Are your taxes giving you fits these days? Take a minute to pity your poor accountant. A study reported at the American Psychosomatic Society (APS) here last week by a team from the University of Toronto described 21 "healthy chartered accountants" who were found at tax times to be not only more anxious and depressed, with more sleep disorders, but also with immune functions significantly altered. Concluded the investigators: This suggests "that chronic occupational stress may increase susceptibility to disease."
"The trouble with doctors today," Hippocrates (according to Plato) said around 200 B.C. "is that they separate the soul from the body. They don't recognize that the soul and the body are one."
"Clinicians," says Dr. Donald S. Kornfeld, professor of psychiatry at Columbia University medical school in New York and secretary-treasure of the 42-year-old APS, "have made these observations for thousands of years, and we've struggled to put it all together. Now in the 1980s, we can do what we've never been able to do before."
In other words, because of the new molecular and biochemical knowledge about the relationships of mind and body, physician and psychiatrist can work together on the same disorder, although from different viewpoints, giving a new meaning to the term psychosomatic.
As University of Texas psychologist David Jenkins, a past president of the society, puts it, the bridge is between "groups where you go to talk about cells and receptors and microscopic corners of cell membranes, and other professional groups where they are concerned about patient care and techniques for dealing with patients."
In other words, psychosomatic studies are aimed at finding the link between biology and the patient's behavior.
This is a relatively new goal for this society, which began in the days when the term "psychosomatic disorder" meant something other than it does today. In the 1940s, says Dr. Jules Hirsch, cardiologist and internist at Rockefeller University in New York, "there was the assumption that there was the personality and the disease and the two somehow made each other happen in almost a mystical way." Now the mysticism has been removed and scientists know that behavior, and even perceptions can affect specific brain chemistry and certain physical disorders can produce specific behaviors. The term is now broadened to encompass the interrelationship.
Dr. Marvin Stein, chairman of the psychiatry department at Mount Sinai School of Medicine in New York and the society's outgoing president, recalls that a peptic ulcer, for example, "meant you were a passive-dependent individual and that was somehow involved in your ulcer." That it was, in effect, your fault.
"Now," says Stein, "the position we're taking is that all diseases are, to some extent, psychosomatic. We're not talking about any one disease, and there is no single cause, but there are a variety of factors and you have to consider both the mind and the brain. It doesn't matter if you're talking about schizophrenia or Alzheimer's disease or ulcers or heart attacks or the flu."
"Part of the problem," says Hirsch, who was the chairman of the recent National Institutes of Health consensus development conference on obesity and who will be the 1986 president of the Psychosomatic Society, "is that not just the public but our medical colleagues suffer from a lack of information about this."
Dr. Bernard T. Engel, the society's new president, is the chief of the Laboratory of Behavioral Research of the National Institute on Aging in Baltimore, where next year's conference will be held. "For me," he says, "psychosomatic medicine is the interaction among patient characteristics: The social milieu, learned characteristics and then the signs, symptoms and disease processes themselves . . . It's not a static relationship between the environment because as you learn, you change, and your interactions with the environment change, and these reflect back on how your disorder may express itself within your body."
Some examples presented at the conference:
* A study done at Cornell found significant psychological differences between hypertensive patients with high readings of the kidney enzyme renin in their blood plasma and those hypertensives with normal or low renin. The high renin hypertensives tended to be "more emotionally unstable, suspicious, guilt-prone and tense." Renin levels have not been thought to be significant in essential hypertension, but the study tends to confirm the link of psychological factors to some hypertension cases and suggests that behaviorial interventions in the high renin patients may be particularly beneficial.
* One reason smokers find it so difficult to quit may be the nicotine-stimulation of an assortment of hormones including the brain feel-good peptide beta-endorphin. Endorphins are believed to be the brain's natural opiates. In addition, a new study at Brown University suggests that the stress hormone ACTH is secreted as well. Both ACTH and endorphins are secreted, notes the study, in response to stress and have behavioral effects.
* The beta blocker propranolol, useful as a heart drug and as an anti-migraine medication, has been used widely by public speakers and musicians to prevent stage fright, although it has not been specifically approved for that purpose by the Food and Drug Administration. In an effort to show the drug's anti-anxiety effect on animals, a test not previously done, a team at the Uniformed Services University of the Health Sciences used it on white pigeons who were trained to peck keys to receive their seedy meals -- at the 30th peck. When a white light was on, they got their seeds. With a red light, they got seeds plus an electric shock. They learned to stop pecking on red. But when treated with propanolol they became significantly less likely to care about the shock. Propranolol was twice as effective as another beta blocker with less access to the brain.
* Columbia's Kornfeld is an exponent of clinical-liaison psychiatry, a subspecialty nurtured by the APS, in which a psychiatrist routinely becomes part of a team in general medicine -- for surgical procedures such as mastectomy or amputation or in cardiac cases. As a group they would like to see family practitioners and surgeons more tuned to mental problems and in a presentation based on a paper (and grant proposal) in a forthcoming issue of the society's journal, Psychosomatic Medicine, a training model is described. Family doctors, studies show, see a high percentage of patients with mental problems, estimated from 15 to 50.
Says Kornfeld, "Traditionally you see first- and second-year medical students overflowing with the milk of human kindness. Then four or five years later they turn into overburdened interns, unable to deal with these issues. The milk of human kindess is still there, but he needs someone to help him understand how to apply it in a scientific, but effective and efficient way."
The value of this kind of psychiatric "bedside intervention" was, says Kornfeld, confirmed in a study of a group of geriatric-orthopedic patients with fractured hips. Those with a psychiatrist on the team were able to leave the hospital sooner and were twice as likely as a control group to go home rather than to an institution."
"It is a paradox," said NIA's Engel, "that all the pressures are to get patients out of hospitals yet here, where it has been demonstrated that patients will leave 25 percent sooner, the tendency has been to diminish this kind of contact."