceptualized as consequences of his renal deeply concerned over what is happenfailure; but when he eventually requires ing and perplexed at their own reacrenal dialysis - first in hospital, then tions. The commonest explanation is at home - he may have symptoms that that the referred patient is depressed, cannot be explained by any single cause which may be true, but often this re(impotence, lethargy, aching limbs, an- presents identification of the nurse or xiety), because dialysis itself and his physician with the patient (i.e., "If I dependence on it for his existence have had what he's got I'd be depressed, so profound physiologic, psychologic and he must be depressed"), rather than an pathologic effects. This patient will dif- empathic "feeling with" the patient fer from his earlier healthy self; he is and a "feeling out" of the total ennot uremic, but the conditions of his vironment he strives to cope with. life mean he is not wholly well and Diagnoses such as "adult situational cannot hope to be; and transplantation, reaction to chronic disease,. or "psychowhile altering the conditions of his life, physiologic reaction" are still only will bring new problems. Also, the shorthand notations but are more acquality of the experience of these pa- curate and productive than "reactive tients, in existential terms, as well as depression", which often leads away those with organ transplants - and from the psychosomatic toward the indeed the living donors of these trans- somatic, with its consequent choice of plants - is so new to us that it takes drugs and electroconvulsive therapy, time to learn to empathize with it and rather than a helping personal relationto distinguish the resulting psychic ship. changes. That the emotional life, for This adventitious suffering of people instance, of patients managed by dial- in general hospitals can escape the ysis is changed has been shown by notice of their physicians in the same Lefebvre, Nobert and Crombez,9 who way that the effects of institutional life pointed out that the inner life of such on patients escaped the notice of patients is opaque and there is "a pov- mental hospital personnel; these effects erty of dialogue with the external object still remain less obvious to them than and an apparent sparseness of inner to observers with a different outlook; life and a certain clinical inertia". They for example, the findings of sociologists noted the similarities of these charac- such as Goffman14 and Caudillt5 or teristics in their dialysis patients to la psychologists such as Rosenhan16 have pens.e op.ratoire, first described by been as original and thought-provoking Marty and de M'uzan.10 This important to the institutional psychiatrist as those symptom, further investigated by Sif- of the psychosomatic physician should neos,'1 refers to an inability in certain be to his hospital-based colleagues. patients to fantasize, with resulting reWho does, and who should do, this striction of their thought content to an immediate, utilitarian reality. Certainly, work? Consultation psychiatrists do it in my experience, based on 4 years' now, but I have used the term "psywork as a psychiatric consultant to a chosomatic physician" partly to avoid busy dialysis unit, the emotional life of inevitable associations with the word most dialysis patients changes consider- "psychiatrist" and partly because many ably regardless of the cause of the renal of the most active workers in this field have been internists with psychiatric or failure or the kind of dialysis. psychoanalytic training. At present the Much of the psychosomatic physi- psyche-soma split is reflected in the cian' s work in a general hospital is to career choices open to the medical search for such indirect effects of med- student: to take up some branch of ical advances, including investigative medicine or psychiatry, the tenuous link 666 CMA JOURNAL/APRIL 17, 1976/VOL. 114
between the two being liaison psychiatry. Thus, the physician who becomes a psychiatrist only intermittently reenters the general-hospital wards and, once there, is seen not as one with a separate discipline but as a psychiatrist who has left his office for a couple of hours. It is rightly called liaison psychiatry but corresponds to no other medical activity - there is no liaison dermatology, for instance. And from the consultation psychiatrist's viewpoint the work differs from that with hospitalized psychiatric patients and from office psychiatry because the patients are ill in a different way. A new, formal discipline is needed as a subspecialty of, and closely associated with, internal medicine rather than psychiatry, and postgraduate medical experience with psychiatric (or psychoanalytic) training should be the basic requirement. Such a discipline, when recognized at the university level and by licensing bodies, might appeal to those who wish to practise holistic medicine and act as consultants and helpers to their colleagues, while keeping a smaller case load in their own subspecialty. It might even be more valuable for consultation psychiatrists to bring this about than to maintain liaison psychiatry in its present form as a part-time clinical activity for a few psychiatrists, who, for the most part, do not make it a career. References 1. KIMBALL CP: Conceptual developments in psychosomatic medicine 1939-1969. Ann Intern Med 73: 307, 1970 2. DEUT5CH F, THOMPSON D, PINDERHUGHEs C,
et al: Body, Mind and the Sensory Gateways, Basel and New York, Karger, 1972 3. HENRY Gw: Some modem aspects of psychiatry in general hospital practice. Am J Psychiatry 9: 481, 1929
4. KoRscii BM, NEGRETE VF: Doctor-patient communication. Sci Am 227: 66, 1972
5. ENGEL GL: Psychogenic pain - and the pain prone patient. Am J Med 26: 899, 1959 6. SzAsz TS: Pain and Pleasure, A Study 0) Bodily Feelings, New York, Basic, 1957 7. Idem: The nature of pain. AMA Arch Neurol Psychiatry 74: 174, 1955 8. LIPowsKY zJ: Psychiatric liaison with neurology and neurosurgery. Am J Psychiatry 129: 136, 1972 9. LEFEBYRE P, NOBERT A, CROMBEZ JC: Psy-
chological and psychopathological reactions in relation to chronic hemodialysis. Can Psychiatr Assoc J 17: SS-9, 1972 10. MARTY P, na M'UZAN J: Aspects fonctionnels de Ia vie onirique. La "pens& op&atoire". Rev Fr Psychanal 27: 1345S, 1963 II. SIFNaos PE: Clinical observations on some patients suffering from a variety of psychosomatic diseases. Paper presented at the 7th
European Congress on Psychosomatic Research, Rome, Sept 11-16, 1967 12. SCHIFFER I: Psychoanalytic implications of
certain medical procedures. Can Med Assoc J 82: 1322, 1960 13. KuBLER-Ross E: On Death and Dying, New York, Macmillan, 1970 14. GOFFMAN E: Asylums, Garden City, NY, Anchor, 1961
15. CAUDILL w: The Psychiatric Hospital as a Small Society, Cambridge, MA, Harvard U Pr, 1958 16. ROsENHAN DL: On being sane in insane places. Science 179: 250, 1973
Psychosomatic medicine in a general hospital: some
dilemmas
John G. Flannery, mb, frcp[c]
"Psychosomatic medicine" is a men¬ tal set used by those physicians who be¬ lieve "that all illness depends on a multiplicity of factors involving the somatic and psychological processes of the in¬ dividual in relationship to the environ¬ ment".1 This concept differs greatly from earlier, simplistic views such as those of Deutsch and colleagues,2 who, using a cause-and-effect model, saw all physical illness as conversion, resulting from unconscious conflict. Today the "environment" that Kimball1 referred to in his definition may be the uncon¬ scious mind or equally it may be the attitudes of physicians and nurses toward the patient, attitudes that can subtly generate a functional symptom, or a remission of organic disease, or an apparently coincidental depression. Indeed, "environment" in psychosoma¬ tic medicine now has the expanded, inclusive meaning that it has in ecology. The physician who holds this multipolar view of illness together with en¬ vironment will consider recorded his¬ tory as only a partial explanation of the patient's distress. He will remember the observation of Henry3 that physi¬ cians do not attend to everything a patient says as they seek specific configurations in the history, symptoms and physical signs in order to make a diagnosis; and, conversely, that their communications to the patient, based on the abstraction they have formed, may be frightening or incomprehensible.4 Thus, the observations, both recorded and unrecorded, are grist to From the department of of Toronto
psychiatry, University
Reprint requests to: Dr. J.G. Flannery, Coordinator, consultation and liaison service, Toronto General Hospital, Toronto, ON M5G 1L7
the mill of the "psychosomatic physi¬ as valid as anyone else's, or he may cian". He sifts through the history, make referrals indifferently to a social notes the trivial, spontaneous and seem¬ worker, psychiatrist, psychologist or the ingly irrelevant things a patient does chaplain, often doing what seems at the and says both during the interview and time to be most expedient. But since at other times, observes the spoken and psychosomatic concepts are not fully unspoken feelings of his medical and integrated into medical thinking and then begins to medical literature, many physicians do nursing colleagues understand the relevance of the present not understand the psychosomatic ap¬ illness to the patient's life situation. The proach or appreciate what it can offer psychosomatic physician's goal is to them that they do not already know. enable the patient's physician and nurse Thus, the failure to be recognized as an expert is a consequence of (a) the to understand the patient. However, the medical team does not assumption that others already believe always find the data thus gathered this to be so and (b) a failure to define helpful. It would be facile to term this and publicize psychosomatic expertise. The belief, already implied, that any a "resistance" (i.e., that awareness of the meaning of the report would cause physician can practise psychosomatic anxiety or depression, and to ward off medicine also has its consequences: these unpleasant effects they ignore it, specialized psychosomatic services are not considered essential or even im¬ or complain they cannot follow it, or deny its import, and so on). This may portant; physicians may decide to teach be true, but often only in part. A more psychiatry themselves, for instance, to consistent explanation is that the psy¬ general practice residents; social service chosomatic physician, usually a psy¬ (an arm of psychosomatic work) may chiatrist, is not considered an expert by be cut back without consultation if the the medical team, and he resists this budget is overrun; the psychosomatic perception of him he wards off the physician is seldom asked to attend blow to his self-esteem. major teaching rounds; and entire pro¬ This point requires elaboration. jects, such as pain clinics and acupunc¬ There is, indeed, a field of psychosoma¬ ture clinics, are set up without any tic expertise, attested to by careful re¬ apparent reference to psychosomatic search and numerous publications, but medicine, so that projects may proceed it seems to be largely unapplied. To along simplistic stimulus-response lines, the average physician it is a remote the staff responsible for them often endeavour, because it does not affect being unaware of the research and his everyday work, he may not be fam¬ theoretical contributions of psychoso¬ iliar with the results of research, and matic workers such as Engel5 and he probably does not read the psycho¬ Szasz.6'7 How much does this failure to be somatic journals. Therefore he does not seen as an expert really matter? In see the psychosomatic physician as an expert in his own right. The conse¬ terms of research, probably not much quences are interesting: the referring in view of the advances in medicine and physician in many hospitals may believe the eventual acceptance of the psycho¬ that his own opinion of a patient is somatic physician through his col.
CMA JOURNAL/APRIL 17, 1976/VOL. 114 665
leagues' good will. This process of ac- procedures. Of these, Schiffer12 has ceptance is well described by Lipow- pointed out the unconscious meanings sky;8 and the psychosomatic physician of many routine investigations, which can still do his research, write his papers are often not apparent to the physicians and have his psychosomatic colleagues using them. Adventitious human sufread them. But one cannot be so com- fering frequently confronts the psychoplacent about the effects on patient somatic physician: Kiibler-Ross13 has ilcare. To the psychosomatic physician luminated brilliantly this dark side of more and more patients appear to hospital life in her studies of the dying need this care and understanding, be- patient, who must carry out the most cause today sophisticated treatment of solitary and private of all human acts a relatively straightforward cause-and- in a public institution, and the suffering effect problem may result in a much of those who care for him, which may more complex disorder, so that a multi- even lead them to deny that he is there plicity of processes begins to take effect at all. Further, since adventitious sufin the patient. For example, a man with fering in hospital is so difficult to depolycystic kidneys and progressive renal fine precisely, many referrals for psyfailure has thirst, polyuria and drowsi- chiatric consultation are vague. The ness, and these can be adequately con- physicians and nursing staff often feel ceptualized as consequences of his renal deeply concerned over what is happenfailure; but when he eventually requires ing and perplexed at their own reacrenal dialysis - first in hospital, then tions. The commonest explanation is at home - he may have symptoms that that the referred patient is depressed, cannot be explained by any single cause which may be true, but often this re(impotence, lethargy, aching limbs, an- presents identification of the nurse or xiety), because dialysis itself and his physician with the patient (i.e., "If I dependence on it for his existence have had what he's got I'd be depressed, so profound physiologic, psychologic and he must be depressed"), rather than an pathologic effects. This patient will dif- empathic "feeling with" the patient fer from his earlier healthy self; he is and a "feeling out" of the total ennot uremic, but the conditions of his vironment he strives to cope with. life mean he is not wholly well and Diagnoses such as "adult situational cannot hope to be; and transplantation, reaction to chronic disease,. or "psychowhile altering the conditions of his life, physiologic reaction" are still only will bring new problems. Also, the shorthand notations but are more acquality of the experience of these pa- curate and productive than "reactive tients, in existential terms, as well as depression", which often leads away those with organ transplants - and from the psychosomatic toward the indeed the living donors of these trans- somatic, with its consequent choice of plants - is so new to us that it takes drugs and electroconvulsive therapy, time to learn to empathize with it and rather than a helping personal relationto distinguish the resulting psychic ship. changes. That the emotional life, for This adventitious suffering of people instance, of patients managed by dial- in general hospitals can escape the ysis is changed has been shown by notice of their physicians in the same Lefebvre, Nobert and Crombez,9 who way that the effects of institutional life pointed out that the inner life of such on patients escaped the notice of patients is opaque and there is "a pov- mental hospital personnel; these effects erty of dialogue with the external object still remain less obvious to them than and an apparent sparseness of inner to observers with a different outlook; life and a certain clinical inertia". They for example, the findings of sociologists noted the similarities of these charac- such as Goffman14 and Caudillt5 or teristics in their dialysis patients to la psychologists such as Rosenhan16 have pens.e op.ratoire, first described by been as original and thought-provoking Marty and de M'uzan.10 This important to the institutional psychiatrist as those symptom, further investigated by Sif- of the psychosomatic physician should neos,'1 refers to an inability in certain be to his hospital-based colleagues. patients to fantasize, with resulting reWho does, and who should do, this striction of their thought content to an immediate, utilitarian reality. Certainly, work? Consultation psychiatrists do it in my experience, based on 4 years' now, but I have used the term "psywork as a psychiatric consultant to a chosomatic physician" partly to avoid busy dialysis unit, the emotional life of inevitable associations with the word most dialysis patients changes consider- "psychiatrist" and partly because many ably regardless of the cause of the renal of the most active workers in this field have been internists with psychiatric or failure or the kind of dialysis. psychoanalytic training. At present the Much of the psychosomatic physi- psyche-soma split is reflected in the cian' s work in a general hospital is to career choices open to the medical search for such indirect effects of med- student: to take up some branch of ical advances, including investigative medicine or psychiatry, the tenuous link 666 CMA JOURNAL/APRIL 17, 1976/VOL. 114
between the two being liaison psychiatry. Thus, the physician who becomes a psychiatrist only intermittently reenters the general-hospital wards and, once there, is seen not as one with a separate discipline but as a psychiatrist who has left his office for a couple of hours. It is rightly called liaison psychiatry but corresponds to no other medical activity - there is no liaison dermatology, for instance. And from the consultation psychiatrist's viewpoint the work differs from that with hospitalized psychiatric patients and from office psychiatry because the patients are ill in a different way. A new, formal discipline is needed as a subspecialty of, and closely associated with, internal medicine rather than psychiatry, and postgraduate medical experience with psychiatric (or psychoanalytic) training should be the basic requirement. Such a discipline, when recognized at the university level and by licensing bodies, might appeal to those who wish to practise holistic medicine and act as consultants and helpers to their colleagues, while keeping a smaller case load in their own subspecialty. It might even be more valuable for consultation psychiatrists to bring this about than to maintain liaison psychiatry in its present form as a part-time clinical activity for a few psychiatrists, who, for the most part, do not make it a career. References 1. KIMBALL CP: Conceptual developments in psychosomatic medicine 1939-1969. Ann Intern Med 73: 307, 1970 2. DEUT5CH F, THOMPSON D, PINDERHUGHEs C,
et al: Body, Mind and the Sensory Gateways, Basel and New York, Karger, 1972 3. HENRY Gw: Some modem aspects of psychiatry in general hospital practice. Am J Psychiatry 9: 481, 1929
4. KoRscii BM, NEGRETE VF: Doctor-patient communication. Sci Am 227: 66, 1972
5. ENGEL GL: Psychogenic pain - and the pain prone patient. Am J Med 26: 899, 1959 6. SzAsz TS: Pain and Pleasure, A Study 0) Bodily Feelings, New York, Basic, 1957 7. Idem: The nature of pain. AMA Arch Neurol Psychiatry 74: 174, 1955 8. LIPowsKY zJ: Psychiatric liaison with neurology and neurosurgery. Am J Psychiatry 129: 136, 1972 9. LEFEBYRE P, NOBERT A, CROMBEZ JC: Psy-
chological and psychopathological reactions in relation to chronic hemodialysis. Can Psychiatr Assoc J 17: SS-9, 1972 10. MARTY P, na M'UZAN J: Aspects fonctionnels de Ia vie onirique. La "pens& op&atoire". Rev Fr Psychanal 27: 1345S, 1963 II. SIFNaos PE: Clinical observations on some patients suffering from a variety of psychosomatic diseases. Paper presented at the 7th
European Congress on Psychosomatic Research, Rome, Sept 11-16, 1967 12. SCHIFFER I: Psychoanalytic implications of
certain medical procedures. Can Med Assoc J 82: 1322, 1960 13. KuBLER-Ross E: On Death and Dying, New York, Macmillan, 1970 14. GOFFMAN E: Asylums, Garden City, NY, Anchor, 1961
15. CAUDILL w: The Psychiatric Hospital as a Small Society, Cambridge, MA, Harvard U Pr, 1958 16. ROsENHAN DL: On being sane in insane places. Science 179: 250, 1973
