What Is Psychosomatic and Addiction Psychiatry?

Session 171

Dr. Walter Luchsinger is an academic psychosomatic and addiction psychiatrist. He joins me today to talk about his unique specialty and what makes it so interesting.

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[01:20] Interest in Psychiatry and Psychosomatic Medicine

From the beginning, Walter has wanted to be a psychologist and when he was in medical school, he just loved his rotation in psychiatry. During medical school, his roommate ended up being diagnosed with schizophrenia and struggled a lot.

This caught his attention and really affected him in many ways. He also knew of people close to him who suffered from addiction. And so, those reinforced his decision to do psychiatry.

[03:18] What is Psychosomatic Medicine?

'Psychosomatic Medicine is basically a combination of psychiatry, medicine, and surgery.'Click To Tweet

When you go through the fellowship, you see a lot of patients with very complicated medical conditions and surgical conditions that have problems with their mental health. Surgical doctors and medical doctors consult you to help them with those conditions because they don’t know what to do.

General psychiatrists will have more difficulty treating those patients because they wouldn’t know how to handle them that well. So in certain ways, it’s like a bridge between psychiatry and the other specialties.

It’s more of an interdisciplinary working hand-in-hand with the other specialties versus general psychiatry which is kind of siloed out and not really interacting with the rest of the medical team.

[05:27] Biggest Myths or Misconceptions Around Psychiatry

One misconception around psychiatrists is that they only give medications “just because.” Walter actually tries to keep his patients off medication. He advises them to have good sleep hygiene, to exercise three times a week, to have a good diet, and do mindfulness and breathing techniques. And if they can do those four things most of the time, he can keep them off medications for depression, anxiety, and stress.

[07:18] Traits that Lead to Becoming a Good Psychiatrist

Number one is to be there and care for your patients because that’s all they need. You also have to have empathy although it’s not easy to do. Try to explain things as easily as possible so don’t use medical jargon. Speak in a language they would understand.

'Give them time. They’re not just another number.'Click To Tweet

[09:50] Types of Patients

Psychiatrists generally treat bipolar, depression, schizophrenia, anxiety, and all that. As a psychosomatic medical specialist, you can do outpatient and treat different pathologies.

“Someone with psychosomatic illnesses related to anxiety disorders would feel they have something, but they really don't have it.”Click To Tweet

People with psychosomatic disorders would think it comes from something else like the environment or illness. They always think they have something but you keep telling them that they don’t have it. They think they have multiple pains all over the body, but they really don’t have that much pain. It’s always subjective.

What they see the most during their fellowship is delirium, wherein people after surgeries get really confused.

So you need to avoid certain medications. Or prevent patients from not getting exposed to light during the day. You need to keep them active during the day and do certain things to avoid them from getting so confused and agitated.

Part of their job too is to make the decision whether a patient is fit for transplant. Thousands of people die every year waiting for a transplant and so that’s a huge decision for you to make.

They also deal with suicidal patients dealing with depression and anxiety as well as neurological conditions like Parkinson’s disease. They could get a patient with a huge list of medications and then you would need to assess all the medications and the patient’s behavior.

Psychiatrists also treat patients who get hospitalized for addiction, whether it’s due to opioid addiction or methamphetamine addiction, cigarette, or alcohol addiction.

[14:43] Typical Day

Generally, Walter would start in the morning and go over the list of all the patients that are hospitalized and that you’ve seen. Then he’d see all the fellows present the cases. And prior to this, he would need to review the charts on the computer to see all the labs. He’d be doing all the notes from the day before overnight, then return all the cases to the attendings and present the treatment plan.

Since it’s a teaching hospital, students would sometimes do the interview and have further discussions. Then at noon, sometimes he would see new patients that come in and they’d review the case. The last new patient could come in until 4 pm. Usually, there are three fellows that handle 20-30 patients, being divided among them.

[17:43] Taking Calls

When an emergency happens, a capacity consult is done. You basically assess the patient if they have the capacity to make decisions because they could be confused or delirious. And some of them want to leave the hospital, for example. So you sometimes need to make a note stating they cannot leave the hospital.

There’s another consult that they get when they need to assess the capacity of patients to make medical decisions. They also get emergencies when the patient gets agitated and they start throwing punches. And they’re being called for that so they can calm the patient down.

And if they cannot do that, they’d order emergency medications. And if they want to leave the hospital, they need to talk to patients to see if they have the capacity to understand the situation and the consequences of leaving the hospital.

'It's really difficult to save someone that has the capacity to leave the hospital and they can die at any moment.'Click To Tweet

[20:50] Life Outside of the Hospital

Walter says that he’s having the best work-life balance. He never felt he was stressed out or he had too much work since he started. Walter recommends that if you like internal medicine but you’re thinking of psychiatry, you can be double-boarded in medicine and psychiatry. Or you can do psychiatry and then do psychosomatics. And then you can give it a touch of addiction. As for Walter, he has done three boards but he feels he’s living the dream.

[22:57] The Training Path

You do four years and then one year of psychosomatic fellowship. It is an ACGME-approved fellowship as well as Addiction Fellowship which also takes another year. In his experience at Yale, you do a little bit of outpatient. You also get to do transplant clinics, geriatric clinics, and HIV clinics. Addiction is a whole different thing where you have different kinds of rotation as well.

'Psychosomatic covers a lot from HIV to transplant to geriatric to women's health. Psychosomatic basically covers everything. 'Click To Tweet

[27:50] Message to Future Doctors When You’re Working with a Psychosomatic Specialist

Try to know the basics like recognizing and diagnosing depression and anxiety. And if you diagnose it, talk to the patient. Try to give them treatment for that to prevent them from getting worse because depression leads to worsening.

Generalized anxiety causes the patient to not sleep well and not work well and everything could get worse. And if you treat it and you feel you don’t know more than that, then just do a referral as soon as possible and people like Walter would be happy to help.

[30:17] Other Specialties They Work the Closest With

They work a lot with OB-GYN, surgery, internal medicine, cardiology, general surgery, and endocrinology. Walter wished he could have told himself to just enjoy the ride and to not take himself seriously.

In the end, you will realize that this is a marathon. Things are never over because they keep going. You need to keep on working and keep going. So it’s important to just enjoy the ride.

'Enjoy the ride and don't take yourself too seriously.'Click To Tweet

[32:45] The Most and Least Liked Things

What he likes best about his specialty is the balance that he has. He feels happy and everyone around him is happy. What he likes the least, on the other hand, is that there are patients wherein there’s no longer anything you can do to help them. For instance, there’s no treatment for Schizophrenia and that’s frustrating.

[34:51] Major Future Changes Coming to the Field

Walter sees a lot of changes coming in the future. For example, IV ketamine is now being used to treat depression, especially in people who are suicidal. When people who don’t respond to antidepressants or anything else get IV ketamine, they could instantly switch from being suicidal to happy. And getting their weekly treatments can make a huge difference.

'New treatments are coming for depression. It takes time but it's amazing.'Click To Tweet

[37:07] Final Words of Wisdom

If he had to do it all over again, Walter would still be a psychosomatic psychiatrist and medicine specialist and he thinks it’s the best combination.

Finally, if this is something you’re interested in, and you’re in between psychiatry and internal medicine, Walter recommends that you consider doing Psychosomatic Medicine.