January 2007 | Back to Table of Contents
Pulse
Psychiatry's Newest Niche
Since 2005, psychiatrists have been able to earn board certification in psychosomatic medicine.
Set in a sleepy Fridley neighborhood of ranch houses and strip malls, Allina Behavioral Health Services’ Northtown Clinic seems an unlikely setting for the cutting edge of brain-body medicine. But the building, which looks more like an apartment complex than a medical center, houses the practice of Anil Sipahimalani, M.D., who last summer became one of a handful of physicians in the state to earn board certification in psychiatry’s newest subspecialty—psychosomatic medicine, a field that sits at the intersection of psychiatry and medicine.
Its practitioners typically focus on the diagnosis and treatment of people with both psychiatric disorders and complex medical conditions, providing what is commonly referred to as “consultation liaison services” for patients whose psychiatric illness is affecting their medical condition or whose medical condition is affecting their mental state. Most have done a one-year fellowship at one of the nation’s 30-plus programs.
But unlike most psychiatrists board certified in the subspecialty, Sipahimalani doesn’t specialize in treatment of medically complex patients. Nor did he do a fellowship at a training program such as Mayo Clinic’s. He simply had a desire to learn about the mechanisms behind brain-body connections, and he wanted to keep abreast of the exploding body of neuroscientific research that is beginning to explain the interplay between emotions and health, thoughts and symptoms, psyche and soma. So he studied on his own, reading 1,000-plus-page textbooks on the subject and myriad journal articles.
Sipahimalani, who grew up in Bombay, India, says he’s always been interested in the mind-body relationship and that psychosomatic medicine was a logical next step in a medical career that has explored both. He first set out to become an internist, along the way did neuroscience research, and eventually ended up in psychiatry.
Yet he insists his practice is quite ordinary. He sees adults and older adolescents with treatment-resistant problems such as depression, anxiety, or a psychosis. And he prescribes the same types of medications his colleagues might.
Sipahimalani says what’s distinctive about his approach is that he looks at the whole patient, spending time on medical problems as well as psychiatric ones. And he believes all illness involves both brain and body. “The brain controls the whole body,” he says, citing the example of the hypothalamus, which controls the sleep-wake cycle, appetite, mood, and sex drive—all of which are affected when a person is depressed.
As to the question of whether physical illness leads to mental illness or vice versa, he’s not all that concerned. “My take on it is that everything eventually becomes chemical, even if it is not originally,” he says. “If you do imaging, you see that the brain looks the same in a depressed person whether the depression was caused by drugs or divorce. Medications clearly alter the brain. Psychotherapy does, too.”
Mayo Clinic’s Sheila Jowsey, M.D., is perhaps more typical of those who’ve earned certification in psychosomatic medicine. Jowsey focuses on the psychiatric needs of transplant patients, who, she says, are at risk for depression, delirium, and other kinds of neuropsychiatric problems. “When a patient comes to a tertiary care medical center and needs highly complex treatments and many medications that could potentially have psychiatric side effects, it’s not surprising that there would be a high incidence of psychiatric consequences,” she says. “When patients experience difficult medical situations, their usual ways of coping start to be overwhelmed.”
Although she did a fellowship in psychosomatic medicine from 1989-90 and has been treating the psychiatric problems of patients with complex medical problems for the past 15 years at Mayo, Jowsey was among the first group of physicians to sit for the certification exam in 2005. “For many years, we’ve had a fellowship, we just haven’t had a certification process,” she notes. The Mayo fellowship program has been offered since 1985.
An Old, New Specialty
Psychosomatic medicine may be psychiatry’s newest subspecialty, but physicians have long been interested in mind-body connections. According to a National Library of Medicine online exhibition, even Hippocrates, who attributed disease essentially to organic causes, noted in his writings the influence of grief on health. And Galen, who followed in the second century A.D., distinguished between diseases with an organic cause and those with an emotional one. In the centuries that followed, the pendulum swung back and forth between psyche and soma.
In the modern era, it took a dramatic swing toward the mind with Sigmund Freud, who theorized that the unexplained symptoms of patients with hysteria were caused by unresolved psychological trauma. By the 1930s, psychoanalyst Franz Alexander, nudged it back toward the body, organizing a scientific research effort that led in 1939 to the founding of the journal Psychosomatic Medicine. In 1977, Alexander protégé George Engle, M.D., attempted to bridge the mind-body gap for good, calling for a new “biopsychosocial” model of medicine.
Today, with technological tools to observe and measure nervous system and brain functioning at the molecular level, researchers are uncovering some of the mechanisms of brain-body interaction. Mustafa al’Absi, Ph.D., of the University of Minnesota Medical School, Duluth, who in 2004 won the American Psychosomatic Society’s Herbert Weiner Early Career Award for Contributions to Psychosomatic Medicine, for example, is looking at the neurobiology of stress. In one of his projects, a study of smokers, al’Absi and his colleagues have measured neurochemical factors released when a person is feeling stress. The surprising findings thus far are that the less the body produces of these neurochemicals, the more susceptible individuals are to the effects of cigarettes. He offers a couple of explanations: “When people are under stress, the brain isn’t able to mount the right response,” he says. “They crave the drug so much because the drug then provides that kick to compensate for this deficiency in how the brain is responding or not.” Or, he suggests, the low brain response to stress might be a risk factor predating their drug-taking behavior.
al’Absi, who teaches behavioral medicine at the medical school, believes that psychosomatic medicine is an important area of research and practice. “I preach to future physicians that the old way of thinking—in a linear fashion, of germs and things causing disease—doesn’t really work because most chronic illnesses are not borne out of simple causes. Since diseases have complicated causes and they tend to be complicated by behavioral, psychosocial factors, then we have to expand the menu of interventions that we have for patients.”
A Slow Start
Despite such evangelism for the blending of psyche and soma in medicine, it doesn’t appear psychosomatic medicine is taking psychiatry by storm. In December, the Minnesota Board of Medical Practice listed 14 psychiatrists as having earned board certification in the subspecialty (Sipahimalani’s name was not yet on the list). Nationwide, 583 psychiatrists had earned certification as of December 1, according to the American Board of Psychiatry and Neurology (ABPN).
A very practical reason will keep the specialty from burgeoning, according to Daniel Winstead, M.D., president of the ABPN and a professor and chair of psychiatry at Tulane University in New Orleans. “Reimbursement has been poor for psychiatry in general. It’s been poor for consultations throughout all of medicine,” he says. “So you are combining psychiatry and consultations and you have a difficult situation.”
But those practicing psychosomatic medicine say that subspecialty status will likely result in an increase in the number of fellowship programs and open positions. And Winstead says that it’s an acknowledgement that psychosomatic medicine is a separate, legitimate body of knowledge and that there’s a need for the services provided by its practitioners.—Carmen Peota