Transcript Medical psychology

:
• DEFINITIONS of medical psychology
• LEVELS of medical psychology: individual
psychological issues of the patient, patient-physician
relationship, cultural and social issues
• MODELS OF illness: biomedical model,
biopsychosocial model
 Medical psychology entails the atitude towards illness
and the patient, atitude of the healthy and sick
individuals towards healthcare systems, and also the
atitude of the doctor towards the medical profession.
 This is the branch of psychology that integrates
somatic and psychotherapeutic modalities into the
management of mental illness and emotional,
cognitive, behavioral and substance use disorders".
 Medical psychologists apply
psychological theories, scientific
psychological findings, and techniques
of psychotherapy, behavior
modification, cognitive, interpersonal,
family, and life-style therapy to
improve the psychological and physical
health of the patient
 are rained for
 service in primary care centers,
 hospitals,
 residential care centers,
 long-term care facilities
 multidisciplinary collaboration and team treatment.
 They are trained and equipped to modify physical
disease states and the actual cytoarchitecture and
functioning of the central nervous and related systems
using psychological and pharmacological techniques
(when allowed by statute), and to provide prevention
for the progression of disease having to do with poor
personal and life-style choices and conceptualization,
behavioral patterns, and chronic exposure to the
effects of negative thinking, choosing, attitudes, and
negative contexts.
 Psychotherapy - helping patients manage the
emotional aspects of chronic illnesses.
 · Pain Management - finding ways to curb the
physical symptoms of a disease and minimize the side
effects of treatments.
 · Pharmacology - prescribing psychotropic
medications for patients with mental issues or
disorders.
 · Behavior Therapy - initiating and implementing
behavioral interventions and stress reduction
techniques that will positively affect patients' immune
systems.
 Most diseases common in modern society are
opportunistic. When we experience a traumatic event or
live in a state of chronic stress, the immune system is
severely compromised.
 As a result, the body becomes more hospitable to
everything from allergies to cancer.
 A medical psychologist helps clients properly process the
stresses in their lives with the intention of bolstering the
immune system.
 They also help clients manage specific conditions. For
example, a patient with cancer might be in a state of shock
from the diagnosis, feel fear and confusion about the
treatment options, or depression over a poor prognosis or
the limitations the disease poses. They might also worry
about the effect the illness will have on loved ones. The
medical psychologist helps the person manage this
emotional turmoil.
 Medical psychologists are also trained in
various interventions to help patients minimize
physical symptoms.
 Some of the techniques that are commonly
used are behavioral interventions
and relaxation techniques, hypnosis, and
guided imagery, which all tend to effect
physical changes by enhancing the person’s
immune system and decreasing tension.
 Energy medicines such as acupressure,
bodywork, and homeopathy are also frequently
used. Different practitioners have different
training and specialties
 Pain is a combination of many things – the
actual physical site of the pain, exacerbated by
tension, fear, and anxiety. When the patient
can learn to relax his or her body, there is a
natural reduction of pain. Most of my work in
Medical Psychology is as a pain specialist
(cancer, fibromyalgia,arthritis, etc.) and
allergy elimination work (yes, in most cases,
allergies can be permanently eliminated).
 Others specialize in neuromuscular, genetic,
or birth disorders, gynecological problems, or
other specific ailments.
MEDICAL psychology is intricated with other research fields:
 psychopathology,
 holistic psychology,
 antropology,
 psychoanalysis and dinamic psychology,
 cronobiology,
 etology,
 sociology,
 experimental psychology,
 neurophysiology.
MEDICAL psychology is connected with GENERAL
psychology in the following areas:
 Communication
 Developmental psychology
 Personality
• MEDICAL psychology is connected with SOCIAL
psychology: Patient-physician relationship – the impact of
the medical profession on related professions: pharmacists,
biologists, nurses etc.
 From the biopsychosocial model of illness to patterns and
models in the pharmaceutic field
 Modern means of assessment of the therapy and medical
care – quality of life
 The hisorical and methodological relationship
•
between medical psychology and psychiatry is
undoubtedly the deepest of all
 • Almost all founding parents of medical psychology
were PSYCHIATRISTS
 • PSYCHIATRY is the main field where medical and
clinical psychology draw information from, and also
the field where medical and clinical psychology data
and techniques are best put into practice
• „There is no illness, there are only sick people”
• More clearly: there is no illness separated from the
sick person with his/her individual characteristics and
particularities
• Sometimes fighting the illness is essential for
healing, some other times changing individual
particularities of reaction is required
• From the viewpoint of medical psychology, these
reactive particularities are physical and related to
person and personality
•.
Patient-physician relationships involve contrary directions,
from idealization to cynical despair
• According to the manner in which each “actor” plays the
role assigned due to various expectations, either satisfying,
effective relationships or suspicious, frustrating,
disappointing ones are underlined
• Patients are specifically tolerant to the therapeutic
limitations of medicine in a context of respect and genuine
communication and empathy from doctors/medical staff.
• Doctors/medical staff deal with sick people, not clinical
syndromes, and sick people bring a complex influence in the
patient-physician relationship – a merge between biological
factors, psychological dynamics and social context
• Predominance of clinician’s speaking time
• Unbalanced focus on medical themes
• Abrupt transitions and deadlocks (premature
consolations, denial of preoccupations, closed
questions)
• Introduction of a third person
• Distance, agressivity, indifference
C
… well, that’s about what I can tell you about the
situation, did you talk to your family ?
P
(sights) I have small children …
C
we have also social workers or psycho- oncologists
in this clinic, they can be of great help !
are related to
 a lack of technique, but also…
 levels of anxiety and defensive styles of clinicians when
facing external and internal pressure
 Structuring the interview
 Negociating the agendas
 Closing topics, transitions
 Transmission of information
 Preparation, setting
N:
P:
N:
P:
N:
… before you receive chemotherapy, we will
administer a medication against nausea
.. Mhm, mhm
chemotherapy is not always associated with
nausea, but we like to prevent nausea, that’s
why we prescribe it anyway, eh: what do you
work ?
I am accountant of a small factory…
the chemotherapy should be well tolerated …
 Complex informations
 Disclosure of diagnosis
 Relaps, progression
 Patient’s emotions
 Irritated patient
C:
… to summarize, the results show that the cancer
has come back again
P:
but I thought I was cured !
C:
but I have told you that the chance for cure is not
100% !
P:
well …
• Professional identity
• Ego and Ego-Ideal
• Narcicistic vulnerability
• Ambivalence of the patient
• Identification, projection
P:
Is there no possibility to clean up this
situation with more surgery ?
C:
What do you think !
C:
Or to utilize again a strong medication ?
P:
In your situation, a chemotherapy ? I could
rather kill you right away ...
 Under the influence of the discoveries made by
Virchow (the cells) and Pasteur (microbes), medicine in
the end of the 19th century and early 20th century was
dominated by the strictly biological causality.
 • Engel develops the biopsychosocial model of illness,
underlining the overlap of specific (biological) and
non- specific (psychological and social) factors
•
 • This model is regarded as more accurate and is
derived from the general theory of systems.
 – Biological System emphasizes the anatomical,
structural, mollecular underpinning of the illness and
its impact on the biological functioning of the patient.
 – Psychological System emphasizes the impact of
motivation and personality in experiencing illness and
reacting to illness
 – Social System emphasizes the influence of cultural,
environmental and family factors in expressing and
experiencing the illness
•
Engel G stated that each of the aforementioned systems can
influence and be influenced by the others
• The novel patterns of illness of the 20th – 21st centuries
demand a complex explanation, approach and management,
directed mostly in prevention through detection and change
of risk factors
• The current stage of knowledge reveals that the traditional,
biomedical model of explanation and management of chronic
illnesses is restrictive and unilateral, because it does not take
into account nonbiological variables .
• The biopsychosocial paradigm incorporates the state-ofthe-art biological medicine and also psychological,
behavioral, social, cultural, ecological variables, as factors
related to the cause and evolution of illnesses (Matarazzo,
1980).
•
It is restraining, constrictive (takes into account only
biological factors)
• It is a liniar pattern of causality (from germ to illness)
• It incorporated Descartes’s duality (separates body
from psyche)
• It emphasizes illness as a state of being
• It disregards prevention of illness
• Focus on the sick organ, disregarding the sick person
• Responsibility for treating the illness is placed solely
on the doctor
•
It developed as a reaction to the biomedical one
• The causes of the illness are seen as multifactorial
• Psyche cannot be separated from body
• Focus on both health and illness
• Focus on both treatment and prevention
• Organ damage generates the person’s distress
• Medical staff, society and the sick person are
regarded as responsible for prevention, treatment
and recovery
Patient-physician relationship is a key element of the
•
biopsychosocial model.
• Any doctor should have both practical medical
knowledge/skills, and knowledge about/insight into the
specific psychological state of the patient.
LEVEL
OBJECTIVE
MEANS
Intelectual
Understanding and
Conceptualization
explaining illness in
accordance with
scientific models
Conceptualization
Affective
Understanding the
personality of the
sick person with its
subjectivity and
mechanisms.
Identification
 Major health problems are stressful
 Stressfulness dependent upon an individual’s
perception of illness
 No clear separation between “normal” and “abnormal”
psychological reaction to illness
 According to the contemporary approach, illness can
be considered a crisis. Especially this concerns serous,
prolonged, disabling illnesses. An individual reacts to
the stress of a disease by activating his/her capacity to
adjustment. If the defence mechanisms fail, the
balance is disturbed, and pathological reaction of the
personality appear.
 In the case of a serious disease, danger threatens the
happy family life, the satisfaction of a favorite work
and other sides of usual everyday life, and the patient
experiences painful anxiety and fear ("What will
happen to me?").
 Do you have any worries or concerns about your
illness?
 Is there anything you’re not sure of?
 Is there anything that you’re really worried about?
 Seeking information
 Seeking practical and social support
 Learning new skills
 Developing new interests
 Helping others
 Sharing feelings and concerns about illness
 Expressing anger or other distressing feelings in an
appropriate way
 Managing loss
 Gaining emotional support
 Giving up idealised hopes of recovery
 Hoping the condition will just disappear
 Denial
 Obsessively focusing on minute details of the disorder
 Seeking others to blame
 Personality traits (e.g. tendency to worry about illness)
 Prior experience of illness within a family
 An individual’s psychological state at the time of the
illness
 Previous experience of trauma, or a neglected or
abusive childhood
 What was this person like before the illness?
 Is there a history of serious illness in the family?
 Was this person suffering from psychiatric illness
when the physical condition began?
 Is there any evidence of a difficult or abusive
childhood?
 Any other major problems?
 Life history crisis activates available
pathological somatic mechanisms (e.g.
hypertensive) which have been conditioned
early in life and possibly maintained by the
organism's coping mechanisms at a
subliminal level. Life situations are
experienced as stressful because of
unresolved emotional conflicts. Each
personality type will have his specific conflict
which in a crisis situation will activate his
specific physiological mechanism.
 The reaction to illness depends not only on
the personality features of the patient, but
also on his/her past experience. The horror
of the disease can increase, if someone else
in the family, or a friend has had a similar
illness or operation with a sad outcome. The
patient's apprehension and fear is grounded
on what he/she sees, hears, imagines, has
once read or learned about the illness.
 Life events and stress can
bring on feelings of sadness
or depression or make a
disorder harder to manage.
 Self Healing
 Calm-even speech
 Even hand gestures away from body
 Open, relaxed body
 Mutual gaze
 Smooth movements
 Charismatic & optimistic
 Disease Prone
 Uneven speech
 Loud, explosive voice
 Sighs, stutters, ums
 Clenched fist, teeth
 Closed body posture
 Fidgets shifts tapping
 Shifty-eyed,downcast
 Facial grimace
 Vocal gesture impatience
 Over controlled calm unexpressiveness
 Acute
 Chronic
 Life threatening
 Terminal
Emotional distress
6
months
Time
The reaction also depends on the organ,
affected by the disease. Many scientists
have pointed out, that the illnesses of eyes,
heart or sex organs have the greatest
psychological impact. The slightest heart
disorder causes panic in most people. The
apprehension of loosing sight, fear of
operations on the eyes have a grave
psychological influence.

Chronic patients develop deeper
psychological problems, than people with
acute illnesses. The long term of suffering
tells, the patients become secluded, they are
interested only in themselves and their
illness. They develop negative personality
features, become fretful, pessimistic,
vulnerable, envious and even begin to hate
everyone.
 Entering into a continuing treatment programme
 Keeping referral and follow-up
 Taking medication correctly
 Following recommended lifestyle changes
 Depressive disorders
 Anxiety states
 Sexual problems
 Alcohol problems
 Mood and motivation
 Persistent low mood
 Diminished interest or pleasure
 Social withdrawal
 Loss of energy
Cognitive changes
Depressive thoughts,
Worthlessness,
Self blame
Suicidal wishes,
Hopelessness
Biological symptoms
Poor appetite,
Weight loss,
Sleep disturbance,
Poor concentration,
Decreased sex drive,
Retardation or agitation
Inflammatory bowel disease
HIV/AIDS
Stroke
Parkinson's
high
low
rheumatoid arthritis
myocardial infarction
cancer
out-patients
0
10
20
30
40
50
60
Per cent
Acute medical inpatients
(n=263)
Follow-up 5
months later
(n=218)
Psychiatric diagnosis
Health Status-SF-36
Duke Severity of Illness Scale
Karnofsky Performance Status
Scale
Health care costs
Creed et al, Psychosomatics;
43:302-309
 27% of acute medical in-patients had diagnosable
depressive or anxiety disorders
 A further 41% had sub-threshold disorders
80
70
60
50
case
subthreshold
control
general population
40
30
20
10
0
physical
function
physical role
health
limitation perception
pain
 Patients with depression and anxiety had significantly
lower quality of life than controls
 Recovery from depression following discharge was very
unlikely
 Costs incurred by patients who were depressed were
higher than controls, but there was no effect on length
of stay
Mean HRQOL in CD by Depression
*
7
*
Mean HRQOL Scores
6
*
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Depressed
*
*
Not depressed
*
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 Panic disorder
 Agoraphobia
 Generalised anxiety disorder
 Specific phobia
 Social phobia
 Obsessional compulsive disorder
 Post-traumatic stress disorder
 Common
 35-40% diabetic males report sexual problems
 Caused by:




the condition itself
Effects of drugs and other physical treatments
Psychological sequelae of the condition
Co-existing psychiatric disorder
 Enquiry
 Know something about the patient and their
circumstances before asking
 Detailed enquiry not necessary
 One or two relevant screening questions
 Enquire in a matter of fact but sensitive way
 Major health problems cause worry and distress.
 The stressfulness of an illness depends upon the
patient’s perception of the illness
 People react and cope in different ways.
 Most people, given time, develop adaptive ways to
manage illness
 Psychiatric disorders are twice as common in




medical patients than in the general population
Approximately one quarter of patients admitted to
hospital develop depressive disorders which are
severe enough to require medical treatment
Psychiatric disorder in the physically ill is often
missed
If untreated, depression results in increased
morbidity, poor physical function and increased
health care costs.
Improved psychological medicine services for
patients whilst in hospital would ensure better
detection and treatment of such problems.