Professional Documents
Culture Documents
S. SOCIAL
BIOPSYCHOSOCIAL
S. PSYCHOLOGY
GEORGE L ENGEL
S. BIOLOGY
CLP
MEDICAL ASPECS + PSYCHIATRY QOL, BRIEF, EFFICIEN, FRIENDLY
CLP fungsinya untuk meningkatkan kualitas hidup, brief (lbh singkat tatalaksananya), efisien (biaya lbh murah)
MEDICAL SERVIS
Uexkll)
In the 50ies and 60ies of the last century, the holistic approach in internal medicine and the object relations approach in psychoanalysis were further developed and combined by clinicians and researchers in the emerging field of psychosomatic medicine, especially in the anglo-saxon countries and the German speaking countries. In my opinion, this early movement had three fathers: George Engel from Rochester/USA, Thure v. Uexkll from Germany, and Michael Balint from the famous Tavistock Clinic in London.
Based on the holistic paradigm of medicine as described earlier, systems theory, and semiotic theory Thure von Uexkll together with Wolfgang Wesiack created a theoretical foundation of medicine that overcomes the old dualistic hydra and includes an explanantion of the interdependence of somatic, psychological, relational, and social aspects in the development of health and disease. George L. Engel and his co-workers developed the bio-psycho-social paradigm, and they have demonstrated how to implement this approach in a liaison model in clinical practice in Rochester, N.Y. Rolf Adler will describe this approach in detail. Michael Balint from the famous Tavistock Clinic in London applied object relations theory to understand the crucial role of the physician as the third actor in the interplay between doctor, patient, and illness. Based on his research that he conducted together with family physicians, he developed an interactional-psychoanalytical method to understand the psychodynamic features underlying the patients compliants. He provided more insight in the power of the doctor-patient-relationship (drug physician) and the placebo phenomenon. Based on these theoretical considerations a series of researchers in the US some of them internists and others psychiatrists started to conduct empirical research. Some of this research like the studies of Mirsky & Weiner on peptic ulcer (to my knowledge the first prospective study in PM)
Spesific:
Theory:
CLP implementation - med & psy field
Technic:
Learning CLP. Practices CLP
Paradigma holistik adanya gangguan krn faktor biopsikososial shg tatalaksananya dgn biopsikososial jg. Tujuan clp: holistik, beri pelayanan kedokteran u/ ningkatin kualitas hidup.
DEFINITIONS
HISTORY
GENERAL MANAGEMENT
CASE FINDING
C-L-P
DIAGNOSIS INTERVENTION
TREATMENT
COMMUNICATIONS
Stimulus luar kortek, lewat 3 jalur: -aksis hpa Sternberg Nature Reviews Immunology 6, 318328 (April 2006) | doi:10.1038/nri1810 -hormonal -aksis sistem imun
(Hawkley)
Mana yg bereaksi thd stressor ditentukan o/ hipotalamus dan amygdala.
Lateral hypothalamus
Sympathetic nervous system activation Tachycardia, Increased blood pressure
Bradycardia
BAB -I
James JS (2000):
Psychiatry subspecialistliaison role synergy by psychiatrist & another medical specialist, witch C-L psychiatrist have role as distributor psychiatry skill in medical field that keep psychiatry as knowledge for helping psychologist, psychiatric, and psychophysiology co morbidity in medical field.
Definition at Indonesia Based on meaning of CLP term it self : Consultation - clinical references for examination and management suggestion. Liaison - connector. Liaison Psychiatry knowledge that develop for that purpose. Liaison Psychiatrist - conector psychiatrist that do the task psychiatry liaison. Consultation-Liaison Psychiatry term based on practice clinical need (companion).
Based on opinion of Pasnau and Lipowski than define CLP as: Subspecialist psychiatry knowledge root that intense psychiatric aspect from another medical condition, including evaluation, diagnosis, therapy, prevention, study and education.
Clp approach pasien medis dan bedah dgn psikiatri. Definisi: pendekatan holistik pd pasien medis dan bedah
C-L-P
Development of psychiatry in relations with another general medical field/another connected field.
Connect medical knowledge with psychosocial/behavioral aspect. Point at final purpose therapy: recover good quality of life (not only cure from symptom/disease).
CLP
1) Karena merupakan subspesialisasi yang kompleks dan luas, CLP tidak dapat dipelajari/dikuasai dalam waktu yang singkat. Presentasi seperti sekarang ini hanya merupakan introduksi. 2) Kesulitan pertama adalah pemahaman konsep CLP. Masih banyak salah pengertian baik dari kalangan psikiatri sendiri, apalagi dari bidang medik lain. 3) Perlu persiapan dan kesiapan dari bidang/pihak psikiatri sendiri baik dalam ilmunya, waktu dan tenaga. Memerlukan junlah SDM yang cukup banyak dan pendalaman khusus pada bidang-bidang tertentu yang menjadi fokus liaison. 4) Di lain pihak perlu pengertian dan kesiapan dari bidang medik yang akan bekerjasama. Bagi bidang-bidang spesialistik lain, tidak mudah menerima konsep liaison ini bila mereka sendiri belum memahami dan tidak merasakan kebutuhan untuk itu. Hal ini akan sulit bila tingkat profesionalisme masih kurang, lebih kearah business dan bukan ke kepentingan pasien. Dalam hal demikian maka konsep liaison ini akan terlihat sebagai campur tangan atau merebut lahan. Menghilangkan sikap prejudice dan arogansi ilmiah di kalangan dokter sangat sulit, apalagi dalam keadaan di mana masing-masing spesialisme berkembang seperti kerajaan sendiri-sendiri. Konsep teamwork dan melihat tujuan terapi secara menyeluruh bagi kepentingan pasien, masih merupakan hal langka. 5) CLP memerlukan keterlibatan bidang medik lain, tidak dapat dipaksakan. Penggalangan kerjasama merupakan proses panjang yang perlu persiapan.
b. Approximation in consultation
Examination models (Psychoanalytic?, > cog) Helping aid and skill Consultation process
Required skills for the evaluation and treatment of patients with psychiatric disorders in the general medical setting
1. Ability to take a medical-psychiatric history 2. Ability to recognize and categorize symptoms 3. Ability to assess neurological dysfunction 4. Ability to assess the risk of suicide 5. Ability to assess medication effects and drugdrug interactions 6. Ability to know when to order and how to interpret psychological testing 7. Ability to assess interpersonal and family issues 8. Ability to recognize and manage hospital stressors 9. Ability to place the course of hospitalization and treatment in perspective 10. Ability to formulate multiaxial diagnoses 11. Ability to perform psychotherapy 12. Ability to prescribe and manage psychopharmacological agents 13. Ability to assess and manage agitation 14. Ability to assess and manage pain 15. Ability to administer drug detoxification protocols 16. Ability to make medicolegal determinations 17. Ability to apply ethical decisions 18. Ability to apply systems theory and resolve conflicts 19. Ability to initiate transfers to a psychiatry service 20. Ability to assist with disposition planning
DISORDER
SICK,
Health services
QOL
INT
Approach Method
1. Non structure interview 2. Structure interview 3. Self-report
Consultation-Liaison Psychiatry
DIAGNOSIS
Prof.Dr.M.Syamsulhadi,dr,Sp.KJ ( K )
LAB/SMF PSIKIATRI FK UNS-RSUD DR.MOEWARDI SURAKARTA 2009
DIAGNO SIS
Pemeriksaan penunjang
Sulit ditegakkan
Ketrampilan dokter Ketersediaan alat penunjang Dx Faktor pasien sendiri
2. Apakah ggn mental yang menyerupai gangguan fisik namun sebenarnya bukan gangguan mental( delusional parasitosis, body dysmorphic
disorder )
3. Gangguan medis yang muncul adalah akibat keterlibatan proses psikologis ( psoriasis,
neurodermatitis, hyperhidrosis dll )
4. Gangguan psikiatri yang timbul merupakan sekunder akibat isolasi sosial atau stigmatisasi dari gangguan kondisi medis ( depresi pada penderita kusta )
5. Baik ggn psikiatri maupun ggn kondisi medis ttt sama-sama timbul akibat dari adanya faktor genetik dan lingkungan
(mania dan psoriasis, keadaan hipo atau hipertoroid, autisme pada anak)
6. Ggn kondisi medis ttt yg muncul akibat kronisitas gangguan psikiatri ( dehidrasi, gizi
buruk pada skizofrenia katatonik, infeksi kulit akibat higiene yang buruk pada skizofrenia )
7. Gangguan psikiatri timbul akibat penggunaan obat-obat untuk penyakit tertentu ( reserpin dan kortikosteroid yang dapat
memunculkan gangguan mood )
8. Gangguan kondisi medis tertentu yang timbul akibat penggunaan obat psikotropika ( distonia, parkinsonisme,
Cancer
Medications
Streroids
Oral contrasceptives
Kesimpulan
Keefektifan konsultasi psikiatri ketrampilan klinis serta kemampuan mengintegrasikan berbagai informasi mjd suatu Diagnosis Ketrampilan esensial dlm CLP : kemampuan melakukan pmx status mental scr komprehensif ( Kemampuan kognitif ) serta melakukan pmx neurologis singkat & berfokus pada pmx fisik
Lanj Kesimp.
Formulasi diagnosis dibuat berdasarkan data tentang riw penyakit (riw psi & medikasi, hasil pmx penunjang), ggn psikiatri, defense mechanisms , kepribadian, serta pemeriksaan status mental scr komprehensif
INTERVENSI
Langkah antara diagnosis & penerimaan pasien terhadap pengobatan Persiapan pasien thd suatu pengobatan
Komunika si dokterPasien Ketrampilan komunikasi
Strategi FRAMES
F = Feedback on the patients risk or impairment R = Responsibility for change belongs to the patient A = Advice to change should be specific and nonambiguous M = Menu of alternative strategies E = Empathetic rather than confrontational counseling style S = Self-efficacy : a positive view of patients ability to change and the treatments efficacy
Kotak dialog : Pasien rawat inap laki-laki pecandu alkohol dan hepatitis
Tn C, Saya pikir kebiasaan anda minum alkohol adalah penyebab penyakit liver anda (feedback), dan anda perlu untuk menghentikan minum alkohol sebelum liver anda menjadi lebih buruk (advice). Saya harap anda membicarakan dengan Dr X untuk mendiskusikan apa yang dapat anda lakukan mengenai kebiasaan anda minum alkohol tersebut (responsibility). Saya sudah minta dia untuk menengok anda hari ini. Saya pikir beliau dapat membantu problem anda (empathy dan self efficacy).
Kotak dialog: Pasien rawat inap perempuan dengan gejala angina dan depresi Ny D, Saya pikir problem anda yaitu insomnia, saat-saat sedih dan menangis, serta kelelahan mungkin disebabkan oleh depresi (feedback) karena kondisi jantung anda. Saya harap anda berbicara dengan Dr Y (advice), seorang yang ahli dalam bidang ini untuk melihat apakah kami dapat membantu anda dengan gejala-gejala ini (empathy). Saya sudah membicarakan dengannya agar datang segera dan melihat anda hari ini. Inilah kesempatan yang baik dimana anda akan merasa lebih baik (self efficacy). Jika anda depresi dan meneruskan pengobatan. Saya senang anda merasa lebih baik dan melakukan lebih banyak dalam hidup anda (empathy).
Intervensi
Ketrampilan komunikasi Perilaku yg positif Ketekunan & latihan Menilai keberhasilan pengobatan dr segi kepuasan pasien, kesehatan & fungsi pasien yg meningkat Nilai usaha : kepuasan profesional yg bertambah
Intervensi : Mengerti kebutuhan kebutuhan psikiatri dan psikososial pasien yang dirawat di rumah sakit Pengobatan (terapi) Memperkecil morbiditas fisik Mengurangi LOS (Length of Stay)
Faktor Psikiatri & Psikososial berlaku pd tiap fase dari episode suatu penyakit
1. Sebelum perawatan sebagai sebab atau tekanan untuk pengakuan 2. Selama perawatan di rumah sakit 3. Selama keputusan yang mempengaruhi pemulangan dan penempatan sesudah perawatan
Kesimpulan
Intervensi mrpk Langkah antara diagnosis & penerimaan pasien terhadap pengobatan
Constitution
Strength resources & other support Life experience
PERSON
Age
Life phase
Religion
Culture Believe
(Wibisono, 2007)
Mental State
Immune Function
Thouhgt-desease pathway
Repetitive Negative Thought
Thougth-healing pathway
Affirmation Positive Thought Form ______________ Negative Thought Form Release of Frozen Emotional State
HEALTH
American Medical Association, 1998
a.BIOLOGICAL/PHARMACHOTHERAP Y TREATMENT
Treatment principle in CLP : 1. Remember that discontinue treatment sometimes is a beneficial action 2. If possible, need to avoid recipe if needed treatment 3. If there is a require to give if needed treatment dose, observe using frequency to decide precise dose level 4. That is important to use minimum dose in maintenance the targets response 5. Change one drug in one time
or symptom 7. Keep to make simple mixed drug 8. Dont give prophylaxis drugs except there is a rational reason 9. Use drugs with proved efficacy 10. Remember that serum drugs levels only one indicator of effect, not evidence for efficacy or toxicity 11. Need to know that generic drugs more cheap but the bioavailability may low 12. Consider that each patient show a new experience
Changes in lifestyle
Substance abuse Stigmatisation Package insert
b. Psychotherapy
Prime form psychotherapy
1. Dynamic psychotherapy. 2. Humanistic-experience psychotherapy. 3. Cognitive-behavior psychotherapy. 4. Ecletic and integration psychotherapy.
(Nash, 2000)
There is some adaptation for psychotherapy technique at patient with medical illness
1. Focus on supportive than conflict, built therapeutic relations that give safe felling. 2. Strengthen resources that patient have. 3. Facilitate patient emotion flooding. 4. More structure in make safety therapeutic schema. 5. Focus on brief time (short time perspective). 6. Strengthen social support (that give benefit). 7. Involve people that have strong influence for the patient. 8. Give support on medical treatment. In psychotherapy, must consider the patient adaptation to the illness. (Sollner, 2006)
Adjustment to illness
Recognition, professional support, treatment
Stress
Vulnerability
Recurrent/chronic life events
Coping
Adjustment to illness depends on various factors: -the severity of distress -The kind of the LE causing distress the (kind and severity of the somatic illness): it is a completely different situation whether a patient suffers early stage cancer with a good prognosis or whether he receives palliative treatment -- the vulnerability of a person, in terms of personality features (whether a person has good coping abilities, or hardiness), whether a person has successfully coped with distressing LE previously, and whether a peson has suffered psychiatric disorder previously. -- support a patient receives and perceives from his or her social network -- his actual coping patterns, whether they are adequate or inadequate in a given situation --whether or not distressing LE emerge again (like recurrence of illness) -- If all these factors contribute to persistent feelings of anxiety, helplessness, hopelessness or depression without constituting another Axis I diagnosis, we classify this as a AD. -This figure shows that a couple of psychological and social factors contribute to the development of an AD as well as somatic factors. The debate on diagnosis whether it is an affective disorder or an AD is often academic. It is important that severely ill patients have specific psychological threats and needs.
(Malt, 2006)
SUMMARY
Dennis H. Novack, M.D., Oliver Cameron, M.D., Ph.D. Elissa Epel, Ph.D., Robert Ader, Ph.D., Shari R. Waldstein, Ph.D. Susan Levenstein, M.D., Michael H. Antoni, Ph.D. Alicia Rojas Wainer, M.D.Psychosomatic Medicine: The Scientific Foundation of the Biopsychosocial ModelAcademic Psychiatry, 31:5, September-October 2007
PATIENT
SIGNIFICANT PEOPLE
CARE TEAM
FOUNDATION
SOCIAL
BIO PSYCHO
PSYCHIATRIC COMMUNICATION
COMPETENCE
EFFECTIVENESS
ANOTHER DEPARTMENT
CLP
PENDEKATAN KOMUNIKASI
EXAMINATION MODEL
ANOTHER DEPARTMENT
SKILL AID
PENDE KATAN
CONSULTATI ON PROCESS
GROUP PRACTICE
SUMMARY
Treatment integration
PATIENT