- Email: [email protected]
Biological adaptation, digestive disorders, and health services
~ Weiss-English ~ Symposium
Biological adaptation, digestive disorders, and health services THOMAS P. ALMY, M.D. Although "psychosomatic medicine" has proved the most durable term to describe the field under discussion, I should like to express some lingering discomfort about the semantics and some of the inferences which have often been drawn from the literal use of this term. "Psyche," according to the largest dictionary available to me, means either the lovely maiden with delicate wings on her scapulae who captivated Eros (or Cupid) and induced him to go steady, or it refers to the human soul. Now the usual rendering of "psychosomatic" as pertaining to mind-body interactions is pretty close to soulbody phenomena, and should give us little trouble; but it is the human connotation, the restriction of our concept to the influences of the highest integrative functions of the human brain, to which I object. Some have denied that psychosomatic mechanisms affecting the digestive tract could possibly be operative in the baby, for lack of cerebral development; yet a considerable body of circumstantial
evidence indicates that the gut does indeed participate in the apparently turbulent emotional life of the newborn. Early in this century, in a darkened room in Boston, Walter B. Cannon observed under the fluoroscope the motility of the bismuth-filled intestine of the cat; and he saw it was profoundly altered when, in the presence of a growling dog, the cat's pulse rate increased, its back arched, and its hairs stood on end. With either the baby or the cat, we have difficulty penetrating its mind, but we infer with some confidence that its soul can be disturbed. Perhaps these reactions ate not unique to civilized man, but they may have been handed down to us through evolutionary processes. Perhaps they have even had survival value for the adapting, coping animal. As far back as we can go in the evolutionary process and still identify specific organs of digestion, we find the gut programmed to defend the body against potentially noxious influences. The coral polyp, for example, which con-
stantly ingests whatever is floating in the saline solution in which it lives, can halt the process of ingestion and regurgitate whatever is recognized as noxious. The human esophagus also reacts with lower esophageal spasm, and at times with regurgitation, upon ingestion of excessively cold or hot liquids or of irritating food. The biological value of such a response seems obvious; but when a similar reaction pattern is evoked by a stress situation which yields no direct stimulation of the esophagus, but which becomes threatening because of the attitudes and feeling states of the individual, one must think of this pattern as one of general defense.' When Cannon's cat, faced with the growling dog, suspended peristalsis and interposed a strong sustained contraction of the distal colon2 which would have prevented defecation as surely as would an opiate, the utility of these reactions in the situation in that darkened room was not entirely clear. But if that same animal, or its wild ancesPSYCHOSOMATICS
tor loose in the jungle, had chosen to fight or to flee from a sharptoothed predator, it would have been awfully inconvenient to have a bowel movement right then. You can say the same for the U. S. Marine veterans I once knew, who, in two extended tours -of duty as scouts behind enemy lines in the Borneo jungle, had gone six weeks without a bowel movement. Their survival, they said, required that they avoid being "caught with their pants down." The same adaptive, coping response favors the pilot'S landing a 747 jet, or the politician's making a speech. In the laboratory again, but more recently in human patients with constipation, rather than cats, emotional arousal has been found associated with similar strong and sustained contractions of the sigmoid colon.3 These responses are not limited to motility changes. The secretions of the gut may be called upon to wash away actual or symbolic noxious agents during the course of vomiting and diarrhea. Even more interesting is the curious behavior of the sea cucumber, which defends itself against other hungry marine animals by extruding its intestinal tract, sloughing it off, and leaving it suspended in the water as an appeasement to the marauder, while the would-be prey crawls off to a safe place and generates a new gut. This most complex pattern of defense has few similarities to known reactions in higher animals, but it must involve rapid autolysis, presumably by endogenous proteolytic enzymes, here abruptly activated in a fantastic adaptive response. Since such enzymes are found in pancreatic juice, could such a response be a trigger mechanism in acute pancreatitis? Could other enzymes, APRIL 1978 • VOL 19. NO 4
found in the cytoplasmic granules of polynuclear leukocytes and the mechanisms of clotting and fibrinolysis, at times initiate the tissue damage in ulcerative colitis or Crohn's disease? All we can say is that it is conceivable. Certainly, with the bulk of experimental studies on stress reactions in the gut still directed at motility alone, many adaptive reaction patterns which could have been passed down to us in the course of evolution must still remain unexplored. Organ language In human patients, we see other phenomena which seem uncharacteristic of coping behavior and unlikely to assist adaptation in the wild state of nature, but which serve to induce protective behavior in others (most often in parents or physicians) and thus acquire survival value. Almost any functional disorder of the gut may be involved, if the individual has learned by trial and error that it elicits the desired response in a protective figure. This "visceral learning" of complex patterns of goal-seeking behavior, probably originating in infancy, has been proposed as a determinant of the pattern of bodily reactions characteristic of a given individual during stress in adult life. This "organ language" may have been learned by the child who discovered that certain symptoms of his, which called forth a tender, loving reaction on the part of his mother, resolved then-painful conflicts over feeding, toilet training, or other imposed discipline. Thus, the phenomena of secondary gain have been speculatively linked to the neurophysiology of reward, or goal-seeking behavior. Although the direct evidence for operant conditioning of
intestinal functions in experimental animals is still fragmentary ,4 the translation of these principles to the therapeutics of human bowel disorders (biofeedback) is already showing promise. What is the relationship of these phenomena to the total scope of illness in man? Many have viewed the psychosomatic disorders of the gut as a specific category of disease, separable by defined personality characteristics or by physiologic parameters from the range of "normal" reactions. Recently, elegant studies by Snape et al s have yielded evidence of a specific pattern of myoelectric activity in the colons of patients with the irritable bowel syndrome. This suggests an analogy to the cerebral dysrhythmia of idiopathic epilepsy-but is the pattern innate or acquired? Can this pattern be a "learned" response to stress? I think these are reasonable questions, for we know that clinically similar reactions (dysphagia, vomiting, constipation, diarrhea) occur transiently under stress in a much larger number of individuals who consider themselves normal and thus never take the problem to their physicians. In extended studies with laboratory colleagues on human distal colonic function under stress, I was unable to distinguish objectively the bodily changes in the patients from those in normal volunteers. Furthermore, disorders of this kind often are part of the total experience of illness to which clear-cut structural lesions contribute. We should abandon the either-or approach ("functional" versus "organic") and ask ourselves how much ofeach is involved in the total picture. Let me cite two illustrations of the importance of this principle. • During World War II, a middle101
~ Weiss-English ~
Symposium
aged woman was admitted to the hospital with a one-week history of intractable vomiting. which had begun within hours after word had come of the death of her son in battle. Prior to this. she had had no digestive symptoms. The vomiting subsided during her five days in the hospital. and she was well for many months thereafter with nothing but supportive psychotherapy. But on the day of her discharge. a GI series revealed a constricting lesion of the gastric antrum. a typical carcinoma. for which she refused to undergo surgery. • At a major cancer center. a follOW-Up study was made of all the patients who were free of disease and physically fit five years or more after abdominoperineal resection for cancer of the rectum-the classic goal of "five-year cure." About two thirds of these patients had nevertheless been unable, because of difficulties in psychosocial adjustment and attendant affective disorders, to return to work or to full household duties.6 I cannot accept these disorders as diseases sui generis, but regard them as an aspect of all illness. the relief of which is often essential if the patient is to return to productive life. In this view, their importance to the planning and the overall cost of health care is very large. Costly disorders In the past, we have recognized that disorders chiefly of psychosocial origin account for 30% to 60% of all digestive illness seen in physicians' offices, and we have calculated that in 1972, digestive diseases were costing the nation $16 billion per year.' Until 1966, we had a "market economy" system of health care, based on supply and demand.
Thus, we could feel right when we had done our best for some of these patients in clinic settings, and then expended large amounts of office time on others like them who, in paying our fees, were using their private resources for private purposes. Particularly with respect to the treatment of the psychosomatic factors in illness, access to care by different economic groups has been distinctly unequal, despite our best efforts. During the 30 years that we have been acting on the insights provided by Weiss and English's landmark publication,8 we have also seen the increasing importance of third-party payers in supporting the total cost of health services. The result is that even now, though we have yet to enact some form of comprehensive national health insurance, we must consider that the decision to treat any person's illness affects in some measure the cost and the availability of health services to the nation as a whole. The public interest is clearly involved, and ceilings and priorities in the use of dollars and manpower will inevitably be set. The public will clearly ask what priority should be assigned to the relief of non-lifethreatening conditions which reflect various degrees of intolerance of the stresses and strains of ordinary living. But if we recognize that psychosomatic factors playa part in all illness and are not uniquely the problems of a neurotic minority, what emphasis should be placed, in any rationing of medical services, on this humanistic aspect of medicine? How, indeed, can we measure its benefits? There are many who would wish us, as physicians, to deny any obligation to deal with social stress, to leave this aspect of our patients' problems to the clergy and to social
agencies, and to limit our attention to ailments definable and treatable in physical or chemical terms. We don't need to imagine the consequences of such a policy, for, to a considerable degree, it is practiced today by many contemporary physicians whose education has been chiefly influenced by reductionistic biology. The policy is visible in the haste with which some hospital residents pass over the details of the medical history, not hearing the patient's main complaint, to focus on the numbers printed out by the AutoAnalyzer. The policy is expressed in terms of expensive laboratory studies, complaints by patients that their doctors don't take time to talk to them, clinic shopping, resort to quackery, and skyrocketing rates for malpractice insurance. Yet despite their disappointments, patients keep coming primarily to their personal physicians to express their bodily complaints, rather than first seeking s0cial solutions for recognized sources of anxiety. I will insist that psychosomatic factors have a significant influence on the mortality from various diseases, such as hypertensive disease, myocardial infarction, duodenal ulcer, and ulcerative colitis; but I believe their medical and economic impact is measurable chiefly in terms of morbidity, with the loss of time from work, and the secondary social consequences of illness among responsible adults, such as the malnutrition and truancy of their children. In a celebrated study of medical care at a distinguished university medical center, half the patients were considered to be "disabled" by psychological problems at the time of discharge from the hospital. Functional disorders of the gut, we are told by one of our PSYCHOSOMATICS
largest insurance companies, vie with the common cold for first place on the list of causes of industrial absenteeism due to illness. It is not possible to estimate, from the figures so far recorded for each major category of illness, how much of the total national bill for health services is attributable to the care of psychosomatic disorders. We can only say that there are many such patients, that they take a great deal of the physician's time, and that the physician's time is a scarce and costly commodity. In trying to predict future costs in terms of money and manpower, we can study the trends in psychiatric services in general, while prepaid health insurance plans have enlarged, multiplied, and provided more comprehensive benefits. According to a recent authoritative study,9 the estimated number of episodes of outpatient mental health care rose from 379,000 in 1955 to nearly 1.8 million in 1968. Utilization of such services tends to rise rapidly on their inclusion in programs of prepaid health care. We can confidently expect that the care of psychosomatic disorders will loom large in our reckoning of the cost, in money and manpower, of comprehensive national health insurance in the U.S. Yet there is evidence that it is more economical to provide services for psychosocial problems than to withhold them. For a group of patients served by a prepaid health plan in an eastern city, the decision to provide liberal access to ambulatory psychiatric services led to a marked drop in utilization of other clinical and laboratory services and a reduction in overall costs of the plan, even though the expense for psychiatric care rose to 11% of all physicians' fees and to 28% of all physicians' APRIL 1978 • VOL 19· NO 4
fees in the nonsurgical category.1O Dealing with stress disorders On the ground of both social necessity and of economic wisdom, the effort to deal constructively with stress-related disorders makes sense; but how are we going to handle the larger load under national health insurance? How can we reduce costs and provide equitable access to our services for all those who need us? I cannot believe that we as professionals can simply sleep fewer hours at night, or persuade our patients to talk faster, or tolerate the "dispensary" model of mass administration of tranquilizers to chronically complaining but little-studied patients. I do believe, on the other hand, that there are many ways in which we can better husband our working time and distribute our services, and that these deserve to be tested critically. First of all, there is teamwork. General physicians can learn much from the experience of psychiatrists, who have extended their services by working in mental health centers with clinical psychologists, nurses, social workers, and lower level health professionals. In rural practice, visiting nurse associations and community social agencies give valuable help to people who must tolerate psychosocial stress. These precedents can be adapted easily to the management of runof-the-mill medical ambulatory patients with initial physical complaints, if we insist that: • The physician whom the patient has chosen must demonstrate personal knowledge of and concern for the psychosocial aspects of the illness, and willingness to participate in their management. • The patient must be aware that his or her physician is in regular
coinmunication with the other professionals seeking to help him or her, has digested their findings, and is to be held fully accountable for the overall result. Under these circumstances, both the physician and the patient will be reassured that nothing important will fall between the chairs. The advantages to be gained by treating a concurrent organic process will be fully realized. The extraordinary power of the personal doctor-patient relationship will not be weakened if the physician plays his or her role and uses his or her authority wisely. The physician should see the patient first, however briefly, and introduce the others as helpers in meeting the patient's needs. The physician should be the only one to attempt overall formulations of the illness to the patient, and answer the patient's questions about the outlook. The roles of the separate characters in this office scenario will have to vary with the attitudes and reactions of the patient; some patients will more readily accept the services of lower level professionals than will others. With time, many patients may develop such a transference to the assistant that the role of the physician, in the eye of the patient, becomes that ofconsultant. This is a far cry from the total delegation of these problems to other professionals. Questionnaires Second, I urge the liberal use of written communications. Beginning with the Cornell Medical Index, I have been impressed with the capability of most patients to give honest and meaningful answers to health questionnaires, thus enabling me to focus better on sig203
~ Weiss-English ~
nificant aspects of the history. The filling out of the questionnaire is seen as a response to a personal request of the physician (rather than an institutional practice), and does not replace the direct interview-style history. The inclusion of questions on psychosocial problems clearly expresses the physician's concern for this area of functioning, and the inquiry moves ahead faster. Third, we need to make the fullest possible use of biological alternatives to psychotherapy, wherever rational and appropriate. The pharmacologic relief of depression, the reinforcement of behavioral change by peer-group pressures, and the growing potential of behavioral methods such as aversive therapy and biofeedback are all needed-both for their intrinsic effectiveness and for the economies they can offer in the use of professional services. The ideas I have just recited include nothing new; on the other hand, the value ofsome of the items may be judged controversial. What is needed most, is much more extensive experimentation to determine the true effects of these measures. For example, even with respect to the operation of mental health centers, I have found no convincing experimental data on the effectiveness and the cost-benefit evaluation of the team approach. We need controlled experiments in the delivery of this kind of health care.
Reducing the problem Beyond the methods by which we may care for psychosocial factors in
developed illness, the magnitude of the problem ought to be reducible to some extent by preventive measures. We can point to the home and the working place as the principal origins of the psychosocial stresses we see in our patients. Programs on sex education, family planning, marital counseling, personnel management, day care for children, and assistance to the elderly are all of potential value in diminishing the frequency of stress-related disorders. II Through programs on health education in the schools, every young person should become aware of the range of bodily adaptations to stress and their relationships to the occurrence and the patterns of illness. This ought to go far in preventing secondary anxieties and fears of catastrophic illness when stressrelated symptoms arise in later life, as well as in helping the patient become more receptive to the physician's explanations. To recapitulate, I have suggested that the psychosocial factors in digestive disorders are important among the humanistic aspects of medicine, yet are patterned after biologic mechanisms of adaptation which originated far back in evolutionary time. They are even more common in the repertoire of human adaptation than is indicated by their high prevalence among our patients. Their rational and effective management, in a system of health care promising equal access to all who require services, will place large and increasing strains on that system. To minimize these, while striving for quality and sensitivity of care, will demand innova-
Dr. Almy is Third Century Professor of Medicine, Dartmouth Medical School. Reprint requests to Dr. Almy there, Hanover, NH 03755. APRIL 1978 • VOL 19 • NO 4
Symposium
tive cost-conscious practices now only dimly perceived, with the primary care physician and allied health professionals as the principal effectors. At the same time, it should be emphasized that a more soundly based strategy of management will require much more fundamental research. Clinical investigators with interdisciplinary training can carry our understanding of integrative processes beyond current concepts of neurohumoral mediation, beyond motor and secretory responses of the end organ, to adaptive changes in intracellular enzymes, intermediate metabolism, and immunologic phenomena. To put such diverse elements together in the service of troubled human beings would be the fulfillment of one of our greatest hopes for medicine in our time. 0 REFERENCES 1. WoK 00, Almy TP: Experimental observations on cardiospasm in man. GastroenterolOgy 13:401,1949. 2. Cannon WB: The movements ot the intestines studied by means of the roentgen rays. Am J Physio18:251 , 1902. 3. Almy TP: Experimental studies on the irritable colon. Am J Mad 10:60, t951. 4. Miller NE: Effect of learning on gastrointestinal functions. Clin GastroenteroI8:533-545, t977. 5. Snape WJ Jr, Carlson GM, Cohen S: Colonic myoelectric activity in the irritable bowel syndrome. GastroenterolOgy 70:326-330, 1976. 6. Sutherland AM, Orbach CEo Dyk RB. et al: The psychological impact of cancer and cancer surgery. I. Adaptation to the dry colostomy: preliminary report and summary of findings. Cancer 5:857-872, t952. 7. Almy TP: The law, the institute, and the $t6 billion heartburn (editorial). GastroenterolOgy 88:t52-156, t974. 8. Weiss E. English OS: Psychosomatic Madicine, ed 1. Philadelphia, WB Saunders, 1943. 9. Reed LS. Myers ES, Scheidemandel PL: Heaffh Insurance and Psychiatric Care: Utilization and Cost. Washington, DC, The American Psychiatric Association, 1972, p 28. 10. Reed LS: Coverage and Utilization of Care for Mental Conditions Under Heaffh InsuranceVarious Studies. 1973-74. Washington, DC, The American Psychiatric Association, 1975. 1t Groen JJ: The challenge ot the future: The prevention of psychosomatic disorders. Psychother Psychosom 23:283, t974.
Biological adaptation, digestive disorders, and health services THOMAS P. ALMY, M.D. Although "psychosomatic medicine" has proved the most durable term to describe the field under discussion, I should like to express some lingering discomfort about the semantics and some of the inferences which have often been drawn from the literal use of this term. "Psyche," according to the largest dictionary available to me, means either the lovely maiden with delicate wings on her scapulae who captivated Eros (or Cupid) and induced him to go steady, or it refers to the human soul. Now the usual rendering of "psychosomatic" as pertaining to mind-body interactions is pretty close to soulbody phenomena, and should give us little trouble; but it is the human connotation, the restriction of our concept to the influences of the highest integrative functions of the human brain, to which I object. Some have denied that psychosomatic mechanisms affecting the digestive tract could possibly be operative in the baby, for lack of cerebral development; yet a considerable body of circumstantial
evidence indicates that the gut does indeed participate in the apparently turbulent emotional life of the newborn. Early in this century, in a darkened room in Boston, Walter B. Cannon observed under the fluoroscope the motility of the bismuth-filled intestine of the cat; and he saw it was profoundly altered when, in the presence of a growling dog, the cat's pulse rate increased, its back arched, and its hairs stood on end. With either the baby or the cat, we have difficulty penetrating its mind, but we infer with some confidence that its soul can be disturbed. Perhaps these reactions ate not unique to civilized man, but they may have been handed down to us through evolutionary processes. Perhaps they have even had survival value for the adapting, coping animal. As far back as we can go in the evolutionary process and still identify specific organs of digestion, we find the gut programmed to defend the body against potentially noxious influences. The coral polyp, for example, which con-
stantly ingests whatever is floating in the saline solution in which it lives, can halt the process of ingestion and regurgitate whatever is recognized as noxious. The human esophagus also reacts with lower esophageal spasm, and at times with regurgitation, upon ingestion of excessively cold or hot liquids or of irritating food. The biological value of such a response seems obvious; but when a similar reaction pattern is evoked by a stress situation which yields no direct stimulation of the esophagus, but which becomes threatening because of the attitudes and feeling states of the individual, one must think of this pattern as one of general defense.' When Cannon's cat, faced with the growling dog, suspended peristalsis and interposed a strong sustained contraction of the distal colon2 which would have prevented defecation as surely as would an opiate, the utility of these reactions in the situation in that darkened room was not entirely clear. But if that same animal, or its wild ancesPSYCHOSOMATICS
tor loose in the jungle, had chosen to fight or to flee from a sharptoothed predator, it would have been awfully inconvenient to have a bowel movement right then. You can say the same for the U. S. Marine veterans I once knew, who, in two extended tours -of duty as scouts behind enemy lines in the Borneo jungle, had gone six weeks without a bowel movement. Their survival, they said, required that they avoid being "caught with their pants down." The same adaptive, coping response favors the pilot'S landing a 747 jet, or the politician's making a speech. In the laboratory again, but more recently in human patients with constipation, rather than cats, emotional arousal has been found associated with similar strong and sustained contractions of the sigmoid colon.3 These responses are not limited to motility changes. The secretions of the gut may be called upon to wash away actual or symbolic noxious agents during the course of vomiting and diarrhea. Even more interesting is the curious behavior of the sea cucumber, which defends itself against other hungry marine animals by extruding its intestinal tract, sloughing it off, and leaving it suspended in the water as an appeasement to the marauder, while the would-be prey crawls off to a safe place and generates a new gut. This most complex pattern of defense has few similarities to known reactions in higher animals, but it must involve rapid autolysis, presumably by endogenous proteolytic enzymes, here abruptly activated in a fantastic adaptive response. Since such enzymes are found in pancreatic juice, could such a response be a trigger mechanism in acute pancreatitis? Could other enzymes, APRIL 1978 • VOL 19. NO 4
found in the cytoplasmic granules of polynuclear leukocytes and the mechanisms of clotting and fibrinolysis, at times initiate the tissue damage in ulcerative colitis or Crohn's disease? All we can say is that it is conceivable. Certainly, with the bulk of experimental studies on stress reactions in the gut still directed at motility alone, many adaptive reaction patterns which could have been passed down to us in the course of evolution must still remain unexplored. Organ language In human patients, we see other phenomena which seem uncharacteristic of coping behavior and unlikely to assist adaptation in the wild state of nature, but which serve to induce protective behavior in others (most often in parents or physicians) and thus acquire survival value. Almost any functional disorder of the gut may be involved, if the individual has learned by trial and error that it elicits the desired response in a protective figure. This "visceral learning" of complex patterns of goal-seeking behavior, probably originating in infancy, has been proposed as a determinant of the pattern of bodily reactions characteristic of a given individual during stress in adult life. This "organ language" may have been learned by the child who discovered that certain symptoms of his, which called forth a tender, loving reaction on the part of his mother, resolved then-painful conflicts over feeding, toilet training, or other imposed discipline. Thus, the phenomena of secondary gain have been speculatively linked to the neurophysiology of reward, or goal-seeking behavior. Although the direct evidence for operant conditioning of
intestinal functions in experimental animals is still fragmentary ,4 the translation of these principles to the therapeutics of human bowel disorders (biofeedback) is already showing promise. What is the relationship of these phenomena to the total scope of illness in man? Many have viewed the psychosomatic disorders of the gut as a specific category of disease, separable by defined personality characteristics or by physiologic parameters from the range of "normal" reactions. Recently, elegant studies by Snape et al s have yielded evidence of a specific pattern of myoelectric activity in the colons of patients with the irritable bowel syndrome. This suggests an analogy to the cerebral dysrhythmia of idiopathic epilepsy-but is the pattern innate or acquired? Can this pattern be a "learned" response to stress? I think these are reasonable questions, for we know that clinically similar reactions (dysphagia, vomiting, constipation, diarrhea) occur transiently under stress in a much larger number of individuals who consider themselves normal and thus never take the problem to their physicians. In extended studies with laboratory colleagues on human distal colonic function under stress, I was unable to distinguish objectively the bodily changes in the patients from those in normal volunteers. Furthermore, disorders of this kind often are part of the total experience of illness to which clear-cut structural lesions contribute. We should abandon the either-or approach ("functional" versus "organic") and ask ourselves how much ofeach is involved in the total picture. Let me cite two illustrations of the importance of this principle. • During World War II, a middle101
~ Weiss-English ~
Symposium
aged woman was admitted to the hospital with a one-week history of intractable vomiting. which had begun within hours after word had come of the death of her son in battle. Prior to this. she had had no digestive symptoms. The vomiting subsided during her five days in the hospital. and she was well for many months thereafter with nothing but supportive psychotherapy. But on the day of her discharge. a GI series revealed a constricting lesion of the gastric antrum. a typical carcinoma. for which she refused to undergo surgery. • At a major cancer center. a follOW-Up study was made of all the patients who were free of disease and physically fit five years or more after abdominoperineal resection for cancer of the rectum-the classic goal of "five-year cure." About two thirds of these patients had nevertheless been unable, because of difficulties in psychosocial adjustment and attendant affective disorders, to return to work or to full household duties.6 I cannot accept these disorders as diseases sui generis, but regard them as an aspect of all illness. the relief of which is often essential if the patient is to return to productive life. In this view, their importance to the planning and the overall cost of health care is very large. Costly disorders In the past, we have recognized that disorders chiefly of psychosocial origin account for 30% to 60% of all digestive illness seen in physicians' offices, and we have calculated that in 1972, digestive diseases were costing the nation $16 billion per year.' Until 1966, we had a "market economy" system of health care, based on supply and demand.
Thus, we could feel right when we had done our best for some of these patients in clinic settings, and then expended large amounts of office time on others like them who, in paying our fees, were using their private resources for private purposes. Particularly with respect to the treatment of the psychosomatic factors in illness, access to care by different economic groups has been distinctly unequal, despite our best efforts. During the 30 years that we have been acting on the insights provided by Weiss and English's landmark publication,8 we have also seen the increasing importance of third-party payers in supporting the total cost of health services. The result is that even now, though we have yet to enact some form of comprehensive national health insurance, we must consider that the decision to treat any person's illness affects in some measure the cost and the availability of health services to the nation as a whole. The public interest is clearly involved, and ceilings and priorities in the use of dollars and manpower will inevitably be set. The public will clearly ask what priority should be assigned to the relief of non-lifethreatening conditions which reflect various degrees of intolerance of the stresses and strains of ordinary living. But if we recognize that psychosomatic factors playa part in all illness and are not uniquely the problems of a neurotic minority, what emphasis should be placed, in any rationing of medical services, on this humanistic aspect of medicine? How, indeed, can we measure its benefits? There are many who would wish us, as physicians, to deny any obligation to deal with social stress, to leave this aspect of our patients' problems to the clergy and to social
agencies, and to limit our attention to ailments definable and treatable in physical or chemical terms. We don't need to imagine the consequences of such a policy, for, to a considerable degree, it is practiced today by many contemporary physicians whose education has been chiefly influenced by reductionistic biology. The policy is visible in the haste with which some hospital residents pass over the details of the medical history, not hearing the patient's main complaint, to focus on the numbers printed out by the AutoAnalyzer. The policy is expressed in terms of expensive laboratory studies, complaints by patients that their doctors don't take time to talk to them, clinic shopping, resort to quackery, and skyrocketing rates for malpractice insurance. Yet despite their disappointments, patients keep coming primarily to their personal physicians to express their bodily complaints, rather than first seeking s0cial solutions for recognized sources of anxiety. I will insist that psychosomatic factors have a significant influence on the mortality from various diseases, such as hypertensive disease, myocardial infarction, duodenal ulcer, and ulcerative colitis; but I believe their medical and economic impact is measurable chiefly in terms of morbidity, with the loss of time from work, and the secondary social consequences of illness among responsible adults, such as the malnutrition and truancy of their children. In a celebrated study of medical care at a distinguished university medical center, half the patients were considered to be "disabled" by psychological problems at the time of discharge from the hospital. Functional disorders of the gut, we are told by one of our PSYCHOSOMATICS
largest insurance companies, vie with the common cold for first place on the list of causes of industrial absenteeism due to illness. It is not possible to estimate, from the figures so far recorded for each major category of illness, how much of the total national bill for health services is attributable to the care of psychosomatic disorders. We can only say that there are many such patients, that they take a great deal of the physician's time, and that the physician's time is a scarce and costly commodity. In trying to predict future costs in terms of money and manpower, we can study the trends in psychiatric services in general, while prepaid health insurance plans have enlarged, multiplied, and provided more comprehensive benefits. According to a recent authoritative study,9 the estimated number of episodes of outpatient mental health care rose from 379,000 in 1955 to nearly 1.8 million in 1968. Utilization of such services tends to rise rapidly on their inclusion in programs of prepaid health care. We can confidently expect that the care of psychosomatic disorders will loom large in our reckoning of the cost, in money and manpower, of comprehensive national health insurance in the U.S. Yet there is evidence that it is more economical to provide services for psychosocial problems than to withhold them. For a group of patients served by a prepaid health plan in an eastern city, the decision to provide liberal access to ambulatory psychiatric services led to a marked drop in utilization of other clinical and laboratory services and a reduction in overall costs of the plan, even though the expense for psychiatric care rose to 11% of all physicians' fees and to 28% of all physicians' APRIL 1978 • VOL 19· NO 4
fees in the nonsurgical category.1O Dealing with stress disorders On the ground of both social necessity and of economic wisdom, the effort to deal constructively with stress-related disorders makes sense; but how are we going to handle the larger load under national health insurance? How can we reduce costs and provide equitable access to our services for all those who need us? I cannot believe that we as professionals can simply sleep fewer hours at night, or persuade our patients to talk faster, or tolerate the "dispensary" model of mass administration of tranquilizers to chronically complaining but little-studied patients. I do believe, on the other hand, that there are many ways in which we can better husband our working time and distribute our services, and that these deserve to be tested critically. First of all, there is teamwork. General physicians can learn much from the experience of psychiatrists, who have extended their services by working in mental health centers with clinical psychologists, nurses, social workers, and lower level health professionals. In rural practice, visiting nurse associations and community social agencies give valuable help to people who must tolerate psychosocial stress. These precedents can be adapted easily to the management of runof-the-mill medical ambulatory patients with initial physical complaints, if we insist that: • The physician whom the patient has chosen must demonstrate personal knowledge of and concern for the psychosocial aspects of the illness, and willingness to participate in their management. • The patient must be aware that his or her physician is in regular
coinmunication with the other professionals seeking to help him or her, has digested their findings, and is to be held fully accountable for the overall result. Under these circumstances, both the physician and the patient will be reassured that nothing important will fall between the chairs. The advantages to be gained by treating a concurrent organic process will be fully realized. The extraordinary power of the personal doctor-patient relationship will not be weakened if the physician plays his or her role and uses his or her authority wisely. The physician should see the patient first, however briefly, and introduce the others as helpers in meeting the patient's needs. The physician should be the only one to attempt overall formulations of the illness to the patient, and answer the patient's questions about the outlook. The roles of the separate characters in this office scenario will have to vary with the attitudes and reactions of the patient; some patients will more readily accept the services of lower level professionals than will others. With time, many patients may develop such a transference to the assistant that the role of the physician, in the eye of the patient, becomes that ofconsultant. This is a far cry from the total delegation of these problems to other professionals. Questionnaires Second, I urge the liberal use of written communications. Beginning with the Cornell Medical Index, I have been impressed with the capability of most patients to give honest and meaningful answers to health questionnaires, thus enabling me to focus better on sig203
~ Weiss-English ~
nificant aspects of the history. The filling out of the questionnaire is seen as a response to a personal request of the physician (rather than an institutional practice), and does not replace the direct interview-style history. The inclusion of questions on psychosocial problems clearly expresses the physician's concern for this area of functioning, and the inquiry moves ahead faster. Third, we need to make the fullest possible use of biological alternatives to psychotherapy, wherever rational and appropriate. The pharmacologic relief of depression, the reinforcement of behavioral change by peer-group pressures, and the growing potential of behavioral methods such as aversive therapy and biofeedback are all needed-both for their intrinsic effectiveness and for the economies they can offer in the use of professional services. The ideas I have just recited include nothing new; on the other hand, the value ofsome of the items may be judged controversial. What is needed most, is much more extensive experimentation to determine the true effects of these measures. For example, even with respect to the operation of mental health centers, I have found no convincing experimental data on the effectiveness and the cost-benefit evaluation of the team approach. We need controlled experiments in the delivery of this kind of health care.
Reducing the problem Beyond the methods by which we may care for psychosocial factors in
developed illness, the magnitude of the problem ought to be reducible to some extent by preventive measures. We can point to the home and the working place as the principal origins of the psychosocial stresses we see in our patients. Programs on sex education, family planning, marital counseling, personnel management, day care for children, and assistance to the elderly are all of potential value in diminishing the frequency of stress-related disorders. II Through programs on health education in the schools, every young person should become aware of the range of bodily adaptations to stress and their relationships to the occurrence and the patterns of illness. This ought to go far in preventing secondary anxieties and fears of catastrophic illness when stressrelated symptoms arise in later life, as well as in helping the patient become more receptive to the physician's explanations. To recapitulate, I have suggested that the psychosocial factors in digestive disorders are important among the humanistic aspects of medicine, yet are patterned after biologic mechanisms of adaptation which originated far back in evolutionary time. They are even more common in the repertoire of human adaptation than is indicated by their high prevalence among our patients. Their rational and effective management, in a system of health care promising equal access to all who require services, will place large and increasing strains on that system. To minimize these, while striving for quality and sensitivity of care, will demand innova-
Dr. Almy is Third Century Professor of Medicine, Dartmouth Medical School. Reprint requests to Dr. Almy there, Hanover, NH 03755. APRIL 1978 • VOL 19 • NO 4
Symposium
tive cost-conscious practices now only dimly perceived, with the primary care physician and allied health professionals as the principal effectors. At the same time, it should be emphasized that a more soundly based strategy of management will require much more fundamental research. Clinical investigators with interdisciplinary training can carry our understanding of integrative processes beyond current concepts of neurohumoral mediation, beyond motor and secretory responses of the end organ, to adaptive changes in intracellular enzymes, intermediate metabolism, and immunologic phenomena. To put such diverse elements together in the service of troubled human beings would be the fulfillment of one of our greatest hopes for medicine in our time. 0 REFERENCES 1. WoK 00, Almy TP: Experimental observations on cardiospasm in man. GastroenterolOgy 13:401,1949. 2. Cannon WB: The movements ot the intestines studied by means of the roentgen rays. Am J Physio18:251 , 1902. 3. Almy TP: Experimental studies on the irritable colon. Am J Mad 10:60, t951. 4. Miller NE: Effect of learning on gastrointestinal functions. Clin GastroenteroI8:533-545, t977. 5. Snape WJ Jr, Carlson GM, Cohen S: Colonic myoelectric activity in the irritable bowel syndrome. GastroenterolOgy 70:326-330, 1976. 6. Sutherland AM, Orbach CEo Dyk RB. et al: The psychological impact of cancer and cancer surgery. I. Adaptation to the dry colostomy: preliminary report and summary of findings. Cancer 5:857-872, t952. 7. Almy TP: The law, the institute, and the $t6 billion heartburn (editorial). GastroenterolOgy 88:t52-156, t974. 8. Weiss E. English OS: Psychosomatic Madicine, ed 1. Philadelphia, WB Saunders, 1943. 9. Reed LS. Myers ES, Scheidemandel PL: Heaffh Insurance and Psychiatric Care: Utilization and Cost. Washington, DC, The American Psychiatric Association, 1972, p 28. 10. Reed LS: Coverage and Utilization of Care for Mental Conditions Under Heaffh InsuranceVarious Studies. 1973-74. Washington, DC, The American Psychiatric Association, 1975. 1t Groen JJ: The challenge ot the future: The prevention of psychosomatic disorders. Psychother Psychosom 23:283, t974.