Transcript The Anxiety Disorders Some Practical Questions & Answers

The Grieving Patient
Some Practical Questions and Answers1,2,3
A Presentation for
SOMC Medical Education
Kendall L. Stewart, MD, MBA, DFAPA
January 15, 2010
I hope to provide practical information that will assist you in your diagnosis and treatment of these patients.
let me know whether I’ve succeeded on your evaluation forms and on Facebook.
3 Refer to the presentation notes for additional information. Let me illustrate.
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Why is this important?
• Grief results from any real or
perceived loss.
• The intensity of the grief
reaction depends on the degree
of emotional investment in the
lost object.
• These painful emotions are
often translated into somatic
symptoms.1,2
• Many patients are grieving and
don’t realize it.
• Their physicians may not
realize it either.
• Grief and depression often
coexist and they are often
confused.
• Grieving patients can present a
considerable clinical challenge.
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• After listening to this
presentation, you will be able to
answer the following questions:
– Why is this important?
– How do these patients present?
– What other losses may trigger a
grief reaction?
– What are the classic stages of
grief?
– What medical disorders are
complicated by grief?
– How are grief and depression
related?
– What are the diagnostic criteria
for major depression?
– What is the role of medication?
– How to people get over grief?
Many of our patients cannot talk about feelings directly.
elderly mother who was very disappointed in her only son talked incessantly about her burning head.
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How do these patients present?
• A 42 year-old mother presents
after the death of her son in a
motorcycle accident.
• “At first I just could not believe
it.”
• “Then for days after it happened
I was numb.”
• “I got so mad at him for refusing
to wear a helmet.”
• “There is this awful hole in my
heart, a terrible sense of loss.
• “I feel so guilty that I didn’t stop
him from buying a motorcycle.”
• “I’m shaky for no reason.”
• “I’m agitated and jumpy.”
• “My chest hurts.”
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“I’m not interested in anything.”
“I am nauseated all the time.”
“I can’t eat.”
“My muscles ache.”
“I’m nervous and worried that
something bad will happen to
my other child.”
“My chest hurts and I can’t
sleep.”
“I wake up hearing him call my
name.”
“I can’t stay focused on
anything.”
“I have a headache constantly.”
You can review the classic
stages of grief here.
The stages of grief model has been largely debunked by Bonanno and others.
has outlined the ebb and flow of processes, shock and numbness, yearning and searching, disorganization
and despair and reorganization, but Kubler-Ross’s model has remained firmly entrenched in the popular culture.
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Aside from death, what other losses
may trigger a grief reaction?
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Any loss
Loss of a job
Death of a pet1
Death of a celebrity
Illness
Disability
Miscarriage
Divorce
Failed friendships
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Financial loss
Failing health
Increasing age
Lost opportunity
Disabled or impaired
children
A child’s failure
Amputation
Sports losses
Any real or perceived
loss
One of my patients suffered acute grief and dissociation after she mistakenly killed her pet.
What medical disorders are
complicated by grief?
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Heart disease
Cancer
Psychiatric illnesses
Duodenal ulcer
The common cold
Autoimmune diseases
All illnesses that are negatively
affected by stress
How long does grief last?
• It depends. (This is the universal
answer to every question.)
• Protracted grief can last for many
years.
• Each grief reaction is unique.1
• The mourner’s emotional
investment in the lost object is the
key variable.
• The available coping resources
have a significant on the course.
• Unrecognized or illegitimate grief
is particularly tough to overcome.
How are grief and depression
related?
• Many of the symptoms are similar or
the same.
• They frequently coexist and it can be
difficult to distinguish between the
two.
• At some time during the first year
after the death of a spouse, 30-50% of
the survivors will become depressed
and meet the criteria for major
depression.
• Physicians are sometimes mistakenly
hesitant to treat major depression in
the context of grief.1,2
Depression is deadly and should always be treated aggressively.
An alarming number of physicians still think medication for depression will interfere with grief work or that depression
in the context of grief is normal.
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What are the diagnostic criteria for
major depression?
• At least five of the following symptoms
have been present for the same 2-week
period and represent a change from a
previous level of functioning
– Depressed mood
– Significantly decreased interest in or pleasure
from things they formerly enjoyed
– Significant weight loss not due to dieting
– Insomnia or hypersomnia
– Psychomotor agitation or retardation
– Fatigue
– Deceased concentration
– Feelings of guilt or worthlessness
– Recurrent thoughts of death or suicide1
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No one can accurately predict suicide attempts.
made a judgment, arranged for follow up and the patient still attempted suicide.
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When might medication be indicated?
• No medication is indicated for the
treatment of grief itself.
• The short-term use of benzodiazepines
may be helpful for incapacitating
anxiety.1
• Antidepressants are indicated for the
treatment of comorbid major depression.
• The stress of grief may trigger or
exacerbate an underlying psychotic
disorder.
• Lithium may be particularly helpful in
treating bipolar patients who become
suicidal—or any patient who is
chronically suicidal.
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Avoid the long-term use of benzodiazepines in the elderly and following psychological trauma.
How do people get over grief?
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They never to—entirely.
They carry on in spite of it.
They focus on distractions.
They reinvest emotionally in other
“objects.”
They reach out to others.
They suffer in silence.
They marvel at others’ lack of
understanding and misplaced priorities.
They tolerate others’ impatience and
stupidity poorly at times.
They focus on the important things and
view life very differently.
They deal with it in unique ways. 1,2
A successful businesswoman lost both sons to drunk drivers.
Another mother became a auto safety activist.
What can you do to help?
• Recognize it.
• Identify it for the patient if
necessary.
• Accept these feelings as
normal.
• Listen.
• Offer bereavement counseling.
• Encourage them to write.
• Offer a brief description of how
this process will play out.
• Offer hope that they will
eventually feel better without
suggesting they will get over
it.1
Parents whose children have been murdered or who have completed suicide have the steepest hill to climb in my
experience.
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The Psychiatric Interview
A Patient-Centered, Evidence-Based Diagnostic and Therapeutic Process
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Introduce yourself using AIDET1.
Sit down.
Make me comfortable by asking some
routine demographic questions.
Ask me to list all of problems and
concerns.
Using my problem list as a guide, ask me
clarifying questions about my current
illness(es).
Using evidence-based diagnostic criteria,
make accurate preliminary diagnoses.
Ask about my past psychiatric history.
Ask about my family and social histories.
Clarify my pertinent medical history.
Perform an appropriate mental status
examination.
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Review my laboratory data and other
available records.
Tell me what diagnoses you have
made.
Reassure me.
Outline your recommended treatment
plan while making sure that I
understand.
Repeatedly invite my clarifying
questions.
Be patient with me.
Provide me with the appropriate
educational resources.
Invite me to call you with any
additional questions I may have.
Make a follow up appointment.
Communicate with my other
physicians.
Acknowledge the patient. Introduce yourself. Inform the patient about the Duration of tests or treatment.
Explain what is going to happen next. Thank your patients for the opportunity to serve them.
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Where can you learn more?
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American Psychiatric Association, Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition, Text Revision, 2000
Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical
Psychiatry, Third Edition, 20081
Flaherty, AH, and Rost, NS, The Massachusetts Handbook of
Neurology, April 20072
Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry
Clerkship, Second Edition, March 2005
Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and
Review, Twelfth Edition, March 20093
Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007
Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the
Brain, January 2008
Median, John, Brain Rules: 12 Principles for Surviving and Thriving
at Home, Work and School, February 2008
Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous
Patients,” 2000
Jacobson and Jacobson, Psychiatric Secrets, 2nd Edition, 2001
Where can you find evidence-based
information about mental disorders?1
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Explore the site maintained by the organization where evidence-based
medicine began at McMaster University,
http://hsl.mcmaster.ca/resources/ebpractice.htm.
Sign up for the Medscape Best Evidence Newsletters in the specialties
of your choice at http://www.medscape.com/psychiatry.
Subscribe to Evidence-Based Mental Health at http://ebmh.bmj.com/.
Search a database at the National Registry of Evidence-Based Programs
and Practices maintained by the Substance Abuse and Mental Health
Services Administration at http://ebmh.bmj.com/.
Explore a limited but useful database of mental health practices that have
been "blessed" as evidence-based by various academic, administrative and
advocacy groups collected by the Iowa Consortium for Mental Health at
http://www.medicine.uiowa.edu/ICMH/evidence/.
visit www.KendallLStewartMD.com to download related white papers and presentations.
How can you contact me?1
Kendall L. Stewart, M.D.
VPMA and Chief Medical Officer
Southern Ohio Medical Center
President & CEO
The SOMC Medical Care Foundation, Inc.
1805 27th Street
Waller Building
Suite B01
Portsmouth, Ohio 45662
740.356.8153
[email protected]
[email protected]
www.somc.org
www.KendallLStewartMD.com
1Speaking
and consultation fees benefit the SOMC Endowment Fund.
Are there other questions?
Terry Johnson, DO
OUCOM 1991
www.somc.org
Adenike Moore, DO
OUCOM 2002
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