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Dr. Webb replies
-----Letters----What's in aname? Sir: In Dr. William Webb's editorial,
•. A new mission for the Academy in the 1980s" (Psychosomatics 27:619620. 1986), in which he notes difficulties in attracting new members to the Academy and its journal. he neglects clearly to specify the reason. Being a recent convert from psychiatry to neurology, which permits me to socialize in both camps, I think I know the reason. The terms psychosomatics and psychosomatic medicine, the slogans used by the Academy ("interaction of mind. body, and environment"), the body of knowledge they connote. and the sorts of patients they bring to mind are simultaneously too specific and too vague to appeal to large numbers of physicians who have much reason to address such issues and. in fact, display their interest in doing so in conversation and practice. The terms and their referents are too specific in that they suggest an emphasis on the strict definition of psychosomatics, ie. the by now (in the opinion of many) fairly discredited attempts to define and prove particular psychodynamic mechanisms responsible for particular disease states. Even if one disagrees that this approach is of marginal validity or utility, one has to recognize that it is of little interest to the great majority of physicians. Equally. the terms are too vague in suggesting a focus on such abstractions as the mind/body problem or, really. on anything in medicine that is not biological or technologic. As a busy clinician, I regret to say that articles on mind-body-environment interactions are rarely found on the top of my in-box. In truth, the Academy that I know and love is neither too specific nor too vague in these senses. Paging through
back issues ofthe journal, one quickly grasps that the interests of Academy members and authors are broad and deal with practical clinical matters. The old-style psychosomatic/psychodynamic perspective is little in evidence, nor do the authors dwell in a forest of philosophic abstractions. They deal with a large variety of down-to-earth clinical problems and their solutions, which are of consuming interest to practitioners in all branches of medicine. And another thing: There is more somatopsychics than psychosomatics in the journal. I think this accurately reflects the Academy's forward movement with the rest of medicine. It also reflects that it has moved away from a purely psychiatric focus and toward general medicine. And if one wished to pick a particular category of clinical subject matter that would have the broadest appeal to the journalreading or conference-attending public. it would be somatopsychics. With the possible exception of orthopedists, practically all physicians are extremely concerned with figuring out what medical disorders might be causing their patients' abnormal behavioral states. The management of the latter they would, for the most part, prefer to leave to the psychiatrists. The Academy's increasing focus on somatopsychics is belied by its favored titles, terms, and slogans. In summary, I would suggest that the vocabulary and (one must add) marketing approach of the Academy and its journal must be adjusted to fit their actual content. I happen to dislike the word somatopsychics, chiefly on esthetic grounds, and do not wish to propose this as the new title of the organization or journal. I defer to Academy management and its mar-
keting advisors to come up with one more elegant and sonorous. But until something is done about our presently archaic, misleading, and disagreeable way of presenting ourselves in public, the internist on the street will continue to walk on by. Robert S. Hoffman. M.D., F.A.P.M. Daly City, Calif.
Dr. Webb replies I very much appreciate Dr. Hoffman's response to my editorial and all the good things he has to say about the activities of the Academy and the character and quality of the articles appearing in Psychosomatics. with all of which I heartily concur. He was accurate in noting that my prescription for reorienting the mission of the Academy was vague. This was on purpose. Reorganizing the direction of an organization is a collective action, dependent, in the final analysis, on the will of its membership, and finally, complex in its execution. Easy prescriptions simply won't work. Dr. Hoffman has offered a solution that, on the surface. appears simple but, in fact, represents a conundrum for the field. Change the name. he suggests. Immediately we are thrown into an area of controversy and nominal vagueness. How. in fact, do we describe our area of medical interest and expertise? The DSM-III categories have really not provided a satisfactory listing of the biopsychosocial interactions that characterize our work. BiopsychosociaJ is a heavyhanded term that is overused and basically vague in its implications. Do we really want to be called The Academy of Biopsychosocial Medicine? Dr. Hoffman is even turned off by the word somatopsychics. I wholeheartedly agree with him. (continued)
MAY 1987· VOL 28· NO 5
235
-----------Letters----------For the time being, I would vote to stay with psychosomatic. I know it is a bit old-fashioned and that it is associated with an outdated and oversimplistic theory of the influence of psychodynamics on somatic function. Nonetheless, it has a good tradition that spells concern for the whole patient. Those psychosomatic patients that cause so much frustration for the medical profession need a group to care about what happens to them. Before our field developed a science, we were a movement that stressed the importance of psychological issues, as well as disease issues, in understanding the patient. This continues to be important. The future of our organization, I believe, depends more on clearly defining the mission of the organization, protecting the scientific integrity of our meetings and journal articles, and providing a forum where practical management issues can be discussed concerning our patients, all of whom are "psychosomatic. " William L. Webb. Jr .. M.D. Hartford. Conn.
PTSD and late treatment Sir: In his paper' 'Treatment noncompliance in patients with post-traumatic stress disorder" (Psychosomatics 27:37-40, 1986), Burstein concluded that patients suffering from this disorder show a greater probability of noncompliant behavior the longer they choose not to enter treatment. He further concluded that patients who entered treatment late were hesitant about accepting a psychiatric referral, had tried other professionals first, were uncertain where to receive assistance, or viewed emotional treatment as the one of last resort.
We would like to amplify these results with another PTSD sample of75 veterans who had been in combat in Vietnam and had experienced various degrees of combat stress. All had a PTSD diagnosis. We recorded 63 study variables, including background factors (eg, education, marital status), premilitary problems (eg, problems in school, seen a counselor), military problems related to combat (frequency or intensity of combat), postservice problems (3l-item stress scale of everyday problems and current Vietnam-related problems), and psychometric variables (MMPI, Profile of Mood States, State-Trait Anxiety scale, Impact of Event Scale [IES] and a well-validated adjustment scale, VETS Adjustment Scale). A correlation analysis was used. Eleven variables correlated significantly with time since combat before first psychiatric treatment. Our findings suggested that PTSD patients who take more time to enter treatment have less self-confidence and experience many current stressors, including marriage and jobs. They tend to be confused, guarded, and highly anxious, and experience intrusion reexperiences. Overall adjustment level is also poor. Some of the variables not found significant were amount and intensity of combat stressors, treatment expectancy, number of reexperiences, and depression or anger. We would conclude that PTSD patients who have experienced a chronic series of stressors and who delay treatment, undergo considerable turmoil and confusion and experience further stress from their current life condition. These people apparently have delayed obtaining assistance because they are disorganized and in psychological turmoil. They often appear
burned out. No doubt treatment will prove more difficult for them. Burstein's study has shown that there seems to be a penalty for this late entry into PTSD treatment. Our findings indicate that the delay in seeking treatment may stem from psychiatric turmoil and current life problems combined with lowered self-confidence. This decision may indeed be one that is important in and of itself and one that bears further study. Lee Hoyer. Ed.D. Wi/liamR. Harrison. M.D. Augusta. Ga.
Contradiction corrected Sir: I noted a confusing statement in Allan Burstein's article, "Treatment length in post-traumatic stress disorder" (Psychosomatics 27:632-637, 1986). In Table 1 (page 633) the author presents the length of the traumato-intervention (T-I) interval as 8.2 weeks for group A and 16.7 weeks for group 0, but in the discussion, the author states, "Although the T-I interval was longer for group A than group D, this was largely due to the extremely long interval of one patient. " Richard Balon. M.D. Detroit. Mich.
The author replies Thank you for your interest and careful reading of my article. The sentence in question should read: "Although the T-I interval was longer for group D than group A, this was largely due to the extremely long interval of one patient. " This sentence was added to the proofof the paper and thus escaped the checking at different levels, which occurred with the total article. AI/an Burstein. M.D. Freehold. N.J.
PSYCHOSOMATICS
•. A new mission for the Academy in the 1980s" (Psychosomatics 27:619620. 1986), in which he notes difficulties in attracting new members to the Academy and its journal. he neglects clearly to specify the reason. Being a recent convert from psychiatry to neurology, which permits me to socialize in both camps, I think I know the reason. The terms psychosomatics and psychosomatic medicine, the slogans used by the Academy ("interaction of mind. body, and environment"), the body of knowledge they connote. and the sorts of patients they bring to mind are simultaneously too specific and too vague to appeal to large numbers of physicians who have much reason to address such issues and. in fact, display their interest in doing so in conversation and practice. The terms and their referents are too specific in that they suggest an emphasis on the strict definition of psychosomatics, ie. the by now (in the opinion of many) fairly discredited attempts to define and prove particular psychodynamic mechanisms responsible for particular disease states. Even if one disagrees that this approach is of marginal validity or utility, one has to recognize that it is of little interest to the great majority of physicians. Equally. the terms are too vague in suggesting a focus on such abstractions as the mind/body problem or, really. on anything in medicine that is not biological or technologic. As a busy clinician, I regret to say that articles on mind-body-environment interactions are rarely found on the top of my in-box. In truth, the Academy that I know and love is neither too specific nor too vague in these senses. Paging through
back issues ofthe journal, one quickly grasps that the interests of Academy members and authors are broad and deal with practical clinical matters. The old-style psychosomatic/psychodynamic perspective is little in evidence, nor do the authors dwell in a forest of philosophic abstractions. They deal with a large variety of down-to-earth clinical problems and their solutions, which are of consuming interest to practitioners in all branches of medicine. And another thing: There is more somatopsychics than psychosomatics in the journal. I think this accurately reflects the Academy's forward movement with the rest of medicine. It also reflects that it has moved away from a purely psychiatric focus and toward general medicine. And if one wished to pick a particular category of clinical subject matter that would have the broadest appeal to the journalreading or conference-attending public. it would be somatopsychics. With the possible exception of orthopedists, practically all physicians are extremely concerned with figuring out what medical disorders might be causing their patients' abnormal behavioral states. The management of the latter they would, for the most part, prefer to leave to the psychiatrists. The Academy's increasing focus on somatopsychics is belied by its favored titles, terms, and slogans. In summary, I would suggest that the vocabulary and (one must add) marketing approach of the Academy and its journal must be adjusted to fit their actual content. I happen to dislike the word somatopsychics, chiefly on esthetic grounds, and do not wish to propose this as the new title of the organization or journal. I defer to Academy management and its mar-
keting advisors to come up with one more elegant and sonorous. But until something is done about our presently archaic, misleading, and disagreeable way of presenting ourselves in public, the internist on the street will continue to walk on by. Robert S. Hoffman. M.D., F.A.P.M. Daly City, Calif.
Dr. Webb replies I very much appreciate Dr. Hoffman's response to my editorial and all the good things he has to say about the activities of the Academy and the character and quality of the articles appearing in Psychosomatics. with all of which I heartily concur. He was accurate in noting that my prescription for reorienting the mission of the Academy was vague. This was on purpose. Reorganizing the direction of an organization is a collective action, dependent, in the final analysis, on the will of its membership, and finally, complex in its execution. Easy prescriptions simply won't work. Dr. Hoffman has offered a solution that, on the surface. appears simple but, in fact, represents a conundrum for the field. Change the name. he suggests. Immediately we are thrown into an area of controversy and nominal vagueness. How. in fact, do we describe our area of medical interest and expertise? The DSM-III categories have really not provided a satisfactory listing of the biopsychosocial interactions that characterize our work. BiopsychosociaJ is a heavyhanded term that is overused and basically vague in its implications. Do we really want to be called The Academy of Biopsychosocial Medicine? Dr. Hoffman is even turned off by the word somatopsychics. I wholeheartedly agree with him. (continued)
MAY 1987· VOL 28· NO 5
235
-----------Letters----------For the time being, I would vote to stay with psychosomatic. I know it is a bit old-fashioned and that it is associated with an outdated and oversimplistic theory of the influence of psychodynamics on somatic function. Nonetheless, it has a good tradition that spells concern for the whole patient. Those psychosomatic patients that cause so much frustration for the medical profession need a group to care about what happens to them. Before our field developed a science, we were a movement that stressed the importance of psychological issues, as well as disease issues, in understanding the patient. This continues to be important. The future of our organization, I believe, depends more on clearly defining the mission of the organization, protecting the scientific integrity of our meetings and journal articles, and providing a forum where practical management issues can be discussed concerning our patients, all of whom are "psychosomatic. " William L. Webb. Jr .. M.D. Hartford. Conn.
PTSD and late treatment Sir: In his paper' 'Treatment noncompliance in patients with post-traumatic stress disorder" (Psychosomatics 27:37-40, 1986), Burstein concluded that patients suffering from this disorder show a greater probability of noncompliant behavior the longer they choose not to enter treatment. He further concluded that patients who entered treatment late were hesitant about accepting a psychiatric referral, had tried other professionals first, were uncertain where to receive assistance, or viewed emotional treatment as the one of last resort.
We would like to amplify these results with another PTSD sample of75 veterans who had been in combat in Vietnam and had experienced various degrees of combat stress. All had a PTSD diagnosis. We recorded 63 study variables, including background factors (eg, education, marital status), premilitary problems (eg, problems in school, seen a counselor), military problems related to combat (frequency or intensity of combat), postservice problems (3l-item stress scale of everyday problems and current Vietnam-related problems), and psychometric variables (MMPI, Profile of Mood States, State-Trait Anxiety scale, Impact of Event Scale [IES] and a well-validated adjustment scale, VETS Adjustment Scale). A correlation analysis was used. Eleven variables correlated significantly with time since combat before first psychiatric treatment. Our findings suggested that PTSD patients who take more time to enter treatment have less self-confidence and experience many current stressors, including marriage and jobs. They tend to be confused, guarded, and highly anxious, and experience intrusion reexperiences. Overall adjustment level is also poor. Some of the variables not found significant were amount and intensity of combat stressors, treatment expectancy, number of reexperiences, and depression or anger. We would conclude that PTSD patients who have experienced a chronic series of stressors and who delay treatment, undergo considerable turmoil and confusion and experience further stress from their current life condition. These people apparently have delayed obtaining assistance because they are disorganized and in psychological turmoil. They often appear
burned out. No doubt treatment will prove more difficult for them. Burstein's study has shown that there seems to be a penalty for this late entry into PTSD treatment. Our findings indicate that the delay in seeking treatment may stem from psychiatric turmoil and current life problems combined with lowered self-confidence. This decision may indeed be one that is important in and of itself and one that bears further study. Lee Hoyer. Ed.D. Wi/liamR. Harrison. M.D. Augusta. Ga.
Contradiction corrected Sir: I noted a confusing statement in Allan Burstein's article, "Treatment length in post-traumatic stress disorder" (Psychosomatics 27:632-637, 1986). In Table 1 (page 633) the author presents the length of the traumato-intervention (T-I) interval as 8.2 weeks for group A and 16.7 weeks for group 0, but in the discussion, the author states, "Although the T-I interval was longer for group A than group D, this was largely due to the extremely long interval of one patient. " Richard Balon. M.D. Detroit. Mich.
The author replies Thank you for your interest and careful reading of my article. The sentence in question should read: "Although the T-I interval was longer for group D than group A, this was largely due to the extremely long interval of one patient. " This sentence was added to the proofof the paper and thus escaped the checking at different levels, which occurred with the total article. AI/an Burstein. M.D. Freehold. N.J.
PSYCHOSOMATICS