Psychiatry and palliative care medicine

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Psychiatry and palliative care medicine

  1. 1. 1 Psychiatry and Palliative care medicine Post graduate Students MD Phase A Department of Psychiatry BSMMU, Dhaka. 30.11.2013
  2. 2. 2 Contents • • • • • • Mind ,Body & Psychiatry What's happening inside Palliative care in psychiatry Psychiatry in palliative care Updates Summary
  3. 3. 3 Mind, body & Psychiatry Dr Md Saleh Uddin
  4. 4. 4 Mind & Body • Mind body dualism (Cartesian dualism) Dualistic categories Psychological Symptoms Physical Symptoms Bodily Pathology Comorbidity Medical disease Psychopathology Psychiatric disorder Somatization
  5. 5. 5 • Integrated approach Neural basis Mind & Brain (Two sides of same coin)
  6. 6. 6 Mind & Body Mental Process/Psychology/Neuro cognition • • • • • • • Perception Emotion Motivation Learning Memory Thought Personality etc
  7. 7. 7 Mind & Body Psychiatry • Perception: Hallucination, Illusion • Thought: Delusion, Obsession • Mood: Mania, Depression • Abnormal behavior etc
  8. 8. 8 Mind & Body Differences • Psychology (Process) Nice flower! • Psychiatry (Function) I saw that! • Neurology (Morphology) Seizure/ICSOL
  9. 9. 9 Normal functioning MENTAL HEALTH Psychopathology MENTAL DISORDER Mental process
  10. 10. 10 THANK YOU
  11. 11. 11 Inside of mind Dr Hosnea Ara
  12. 12. 12 Contents • • • • • • • • Learning Motivation Memory Perception Thought Personality Emotion Stress
  13. 13. Personality Personality can be defined as the unique patterning of behavioral and mental process that characterizes an individual and the individuals interactions with the environment Perspective on personality 1. 2. 3. 4. Psychodynamic perspective Trait perspective Behavioral perspective Humanistic perspective
  14. 14. personality • Types of Personality Introvert Extrovert • Personality Trait • Personality Factors
  15. 15. Emotion An emotion defined by psychologist usually includes three components... 1.A characteristics feeling or subjective experience 2.A pattern of physiological arousal 3.A pattern of overt expression
  16. 16. emotion Types: • Positive emotions • Negative emotions • Primary emotions • Complex emotions • Opposite emotion
  17. 17. Stress Stress can be defined as a disruption of our normal psychological and physiological functioning that occurs when a challenge threatens our ability to cope adequately Stressful events Minor or daily hassles Chronic sources of stress
  18. 18. Stress Stress reaction 1. Disruption of emotion 2. Cognitive disruption 3. Physiological disruption Methods of coping 1.Emotion focused 2.Problem focused
  19. 19. 19 THANK YOU
  20. 20. 20 Palliative care in Psychiatry Dr. Towhidul Islam
  21. 21. • A 42 year old lady suffering from MDD for last 10 years consulted with her psychiatrist complaining recent low mood , anorexia, weight loss and headache , insomnia and suicidal ideation. • Her husband informed that she had cough for last one month
  22. 22. Who needs palliative care in psychiatric population? • • • • • • • • Schizophrenia Major Depressive Disorder Bipolar mood disorder Dementia PTSD PD Anorexia Nervosa Organic /Secondary
  23. 23. Why ? • Psychiatric disease itself may be non-curable, potentially life threatening due to higher suicidal and accident rates • Patient with severe persistent psychiatric illness (SMPI) has double the incidence than general population of diseases including neoplasm. • Patients are often neglected , marginalized both by family and medical community • Patient often fail to communicate symptoms further complicating diagnosis and management
  24. 24. How? • Palliative care should be provided to psychiatric patients in the same way it is provided to any other -needs for pain and symptom control, maintenance of function, enhancement of quality of life, support for relationships, and the possibility of dying well • Unique nature of psychiatric patient should be taken in to account
  25. 25. How? • A therapeutic relationship based on respect, dignity, hope, and nonabandonment is central to this approach • Access to care should be ensured • Revise or develop policies and guidelines to address the needs of this population. • Integrate principles of hospice palliative care in endof-life care for people with SPMI • Conduct more research specific to this population
  26. 26. Challenges • Different presentation of diseases than general population • Psychiatric units may not be trained to deal with palliative needs. • Palliative units may not be trained to deal with psychiatric problems. • Patient‟s difficulty to exercise autonomy in decision making
  27. 27. Can we overcome the challenges?
  28. 28. Similarities
  29. 29. Something is common A person-centered practice Relationship- based connectedness Compassionate and Holistic Care Respect for autonomy and choice Concern for quality of life as defined by the client • Focus on family as unit of care • Concern to keep patient in familiar environment • • • • •
  30. 30. Next steps • Cross training ( already started !!!) • Multi disciplinary assessment • Multi disciplinary treatment planning • Service integration
  31. 31. THANK YOU
  32. 32. 32 Psychiatry in palliative care Dr Mahjabeen Aftab Solaiman
  33. 33. What is Palliative Care? • Medical care that focuses on alleviating the intensity of symptoms of disease. • Palliative care focuses on reducing the prominence and severity of symptoms.
  34. 34. WHO Definition “An approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual."
  35. 35. Aspects of Palliative Care  Provides relief from pain and other distressing symptoms  Affirms life and regards dying as a normal process  Intends neither to hasten or postpone death  Integrates the psychological and spiritual aspects of patient care  Offers a support system to help patients live as actively as possible until death  Offers support system to help the family cope during the patients illness and in their own bereavement  Uses a team approach to address the needs of patients and their families, including bereavement counseling, if indicated
  36. 36. Aspects of Palliative Care  Enhances quality of life, and may also positively influence the course of illness  Applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications  Overall improvement of the quality of life for individuals who are suffering from severe diseases  Offers a diverse array of assistance and care to the terminal patients.
  37. 37. Psychiatry in Palliative Care • Common Symptoms in Palliative Patients     Pain Fatigue Somnolence Gastro-intestinal problem
  38. 38. Psychiatry in Palliative Care • Spectrum of Disorder 50% 0% 80% Normal Response to Terminal Diseases Day-to-Day Stress Adjustment Disorders With depressive & Anxiety symptoms Crisis Depression Delirium Anxiety Disorder Personality Disorder Others 100%
  39. 39. Psychiatry in Palliative Care • Periods of Distress
  40. 40. Psychiatry in Palliative Care • Major Psychiatry issues in Palliative Care ▫ Depression ▫ Anxiety ▫ Delirium
  41. 41. Depression
  42. 42. Depression • Median prevalence of major depression in advanced cancer 15% (5-26%) • Often undiagnosed or under diagnosed ▫ Low mood „understandable‟ ▫ Some physical symptoms – appetite change, lethargy, sleep disturbance – common in advanced cancer
  43. 43. Depression • The Depression Continuum Normal (Grief / Stress Reaction) Adjustment Disorder Minor Depression (Sub Clinical) Major Depression (Functional / Organic)
  44. 44. Depression • Diagnosis of Depression ▫ ▫ ▫ ▫ ▫ ▫ ▫ Weight change Sleep disturbance Psychomotor problems Lack of energy Excessive guilt Poor concentration Suicidal ideation
  45. 45. Causes • Illness Related Causes ▫ Persistent symptoms eg pain ▫ Increased physical impairment or discomfort ▫ Treatment-related eg radiotherapy, chemotherapy, drugs such as corticosteroid, ▫ Endocrine/Metabolic abnormalities e.g . hypothyroidism, hypercalcemia, ▫ Types: Pancreatic, head & neck cancer
  46. 46. Causes • Others ▫ History of depression, suicide attempts ▫ Family history of depression (genetic vulnerability) ▫ History of alcoholism or drug abuse ▫ Concurrent Life stressors e.g. going through divorce, financial strain
  47. 47. Management • Medication • Psychosocial Intervention • Psychological Therapy
  48. 48. Anxiety
  49. 49. Causes • • • • Disease & Treatment Related Anxiety Substance Induced Anxiety Reactive Anxiety / Adjustment Psychiatric Anxiety
  50. 50. Symptoms • Physical Autonomic Hyperactivity, Insomnia, Loss of Appetite • Mood Anxiety, Irritable, Vigilance • Cognitive Impaired Concentration, Negative Thinking, Excessive Worrying
  51. 51. Management • Relieving Pain & other Distressing Symptoms • Medication / Drugs Adjustment • Psychological methods ▫ Explanation ▫ CBT, relaxation therapy ▫ Counseling
  52. 52. Delirium
  53. 53. Delirium • Is an acute state of confusion • Characterized by mental clouding – poor attention, disorientation, cognitive impairment • Fluctuating conscious level • Common in hospitalized elderly patients
  54. 54. Symptoms • Early Symptoms ▫ Transient periods of disorientation esp time (confused) ▫ Irritability , restless ▫ Withdrawal , refusal to talk ▫ Forgetfulness that was not previously present
  55. 55. Symptoms • Advanced Symptoms ▫ Disorientated to time, place and person ▫ Delusion – often paranoid ▫ Hallucinations - visual , auditory
  56. 56. Causes • • • • • • Intracranial pathology Metabolic e.g. Organ failure, electrolyte disturbance Sepsis Drugs Drug withdrawal Circulatory e.g. dehydration But often patients are too frail for a thorough search for causes
  57. 57. Management • Treatment of the cause ▫ Including review of medications • General measures ▫ Well-lit, calming environment ▫ Try to avoid restraints • Drug treatment
  58. 58. THANK YOU
  59. 59. 59 Palliative care psychiatry Dr Md Saleh Uddin
  60. 60. 60 Talk plan • The need for psychiatry • Recent Advances • Steps ahead
  61. 61. 61 Why needed? • “Total pain” • Psychiatric syndromes Normal response? Unrecognized? Primary/ Secondary? Chronic cases? Interventions?
  62. 62. 62 Recent Updates • Psychotherapy • Depression, Anxiety, Delirium • Models of care, Education, System development
  63. 63. 63 Recent updates
  64. 64. 64 Recent updates Psychotherapy (Randomized Clinical Trial) • Dignity therapy: Existential distress Greater level ofPerceived helpfulness, Improved QOL, Greater dignity, Helpfulness to the family • Meaning centered group psychotherapy(MCGP): Bolster meaning and spiritual wellbeing.
  65. 65. 65 Recent updates Clinical syndromes: • Hospice patient: 50% -depression, 70%-anxiety Nearly all- Delirium • Depression • Anxiety • Delirium Stimulants (Methylphenidate) Ketamine Non pharmacological (Hypnotherapy, Concreteness training) No clinical trial
  66. 66. 66 Recent updates Education, Models of care • Educational opportunity (training) • Integration model Liaison consultation Part of team
  67. 67. 67 Steps ahead • Distinguishing variations of illness • Managing Comorbidities • Ethical issues
  68. 68. 68 Summary • Mental Health and mental illness is not synonymous. • EBM approach of management. • Education is needed both way. • Palliative care psychiatry is an emerging dimension.
  69. 69. 69 References • Shorter Oxford textbook of Psychiatry, Sixth edition, Philip Cowen, Paul Harrison, Tom Burns, Oxford university press, 2012 • Oxford Handbook of Psychiatry, Third edition, David Semple, Roger Smyth, Oxford university press, 2013 • Psychology, Fourth edition, Andrew B Crider, George R Goethals, Robert D Kavanaugh, Paul R Solomon, Harper Collins College Publisher, 1933 • Desk reference to the DIAGNOSTIC CRITERIA from DSM5, American Psychiatric Association, 2013 • Palliative care Psychiatry: Update n Emerging Dimension of Psychiatric Practice, N Fairman, S A Irwin, Corr Psychiatry Rep (2013)15:374, Springer • Availability of psychiatric consultation liaison services as an integral components of palliative care programs at Japanese cancer Hospital, Aogawa et al, Jpn J Clin Oncol 2012; 42(1)42-52 • Palliative Medicine and Psychiatry, Editorial, AD Macleod, Journal of Palliative Medicine, Volume 16, Number 4, 2013 • How we can improve end of life care, Rachel Kester, Psychiatry resident, Residents voice, Current Psychiatry, Vol 12, No5, 2013
  70. 70. 70 References • Plaskota M, Lucas C, Pizzoferro K, et al. A hypnotherapy intervention for the treatment of anxiety in patient with cancer receiving palliative care, Int J Palliat Nurse. 2012;18(2):69-75 • Chochinov HM, Hack T, et al. Dignity therapy: a novel psychotherapeutic intervention for pateints near the end of life, J clin Oncol, 2005;23(24)5520-5525. • Breibart W et al. Meaning centered psychotherapy for patient with advance cancer: pilot randomized controlled trial, psychooncology, 2010 january‟19(1) 21-28
  71. 71. 71
  72. 72. 72 THANK YOU

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