Psychosomatic Medicine: Who Are We?

I received a fascinating proposal regarding the issue over a new name to replace “Psychosomatic Medicine” for our specialty. My former teacher, Dr. William R. Yates, MD, FAPM, just sent me this message about his thoughts on the matter:

Dr. Bill Yates

Dr. Bill Yates

Your posts have got me thinking on this topic.

Here is my proposal.
1. Combine neurology and psychiatry into new specialty called Neuroscience Medicine.
2. Neuroscience Medicine specialists doing consults would be called Neuroscience Medicine Consult Service

There have been similar proposals for a psychiatry name change to clinical neuroscience. Patients don’t know what clinical means so I think neuroscience medicine is better.

Can you think of any other consult service struggling with this issue?

Psychosomatic Medicine really needs to go. Psychosomatic is derived from Freud. Freud is dead and so is psychoanalysis. The goofy Academy of Psychosomatic Medicine carries a semantic remnant that needs to be purged.–WRY

Strong words. Dr. Yates’ proposal raises even more questions, which I mentioned in my reply:

Jim Amos MD 7

Dr. Jim Amos

You raise fascinating questions which lead me to wonder how it would be received by the ACGME, ABMS, and the ABPN. What would be the implication for the controversial Maintenance of Certification (MOC) program? How would residency training programs change?

I doubt any other consult service in medicine has a problem with their name, not like we do.

When APM sent out the poll asking members whether or not the name “Psychosomatic Medicine” ought to be changed, I voted that it should. Did you see my post on what the American Psychosomatic Society did with their own angst about the name of their organization, “Name Change A Game Changer?” They kept the name.–JJA

I included Bill’s suggestion in my poll (don’t forget to vote!):

I also sent a message today to Dr. Don R. Lipsitt asking his opinion about this question about our specialty name. He promptly replied,

I strongly agree that PM is wrong. And probably one-third of my book is a kind of polemic about the issue. Of course, the name “thing” has existed since Dunbar herself originally opposed it, especially as a specialty.

Read about Dunbar here. I’m still waiting for my copy of Dr. Lipsitt’s book, “Foundations of Consultation-Liaison Psychiatry: The Bumpy Road to Specialization,” which shipped on May 13.

Don Lipsitt book FoundationsofCLPsychiatryBumpyRoadtoSpecialization_

Should we change the name of the Academy of Psychosomatic Medicine to the Academy of Neuroscience Medicine? Should we change the name of its journal, Psychosomatics, to The Journal of Neuroscience Medicine? Should we propose a new specialty, Neurosocience Medicine? I bet it makes some people feel tired just thinking about it when they think of all the work involved, starting back in the early 1990s [1]. And the name issue was trouble even then, according to Dr. Thomas Wise:

The major issue in consultation-liaison psychiatry was what to call our subspecialty. There were many names that were suggested. Medical Psychiatry was rejected because it was thought that there would be the suggestion that there is “non-medical psychiatry.” Psychiatry in the Medically Ill was a suggestion, as was Medical-Surgical Psychiatry. Finally, the American Board of Psychiatry and Neurology suggested the term” Psychosomatic Medicine” would be a useful consideration and this was adopted.

There you have it. The ABPN is to blame for all the trouble with the name. Why did we let that happen? Probably because no one wanted to jinx the process of finally getting approval of the specialty.

Adding yet another psychiatric specialty worries me a little, reminding me of the fear of balkanization by the American Psychiatric Association which was a barrier to approval of the Psychosomatic Medicine subspecialty many years ago. Some people say there are already 7 psychiatric subspecialties, which made me scratch my head. The ACGME lists 7:

  1. Psychiatry (the parent)
  2. Brain Injury Medicine (I didn’t know about this one)
  3. Child and Adolescent Psychiatry
  4. Forensic Psychiatry
  5. Geriatric Psychiatric
  6. Psychosomatic Medicine
  7. Addiction Psychiatry

What happened to the combined specialties: Internal Medicine and Psychiatry and Family Medicine and Psychiatry. We probably shouldn’t omit Neuropsychiatry just because the ACGME doesn’t list that one either. But hang on, there’s also the Combined Psychiatry/Neurology Program at NYU School of Medicine. Could there already be a couple of paths to a Neuroscience Medicine specialty? Could they replace Psychiatry, Psychosomatic Medicine and Neurology?

I don’t think so. What I do in the general hospital as a psychiatric consultant goes beyond neurology and psychiatry. In fact, I can think of a great example of what I mean. It’s a comprehensive article (Differential Diagnosis of Psychotic Symptoms: Medical “Mimics” – See more at: http://www.psychiatrictimes.com/forensic-psychiatry/differential-diagnosis-psychotic-symptoms-medical-%E2%80%9Cmimics%E2%80%9D#sthash.Pw4pM7b3.dpuf) on the evaluation of secondary causes of psychoses by Oliver Freudenreich, MD. You can read the entire article by taking advantage of free registration with Psychiatric Times.

It’s a tour de force and underscores why it’s so difficult to find an adequate name for the psychiatric subspecialty which combines internal medicine and psychiatry because–that’s not all we do either. In fact, like it or not, we also deal with psychosomatic themes, one example being the fascinating opposites, false pregnancy and denial of pregnancy in which the signs and symptoms of false or genuine pregnancy including abdominal contour can appear or not, depending on how the mind (especially in the form of defense mechanisms) affects the body [2]. Cases like these probably make many of us doubt that psychoanalysis is truly dead. Maybe it’s a zombie.Zombies_Need_Love_Too_small

I’m pretty sure Freud is dead, though. And “PM” must die.

References:

1.Wise, T. N. (2003). “The journey to subspecialization in psychosomatic medicine (or consultation liaison psychiatry): a United States experience.” Seishin Shinkeigaku Zasshi 105(3): 325-330.

2.Kenner, W. D. and S. E. Nicolson (2015). “Psychosomatic disorders of gravida status: false and denied pregnancies.” Psychosomatics 56(2): 119-128.
OBJECTIVE: The authors review the literature on two dramatic psychosomatic disorders of reproduction and offer a potential classification of pregnancy denial. METHOD: Information on false and denied pregnancies is summarized by comparing the descriptions, differential diagnoses, epidemiology, patient characteristics, psychological factors, abdominal tone, and neuroendocrinology. Pregnancy denial’s association with neonaticide is reviewed. RESULTS: False and denied pregnancies have fooled women, families, and doctors for centuries as the body obscures her true condition. Improvements in pregnancy testing have decreased reports of false pregnancy. However, recent data suggests 1/475 pregnancies are denied to 20 weeks, and 1/2455 may go undiagnosed to delivery. Factors that may contribute to the unconscious deception include abdominal muscle tone, persistent corpus luteum function, and reduced availability of biogenic amines in false pregnancy, and posture, fetal position, and corpus luteum insufficiency in denied pregnancy. For each condition, there are multiple reports in which the body reveals her true pregnancy status as soon as the woman is convinced of her diagnosis. Forensic literature on denied pregnancy focused on the woman’s rejection of motherhood, while psychiatric studies have revealed that trauma and dissociation drive her denial. CONCLUSIONS: False pregnancy has firm grounding as a classic psychosomatic disorder. Pregnancy denial’s association with neonaticide has led to misleading forensic data, which obscures the central role of trauma and dissociation. A reappraisal of pregnancy denial confirms it as the somatic inverse of false pregnancy. With that perspective, clinicians can help women understand their pregnancy status to avoid unexpected deliveries with tragic outcomes.

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Comments

  1. I prefer sticking with C-L psychiatry. And I definitely don’t think psychoanalysis is dead.

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