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Psychosomatic Medicine

Psychosomatic Medicine
Michael Blumenfield, MD
The Sidney E. Frank Distinguished Professor of Psychiatry
Professor of Psychiatry, Medicine & Surgery
Behavioral Health Center
New York Medical College
Director of Consultation-Liaison Psychiatry
Department of Psychiatry
Behavioral Health Center
Valhalla, New York

James J. Strain, MD
Professor of Psychiatry
Former Director of Behavioral
Medicine and Consultation/Liaison Psychiatry
Mount Sinai School of Medicine
Attending Psychiatrist
Mount Sinai Hospital
New York, New York

Executive Editor: Charles W. Mitchell


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2006 by LIPPINCOTT WILLIAMS & WILKINS, a Wolters Kluwer business
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Library of Congress Cataloging-in-Publication Data


Psychosomatic medicine / [edited by] Michael Blumenfield, James J. Strain.
p. ; cm.
Includes bibliographical references and index.
ISBN 0-7817-6046-1 (case : alk. paper)
1. Medicine, Psychosomatic. I. Blumenfield, Michael. II. Strain.
James J., 1933- . III. Title.
[DNLM: 1. Psychosomatic Medicine. WM 90 P9751 2006] RC49.P822 2006
616.0019dc22
2006007919

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Dedicated to my parents, the late Clara and Dr. Abner Blumenfield, who provided me with
confidence and encouragement to pursue a career in medicine; and to my wife and friend
Dr. Susan Blumenfield, who has supported and shared my many projects throughout the years,
not the least of which have been our amazing children and wonderful grandchildren.
Michael Blumenfield, MD

Dedicated to my wife, Dr. Gladys Witt Strain, for her steadfast and loving support over the years;
to my sons Drs. Jay, Jeffrey, and Jamie Strain, who have contributed to my academic efforts; and
to Mrs. Cynthia Green Colin, who has been generous, a true friend, and a collaborator for
consultation-liaison psychiatry and the electronic medical record.
James J. Strain, MD

Foreword
In June 2005, the American Board of Psychiatry and Neurology administered the first subspecialty examination in psychosomatic medicine. This marked the culmination of the evolution of an important aspect of psychiatry that has its roots predating and including the work
of a young neurologist by the name of Sigmund Freud, running through mid-20th-century
American psychiatry, and reaching into the biomedical genetic explosionthe decade of the
brainof the late 20th century (sponsored by the National Institutes of Mental Health).
Well-trained psychiatrists who have completed training since the 1940s have learned how to
work alongside physician colleagues in the medical/surgical setting.
After the Cocoanut Grove fire in Boston, psychiatric understanding about grief and bereavement emerged in the 1940s. Interestingly, the first antidepressant, iproniazid, a monoamine oxidase inhibitor, was discovered in the medical setting in the 1950s by serendipity. It was noted
that this drug, which was being used to treat tuberculosis, elevated the mood of many patients.
In the 1960s, many psychiatry programs with federal funding established consultation-liaison
(C-L) services that supported psychiatrists working at the bedside with internists and surgeons.
Many departmental chairmen and deans of medical schools began their early academic careers
in such clinical programs. It was in this atmosphere that Engels biopsychosocial model, which
included a psychoanalytic underpinning, was born. As neuroscience research became a priority
of the National Institutes of Mental Health in the 1970s and 1980s, the working relationship between psychiatrists and their medical colleagues in the hospital setting became forged. They
shared clinical problems and collaborated on research projects in the intensive care unit, oncology ward, dialysis unit, and burn center, as well as on the neurosurgical floor as brain imaging
and positron emission tomography scans brought forth new information that had to be correlated with psychiatric observations. In the 1990s, the AIDS epidemic, in presenting devastating
medical and psychiatric problems, once again demonstrated the value of having psychiatrists
who could comfortably and skillfully work at the interface of these two specialties.
As we move into the 21st century, we see great advances in the treatment of cancer, heart
disease, and many other illnesses, along with high-tech diagnostic and surgical techniques
that have literally changed the face of medicine. At the same time, we have made tremendous
strides in the treatment of mental illness with a new generation of psychotropic medicationsthe atypical antipsychoticsand new psychotherapy approaches. Evidence-based
medical research will allow us to redefine some of our most important diagnostic entities in
the upcoming DSM-V.
Once again, frontline medicine and updated psychiatry meet at the bedside on the medical
and surgical units of the modern hospital. Regardless of whether they are called C-L psychiatrists or psychiatrist subspecialists in the newly named field of psychosomatic medicine, they
have found their place at the interface of medicine and psychiatry.
Because this is the time of the official birth of the new subspecialty of psychosomatic medicine, one might expect new textbooks to emerge on the scene. Drs. Blumenfield and Strain
have brought together leaders and experts in each of the wide range of topics that comprise
this rich field of study and practice. The names of the authors include chairmen of departments, directors of C-L psychiatry services, accomplished researchers, and renowned clinicians. The inclusion of some junior faculty and fellows as coauthors reflects the tradition of
mentorship and teaching, which is a most important aspect of this discipline. The 51 chapters
not only explore in depth the topics of medical and psychiatric conditions encountered by
specialists in psychosomatic medicine, but they also provide up-to-date information on
ethics, forensics, pain and palliative care, death and dying, sexuality, pregnancy, evidencebased medicine, outcomes and costs, genetics, brain imaging, and medical informatics. An
Copyright 2006 by Lippincott Williams & Wilkins. Psychosomatic Medicine, by Michael Blumenfield and James J. Strain.

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FOREWORD

important theme of this book is the problem of psychiatric diagnosis in the medical setting
and the need for a diagnostic conceptual framework that, in some cases, views mental illnesses as systemic illnesses (e.g., depression and its effects on coronary artery disease, cerebral vascular accidents, and diabetes mellitus). The need for an electronic medical record has
been echoed by the National Institute of Science. This book provides examples of such programs that can be employed in this new subspecialty of medicine.
This is not an ordinary textbook. Not only does the content reflect the up-to-date evidence-based literature and expert opinions on theory and practice, but it also includes a DVD,
which makes it a book of its time. On the DVD, there is an electronic version of the complete
text, as well as references that are completely searchable. There are also PowerPoint slides for
most of the chapters, which enable lectures to be given using the material in the text. There
are questions and answers that can also be used for teaching. These components make this
volume a unique learning tool for the promulgation of this newest subspecialty of psychiatry.
I have known the editors for many years. Dr. Strain is one of the pioneers in C-L psychiatry, and his three earlier books are classics in the C-L field. While at Montifiore Hospital and
most recently at Mount Sinai Hospital in New York City, he trained many of the leaders in this
field. He has lectured around the world, led a multinational research project, and pioneered
the development of an electronic database and an ongoing updated literature compendium for
C-L psychiatry. Dr. Blumenfield has taught residents and medical students at Downstate Medical College and New York Medical College in Valhalla, where he is Director of ConsultationLiaison Psychiatry. He has written books on burn and trauma, as well as a guide for C-L psychiatry. He has lectured on disaster psychiatry and on the psychiatric aspects of terrorism.
More recently, he was elected Speaker of the Assembly of the American Psychiatry Association. Both editors care a great deal about the importance of providing the best possible psychiatric care for patients in the medical/surgical setting.
I share their concern, and I am pleased to write the foreword to this book.
Herbert Pardes, MD
Dr. Pardes is President and Chief Executive Officer of New York-Presbyterian Hospital. He
was Dean and Former Chairman of the Department of Psychiatry of Columbia College of
Physicians and Surgeons. He served as Director of the National Institute of Mental Health and
is a past president of the American Psychiatric Association.

Copyright 2006 by Lippincott Williams & Wilkins. Psychosomatic Medicine, by Michael Blumenfield and James J. Strain.

Prologue
Psychosomatic Medicine examines the definition, constructs, and dilemmas that confront professionals working at the interface of medicine and psychiatry, psychosomatic medicine, and
consultation-liaison psychiatry. It is intended to define key problems and advise methods of
diagnosis and treatment, and to adumbrate where the field needs to develop in the 21st century to fulfill its mission. Accompanying the book is a DVD with searchable references, PowerPoint lectures, questions and answers for the reader, and other clinical work and materials
for teaching. This includes trial software to enhance documentation of patient encounters,
pertinent literature citations from experts in addition to those listed at the end of each chapter, and an innovative method to assess medical students on clerkships in regard to their clinical learning experiences. These cutting edge technologies are an example of the kinds of
advances that are hoped for in the 21st century.
An important theme throughout the book is the dilemma of diagnostic accuracy: Diagnosis remains the bte noire of psychosomatic medicine. Even the name psychosomatic medicine contributes to the confusion in that it could refer to a patient with (a) physical illness
that affects mental thoughts and feelings (e.g., mastectomy and its mental aftermath); (b) a
psychiatric disorder that occurs in a medically ill patient (e.g., bipolar disorder in a patient
with an acute myocardial infarction); (c) a psychological reaction to the use of medical, psychiatric medications, or drugdrug interactions; (d) the precipitation of a physiological
process by a mental eventpsychosomatic (e.g., a stressor); and (e) psychiatric symptoms
from medical illnessessomatopsychic phenomenon (e.g., delirium, depressive disorders
from visceral neoplasia).
So many clinical and research opportunities prevail under the psychosomatic medicine
rubric that it remains a diverse and noninstructive name. It does not involve one cohort of patients, e.g., older persons or children, but rather it involves the medically/surgically ill who
are in need of psychological care. This, however, does not give insight to the process that embodies psychosomatic medicine. The processes of psychotherapy, psychopharmacology, and
psychoanalysis are much easier to understand than the process in psychosomatic medicine.
Although the definition of psychosomatic medicine may be elusive and encompasses a vast
domain of possibilities, it can best be described as the subspecialty of psychiatry that focuses
on medical and psychiatric comorbidity.
In a sense, this is the dilemmajoining two major disciplines, two pharmacopoeias, two
medical care settings, and two sets of caregivers. It challenges diagnostic accuracy and confronts physicians with cases in which no current medically explained symptoms exist (e.g.,
Briquets syndrome, fibromyalgia, chronic fatigue syndrome).
Because psychosomatic medicine has a central focus on patients with somatic problems,
disorders, and diseases, it involves the combination and/or interaction of somatic and psychic
phenomenon in a matrix that at times defies definition. It reignites the centuries-old dilemma
of mind and body: Is it somatic, the psychic, both, or a new entity divined by an amalgamation of the two?
As is seen in several chapters in this book, the questions remain as to how clinical depressive disorders are diagnosed, and how accurate (valid) these diagnoses are considering they
rely on measures that by and large have been developed for pure psychiatric states uncontaminated by physical disorders and their array of physical symptoms (e.g., fatigue, insomnia,
anorexia, diminished libido)?
It is apparent that an atheoretical conceptual framework that ignores or does not have
available a mechanism-based or disease/disorder-based etiology will lead to uncertainty, and

Copyright 2006 by Lippincott Williams & Wilkins. Psychosomatic Medicine, by Michael Blumenfield and James J. Strain.

ix

PROLOGUE

often to under- or overreporting of diagnostic entities (DSM-IV stressed reliability over validity). McHugh and Markova underscore the shortcomings of the biopsychosocial model. Several authors in this book suggest that without a subjective component, a valid psychiatric diagnosis in the medical setting cannot be made. The vegetative signs and symptoms that can
emanate from physical illness, medication, drugdrug interactions, physical treatment, and
trauma cannot be easily filtered out from those that are psychological induced in such disorders as depression, anxiety, and somatoform disorders. Whether it is the pregnant patient
(and pregnancy is not a medical illness) or pain, it is difficult or impossible to interpret the
signs and symptoms and their attribution.
It is anticipated that in the 21st century the issue of diagnosis will move well ahead of its
current dilemma. Berrios presents a thoughtful discussion of the place of medically unexplained symptoms with an historical perspective and an eye toward the future. Where do such
symptom states lie, and what will happen to them in the unfolding of this century? He breaks
new ground with his primordial soup as the elixir for new diagnostic entities. Gallagher, in
his exposition of pain, also talks about the soup that needs to be differentiated: Diagnoses
need to be made with more refined instruments. Some remain in a no mans landsomatic
or psychologicalbecause we do not have the technology to measure physical changes
organic mechanismsthat are beyond our current instrumentality.
One is reminded of the not too distant finding of Helicobacter pylorus as an etiologic agent
in some forms of gastric ulcer formation. This leaves disorders in an uncertain space that, too
often by default, places them in a psychiatric lexicon. Will fibromyalgia and chronic fatigue
syndrome give way to more microdiagnoses in time and emerge out of the primordial soup
with the use of sensitive measurement tools? Will they enter the psychiatric lexicon of the
American Psychiatric Association? Are the somatoform disorders only labeled psychiatric as
a way station during the 21st century until we can find their H. pylorus?
Barsky describes hyperacusis in hypochondriacal patients, a hyperawareness or hypersensitivity that could well be the basis for a different wiring system than had by most persons,
so that body sensations are registered as aberrant and exaggerated by them, but ignored or
only momentarily noticed by most others.
Such thinking may liberate the patients and the scientific world from constructs that are restrictive and by default place somatic symptoms in psychiatry, while their mechanism of causation lies indelibly in an organic sphere (e.g., general paresis). In a similar vein, Fletcher
foreshadows the future prospects for imaging. Although he takes the reader through a demanding basic course in physics, one begins to understand how imaging and its increasing
sensitivity may dawn a new understanding of the origin of the symptoms that remain neither
fish nor foul. Berrios and Fletcher make some complicated technical abstractions, but they
suggest important pathways for the 21st century and what our fund of knowledge may encompass in this ensuing centurythat is, what the psychiatrist in psychosomatic medicine
may have to learn. They are a long step ahead of our current thinking, and we are grateful.
In another dimension, Chapter 6 points out the need for innovative assessment measures
to cope with the double burden of medically induced and psychiatric symptomatology. Even
the Hospital and Anxiety Scale does not adequately deal with symptom attribution for psychiatric decision making in the medically ill. There is a critical need for a refinement in our
diagnostic instruments to ferret out somatic versus psychological origin of symptoms if they
are to be employed in an algorithm for a reliable and valid assignment of diagnosis.
This is further complicated in that psychiatric illnesses such as major depression will increasingly be considered as systemic diseasesaffecting and interacting with the somaas
articulated in Chapter 5. Major depressive disorders, via stress mechanisms, impact platelet
activity and other mechanisms that can further complicate cardiovascular disease and enhance morbidity and mortality. This dictates that patients with a myocardial infarction need
psychological assessment, and it probably should have occurred when the illness was just
coronary artery disease. As we go forward in this century, more psychiatric disorders may be
seen as systemic illnesses that must be evaluated and treated with the same enthusiasm as the
physical disorder.
From a different perspective, there is a need for an electronic health record for clinical documentation of medical and psychiatric comorbidity where data can be entered at the patients
Copyright 2006 by Lippincott Williams & Wilkins. Psychosomatic Medicine, by Michael Blumenfield and James J. Strain.

PROLOGUE

side. This is a goal of our near future and in consort with the governments mandate to hopefully construct such a record within the next 5 years. With 6,000 to 7,000 papers published in
science every day, there is an essential need for the physician to have methods to manage this
overwhelming database. The references alone in this volumes chapters have been put on a
DVD with a search engine so the hundreds of studies cited can be easily perused for readers
to develop their own clinical and teaching literature database. Surely, an important advance in
the 21st century will be the computerized medical record management for patients with medical and psychiatric comorbidity, carefully collating both the medical and the psychiatric clinical information. In addition, data and literature management schemes will be routine accessories to the physicians armatarium.
Finally, psychosomatic medicine in its role as teacher is in a most important position to
affect and contribute to translational medicineexpediting findings from the bench to the
bedside. In fact, psychosomatic medicine must translate in two ways: teaching physicians in
medicine and surgery, and teaching psychiatrists. With the first board examination in psychosomatic medicine having taken place in 2005, this newest of psychiatrys subspecialties
has a unique role as teacher both within and outside psychiatry. One purpose of this volume
was to provide the psychosomatic physician with information and materials to assist this pedagogic process as it moves forward. To this end, not only does the teacher have the typical
hard copy chapter available, but he or she also has available, in many cases, a PowerPoint lecture, significant questions and answers, a method of documenting clinical information, and a
comprehensive multiedited literature database. These tools should be helpful in effecting
translational medicine within and between specialties.
As the 21st century unfolds, there will be more of an amalgamation of medicine and psychiatry. One example, as said previously, is the emergence of depression as a systematic disease affecting mind and body. How will anxiety be regarded as time and studies advance? As
reported in the Smith chapter, tools to examine case complexity and predict resource use (e.g.,
INTERNO, COMPRI) will allow early admission screening for patients who will need extra
resources to decrease hospital length of stay and foster more optimal outcomes. This work has
been pioneered by Huyse. Evidenced-based medicine will flourish. The study and understanding of genetics will assist in the tailoring of interventions and early identification of carriers of disease to assist them in the decision-making process of reproduction. Furthermore,
globalization of ideas and tools using the Internet will permit the distribution of new tools
and approaches throughout the 21st century to all countries, hospitals, and interested physicians to enhance psychological care of the medically ill.
James J. Strain, MD
Michael Blumenfield, MD
Spring 2006

Copyright 2006 by Lippincott Williams & Wilkins. Psychosomatic Medicine, by Michael Blumenfield and James J. Strain.

xi

Acknowledgments
The editors would like to gratefully acknowledge the many people who have made this book
a reality. We are so appreciative of the nearly 100 contributors to all the components of this
book. The depth of their knowledge and dedication to their specialties is why we are so proud
to have them as colleagues.
There are many people at Lippincott Williams & Wilkins who have done their job with amazing skill and efficiency. There are two whom we would like to single out in particular. Lisa R.
Kairis, senior managing editor, worked closely with us through every stage of this project. We
greatly appreciate her wide range of talents as well as her wonderful temperament and diplomacy.
She made it possible for us to stay on our very tight schedule. Charles W. Mitchell, executive
editor, was present at the birth of the idea for this entire endeavor. It was his understanding of our
vision that brought Lippincott to enthusiastically support all aspects of this book and DVD. They
both have made invaluable contributions to make this a better book. We would also like to thank
Joanne Bowser, senior project manager at Techbooks, for her work in the production of this book.
On a personal level, I (MB) would like to thank my chairman, Joseph T. English and vice
chair, Neil Zolkind for their continued support of my activities in the Department of Psychiatry at New York Medical College. I also would like to acknowledge my many colleagues as
well as residents, students, and support staff with whom I work closely every day. The generous donation of the late Sidney E. Frank and support of his daughter Cathy Halstead, trustee
of the Sidney E. Frank Foundation, are very meaningful to our department and me in so much
of our professional work. I recall with fondness and appreciation my teacher, the late Franz
Reichsman, who introduced me to psychosomatic medicine, and another mentor, Norman
Levy, who has been my friend and colleague for many years. As always, my inspiration and
behind-the-scenes collaborator has been my wife, Dr. Susan Blumenfield. I acknowledge her
support and that of our children: Jay and Jaclyn, Bob and Kafi and Sharon. I also look forward
to the possibility sometime in the future of our grandchildren Lucy, Leo, and Nia studying
from this textbook and using the DVD in some aspect of their work.
I (JJS) would like to acknowledge the constant support of my wife, Dr. Gladys Witt Strain,
who has enthusiastically endorsed my many projects. I would like to acknowledge my three
sons, Jay, Jeffrey, and Jamie, who have assisted me in my projects in a variety of waysespecially
Jay, who has been a working collaborator since he was 14. I would like to acknowledge Mrs.
Cynthia Green Colin, a trustee of the Mount Sinai Medical Center, who has endorsed the research effort in our Consultation-Liaison Program at Mount Sinai Hospital since 1980, and who
has been enthusiastic that computers could make a real difference in the life of the patient and
medicine. She has been most generous with support from first the Green Fund and currently the
Malcolm Gibbs Foundation, both of New York City. Mrs. Colin has been a true heroine for
consultation-liaison psychiatry. My high school friend, Dr. Thomas Dell, was responsible for my
initially going into medicine. The fellows I have trained have added greatly to my knowledge
and experience. I would also like to acknowledge important earlier teaching from T. George
Bidder (formerly of Case Western Reserve University), especially his interest in and the use of
electroconvulsive therapy in the medically ill. Charles Brenner, of the New York Psychoanalytic
Institute, also was seminal in my understanding of psychoanalytic and psychological mechanisms of coping and the stresses on the individual. These were important to the formulation of
universal stresses encountered by the medically/surgically ill patient. Finally, I have to thank
Marvin Stein (former chair of psychiatry at the Mount Sinai Medical Center) for his many
thoughtful ideas regarding the interface of psychiatry and medicine, and for his providing me a
clinical laboratoryMount Sinai Hospitalin which to develop psychological approaches to the
medically ill and experiment with strategy and tactics of psychiatric care in the medical setting.
Copyright 2006 by Lippincott Williams & Wilkins. Psychosomatic Medicine, by Michael Blumenfield and James J. Strain.

xiii

Contributors
Alan Altman, MD

Michael Blumenfield, MD

Assistant Clinical Professor


Department of Obstetrics, Gynecology, and
Reproductive Biology
Harvard Medical School
Boston, Massachusetts

The Sidney E. Frank Distinguished Professor of


Psychiatry
Professor of Psychiatry, Medicine and Surgery
Behavioral Health Center
New York Medical College
Director of Consultation-Liaison Psychiatry
Department of Psychiatry
Behavioral Health Center
Valhalla, New York

Scott C. Armstrong, MD

Associate Clinical Professor


Department of Psychiatry
Oregon Health and Science University
Portland, Oregon
Medical Director
Tuality Center for Geriatric Psychiatry
Tuality Forest Grove Hospital
Forest Grove, Oregon
Thomas P. Beresford, MD

Soenke Boettger, MD

Clinical Fellow
Psychiatry Service
Department of Psychiatry and Behavioral Sciences
Memorial Sloan-Kettering Cancer Center
New York, New York
William Breitbart, MD

Professor, Director
Laboratory for Clinical Research in Psychiatry
Department of Psychiatry
University of Colorado School of Medicine
Director of Clinical Research
Mental Health Service (116)
Department of Veterans Affairs Medical Center
Denver, Colorado

Professor of Psychiatry
Weill Medical College of Cornell University
Chief, Psychiatry Service
Department of Psychiatry and Behavioral Sciences
Attending Psychiatrist
Pain and Palliative Care Service
Department of Neurology
Memorial Sloan-Kettering Cancer Center
New York, New York

Harvey M. Berman, MD

Harold Bronheim, MD

Clinical Associate Professor


Department of Psychiatry and Behavioral Sciences
New York Medical College
Valhalla, New York
German E. Berrios, BA (Oxford), MD, FRCPsych,
FBPsS, FMedSci

Reader in the Epistemology of Psychiatry


Department of Psychiatry
University of Cambridge
Consultant Neuropsychiatrist
Department of Neuropsychiatry
Addenbrookes Hospital
Cambridge, United Kingdom

Clinical Professor
Department of Psychiatry
Mount Sinai School of Medicine
Attending
Department of Psychiatry
Mount Sinai Hospital
New York, New York
Caroline P. Carney, MD

Associate Professor
Departments of Internal Medicine and Pyschiatry
Research Scientist
Regenstrief Institute
Indiana University School of Medicine
Indianapolis, Indiana

Copyright 2006 by Lippincott Williams & Wilkins. Psychosomatic Medicine, by Michael Blumenfield and James J. Strain.

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CONTRIBUTORS

Michael R. Clark, MD, MPH

Francis Creed, MD, FRCP, FRCPsych, FMedSci

Associate Professor and Director


Chronic Pain Treatment Programs
Department of Psychiatry and Behavioral Sciences
Johns Hopkins Medical Institutions
Baltimore, MD

Professor of Psychological Medicine


Department of Psychiatry
University of Manchester
Manchester Royal Infirmary
Manchester, United Kingdom

Lewis M. Cohen, MD

Robert E. Feinstein, MD

Professor
Department of Psychiatry
Tufts University School of Medicine
Boston, Massachusetts
Director
Renal Palliative Care Institute
Baystate Medical Center
Springfield, Massachusetts

Professor of Psychiatry
Vice Chairman of Clinical Education
University of Colorado Health Sciences Center
Practice Director
Psychiatric Outpatient Department
University of Colorado Hospital
Denver, Colorado
Stephen J. Ferrando, MD

Eric Collins, MD

Assistant Professor of Clinical Psychiatry


Department of Psychiatry
Columbia University College of Physicians and
Surgeons
New York, New York

Professor of Clinical Psychiatry


Vice Chair for Psychosomatic Medicine
The New York-Presbyterian Hospital
Weill Medical College of Cornell University
New York, New York

Eduardo A. Coln, MD

Jennifer M. Finkel, MD

Professor
Department of Psychiatry
University of Minnesota
Vice Chief
Department of Psychiatry
Hennepin County Medical Center
Minneapolis, Minnesota

Assistant Professor of Psychiatry


Mount Sinai Medical Center,
New York, New York

Philip R. Corlett, BA

Post-Graduate Research Student


Brain Mapping Unit
Department of Psychiatry
University of Cambridge
Cambridge, United Kingdom
Monica Kelly Cowles, MD, MS

Psychiatric Research Fellow


Department of Psychiatry and Behavioral Sciences
Emory University School of Medicine
Atlanta, Georgia

Paul C. Fletcher, MRCPsych, PhD

University Lecturer and Wellcome Trust Senior


Research Fellow
Department of Psychiatry
University of Cambridge
Honorary Consultant Psychiatrist
Department of Psychiatry
Addenbrookes Hospital
Cambridge, United Kingdom
Miriam M. Friedlander, MD

Clinical Instructor
Department of Psychiatry and Behavioral Sciences
Memorial Sloan-Kettering Cancer Center
New York, New York
Marc Galanter, MD

Kelly L. Cozza, MD

Assistant Professor
Department of Psychiatry
Uniformed Services University of the Health Sciences
F. Edward Herbert School of Medicine
Bethesda, Maryland
Psychiatrist
Infectious Disease Service
Department of Medicine
Walter Reed Army Medical Center
Washington, District of Columbia

Professor
Department of Psychiatry
New York University School of Medicine
New York, New York
Elizabeth W. Galik, MSN, CRNP

Lecturer
Department of Geriatric and Neuropsychiatry
Johns Hopkins University School of Medicine
Baltimore, Maryland

Copyright 2006 by Lippincott Williams & Wilkins. Psychosomatic Medicine, by Michael Blumenfield and James J. Strain.

CONTRIBUTORS

Rollin M. Gallagher, MD, MPH

Steven E. Hyler, MD

Clinical Professor and Director


The Center for Pain Medicine, Research and Policy
Departments of Psychiatry and Anesthesiology
University of Pennsylvania
Director of Pain Medicine
Departments of Anesthesia and Psychiatry
Philadelphia VA Medical Center
Philadelphia, Pennsylvania

Clinical Professor
Department of Psychiatry
Columbia University
Senior Attending Psychiatrist
St. LukesRoosevelt Hospital Center
New York, New York

Martha Gamboa, MD

Professor
Departments of Neurology and Psychiatry
Albert Einstein College of Medicine
Attending Neurologist
Deputy Director Residency Training, Psychiatry
Departments of Neurology and Psychiatry
Montefiore Medical Center
Bronx, New York

Resident in Training
New York Medical College
Behavioral Health Center
Westchester Medical Center
Valhalla, New York
Evan Goldfischer, MD

Director of Research
Hudson Valley Urology
Poughkeepsie, New York
Stanley Grossman, MD

Clinical Professor
Department of Psychiatry
New York University School of Medicine
New York, New York
Attending
Department of Psychiatry
North Shore University Hospital
Manhasset, New York
Elizabeth Haase, MD

Assistant Clinical Professor


Department of Psychiatry
Columbia Presbyterian Medical Center
New York, New York
Jimmie C. Holland, MD

Attending Psychiatrist
Wayne E. Chapman Chair in Psychiatric Oncology
Department of Psychiatry and Behavioral Sciences
Memorial Sloan-Kettering Cancer Center
New York, New York
Robin Horwitz-Stern, MD

Assistant Professor of Psychiatry and Behavioral


Sciences
New York Medical College
Director of Psychiatry for the AIDS Care Center
Westchester Medical Center
Valhalla, New York
Michael Hudson, MD

Director of Coronary Care Unit


Department of Cardiology
Henry Ford Hospital
Detroit, Michigan

David Myland Kaufman, MD

Susan Kemker, MD

Clinical Assistant Professor


Department of Psychiatry
New York Medical College
Assistant Attending Psychiatrist
Department of Psychiatry
Behavioral Health Center
Westchester Medical Center
Valhalla, New York
Mark W. Ketterer, PhD, APPP

Clinical Professor
Department of Psychiatry and Behavioral
Neuroscience
Wayne State University
Senior Bioscientific Staff
Department of Behavioral Health
Henry Ford Hospital
Detroit, Michigan
Sanjay Khanal, MD

Associate Professor
Department of Medicine
Wayne State University
Director of Interventional Cardiology
Department of Cardiovascular Medicine
Henry Ford Hospital
Detroit, Michigan
David W. Kissane, MD, MPM, FRANZCP

Professor
Department of Psychiatry
Weill Medical College of Cornell University
Chairman and Alfred P. Sloan Chair
Department of Psychiatry and Behavioral Sciences
Memorial Sloan-Kettering Cancer Center
New York, New York

Copyright 2006 by Lippincott Williams & Wilkins. Psychosomatic Medicine, by Michael Blumenfield and James J. Strain.

xvii

xviii

CONTRIBUTORS

Kimberley Klipstein, MD

Mark Loigman, MD

Assistant Professor of Psychiatry


Director of Behavioral Medicine and
Consultation Psychiatry
Mount Sinai Medical Center
New York, New York

Mount Sinai Medical School


New York, New York

Walter Knysz, MD

Director of Consultation-Liaison Psychiatry


Henry Ford Hospital
Detroit, Michigan
Oladipo Kukoyi, MD

Assistant Professor
Departments of Family Medicine and Psychiatry
University of Iowa, Carver College of Medicine
University of Iowa Hospitals and Clinics
Iowa City, Iowa
Lawrence A. Labbate, MD

Professor
Department of Psychiatry and Behavior Sciences
University of Arkansas for Medical Sciences
Deputy ACOS for Mental Health
Mental Health Service
Central Arkansas Veterans Healthcare System
Little Rock, Arkansas
John B. Levine, MD, PhD

Assistant Clinical Professor


Department of Psychiatry
Harvard Medical School
Clinical Assistant in Psychiatry (Child Psychiatry)
Massachusetts General Hospital and Shriners Burns
Hospital
Boston, Massachusetts
Norman B. Levy, MD

Clinical Professor
Department of Psychiatry
SUNY Downstate Medical Center
Director
Department of Psychiatry
Kingsboro Psychiatric Center
Brooklyn, New York
Don R. Lipsitt, MD

Clinical Professor
Department of Psychiatry
Harvard Medical School
Boston, Massachusetts

Kate K. Lund, MSW, PsyD

Clinical Fellow in Psychology


Shriners Burns Hospital
Boston, Massachusetts
Constantine G. Lyketsos, MD, MHS

Professor of Psychiatry and Behavioral Sciences


Johns Hopkins University
Co-Director
Division of Geriatric Psychiatry and
Neuropsychiatry
Johns Hopkins Hospital
Baltimore, Maryland
John S. Lyons, PhD

Professor
Department of Psychiatry and Behavioral Health
Northwestern University, Feinberg School of
Medicine
Chicago, Illinios
Jos R. Maldonado, MRCPsych, MD

Associate Professor and Chief


Medical and Forensic Psychiatry Section
Director
Medical Psychotherapy Clinic
Department of Psychiatry and Behavioral Sciences
Faculty at the Stanford Center for Biomedical
Ethics
Stanford University School of Medicine
Medical Director
Psychosomatic Medicine Service
Chair, Ethics Committee
Stanford University Medical Center
Stanford, California
Eva Albertson Malt, MD, PhD

Medical Advisor
Pfizer Norway
Oslo, Norway
Ulrik Fredrik Malt, MD, PhD

Geoffrey G. Lloyd, MD, FRCPsych

Consultant Psychiatrist
Department of Liaison Psychiatry
The Royal Free Hospital
London, United Kingdom

Professor
University of Oslo
Institutue of Psychiatry
Chief
Department of Psychomatic Medicine
Rikshospitalet University Hospital
Oslo, Norway

Copyright 2006 by Lippincott Williams & Wilkins. Psychosomatic Medicine, by Michael Blumenfield and James J. Strain.

CONTRIBUTORS

Ivana S. Markov, MRCPsych, MD

Cynthia R. Pfeffer, MD

Senior Lecturer in Psychiatry


Department of Psychiatry
University of Hull
Consultant Psychiatrist
Department of Psychological Medicine
Hull Royal Infirmary
Hull, United Kingdom

Professor
Department of Psychiatry
Weill Medical College of Cornell University
Attending Psychiatrist
New York Presbyterian Hospital
White Plains, New York

Paul R. McHugh, MD

Professor of Psychiatry
Department of Psychiatry and Human Behavior
Brown Medical School
Director
Body Dysmorphic Disorder Program
Butler Hospital
Providence, Rhode Island

University Distinguished Service Professor of


Psychiatry
Department of Psychiatry and Behavioral
Sciences
The Johns Hopkins University School of
Medicine
Psychiatrist
Department of Psychiatry and Behavioral
Sciences
Johns Hopkins Hospital
Baltimore, Maryland
David A. Mrazek, MD

Chair
Department of Psychiatry and Psychology
Mayo Clinic
Rochester, Minnesota
Dan-Vy Mui, MD

Assistant Professor
Department of Psychiatry
University of Arkansas for Medical Sciences
Little Rock, Arkansas
Charles B. Nemoroff, MD, PhD

Reunette W. Harris Professor and Chairman


Department of Psychiatry and Behavioral
Sciences
Emory University School of Medicine
Atlanta, Georgia
Russell Noyes, Jr., MD

Emeritus Professor
Department of Psychiatry
University of Iowa Carver College of Medicine
Staff Psychiatrist, Retired
Department of Psychiatry
University of Iowa Hospitals and Clinics
Iowa City, Iowa
Jessica R. Oesterheld, MD

Clinical Associate Professor


Department of Psychiatry
University of Vermont College of Medicine
Burlington, Vermont

Katherine A. Phillips, MD

Kenneth M. Pollock, PhD

Assistant Professor of Psychiatry


Director, The Sexual Health Practice
Department of Psychiatry
New York Medical College
Director of Group Psychotherapy
Department of Psychiatry
Westchester Medical Center
Valhalla, New York
Shannon Poppito, PhD

Clinical Psychologist
Department of Psychiatry and Behavioral Sciences
Memorial Sloan-Kettering Cancer Center
New York, New York
Seema Quraishi, MD

Assistant Professor of Psychiatry


Mount Sinai Medical Center
New York, New York
Peter Rabins, MD, MPH

Professor
Department of Psychiatry and Behavioral Sciences
Johns Hopkins School of Medicine
Baltimore, Maryland
James J. Rasimas, MD

Department of Psychiatry and Psychology


Mayo Clinic
Rochester, Minnesota
Phillip J. Resnick, MD

Professor
Department of Psychiatry
Case School of Medicine
Director
Division of Forensic Psychiatry
University Hospitals of Cleveland
Cleveland, Ohio

Copyright 2006 by Lippincott Williams & Wilkins. Psychosomatic Medicine, by Michael Blumenfield and James J. Strain.

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CONTRIBUTORS

Rosamond Rhodes, PhD

Graeme C. Smith, MD, FRANZCP

Professor and Director of Bioethics Education


Department of Medical Education
Mount Sinai School of Medicine
Professor
Department of Philosophy
The Graduate Center, CUNY
New York, New York

Professor Emeritus
School of Psychology, Psychiatry and Psychological
Medicine
Monash University
Honorary Psychiatrist
Mental Health Program
Southern Health
Monash Medical Centre
Clayton, Victoria, Australia

Robert G. Robinson, MD

Paul W. Penningroth Professor and Head


Department of Psychiatry
University of Iowa
Head
Department of Psychiatry
University of Iowa Hospitals and Clinics
Iowa City, Iowa
Stephen Ross, MD

Assistant Clinical Professor of Psychiatry


Director
Bellevue Dual Diagnosis Training Unit
Associate Director for Education
Division of Alcoholism and Drug Abuse
New York University School of Medicine
New York, New York

Yvette Smolin, MD

Assistant Professor of Psychiatry and Behavioral


Sciences
New York Medical College
Valhalla, New York
Daniel J. Smuckler, MD

Assistant Professor
Department of Psychiatry
Albert Einstein College of Medicine
Associate Director of Residency Training
Department of Psychiatry
Bronx Psychiatric Center
Bronx, New York

Neil B. Sandson, MD

Clinical Assistant Professor


Department of Psychiatry
University of Maryland Medical System
Baltimore, Maryland
Director
Education and Residency Training
Sheppard Pratt Health System
Towson, Maryland

Rene M. Sorrentino, MD

Clinical Assistant in Psychiatry


Department of Psychiatry
Harvard Medical School
Director of Forensic Psychiatry at the ELMHC
Department of Psychiatry
Massachusetts General Hospital
Boston, Massachusetts

Stephen M. Saravay, M.D.

Clinical Professor
Department of Psychiatry
Albert Einstein College of Medicine
Bronx, New York
Chief
Consultation-Liaison Psychiatry
Department of Psychiatry
Long Island Jewish Medical Centera Clinical
Campus of the North
ShoreLong Island Jewish Health System
New Hyde Park, New York

Frederick J. Stoddard, Jr., MD

Ulrich Schnyder, MD

James J. Strain, MD

Professor
Faculty of Medicine
Zurich University
Head
Department of Psychiatry
University Hospital
Zurich, Switzerland

Professor of Psychiatry
Former Director of Behavioral Medicine and
Consultation/Liaison Psychiatry
Mount Sinai School of Medicine
Psychiatrist
Mount Sinai Medical Center
New York, New York

Associate Clinical Professor


Department of Psychiatry
Harvard Medical School
Psychiatrist
Massachusetts General Hospital
Chief of Psychiatry
Shriners Burns Hospital and Massachusetts General
Hospital
Boston, Massachusetts

Copyright 2006 by Lippincott Williams & Wilkins. Psychosomatic Medicine, by Michael Blumenfield and James J. Strain.

CONTRIBUTORS

Jay J. Strain, MD

Maria L.A. Tiamson-Kassab, MD

Assistant Professor of Surgery


Jefferson Medical School
Attending
Albert Einstein Medical Center
Philadelphia, Pennsylvania

Clinical Assistant Professor


Department of Psychiatry and Behavioral Sciences
New York Medical College
Valhalla, New York
Program Manager
Mental Health Care Line
VA Hudson Valley Healthcare System
Castle Point, New York

David A. Straker, DO

Assistant Clinical Professor


Department of Psychiatry
Columbia University
New York, New York
Assistant Attending
Department of Psychiatry
New York Presbyterian Hospital and Long Island
Jewish Medical Center
New Hyde Park, New York

xxi

Courtland Tisdale, BS

Doctoral Student
Division of Psychology
Department of Psychiatry and Behavioral Science
Northwestern University, Feinberg School of Medicine
Chicago, Illinois
Nora Turjanski, MRCPsych

Jon Streltzer, MD

Professor
Department of Psychiatry
John A. Burns School of Medicine
University of Hawaii
Consultant Psychiatrist and Head of Queen Emma
Pain Clinic
Queens Medical Center
Honolulu, Hawaii

Specialist Registrar
Liaison Psychiatry Service
The Royal Free Hospital
London, United Kingdom
Nancy Wiedemer, MSN, CRNP

Pain Management Coordinator


Philadelphia Veterans Medical Center
Philadelphia, Pennsylvania

Stephen P. Sullivan, MD

Gary H. Wynn, MD

Clinical Instructor
Department of Psychiatry
New York Medical College
Attending Physician
Department of Psychiatry
Westchester Medical Center
Valhalla, New York

Assistant Professor
Department of Medicine
Uniformed Services University of the Health Sciences
Bethesda, Maryland
Chief Resident
Psychiatry-Internal Medicine Residency
Departments of Psychiatry and Medicine
Walter Reed Army Medical Center
Washington, District of Columbia

Edward G. Tessier, PharmD, MPH, BCPS

Lecturer
School of Nursing
University of Massachusetts Amherst
Amherst, Massachusetts
Clinical Pharmacist
Department of Pharmacy
Franklin Medical Center
Greenfield, Massachusetts

Sean H. Yutzy, MD

Associate Professor
Department of Psychiatry
University of New Mexico
Albuquerque, New Mexico

Wendy L. Thompson, MD

Professor of Clinical Psychiatry


Department of Psychiatry and Human Behavior
New York Medical College
Director of Education
Department of Psychiatry and Human Behavior
New York Medical College at Westchester Medical
Center
Valhalla, New York
Copyright 2006 by Lippincott Williams & Wilkins. Psychosomatic Medicine, by Michael Blumenfield and James J. Strain.

Contents
Dedication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii
Prologue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ix
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiii
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xv

SECTION
1

I Evolution of Psychosomatic Medicine

Psychosomatic Medicine: History of a New Specialty . . . . . . . . . . . . . . . . . .3


DON R. LIPSITT, MD

An International View of Consult-Liaison Psychiatry . . . . . . . . . . . . . . . . . . .21


GRAEME C. SMITH, MD

SymptomsHistorical Perspective and Effect on Diagnosis . . . . . . . . . . . . . .27


GERMAN E. BERRIOS, BA (OXFORD), MD, FRCPsych, FBPsS, FMedSci
IVANA S. MARKOV, MRCPsych, MD

Diagnostic and Classificatory Dilemmas . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39


PAUL R. M C HUGH, MD
MICHAEL R. CLARK, MD, MPH

DepressionA Systemic Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47


MONICA KELLY COWLES, MD, MS
CHARLES B. NEMEROFF, MD, PhD

Evolution of Measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67


COURTLAND TISDALE, BS
JOHN S. LYONS, PhD

Implications of Culture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81


JON STRELTZER, MD

Forensic Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91


PHILLIP J. RESNICK, MD
RENE M. SORRENTINO, MD

SECTION
9

II Physical Conditions

Cardiovascular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109


MARK W. KETTERER, PhD, APPP
WALTER KNYSZ, MD
SANJAY KHANAL, MD
MICHAEL HUDSON, MD

Copyright 2006 by Lippincott Williams & Wilkins. Psychosomatic Medicine, by Michael Blumenfield and James J. Strain.

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xxiv

CONTENTS

10

Oncology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .121
JIMMIE C. HOLLAND, MD
MIRIAM M. FRIEDLANDER, MD

11

Gastrointestinal Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .145


FRANCIS CREED, MD, FRCP, FRCPsych, FMedSci

12

Renal Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .157


NORMAN B. LEVY, MD
LEWIS M. COHEN, MD
EDWARD G. TESSIER, PharmD, MPH, BCPS

13

Endocrine and Metabolic Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .177


EDUARDO A. COLN, MD

14

Pulmonary Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .193


WENDY L. THOMPSON, MD
STEPHEN P. SULLIVAN, MD

15

Neurological Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .213


DAVID MYLAND KAUFMAN, MD
DANIEL J. SMUCKLER, MD

15A

Parkinson Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .214

15B

Epilepsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .222

15C

Migraine Headaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .231

15D

Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .238

15E

Amyotrophic Lateral Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .244

15F

Creutzfeldt-Jakob Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .249

16

Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .255
ROBERT G. ROBINSON, MD
OLADIPO KUKOYI, MD

17

HIV Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .277


STEPHEN J. FERRANDO, MD
MARIA L.A. TIAMSON-KASSAB, MD

18

Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .297


MARIA L.A. TIAMSON-KASSAB, MD
STEPHEN J. FERRANDO, MD

19

Burn Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .309


FREDERICK J. STODDARD, JR., MD
JOHN B. LEVINE, MD, PhD
KATE K. LUND, MSW, PsyD

20

Physical Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .337


ULRIK FREDRIK MALT, MD, PhD
EVA ALBERTSEN MALT, MD, PhD
ULRICH SCHNYDER, MD
Copyright 2006 by Lippincott Williams & Wilkins. Psychosomatic Medicine, by Michael Blumenfield and James J. Strain.

CONTENTS

21

Surgical Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .357


JOS R. MALDONADO, MRCPsych, MD

22

Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .389
NORA TURJANSKI, MRCPsych
GEOFFREY G. LLOYD, MD, FRCPsych

23

Rheumatoid Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .401


HARVEY M. BERMAN, MD

SECTION
24

III Psychiatric Conditions

Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .411
RUSSELL NOYES, JR., MD
CAROLINE P. CARNEY, MD

25

Suicidality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .433
CYNTHIA R. PFEFFER, MD

26

Alcoholism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .447
THOMAS P. BERESFORD, MD

27

Substance Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .461


STEPHEN ROSS, MD
ERIC COLLINS, MD
MARC GALANTER, MD

28

Delirium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .493
SOENKE BOETTGER, MD
MIRIAM FRIEDLANDER, MD
WILLIAM BREITBART, MD

29

Dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .513
ELIZABETH M. GALIK, MSN, CRNP
PETER RABINS, MD, MPH
CONSTANTINE G. LYKETSOS, MD, MHS

30

Somatization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .537
SEAN H. YUTZY, MD

31

Body Dysmorphic Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .545


KATHARINE A. PHILLIPS, MD

32

Conversion Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .555


ELIZABETH HAASE, MD

33

Hypochondriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .565
JAMES J. STRAIN, MD
MARK LOIGMAN, MD

34

Factitious Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .571


DAVID A. STRAKER, DO
STEVEN E. HYLER, MD

Copyright 2006 by Lippincott Williams & Wilkins. Psychosomatic Medicine, by Michael Blumenfield and James J. Strain.

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CONTENTS

SECTION
35

IV Special Topics

Womens Health Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .581


ROBIN HORWITZ-STERN, MD
YVETTE SMOLIN, MD

36

Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .603
SUSAN KEMKER, MD
MARTHA GAMBOA, MD

37

Sexuality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .631
KENNETH M. POLLOCK, PhD
EVAN GOLDFISCHER, MD
ALAN ALTMAN, MD

38

Death and Dying . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .671


DAVID W. KISSANE, MD, MPM, FRANZCP
SHANNON POPPITO, PhD

39

Pain and Palliative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .695


ROLLIN M. GALLAGHER, MD, MPH
NANCY WIEDEMER, MSN, CRNP

40

Ethical Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .725


ROSAMOND RHODES, PhD
JAMES J. STRAIN, MD

41

Psychotropic Drugs in the Medically Ill . . . . . . . . . . . . . . . . . . . . . . . . . . . . .739


DAN-VY MUI, MD
LAWRENCE A. LABBATE, MD

42

Overview of Drug Interactions in Psychosomatic Medicine . . . . . . . . . . . . .767


KELLY L. COZZA, MD
SCOTT C. ARMSTRONG, MD
JESSICA R. OESTERHELD, MD
NEIL B. SANDSON, MD
GARY H. WYNN, MD

43

Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .801
HAROLD BRONHEIM, MD

44

Psychodynamic Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .817


MICHAEL BLUMENFIELD, MD
JAMES J. STRAIN, MD
STANLEY GROSSMAN, MD

45

Cognitive Behavioral Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .829


JAMES J. STRAIN, MD
KIMBERLEY KLIPSTEIN, MD
SEEMA QURAISHI, MD
JENNIFER M. FINKEL, MD

46

Personality Traits and Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .843


ROBERT E. FEINSTEIN, MD

47

Interventions, Outcomes, and Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .867


STEPHEN M. SARAVAY, MD
Copyright 2006 by Lippincott Williams & Wilkins. Psychosomatic Medicine, by Michael Blumenfield and James J. Strain.

CONTENTS

SECTION
48

V Future Perspectives

Evidence-Based Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .881


ROBERT E. FEINSTEIN, MD

49

Genomic Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .899


DAVID A. MRAZEK, MD
JAMES J. RASIMAS, MD

50

Brain Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .907


PAUL C. FLETCHER, MRCPsych, PhD
PHILIP R. CORLETT, BA

51

Medical Informatics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .919


JAY J. STRAIN, MD

Epilogue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .933
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .935

Copyright 2006 by Lippincott Williams & Wilkins. Psychosomatic Medicine, by Michael Blumenfield and James J. Strain.

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