Conceptual understanding of bio-psycho-social presentation in psychiatric disorders and role of pharmacological and psycho-therapeutic interventions in management of the same. Pointers to identifying when to refer a patient/ client for Psychiatric (medical) evaluation.

1. Working with a Psychiatrist
Dr Bhakti Murkey
Consultant Psychiatrist (MD)

2. Outline
 Bio-psycho-social context
 Mechanisms/ importance of medication use
 Soft Psychiatry
 Dealing with stigma
 When to refer to a Psychiatrist?
 Evidence-based management protocols

3.  Normal
 Abnormal:
 Organic
 Functional:
 Neurosis:
 Anxiety/ Depression/ Phobia/ OCD
 Psychosis:
 Schizophrenia/ Bipolar Disorder/ Delusional Disorder
 Mixed:
 Substance Use/ Personality Disorder
Revision: Diagnostic classification

4. Bio-Psycho-Social model

5. Bio-Psycho-Social model
 Interventions targeted towards each sphere:
 Pharmacotherapy
 Individual Psychotherapy
 Family Therapy/ Couple Therapy/ Psycho-education

6. Stress-Diathesis Model

7. Stress-Diathesis Model

8. Medication: Mechanisms
 Result of Stress Diathesis: Cortisol, Adrenaline surge
 Role of Neurotransmitters in symptomatology: Serotonin, Dopamine
deficiency
 Impact on functioning of neurons: sleep/ appetite centre, prefrontal cortex,
control centre in brainstem, amygdala…
 Anti-depressants: SSRI, SNRI, NDRI, NASSA, NRI…
 Anti-psychotics: Dopamine receptor antagonists
 Action on multiple receptors
 Restores Neuro-chemical balance

9. Therapy: Mechanisms
 Oxytocin, Endorphins
 Enhanced Neuroplasticity over time
 Experience of comfort, trust, assurance, melt-down, catharsis and
instillation of hope
 Mainstream or Adjunctive role
 Providing structure, direction and a face to recovery

10. Indications for medication use
 Moderate to severe intensity of
symptoms:
 Subjective clinical judgement or
 Objective assessment with
scales/ tools
 Progression in symptom
severity
 Impaired social relations,
occupational functioning or
interpersonal bonding
 Poor response to counseling/
psychosocial treatment alone
 Sustained symptom occurrence
(>2 weeks)
 Poor self care
 Risk of suicide/ aggression/
violence

11. Stigma for medication use
 “I am weak”
 “S/he is mad/mental”
 Fear of side effects
 Fear of dependence on Rx
 Confidentiality issues

12. Limitations of Psychotherapy alone
 Lack of prompt and efficient control in symptom severity
 Prolonged duration of untreated illness
 Worsening of underlying psychopathology
 Inattention towards co-morbid physical illness
 Patient complacence towards therapy due to interference of
symptoms
 Lack of motivation to participate in/ pursue therapy with on-going
symptoms (without adequate response)

13. When to refer?
 At the start:
 Active suicidal ideation
 Severe impairment in
individual functioning
 Poor self care
 Previous medication use/
ECT
 To rule out co-morbid medical
illness
 During therapy:
 Non-response to therapy
inputs
 Suspected contributory
personality factors
 Worsening of symptoms over
time
 Medico-legal complications

14. Soft Psychiatry
 Areas of psychology that do not always make rigorous use of
scientific methods in developing, evaluating and applying the
principles and techniques of academic psychology
 Symptom/ need-based treatment (rather than diagnostic)
 Recent evolving trends
 Cosmetic Psychiatry?
 Especially targeted for Personality Disorders and dysfunctional
family/ interpersonal dynamics
 Use of low dose SSRI/Anti-psychotics/Mood stabilisers

15. Formulating Holistic Treatment
 Effectiveness of combined approach to Rx
 Lack of stigma for ‘talk therapy’ and trust developed on the therapist
 Role of a therapist in introducing the role of medical management
 Mutually conducive team-work and growth environment
 Holistic approach to treating mental illness/ discomfort

16. Scientific Evidence

21. Take-away Points
 Bio-psycho-social approach to treatment
 Mechanisms and importance of medication use
 Soft Psychiatry
 Dealing with stigma
 When to refer to a Psychiatrist?
 Evidence-based management protocols
 Holistic health care

22. Questions