1. 1
Psychiatry and Palliative care
medicine
Post graduate Students
MD Phase A
Department of Psychiatry
BSMMU, Dhaka.
30.11.2013

2. 2
Contents
•
•
•
•
•
•
Mind ,Body & Psychiatry
What's happening inside
Palliative care in psychiatry
Psychiatry in palliative care
Updates
Summary

3. 3
Mind, body & Psychiatry
Dr Md Saleh Uddin

4. 4
Mind & Body
• Mind body dualism
(Cartesian dualism)
Dualistic categories
Psychological
Symptoms
Physical
Symptoms
Bodily Pathology
Comorbidity
Medical disease
Psychopathology
Psychiatric
disorder
Somatization

5. 5
• Integrated approach
Neural basis
Mind & Brain
(Two sides of same coin)

6. 6
Mind & Body
Mental Process/Psychology/Neuro cognition
•
•
•
•
•
•
•
Perception
Emotion
Motivation
Learning
Memory
Thought
Personality etc

7. 7
Mind & Body
Psychiatry
• Perception: Hallucination, Illusion
• Thought: Delusion, Obsession
• Mood: Mania, Depression
• Abnormal behavior etc

8. 8
Mind & Body
Differences
• Psychology (Process)
Nice flower!
• Psychiatry (Function)
I saw that!
• Neurology (Morphology)
Seizure/ICSOL

9. 9
Normal
functioning
MENTAL
HEALTH
Psychopathology
MENTAL
DISORDER
Mental process

10. 10
THANK YOU

11. 11
Inside of mind
Dr Hosnea Ara

12. 12
Contents
•
•
•
•
•
•
•
•
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 arousal
3.A pattern of overt expression

16. emotion
Types:
• 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. Stress
Stress reaction
1. Disruption of emotion
2. Cognitive disruption
3. Physiological disruption
Methods of coping
1.Emotion focused
2.Problem focused

19. 19
THANK YOU

20. 20
Palliative 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.
• Patient‟s difficulty to exercise autonomy in decision
making

27. Can we overcome the challenges?

28. Similarities

29. Something is common
A 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. 32
Psychiatry 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 Stress
Adjustment
Disorders
With depressive &
Anxiety symptoms
Crisis
Depression
Delirium
Anxiety Disorder
Personality Disorder
Others
100%

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. dehydration
But 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. 59
Palliative care psychiatry
Dr Md Saleh Uddin

60. 60
Talk plan
• The need for psychiatry
• Recent Advances
• Steps ahead

61. 61
Why needed?
• “Total pain”
• Psychiatric syndromes
Normal response?
Unrecognized?
Primary/ Secondary?
Chronic cases?
Interventions?

62. 62
Recent Updates
• Psychotherapy
• Depression, Anxiety, Delirium
• Models of care, Education, System development

63. 63
Recent updates

64. 64
Recent updates
Psychotherapy
(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. 65
Recent updates
Clinical syndromes:
• Hospice patient: 50% -depression, 70%-anxiety
Nearly all- Delirium
• Depression
• Anxiety
• Delirium
Stimulants (Methylphenidate)
Ketamine
Non pharmacological (Hypnotherapy,
Concreteness training)
No clinical trial

66. 66
Recent updates
Education, Models of care
• Educational opportunity (training)
• Integration model
Liaison consultation
Part of team

67. 67
Steps ahead
• Distinguishing variations of illness
• Managing Comorbidities
• Ethical issues

68. 68
Summary
• 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. 69
References
•
Shorter Oxford textbook of Psychiatry, Sixth edition, Philip Cowen, Paul Harrison, Tom Burns,
Oxford university press, 2012
•
Oxford Handbook of Psychiatry, Third edition, David Semple, Roger Smyth, Oxford university
press, 2013
•
Psychology, Fourth edition, Andrew B Crider, George R Goethals, Robert D Kavanaugh, Paul R
Solomon, Harper Collins College Publisher, 1933
•
Desk reference to the DIAGNOSTIC CRITERIA from DSM5, American Psychiatric Association,
2013
•
Palliative care Psychiatry: Update n Emerging Dimension of Psychiatric Practice, N Fairman, S A
Irwin, Corr Psychiatry Rep (2013)15:374, Springer
•
Availability 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)42-52
•
Palliative Medicine and Psychiatry, Editorial, AD Macleod, Journal of Palliative Medicine, Volume
16, Number 4, 2013
•
How we can improve end of life care, Rachel Kester, Psychiatry resident, Residents voice, Current
Psychiatry, Vol 12, No5, 2013

70. 70
References
• 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 january‟19(1) 21-28

71. 71

72. 72
THANK YOU