A newsletter from the Academy of Psychosomatic Medicine for residents and fellows training in psychiatry

Konsültasyon Liyezon Psikiyatrisi (Psikosomatik Tıp) ile ilginenlerin bilgisine : 

 

A newsletter from the Academy of Psychosomatic Medicine for residents and fellows training in psychiatry – and anyone else interested in this expanding field at the interface of medicine and psychiatry…

April, 2012

 

In this issue
A Case of Hyponatremia in a patient with schizophrenia: is this SIADH?
An Interview with Steve Saravay, MD
Case Discussion: A Case of Hyponatremia
Have something to submit to this newsletter?

 

 

A Letter from the Fellowship Education Subcommittee to residents training in psychiatry…Psychosomatic Medicine, the new name that includes consultation liaison psychiatry, was only recently recognized as a subspecialty in psychiatry. The American Board of Medical Specialties approved the issuance of subspecialty certificates in Psychosomatic Medicine by the American Board of Psychiatry and Neurology (ABPN) in 2003. Approval from the Accreditation Council for Graduate Medical Education (ACGME) followed later that year. The first ABPN examination in Psychosomatic Medicine was given in 2005. At this time, several hundred psychiatrists have obtained special qualification in Psychosomatic Medicine. An initial grandfathering period is now ended. At this time, candidates must complete an accredited one-year fellowship in Psychosomatic Medicine in order to sit for the written examination.

 

Psychosomatic Medicine is a dynamic and growing field. The field has an extensive and specialized knowledgebase. Inpatient hospital practice has long been a key area of practice. The field is expanding into more outpatient clinical contexts. Areas of specialization within the field continue to develop, such as psycho-oncology, transplant psychiatry, or primary care psychiatry. The skill set of our area includes as essential components both biological and psychotherapeutic approaches. For many of us in the field, a particular appeal is the close connection with medicine, and the opportunity to maintain and hone medical skills.

 

The credential of subspecialty qualification in Psychosomatic Medicine is increasingly recognized. We predict that this recognition will grow with the trend towards increasing integration of care. Co-localization of providers from different specialties is now seen as an essential tool in efficient care. The movement towards the “medical home” is another example of the realization that coordination of treatment must improve. As Dr. Saravay notes in the interview below, specialists in Psychosomatic Medicine are ideally situated to provide service and leadership in this area.

 

Qualification in Psychosomatic Medicine is particularly critical if you are considering a career in academic consultation psychiatry, as programs will need to demonstrate staff qualified in the subspecialty for accreditation.

 

Since the recognition of the subspecialty, many institutions have opened new accredited fellowship programs. Fellowship programs with different approaches and orientations are available in all regions of the country. Most candidates apply to fellowship programs in the fall.

 

Even at this point in the year, however, many programs still have positions available. The qualified candidate will have no difficulty finding a position in a suitable program starting this July. For a list of programs, please see link at the end of this newsletter

 

We hope you will consider fellowship training in the new subspecialty of Psychosomatic Medicine.

 

The Fellowship Education Subcommittee

Academy of Psychosomatic Medicine

 

A Case of Hyponatremia

 

A 42 year man with schizophrenia is admitted with confusion. He is being treated with haloperidol by his psychiatrist, but has a history of erratic compliance. Diagnostic work up is significant for a serum sodium 118 and a near minimal urine specific gravity. The medical team believes this is SIADH due to the neuroleptic and wishes to discontinue the medication.

 

Is this SIADH?

 

For a discussion of this case, scroll down to the end of this email

 

An interview with Steve Saravay, M.D.

 

Frontiers in Psychosomatic Medicine spoke with Steve Saravay, MD. Dr. Saravay talks about the dramatic changes in consultation liaison psychiatry since he joined the field in the 1970s. His account emphasizes that our field is continuing to change, perhaps even at an accelerating pace…

 

Good afternoon. When was it that you started in consultation liaison psychiatry, which we now call psychosomatic medicine?

 

Well, Paul, I began my consultation liaison career at the Long Island Jewish Medical Center in 1972.

 

Did you have any special background to become a CL psychiatrist at that point?

 

There was really no training in CL then. My preparation consisted of a brief elective rotation during my last year of psychiatry residency on a psychosomatic service at Kings County Hospital in Brooklyn. The unit was established by Franz Reichsman, an internist, who himself had trained with George Engel in Rochester. And at that time, it was more training in CL than the majority of psychiatrists would have had.

 

How did that unit work?

 

The purpose was to educate, train and work with the internists in the hospital about psychosomatic disorders. The mission was to look at medical patients and try to determine what psychosomatic factors might be involved.

 

What were the chief kinds of psychosomatic illnesses you would see?

 

All sorts of medical problems. One patient who I worked up was thought to have hysterical vomiting. There was a good deal of underlying analytic material that seemed to explain her condition. Then we got the lab results which showed that she had a peptic ulcer due to hypercalcemia, that was obstructing the antrum of the pylorus. I was much chastened by the experience, and realized one needed to be better acquainted with the medical disorders in patients whom one was called to consult upon.

 

So a major focus was trying to explain the disease as a reflection of psychological factors?

 

Yes, both psychoanalytic concepts and those of Franz Alexander. For many of these patients we would now use a more medically based and/or pharmacologic approach, although there is still an important role for understanding the psychodynamic issues.

 

I presume you all also dealt with adaptation to disease and its psychosocial contacts.

 

I do not recall that being a significant aspect at that time. So, in retrospect, that certainly should have been.

 

When you moved to that job, you were not on a specialized unit but back in a regular general medical center.

 

The situation there was considerably different. The focus was still on trying to educate and convince medical colleagues about the importance of the role of emotions interacting with physical disorders, and the valuable role that psychiatrists could play in diagnosing and treating them. In many ways, working with staff resistances was like trying to convince a resistant patient, who had no insight and who saw no reason to change, to consider psychotherapy.

 

Can you say more about how that service operated and what sort of patients you saw?

 

Well, the emphasis was on difficult patients and patients with possible psychosomatic disorders. These were problem patients who the nurses and the medical staff were often relieved to pass on to us.

 

How did that care model work?

 

The real problem was getting to the patients who we felt might need our services. We were very much in a position of trying to justify our presence on the unit. As a result of that, those of us who were working in the field struggled with poor morale, feelings of self-doubt about what we were doing, trying to get acceptance from the rest of the staff. These were topics that emerged frequently in professional meetings, local or national.

 

Another complicating factor was we were dealing with the results of the community psychiatry movement, which had further contributed to psychiatry’s risk away from the medical establishment. The focus was on community settings without interaction with a medical colleague, much of the work being done by nonmedical professionals without supervision. There was a real concern about the drift of psychiatry away from academic medicine.

 

This was something that was recognized by Jim Eaton at the Psychiatry Education Branch at NIMH. In an attempt to move psychiatry closer to general medicine, he developed a program that offered funding grants for additional CL staff positions to eligible programs. The hope was that CL programs would better integrate their care with their general medical colleagues.

 

Can you compare what it was like working in CL in the 1970’s with what it is like now?

 

It is totally different. CL psychiatrists became very active in trying to gather data to look at the impact of comorbid psychiatric disorders. This was a shift away from an unduly psychosomatic approach. This was something that the assistant director of the psychiatric program at Hillside said that we needed: to get data to show that we were providing a reasonable product. Frankly, I was quite skeptical that we were going to find any such data. Lo and behold we, along with many other colleagues in different institutions, were able to document the high prevalence, the under-recognition and the low referral rate of comorbid psychiatric disorders. We were able to show the value of CL for the general hospital. Outcome studies showed integrated CL programs provided better recognition and referrals, clinical improvement, decreased length of stay in the hospital, decreased hospital cost, and so on.

 

Do you think that the type of patient that you were consulted on then is different from the patients seen now?

 

It gradually changed from the troublesome patient to a variety of patients, as the staff became more sophisticated, as a result of our working with them and by virtue of the educational programs we developed for them. They became more adept in recognizing the disorders and the value of the help that we could provide. So, delirium, adjustment disorder, a patient whose mood or personality had changed, diagnostic dilemmas, such as conversion reactions and other somatizing patients became part of the mix.

One of the ways to measure the change is very interesting. What would now be generally referred to as delirium was called confusional state, sundowning, and so forth. We probably had somewhere between 9 and 12 different names for this one disorder. In the present, they are referred to as delirium because of the research that came from CL psychiatrists on general and specialty units. Our medical colleagues became more energized in calling us, having seen that we could help solve problems that they were struggling with, or helping to accurately diagnose problems that were perplexing.

 

So probably many of the concepts we take for granted such as delirium were not available to them at that time?

 

When specialists on the ICU use the term delirium, they are benefiting from the research work that members of our specialty have provided.

 

We also became a more sophisticated and up to date in our knowledge of the medical conditions that we were treating. I myself had a straight medical internship followed by three years of a psychiatry residency and I felt more comfortable in that role than I would have if I had less training in internal medicine.

 

Do you regret that psychiatry now has gone to the half-year internship?

 

Yes, I do.

 

I certainly agree with you. Have the kind of interventions you provide changed, comparing the 1970s with now?

 

One helpful approach concerned different personality types in patients on the medical floor. There was an influential article, published in 1964 by Kahana and Bibring. These approaches were useful in being able to deal with character disorders different personality types and their reaction to illness. They provided a list of about seven or eight different personality types and the type of supportive or psychodynamic therapy most likely to assist in their management.

 

Since that time, our pharmacological armamentarium has grown considerably. We have become more sophisticated in the psychological aspects of illness, in psychosomatic aspects, and in dealing with drug interactions. The complications of medical drugs and the side effects and psychiatric problems that they can produce also helped us to establish our credentials.

 

Were there other differences in CL that you would like to point out?

 

Even the uniforms that we wore – it was more common for CL psychiatrists or residents to come over to the general hospital in tweed jackets and ties as opposed to wearing the lab coats common in general hospitals now.

 

Many of the techniques that residents were trained to use in psychoanalytic psychotherapy needed to be changed when dealing with hospitalized patients. For example, one might appropriately touch a patient, usually proscribed in a psychoanalytic treatment, either to provide a limited examination of the patient or to put a hand on the shoulder to reassure the patient.

 

That brings us to the topic of a national organization. The membership of the APM was much more diverse several decades ago.

 

It contained physicians from different specialties including, for example, dentists and also non-physician members.

 

How has the kind of paper presented at the APM changed since then?

 

It is like night and day. In the earlier years after it became the national organization for consultation liaison psychiatry, it served as a forum for ventilating the frustrations of proving our worth. The discussion groups often served to seek relief from feeling a lack of respect from our medical colleagues. As time went on, the focus became more clearly how could we overcome these resistances, and how to secure financial support. Many presentations were anecdotal in nature. As the research expertise of our members has grown, and the results that they have produced have grown, we have a much more exciting scientific program. Now we hear results derived from prospective randomized studies and from data derived from other well designed research investigations.

 

The APM I understand started out very much looking at the psychological causation of disease and had a minority representation from what we would call a CL psychiatrist now. How did it happen to transition to being a CL organization as it is now?

 

Well, partly it occurred during the presidency of Troy Thompson. A vote of the membership was taken that restricted the membership to psychiatrists who were involved in some way in consultation liaison psychiatry. The importance of that move too was that we now had an organization that could represent us at a national level, at a political level, and so on.

 

Are the APM meetings still changing and if so in what direction?

 

The organization has permitted special interest groups to become involved in the program, to increase the integration of our efforts with different disciplines such as Ob-Gyn, Surgery, Intensivists, and other subspecialties. In addition, we have fertile interactions and collaborative activities with international C-L organizations, who look to us as leaders in the field, and from whom we have prospered as a result of their increasingly valuable research. For example, Frits Huyse from the Netherlands, the past president of the European Association of Consultation Liaison Psychiatry and Psychosomatic Medicine, and a good friend, has been a leader in that area.

 

I think that there is, and will continue to be, a spread of CL programs developing out of academic centers to smaller hospitals and institutions. We are poised to have a really fruitful integration with the new models of the practice of medicine that are currently being developed. In particular, we are in an excellent position to assist in the integration of medical services.

 

We have the data to support the value of our involvement in keeping costs down and doing preventive services, by making earlier diagnosis of patients in the general hospital. We probably have the data to support an expansion out of the general hospital as well integrated clinics where onsite CL psychiatrists can provide additional benefits.

 

I hope that our profession is going to step up to the plate and show leadership.

 

Well, I do not think we have to worry about that with the influx of new younger people, who are very excited about the prospects, and who are very creative and pro-active. You can see these directions are emerging in the presentations in the national meetings. I think it is a very exciting time. Members of our organization have always been ready to look at new ways of doing things and new opportunities to collaborate with our medical colleagues.

 

Thanks for sharing your views and your experiences.

 

It has been my pleasure.

 

Case Discussion: A Case of Hyponatremia

 

The tonicity of body fluid is tightly maintained near 285 mOsm/kg by the joint action of ADH (arginine vasopressin) released by the hypothalamus and by thirst for fluid intake. Plasma ADH is linearly proportional to plasma osmolality, reaching undetectable levels with plasma osmolality less than about 275 mOsm/kg (Na about 130). In the absence of ADH, the normal kidney excretes about 1000 ml/hr of urine with an osmolality of about 40 mOsm/kg. As plasma osmolality rises, ADH rises and urine becomes progressively more concentrated, to a maximum near 1400 mOsm/kg. Additionally, thirst is activated as plasma osmolality rises above normal: thirst is a backup to ADH. In normal health plasma tonicity is within 3 mOsm/kg of 285.

 

Psychogenic polydipsia is seen in about 10-20% of patients with chronic schizophrenia, but only a minority of these, about 2-5% of all schizophrenics, ever develop symptomatic hyponatremia. Usually severe hyponatremia is intermittent and associated with exacerbation of psychosis. Most patients with polydipsia do not consume enough water to produce severe hyponatremia in the presence of normal renal function and ADH secretion. A number of studies have helped clarify the mechanism of this intermittent hyponatremia induced by polydipsia. First, these patients have a subtle form of SIADH called “reset osmostat” so that low levels of ADH are present at plasma osmolalities that normally completely suppress ADH secretion. Complete ADH suppression occurs if osmolality falls far enough, and thus the impairment is only apparent at certain plasma osmolalities.

 

Furthermore, this impairment is frequently worsened by acute psychosis, as shown in a remarkable study by Goldman and colleagues. Stable schizophrenic patients with polydipsia were recruited from a state inpatient facility. The sample included patients who did have a history of severe hyponatremia and those who did not have such a history. Subjects received a challenge of methylphenidate producing an exacerbation of psychosis while ADH and plasma osmolality were monitored. In patients with a history of severe hyponatremia, acute psychotic exacerbation produced a significant rise in ADH, but not in subjects without a history of water intoxication. The ADH response was correlated with concurrent plasma osmolality, indicating that osmotic regulation of ADH was intact. Psychosis thus produces hyponatremia by lowering the set point for ADH secretion.

 

In contrast, SIADH due to drug action is characterized by a more stable lowering of plasma osmolality, elevated ADH that does not vary with plasma osmolality, and urine osmolality that exceeds plasma osmolality. SIADH is rarely attributable to antipsychotics. When it does occur, it produces the classic drug-induced SIADH (and the clinical picture is often confounded by other problems, such as serotonin syndrome, rhabdomyolysis, or neuroleptic malignant syndrome). In the present case, the dilute urine tonicity is more consistent with reset osmostat.  The relationship between antipsychotics and hyponatremia is not straightforward. In some cases antipsychotics appear to diminish hyponatremia. In general, hyponatremia is not improved by lowering neuroleptic doses. Antipsychotic drugs routinely cause a very mild increase in renal response to ADH but do not cause reset osmostat.

 

The patient underwent a work up which did not reveal any medical cause for hyponatremia. Collateral from family revealed that the patient had stopped taking antipsychotic medication several weeks previously. The patient was admitted to a psychiatric unit, haloperidol treatment was resumed and serum sodium remained in the borderline low normal range. In the longer term, management of such patients is often a difficult clinical challenge. Recent studies suggest that vasopressin receptor antagonists, known as vaptans, may be useful in relapsing symptomatic polydipsia.

 

 

From the editor

 

This newsletter particularly seeks to disseminate information relevant to psychosomatic medicine which will be of interest to residents and fellows training in psychiatry. We would be delighted to receive suggestions or submissions. If you have a brief case, a first person experience in Psychosomatic Medicine, a brief discussion of a topic in this field, an opinion piece or other item you wish to submit, please email the newsletter editor, Paul Desan, MD, PhD, at frontiers@apm.org. Clinical cases will be edited to our format and do not need to be submitted in final form. Authorship will be acknowledged. We wish to thank Dr. Morris B. Goldman for helpful comments on our discussion of hyponatremia. If you would like to receive this newsletter directly, please send an email to frontiers@apm.org.

 

Click here for a listing of Psychosomatic Fellowship Programs.

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