Medical psychology: definition, subject and tasks. Psychosomatic and somato-psychological cooperations. : Determination of psychical health AGENDA DEFINITIONS of medical psychology LEVELS of medical psychology: individual psychological issues of the patient, patientphysician relationship, cultural and social issues MODELS OF illness: biomedical model, biopsychosocial model
DEFINITIONS OF MEDICAL PSYCHOLOGY 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
Clinical psychologists are rained for service in primary care centers, hospitals, residential care centers, long-term care facilities multidisciplinary collaboration and team treatment. Clinical psychologists 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 :
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s 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.
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R 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 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 persons 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 management 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. THE RELATIONSHIP BETWEEN MEDICAL PSYCHOLOGY AND OTHER
FIELDS MEDICAL psychology is intricated with other research fields: psychopathology, holistic psychology, antropology, psychoanalysis and dinamic psychology, cronobiology, etology, sociology, experimental psychology, neurophysiology. MEDICAL PSYCHOLOGY AND
PSYCHOLOGY 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 MEDICAL PSYCHOLOGY AND MEDICINE 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 POSTULATES IN MEDICAL PSYCHOLOGY 1. The individuality of the patient 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 . POSTULATES IN MEDICAL PSYCHOLOGY 2. Patient physician relationships 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 Key Elements of a PatientCentered Communication Structured informations Clinicians agenda Rational approach Defined timeframe
Professional relationship Routine situation Independence Comprehension Integration Negociation Balance Alliance Common project Ligue suisse contre le cancer 2003
Narrative, general informations Patients agenda Individual approach Subjective timeframe Highly significant relationship Exceptional situation Dependence 6 Indicators of communicational difficulties
Predominance of clinicians 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 CST-Example: Introduction of a Third C
well, thats 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 psychooncologists in this clinic, they can be of great help ! Communicational Difficulties are related to a lack of technique, but also levels of anxiety and defensive styles of clinicians when facing external and internal
pressure 1. Lack of Technique: Examples Structuring the interview Negociating the agendas Closing topics, transitions Transmission of information Preparation, setting CST- Example: structure / transitions N: before you receive chemotherapy, we will administer a medication against nausea
P: .. Mhm, mhm N: chemotherapy is not always associated with nausea, but we like to prevent nausea, thats why we prescribe it anyway, eh: what do you work ? P: I am accountant of a small factory N: the chemotherapy should be well tolerated 2. External Pressure: Examples Complex informations Disclosure of diagnosis Relaps, progression Patients emotions
Irritated patient CST-Example: Relapse 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 3. Internal Pressure: Examples Professional identity Ego and Ego-Ideal Narcicistic vulnerability
Ambivalence of the patient Identification, projection Real Life-Example: Professional identity / ovarian cancer 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 ... Models of illness
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 Models of 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-of-the-art biological medicine and also psychological, behavioral, social, cultural, Biomedical Model It is restraining, constrictive (takes into account only biological factors) It is a liniar pattern of causality (from germ to illness) It incorporated Descartess 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 Biopsychosocial Model 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 persons distress Medical staff, society and the sick person are regarded as responsible for prevention, treatment and recovery Patient-physician relationship from the biopsychosocial viewpoint 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. LEVELS OF PATIENT-PHYSICIAN LEVEL OBJECTIVE RELATIONSHIP (apud Tatossian A.) 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 Psychological response to illness Stress associated with illness Major health problems are stressful Stressfulness dependent upon an individuals perception of illness No clear separation between normal and abnormal psychological reaction to illness
Crisis 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. Danger 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?"). Eliciting beliefs Do you have any worries or concerns about your illness? Is there anything youre not sure of? Is there anything that youre really worried about?
Coping strategies Seeking information Seeking practical and social support Learning new skills Developing new interests Helping others Emotion focused coping 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 Less helpful coping strategies Hoping the condition will just disappear Denial Obsessively focusing on minute details of the disorder Seeking others to blame Individual Factors Personality traits (e.g. tendency to worry
about illness) Prior experience of illness within a family An individuals psychological state at the time of the illness Previous experience of trauma, or a neglected or abusive childhood Identifying personal factors 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. Past experience 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. Nonverbal Cues of Self-Healing or Disease Prone Personality Self Healing Calm-even speech
Even hand gestures away from body Open, relaxed body Mutual gaze Smooth movements Charismatic & optimistic Nonverbal Cues of Self-Healing or Disease Prone Personality 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 Factors related to illness Acute Chronic Life threatening Terminal
Psychological Adjustment to Physical Illness 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. Adherence Entering into a continuing treatment programme Keeping referral and follow-up Taking medication correctly Following recommended lifestyle changes
Psychiatric problems in the medically ill Psychiatric problems Depressive disorders Anxiety states Sexual problems Alcohol problems Depressive symptoms Mood and motivation Persistent low mood Diminished interest or
pleasure Social withdrawal Loss of energy Depressive symptoms Cognitive changes Depressive thoughts, Worthlessness, Self blame Suicidal wishes, Hopelessness Depressive Symptoms Biological symptoms
Poor appetite, Weight loss, Sleep disturbance, Poor concentration, Decreased sex drive, Retardation or agitation Prevalence of psychiatric disorder in different organic conditions (bars show the highest and lowest recorded rates) 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 Prospective Longitudinal Cohort Study of Anxiety and Depression in Medical In-Patients Acute medical
in-patients (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- Prevalence of psychiatric disorder 27% of acute medical in-patients had diagnosable depressive or anxiety disorders A further 41% had sub-threshold disorders Mean SF36 scores for physical dimensions at 5 months follow-up, adjusted for severity of illness 80 70
60 50 case subthreshold control general population 40 30 20 10 0
physical function physical role health limitation perception pain Main findings 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 * M ean HRQOL Sco res 7 6 *
* * * * Depressed * * Not depressed
5 4 3 2 1 0 Irvine et al 2002 Anxiety states Panic disorder Agoraphobia Generalised anxiety disorder Specific phobia
Social phobia Obsessional compulsive disorder Post-traumatic stress disorder Sexual problems 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 Sexual problems 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 Summary Major health problems cause worry and
distress. The stressfulness of an illness depends upon the patients perception of the illness People react and cope in different ways. Most people, given time, develop adaptive ways to manage illness Summary 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.
