A RT I S S SYMPOSIUM 2 0 1 5

Current Concepts in
Psychosomatic Medicine

SPONSORED BY
Department of Psychiatry, Walter Reed National Military Medical Center
National Intrepid Center of ExcellenceCenter for the Study of Traumatic Stress
Department of Psychiatry, Uniformed Services University

A RTI S S SYMP OSIUM 2 0 1 5

Current Concepts in
Psychosomatic Medicine

SPONSORED BY
Department of Psychiatry, Walter Reed National Military Medical Center
National Intrepid Center of Excellence
Sleep Laboratory Department
Center for the Study of Traumatic Stress
Department of Psychiatry, Uniformed Services University

From the Conference Series:
ARTISS SYMPOSIUM

Current Concepts in Psychosomatic Medicine
Editor’s Note: This transcript has been edited, however, as in most transcripts someerrors may have been missed. The editors are responsible for any errors of content
or editing that remain.

IPD 2016 by Center for the Study of Traumatic Stress
Department of Psychiatry
Uniformed Services University
4301 Jones Bridge Road
Bethesda, MD 20814-4799
First Edition
Mary Lee Dichtel, RN
Senior Medical Editor
Educational Support Management Services, LLC
mlbd.esms@gmail.com
The Editor would like to thank K. Nikki Benevides, MA, Center for the Study ofTraumatic Stress, Department of Psychiatry, USU for her editorial assistance.

Contents
List of Speakers.....................................................................................................i
Welcome...............................................................................................................7
Brett J. Schneider, MD and Russell B. Carr, MD
Introduction to Concepts in Psychosomatic Medicine..................................9
Harold J. Wain, PhD
Psychosomatic Medicine: Paradigms and Populations............................... 15
Thomas N. Wise, MD
The Social Brain in the Ordered and Disordered Minds............................ 25
Alex Martin, PhD
Ethical Concerns in Patients with Complex Medical Surgical and other
Unexplained Medical Issues........................................................................... 33
Edmund G. Howe, III, MD, JD
Essentials for the Psychiatrist Working with Transgender Patients.......... 43
Jack Pula, MD
Psychiatric Concerns in Evaluating Low Back Pain.................................... 55
David E. Gwinn, MD
Critical Role of Psychiatric Evaluation and Support in Orthopaedic
Trauma and Amputee Care............................................................................. 61
Benjamin Potter, MD
WRNMMC Complex Spine Program: A Multidisciplinary Approachto the Surgical Patient...................................................................................... 67
Christopher J. Neal, MD
The Neurobiology and Emerging Therapeutics for Functioning(Conversion) Neurological Symptoms.......................................................... 73
James L. Griffith, MD
Speaker Biographies......................................................................................... 83

History of the Artiss Symposium
Kenneth L. Artiss (1913–2001), the namesake of this symposium, was an
Army officer, a research psychiatrist and instructor at Walter Reed Army
Medical Center. Dr. Artiss, who served for 21 years in the Army Medical
Corps retired in 1964 as a Lieutenant Colonel. He was Chief of the Department of Psychiatry in the Division of Neuropsychiatry at Walter Reed’s Institute of Research. His work included development of treatment methods
for combatants with severe psychiatric disorders.
After his retirement from the Army, Dr. Artiss was a senior consultant
for many years to Walter Reed’s psychiatric residency training program. Dr.
Artiss created an award in 1983 to spur military psychiatry residents to conduct high quality research. This award still exists today and was presented at
the conclusion of this symposium.

i

Speakers
Russell B. Carr, MD
CDR, MC, USN
Chief, Department of Psychiatry
Walter Reed National Military Medical CenterJames L. Griffith, MD
Chairman, Department of Psychiatry and Human Behavior
The George Washington University School of Medicine
and Health Sciences
David E. Gwinn, MD
CDR, MC, USN
Chief, Department of Orthopaedic Surgery
Walter Reed National Military Medical Center
Edmund G. Howe, III, MD, JD
Professor, Department of Psychiatry
Uniformed Services University
Alex Martin, PhD
Chief, Section on Cognitive Neuropsychology
National Institute of Mental HealthChristopher J. Neal, MD
CDR, MC, USN
Department of Neurosurgery
Walter Reed National Military Medical Center
Benjamin Potter, MD
LTC, MC, USA
Vice Chair, Orthopaedic Surgery
Walter Reed National Military Medical Center
Continued

iiJack Pula, MD
Instructor, Clinical Psychiatry
Columbia University
Brett J. Schneider, MD
COL, MC, USA
Director for Behavioral Health
Walter Reed National Military Medical Center
Harold J. Wain, PhD
Chief, Psychiatry Consultation Liaison Service
Walter Reed National Military Medical Center
Thomas N. Wise, MD
Director of Behavioral Health
Inova Medical Group2015 Conference Organizing Committee
Harold J. Wain, PhD, Chairman
Russell B. Carr, MD
Shannon Ford, MD
John Magera, MD
Michael Mrizek, MD
Patcho Santiago, MD
Robert J. Ursano, MD
Joseph Wise, MD
Mary Lee Dichtel, RN
For their support the committee wishes to thank:— Ms. Lisa Moore— Mr. Vernon Woods— Staff at NICoE— Our clinicians and support teams for providing the best care to ourwounded warriors and their families.
— The Command at WRNMMC for providing a climate where we are allowed the space and creative license to think about complex issues.
— Dr. Robert Ursano for his support and encouragement to document thisimportant symposium.
— All the patients who continue to inspire and teach us.

7

WelcomeBrett J. Schneider, MD and Russell B. Carr, MD
DR. SCHNEIDER: The first Artiss Symposium was held in 2003 at theold Walter Reed location in Washington, DC. It began with a combat andmilitary theme and people returning from the wars in Iraq and Afghanistan
gave talks about their experiences. When we moved to the new Walter Reed
National Military Medical Center (WRNMMC), the Artiss Symposiumchanged its focus to include broader topics. We are grateful for the work Dr.
Wain has done to make sure the Artiss Symposium continues each year.
One of our guest speakers mentioned to me the impact that Dr. Ken Artiss had on him, how well-known he was in the area, and how dedicated Dr.
Artiss was to educating physicians who provided wonderful care to patients.
If General Clark were here, I know he would ask you to consider how yourtime spent in this room today ultimately will contribute to your patients’ experiences. How will you take what you learn today and put the patient in thecenter, and how will you use what you learn to help your patients? If you canidentify that, then the time you spend at this symposium will be time wellspent. We are glad that we are able to offer you this opportunity. I hope you
enjoy the day.
DR. CARR: Dr. Artiss was at Walter Reed for more than 20 years and during that time he was very involved in teaching. His legacy is still felt, and I
think it is important that we have continued to honor him. In 1983, Dr. Artiss began giving an award to residents for research activity that was aheadof its time in terms of engaging residents in research and scholarly activity.
It is fitting that the day will end with the annual Artiss Award presented to
one of our residents for outstanding scholarly activity.

8 Artiss Symposium 2015— Current Concepts in Psychosomatic Medicine

9Introduction to Concepts in
Psychosomatic Medicine
Harold J. Wain, PhD
Welcome to Concepts in Psychosomatic Medicine: The Mind-Body Duality.
Over the centuries, the interaction between mind and body and how it responds to both the somatic symptoms and the emotional symptoms that one
develops has become very important for us to understand. Psychosomatic
medicine has evolved from the time of Hippocrates and Galenic traditions
where diseases were described along with religious and ideological aspects.
There was also recognition of the role that emotions contribute to the genesis of physical disorders and Hippocrates showed that adaptive factors were
important in health and diseases. Socrates said that when he came back froma battle his body could not be cured without concern for the mind. Galen, inthe years before Christ, understood the concept of adaptive biology in which
diseases would create a disturbance in the natural harmony of the body, especially the humors.
Other noted physicians throughout the years recognized the impact ofmind and body, and body and mind, because they go hand in hand. Toooften we think about how the mind affects the body, but the body also affects
how we respond. Carl Carus, in the 19th century, postulated the impact of
the unconscious mind and how it animates with all physiological processes.
I always thought it was Sigmund Freud, but it was Carus who first talked
about the unconscious mind. Freud, in his discussion of the unconscious,
established a fundamental dynamic principle of psychological causality. Ivan
Pavlov’s exploration of conditioned reflex provided a tool for the introduction of stress and for the measurement of emotional correlates of physicalstress. He postulated that even the most complex higher cerebral processes
were elaborations of simple conditioned reflexes.
Walter Cannon suggested that emotions were energizers, and that situations evoking fear and rage could provoke important changes in body fightor flight responses. We tend to forget about Freud, Pavlov, and Cannon’s impact on us. Think about Pavlov when studying non-epileptiform seizures.

10 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

Five years down the road about 30% turn into true seizures. Could it bethat epilepsy is a conditioned response that changes the physiology of thebrain? I posed that question to one of our neurologists and it has not beenanswered for me.
Helen Dunbar, who studied large numbers of patients with organic disease, noted marked similarities in personality profiles as though they were
suffering from the same disorder. Dunbar described the ulcer personality,
the coronary personality, and the arthritic personality, among others. I was
engaged with these concepts in my own training, and I kept looking for different personality styles.
Franz Alexander emphasized the relevance of psychodynamic conflictrather than personality profile. Alexander postulated that there were threevariables in operation: inherited or acquired organ system vulnerability,
psychological patterns of conflict, and defense. The latter is formed early inlife corresponding to precipitating life situations which are operative in the
etiology of psychosomatic disorders. George Engel and Arthur Schmale described inappropriate grieving following object loss as a precipitant of psychosomatic disorders. Psychoanalysts and psychophysiologists contributed
to the growth of this field. The first major approach intended to identify
specific psychological variables underlying specific somatic disorders. The
second approach involved experimental epidemiological studies to discovercorrelations between social stimulus situations, subjects’ responses to them,and changes in physiological functioning.
The historical impact of Franz Mesmer is also interesting. Look at themind-body interaction, look at the impact that James Esdaile, a Scottish
surgeon, had in his description of mesmerism in India. Why are patientsable to tolerate surgery without an anesthetic? What are the variables that
contribute to one’s ability to anesthetize the body? Does this occur with pathology, not just in hygiology, and does it also occur with psychopathology?
Tom Hackett, from Harvard University, was fluent in his use of hypnosis andpsychotropics. David Spiegel, a colleague at Stanford, has done wonderfulwork using hypnosis. He looks at it clinically, as contemporary or integrative medicine. At Walter Reed, we have used hypnosis in consultation liaison
psychiatry. I have written several chapters on hypnosis and most of my writing described hypnosis for anesthesia for surgery. Why does it work? Was
Pavlov right? Is there cortical inhibition, and how does that occur? How
do the mind and the body interact to allow this to occur? All cases demonstrated the significance of hypnosis in psychosomatic medicine where themind affects the body. Some of the patients we have had recently refer backto classic cases that Dunbar and Alexander described.
What about gastrointestinal (GI) function? We have a GI clinic where weuse both traditional psychotherapy and hypnotic techniques to control some

Harold J. Wain, PhD 11

GI functioning. What about respiratory conditions? Most of you know that
one of the classic cases that Dunbar described as a psychosomatic disorder
was asthma. What we see now is a great deal of vocal cord dyskinesia. Is thatreally the offshoot of what others were diagnosing at one time, before we
had the instrumentation to evaluate it? How is the mind able to control the
respiratory phenomena by use of a variety of techniques?
What about neurodermatitis? Drs. Hackett and Gottlieb, dermatologists
at Harvard, removed warts on half the body but not the other half. How?
Why does this occur? Why do some of these things work? How do we sometimes use suggestibility to ablate warts? What about adult encopresis? Why
do people have encopresis and what occurs with it? What are the dynamic
interpretations of encopresis, and what techniques do you want to use tohelp patients control their bowels? What about non-epileptiform seizures,movement disorders, hyperemesis gravidarum, nausea following chemotherapy, gastric reflux, and hypertension? These are just a few of the cases
where you can see how the mind can affect the body.
More recently, Henry Christian defined psychosomatic medicine as concerned with an appraisal of both the emotional and the physical mechanism
involved in disease development. The editors of the first journal of psychosomatic medicine defined it as a study of interrelation of the psychologicaland physiological aspects of all normal and abnormal bodily functions, withan attempt to integrate somatic therapy with psychotherapy.
I consider Zbigniew Lipowski the grandfather of consultation liaison(CL) psychiatry. He defined CL in this way: the scientific study of the relationship among psychological, biological, and social factors in determining health and disease. This holistic approach to medicine, Lipowski thinks,
should be done through consultation liaison psychiatry.
In 1935, the Rockefeller Institute funded the first psychosomatic clinics
at Duke, Colorado, and Massachusetts General Hospital. The American Psychosomatic Society (APS) was founded in 1935, and the Academy of Psychosomatic Medicine (APM) was founded in 1954. The psychosomatic fellowship received its final approval by APM in 2003. Prior to that, the APS
recognized the consultation liaison psychiatry fellowship.
How do we manage patients with comorbid psychiatric and general
medical conditions complicating the management of both disorders? What
do we do if a patient is bipolar and is experiencing depression and anxiety complicated by other conditions? How do you manage these patientson the ward? How do you manage these patients when they have a medical
condition and are scheduled for surgery? How do you approach and manage patients with somatoform and functional disorders, conversion, somatic
symptoms, dissociation, and body integrity identification disorder (BIID)?
One of our orthopaedic surgeons will talk to you about some of these vari-12 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

ants because CL is often asked to screen patients prior to potential surgery.
Often we are asked to assess patients who want amputation of healthy limbs.
This scenario is more frequent than we recognize for people with psychiatricdisorders that are a direct result of a primary medical condition or of theirtreatment for delirium, dementia, etc.
How do you initiate treatment? You must listen to patients; you must listen to the medical staff who are treating the patients. Many times we do notlisten. You must be flexible. You cannot approach a patient without flexibility,
especially a patient with a complex biopsychosocial presentation. The key isan empathic approach. If you look at the studies in psychotherapy, empathy
accounts for about 80% of the variance in psychotherapy. We accept the patient’s description rather than telling them they are wrong. Recognize theimpact that the mind has on the body and the body has on the mind. Try
to develop individualized strategies. We stress the concept of a therapeutic
alliance. How do you develop a therapeutic alliance and maintain it? The
literature tells us to meet the patient where they are and not have them meet
us where we are. In the latter case, we lose and patients lose. The therapeutic
alliance can go a long way in helping solve the puzzle to give our patients thehomeostasis they need.
I have several questions. To what degree was Pavlov correct? To what degree was Cannon correct? To what degree were Freud, Dunbar, and Alexander correct? What about the aspects of the pharmacological approach? Isthat correct? What role do the limbic system, the amygdala, the hippocampus, and the frontal cortex play in this discussion? What are we missing inunderstanding and helping another person return to homeostasis?
There is a stigma associated with psychosomatic medicine, whether you
recognize it or not. I voted against the name “psychosomatic medicine fellowship” because of the stigma. My preference was somatopsychic rather
than psychosomatic because as soon as you say psychosomatic people suggest it is a somatoform spectrum disorder or an unexplained medical symptom.
When you are dealing with a biopsychosocially complex patient, especially in the hospital, you must remember your patients are not the only patient.
Your patients are other providers who take care of that patient; the nurses,
the entire staff on the ward, some patients on the floor, as well as your bosses
and the command, especially here at Walter Reed. We recently had a patientin the ER who had a service dog. How do you handle the logistics of admitting a patient to an in-service unit who has a service dog? These are issues
you have to deal with. These issues go all the way up the chain of command.
How do you put all this together? Dealing with these types of questions iswhat makes the area of psychosomatic medicine so stimulating and electrifying. It forces us to integrate data from a variety of sources. It makes you

Harold J. Wain, PhD 13

think, and it requires all of us to think holistically about another individual.
Solving the puzzle of some of these complex biopsychosocial cases can be
stimulating and can help prevent burnout.
The process is very interesting. For example, every Wednesday morning,I, along with two fellows, attend the medicine clinic supervising the staff andsome of the residents on their morning cases. We do not see the patients.
We talk about each case and help them understand each patient. Residents
and staff are now doing exactly what Lipowski talked about. We are teaching
residents how to talk to patients. They are asking the right questions, they arelistening, and they are responding effectively, and integrating the data gathered. Lipowski would be proud of everyone who is following that dictate.
With this approach you are likely to have a very exciting day.
Today’s speakers are also stimulating and exciting. They are experts intheir areas. They can help us integrate our knowledge from a biopsychosocial perspective because, as George Engel once taught us, you need to evaluate your patients from a biopsychosocial approach.

14 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

15

Psychosomatic Medicine:
Paradigms and Populations
Thomas N. Wise, MD
Dr. Wain emphasized the role of curiosity, which is so important in what
we do. We have to cope with the trajectory of psychosomatic medicine. A
group of us from the Academy of Psychosomatic Medicine have been working to get consultation liaison psychiatry accredited as a sub-specialty ofpsychiatry. The American Psychiatric Association (APA) did not like theterm consultation liaison because they argued that all doctors do consultations. We went back and forth for a number of years about lobbying the
APA and obtaining support from a broad group. The name was a problem.
Finally someone said, “What about psychosomatic?” The board of the APA
said, “Yes, that’s fine,” so we took it. The rest is history.
What is interesting is that we still ask what psychosomatic is. Psychosomatic was first defined in 1836 by Heinrich, a German pre-psychiatrist. In
English, psychosomatic was first talked about by Isaiah Gray, who was an
editor of the American Journal of Psychiatry in 1860. These are trivia questions for psychosomatics, but 150 years later we are still talking about what
it is. It is fairly interesting to me but also problematic. Dr. Wain talked about
Zbigniew Lipowski who spent some of the happiest hours of his life at the
National Library of Medicine. Everyone in this room should read Dr. Lipowski’s classic papers. He was the greatest scholar in psychosomatic medicine
and I do not think we have anyone to replace him.
What do we do in psychosomatics? It is a research strategy. It is part of themission of the American Psychosomatic Society that Dr. Wain mentioned.
The answer is that we consider behavioral and psychological issues as variables. It is not done often in biomedical research. We will discuss the resultof that problem using George Engel’s biopsychosocial model. It is a clinicalapproach. It sounds good, but, due to limited time and limited numbers of
doctors and other health providers, it is not done in most parts of the UnitedStates or Canada.

16 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

Consultation psychiatry is the clinical derivative of psychosomatic medicine. Some people do not like to hear this. It is not universally accepted ingroups who see psychosomatics as what every psychiatrist should be doing.
I agree with that, but it is not always realistic. There are several basic assumptions about why we focus on population health. There are a limited numberof mental health professionals — whether they are psychiatrists, psychologists, or counselors. Primary care physicians have limited time. It is unrealistic to think that primary care physicians can spend a great deal of time with
their patients. On the other hand, if you see a patient regularly, over time you
will be able to quickly recognize changes in their mood and their behavior.
Our new models include many groups of doctors that do not know theirpatients well. It is an important issue. Psychiatric co-morbidity increases
cost. There are psychosocial and behavioral issues that globally cause andmaintain disease such as low socioeconomic strata, poor diet, tobacco, alcohol abuse, and lack of exercise. All of these things create an undercurrent and suggest the importance of behavior, which can be driven by psychosocial issues in health. Health is a global construct. Dr. Wain beautifully
described the clinical paradigms in psychosomatic medicine. To an extent,
the ancient thinkers, whether it was Hippocrates or Galen, spoke in a much
more global way. It was only when we got to Sigmund Freud and some of hiscolleagues, like Franz Alexander, that there was much more linear thinking.
Helen Dunbar, who was very important, emphasized personality. However,the fact is that none of her data really worked out. Dunbar was a dramaticcharacter and she wrote a book that you can still buy in used bookstores.
Dunbar fostered the early thinking about Type A personality, which we still
debate today.
Engel focused on what is called the biopsychosocial model. Engel was aninternist. He was also a psychoanalyst who completed his analytic training
in Chicago, under Franz Alexander. Engel was amazed during rounds by
the fact that people gated out all the psychosocial elements and would talkabout molecular biology. Physicians focused on what disease the patient had
and why the disease occurred. They focused on the latest articles in the New
England Journal of Medicine or the Journal of Clinical Investigation. Often
the result was that no one really knew who the patient was.
You cannot deny the importance of the disease process, but it is also important to know the patient. Arthur Schmale was one of Engel’s greatest
students and later joined his staff. Dr. Schmale trained at the University of
Maryland, and afterwards spent his career at Rochester. Dr. Schmale was oneof the kindest and greatest of the psychosomatocists. Those of us who wereprivileged to know him still miss him. He was the one that had the clinicalabilities. Sir William Osler said you have to know the patient and what disease they have, but Schmale embodied that statement. Schmale, who wrote

Thomas N. Wise, MD 17

beautifully, studied the life setting conducive to illness in a series of papers
that are not typically read now. When I ask our fellows to read Schmale’s papers I know some of them wonder why. I ask because the papers describe theessential aspect of the clinical encounter. Schamle wrote the seminal article
that coined the term biopsychosocial. I was a history major in college, and I
believe if we do not learn about what occurred in the past, we are doomed
to repeat failure.
Roy Grinker first used the word biopsychosocial, but he was talking about
the focus on reductionism in biologic psychiatry that I still believe is important. Engel said we need a new model. The biopsychosocial approach
incorporates psychosocial aspects into how we think about our patients. It
has not been fulfilled today. We thought this was going to be the relief act for
consult psychiatry but it did not turn out that way. There are time pressures
on clinicians of all specialties. I have heard psychiatrists say it is not their
job to talk to patients and do therapy. There are several residency programs
that embody that approach. There are some residencies that do a great dealof good research, but that do not necessarily promote psychiatrists talking
to patients.
We are now faced with another problem. What was originally called population medicine is now called personalized medicine. Francis Collins, whodeveloped the human genome project, does not like the word personalized
medicine. He prefers precision medicine, which, in fact, is much better. We
want to be as precise as possible with some of our new, colorful therapies.
I use the word colorful because the press thinks this is, perhaps, a new erain treating cancer and some other diseases. Inova Fairfax Hospital, where I
work, recently purchased the Exxon Mobil headquarters for close to $1 billion. We have spent millions of dollars looking at genetics and personalized
or precision medicine. Time will tell how this will work, but this approachleads us away from sitting down and talking to the patient and getting toknow them.
One of Engel’s articles says that we exist in a series of levels from thebiosphere to the intracellular organisms. It seems to me that the clinical encounter is in a levels of experience construct, basically psychosocial behavior. I believe it is accurate, but we are also in a digital age and humans exist init, whether it is Facebook or another form of social media. We all deal withthis. In the Middle East combat soldiers have satellite phones. They can callhome any day and Skype. This dramatically changes their personal experience of being away from home and dealing with stress. We do not use Skype
frequently in the hospital yet, but I suspect in the future we will have thistechnology in every hospital room. We live in a digital age that we have tocome to grips with at some level.
We are changing the game from biopsychosocial perspectives to co-mor-

18 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

bid management. Is that a dialectic? One could argue they are not contradictory. I think there is some merit to that. I would advocate for the biopsychosocial model. Change is not easy. To illustrate, here is a story from theLondon Times about Rene Laennec, who developed the stethoscope: “If it
ever comes into general use, notwithstanding its value — extremely doubtful, that is, the value — it gives a bit of trouble both to the patient and thepractitioner. Its character is foreign, opposed to all our habits and associations. There is something ludicrous, the picture of a grave physician proudly
listening through a long tube applied to the patient’s thorax.” Change is complicated. The stethoscope was a foreign, useless object. Now it has come fullcircle, since the stethoscope, in many ways, is a bearer of bacteria. I do notknow if you subscribe to the hand hygiene concept but we are in the midst of
a big campaign. Stethoscopes and cell phones are bearers of bacteria.
Today we do so many imaging studies that the wonderful auscultation
skills are being lost. We have many new technologies on the horizon. Someare called disruptive technologies, a term often used in the business world.
A disruptive technology is one that displaces an established technology andshakes up the industry or a ground-breaking product that creates a completely new industry.
I think many of us would agree that good psychotherapy by a well-trained
clinician is useful, and, at times, is the best treatment. Many people would
disagree. The data is lacking to show the dosage of psychotherapy. Are threevisits a week better than one? If we think of psychotherapy as a drug, which
I would argue is a good analogy, we need to know the dosing. The other isbehavioral therapy — using hypnosis as an adjunct. All are essential. These
are, unfortunately, often looked upon as sustaining services versus disruptive
technologies.
HealthSpot is an example of a disruptive technology in medicine.
HealthSpot is a company that provides telemedicine or virtual healthcare
connecting patients to providers in convenient settings. The patient walks
into a kiosk and begins a video that connects them to a health care provider.
For example, if you have a cough or think you hear something in your chest,
the healthcare provider, via video, will ask you to place a stethoscope on
your chest that is amplified back to the central person. HealthSpot has healthsystems frantic. What will be the effects of this type of health care delivery
system?
The University of Pittsburgh is one of the most powerful health systems
in the country in terms of financial stability and aggressiveness. Recently
they acquired a contract for telemedicine psychotherapy in their health system. It is called Beating the Blues. Beating the Blues has been available for atleast a decade. The data shows that, when implemented in collaboration with
face-to-face humans, this program has some merit. It certainly is as good asThomas N. Wise, MD 19

not using it. The data is less supportive without face-to-face psychotherapy.
We are facing paradigmatic change. Most people cannot afford private
psychotherapy and most psychiatrists do not accept insurance in larger cities in the U.S. Generally, this has led to a two-tiered system of access to careand that is a problem. Look at the example of Eastman Kodak. Who would
have ever thought that cameras would go down the drain? I am old enoughto have owned a Brownie. Then we had little pocket digital cameras that weregreat and I still carry one of them around on trips. With the iPhone cameracontinuously getting better, I am less likely to carry the digital camera in mypocket. Kodak, who supported Rochester for centuries, had to re-invent itself. They are not a film company anymore. Who would have imagined that?
I suggest that we have to be careful in our own thinking.
Why would telemedicine psychotherapy be accepted? We know that human interaction is really important. Acceptance has to do with the changes
in individuals’ acceptance of rapid-fire, computerized psychotherapy, andacceptance of computerized telemedicine where strangers diagnose some ofyour medical problems. Acceptance is a generational change. The individual
who best described this phenomenon is Karl Mannheim. Mannheim was a
German sociologist in the Frankfurt School, a liberal “thinking out of thebox” group that was active in the late 1920s and early 1930s. Fortunately,
for the U.S. and Great Britain, we got most of these folks as émigrés before
World War II. Mannheim went to London, where he did most of his work.
You can still read some of his beautifully written essays on the Internet. In
one essay, he said the reasons these changes work, versus eternal romantic
views of what works, is because cohorts change. Our current millennials likewhat is convenient. They are also comfortable with social media technology.
The current generation is interested in quality of life. They do not want tocome in during the day and wait a long time to see a doctor. They want quick
fixes.
What are the psychosomatic paradigms? There are two buzzwords thathave become popular recently. The first is co-morbidity. Co-morbidity is aterm popularized by Alvin Feinstein in a book called Clinical Judgment written in 1967. Feinstein was an epidemiologist and a professor of medicine
at Yale University. The second buzzword is population health. The military
understands population health. The civilian side, fostered by insurance, isforced to deal with population health.
I suggest that the newest paradigm in psychosomatic medicine is the psychiatry of co-morbidity. There are functional effects of co-morbidity, basedon time and detection. Symptoms of multiple sclerosis (MS) are often initially diagnosed as hysteria. We know depression can worsen diabetic control and make the course of that illness worse. You can educate a patient
about a healthy diet and the importance of taking prescribed medicines, but

20 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

if the patient has either a personality disorder that is low on conscientiousness and they cannot plan well, or is anxious or depressed, he might not
do well. If a patient has mild dementia, or bad arthritis and cannot open a
blister pack, that is a problem. Post-therapeutic outcomes can all be affectedby co-morbidity. Rates of depression are high in the general population, butparticularly high in people with medical illnesses.
Consultation liaison psychiatry and psychosomatic medicine are awareof this, but how well have they addressed the issues? We thought we could
teach other healthcare providers. If you teach consistently each week thenpeople begin to learn, but in an inpatient unit how effective is this approach?
You have to be there to help out. That is the key. There is data showing that
lectures to primary care doctors on common outpatient psychiatric issues
do not work. For complex cases you must be present to teach. How well did
our approach work? If we look at the meta-analyses of success rates we were
accurate. For depression, under half. For distress and demoralization, under
half. For mild depression, only a third. We do not do well with delirium. It isamazing how little we study delirium. Tom Inui and his folks at Seattle areabout the only ones who have done good work with delirium. We certainly
have not solved the problem. Is it consultation liaison’s fault? No, not necessarily, but perhaps we need better models. We have a long way to go.
Why are we moving out of population health? Our traditional models
have not worked as well as we would like. It is a money issue. The cost of depression is fairly impressive with absenteeism from work. Presentism is low
productivity at work, which is also costly. As we move forward, worldwide,
depression will be one of the leading causes of disability. Money seems to
be a driving force, and because of this the focus is now on populations. We
are moving from a fee-for-service system, which is based on volume andper person, to a whole population. The shift will be based on how much we
spend and how much we can save. Those of you in the military have to deal
with this when you make requests for money. It is all based on economics
and an outcome. How well are you doing in treating these populations? How
accurate are some of the outcome measurements? We need to reduce thecosts because things are supposedly becoming too expensive. We use tools
for population health, and mental health is part of this. We are tasked withtreating the mental health of a broad population with medical co-morbidities and those without who have psychiatric morbidities.
How do we approach this complicated task? We use psychometric screening and electronic health records. What about talking to patients? In most of
the models it is not the first thing you consider. We have two tools: the electronic medical record (EMR) and telepsychiatry. At Inova Fairfax, we use agreat deal of telepsychiatry and it is surprisingly helpful. Patients seem toaccept it but our doctors do not always accept it. Telepsychiatry allows us toThomas N. Wise, MD 21

expand services in places that are not accessible to a psychiatrist, psychologist, or social worker. An interesting question is, how well is the new model
accepted? There is a good story about Albert Relman, former editor of the
New England Journal of Medicine. He was a leading light in health change
and was convinced that most doctors would accept HMOs and salaried positions. I think he is probably right. Tragically, he fell down and sustained
fractures in his cervical vertebrae. He had a tough time in the hospital anddeveloped pneumonia. He was hospitalized at Massachusetts General Hospital and then Spaulding Rehabilitation Hospital.
Relman said, “Attention to Mass’s data generated by laboratory and imaging studies has shifted their focus away from the patient. I found only a few
brief descriptions of how I felt or looked.” Relman, who had never supported
the role of biopsychosocial approaches saw this as a real problem and wrote
a beautiful article in the New York Times. If anyone wants to read the ills of
the EMR, read Robert Wachter’s book.
One problem is that bad data stays in the record. We cut and paste. Whilethe doctor is talking to the patient, the doctor is typing on a computer andnot looking at the patient. How do you capture all the visual informationthat Charles Darwin talked about? Darwin’s early observations on animals
and how they looked are probably still accurate today. If you read any good
textbook on the medical interview, you will read about talking to a patient,seeing how they sigh, how they look, and when they become tearful. If you
are looking at a laptop, you cannot do that.
We recently completed a study looking at 100 inpatients and what they
thought about all of the types of technology we use. Everything in our psych
unit is computerized. Everything is electronic. We talk to patients but there
are ever-present computers. What was dramatic to me was that most patients accept it. They were not worried about confidentiality, which is a constant theme in the literature. We found that if the patient thought the doctor
was good, everything else vanished. It has something to do with the doctorpatient relationship, which has always been the case. Transference has always
been the case. It is what Ken Artiss tried to teach about the group process.
Artiss’s work complemented Jerome Frank’s work at Johns Hopkins and therole of transference and the socially sanctioned healer. Wearing that white
coat, no matter what discipline you are, means a great deal. When you wear
a name badge you are somehow involved in the hospital treatment team.
Patients accept this, but what are the consequences?
Here is a good example. A 53-year-old woman was transferred to our hospital with a ten-year history of MS. She had worked as a neurologic nurse.
She was admitted to Inova, screaming and yelling, completely out of control,and could not walk since she had been mostly bedridden for four or five
years. I saw her on rounds and performed a neurologic examination. There22 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

was no evidence she had MS, but the diagnosis was repeated in the EMR at
our hospital and in the record from the transferring hospital. One of our fellows carefully reviewed the records. There were absolutely no positive findings that could be confirmed. Confirmed was the operative word. She supposedly had an abnormal spinal tap and supposedly had an abnormal EEG,
but nothing was confirmed. When I spoke to her I said, “Look, we’re going
to commit you if you don’t cut it out. You’ve got to come to psychiatry.” She
got out of bed, went to the bathroom, came back and said, “Okay.” It turned
out that her symptoms were histrionic but the diagnosis was also an EMR
failure. The cut and paste was perpetrated for at least five years. This is aproblem that occurs repeatedly.
How do we deal with populations? Collaborative care is the newest term.
It is also called shared care, integrated care, or coordinated care. The process
is integration with primary care based on step models. Stepped care is themethod that is used and you screen an entire population. It is organized todeal with large numbers of people in a cost-efficient way. Clinically, it seems
to work in certain hospital settings. There are other approaches though.
Roger Kathol is an innovative health strategist in the development of integrated programs and systems for patients with illness complexity. He is atireless champion of integration between psychiatry and medicine. Kathol
is trained in internal medicine and psychiatry. He thinks everyone should
be screened, not necessarily by a mental health professional but for levels ofcomplexity of their illness. The entire hospital population is screened andyou can intervene when needed. Social Service departments can do this.
This approach is not utilized much in the U.S. but in Holland it is utilized agreat deal. Another approach incorporates a behavioral integration team. A
psychiatric nurse screens all admissions on a unit to determine who might
be at high risk, such as people with prior psychiatric disorders and people
who seem to have current psychiatric symptoms. Those patients are seen.
This approach seems to save money since patients have a shorter length of
hospitalization.
What about primary care settings and outpatient settings? The main project is one that never gets cited, but is being funded by the NIH and it isimpressive. In Maine there are not many psychiatrists outside of Portlandand perhaps Augusta where the state hospital is located. The NIH project
co-located social workers, licensed professional counselors, and occasionally a psychologist/psychiatrist with primary care physicians throughout thestate. They saw the patients that needed to be seen and they used a sharedelectronic health record. This is where the electronic record is good becauseof its portability and its ease of use. By and large, treatment times were short.
What were the clinical outcomes? Patients did well on the various metrics
that were measured.

Thomas N. Wise, MD 23

What are we doing at Inova? We are using the collaborative care model,
working with our 22 primary care clinics that are part of the Inova Health
System. We are also using the PHQ-9 to screen every patient. If a patient
has moderate to severe depression, we implement more aggressive interventions that are coordinated between the primary care doctor and our mental
health group. Soon we will begin to co-locate people in convenient areas.
In the DC area distance is not the problem, traffic is, so we are working onwhom to place in the various centralized primary care clinics that are located throughout Fairfax County, VA. We will measure outcomes carefully.
The key to collaborative care is developing a useful registry that is comprehensive.
Will any of these models work? When I say work I mean, will they improve mental health? Will they modify costs? I am not convinced we know.
Can we generalize a model that we use, which is basically owned by all ofus, to the private situation? Accountable care organization is a model where
healthcare providers from primary care, specialists, hospitals, and large
health systems are all collaborating and coordinating care with each otherto improve outcomes for their patient populations. Who knows if that will
work? What about employee versus contracted doctors? At Inova we have acompletely employed model, as does the military. We sign contracts and wehave a chain of command, just as the military does. It is probably not as rigorous as the military, but we have a chain of command and I answer to oursenior officers. Will this model be different for contracted people that do not
feel like they are part of a team? None of us know and we cannot predict the
future, but I know it will change.
In conclusion, I encourage you to keep up the curiosity that Dr.Wain
talked about. Stay curious about our healthcare models and where we havealready been. We have to remember where we have been in order to move
forward in a reasonable way.

24 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

25

The Social Brain in the Ordered andDisordered Minds
Alex Martin, PhD
I will discuss the idea of the social brain and why it is important. We havebeen studying autism in a narrowly defined way with adolescents, however
this talk is not about autism. This talk is about taking one clinical group,in this case high-functioning autistic individuals, and considering them amodel system. The model is a system for approaching people who have social difficulties in the world, and for studying them to learn what might bewrong with their brain circuitry.
I want to accomplish three things. First, I will define what we mean by the“social brain” as a domain-specific system. Second, I will provide examples
of how we probe the brain with functional brain imaging and how we canuse different tests to activate the social brain and see how it responds. In thethird part of the talk, I will turn to studying different patient populations
without any tasks, just having people lie in the MRI magnet. This approach isa fairly recent discovery that shows a slowly fluctuating, spontaneous neuralactivity that, through different types of analyses, can inform us about brain
circuitry and the status of circuitry in different patient populations.
What is the social brain? One argument is that the whole brain is thesocial brain, which I think can be defended to a certain degree. However,
we need to be splitters before we can be lumpers. This is a story that began
about 25 years ago with a woman named Leslie Brothers. I am sure few, ifany, of you have ever heard of her. She is another woman who never received
her due in the sciences. Dr. Brothers is in private practice at UCLA. In 1990
she wrote a paper that introduced the field to the idea of a social brain withregard to certain areas being particularly important. In her paper she described different areas of the brain, including the inferior part of the temporal cortex, the superior temporal sulcus, orbital frontal cortex, cingulate,
temporal lobe, and the amygdala. Since then, there have been many studies— both in monkeys, and more importantly, in the human brain — to flesh
out what this might look like.

26 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

The superior temporal sulcus is particularly responsive to biological motion, which is one of the ways we make contact with the world outside. This
is where we store information about a highly flexible motion that is a characteristic of animate things, living things that move on their own — what wecall biological motion. Lateral parts of the fusiform gyrus are particularly
important for representing the form of biological entities such as people andfaces; not their motion, but their form. Other important areas of the brain
include parts of the medial prefrontal cortex, the posterior cingulate, and, inparticular, the anterior insula somatosensory cortex. These are the areas thathave been implicated as part of the social brain, each with different functions but working together to allow us to understand the social world.
I want to point out some characteristics of what I mean by a domainspecific system. One characteristic of a domain-specific system is the idea
of automaticity. These are systems that work incredibly quickly and appear
to fire easily. What I mean by automaticity is that you can detect, in a visual
scene, a face and/or an animal (biological/animate images) amazingly fast.
This type of recognition happens within 100 milliseconds, based on recording eye movements from the time something happens out in the world. Thatis very different from other types of objects that take humans longer to detect. The other piece is called the poverty of the stimulus. What I mean bythat is it takes very little information to trigger the system. In addition, thiskind of activity is typically triggered, and most easily triggered, by dynamic
stimulation — meaning things in motion. It takes a tiny little spark, in asense, to fire the whole network. Let me give you an example of the stimuli
we are talking about.
[A slide was shown of an image of dots on the screen.]
You have probably all seen examples of this. Does everybody see this assomebody walking? Is it a male or a female?
PARTICIPANT: Female.
DR. MARTIN: Some people say female, but it is a male. This might be a
projective test. It is difficult for most people not to see the image as a biological entity. Another example is a simple motion coherence task. You arein the magnet and your task is to report whether dots are moving to the leftor to the right. A small number of dots are moving, about 10% coherence.
Another example is the stimuli of a group of little red dots and whether or
not you see them as a little Pac-Man, whether or not you see that as animate.
The social brain goes crazy.
We know from many other studies that the superior temporal sulcus isparticularly responsive to biological motion. When little dots that look like
Pac-Men appear, even though your task is to report if the dots are moving
left or right, this part of the brain fires. It is biological. Again, you may notconsciously recognize it as such because your task is to report motion to theAlex Martin, PhD 27

left or right. One last point is that this circuitry is involved in understanding
the social world, even when the stimuli are quite different.
Here is an example using solely verbal information. Subjects in a magnet
are asked to read the following sentence and each word appears for about
300 milliseconds: “The tyrannical chef insulted the busboys.” We comparethat activity to another sentence, matched for word length and frequencyof the words: “The paper lantern quickly floated upward.” When people arereading these sentences the whole brain system is activated when we compare the social-emotional sentences to the more object-related sentences.
There is a system that represents biological motion and another that represents biological form.
The amygdala is involved in emotional responses. The medial prefrontal
cortex, the higher order affective control system, also comes online fromreading these types of stimuli. This is the social brain. What is it for? We, andmany others, have done studies with different objects looking at different
types of circuitry. When you see different classes of objects, different circuits
are activated and their function allows us to make inferences about that object. For example, when you see two holes through a hammer, there are anumber of areas that are involved in the manipulation and action with objects. The circuits come online only when you see the object. That is how weunderstand what the object is, and that is how we know what we are goingto do with the object. If the object is something like appetizing food, a different set of circuitry is activated that is involved in making inferences about
the taste of things and their reward value; the insula and the orbital frontal
cortex. In that context, this system is all about making inferences about what
others are feeling and thinking.
We now have the background. With that in mind we can look at our clinical population, which is defined particularly by their difficulties in the socialworld like many of your patients. This is autism narrowly defined. This is notabout all of autism. This is about typical Bethesda or Potomac, Maryland highsocioeconomic status, intelligent but socially awkward teenagers. We know
these people. They are, on average, about 17 years old. We conducted a study
that tracked eye movements when participants looked at social stimuli suchas faces. We found, maybe not so surprisingly, that the autistic adolescentslook less at the faces and their memory for faces is not very good. However,the behavior is specific for these stimuli because they are doing just as wellas the controls with other types of stimuli, which are round, similar to faces,
but not animate, not social. The autistic adolescents have a domain-specificmemory impairment because of a domain-specific scanning impairment. We
found that there are aberrant responses within the system for social animate
stimuli versus non animate control stimuli, which means the autistic adolescents are using a different type of circuitry for their understanding.

28 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

Here is the point I want to make for the rest of my talk. There are manystudies in the literature — in autism groups and other clinical groups —showing aberrant responses in several areas of the brain. We see the fusiform face area, the superior temporal sulcus, the amygdala, and the medial
prefrontal cortex — all those social areas in one study after another — responding in an abnormal way in people with social difficulties. Here is theissue. When we do these studies, we can document that there is aberrant,
abnormal activity throughout a whole host of areas that I described to you as
the social brain. The point is, this is not a local problem. There are not one or
two particular areas; instead perhaps something is wrong with the circuitry
and that is what we are studying. I take people who have social difficulties,
I do a social task, and I find that there is something aberrant in their brain
circuitry. That is important in terms of proof of concept — that we can engage the correct areas of the brain and we can understand what is going on.
In this sense, we are always looking under the light. What about other tasks?
What about other types of abilities? How are we going to get a whole pictureof an individual’s brain if we are constantly doing this, which is circular, if
you think it through?
What we really want is some way to systematically evaluate all the circuits
in a patient’s brain in an unbiased way, without pre-deciding what the task
should be. I will describe how we go about doing this and how others do it.
The question is not whether there are aberrant functional circuits in autism,
depression, schizophrenia, etc. We know that is true. It has to be true if you
accept the fact that these are all disorders of the brain. If they are brain disorders, they are circuitry disorders. There is no alternative. Carl Wernicke
said this in 1906. This is not new information. Nobody needs a scanner toknow this.
Wernicke called this sejunction, which means a loosening of connections.
Now we can expand this because there are many alternatives. We call this the
hypothesis phase. There are many ways all circuits can malfunction. Somecircuits could be hypo-connected, reducing connections. Other circuits canhave increased connections or hyper-connectivity. There can be differential
involvement of the brain of short-term versus long-term connections. Therecan be system-specific connections, only in the social brain, or there could
be different types of subgroups. How can we make progress, given all thealternatives in the hypothesis phase of ways that brains can malfunction?
We want something that is unbiased; not pre-determined by me with mylittle circles on the screen or whatever social task I come up with. We wantsomething that is driven by the data we plan to collect.
I will describe the model system that we, and others, are using for different neuropsychiatric disorders. We want to take advantage of a fairly recent
discovery that within the brain there are incredibly slow moving waves that

Alex Martin, PhD 29

you can record with fMRI. This is called rest-state scanning of slowly fluctuating, spontaneous neural activity.
[Slides were presented showing what eight minutes of data looked like. The
audience saw that some wave forms were very slow and some were very fast
depending on what part of the brain was highlighted.]
There was a significant relationship between the way the waveforms fluctuated, and that correlation was used to make a claim about the co-variationof these activities — the neural activity. If they are related, they are correlated. That allows us to make the claim of connectivity. It is all about correlation of waveform.
[A slide was shown illustrating the concept of a voxel, which is one small
square in an MRI image, and how using data from voxels can measure how
connected different parts of the brain are.]From voxels we can create things called connectedness maps. Remember,the subject is doing nothing. The subject is just lying in the scanner while wecollect eight minutes of data. Now we have all our control data along withall our patient data and we can create connectedness maps. What are we going to do? We do a comparison, using the simplest statistics you know. We
do simple t-tests and see which areas are different between our patients andour controls — no picking, no selecting, nothing. What happened? In thiscase we found several areas more connected in the control subjects than in
the patients, and these areas were all part of that social brain, including themedial prefrontal cortex. We found more connections in the controls thanthe patients.
Twelve regions of the brain were identified by doing the t-test, all of them
part of the idea of the social brain, plus the cerebellum. We used the 12 areas
to see where, in fact, they were connected. We looked for connections in thepatient group and the control group, and we looked to see how they differ.
We did a procedure called multi-dimensional scaling, which is a mathematical test to look for regions that show the same types of patterns of connectivity. We found three different clusters and we color coded them. I want you tokeep in mind that, again, we are not selecting anything. In a real sense, thebrains of these patients are selecting the circuits for us.
[A slide was presented showing the colored sub-circuits and what parts ofthe brain they represented.]
Color coding allows researchers to order the regions and to measure thecorrelation values across the control subjects. What does that mean? It basically says that, out of this large-scale social circuitry, there is a particular
type of disconnection. It is the disconnection between Circuit 1, which I
call social inferences and affect, and the other two circuits —one involvedin communication and control; and the other involved in social perception,
biological form, and motion.

30 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

The last point I want to make is that today in modern cognitive neuroscience there are many patient studies of this type. Everybody is going to finda difference. This is the critical question. We call it grounding; the idea of
how do you know any of this information matters? Is it meaningful? We
have two ways to say that maybe this is meaningful. One question to ask is,is this effect neurobiologically plausible? The second, more important question is, is it clinically relevant? To assess neurobiological plausibility, we canlook at monkey neuroanatomy in the macaque, for example, and find that
yes, Circuit 1 in the macaque is monosynaptically connected. The regions we
see in our analyses, at least in the monkey, do have connections; in this caseconnections in the superior parts of the anterior temporal lobe with medial
prefrontal cortex. The circuits make sense, not only based on human data,
but based on true track tracing in the macaque.
Does it matter clinically? Does this have any relevance to behavior? Our
answer is yes, in the following sense.
[Slides were shown illustrating a typical measure of social ability, not usedin the diagnosis. The measure is a social responsiveness scale that is filled out
by the parents of the patients. The higher the score, the more autistic symptoms
seen in the individual. Slides showed the measures of connectivity.]
Lower connectivity, or the more that there is a disconnection between
Circuit 1 and the other two circuits, correlates with the presence of more
autistic symptoms. That holds for the relationship of Circuit 1 to 2 and 3,
and for each circuit separately. This means that the weaker the correlations
are, the more impaired the patients are and the weaker they are within thisparticular set of circuits. The types of social impairments that we have been
studying appear to be related to what we call a fractionation of the social
brain. It is the fractionation of a large-scale set of regions and circuits characterized by a de-coupling of limbic areas, such as the amygdala, and theanterior part of the hippocampus, from lateral, frontal, temporal, and posterior sites. The general point is that resting-state scanning, the analysis of theslowly fluctuating neural activity recorded at rest, is useful for identifying
the large-scale circuitry associated with different types of neuropsychiatricdisorders.
DR. WAIN: What about patients with unexplained medical symptoms?
What might you think would be going on brain wise? For example, you havea patient with a non-epileptiform seizure with no previous history of seizure
disorders, or even any of what we typically call somatoform spectrum disorders, and without an Axis III diagnosis; without a true medical diagnosis.
DR. MARTIN: I do not know. It would be interesting to take patients likethat and put them into this situation to get a sense of what is going on withthe circuitry. Is there anything in common among them? One of the big
problems with these studies is the inability to say anything about individuals

Alex Martin, PhD 31

at this point, which is really the goal you want to achieve. You want to be able
to say something important about a single patient. Nobody is at that point
yet, but I think that is what it would take. It turns out that in autism, about
40% have epilepsy as a syndrome. Why is that? Where is that coming from?
You would think it must be related to something different about the circuitry
in those individuals, but the question has not been answered.

32 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

33

Ethical Concerns in Patients with Complex
Medical-Surgical and other Unexplained
Medical Issues
Edmund G. Howe, III, MD, JD
Dr. Shannon Ford, a psychosomatic medicine fellow, presented three casestudies for Dr. Howe to provide comments:
DR. FORD: The first case is a prominent member of a community sports
league who is on dialysis and in need of a donor kidney. She is a 31-year-old
female, and is eligible for TRICARE because she was medically retired fromthe military after being diagnosed with glomerulonephritis and IgA nephropathy while deployed to Afghanistan for the seventh time. She also hasdiagnoses of major depressive disorder and posttraumatic stress disordersecondary to her experiences while deployed as a combat camerawoman.
She belongs to a community sports league and reached out to them throughsocial media. Two people responded to her request for a donor kidney. Bothpotential donors completed the routine medical screening and were foundto be medically acceptable for donation.
The medical team had strong concerns about her participation in thetransplant process because she had a history of non-compliance when she
first required dialysis. She had lost her military career, her boyfriend, and,in her mind, her future as she knew it. At that point she felt hopeless andstopped treatment. She was not adherent to diet and she was difficult toreach for follow-up. However, in the past year her behavior changed andshe was much more compliant. There were still lingering concerns that she
would be minimally participative in her recovery since things such as signing up for Social Security had yet to happen.
The first donor, who volunteered via social media, was a 32-year-old female, married, with one child. The potential donor denied any current moodor anxiety symptoms. She was obese but ultimately lost 40 pounds in preparation to become a suitable donor. She had a past psychiatric history notablefor depression, but this had been well controlled with fluoxetine for many

34 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

years. She had a strong, supportive, stable marriage, family support, and was
employed full time. The potential donor felt she had an opportunity to help
someone she knew even though the two women were not close. She understood the risks associated with the surgical procedure, that the donatedkidney may be rejected or may fail, and she was willing to fully participate.
The second potential donor was a 29-year-old single male who separated
from the military about one year earlier. He found a bond with the recipient
through their military service. They had common diagnoses of PTSD, andhe volunteered to be a donor during the time the two of them were getting
to know each other. When we saw him he denied current overt depressedmood or anxiety, but something was still “off ” to the consult team. We encouraged him to return to the Veterans Administration Hospital (VA) for
further support and treatment since he continued to report a sense of loss
and purposelessness to his life. Still, he had responded appropriately andwithout any concerns to the standard questionnaire that is used for psychiatric clearance for all donors. We questioned aspects of his true motivation
to donate and asked about what appeared to be ambivalence on his part
regarding this donation. He had significant difficulty answering some of ourquestions about how he would feel if this donated kidney were to ultimately
fail. His answers led the consult team to ask him to consider what it meant
to him to be a donor, and then to come back and see us in two to three weeks
to re-discuss.
In the interim between the first and second appointment with the maledonor, who medically was preferable for a few reasons, the male donor andthe recipient met again. They were in the process of potentially beginning aromantic relationship. The potential donor reported significant distress to
the recipient about the interview process and the intensity of the psychiatric interview that we conducted with him. He disclosed to her that he was
not actually interested in a romantic relationship with her and that he hadstrongly considered he would suicide in the next two years. He hoped that
if he donated his kidney a piece of him would “live on beyond him.” It had
not occurred to him that his kidney would fail, thus essentially ruining hisplan of continuing to exist after his death. The recipient then disclosed thisinformation to the transplant team.
The ethical question I have for Dr. Howe is, what role does the consulting psychiatrist play in preventing a patient who has the capacity to makemedical decisions from becoming an altruistic donor, given the secondhand
information about a suicidal fantasy that he had not previously disclosed?
Since we had a viable donor, the female with the stable marriage and stable
employment, does that change the decision?
DR. HOWE: I want to make several preliminary comments about what
ethics has to do with psychiatry. Why ethics? The answer is that it may send

Edmund G. Howe, III, MD, JD 35

you on an alternative clinical flow chart for your patients. For example, if
there is an empirical question such as which antibiotic to use, we ask thedoctors or nurses because they are the experts. On the other hand, if there
is an ethical question, should the doctors and nurses decide? The question
here is, does empirical expertise lend itself to greater ethical expertise thanpatients have? Many physicians tend to assume that, but it has been questioned a great deal by the community at large. Clinical expertise does notnecessarily generalize to ethical expertise. This means that, perhaps, physicians should not make ethical decisions for patients since it is the patients’needs that are at stake. Maybe we should use a different flow chart. From an
ethical perspective, maybe patients should decide.
I have one more preliminary comment. When we began teaching ethics
at USU, medical ethics was a new field. In 1977, there were only ten medical
schools that taught medical ethics and USU was one of them. How do you
begin to teach a new field? We brought in Sam Gorovitz, Chair of Philosophy at the University of Maryland, who had written one of the few books
available on medical ethics, Moral Problems in Medicine. Dr. Gorovitz told
us an interesting story. When he spoke to doctors they would protest, as you
all might protest at some of the things I say, that he was being too hard on
physicians. When he spoke to lawyers, they would say you are being too easyon the physicians. The point of the story is that we all have particular biases
that make us think we should make certain decisions for patients.
In ethics those terms are paternalistic. There are two flow charts that I will
describe. The first will emphasize what, in ethics, are called deontologicalvalues, which focuses on the rightness or wrongness of actions themselves as
opposed to the rightness or wrongness of the consequences of those actions.
The second is a perspective in ethics that is about two decades old, the care
perspective, which emphasizes relationships.
In these three case studies we will see how placing emphasis on autonomy
and equality, which are deontological or non-consequentially based values
that violate utility and paternalism, may alter what one might want to do. We
will also look at the care perspective.
Should I allow a person who is competent, namely the persons who werewilling to be donors and the particular male donor who might have beensuicidal, to donate a kidney to a stranger? First, let us look at the person who
needed the kidney. She was the one who shared information that the potential male donor might be suicidal. Let us consider that before we pass overit and look at the big question. We can ask, should the psychiatrist have informed the recipient that any information she shared might be used to makedecisions? Should a psychiatrist say before the interview, “I’m going to ask
you questions, and if you tell me anything like the donor might be suicidal,
that could affect whether we accept him or not. And we may have to tell him

36 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

that that’s why we aren’t accepting him.” She might say, “He’s my buddy. He
used to be my boyfriend. I don’t want you to give him that information. He’ll
think I’ve betrayed him.”
The general notion is to be as transparent as possible. For example, I recommend that you share with all patients the information you know, basedon your background, that might be relevant to the decisions the person
makes. The burden should not be on you about whether to share information if it may influence the patient. Transparency is the operating premise.
The burden is on the person to make the case to themselves. Are there consequences? Yes. If you are transparent, you may lose important information. In
this case you could lose the information that the male donor may be suicidal.
There are always “hits” with every ethical issue. What if you did not warn
her and she says, “Whoa, you didn’t tell me that. I don’t want you to use that.”
Does the analysis change at all? Should you put any more moral weight on
not using the information about suicide, or not telling the male donor thatis what you are worried about? Alternatively, the recipient could change hermind after you have warned her. What moral weight should those considerations have? Those are items you want to be sure to take into account.
What about the male donor that talked about suicide? He passed thescreening test. He was competent. What is the healthcare provider’s ethicalexpertise? Some physicians may have great expertise, but some may haverelatively little. Is having a license to practice medicine enough? What does,“I may commit suicide in two years,” mean? Can we predict from that? Is it
the same as saying, “I have my gun loaded at home?” No, so that is an empirical question which might also warrant a large moral weight in this case. The
bottom line question is, can the doctor or the evaluation team decide whether or not to include this donor based on the information about suicide? A
case can be made both ways, and that is the question that should be asked.
I spoke about the care perspective before, which puts emphasis on relationships between people and feelings. You might consider sharing yourconcerns with the donor, “We know that you are thinking of suicide twoyears from now, and we are concerned about allowing you to be a donor
under that consideration. What do you think?” That is, of course, a clinicalquestion that we could discuss the whole afternoon. Finally, in this instance,
should I allow a person who is competent, but impaired, to donate a kidney
to a stranger when there is another donor who is motivated to donate? She
lost 40 pounds and she understands the risks, unlike the second potential
donor who shared the suicide information.
What does equality mean? We have two donors who are considered competent. Equality might mean flipping a coin between the two, not paternalistically, but deciding on the basis of components other than being competent.
Is one donor a better match for a successful transplant? How should that

Edmund G. Howe, III, MD, JD 37

balance your decision? In summary, you might want to ask what the risk isin terms of the match. You want to get the best match to maximize the success of the transplant. However, you may also want to consider the principleof autonomy — that is that both people want to be donors — and that might
warrant greater moral weight. That might lead you to be more open to accepting the male donor who talked about suicide. Again, we talked aboutburden. That is a tool I am trying to give you. The burden is saying why one
should not give equal opportunity to the male donor.
You must recognize the limits of your own expertise when making a decision. For that reason you might want to refer the decision to another appropriate body to decide, for example the Ethics Committee or the Commandant. The idea is to “turf ” it to the process which is likely to work best, eventhough that group might make the wrong decision.
DR. FORD: The second case involves a former Marine who also wants tobecome a donor. He left the Marine Corps about six months prior to our firstmeeting. He moved to the District of Columbia to enroll in school. His wife
was already well established in her career. He had 180 days of TRICARE eligibility after separating from the Marine Corps. When he was in the hospital
to refill a medication, he walked by the transplant office and reported to us
that God had spoken to him and he now had a calling to be a donor. He andhis wife both decided to volunteer to be screened, but she was ultimately
ruled out for medical reasons. He continued with the process, and because
he had a history of ADHD and a prescription for Concerta, he was referredto the consult service. He reported that the Concerta was for memory problems. At the time of the interview, not surprisingly, AHLTA (Armed Forces
Health Longitudinal Technology Application) was unavailable, so we had noaccess to his prior records. He discussed freely his desire to donate. He talked
about his faith. He did not identify himself as religious, but reported that he
attends church regularly, feels God routinely speaks through him, and he hasa call to serve. He felt that he had the ability to change someone’s life throughdonation and should be allowed to do so. He physically demonstrated having his hand come down and touch another person by this donation.
When we had access to AHLTA we conducted a complete record review.
He was separated from the Marine Corps administratively for a personality
disorder not otherwise specified which was diagnosed with psychometrictesting and an interview. He originally sought behavioral health treatment
before this diagnosis because he was having difficulty at work. He transferred to a more administrative specialty, and he was struggling with thejob requirements and the personnel in his office. His original diagnosis wasan adjustment disorder. He was treated for ADHD, which was a diagnosis
presumably carried forward from childhood, but he continued to struggle
interpersonally in the office.

38 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

An administrative route was found for him to separate from the Corps,
and he completely agreed. He said he was done. We asked him to come backand see us because we had new information that he had not shared at thefirst appointment. He was rather irate, to say the least, that he had not been
immediately cleared as a donor, and he was angry that the follow-up appointment took several weeks to schedule. He accused the establishment ofcovering its own backside and preventing him from using his God-given
power to reach down and change someone’s life with this donation. I wasable to get more psychiatric history from him at the second appointment. It
was all completely congruent with what was reported in AHLTA. The question we pose to Dr. Howe is, was withholding information about how he had
been administratively separated from the Marine Corps or the fact that hehad been previously diagnosed with a personality disorder sufficient reason
to take a more paternalistic approach and prevent this individual from becoming an altruistic donor? We were apprehensive about the patient’s ability
to manipulate the system post-operatively, or to use his donation as a way tomaintain healthcare benefits for an extended period of time.
DR. HOWE: One’s competency is a legal determination; one’s capacity isa psychiatric determination and it is complicated. There can be fixed standards that one must meet, but there can be a sliding standard that one canuse which varies the degree to which the person has to be competent withthe outcomes at stake. If so, one might clinically apply the sliding standard
and then present to a judge how they might play out. Judges, by and large,
tend to defer to their psychiatric experts.
There are different ways to determine whether or not a patient has capacity because the determination is a judgment call that involves some ethicalvalues. How much moral weight do you place on somebody not sleeping fora week versus losing their family one day ago in a car accident? This is unlike tuberculosis, where we can grow the bacteria and look at it under a slide
to externally verify a diagnosis. That being the case, if one psychiatrist says,“Yes, I find him competent,” then it is the end of the conversation. However,
if you have a different view, the question is, should you accept right awayor should you say, “I want to present this case to the Ethics Committee?” If
the Ethics Committee presents a decision you disagree with, then there isanother question. Do you go to JAG and say, “I want to bring this forward
to a court. This should be decided by a judge with procedural safeguards. I
disagree with the determination of the psychiatrist on call.”Whichever standard we use, clearly the standard does not say someone isincompetent if they have a personality disorder or ADHD. Does the burdenof competency of the donor belong to the psychiatrist? Footnote: it may bethat the competency standards are not adequate. For example, years ago at
Walter Reed a psychologist raised questions about whether a patient with

Edmund G. Howe, III, MD, JD 39

traumatic brain injury was competent to make decisions about a major procedure. He met the present standards of competency, but on more subtle
extensive psychological testing he showed a number of deficits which suggested that his determination might not be intact. The concern arose because
the standard of competency might not take his other deficits into account.
Competency is more complicated than simply asking what the standard
is, applying it, and then getting an automatic result. In this case the donor
wants to be altruistic. There is a great deal to be said for allowing people to be
altruistic. For many, altruistic behavior might be the major way they derive
meaning from life. It is not trivial and that is the donor’s point. One could
say the burden is on the psychiatrist to make a case in favor of the donor’s
altruistic behavior once the competency issue has been met.
Health care providers can have biases, referring back to the Marine’s
words — “covering one’s backside.” People might also have biases about donating to strangers. Indeed, the literature shows that our society does havethat bias. Iran is the only country that does not have a donor problem interms of having enough kidney transplants. There are reasons why a person
might be biased, and you always want to check out the possibilities.
If we allow this Marine to become a donor, what are the consequences?
Remember, there are always consequences. He might be manipulating thesystem, as Dr. Ford pointed out. He might be able to maintain medical benefits if he donates. What is the take-home point in this case? In general, thepoint is that there is a problem when you wear two hats. In this case theclinician is raising ethical concerns, while having a mixed, possibly mutually exclusive, conflicting loyalty as a member of the military, and wanting
to protect the system from being manipulated. You might easily think you
can wear both hats at the same time, but the price of wearing both may be
profound. You may be unable to do either well.
DR. FORD: The third case is not a donor/transplant case. This case involves an unexplained medical symptom. The patient is a 28-year-old active
duty soldier, who has approximately a year and a half history of a truncal
tremor that became abruptly worse. He was evaluated by a movement disorder specialist in the neurology clinic, received a second opinion, and has
an appointment to get a third opinion. We were asked to consult on the case.
The symptoms are a near-constant movement, with mainly forward flexion, and intermittent head and leg shaking. What are most important about
these movements are not necessarily their intensity, but the duration and thefact that they are consistently distractible during the neurology evaluations
with changes in the amplitude and intensity when he is asked to perform
other tasks. Every health care provider who has seen him has noted that theintensity of his symptoms in the waiting area versus the clinical office are
significantly different.

40 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

During his psychiatric evaluation he demonstrated limited insight into
the potential cause of his current symptoms, and he was focused on the ideathat there may be an impinged nerve causing this almost full-body tremor. He denied every symptom of depression, anxiety, or mania, but he didnote some disruption in sleep and an increased appetite due to the constant
movement leaving him hungry and dehydrated. He denied any issues fromchildhood including no history of abuse. Interestingly, he completed three
years of college and then abruptly left to join the military. He is due to finish
his commitment in the Army in seven months. His job, which is partly ceremonial, requires him to stand at attention in full body armor for 14-hour
shifts. This is very distressing and clearly his symptoms have interfered withhis ability to work. He has not been working since his symptoms began. Hiscommand is very interested in helping him. Either the symptoms have toresolve so he can return to work, or he will be moved to a transition unit andprocessed out of the military through a medical board.
The soldier reports being interested in seeking other opinions and undergoing more tests and procedures to find out the organic cause for his
symptoms. He says he wants to remain on active duty, though we sense there
is probably some ambivalence. He is not interested in individual psychotherapy so if his symptoms do not improve he will go to a medical board, forcing
his separation from the military. Ethically, how do we handle the potentially
coercive nature of this treatment recommendation, which is basically seek
behavioral health or else?
DR. HOWE: Is it potentially coercive to say to him, “Here’s the deal. You
either get out of the military or you seek therapy with me and we take ourbest shot?” Yes, it is coercive. My compliments to the team for recognizingthat this action is coercion. However, that does not mean that it is a poor
choice. Sometimes, these types of side effects are unavoidable. It is importantto recognize the coercive aspects. In this case, this might be the best way tolook at and acknowledge what the problem is with the patient. This raises
the general question of, how often should one explain what is going on sothat you and the patient can go forward as a pair? Is this an example of sucha case?
When Dr. Schneider presented at grand rounds in the Fall he said, “We
don’t want your psychiatrists making suicidal contracts with patients.” Yearsago, it was thought that suicidal contracts were what you should do. Thatwas before new data came out suggesting that the contracts were not advisable. The hypothetical question is, if the policy was to do suicidal contracts,
but you were ahead of the game and thought it was wrong because it might
destroy the doctor-patient trust and the relationship, should you share thatwith a patient? Should you have said 20 years ago, “My department says I’m
supposed to do a suicidal contract, but I personally think that won’t help at

Edmund G. Howe, III, MD, JD 41

all, and I’m worried about losing trust. I want us to have a therapeutic relationship.”
The first case today illustrated how one might want to use the principles
of autonomy and equality to go down a different path or flow chart. The
second case used the same principles. In the final case, we looked at the new
ethical care perspective, two decades old, to wonder whether we would want
to involve the patient in the decision even though it is a coercive approach.
Some of you were around when I was working with Dr. Wain years ago.
In those days, for this type of patient, we might have used sodium amytal.
There were fascinating outcomes with that approach. That is my segue intosaying the next question is for Dr. Ford. How will you treat our third patientin psychotherapy? That is something we should all look forward to learning.

42 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

43

Essentials for the Psychiatrist Working
with Transgender Patients
Jack Pula, MD
Today’s objectives are: 1) to understand the historical context and current
clinical barriers to care, as well as some of the social barriers transgenderpeople face; 2) to learn important terminology; 3) to learn high-yield aspectsof the gender dysphoria diagnosis; 4) to update you on treatment standards;
and 5) to increase awareness and understanding through my own autobiographical account.
I am currently on the working group for the treatment of gender dysphoria at the American Psychiatric Association (APA). There are seven of us on
the group, and six of us recently presented at the APA conference. We offereda seven hour course on this topic, and we had about 40 participants. It will bequite difficult for me to condense seven hours into well under one hour, but
I will do my best to give you the high-yield information, leave time to tell myown story, and then have time for questions and discussion.
In 2012, the APA task force on the treatment of Gender Identity Dysphoria (GID) published its findings in the Archives of Sexual Behavior. The task
force reviewed the literature for evidence for the treatment of what we thencalled GID. The question was whether or not clinical guidelines could be developed for psychiatrists so they could better understand GID. The evidence
was not robust enough to support clinical guidelines, so we are working tocreate clinical recommendations, which is part of the function of my working group. Clinical recommendations will be helpful to ensure competent,
realistic, ethical, and humane treatment.
It is important for you to understand some basic terminology, with the caveat that the terminology changes over time. If you work with trans people,
you will find a great deal of different terminology floating in and out. The
terminology evolves quickly, so it is important to speak with your patients
about what terms they are using. Gender is the publicly lived role as boy
or girl, man or woman. A gender assignment is that initial assignment one
gets at birth, which we call natal gender. That is the gender the pediatrician

44 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

says we are when he or she examines the anatomy of an infant at birth. Gender identity is one’s subjective identification as male, female, or some othercategory. Gender atypical describes somatic features or behaviors that are
not statistically typical in a given society and historical era. Other terms forgender atypical include gender non-conforming, gender variant, and genderdiscordant. Cross-gender is when one identifies with the gender opposite togender assignment. Gender fluid describes a flexible and mixed gender expression, and gender spectrum is a way to think about gender, as opposed tothe traditional binary. Many people today think more on a gender spectrum.
Gender queer is a newer term that is used by those who identify outside the binary or with a mixed gender identity. This term evolved because
people did not feel that transgender adequately described them, and theywanted a word to express their need to be somewhere in the middle. Transgender is a very popular term. It is an umbrella term that evolved between
1970 and 1990 and became rooted in the 1990s. It refers to a broad spectrumof individuals who transiently or persistently identify with a gender different
from their natal gender. Transsexual describes individuals who have sought
or undergone a social transition, and who may use somatic transitions orsomatic technology, including hormones and surgery. There has been banterback and forth within the community about whether to use the word transgender or transsexual.
Trans is a very new term. You will not see the word trans in the academic
literature, but you might begin to see it appearing in different types of literature, and certainly online. Trans is meant to be a new umbrella term torepresent all atypical genders. F-to-M is female to male. You will hear thephrase F-to-M transman. M-to-F is male to female, and M-to-F is called
transwoman. Some people want to be called transman or transwoman. Somepeople want to be called man or woman. This is a very important distinction.
Transgender non-conforming is shortened to TGNC. Cis is a word used todescribe the opposite of trans. Gender conforming treatment and genderconfirming surgery (GCS) are other phrases to know. You may also hear
SRS, which is an older term for sexual reassignment surgery. Gender reassignment usually refers to the official legal change of gender. Many of theseterms are in the DSM. Gender dysphoria is the effect of cognitive discontent
with assigned gender, and that can extend to the DSM diagnosis.
Transgender people date back to ancient time. We have evidence of that,and we have evidence of trans people in colonial times, certainly in the Native American culture. Over the past century there has been a blossomingof trans people. In the fields of endocrinology, surgery, psychiatry, sexology,
and psychoanalysis we have at least a century or more of experience. In thelate 19th century and early 20th century, there was a conflation between
sexual orientation and gender identity, so we spent 120-130 years trying toJack Pula, MD 45

parse that out. That is a very important distinction. People still become confused over this. I think part of the reason for the confusion is that the twoissues are intimately intertwined.
One of the main take homes for today is to move the arc from pathologizing to de-pathologizing trans people. That is where we are in modern
medicine, modern psychiatry, and in the culture today. De-pathologizing isa source of tension within psychoanalysis, perhaps less so in psychiatry, andcertainly in the field of child psychiatry. There is a great deal of stigma attached to being trans. When our field pathologizes it, the stigma becomesworse and can contribute to violence. Today we think of trans as more of avariation. There are many questions asked about gender, including why do
we have gender in the first place?
Some of you may know Harry Benjamin. Dr. Benjamin was a famous
endocrinologist who worked with hundreds of trans people, and we havelearned a great deal from his work. He was actually a bit hostile toward psychiatry because, at the time, psychiatry was trying very hard to talk people
out of their gender identity. Dr. Benjamin thought gender identity was abiological problem that deserved treatment with hormones and surgery. He
founded the Harry Benjamin Society, which later became the World Professional Association for Transgender Health (WPATH). They have issued seven iterations of the standards of care, which I will talk about if we have time.
Many of you will know Robert Stoller, a famous psychoanalyst and psychiatrist at UCLA. He worked with trans people and wrote many case studies. Some of the case studies are a bit disturbing because it looks like he ispathologizing, and in some ways he was since it was what people were doingat that time. But in other ways, Dr. Stoller is seen as a champion for transpeople. He said that you could not talk a person out of their gender identity,
so it was a waste of time to try to analyze it out of them. From 1970 to 1979,
we saw the rise and fall of gender clinics in 40 universities in this country,
including the clinic at Johns Hopkins University. Why they all closed is acomplicated question. Some of the closures were political and some were
due to funding.
The Dutch have been the mainstay and have provided us with very important research because they keep such good data. You are all aware that
this is a hot political issue. Obviously it is a political issue in the military
and around the country. It has been part of the civil rights movement thathas gained momentum since the 1990s. The impact of the Internet and theglobal network of activists bringing information to the public have had alarge influence as well.
One of the recent controversies in psychiatry centered on the diagnosis,
which used to be GID. Today the diagnosis is gender dysphoria. The diagnosis was changed in an effort to de-stigmatize trans people. Think about

46 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

the psychiatric approach. Do you try to work with people? Do you accept
their identity? I believe it is very important for psychiatry and medicine tothink about the ways in which we label people’s identity. Identity was an issue when it came to homosexuality. It is also an issue for trans people, andcould be an issue for other forms of identity. When we label identity, and assign pathology to it, we create many problems. The challenge for psychiatry
is to reclaim what we can provide for trans people.
We do not want to pathologize. We do not want to control. What can wedo? I believe we can do a great deal because we are well oriented to work inthis area if we increase our training. Recently, the APA has taken a positive
position towards trans people. In 2012, the APA issued its Access to Careposition paper, and subsequently a non-discrimination position paper. In
2011, the National Transgender Discrimination Survey, an online and paper survey of over 6,000 participants, gave us a wealth of information about
discrimination. We learned a great deal about discrimination against transpeople, and the types of problems they struggle with every day. For instance,
30% of trans people claimed to have a mental or physical disability, compared to 20% of the national population.
A very startling statistic is one on suicide. Forty-one percent of trans people reported attempts to commit suicide, compared to 1.6% of the national
population. The suicide figure comes from an online and paper survey so
we do not know what the statistic actually means since no assessment wasdone. There is some nuance, but suicide is a big problem and a big risk. HIV
was reported in 2.64% of trans people, and 25% reported abuse of drugs or
alcohol to cope with discrimination. Twenty-eight percent of trans people
reported having been harassed. These numbers may reflect one of the big
problems that trans people face. They often feel they cannot turn to medical
providers or psychiatric providers for help. Nineteen percent of trans people
reported refusal of care when showing up for medical care, 28% reported
postponing their care in order to avoid these types of experiences, and 50%
felt that their providers lacked knowledge in transgender care. We have all
been through medical school, and we have all been through residency training, so we know that statement to be a fair one. I have struggled with whom
to go to for medical care and have had various experiences. I have left some
doctors because of my experiences.
Forty-eight percent of trans people delayed care when sick or injured dueto their inability to pay. Poverty and lack of socioeconomic opportunity isa big problem for trans people due to many reasons, including discrimination in the work place. There is no federal legislation precluding private
sector employment discrimination. You may know about the Employment
Non-Discrimination Act that has been proposed and passed by the Senate,
but has stalled in the House of Representatives. In 2014, the 1964 U.S. Civil

Jack Pula, MD 47

Rights Act, Title VII, expanded its interpretation, by the U.S. Office for Civil
Rights, to include people with different gender identity and people who do
not conform to stereotypical notions of masculinity or femininity. They haveoffered to hear discrimination cases. This applies to public and private sector employers with 15 or more employees, but how many trans people know
about this, or how many trans people can make use of it? In the future you
may be hearing more about lawsuits due to transgender employment discrimination. Eighteen states have policies that prevent transgender employment discrimination in a handful of cities, including Washington, DC, NewYork City, and Philadelphia. I work with many patients in their forties whoare professionals. They are established in their fields, and they are trying tocome out. They are struggling and worried about what is going to happen tothem. They experience a great deal of intense fear.
A study of over 5,000 trans veterans in the electronic health records database showed an increased prevalence of mental health conditions, including
suicidality, PTSD, alcohol, depression, and increased prevalence of medical
diagnoses. These findings are consistent with the National Trans Discrimination Survey. In 2008, another survey of 827 trans veterans showed that
10% were turned away for being trans and many reported lack of respectfrom doctors, non-medical staff, and nurses. This is a very important point.
Some people were denied services consistent with their natal gender. I ama female to male trans person. If I go to the emergency room for medical
help and the medical staff cannot accept the discrepancy between my anatomy and my gender identity, I would be in a very difficult situation. This issomething that happens and requires doctors to think outside the box anduse their knowledge of anatomy and gender and the expectations that transpeople have for their health care providers to be more creative.
The Veterans Health Administration (VA) has a directive on “Providing
Health Care for Transgender and Intersex Veterans,” that requires a nondiscrimination policy. The directive requires respectful, culturally sensitivecare, and also clarifies what transgender services are provided by the VA.
Significant progress has taken place. There are mental health evaluations
and services provided, but now the VA also provides gender affirming hormones, mental health and medical evaluations for sexual reassignment surgery (SRS), and SRS follow-up care. The VA does not provide surgeries orreimburse for them, nor does the VA have a provision for cosmetic surgery.
The Palm Center is a leader in commissioning and disseminating researchin the areas of gender, sexuality, and the military. Through their research
they found that there are over 15,000 trans personnel in active Guard andReserve components of the military. A high proportion of the personnel are
male to female. There are approximately 134,000 transgender veterans, andtrans citizens are twice as likely as cis citizens to serve in the military. Why

48 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

is this? One thought is that the very strong gender binary tradition in the
military provides some sort of psychological conversion training for individuals or provides structure that helps alleviate the strain for trans people.
However, many of them cannot cope and comply with the strain, and they
end up buckling under the system. It is at this juncture where you might see
them as patients. What is it like for those of you who have trans people aspatients? I imagine that if the ban in the military is lifted, you will be seeing
more and more transgender patients. Transgender related conditions are theonly gender related conditions that require discharge, irrespective of fitness
for duty. There is no medical evidence that shows transgender people areunfit to serve.
We began with the term gender identity disorder. The phrase put thewords “gender identity” and “disorder” together, which was problematic. Today we say gender dysphoria, and we are focusing on the actual dysphoria
since that is where the pathology lies for people who are struggling. How
do we diagnosis gender dysphoria? The diagnosis requires a marked incongruence between experienced and assigned gender of six months duration
or more with clinically significant distress or impairment. I do not know ifmany of you work with children, but the diagnosis for children requires 6
out of 8 of the category A symptoms. For adolescents and adults, a diagnosis
requires 2 out of 6 symptoms. Symptoms include things such as a persistentdesire to be the other gender, a persistent desire to have the primary/secondary sex characteristics of the other gender, or the desire to get rid of one’s
own primary/secondary sex characteristics. Interestingly, the diagnosis expands to people who feel they have an alternative gender. We are in the realmof a gender spectrum as opposed to a gender binary. The DSM-5 diagnosis
adds a post-transition specifier for people who are living full-time as thedesired gender (with or without legal sanction of the gender change). This
ensures treatment access for individuals who continue to undergo hormone
therapy, related surgery, or psychotherapy or counseling to support theirgender transition. Gender dysphoria now has its own chapter in DSM-5 andis separated from sexual dysfunctions and paraphilic disorders.
What about treatment? WPATH has issued seven iterations of the standards of care. The most recent one was in 2011, Number 7, which is usedworldwide. You are probably not very familiar with it; however, the VA uses
it. It is a flexible guideline that seeks an approach of harm reduction to help
people find a lasting well-being. Many of you may be familiar with the oldstandard where people went through psychotherapy. That is an outdated
model. The psychotherapy approach was problematic because it corrupted
the therapy since trans people would develop trans narratives. Therefore, thepsychotherapy was not a true psychotherapy. It also put the psychotherapist
in the role of being a gatekeeper, which was problematic. This is one of theJack Pula, MD 49

reasons I think trans people distrust psychiatrists, and we need to try toregain that trust.
WPATH promotes an informed consent process that has replaced the oldapproach. I think both these processes have their advantages and disadvantages and can be problematic. The informed consent process is one where aperson goes to a clinic; hopefully it is a clinic that specializes in screening
people who wish to proceed with hormone therapy. The screening process
is used to access hormone therapy, not surgery. I think the word “informed”
consent is key. How informed is the patient? You want to make sure the patient is informed about what they are about to go through. I have had experiences where I have been concerned about patients who have gone throughthe informed consent process. I have brought this up with one of the clinics
in my area because I am on their quality assurance board. I said, “I have apatient who suffers from anxiety, and you did not ask him about his anxiety
problem. That should not happen.” The informed consent form has many
details for people to review and answer. For some reason, with this particularpatient, his anxiety was missed. You can appreciate how that concerned me.
I felt confident about him going through hormone therapy, so I was not too
concerned, but he was given what seemed like a high dose, and then he had
several days of feeling anxious. I was worried about the monitoring process.
I think the informed consent has to be truly informed consent. I am notso sure that it is all of the time. This is an area where the more we know, themore we can help make sure our patients are giving informed consent, evenif we are not the one signing. Even if we are not performing the evaluation,
we can help the patient, and make sure that they are informed about what
they are about to do.
The standard of care today is the medical and surgical transition, which
can include hormone blockers and cross-sex hormones. The most common
surgeries are chest surgery for both transmen and transwomen and genital
surgery. There are also many different forms of non-medical social transition techniques people can use such as voice training, changing their style ofdress, changing their name, changing their pronoun, changing their identity
marker on their identification cards, etc.
What is important when you are working with people going throughtransition? These are some of the things that I think deserve attention. Whatis the progression of your patient’s identity? Do they have a narrative? Is
there a role for you to help them construct that narrative or become awareof what their narrative is, especially if this is something that they have nottaken the time to think about? I believe this can be very helpful. The age ofthe person when they come out or when they transition is also crucial. People have different considerations at different stages in life. You can imagine
someone at age 20 versus someone at age 50 having a very different life, pro-

50 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

fession, and family dynamic. You can play an important role in helping themconsider these areas of their lives. I worry about people who go throughtransition without addressing and thinking about these issues.
Trauma is a big problem for trans people. You all know a great deal about
trauma. You want to look for any past and recent trauma in their history.
Certainly, if they are in the military, you want to look for trauma. Gender
trauma is important to consider. Gender trauma is something that you may
not have thought of before, but going back to an early age, people may besuffering from forms of gender trauma. I also add psychiatric trauma to thelist because I think psychiatrists can cause a great deal of trauma if we try
to talk young patients out of their identity. Let your patients know that you
are aware of potential denial and stigma in their history. Let them know thatyou are not interested in re-traumatizing them, and be sensitive to moments
when you might be re-traumatizing them. I had my own experience with ananalyst that was traumatizing so I am quite sensitive to this particular point.
If a patient is going through transition, you want to be there to help themthink about the process and what they are facing next. If a person is taking
hormones or they have surgery, their body is changing. They may be feelingdifferent. Some of how they are feeling could be linked to the hormonal effect, but many times it has a psychological component as well. Some people
may feel better about themselves. Sometimes people may feel worse because
their transition is not going the way they wanted or anticipated. Paying attention to what is going well and what is difficult can be very helpful because
you want to help patients move through the joys of their transition as wellas the disappointments.
Substance abuse, depression, anxiety, and suicidality are also issues fortrans people. Interpersonal issues are very important. The ability to copewith interpersonal contact might improve, but it also might be strained, especially if a person is transitioning around people who are not accepting.
Assess their personality traits, both adaptive and maladaptive, and help them
form more adaptive coping mechanisms. Look for resilience. I would imagine trans people in a military setting would be very resilient for both being
in the military and being trans.
When you are working with someone who is transitioning you may be ina position to evaluate them for surgery. You are probably not doing this rightnow, but this could be a consideration for you in the future if any of you go
into private practice. You will need special training, and you will want to be
in a position to liaison with the medical team to manage any co-morbid illnesses. If a person has another psychiatric diagnosis, in addition to gender
dysphoria that does not rule out the option of hormones or surgery, but
you want to make sure the illness is well managed. Pay attention to the relative safety and efficacy of their transition plan, of their coming out, etc., andJack Pula, MD 51

keep in mind that the time frame is going to be individual dependent. Somepeople may want to move through the process quickly and others may takemany years. We talked about the risks of coming out and how that might
affect professional, personal, and family life. You want to look for areas of
support. We know that support promotes good outcomes. The role of psychotherapy is to support, not coerce, and to provide open exploration, notmanufactured narratives.
Psychiatrists always want to know what effect hormones will have on theirpatients. For the most part, studies show documented positive changes whenpeople go through this process, but not everyone has a positive experienceso you want to stay alert. There are emotional changes that may occur withtestosterone or estrogen, but the changes are likely to be subtle and congruent with pre-treatment personality. There can be an increased risk for hypomania, manic, and psychotic symptoms in female-to-male transmen who
are taking supraphysiological testosterone and who also have an underlying
diagnosis. This is why it is so important to have a good internist or endocrinologist onboard treating and monitoring patients on hormone therapy. It is
important to monitor their psychiatric symptoms for any exacerbation andto check their hormonal levels to see if there is any correlation. F-to-M men
often experience increased libido with testosterone. Some people experience
increased aggression or agitation. You can see decreased libido in M-to-Ftranswomen on hormones, or sometimes increased libido thought to be dueto the psychological affirmation of the transition. There are also rare casesof psychosis in transwomen who suddenly stop hormones. There are reports
of depression at the start of hormones in transwomen and some reports ofdecompensation of Axis I disorders with the start of testosterone.
What about some of the surgeries? Female-to-male “top” surgery is adouble mastectomy and no hormones are required. Male-to-female andfemale-to-male genital surgery usually requires approximately one year on
hormones, depending on the person. The complications for chest surgery
are minimal, with a two to four-week recovery time. Genital surgery is much
more complicated. For transwomen, it can include orchiectomy, penectomy,
and vaginoplasty. Genital recovery can be three months, but may include alifelong commitment to dilating the neo-vagina, which is important to assess in your patients. For the most part, female-to-male people do not havea phalloplasty because the technology is not advanced enough. That couldchange in the future. In a one year period, it is estimated that less than 2%of transgender service members would seek genital surgery if given the opportunity. I will not delve into this, but if you are assessing someone, you
may be assessing them for hormone therapy as well as surgery. You want tolook for the diagnosis. See if they have the diagnosis. You want to see if theperson can give informed consent, and you want to see if there are any active

52 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

psychiatric reasons that they could not go through with the process. If theydecide to proceed, then you want to work to help them stabilize. You also
should assess for potential sexual function and anticipated changes. This is
an area that is missed by many doctors. Is the patient aware of what it means
to have a penectomy and vaginoplasty and how that will change their sexuality? Is it going to change their sexuality? I would try to have these conversations with your patients early on to anticipate any problems.
I want to spend several minutes talking about my personal experience. I
am a 43-year-old transman, a psychiatrist, and a candidate in psychoanalysis. I came out when I was 40 years old, after I began my psychoanalytic
training. I was working as a fellow in the psychiatric emergency room atColumbia University. I began hormones at age 40, and had surgery when I
was forty-two. Growing up, I was always considered a tomboy, but as a childI did not feel distressed. I did fairly well. I was not preoccupied with gender,
although now that I have been in analysis for seven years and have had time
to look back, I think I probably was much more distressed than I realized.
In high school, I tried hard to be a typical girl and I considered myself to bestraight. In my last years of college I came out as gay. In my twenties I started
cutting my hair which had been long. I became more butch-identified andI felt much more comfortable. I lived pretty comfortably that way for about
two decades and I went through medical school. You all know what medical school is like. My head was buried in the sand, and I was busy learning
medicine. After medical school, I began a psychiatry residency. I tried to
advocate for LGBT people. I found that somewhat stressful, but I did a little
bit of it here and there. My interactions with patients became more and more
uncomfortable.
At the time, I was in my own psychotherapy so I began talking more
about my gender conflicts. I really did not want to be trans so when I cameout it was a big struggle for me. I became depressed and hit a bottom point,
which has actually been interesting for me now, working with trans people,
because I feel very sensitive to some of the struggles that they have. It has
been quite helpful for me to have had that experience. I had a break with mypsychotherapist, who had become my psychoanalyst, because I began talking about wanting to transition. My analyst thought I was moving too fastand he wanted me to slow down. I was about to turn 40, and I had a daughter
who is now five. I did not want to go slowly. I went to another psychoanalyst
in New York. Over a period of a summer I decided to leave my analyst. I had
a supervisor in my training who became very anxious about my transition
and recommended that I go on a leave of absence. My analytic institute had
unilaterally told me I was going to take a leave of absence. At that point, I
put my foot down and said that is not going to happen, and I received a great
deal of support from other people in my institute. That time period was filled

Jack Pula, MD 53

with tense conflict, but the tension died down, wiser minds prevailed, and I
stayed on. I have stayed there, but it was a traumatic experience for me, andperiodically I experience the trauma over again. Ultimately, though, I founda new analyst, a new supervisor, and I am now in my fourth year.
I came out when I was working in the psychiatric emergency room. I
received a great deal of support from the department of psychiatry so there
was a strange experience of receiving support from the department but notfrom my institute. In a way, that describes some of the tension between modern psychiatry and psychoanalysis. Even though I very much affiliate withpsychoanalysis, there is a strange matrix that I have been in for the past few
years. I am doing well now. I am on the faculty at Columbia and I have a fullpractice. I came out to many of my patients when I transitioned. I had todo that. I had about 30 patients and that went very well, though I was quite
worried about it. I did well with my family. My partner and I are married. We
have a 5-year-old, and that is going well, with certain bumps and problems
along the way, as you might imagine. I did not anticipate that this would become one of my professional focuses, but it has, and I am glad that I am able
to speak to audiences about this topic because I think it is very important.

54 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

55

Psychiatric Concerns in Evaluating
Low Back Pain
David E. Gwinn, MD
CDR, MC, USN
I am honored to be here and a bit amused that Dr. Wain invited an orthopaedic surgeon to talk “psychiatry” to a room full of psychiatrists. I see
patients with back pain on a consistent basis so in that way, perhaps, myexperience will add to the symposium. I will discuss the psychological aspectof low back pain from a spine surgeon’s perspective. My objectives are tohighlight the psychiatric diagnoses that occur with and/or contribute to low
back pain presentations, to discuss some diagnostic tools, including heuristic models to screen for psychiatric disorders in patients with low backpain, and to develop an understanding of some psychiatric interventions
to maximize outcomes for both surgical and non-surgical patients with low
back pain.
As student and resident trainees we are taught the importance of evaluating patients holistically to consider the biological, psychological, and social aspects of patients’ presentations when developing a treatment plan. As
surgical trainees, whether an orthopaedic surgeon or a neurosurgeon, we
are focused on the biological presentation, learning the surgical indications,figuring out what patients need surgery, and why. It takes quite a few years
of practice and experience to begin to understand how important psychosocial considerations are. For an orthopaedic surgeon low back pain is thesignature complaint to study when trying to understand the interactions between the biological, psychological, and social aspects of patient care. Thatis because low back pain is often a non-organic symptom and it is such acommon symptom.
When I was a spine surgery fellow at the Cleveland Clinic, I was in clinicwith my favorite staff member, Dr. Gordon Bell. We had a patient with a lumbar degenerative spondylolisthesis with neurogenic claudication. He had
failed three months of physical therapy, activity modification, nonsteroidal
anti-inflammatories, and epidural steroid injections. The patient was not a

56 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

smoker, he was not seeking workmen’s compensation, and he was not obese.
We talked to the patient and looked at his films. As was his usual custom, Dr.
Bell took me outside the office and asked, “Dave, what do you think?” I said,“There is no doubt about it. This is a rock solid surgical indication. The patient has met all his pre-operative requirements. I think we should book him
for a fusion and a decompression.” Dr. Bell said, “I agree he has rock solid
surgical indications, but I would not operate on this patient.” I asked why
not. I was completely stunned. He said, “There is something strange abouthim. He is not the kind of man I would have at my dinner table, and I havethe choice of whether or not to operate on this man. I do not know what it is,but there is something about him.” Dr. Bell had performed his own psychiatric evaluation of the patient heuristically, based on his experience. Because I
was so ingrained in the biological aspect of spine care, I had not considered
the psychosocial evaluation in ways that I do now.
This vignette encapsulates so much of what we will discuss today. It showsthat surgeons have choices, even in the face of rock solid, biologically soundindications for surgery, based on considerations of psychosocial factors in apatient. This story highlights the fact that low back pain, with hard and fast
surgical indications, is even more difficult to manage for the medical system.
It shows how experience can, as Malcolm Gladwell discusses in Blink, allow
surgeons to thin-slice a patient during a brief encounter. Gladwell describes
thin-slicing as cognitive intuition, or the idea that the sum of our experiences, education, and common sense can rapidly lead us to a fairly accurate
assessment of an interaction, especially within our subject matter expertise.
Thin-slicing is what Dr. Bell was doing and that is what I have learned to
do over time. In large part our intuition as physicians has improved with the
emergence of the biopsychosocial model of back pain, which was described
by Gordon Waddell in 1987. This model can be expanded to include any
chronic pain. Prior to the psychosocial model we used a reductionist theory
where physicians believed that physical complaints, such as back pain, were
biologically mediated, and that psychiatry had their psychiatrically mediated disorders, and never the twain shall meet. If you look at the surgicaloutcomes for back pain, particularly prior to the biopsychosocial model,
they were uncommonly poor compared to many of the other diagnoses thatsurgeons see.
I will briefly describe the biopsychosocial model and discuss the individual components that I, as a spine surgeon, use when evaluating a patient. The
biological component evaluation of a patient presenting with back pain includes a thorough neurologic exam, thorough musculoskeletal exam, and areview of radiographic images. In the majority of patients that I see with low
back pain, there is a paucity of organic findings and many of them are nonspecific. In those cases, as spine surgeons, we usually refer the patient backDavid E. Gwinn, MD 57

to physical medicine or physical therapy for routine non-operative management and we are happy to move them out of our office. This is not the best
approach for the care of these patients unless a multi-disciplinary team ofoccupational therapists, cognitive behavioral therapists, psychiatrists, andpain management doctors are involved in the non-operative care.
In cases where objective findings do lend themselves to solid surgicalindications, surgeons still have to consider the psychosocial aspects of thepatient care because these aspects potentially have the greatest impact onpatient outcomes, whether the patients are surgical candidates or not. This isa fact that I, and I am sure many other spine surgeons eager to cure a patient
who has a rock solid surgical indication, have learned the hard way. The literature supports this assertion. Patient satisfaction and objective functional
outcomes are significantly denigrated by the presence of emotional distress,
whether psychologically or socially induced, as well as in certain personality types. This is true for all types of spine surgery including degenerative
disc disease, disc herniation, spinal stenosis, instability, and deformity. Thisis true across the board for almost all orthopaedic surgeries, and I would
imagine all surgeries in general.
Typically it does not matter if the distress is from psychological issues,
such as anxiety or depression, or social issues, such as family dysfunction
or a loss of work, particularly if the patient has fear avoidance behaviors
or traits that indicate a somatoform component to their presentation. As
you all know, somatoform disorders are defined as physical symptoms initiated by emotional distress. Back pain, particularly in males, and pelvic painin females are well studied somatoform symptoms. The signature traits thatare associated with poor outcomes in these patients and in these disorders
include pain, catastrophizing, and fear avoidance beliefs. In my experience,
most surgeons glean this information from the history and physical portionof the exam during a patient interaction. This is the thin-slicing that we dowhen we are forming our overall decision. I want to briefly break down theprocess during the history and physical, particularly with regard to yellow
flags.
All of us know the term red flags, and since this room is full of psychiatrists you probably know the term yellow flags. Red flags are the things thatworry us about presentation of back pain that we think may be an urgent or
emergent indication for surgery. Yellow flags are the biological, psychological, and social considerations that can be identified through the history andphysical exam that alert us to the fact that there is emotional distress present,
and perhaps a component of the pain is somatoform.
Patients who catastrophize believe their pain is far worse than it really is.
For example, they walk into the office with a smile and then describe theirpain level as nine out of ten. These patients may also correlate their excessive

58 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

pain to an irrational inability to perform daily tasks or work. Fear avoidance
beliefs take the catastrophizing component and patients avoid simple, everyday work activities because of anxiety. They may have histrionic descriptions or dramatic, sometimes emotional descriptions of pain. Often there
is a history of an exacerbating event causing catastrophic loss of function,
like leaning over and picking something up. Patients might say, “I had tojust lie on the floor for an hour because it hurt so bad.” I am always on alert
when patients have seen multiple surgeons. Seeking a second opinion is notuncommon, but seeing three, four, or five surgeons can be a sign of drugseeking behavior. When you make an assertion to the patient they say, “Yes,but my other doctor said this. Why are you saying this?”Those types of things, to me, are yellow flags that indicate possible psychiatric problems. Other yellow flags are somatoform symptoms such as
forehead headaches, muscle twitching, sweating, and nausea. These are
symptoms that do not usually occur with back pain presentation. Other
non-organic complaints such as my entire back hurts, my leg goes numb,
I get paralyzed, are also yellow flags. I ask all my patients what their pain is
on a scale of 1 to 10, what it is at its worst, what it is on a regular daily basis,
and what exacerbates their pain. Reports of pain that are 9 out of 10 every
day, all day long, raise a big yellow flag for me. Even reports of 7 or 8 would
raise a yellow flag.
Addictive behavior, such as prolonged use of opioid analgesics, is anotheryellow flag. From a social history it is important to identify self-destructive
behaviors such as smoking or excessive alcohol/substance abuse. I also evaluate patient’s social support, and ask about their family network, spousal
problems, divorce, childcare issues, and deaths in the family. From a work
history, especially in the military, I worry about command-directed referrals.
Rank/age discrepancies are always yellow flags for me. Any voiced negative
opinions about leadership or unit morale, fear of patient’s ability to performtheir job, or discussion of disability benefits also raise yellow flags. In the
non-active duty population we have some workmen’s compensation issues.
On physical examination, biological yellow flags include obesity, poor
diabetes control, and smoking. I also evaluate any secondary gain or malingering behaviors such as excessive limping or poor effort on muscle testing.
Waddell’s signs are a group of physical signs that may indicate non-organicor psychological components to chronic low back pain. They may also be
used to detect malingering in patients with back pain. For example, a patient
limps into my office and then I see him 30 minutes later on Main Street
walking around without a limp. Using Waddell’s signs can help distinguishmalingering behaviors from somatoform behaviors.
There are many validated instruments that support these assertions. The
stress and risk assessment method is a combination of the Modified Somat-

David E. Gwinn, MD 59

ic Perception Questionnaire (MSPQ) and the Zung Depression Scale. The
MSPQ consists of 13 questions about patients’ symptoms that all tend tobe somatoform type complaints. The Fear Avoidance Belief Questionnaire,
which was developed by Waddell, specifically quantifies the somatoform traitof fear avoidance. The SF-36, the Pain Disability Questionnaire, the Beck Depression Inventory, and the Minnesota Multiphasic Personality Inventory(MMPI) have been validated and are reliable. Some of these instruments areeasy to implement in a clinical setting. The only one that I use on a regularbasis is the MMPI with a psychological interview prior to deciding whether
to schedule patients for surgery. This is done through referral to the Department of Psychiatry. However, that is probably not enough. I probably needto do more in clinic to screen patients for emotional distress, more than myheuristic abilities allow.
Almost everything I have talked about has an implication on outcomesfor patients with back pain, whether they have surgery or not. Patients thatsmoke who go through a smoking cessation program and quit smoking havebetter outcomes for back pain, whether treatment is surgical or non-surgical.
Patients with anxiety disorders and somatoform traits or fear avoidance beliefs who go through psychotherapy have better outcomes after their therapy. You can modify these traits in a patient and improve patient outcomes.
Cognitive behavioral therapy is useful in patients with fear avoidance beliefs. A multi-disciplinary approach utilizing cognitive behavioral therapists,
psychiatrists, physical therapists, and occupational therapists is also helpful.
Surgeons sometimes criticize therapeutic approaches in the literature because they are time-consuming, involve multiple providers, in most cases are
unreasonable in the civilian world, and are often not reimbursed.
The environment is changing and outcomes-based reimbursement isaround the corner. In the military, where we have a no-fault workers’ compensation model and patients get paid even when they are not working andin rehabilitation, it is not unreasonable to dedicate the time and resources
to psychosocial rehabilitation. If it returns patients back to duty faster, if it
prevents future recurrence of back pain and time lost from duty, and if it improves the outcomes of those that need surgery, then psychosocial rehabilitation is worth it. Unfortunately we have not dedicated the people, the time,or the money towards the back pain epidemic and it truly is an epidemic,
particularly in the military.
Currently, back pain is the leading cause of disability in the world. It is themost common reason to seek medical care in the military, comprising 6% of
all healthcare visits. Treatment and the consequences of back pain cost the
Department of Defense (DoD) $19 billion per year, which is one third of the
DoD healthcare budget. The impetus for reform and research is readily apparent, even to the most obtuse observer.

60 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

In my earlier vignette, I discussed Dr. Bell’s luxury of denying surgery to apatient that he thin-sliced as having a poor outcome, but I did not mention
that he never referred the patient to anyone else. The patient probably went
to another spine surgeon who saw rock solid indication for surgery and operated on him. The patient probably had a less than ideal outcome becauseof what Dr. Bell saw in him. We have an opportunity to do a better job thanthat. We owe it to our military members, our taxpayers, and the mission toprovide more comprehensive treatment.
My colleague, Dr. Neal, does not need to see the patient I have denied forpsychosocial issues before those issues have been addressed. It wastes histime, it wastes the patient’s time, and it wastes the military’s time and money.
We have research funding that may be available soon. If we cannot get ourleadership to buy into a program that incorporates a biopsychosocial modelin the near future, I think it is something that we should all discuss in a
multi-disciplinary manner in order to create a multi-disciplinary approach
to what is an incredibly important aspect of medical care within the military.

61

Critical Role of Psychiatric Evaluation andSupport in Orthopaedic Trauma
and Amputee Care
Benjamin Potter, MD
LTC, MC, USA
In a trauma scenario patients do not choose when their trauma occurs.
This is different from many orthopaedic scenarios where the procedures
we perform are elective. Orthopaedic trauma is unexpected. It is always lifechanging, and occasionally it is life devastating. Any pre and post morbid
psychiatric issues can have a profound impact on patient outcomes and recovery from trauma. Because we are not scheduling the car accident or the
improvised explosive device (IED), we have little impact retrospectively ona patient’s pre-morbid psychiatric condition, but there is a great deal that we
can do to improve psychosocial, medical, and functional outcomes following
a traumatic event.
By the time I see a patient they have sustained some sort of physical injury
to their pelvis or extremities. They are dealing with a great deal of pain following what orthopaedic surgeons would call high energy trauma. The rates
of moderate to severe disability are as high as 40–50 percent. Some patients
recover and are minimally disabled or not disabled at all. Other patients are
lucky to survive. Surgeons say, “Hey, we saved that leg. Your fracture healed.
Your soft tissues look okay. You must be doing all right.” If you look at survey
measurements patients are actually moderately to severely disabled.
Certainly within the military, with the Medical Evaluation Board system, and definitely in the civilian sector, the ability to return to productive
employment is an important issue. The inability to return to work leads todecreased quality of life and the potential for depression, even if a patient
did not have depression or any psychiatric diagnoses before their injury.
First-episode depression comes on relatively early after an injury because
patients are sad about what happened to them, and they may also be bitterand angry about the trauma. I think an internal versus an external locus ofcausality can have a big impact on patients’ perspectives and their coping62 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

mechanisms. Unfortunately depression often lingers, even when a patient’s
condition improves. I do not need to tell anybody in this room that depression is difficult in its own right but what I know, as an orthopaedist, is thatit negatively impacts my patients’ outcomes. Depression increases patients’
pain complaints, both when subjectively and objectively scored, increases
narcotic use, and delays functional recovery.
Dr. Gwinn mentioned pain catastrophizing, which is a tendency to focus
on, ruminate about, or magnify pain. If you combine that with fear of movement and depression, you create the setting for the fear avoidance model. It
fits in nicely with the biopsychosocial model that Dr. Gwinn spoke about.
Certainly, someone that just broke their leg or who is in the immediate postoperative period will have pain at rest, and that type of pain will likely getworse with movement. But if you are weeks or months out from injury, mostthings do not hurt when you are not physically insulting them. It is a big red
flag if a patient complains of pain at rest. Pain at rest can lead to both chronic
pain and a fear of movement that is a big barrier to both physical therapy
and occupational therapy outcomes, and to dedication, motivation, participation, and improved physical health.
Resilience is defined, according to Wikipedia, as the ability of material
to absorb energy when it is deformed elastically and to release that energy
upon unloading. I think that is a good definition of resilience in people aswell. Simply said, resilience refers to our ability to adapt to change. There isan evolving body of literature that suggests resilience can be learned andthat people learn it in different ways. What is still somewhat controversial
or a matter of debate in the medical literature is whether resilience can betaught. I think the jury is still out on whether or not you can teach someone
resilience, with or without their participation.
The lower extremity assessment project (LEAP) was a prospective observational trial of patients with severe limb-threatening lower extremity
injuries conducted at eight Level 1 trauma centers in the United States. The
study enrolled 601 patients and followed them at one year, two years, andseven years out. Although there were some good surgical findings from thestudy, the study showed that the biggest determinants of patient outcomes
were not in the surgeon’s control. The study showed that self-efficacy andsocial support were critical. Both can be modified moving forward.
Posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI)
have different trajectories for different people. TBI is important because it
can impair the cognition of patients. TBI can affect a patient’s ability to makedecisions, their ability to participate in therapy, and can affect their competence to make decisions about late amputations. Recently, I read that PTSD
is often worse in patients that were not exposed to direct trauma. A soldiergoes to Afghanistan and hears about people getting blown up. He is scaredBenjamin Potter, MD 63

every day, but he never shoots anybody or gets shot. Soldiers with these experiences tend to struggle the most with recovery from PTSD.
Cognitive behavioral therapy (CBT) is effective for patients with pain
catastrophizing and fear of movement. Dr. Wain and I recently spoke at
the American Psychiatric Association (APA) symposium in Toronto, and I
heard him say that cognitive behavioral therapy never hurt anybody, so it
is a great thing to try. CBT is a relatively low cost intervention. You have an
opportunity to intervene by helping patients to better conceptualize theirdeficits, their pain, and their situation in life. Intervention can have a profound impact.
I will now transition to discussion of psychiatric issues in limb salvage
versus limb amputation. At the time of your initial injury, we put your life
before your limb. We try to err on the side of limb salvage whenever possible
and preserve options for the upstream surgeons when patients are comingback from the combat theater. The problem that we often encounter, especially with the broad zone of injury that you see with an IED, for example,
is that the patients who are not very good candidates for limb salvage often
are not very good candidates for amputation. If you have a patient who is nota good candidate for either, we err on the side of salvage. It is important todiscuss limbs at risk candidly with patients and family very early on. I cannot tell you how many times I have had patients come back from Bagram or
Kandahar or Landstuhl where a doctor or nurse told the patient, “We’re going
to be able to put you back together. You’ll be good as new.” It is important to
not over-promise and to let patients know that they have a long road ahead ofthem, whichever road they travel, so they can manage expectations early on.
We have defined delayed and late amputation as greater than threemonths (or 12 weeks) from injury. The time frame is completely arbitrary,
but we had to draw a line in the sand somewhere. Limb salvage patients who
are more complex are still healing and in recovery at that point and often are
not finished with surgery. Still, we have a pretty good idea of where things
are headed and where the pitfalls are going to be and if things are working
out. Consequently, many of what we call delayed amputations are not necessarily elective. They are complications of limb salvage. “We tried to save yourleg. You have an intractable infection; your flap died; it didn’t work.” We try
to use the terms delayed or late amputations because some patients do not
feel they had a choice. They did not elect to have surgery and they wish they
had not sustained an injury. The surgery is only elective in the sense that theamputation was not done in the middle of the night for necrotizing fasciitis.
The amputation was a scheduled procedure.
In my clinic, all too often, I see someone who comes back six months,
one year, or as late as five years from injury and says, “Thanks for saving myleg, Doc. Now cut it off.” Why on earth would a person say that? You have

64 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

a salvaged limb, or usually a salvageable limb, so why would you ask for
an amputation? Non-neurogenic pain is one good reason. Certainly motor
function is more important than sensation, but loss of sensation, especiallyon the bottom of the foot or the palm of the hand, is very difficult and creates functional impediments. Sometimes patients will have a list of six orseven complaints and say, “At the end of the day, I just want more function.”
It is not surprising that chronic infection and neurogenic pain are also frequently on the list of patient complaints. Despite our best efforts, sometimes
bones heal crooked or the bone does not heal at all. The patient may ask
for an amputation because you have something else to offer them to get ridof their infection or to make the bone heal. But in its truest sense there aremany complications of bone salvage that are driving the boat
Why not amputate? Amputation is widely maligned as an easy thing.
Anybody can do it. It is an ablative procedure, and it is often viewed as a failure option. In reality, amputation is and should be viewed as a complicatedreconstructive procedure. When you amputate, you are removing a diseased
or injured body part and restoring the optimal possible function. If you areamputating for appropriate medical indications, with appropriate psychiatric screening, you can absolutely help somebody by removing a limb.
Why would you not want to amputate? There are several considerations.
We have better bracing alternatives now. Over the last four or five years,
researchers in San Antonio developed the Intrepid Dynamic Exoskeletal Orthosis (IDEO). We have this technology at WRNMMC and in San Diego as
well. The IDEO is an offloading brace. It is basically a transtibial amputation
socket with the bottom cut out so a leg can go through it. It can relieve 3050% of the pressure on the foot if you have heel pain or plantar neuropathy
or similar problems. The IDEO has the capacity to store some energy so patients get some feedback and push-off, similar to wearing a prosthesis. If you
have an ankle fusion or your calf muscles do not work or you have foot drop,
the IDEO can restore some function. What is another reason not to amputate? Amputation is forever. There are a few hand transplants done each year,
but we do not have the technology to overcome many of the obstacles forlower extremity transplants.
Patients with neurogenic pain have to be evaluated carefully. If you havechronic regional pain syndrome or reflex sympathetic dystrophy syndrome(RSD), there is some potential for improvement with an amputation. Sometimes RSD goes away on its own but sometimes it recurs. You cannot walkvery much with RSD in your foot, but you cannot walk at all with RSD in
a residual limb if you cannot tolerate a socket. You would make somebody
worse if severe neurogenic pain recurred in their residual limb. Separate
from that, patients can also experience phantom pain after an amputation,
which can be substantially debilitating.

Benjamin Potter, MD 65

Secondary gain is a poor reason to perform medical procedures. Unfortunately, the perceived or desired gains are often not realized. What are
the psychiatric confounders? We have already discussed a few of them —depression, pain catastrophizing, and insufficient patient resilience. It is aserious life event to go through an amputation, even when you have alreadysurvived the trauma.
How do we evaluate patients who request amputations? Our practice at
Walter Reed is strictly voluntary, but it is designed to protect both the surgeon and the patient. We require an initial evaluation of the patient by two
orthopaedic surgeons, typically the treating surgeon or the person that thepatient came to asking for the amputation. Patients also undergo a dedicatedpsychiatric evaluation. Often my patients will say, “I just saw psych last week.
They upped my Cymbalta, or whatever.” I say, “No, I want you to see Dr. Wain
or Dr. Prieto, somebody who does evaluations like this all the time, who isgoing to talk to you for hours and knows the right questions to ask, andthat can really drill down a little deeper. I want more than just tweaking anantidepressant or an anti-anxiety medication.” Most patients will also havea limb salvage and/or amputee peer visit. They will talk to physical therapy,
psychiatry, and prosthetics so they can get an idea of what to expect. Amputation is not a two-hour procedure to a better life. Amputation is a two-hourprocedure followed by months and months of rehabilitation. It can be a fulltime job to recover. The answer is not always yes when patients ask for an
amputation.
What am I looking for in a psychiatric evaluation? Competence is firstand foremost. Is the patient able to make a competent decision? This is rarely
an issue, but we have had a few patients where it was. Perhaps the patient
has had a TBI and you are not sure if they are ready to make this kind ofdecision. Is the patient seeking secondary gains? Fortunately this has been
remedied, but even the relatively small payments that soldiers get from TSGLI (Traumatic Servicemembers’ Group Life Insurance) used to be higher
for amputation than limb salvage at the beginning of the conflicts. I worry
about a young, short sighted 22-year-old private saying, “I’m kind of on thefence anyway. For another $10,000 I’ll just cut my leg off.” That money goesaway pretty fast when you spend it on a Humvee. It is helpful to have somebody looking in from the outside to give a surgeon feedback on aspects ofa patient’s psychological health. I think a psychosocial and family support
assessment is really important.
Dr. Wain has seen some of my patients and said, “This guy’s a mess. I
would be really careful here.” He has seen other patients and said, “Really
good family situation. I cannot believe his wife hasn’t left him, but she’s rocksolid and things are going well. Go ahead.” What does Dr. Wain tell me? Occasionally, he will say the patient is a very good candidate for amputation

66 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

from a psychosocial perspective. He will typically say, “Yes, there are someissues, but if this is reasonable, if you feel comfortable with it, it’s okay to proceed. I don’t have any big concerns.” Sometimes patients have things to workout such as family problems, financial problems, or substance abuse and dependence issues. You are not going to make someone’s narcotic dependence
better by cutting off their leg. It is a bit counterintuitive, but if you can wean
someone off narcotics going into surgery, you can sometimes avoid narcotics altogether, and certainly start back at a lower dosage when they do havean amputation. Sometimes Dr. Wain says, “No way.” I am proud to say that
we typically see eye-to-eye on the “no way” patients, but I send them to Dr.
Wain so that I am not the only one saying no. The entire team is involved
with the decision, and we are able to say to the patient that we all said no.
What is our experience? Approximately 15% of the 2,250 amputations
from the conflicts are late amputations. Most of these are transtibial anda few have been higher up. Amputation is rare in the upper extremity. We
have had eight or ten upper extremity amputations. This most often happens
when a person has a painful, stiff, useless hand that they think is a biologic
paperweight, and they want to be able to do more. Our orthopaedic dogma
is typically that a bad hand is better than an amputation but a bad foot is not.
However, sometimes the hand is bad enough that you are better off with an
amputation and patients realize that. The few upper extremity amputations
that I have seen or done were very reasonable and pragmatic in their approach. These patients raised fewer red flags than some of our lower extremity patients. What are the outcomes? Generally, they are good. I think carefulpatient selection is critical.
In summary, good results are achievable with limb amputation. We allsee our poster children running around here. We have patients participatingin the Special Olympics, people have returned to duty, returned to theater,and returned to the Special Forces after limb loss, but there is no guaranteeof success. A patient’s function may not be as good as he thought it was going to be when he asked for the amputation. You hate to do something to apatient that is theoretically disfiguring and definitely permanent and havethem regret their choice. Again, patient selection is critical, as is the teamapproach, in order to evaluate patients from a psychosocial perspective andfrom a surgical perspective.

67

WRNMMC Complex Spine Program:
A Multidisciplinary Approach to the
Surgical Patient
Christopher J. Neal, MD
CDR, MC, USN
As a neurosurgeon I primarily perform spine surgery. Today I will discuss
our multidisciplinary approach to patients with spinal deformities at Walter
Reed National Medical Center (WRNMMC). This is a project that we beganalmost four years ago.
What does it mean, from a spine surgeon perspective, to bring in a multidisciplinary approach? What are the components that we have used, added,
changed, and rejected? What are the benefits that surgeons gain from theperspective of mental health professionals in dealing with patients with spinal deformities? We know that, especially in the military, multidisciplinarygroups are like building sand castles. If maintenance is not consistent, thetide will come in and wash them away. If you are deployed, you have to return and build it back up. This process is constantly evolving, which I thinkis good because each year the process is better.
In 2011, we introduced the multidisciplinary approach with a basic question: how can we improve the outcomes of patients undergoing spinal deformity surgery? The model comes from Northwestern University, where I did
my fellowship. Complex spine surgery was defined as having surgery longer
than six hours with more than six levels of surgery. We were initially focusedon medical risk stratification, post-operative ICU care, and taking care ofinter-operative issues. We quickly realized that we could do more and that
we should do more for these patients.
Here is an example of a typical patient. The patient had many complex
problems. He had multiple surgeries prior to his admission to us, he had
narcotic addiction and was frequently admitted to the hospital for narcotic
overdoses, and he was depressed, we think, due to chronic pain. He was not
improving. We know surgery cannot treat depression or anxiety, nor can surgery treat bipolar disorder, but surgery can help with pain. If we can identify

68 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

the pain and what is causing it, and fix it, then I think we can begin to makesome improvements in patients’ lives. This is extremely simplistic, but I haveseen this time and time again in clinic, where a patient has a spinal disorder, whether it is scoliosis, kyphosis, or spondylolisthesis. Some conditionis pinching a nerve and the patient has pain. Was the patient’s depression
or anxiety, or fill that blank in with whatever you want, there before? Did it
begin with the chronic pain? The patient is not getting better. Their lifestyleis limited. They cannot do the activities they enjoy and they are sitting at
home all the time. They may begin drinking and they are typically using
narcotics. They are in a downward spiral. The question that we always haveto ask ourselves when we see these patients is, what came first? Were thesepatients already severely depressed and they happened to have an X-ray thatshowed a spinal disorder? Or was their pain driving the process? This is hardto assess and it takes people a lot smarter than I am to try to figure this out.
Fortunately, in the 2011–2012 academic year, we added a mental healthcomponent to our program. What component does a patient’s mental healthplay in pain that comes from a spinal deformity? We started looking at how
we treat pain, both before, during, and after surgery, and then brought someof our anesthesiologists on board. We asked, “What can we do during surgery that will begin to make pain better?” I think that this approach changed
the way that we look at a patient facing complex spine surgery. In addition
to significant medical problems, there may be significant mental health comorbidities. We needed to think about co-morbidities up front. Specificallywith chronic pain patients, we needed to address their issues up front otherwise we will not achieve the desired outcomes.
To put this type of surgery in perspective, patients will lose one to three liters of blood during surgery. There is significant risk of heart attack and pulmonary embolism. As patients get older, especially patients in their 70s and
80s, the complication risk approaches 100 percent. We tell patients up front,“You’re going to have complication. I don’t know what it is. I don’t knowwhat it’s going to be, but it’s going to happen.” The goal of the multidisciplinary group is to figure out what the complication is going to be and head
it off before it occurs. This is a quality of life surgery with life-threatening
complications. This is not a surgery we schedule the day before.
The goal of spine surgery for deformity is a tradeoff. Ideally we are trading
less motion for less pain. About 70% of patients get 70% reduction in theirpain, but then the question we always have to ask ourselves is, what happens
to the other 30 percent? One of the hardest things I have to tell patients isthat it will take a year to recover from their surgery. Everybody wants the
Snickers Bar® satisfaction. Right after surgery everyone wants to feel great.
There are some spine surgeries that are like that, but surgeries to correct deformities take one year of recovery time. That is a difficult concept for people

Christopher J. Neal, MD 69

to fully understand.
The mental health component that hit home for me was with a patient
I will call Eddie. Eddie had a long-standing history of depression. He had
several back surgeries and was miserable not only from back pain, but froma pinched nerve causing severe leg pain. Eddie had undergone the first stageof the surgery and was preparing for stage two. We presented his case at oneof our meetings. Dr. Mrizek said, “Hold on. I think we should hold off onsurgery.” Why should we hold off on surgery? We had a filter in to preventa pulmonary embolism from occurring. We had a plan for anticoagulation
after surgery. His heart was clear. His lungs were good. He was ready forsurgery. “Yes, but he’s got a plan for how he’s going to kill himself next Saturday.” I had just seen Eddie the day before and talked with him. Everything
seemed fine to me, perhaps because I was too focused on his X-rays or talking about the surgical plan or what was going to happen afterwards. Sometimes it takes the experience and the expertise of a Dr. Mrizek to look anddig a little deeper.
I think the delay saved Eddie’s life. At a later date he had a great surgicaloutcome and now has less pain. Did the screws and rods treat his depression? No. Is he still being treated? Yes. Does he have less pain? Yes. Is he pain
free? No, but he is better. I always ask patients two questions, usually about
one year post surgery. Are you glad you had surgery, and would you do it
again? Eddie said yes to both questions and he is now several years out, but
I do not think that would have been the case if I had proceeded with my approach solo. It takes a team approach to assess complex patients like Eddie.
Another familiar example is the patient who is a chronic marijuanasmoker. “Oh, no, Doc, I’m good. I stopped.” The patient has some dementia,
underlying bipolar disorder, and he is losing function in his hands. He wasdenied by transplant surgery service for transplant due to his underlying renal failure because he lacked the consistent mental capacity to comply withthe medical regimen afterwards. What do we do with complicated patientslike this man? His life expectancy for five years is pretty good, but looking
ten years down the road it begins to get a little sketchy. However, he is losing
hand function and he has many other problems. It takes a team approach toprepare a patient like this for surgery and to prepare him for the extensive
rehabilitation afterwards. We operated on him, and four weeks out he wasable to tie his shoes and button his pants. He is still smoking marijuana, but
I cannot treat that problem with surgery.
How do we know if what we do really works? The key is to look at outcome measures. We have several instruments available to measure outcomes and to follow patients over time. Some examples include the Short
Form-36 (SF-36), The Generalized Anxiety Disorder-7 (GAD-7), the Patient
Health Questionnaire-9 (PHQ-9), and the Distress Risk Assessment Method

70 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine(DRAM). All of these instruments help us in the psychological approach topain management.
The Pain Assessment Screening Tool and Outcomes Registry (PASTOR)
is being introduced by the pain service at WRNMMC. PASTOR is a 20–30
minute survey that produces a comprehensive three-page clinician report ofa patient’s chronic pain. PASTOR was developed in response to the National
Defense Authorization Act (NDAA) 2010 recommendations for “performance measures used to determine the effectiveness of the policy in improving pain care for beneficiaries enrolled in the military health care system.”
The detailed report graphically demonstrates where and how a patient isexperiencing their pain. In addition, the report contains information about
three activities that the patient finds important and how pain is directly impacting their ability to perform these activities. Warnings are also included
to notify the physician about key concerns such as alcohol or opioid abuse,suicide ideation, PTSD, depression, and anxiety.
I think PASTOR will be very useful to patients who are classified as complex spine patients as well as all patients who are in chronic pain. It will help
clinicians assess the patient’s readiness for surgery on many levels. It will also
help us assess what we might do differently. For example, do we need to stop
certain medications prior to surgery or come up with a different plan in theoperating room because their SSRIs are going to inhibit their platelet function and therefore they will lose more blood? Can we stop the SSRI or do
we just need to work faster in the operating room? There is a balance. Does
the patient have enough strategic reserve to handle a complex spine surgery
with a year of recovery time? Are they ready? Does the patient fully understand what it means when I tell them that I am going to cut their back open,
insert screws and rods, and cut their bones? Are they ready? Sometimes wewill get the answer that we want, “Okay, yes, you’re ready,” but it takes a second assessment or perspective to feel confident.
How do we treat pain? I believe pain impacts the mental health of patients before surgery, during surgery, and after surgery. We focus on weaning
patients from narcotics before surgery and then we plan their inter-op andpost-op pain management. We rely heavily on non-narcotic medications before surgery, and during surgery we begin ketamine. We are almost readyto launch a study to see if ketamine actually helps decrease patients’ postoperative narcotic usage. We continue ketamine for 24-48 hours, or evenlonger, depending on the patient’s response.
The beautiful part about our multidisciplinary meetings is that every
week or every month that we meet, we take away something new from talking to each other. Effective pain management for patients with complex
spine issues takes a multidisciplinary approach. It is a group effort and welearn from each other. The multidisciplinary approach is a work in evolu-

Christopher J. Neal, MD 71

tion, and hopefully we will continue to make improvements that will help
our patients.

72 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

73

The Neurobiology and Emerging
Therapeutics for Functioning (Conversion)
Neurological Symptoms
James L. Griffith, MD
Today I will discuss patients with medically unexplained symptoms who
are diagnosed with conversion disorder. This is a tricky diagnosis. Years ago,
a Queen Square study showed that if you followed up with people diagnosed
with conversion disorder, about 40% had degenerative diseases and otherneurological diseases that were misdiagnosed. I think that has changed withimaging technology, but diagnosis is still tricky.
Conversion disorder is probably the most complex issue we deal with inpsychiatry. This is mostly because a large part of the variance typically has to
do with evolutionarily designed stress responses that we share with amphibians, reptiles, and other mammals. Basically, it is part of the normal nervous
system. Conversion disorder has a relationship with trauma that adds somecomplexity, and it also has some relationship with brain injuries. People whohave had brain injuries are more likely to develop conversion symptoms. I
will try to explain conversion disorder so that you can take ideas and apply
them to your patients.
Resilience has been discussed today. At the end of my talk I will present
a case on resilience building therapy because that is what most people withconversion symptoms need. Treatment is focused on helping patients move
forward and engage assertively when facing adversity instead of using avoidant coping. I often say to patients, “What we’re doing together is working to
get you where you’re ready to face whatever comes down the road.”
It is mostly about what conversion is not, and not about what it is. All
unexplained and unrelated results from imaging studies and other neurophysiological studies wind up in the same category labeled as medically unexplained. Conversion disorder winds up being a wastebasket term. It would
be interesting to hear stories about patients you have all had with unexplained tremor, numbness, paralysis, or almost any symptom of the nervous
system. The key piece is that the patient is honestly baffled. They are often

74 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

scared, and they are aware that despite all the willpower they can muster,
they cannot control what their body is doing. This separates the diagnosis from factitious disorder where patients know what they are doing eventhough the motivation may be unclear, especially in cases involving malingering. I recommend not using the DSM-5 diagnosis. It is a good way to give
somebody a label without getting any useful information to move forward.
In public health, conversion disorder has a large impact on health cost
expenditures and on patients’ suffering. Would you rather hear about a studyof functional brain imaging or hear about culture? It is counterintuitive, butwhat turns out to be most useful is understanding the cultural piece. If you
understand that, you will learn some pragmatic and useful tools. What ishappening inside the brain is interesting, but it is somewhat like when yourcar malfunctions. You know what is not working under the hood, but you do
not know what is going on with the driver or with other variables that are
not described in the mechanical description.
Later, I will tell you about a case I selected because it does not have to dowith trauma. A 35-year-old man, who is probably more mentally healthythan I am, developed a clicking with his fingers and toes. When I presented
this case, I asked my residents whom they were going to call. You do not ask
for a neurology consult for that.
Why is culture important? If you look around the world where there is alarge correlation of functional neurological symptoms, not just where there
is violence but where there are human rights violations, you can track thiseasily. Arthur Kleinman, an important figure in medical anthropology, dida great deal of his research in China. He studied the impact of the Cultural
Revolution and documented detailed descriptions of what is diagnosed asneurasthenia in China. For us neurasthenia is an old term, but in China
neurasthenia is regarded as a physical disease of the nervous system involving too little physical energy. People develop fatigue, sleep problems, lowmood, and many other symptoms. We would say the person is depressed.
The Chinese neuropsychiatrists would say the person is depressed because
they have neurasthenia. What Kleinman observed is that if you treat patientswith anti-depressants the neurovegetative symptoms improve, but the person’s functioning does not improve. From Kleinman’s studies we learned thatwhen verbal processes for expressing distress are attenuated or suppressed,
people can develop medically unexplained symptoms. Kleinman thinks ofsomatization as a bodily idiom of distress, basically a language or a communication of the body that speaks when you are not permitted or not able touse words to express your distress.
My close friend and colleague, Carlos Sluzki, who managed to get outof Argentina during the Dirty War by the military dictatorship that ruled
from 1976-1983, wrote about the 10,000 Argentinians who disappearedJames L. Griffith, MD 75

from their homes in the middle of the night. The families were told if theysaid anything about the disappearance they would never see their loved ones
again. Sluzki documented outbreaks of physical symptoms in these families.
Richard Mollica’s observations with the Cambodians in lower north and eastof Boston who survived Pol Pot were similar. What stood out to me was thatyou do not need the unconscious to play a role. People know perfectly wellwhat is causing their distress and why they are suffering. There is no repression.
We can take a clue from this and work backwards. If somatization is abodily idiom of distress that appears when speaking is not permitted andnot possible — and it might not be possible because of political oppression,or because it would be shameful, or because if you speak openly you may
hurt someone else — working back from this is fairly straightforward. You
create context where it is possible to have conversations that were not possible to have safely before. We will come back to this.
I think ICD-10, by and large, has been useful. In the trauma field more
people working with PTSD will use ICD-10 because an ICD-10 conversion disorder is simply somatic dissociation. It is a branch of dissociation.
From the beginning, John Nemiah said conversion disorder should never
have been split off in DSM-III. It is a part of a dissociation. What does thishave to do with posttraumatic stress? The connection between childhood
trauma and the later appearance of physical symptoms in PTSD was notknown years ago. A basic piece to understand is that the brain responds toexperience, not to objective events. It works like this: from your viscera, up
the afferents to the vagus nerve, and from the five senses tracking down andturning medially through the temporal lobe, through the amygdala, and thebasolateral nucleus, the brain picks up any emotionally salient event that
may have to do with threat. We have multiple memory systems in the brain,
but certainly two of the big ones are the one for narrative memory organized more around the hippocampus (explicit), and the one for emotional
memory organized around the amygdala (implicit).
What is the connection with PTSD? From birth your amygdala is set togo. Some of the earliest implicit emotional memories in human life are theattachment memories which have no association with your memory. However, implicit memory codes images, body sensations, and emotional states.
There is no story. There is no sense of remembrance. The amygdala is mature from birth and gets more efficient the higher the state of alarm. On theother hand, explicit memory is organized more around the hippocampus.
The Circle of Papez is associated with narrative memory. Everything that I
remember — coming to work today, leaving GWU, calling Mr. Obie to meet
me at the security gate — is a story. It has a beginning, a middle, and an end.
It is in language.

76 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

Most people do not have a system mature enough to remember things
earlier than about two or three years of age. Many people have the memoryof studying for an exam, getting so scared about it that you were unable
to remember anything, and then failing the exam. On the other hand, with
implicit memory the higher the state of arousal, the more the circulatingcatecholamines, the more efficient implicit memory gets, so that at the endof the day the person winds up being in a state with powerfully remembered
images, emotional states, and body sensations, but with no story. These sensations come out of nowhere with subliminal cues.
In our epilepsy center we had high rates of pseudo-seizure cases for aperiod of time. One patient stood out. We knew the patient had an abortion.
We knew that her seizure in the hospital had no seizure phenomena on the
split-screen EEG. There was no other clear history, but, without telling you
her whole story, there was a great deal of guilt about the abortion. There wasa great deal of yearning for the pregnancy. We used a four-column checklistof date, time, situation, thoughts, feelings, and body sensations to track a
seizure that happened in a drug store and occurred when the patient waswalking down the aisle containing the home pregnancy kits. Had we not
had the data to go back carefully to track the details, we could have missed
the connection since the patient was not aware. It was completely subliminal
until we talked about it. Someone with PTSD is often in a similar state. Cues
set off emotions and bodily sensations that come out of nowhere, and you
wind up with two big disorders that bring people in with medically unexplained symptoms. One is panic disorder, but the number one disorder is
PTSD. With both disorders there are correlations with over-utilization ofhealthcare.
When you study large populations, you will see high rates of functional
neurological symptoms in places where there is violence and other threats
to safety, and also in places where there are human rights violations withsilencing and suppression. When we look at populations clinically we see
a significant correlation. We learned to appreciate that many soldiers in
Vietnam who came home with PTSD were also individuals who had been
abused in childhood.
If you go to Mark Hallett’s laboratory at the National Institutes of Health(NIH), you will learn a great deal about functional symptoms. If you go to an
epilepsy center, you will see many people with non-epileptic seizures. They
will talk a great deal about trauma. Are they the same or are they different? I
will make the case that they are different. How many people have witnessed
loss of speech or a paralyzed limb as a conversion symptom? This is easy to
study in the lab because your control is the other side of the bike. Generally,
if you do sensory evoked potentials or motor evoked potentials, the input
and the output at the elementary level is okay. What is happening is more

James L. Griffith, MD 77

in the middle, with a complex analysis integration of information. If my left
arm is paralyzed, we will order a neurological consultation. The neurological evaluation demonstrates that my motor functioning is intact. Neurology
residents spend a great deal of time practicing the “tricky things” that will
demonstrate a patient’s motor function is intact. The right side of my sensory motor cortex shows deactivation compared to the left side. On the other
hand, if we go forward and look at the prefrontal cortex and the anterior
cingulate, these areas show a high level of activation.
Does anybody know why your motor cortex is deactivated, but your prefrontal cortex and anterior cingulate are activated? It works like this. Somepeople compare it to a family therapy model. The prefrontal cortex is theexecutive system in the family, or the parents. The parents have to ride herd
over the subcortical systems that tell you to move toward things. Your amygdala tells you to move away from things. Your ventral anterior cingulate
modulates emotional responses. Much of our current thinking in psychiatry
has to do with whether these regulatory systems are intact, but basically theprefrontal cortex can send down fast conducting glutamate receptors andmake adjustments. When the prefrontal cortex is deactivating the sensory
motor cortex, the person is not able to move the limb on the opposite sideof the body. The ventral anterior cingulate is an interesting area because it ismainly a conflict detector. Within the brain, you always have to worry aboutcrosstalk between information streams. Let us say that there is an area in thisbuilding that is supposed to be for officers and someone who is not an officer
enters the area. How fast would that be detected? You can be sure that thepeople who do the detecting will get an activation of the anterior cingulate
because this is an area that takes the virtual images your prefrontal cortex
uses to determine what reality should be. If the information streams do notmatch, the anterior cingulate picks up the conflict and signals the prefrontal
cortex to fix it.
In terms of psychogenic paralysis there are other activations of the limbic
forebrain. The limbic areas are sending information streams that the prefrontal cortex would say is expectable reality. If the information streams are
not fitting well the fix is to shut down the motor cortex. All of this makes
good sense. Interestingly, transcranial magnetic stimulation (TMS) generates small electric currents that can reverse this process. In people with motor paralysis as a conversion symptom, often you can reverse the paralysis
easily with TMS over the area of the motor cortex.
What about psychogenic movement disorder? After the physician completes all the appropriate examinations, if you have a physician skilled inmovement disorder, they can demonstrate that the movements are notcaused by a neurological condition. As you might expect, there are no functioning brain images because you cannot do an MRI scan, but there are stud-78 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

ies that focus on management of attention. What is interesting is that psychogenic movement disorder seems to be an over-control phenomenon. It
is different from the paralyzed limb. Imagine you are a millipede with yourthousand little legs, and I ask you to focus on walking. Or imagine the NBA
playoff finals and I ask Stephen Curry to focus hard on how he dribbles andwhich muscles he is moving to dribble. What do you think will happen?
A great deal will happen. In fact, with static posture there are many tiny
movements that are under automatic control of your vestibular apparatus,of your vision, and of net receptors that are constantly making adjustments,
so that, without thinking about it at all, it is automatically programmed tokeep you more or less standing in one place. When people have psychogenic
movement disorders you can show that there is an effort to try to overuse
the executive division of the attention system to try, with volition, to manage
movements that should be under automatic control. What happens when
you distract the person? The movement goes away and control is restoredwith autonomic regulation.
There is a big debate about non-epileptic seizures. One can make a casethat non-epileptic seizures may be a remnant of or the same thing that we
see in other animals with a freeze response or immobility reflex; in otherwords not an abnormality. A carefully done MRI study showed that there
was a significant amount of cortical atrophy over the right hemisphere motor and premotor areas. The premotor area controls much more integrated
movements, but one key thing is that when seizures occur there, they often
happen explosively. The seizures can sometimes happen in clear consciousness. There is discussion about whether non-epileptic seizures have to dowith an emotional activation of this area. The bottom line suggests that limbic behavioral activation of the premotor cortex may be a mechanism.
Evolution builds on platforms. Whatever amphibians have, we still have,but we can overlay it. Most of the time human beings do not engage thefight-flight response when they are threatened. Instead, I say humans engage in tend and befriend. I remember this phrase well from September 11th.
From my eighth-floor office window I could see smoke coming from thePentagon. I knew I was not going anywhere because there was no traffic
moving in Washington for hours. Why? People were not trying to flee. They
were trying to get home to their families. They were trying to get to theirchildren without any evidence that their children would be safer with themthan if they were not with them. Under threat, human beings generally activate an oxytocin-vasopressin-dopamine system and we huddle, we group.
We gather together, and that has been and is our evolutionary strength. Antelope flee, but down at the bottom, all animals, down to amphibians, will
have a freeze response, which may have to do more with cholinergic systems.
The evolutionary argument is that predators tend not to like dead meat, so if

James L. Griffith, MD 79

you act like dead meat you are less likely to be eaten. Among humans, about
20% of people can easily go into a freeze response so there is some variance.
To summarize the big points, violence with suppression of expression
produces high rates of conversion symptoms. Trauma history has a distal
effect. If your amygdala is in a hyper-aroused state, you are more likely totrigger somatic dissociation. The immobility reflex is well understood. Dr.
Bill Klemm at Texas A&M Veterinary Medicine has spent his entire career
studying the immobility reflex. The reflex is a descending inhibitory reflex
to the brain stem, but the formula for producing immobility is fear plus restraint. When a person feels trapped and scared, if they are vulnerable tofreeze, that is when the freeze response will occur.
How do you help people? Again, the big points are that conversion
symptoms are not about repression of unconscious impulses most of thetime. Symptoms occur when there is an explicit suppression of the ability
to express experience. How do you deal with somebody who has traumas
or risk factors like PTSD? In its chronic form, PTSD might be lifelong. You
can manage it, but you are never going to cure it. Hyperarousal will always
be an issue. You work with people to teach them how to quickly move fromhigh-arousal states into low-arousal states. What do you do if there is a riskof freeze response? You either decrease the fear or you decrease the restraint.
When I talk to medical students they are always thinking about making
rounds on patients. If you want to earn honors on your surgery rotation, youbetter act like you are excited to be on surgery rounds. What if you hate it?
You act like you are excited. In the right person, this will be enough to trigger
a symptom. Imagine a social situation that you cannot stand being in, but
you are obligated to be there. Not only are you obligated to be there, you are
obligated to act as though you enjoy it. The useful tool is being able to work
backwards. What you try to do is create safety and create settings where dialogues can happen that have not been able to happen.
Dialogue can take many different trajectories. Dialogue can often identify
issues surrounding identity. There are three big groups in identity: who you
know yourself to be in your heart of hearts; who you know yourself to be inyour group role; and who you know yourself to be in the collective group.
Suppose you are a physician and in your heart you feel a great deal of gratification in helping other people. You come from a family where others are
physicians and you have good role models. The Hippocratic Oath means
something to you so all three identity groups line up and that is powerful.
Suppose there are many physicians in your family. You feel obligated to bea physician, but you really want to be an artist. This is when identities clash.
These often give rise to some of the most difficult, unspeakable dilemmas
that simply cannot be talked about.
This is a case I selected because there is no trauma history. A man in

80 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

another part of the world began experiencing slow, sporadic, non-rhythmic
clicking sounds that occurred whenever he tried to fall asleep. The clicking sounds progressed and began to occur during the day. He consulted aneurologist, a behavioral psychologist, and other health care professionals.
Nobody was helping him. He began to have similar sensations in his throat.
His neurological history was negative; there was no history of psychiatricproblems, no drug abuse, and no trauma. We always ask what is time-linked.
When did something change? This is his story. The patient was a talented,
upwardly mobile man who had many job promotions. Recently he turned
one down. He was offered a big promotion, but he was the type of person
more inclined to be a parish priest and not the bishop. That is when his
symptoms began.
Earlier I said I think of this as a resilience-building therapy. I have threesets of conversations with patients. The first conversation involves threequestions, and they are not simple. What do you desire? What do you wantin your life? What would be the future that you would want if you could
have it? If the questions are too difficult and patients cannot answer, then I
go back and ask, “Can you tell me when you felt that life was on track, andhow is that different now?” The second conversation is about what skills,
resources, and competencies the patient has to work with. The third pieceof the conversation is obstacles. I go back to the pivotal event. When you
turned down that promotion, what changed? The patient said, “This is how
it works. If you turn down a promotion people look at you differently. You
are no longer the go-to person.” This is a clash between the heart of hearts
self — whom I know myself to be, whom I want to be — and the workgroupself. The approach I would use is one that would help the patient move fromavoidant coping and begin to utilize assertive coping.
When people use avoidant coping they shut down a great deal of awareness; awareness of feelings, awareness of impulses, and awareness of desires. This dovetails with some of the functional brain imaging. We talked
it through. One thing I was able to learn from this man was that he felt likehe had not been entirely authentic. He had not been honest about what hewanted. He attended the right prep school, the right university, and thenthe right graduate school. He had a great family with resources to support
his education. Then he was out of school and in a downtown law firm. At acertain point, you veer off the map and do not know what you are supposed
to do next. In fact, the path he took did not match up with what he wanted.
A great deal of what we worked on was being sensitive to the spontaneous things that he felt. For example, he was at a dinner party and heard thesong, Everybody Needs Somebody to Love and he felt overcome. I asked him
about his feelings because this was a popular young man who had dated extensively but he had never had a long-term, committed relationship. He said,

James L. Griffith, MD 81“I’ve been avoiding it.” I asked him to do some homework. The homework
was to spend time imagining what life might be like in a long-term, committed relationship, and when he thought that it was a bad idea to keep track of
the thoughts. I asked him to write it down and bring his journal to the next
session where we would talk about what he had written. We talked about his
conflict between his personal self and his group self, and that he was dealing
with his conflict by self-silencing. Once you begin self-silencing, you activate
all the things I have talked about, minus the trauma. This man did not have a
trauma history. What came out is that this was a man that people envied for
his life, his income, his resources, and his abilities, but he did this by coastingin life. If he put himself out there, if he took chances, he would have to face
failure. At the end of the day, the coasting gives contentment and the risktaking gives happiness. That is basically the therapy.
What happened to his clicking? This is interesting. Often the symptoms
do not go away completely, but they become a way to monitor your life. He
still has some clicking, but now when it happens he can relate it to specificthings he does. It is no longer an alarm. The clicking does not mean he is sick.
I pulled out seven cases that were referred to me. In four cases 50% had
remission of symptoms with no more than six therapy sessions. In threecases I could not engage the person. At least one of those, I think, was probably factitious disorder, which is a different diagnosis. I will end here, but
hopefully I have given you some ideas and tools that you can use with yourpatients.

82 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

83

Speakers
Russell B. Carr, MD
CDR, MC, USN
CDR Russell Carr is Chief of the Psychiatry Department at Walter Reed
National Military Medical Center. He is a board-certified psychiatrist andthe only fully-trained psychoanalyst on active duty in the DoD. He graduated from the University of North Carolina at Chapel Hill with a BA in Russian
Language and Literature with Highest Honors, and then completed medical
school at the University of Tennessee at Memphis. He completed an internship in Psychiatry at Naval Medical Center Portsmouth. After five years as
a General Medical Officer, Dr. Carr completed a psychiatry residency at the
National Capital Consortium. He has served fifteen years of active duty in
the Navy, including a deployment as a General Medical Officer in 2002 with
the JFK Battle Group to the Persian Gulf in support of Operation Enduring
Freedom and another deployment in 2008 to 2009 with an Army Combat
Stress Control Unit to Mosul, Iraq. Prior leadership roles in the Navy haveincluded being the Medical Department Head aboard the USS SEATTLE asa GMO, the Chief of Inpatient Psychiatry and Department Head of the Psychological Health-Traumatic Brain Injury Department at the National Naval
Medical Center in Bethesda, and then the Service Chief for the Integrated
Adult Behavioral Health Clinic for Walter Reed.
In 2013, CDR Carr completed six years of training in adult psychoanalysis at the Institute of Contemporary Psychotherapy and Psychoanalysis(ICP&P) in Washington, DC. Recognitions have included being named a
Laughlin Fellow of the American College of Psychiatrists in 2008 (which
recognizes the top ten psychiatry residents in the country), being selected
in 2013 to testify before the Military Personnel Subcommittee of the House
Armed Services Committee along with the three Surgeons General and Dr.
Woodson on PTSD treatment in the military, and being requested by nameby the Ugandan military to train their mental health providers on his published approaches to difficult-to-treat combat trauma.

84 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

James L. Griffith, MD
James L. Griffith, MD is Leon M. Yochelson Professor and Chair of the
Department of Psychiatry and Behavioral Sciences at The George Washington University School of Medicine and Health Sciences in Washington, DC.
Dr. Griffith received his MD in 1976, followed by Neurology Residency andan MS in Neurophysiology at the University of Mississippi School of Medicine in 1979. He completed Psychiatry Residency at Massachusetts General
Hospital and Harvard Medical School in 1983, followed by a Clinical andResearch Fellowship in 1985.
Dr. Griffith has developed a model of psychiatric residency training thatbalances biological and psychosocial therapies in the treatment of patients
within their family, community, and cultural contexts. He provides psychiatric treatment for immigrants, refugees, and survivors of political torture in
the Program for Survivors of Torture and Severe Trauma (PSTT) at Northern Virginia Family Services. Under his leadership, the George Washington
University Department of Psychiatry has become nationally recognized for
its excellence in global mental health, psychotherapy training, neurosciences education, and psychosomatic medicine. In his clinical practice at The
George Washington Medical Faculty Associates, Dr. Griffith treats psychosomatic disorders, psychiatric complications of medical illnesses, and otherproblems of couples and families. Dr. Griffith has been named a Washingtonian Magazine Top Doctor.
David E. Gwinn, MD
CDR, MC, USN
CDR David Gwinn, MD is Chief, Department of Orthopaedic Surgery at
Walter Reed National Military Medical Center in Bethesda, MD. He is also
the Orthopaedic Consultant to the White House Medical Office.
Dr. Gwinn is a 1994 graduate of the United States Naval Academy. He
attended medical school at the Uniformed Services University and in 2007
completed his residency in orthopaedic surgery at the National Capital Consortium, National Naval Medical Center Bethesda, Walter Reed Army Medical Center. Following his residency, Dr. Gwinn completed a fellowship inspine surgery at the Cleveland Clinic.
Dr. Gwinn is the recipient of numerous honors and awards and received
the Joint Service Commendation Medal in 2014. He is the author of several
publications and three book chapters.
Edmund G. Howe, III, MD, JD
Dr. Howe is Professor of Psychiatry, Director of Programs in Medical Ethics, and Senior Scientist, Center for the Study of Traumatic Stress (CSTS) at
the Uniformed Services University (USU).

Speakers 85

He received his undergraduate degree at Yale University and his MD at
Columbia University. Dr. Howe completed an internship at Harlem Hospitaland his residency in Psychiatry at Walter Reed Army Medical Center. He attended Rutgers University law school and then received his law degree from
Catholic University. Dr. Howe joined the USU faculty in 1977. His research
has focused on medical ethics with an emphasis on ethics in military medicine and clinical care at the end of life.
Dr. Howe’s professional contributions center on his interest in ethics. He
is the Founding Editor-in-Chief of The Journal of Clinical Ethics and has
served as a member of the Walter Reed Army Medical Center, National Naval Medical Center, and Malcolm Grow U.S. Air Force Medical Center Ethics
Committees, as well as the Ethics Committees at Montgomery Hospice, theVisiting Nurse Association, Springfield Psychiatric Hospital, the V.A. Hospital of Washington, DC, and the National Institutes of Health. He is Chair of
the Human Use Institutional Review Board, USU, and a member of the CIA
IRB. He is a member (and Past President) of the Academy of Medicine of
Washington, DC, the Group for the Advancement of Psychiatry (GAP), andthe Newborn Screening Translational Research Network (NBSTRN) Bioethics Workgroup, American College of Medical Genetics (ACMG).
Dr. Howe is past Chair of International Health Law Committee of theInternational Law Section of the American Board Association, presently the
Liaison: International Section of the American Bar Association (ABA) andthe Bioethics and Law Committee, and a past appointee to the Governor’s
Commission of Health Care Policy and Financing for the State of Maryland.
He is or has been a consultant at NIH, OTA, HHS, FDA, the U.S. Public
Health Service, the National Science Foundation, and NASA. Dr. Howe ison the editorial boards of the Journal of Contemporary Health Law and Policy, The Mid-Atlantic Ethics Committee Newsletter, University of Maryland
School of Law, Baltimore, MD, BMC Medical Ethics and Innovations in Clinical Neuroscience (formerly Psychiatry (Edgemont)).
Alex Martin, PhD
Dr. Alex Martin is Chief of the Cognitive Neuropsychology Section in
the Intramural Research Program of the National Institute of Mental Health(NIMH). The program’s research is focused on understanding the neuralorganization of human memory and social processing systems and how they
breakdown in neuropsychiatric disorders. Dr. Martin received his PhD fromthe City University of New York and did his post doctoral work at the National Institute of Neurological Disorders and Stroke on the breakdown of
language and memory processes in Alzheimer’s disease. In 1985, he joined
the faculty of the Uniformed Services University where he studied cognitive
dysfunction associated with HIV infection. Dr. Martin is an elected Fellow

86 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicineof the American Association for the Advancement of Science, the Association for Psychological Science, and the American Psychological Association.
Christopher J. Neal, MD
CDR, MC, USN
Dr. Christopher Neal is Associate Program Director, Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, MD.
CDR Neal was born and raised in Missouri and came to the Medical
Corps via the Health Professional Scholarship Program. Dr. Neal received his
BS from the University of Missouri–Columbia in 1997. He attended medical school at the University of Missouri–Columbia School of Medicine andafterwards did his internship and residency in neurosurgery at the Walter
Reed Army Medical Center, Washington, DC. In 2009, Dr. Neal completed
a fellowship in complex and reconstructive spine surgery at Northwestern
University. He is a member of the American Board of Neurological Surgery.
Upon completion of his training, CDR Neal was stationed at the National
Naval Medical Center where he deployed in 2010 as an Individual Augmentee to Landstuhl Germany in support of the Global War on Terror. In 2014,
he deployed as the sole neurosurgeon to Kandahar, Afghanistan where heserved as the Director of Surgical Services for the NATO ROLE 3 Hospital.
Dr. Neal’s academic awards include the Kempe Award for the Outstanding Neurosurgery Resident in the National Capital Consortium, the General
Graves B. Erskine Award for Outstanding Resident at Walter Reed Army
Medical Center, the National Naval Medical Center Outstanding Resident
Teaching Award, and the COL Juan d’Avis Award for the Outstanding Department of Surgery Resident. His military awards include the Meritorious
Service Medal, Navy Commendation Medal, Army Commendation Medal(2), Overseas Service Ribbon, Afghanistan Campaign Medal, and the NATOInternational Security Force Medal. Dr. Neal is the author of more than 20
peer reviewed journal articles and several book chapters.
Benjamin Potter, MD
LTC, MC, USA
Dr. Benjamin “Kyle” Potter is Vice Chair of Orthopaedic Surgery at Walter Reed National Military Medical Center and the Vice Chair (Research)
and Associate Professor of Surgery in the Uniformed Services University
Department of Surgery. He is also the Chief Orthopaedic Surgeon for the
Amputee Program and a musculoskeletal oncologist at Walter Reed, and a
musculoskeletal oncology consultant at the National Institutes of Health.
Dr. Potter is an honor graduate of the United States Military Academy atWest Point. He attended medical school at the University of Chicago, Pritzker School of Medicine, where he obtained his doctorate of medicine degree

Speakers 87

and graduated Alpha Omega Alpha. He then completed his orthopaedic internship and residency training at Walter Reed Army Medical Center, winning the General Graves B. Erskine Award for outstanding graduating resident from any program in the NCR as well as the Bailey K. Ashford Awardfor best clinical research. Dr. Potter subsequently completed a fellowship inmusculoskeletal oncology at the University of Miami, Miller School of Medicine before returning to Walter Reed as an attending physician and surgeon.
LTC Potter deployed to Afghanistan in 2011, serving as the Chief Orthopaedic Surgeon of the Task Force 115 Combat Support Hospital (Role III)in Camp Dwyer, Helmand Province. Dr. Potter has authored or co-authoredmore than 120 peer-reviewed publications, as well as numerous invited
manuscripts and book chapters. He has been a principle, co-principle or associate investigator on more than 20 grants and programs totaling nearly$65 million in funding, including serving as a Deputy Director for the ongoing Surgical Critical Care Initiative (SC2i). His research interests include
heterotopic ossification, trauma-related amputation techniques (including
osseointegration and targeted muscle reinnervation) and outcomes, management of metastatic disease of bone, and bone and soft tissue sarcoma
treatment.
Jack Pula, MD
Dr. Jack Pula is a psychiatrist and psychotherapist in private practice in
New York City, Assistant Clinical Professor of Psychiatry at Columbia University, and psychoanalytic candidate at the Columbia Center for Psychoanalytic Training and Research.
Dr. Pula has given multiple talks in psychiatric and psychoanalytic settings on transgender experience and mental health. He serves on several related committees, including the American Psychiatric Association’s Working
Group on the Treatment of Gender Dysphoria, the Committee of Genderand Sexuality of the American Psychoanalytic Association, the Group for
the Advancement of Psychiatry Committee on LGBT Issues, and the transgender committee of the Association of Gay and Lesbian Psychiatrists. He
is an active member of the World Professional Association of Transgender
Health (WPATH).
Dr. Pula combines his experience as a gender and sexual minority, andadvocate for disenfranchised populations, with his psychoanalytic education and unusual clinical experiences as patient and doctor, in a way thatuniquely informs his thinking about mental health, psychopathology, transgender experience, and his role in helping others.
Dr. Pula’s publications include: “Ethical Issues Raised by the Treatmentof Gender-Variant, Prepubescent Children,” with Jack Drescher, MD; “OnPsychotherapy, LGBT Identity, and Cultural Visibility: In Conversation with

88 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

Alison Bechdel,” with Adam Critchfield, MD; and “Understanding Genderthrough the Lens of Transgender Experience,” forthcoming in the Journal of
Psychoanalytical Inquiry.
Brett J. Schneider, MD
COL, MC, USA
Colonel Brett Schneider, MD is Director for Behavioral Health Services,
Walter Reed National Military Medical Center (WRNMMC), Bethesda, MD.
He also serves as the appointed Child and Adolescent Psychiatry Consultant
to the U.S. Army Surgeon General. Dr. Schneider graduated from Creighton
University with a co-major of Biology and Philosophy. He attended Creighton University School of Medicine and after graduation he did his psychiatry
residency and a child and adolescent psychiatry fellowship at Walter Reed
Army Medical Center. After completing his training, Dr. Schneider served
as the division Psychiatrist for the 1st Infantry Division in Vilseck, Germany
for two years before returning to Walter Reed to do a fellowship in forensic
psychiatry. He served two tours in Iraq for Operation Iraqi Freedom. Dr.
Schneider served as the Chief of Telepsychiatry and the Chief of Child andAdolescent Psychiatry prior to being named the first Chief of Psychiatry,
WRNMMC.
Harold J. Wain, PhD
Dr. Harold Wain PhD, FAPM, is Chief of the Psychiatry Consultation Liaison Service at Walter Reed National Military Medical Center. He is also a
Professor in the Department of Psychiatry at the Uniformed Services University, Bethesda, Maryland. Dr. Wain was Chief of the Psychiatry Consultation Liaison Service at Walter Reed Army Medical Center. He has previously
been Director of the Psychiatry Consultation Liaison Service and the Director of the Psychosomatic Clinic. Dr. Wain has also been Chief of the Psychology Service at Walter Reed Army Medical Center.
Dr. Wain completed his clinical training at Walter Reed Army Medical Center. He has published and lectured extensively both nationally andinternationally in the areas of psychosomatic medicine, hypnosis, somatoform spectrum disorders, trauma, pain, and consultation liaison psychiatry.
Thomas N. Wise, MD
Dr. Thomas Wise is Medical Director of Behavioral Services at Inova
Health System. He serves as Professor of Psychiatry and Associate Chair of
the Department of Psychiatry at The George Washington University Schoolof Medicine. Dr. Wise is also Professor of Psychiatry and Behavioral Sciencesat The Johns Hopkins School of Medicine and Professor of Psychiatry at The

Speakers 89

Virginia Commonwealth University Inova Campus School of Medicine. His
research interest is in the area of coping with medical illness.
Dr. Wise is series editor of Advances in Psychosomatic Medicine. He is coeditor of Psychiatry in Primary Care in its second edition. Dr. Wise is also
editor of a new textbook, Psycho Oncology. He has published more than 315
papers and chapters
Dr. Wise was born in Reno, Nevada, and raised in the District of Columbia. He graduated from Dartmouth College and Duke University Schoolof Medicine. Dr. Wise is board certified in Psychiatry and Psychosomatic
Medicine.

90 Artiss Symposium 2015 — Current Concepts in Psychosomatic Medicine

Center for the Study of Traumatic Stress
Uniformed Services University
4301 Jones Bridge Road, Bethesda, MD 20814-4712
www.CSTSonline.org