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Thursday, February 28th, 2013
The patient often dreaded getting out of bed and frequently spent the whole day indoors. He was on multiple medications for panic attacks and had musculoskeletal tension and injuries stemming from sports accidents.
He visited psychiatrist Eric Hegybeli, DO, who suggested osteopathic manipulative treatment to reduce his anxiety and improve his musculoskeletal function.
“After a couple of treatments his body was much more relaxed,” says Dr. Hegybeli, who practices in Avondale, Ariz. “His ribs were moving, and his body was more symmetrical. He was able to come off of most of his medications, and he was not having any of the anxiety or the panic attacks.”
Like Dr. Hegybeli, some osteopathic psychiatrists approach their discipline differently than allopathic psychiatrists do by incorporating OMT. While the majority of osteopathic psychiatrists don’t perform OMT on their patients, experts suggest many of them employ other tactics that set them apart from their allopathic colleagues.
“If you look at the core principles of osteopathic medicine, one of those is the mind and body connection, which is the same basic principle that is the foundation of psychiatry.”
“At the root, osteopathic psychiatrists are primary care doctors,” says Stephen M. Scheinthal, DO, the chairman of the AOA Bureau of Osteopathic Specialists and an associate professor of psychiatry at the University of Medicine and Dentistry of New Jersey-School of Osteopathic Medicine in Stratford. “We look at the whole person. We look at not only the psychiatric issues, but the environmental issues, social issues and underlying medical disease. We’re also more attuned to side effects of medication and how medication may actually be causing the problem. I stop more medication than I start, and people get better.”
Osteopathic physicians often thrive in psychiatry because the two disciplines’ values are closely aligned, says Alyse Ley, DO, an assistant professor of psychiatry at Michigan State University College of Osteopathic Medicine in Lansing.
“If you look at the core principles of osteopathic medicine, one of those is the mind and body connection, which is the same basic principle that is the foundation of psychiatry,” she says.
James N. Horst, DO, a psychiatrist in private practice in Miami, says his experience in a dual-accredited psychiatry residency revealed differences in practice philosophy to him.
“I have firsthand knowledge of the approach and thought process of allopathic physicians, and it can be much more linear and much more disease-oriented,” he says. “Whereas I felt that myself and my DO colleagues took a more global and more holistic approach.”
This approach starts with considering how chronic conditions such as diabetes and heart conditions affect mental health, Dr. Horst says. However, he notes that he also sees similarities between MDs and DOs.
“When it comes down to prescribing Prozac, frankly, I think we’re the same,” he says. “But it’s the screening process and the differential diagnosis process that I find different.”
Thomas Wise, MD, a professor of psychiatry at the George Washington University Medical Center in Washington, D.C., sees commonalities between MD and DO psychiatrists. In fact, he says he thinks any differences are negligible.
“Patients are much more open to the osteopathic philosophy of treating the whole person.”
“I’ve always looked at osteopathic physicians as those who think in same way we do,” he says. “Many osteopathic physicians are interested in primary care, so they’re interested in the whole patient rather than dividing medicine up into specialties. But that fits in well with psychiatry.”
Dr. Wise notes that there may have been more of a difference between allopathic and osteopathic psychiatrists years ago. These days, he feels the two are closer than ever.
“Now there’s such an emphasis in psychiatry to look at the needs of primary care and the integration of primary care both in allopathic and osteopathic schools,” he says. “My guess is the difference is less and less, if any.”
One inarguable difference between MD and DO psychiatrists is that osteopathic physicians learn OMM in school—and some osteopathic psychiatrists perform OMT on their patients.
Historically, many in the psychiatry community held the belief that psychiatrists should not perform OMT on their own patients. In general, psychiatrists are discouraged from touching their patients due to the personal nature of the psychiatrist-patient relationship and the illnesses psychiatrists help patients with. For instance, when a patient’s illness is characterized by impulsivity, risky sexual behavior and an altered sense of reality, he or she could misinterpret touching from a psychiatrist as amorous, which could spell legal trouble.
“It’s a medicolegal issue,” Dr. Horst says. “When you’re seeing someone for mental health concerns or conditions, it tends to be pretty intimate because you’re telling the doctor multiple things about your life that you probably haven’t told anyone else. If a physician were to touch the patient, is the patient then thinking that this is somehow romantic? It’s called transference and countertransference. Physicians don’t think like that in any other form of medicine.”
Dr. Scheinthal says most DO psychiatrists don’t perform OMT on their patients, but that he believes it’s becoming more common for younger DOs to use this skill.
“Osteopathic medicine has changed a lot in the past decade,” he says. “Younger doctors are very proud of being DOs, they are proud of their skills, and they are proud to use their skills.”
The older generation of DOs who are now in their 60s and 70s struggled to be like their allopathic counterparts—and part of that was not performing OMT, he says.
Dr. Scheinthal occasionally performs OMT on a few of his elderly patients.
“With some very anxious older adults, it may be the only thing that helps them with their anxiety,” he says. “It’s certainly much safer than using drugs. OMT doesn’t cause falls or delirium.”
In 2010, the AOA House of Delegates approved a resolution, submitted by the American College of Osteopathic Neurologists and Psychiatrists, affirming that OMT is an accepted treatment modality in osteopathic neurologic and psychiatric care.
Dr. Hegybeli says OMT helps his patients with anxiety. He specifically works to decrease tension at the back of the head, and this allows the vagus nerve to put more parasympathetic input into the body, which makes the patient more relaxed and less tense, he says.
OMT helps anxiety patients with breathing as well, Dr. Hegybeli says.
“I work on my patients’ ribs, so the rib cage can move better and the patient can take in deeper breaths,” he says. “Then that can send signals to the brain that the person is less tense physically, and that causes him or her to be less tense mentally and emotionally.”
Also, one of the principles of osteopathic medicine is that helping the body have better circulation helps it to heal more quickly and completely, which has specific implications for certain psychiatric patients, Dr. Hegybeli says.
“If the brain is getting good circulation, the medication that I’m providing, whether it’s an antipsychotic or an antidepressant or an antianxiety agent, is going to have more perfusion into the brain,” he says.
These benefits aside, many DO psychiatrists still avoid performing OMT on their patients, though they will sometimes refer patients to OMM specialists.
Osteopathic psychiatrists’ understanding of OMM will help them know when to refer patients out for it and how to collaborate with the physician providing it, Dr. Ley says.
“Osteopathic medicine has changed a lot in the past decade. Younger doctors are very proud of being DOs, they are proud of their skills, and they are proud to use their skills.”
“It’s an integral part of some of our patients’ treatment,” she says. “Most of the time OMM cannot be provided by the psychiatrist, but it still can be a very important part of the treatment.”
Dr. Wise, who says his knowledge of OMM is limited, doesn’t think psychiatrists should perform manipulation on their patients.
“One has to be terribly careful about boundaries when it comes to that kind of manipulation,” he says. “I don’t see why you wouldn’t refer somebody to a separate person.”
Dr. Horst sometimes refers patients for OMT, but he says this can be inconvenient for the patient.
“It’s another appointment, another person, another office,” he says. “All these things can be barriers for patients. But it has worked well for the ones who have had the time and the resources.”
Dr. Horst says the medicolegal risk is the biggest obstacle preventing psychiatrists from performing OMT on their patients. But Dr. Hegybeli says it hasn’t been a problem for him in six years of practicing. His professional liability insurance covers him for both psychiatry and OMM, and he’s spoken with his carrier about his work. He says physicians can take various steps to minimize risk, such as putting the OMT table in a different room or having a monitor in the room during the treatment.
“I use my best judgment, and I make sure that I talk with the patient about the relationship between his or her mental health and the problems I am seeing with his or her body,” he says. “I also document that he or she is agreeing to and consenting to manipulation.”
Dr. Hegybeli also tells patients that he’ll stop the treatment immediately if they ever feel uncomfortable or experience pain. The vast majority of his patients are satisfied with their treatment, he says, and new patients are often receptive to receiving manipulation.
“Patients are much more open to the osteopathic philosophy of treating the whole person,” he says. “So when a physician says, ‘Hey, you’re having problems due to the dysfunction of your brain. There is also some dysfunction of your body present, and it’s contributing to the problems with your mental health. We can help your whole person get better by doing some work with osteopathic manipulation,’ the patient is usually open to it.”
Patients tend to notice the benefits because the manipulation usually produces rapid results, Dr. Hegybeli says, which makes them to want to continue the treatments.