Beginnings: Psychosomatic Medicine and Consultation Psychiatry in the General Hospital

Psychosomatic Medicine

A keen interest in the relationship between the psyche and the soma has been maintained in medicine since early times, and certain ancient physicians (such as Hippocrates) have been eloquent on the subject. A search for the precise origins of psychosomatic medicine is, however, a difficult undertaking unless one chooses to focus on the first use of the term itself. Johann Heinroth appears to have coined the term psychosomatic in reference to certain causes of insomnia in 1818. The word medicine was added to psychosomatic first by the psychoanalyst Felix Deutsch in the early 1920s. Deutsch later emigrated to the United States with his wife Helene, and both worked at Massachusetts General Hospital (MGH) for a time in the 1930s and 1940s.

Three streams of thought flowed into the area of psychosomatic medicine, providing fertile ground for the growth of general hospital and consultation psychiatry. The psychophysiologic school, perhaps represented by the Harvard physiologist, Walter B. Cannon, emphasized the effects of stress on the body. The psychoanalytic school, best personified by the psychoanalyst Franz Alexander, focused on the effects that psychodynamic conflicts had on the body. The organic synthesis point of view, ambitiously pursued by Helen Flanders Dunbar, tried with limited success to unify the physiologic and psychoanalytic approaches. George Engel's biopsychosocial model sought and seeks to apply not just these approaches, but all branches of knowledge to health-related considerations. It has perhaps had more impact on medical education than practice. More recently, a higher overall profile for mind–body investigations practices is evident in mainstream medicine. These latter two trends affiliate themselves with medicine more broadly than these earlier approaches. While often championed by, and important to psychosomatic medicine, they are not its “property,” per se .

History

The history of general hospital psychiatry in the United States in general, and consultation–liaison (C-L) psychiatry in particular, has been extensively reviewed elsewhere. For those interested in a more detailed account of both historic trends and conceptual issues of C-L psychiatry, the writings of Lipowski are highly recommended.

In years gone by, controversy surrounded the use of the term liaison in C-L psychiatry. We believe that using the term liaison has been confusing and unnecessary. It has been confusing because no other service in the practice of medicine employed the term for its consultation activities. In addition, the activity it referred to—to teach non-psychiatrists psychiatric and interpersonal skills—is undertaken as a matter of course during the routine consultation. The term liaison , although still used, has come to be associated with educational and outreach efforts that run far afield of the original meaning of the word.

In March 2003, the American Board of Medical Specialties unanimously approved the American Board of Psychiatry and Neurology's (ABPN's) issuance of Subspecialty Certification in psychosomatic medicine. The first certifying examinations were administered in 2005. As of 2009, the completion of an American Board of Medical Specialties-certified fellowship in psychosomatic medicine became mandatory for all who wish to sit for that examination. The achievement of subspecialty status for psychosomatic medicine was the product of nearly 75 years of clinical work by psychiatrists on medical–surgical units, an impressive accumulation of scholarly work contributing to the psychiatric care of general medical patients, and determined intellectual and organizational efforts by the Academy of Psychosomatic Medicine (APM). The latter's efforts included settling on the name psychosomatic medicine after C-L Psychiatry met with resistance from the ABPN during the first application for subspecialty status in 1992. Psychosomatic medicine was ultimately felt to best capture the field's heritage and work on mind–body relationships, though there remains controversy and continued deliberation over its nebulous boundaries and linguistic awkwardness.

When the history of consultation psychiatry is examined, 1975 seems to be the watershed year. Before 1975, scant attention was given to the work of psychiatrists in general medicine. Consultation topics were seldom presented at the national meetings of the American Psychiatric Association. Even the American Psychosomatic Society, which has many strong links to consultation work, rarely gave more than a nod of acknowledgment to presentations or panels discussing this aspect of psychiatry. Residency training programs on the whole were no better. In 1966, Mendel surveyed training programs in the United States to determine the extent to which residents were exposed to a training experience in consultation psychiatry. He found that 75% of the 202 programs surveyed offered some training in consultation psychiatry, but most of it was informal and poorly organized. Ten years later, Schubert and McKegney found only “a slight increase” in the amount of time devoted to C-L training in residency programs. Today, C-L training is mandated by the ABPN as part of general adult psychiatry training.

Several factors account for the growth of C-L psychiatry in the last quarter of the 20th century. One was the leadership of Dr. James Eaton, former director of the Psychiatric Education Branch of the National Institute of Mental Health (NIMH). Eaton provided the support and encouragement that enabled the creation of C-L programs throughout the United States. Another reason for this growth was the burgeoning interest in primary care, which required skills in psychiatric diagnosis and treatment. Finally, parallel yet related threats to the viability of the psychiatric profession from third-party payers and non-physician providers were an incentive to (re-)medicalize the field. Although creation of the Diagnostic and Statistical Manual of Mental Disorders (3rd edition; DSM-III), and increased pharmacotherapy were the two most obvious upshots of this trend, an elevated profile for C-L psychiatry also emerged as uniquely tailored to the psychiatrist's skill set. For these reasons, and because of expanding knowledge in neuropsychiatry, consultation work enjoyed a renaissance.

The origins of organized interest in the mental life of patients at the MGH dates back to 1873, when James Jackson Putnam, a young Harvard neurologist, returned from his grand tour of German Departments of Medicine to practice his specialty. He was awarded a small office under the arch of one of the famous twin flying staircases of the Bulfinch Building. The office was the size of a cupboard and was designed to house electrical equipment. Putnam was given the title of “electrician.” One of his duties was to ensure the proper function of various galvanic and faradic devices then used to treat nervous and muscular disorders. It is no coincidence that his office came to be called the “cloaca maxima” by Professor of Medicine George Shattuck. This designation stemmed from the fact that patients whose maladies defied diagnosis and treatment—in short, referred to as the “crocks”—were referred to young Putnam. With such a beginning, it is not difficult for today's consultation psychiatrist to relate to Putnam's experience and mission. Putnam eventually became a Professor of Neuropathology and practiced both neurology and psychiatry, treating medical and surgical patients who developed mental disorders. Putnam's distinguished career, interwoven with the acceptance of Freudian psychology in the United States, is chronicled elsewhere.

In the late 1920s, Dr. Howard Means, Chief of Medicine, appointed Boston psychiatrist William Herman to study patients who developed mental disturbances in conjunction with endocrine disorders. Herman's studies are hardly remembered today, although he was honored by having a conference room at the MGH named after him.

In 1934, the Department of Psychiatry took shape when Stanley Cobb was given the Bullard Chair of Neuropathology and granted sufficient money by the Rockefeller Foundation to establish a ward for the study of psychosomatic conditions. Under Cobb's tutelage, the Department expanded and became known for its eclecticism and for its interest in the mind–brain relationship. A number of European emigrants fled Nazi tyranny and were welcomed to the department by Cobb. Felix and Helene Deutsch, Edward and Grete Bibring, and Hans Sachs were early arrivals from the continent. Erich Lindemann came in the mid-1930s and worked with Cobb on a series of projects, the most notable being his study of grief, which came as a result of his work with victims of the 1942 Cocoanut Grove nightclub fire.

When Lindemann became Chief of the Psychiatric Service in 1954, the Consultation Service had not yet been established. Customarily, the resident assigned to night call in the Emergency Department saw all medical and surgical patients in need of psychiatric evaluation. This was regarded as an onerous task, and such calls were often set aside until after supper in the hope that the disturbance might quiet in the intervening hours. Notes in the chart were terse and often impractical. Seldom was there any follow-up. As a result, animosity toward psychiatry grew. To remedy this, Lindemann officially established the Psychiatric Consultation Service under the leadership of Avery Weisman in 1956. Weisman's resident, Thomas Hackett, divided his time between doing consultations and learning outpatient psychotherapy. During the first year of the consultation service, 130 consultations were performed. In 1958, the number of consultations increased to 370, and an active research program was organized that later became one of the cornerstones of the overall operation and part of its legacy of scholarship.

By 1960, a rotation through the Consultation Service had become a mandatory part of the MGH residency in psychiatry. Second-year residents were each assigned two wards. Each resident spent 20 to 30 hours a week on the Consultation Service for 6 months. Between 1956 and 1960, the service attracted the interest of fellowship students, who contributed postgraduate work on psychosomatic topics. Medical students also began to choose the Consultation Service as part of their elective in psychiatry during this period. From our work with these fellows and medical students, collaborative research studies were initiated with other services. Examples of these early studies are the surgical treatment of intractable pain, the compliance of duodenal ulcer patients with their medical regimen, post-amputation depression in the elderly patient, emotional maladaptation in the surgical patient, and the psychological aspects of acute myocardial infarction.

By 1970, Hackett, then Chief of the Consultation Service, had one full-time (postgraduate year [PGY]-IV) chief resident and six half-time (PGY-III) residents to see consultations from the approximately 400 house beds. A private Psychiatric Consultation Service was begun, to systematize consultations for the 600 private beds of the hospital. A Somatic Therapies Service was created and it offered electroconvulsive therapy to treat refractory conditions. Three fellows and a full-time faculty member were added to the roster in 1976. Edwin (Ned) Cassem became Chief of the Consultation Service, and George Murray was appointed director of a new fellowship program in psychosomatic medicine. In 1995, Theodore Stern was named Chief of the Avery Weisman Psychiatric Consultation Service. Now both fellows and residents take consultations in rotation from throughout the hospital. Our Child Psychiatry Division, composed of residents, fellows, and attending physicians, provides full consultation to the 50 beds of the MGH Hospital for Children.

In July 2002, Gregory Fricchione was appointed director of the new Division of Psychiatry and Medicine, with a mission to integrate the various inpatient and outpatient medical–psychiatry services at the MGH and its affiliates, while maintaining the diverse characteristics and strengths of each unit. The Division includes the Avery D. Weisman Psychiatry Consultation Service; the MGH Center for Psychiatric Oncology and Behavioral Sciences at the Massachusetts General Hospital Cancer Center; the Transplant Psychiatry Consultation Service; the Trauma and Burns Psychiatry Service; the HIV and Infectious Disease Psychiatry Service; the Primary Care Psychiatry Service; the Pain Center Psychiatry Service; the Cardiovascular Disease Prevention Center Service; the Behavioral Medicine Service; and the Spaulding Rehabilitation Hospital's Behavioral and Mental Health Service.