1.1Psychiatry and Palliative care medicine Post graduate Students MD Phase A Department of Psychiatry BSMMU, Dhaka. 30.11.2013

2. 2Contents Mind ,Body & Psychiatry What's happening inside Palliative care in psychiatry Psychiatry in palliative care Updates Summary 3. 3Mind, body & Psychiatry Dr Md Saleh Uddin 4. 4Mind & Body Mind body dualism (Cartesian dualism) Dualistic categories Psychological SymptomsPhysical SymptomsBodily PathologyComorbidityMedical diseasePsychopathologyPsychiatric disorderSomatization 5. 5 Integrated approach Neural basis Mind & Brain (Two sides of same coin) 6. 6Mind & BodyMental Process/Psychology/Neuro cognition Perception Emotion Motivation Learning Memory Thought Personality etc 7. 7Mind & BodyPsychiatry Perception: Hallucination, Illusion Thought: Delusion, Obsession Mood: Mania, Depression Abnormal behavior etc 8. 8Mind & BodyDifferences Psychology (Process)Nice flower! Psychiatry (Function)I saw that! Neurology (Morphology)Seizure/ICSOL 9. 9Normal functioningMENTAL HEALTHPsychopathologyMENTAL DISORDERMental process 10. 10THANK YOU 11. 11Inside of mind Dr Hosnea Ara 12. 12Contents Learning Motivation Memory Perception Thought Personality Emotion Stress 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. personality Types of Personality Introvert Extrovert Personality Trait Personality Factors 15. Emotion An emotion defined by psychologist usually includes three components... 1.A characteristics feeling or subjective experience 2.A pattern of physiological arousal3.A pattern of overt expression 16. emotionTypes: Positive emotions Negative emotions Primary emotions Complex emotions Opposite emotion 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. StressStress reaction 1. Disruption of emotion 2. Cognitive disruption 3. Physiological disruption Methods of coping1.Emotion focused 2.Problem focused 19. 19THANK YOU 20. 20Palliative care in Psychiatry Dr. Towhidul Islam 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. Who needs palliative care in psychiatric population? Schizophrenia Major Depressive Disorder Bipolar mood disorder Dementia PTSD PD Anorexia Nervosa Organic /Secondary 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. 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. 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. 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. Patients difficulty to exercise autonomy in decision making 27. Can we overcome the challenges? 28. Similarities 29. Something is commonA 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. Next steps Cross training ( already started !!!) Multi disciplinary assessment Multi disciplinary treatment planning Service integration 31. THANK YOU 32. 32Psychiatry in palliative care Dr Mahjabeen Aftab Solaiman 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. 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. 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. 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. Psychiatry in Palliative Care Common Symptoms in Palliative Patients Pain Fatigue Somnolence Gastro-intestinal problem 38. Psychiatry in Palliative Care Spectrum of Disorder 50% 0%80%Normal Response to Terminal Diseases Day-to-Day StressAdjustment Disorders With depressive & Anxiety symptomsCrisis Depression Delirium Anxiety Disorder Personality Disorder Others100% 39. Psychiatry in Palliative Care Periods of Distress 40. Psychiatry in Palliative Care Major Psychiatry issues in Palliative Care Depression Anxiety Delirium 41. Depression 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. Depression The Depression Continuum Normal (Grief / Stress Reaction)Adjustment Disorder Minor Depression (Sub Clinical) Major Depression (Functional / Organic) 44. Depression Diagnosis of Depression Weight change Sleep disturbance Psychomotor problems Lack of energy Excessive guilt Poor concentration Suicidal ideation 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. 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. Management Medication Psychosocial Intervention Psychological Therapy 48. Anxiety 49. Causes Disease & Treatment Related Anxiety Substance Induced Anxiety Reactive Anxiety / Adjustment Psychiatric Anxiety 50. Symptoms Physical Autonomic Hyperactivity, Insomnia, Loss of Appetite Mood Anxiety, Irritable, Vigilance Cognitive Impaired Concentration, Negative Thinking, Excessive Worrying 51. Management Relieving Pain & other Distressing Symptoms Medication / Drugs Adjustment Psychological methods Explanation CBT, relaxation therapy Counseling 52. Delirium 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. Symptoms Early Symptoms Transient periods of disorientation esp time (confused) Irritability , restless Withdrawal , refusal to talk Forgetfulness that was not previously present 55. Symptoms Advanced Symptoms Disorientated to time, place and person Delusion often paranoid Hallucinations - visual , auditory 56. Causes Intracranial pathology Metabolic e.g. Organ failure, electrolyte disturbance Sepsis Drugs Drug withdrawal Circulatory e.g. dehydrationBut often patients are too frail for a thorough search for causes 57. Management Treatment of the cause Including review of medications General measures Well-lit, calming environment Try to avoid restraints Drug treatment 58. THANK YOU 59. 59Palliative care psychiatry Dr Md Saleh Uddin 60. 60Talk plan The need for psychiatry Recent Advances Steps ahead 61. 61Why needed? Total pain Psychiatric syndromes Normal response? Unrecognized? Primary/ Secondary? Chronic cases? Interventions? 62. 62Recent Updates Psychotherapy Depression, Anxiety, Delirium Models of care, Education, System development 63. 63Recent updates 64. 64Recent updatesPsychotherapy (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. 65Recent updatesClinical syndromes: Hospice patient: 50% -depression, 70%-anxiety Nearly all- Delirium Depression Anxiety DeliriumStimulants (Methylphenidate) Ketamine Non pharmacological (Hypnotherapy, Concreteness training) No clinical trial 66. 66Recent updatesEducation, Models of care Educational opportunity (training) Integration model Liaison consultation Part of team 67. 67Steps ahead Distinguishing variations of illness Managing Comorbidities Ethical issues 68. 68Summary 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. 69References Shorter Oxford textbook of Psychiatry, Sixth edition, Philip Cowen, Paul Harrison, Tom Burns, Oxford university press, 2012Oxford Handbook of Psychiatry, Third edition, David Semple, Roger Smyth, Oxford university press, 2013Psychology, Fourth edition, Andrew B Crider, George R Goethals, Robert D Kavanaugh, Paul R Solomon, Harper Collins College Publisher, 1933Desk reference to the DIAGNOSTIC CRITERIA from DSM5, American Psychiatric Association, 2013Palliative care Psychiatry: Update n Emerging Dimension of Psychiatric Practice, N Fairman, S A Irwin, Corr Psychiatry Rep (2013)15:374, SpringerAvailability 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)42-52Palliative Medicine and Psychiatry, Editorial, AD Macleod, Journal of Palliative Medicine, Volume 16, Number 4, 2013How we can improve end of life care, Rachel Kester, Psychiatry resident, Residents voice, Current Psychiatry, Vol 12, No5, 2013 70. 70References 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 january19(1) 21-28 71. 71 72. 72THANK YOU