Medical psychology: definition, subject and tasks. Psychosomatic

and somato-psychological co-operations.

Determination of psychical health:

•  DEFINITIONS of medical psychology

•  LEVELS of medical psychology: individualpsychological issues of the patient, patient-physician relationship, cultural and social issues

•  MODELS OF illness: biomedical model,biopsychosocial model

AGENDA

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".

DEFINITIONS OF MEDICALPSYCHOLOGY

 

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.

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.

Clinical psychologists

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.

Responsibilities of medical psychologists include:

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.

Pain management

MEDICAL psychology is intricated with other research fields: psychopathology, holistic psychology, antropology, psychoanalysis and dinamic psychology, cronobiology, etology, sociology, experimental psychology, neurophysiology.

THE RELATIONSHIP BETWEENMEDICAL PSYCHOLOGY AND OTHERFIELDS

  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 ANDPSYCHOLOGY

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

MEDICAL PSYCHOLOGY ANDMEDICINE

• 

•  „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 andparticularities•  Sometimes fighting the illness is essential forhealing, some other times changing individualparticularities of reaction is required•  From the viewpoint of medical psychology, thesereactive particularities are physical and related toperson and personality

POSTULATES IN MEDICAL PSYCHOLOGY1. The individuality of the patient

  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

POSTULATES IN MEDICAL PSYCHOLOGY2. Patient – physician relationships

•.

Ligue suisse contre le cancer 2003 6

Key Elements of a Patient-Centered Communication

Structured informationsClinician’s agendaRational approachDefined timeframeProfessional relationshipRoutine situationIndependence

ComprehensionIntegrationNegociationBalanceAllianceCommon project

Narrative, general informationsPatient’s agendaIndividual approachSubjective timeframeHighly significant relationshipExceptional situationDependence

• 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

Indicators of communicational difficulties

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 !

CST-Example: Introduction of a « Third »

are related to

a lack of technique, but also…

levels of anxiety and defensive styles of clinicians when facing external and internal pressure

Communicational Difficulties

Structuring the interviewNegociating the agendasClosing topics, transitionsTransmission of informationPreparation, setting

1. Lack of Technique: Examples

N: … before you receive chemotherapy, we will administer a medication against nausea

P: .. Mhm, mhmN: 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 ?

P: I am accountant of a small factory…N: the chemotherapy should be well

tolerated …

CST- Example: structure / transitions

Complex informationsDisclosure of diagnosis Relaps, progressionPatient’s emotions Irritated patient

2. External Pressure: Examples

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 …

CST-Example: Relapse

• Professional identity • Ego and Ego-Ideal• Narcicistic vulnerability • Ambivalence of the patient• Identification, projection

3. Internal Pressure: Examples

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 ...

Real Life-Example: Professional identity / ovarian cancer

  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.

Models of illness

•

–  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-of-the-art biological medicine and also psychological, behavioral, social, cultural, ecological variables, as factors related to the cause and evolution of illnesses (Matarazzo, 1980).

Models of illness

• 

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 bodyfrom 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 solelyon the doctor

Biomedical 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 person’s distress•  Medical staff, society and the sick person are regarded as responsible for prevention, treatment and recovery

Biopsychosocial Model

• 

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.

Patient-physician relationship fromthe biopsychosocial viewpoint

• 

LEVEL OBJECTIVE MEANS

Intelectual Understanding and Conceptualizationexplaining illness inaccordance withscientific models

Conceptualization

Affective Understanding thepersonality of thesick person with itssubjectivity andmechanisms.

Identification

LEVELS OF PATIENT-PHYSICIANRELATIONSHIP (apud Tatossian A.)

Psychological response to illness

Major health problems are stressfulStressfulness dependent upon an individual’s

perception of illnessNo clear separation between “normal” and

“abnormal” psychological reaction to illness

Stress associated with 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.

Crisis

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?").

Danger

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?

Eliciting beliefs

Seeking informationSeeking practical and social supportLearning new skillsDeveloping new interestsHelping others

Coping strategies

Sharing feelings and concerns about illnessExpressing anger or other distressing

feelings in an appropriate wayManaging lossGaining emotional support Giving up idealised hopes of recovery

Emotion focused coping

Hoping the condition will just disappearDenialObsessively focusing on minute details of the

disorderSeeking others to blame

Less helpful coping strategies

Personality traits (e.g. tendency to worry about illness)

Prior experience of illness within a familyAn individual’s psychological state at the time

of the illnessPrevious experience of trauma, or a neglected

or abusive childhood

Individual 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?

Identifying personal factors

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.

Past experience

Life events and stress can bring on feelings of sadness or depression or make a disorder harder to manage.

Self HealingCalm-even speechEven hand gestures away from

bodyOpen, relaxed bodyMutual gazeSmooth movementsCharismatic & optimistic

Nonverbal Cues of Self-Healing or Disease Prone Personality

Disease ProneUneven speechLoud, explosive voiceSighs, stutters, umsClenched fist, teethClosed body postureFidgets shifts tappingShifty-eyed,downcastFacial grimace Vocal gesture impatienceOver controlled calm unexpressiveness

Nonverbal Cues of Self-Healing or Disease Prone Personality

AcuteChronicLife threateningTerminal

Factors related to illness

Psychological Adjustment to Physical Illness

Time

6 months

Emotional distress

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-upTaking medication correctlyFollowing recommended lifestyle changes

Adherence

Psychiatric problems in the medically ill

Depressive disordersAnxiety statesSexual problemsAlcohol problems

Psychiatric problems

Mood and motivationPersistent low moodDiminished interest or pleasure

Social withdrawalLoss of energy

Depressive symptoms

Cognitive changesDepressive thoughts,Worthlessness, Self blameSuicidal wishes, Hopelessness

Depressive symptoms

Biological symptomsPoor appetite,Weight loss, Sleep disturbance, Poor concentration, Decreased sex drive, Retardation or agitation

Depressive Symptoms

Prevalence of psychiatric disorder in different organic conditions (bars show the highest and lowest recorded rates)

0 10 20 30 40 50 60

out-patients

cancer

myocardial infarction

rheumatoid arthritis

Parkinson's

Stroke

HIV/AIDS

Inflammatory bowel disease

highlow

Per cent

Prospective Longitudinal Cohort Study of Anxiety and Depression in Medical In-Patients

Psychiatric diagnosisHealth Status-SF-36Duke Severity of Illness ScaleKarnofsky Performance Status ScaleHealth care costs

Acute medical in-patients Follow-up 5

months later

Creed et al, Psychosomatics; 43:302-309

(n=263)

(n=218)

27% of acute medical in-patients had diagnosable depressive or anxiety disorders

A further 41% had sub-threshold disorders

Prevalence of psychiatric disorder

Mean SF36 scores for physical dimensions at 5 months follow-up, adjusted for severity of illness

0

1020

3040

50

6070

80

physicalfunction

physical rolelimitation

healthperception

pain

casesubthresholdcontrolgeneral population

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

Main findings

0

1

2

3

4

5

6

7

Mea

n HR

QOL

Scor

es

DepressedNot depressed

*

** * * * *

*

Mean HRQOL in CD by Depression

Irvine et al 2002

Panic disorderAgoraphobiaGeneralised anxiety disorderSpecific phobiaSocial phobiaObsessional compulsive disorderPost-traumatic stress disorder

Anxiety states

Common35-40% diabetic males report sexual

problemsCaused by:

the condition itselfEffects of drugs and other physical treatmentsPsychological sequelae of the conditionCo-existing psychiatric disorder

Sexual problems

EnquiryKnow something about the patient and their

circumstances before askingDetailed enquiry not necessaryOne or two relevant screening questionsEnquire in a matter of fact but sensitive way

Sexual problems

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

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.

Summary