Psychiatry for Physicians
Review of Psychological Aspects of Clinical Medicine. By Stephen Barton Hall, M.D., D.P.M. (Pp. 416.) London H. K. Lewis and Co. 1949; and of Psychosomatic Medicine. By Edward Weiss, M.D., and O. Spurgeon English, M.D. (Pp. 803) Philadelphia and London: W. B. Saunders Company. 1949.
British Medical Journal, 18 March 1950, p. 650
What does the general practitioner and the newly qualified student really need to know about psychological medicine ? This important problem is raised by the appearance of Dr. Barton Hall's book. It is a question that must be frequently discussed in the academic boards of medical schools, but it is very far from settled. There are plenty of people with axes to grind who are likely'to take part in such discussions.
There are, perhaps, some guiding principles which could be considered. One of these is the relative frequency of the conditions the doctor will meet in the course of practice, a second the gravity of the decisions which will be imposed on him, and a third the relative preponderance of established fact and theoretical speculation.
It will hardly be contested that a very large part of the practice both of general practitioners and specialists in nonpsychiatric subjects is made up by patients with some emotional disturbance and without detectable physical abnormality or gross insanity. On this criterion alone, much space should be allotted to the psychoneuroses in any well-balanced textbook of psychological medicine intended for the generality of medical men. If the other criteria are taken into account, however, this is less certainly so. In this section of medicine grave decisions are seldom called for, and what is known for sure stands in startling disproportion to what is so often earnestly taught. It would seem wise for the teacher to provide an account of what we know about the physiology of the emotions and show how this provides a frame of reference for the understanding of neurotic reactions, which would then be described from the clinical standpoint. The main outlines of more highfalutin theory could then be briefly laid out, so that the student could at least appreciate what it was all about when he reads some of the contributions which are made to the medical press.
In other fields of psychiatry the criteria suggested would have a different incidence. Schizophrenia is less common than the neuroses, but it is common enough, and it will often call for decisions of great importance. It is very desirable that the practitioner should be able to recognize it or suspect its presence in the earliest stages, and should then know what to do. The same thing applies to such diseases as general paresis and the dementias, but above all to depressive states in which the acute perception of the family doctor may be the only thing which stands between the patient and a tragic and unnecessary suicide.
In days happily past, but still within recall, the medical student was instructed about psychiatry by sterile lectures and demonstrations on the pathetic and irretrievable inmates of chronic mental hospitals. As Dr. Barton Hall sensibly recognizes, he needs to be provided with guidance about the conditions which he will meet in abundance in the course of ordinary practice. Perhaps Dr. Barton Hall has gone too far, however, and does not tell his readers enough about the more serious conditions they will meet, in distinction to those which are commonest.
One of the most obvious gaps in the physician's bookshelf is that which should be occupied by a short, simple, and sensible work on psychosomatic medicine. A number of efforts have been made to fill this gap, none of them very successful because they were usually too ambitious, and Drs. Weiss and English are the latest authors to try to meet this need. Psychiatrists are accustomed to speak with authority on a subject of which we really know very little. For example, it is often said that there are important psychosomatic aspects to diseases of the heart and blood vessels. By this it is usually meant that emotional factors play a part in their causation. The enhanced liability of the medical man to diseases of this kind is often attributed to a life spent in an atmosphere of rush and anxiety. Anxiety tends to raise the blood pressure and to strain the cardiovascular system. The connexion therefore seems probable enough: it has, however, not been established. The blood pressures of patients who suffer from essential hypertension show (as a rule) little response to the emotional situation of the moment, and the true anxiety neurotic, whose blood pressure fluctuates a good deal, does not seem to be specially liable to vascular disease. An analysis of the past lives, the personalities, and the present circumstances of patients suffering from vascular disease will indeed disclose sources of anxiety, but such sources would be found in any parallel group of patients suffering from other disorders.
We are not even helped in the field of therapy, since it is seldom possible to remove the causes of strain. When the experts suggest that unconscious conflicts and repressed aggression are important causative influences for which some form of deep psychotherapy is required, one may legitimately ask them to prove their case. Treatment along such lines would seem to be no better founded than other methods which the authors of Psychosomatic Medicine properly question, such as dietary restrictions, sympathectomy, and extensive operations on teeth and tonsils. Finally, the psychosomatic aspects of cardiovascular disease are not exhausted by a discussion of their possible emotional causation. The chain of cause and effect must be looked at from the other end, too, and inquiry made into the mental effects of the vascular abnormality. One of the most important deficiencies of Psychosomatic Medicine is that it gives little attention to "somatopsychic" relations.
The authors' main thesis is, however, one that deserves support. The past life, personality, and present circumstances of the patient are important: whatever the condition, the doctor should know how his patient's life is being affected by it. If this is to some extent true in a case of hernia, it is still more so in those disorders which are discussed at length in this book. Valuable lessons can be drawn from the case histories so lavishly provided. These are the most informative part of a work which could otherwise be criticized for excessive diffuseness, for a psychodynamic bias too exclusively psycho-analytic, and for the inclusion of many chapters on psychopathology of limited relevance.