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Consultation Liaison Psychiatry ( C-L-P )

Prof. DR. Dr. M Syamsulhadi, SpKJ (K)

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

The early movement? Development PM


The holistic paradigm of medicine (Thure von

Uexkll)

The bio-psycho-social paradigm (George L. Engel)

Paradigm of object relations in medicine (Michael Balint)


The Physician, the Patient, and his Illness Michael Balint 1957

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)

AIM AND TARGETS


General :
role CLP Holistic medical services management QOL

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.

Dotted lines: negative regulatory Solid llines: positive regulatory


Andrea H Marques, Giovanni Cizza, Esther Sternberg. Brain-immune interactions and implications in psychiatric disorders. Rev Bras Psiquiatr. 2007;29(Supl I):S27-32

JALUR TANTANGAN MENTAL DAN RESPONS KARDIVASKULER


AMIGDALA
Lateral periaqueductal grey Sympathetic autonomic activation Cardiovascular respons Dorsal motor nucleus of the vagus Parasympathetic nervous system activation

Lateral hypothalamus
Sympathetic nervous system activation Tachycardia, Increased blood pressure

Bradycardia

BAB -I

CONSULTATION LIAISON PSYCHIATRY

UNDERSTANDING AND DEFINITION


CLP definition develop side by side with the development of CLP it self. Strain JJ. Grossman (1975): primary, secondary, tertiary prevention. Robert O. Pasnau (1982): Related with study, diagnosis, treatment, dan prevention from psychiatry disorders at physical illness, Psychological factors that influence physical conditions, and interrelations somatopsychic and psychosomatic
Diagnosis faktor pasien sndiri kooperatif/ tdk.

Zbigniew J. Lipowski (1996):


Psychiatric subspecialist that union clinical service, education, and study at psychiatry and medical field.

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

Not only psychiatric consultation


Cant learn it in short time. Important to start with concept understanding. Prepare and intent from psychiatry field. Understanding and preparation of another medical field. Make a collaboration.

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.

CLP GENERAL MANAGEMENT


1. Liaison psychiatry working consept
Primary, secondary, tertiary prevention Detection & Diagnosing (CLP vs. Consults Psi) Health services evaluation (group responsible) Giving authority to non psychiatry staff Develop new knowledge Change health service structure ( Modern Service )

2. CL preparation and aplication (at Indo)?


a. Consultant psychiatry
CP quality and effectively and competency (Abel?Leader) Another physician hope (Dx, Gx, Tx, Help)

b. Approximation in consultation
Examination models (Psychoanalytic?, > cog) Helping aid and skill Consultation process

3. Organization Structure CLP Service


General organization field Group practice CLP with another specialist

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

Health services as system


EXT

DISORDER

SICK,

Health services

QOL

INT

CASE FINDING APPROACH


Liaison approach direct to medical staff sensitivity increasing, so that its can product more effective budget management and early detection at patient services.

Approach Method
1. Non structure interview 2. Structure interview 3. Self-report

MANAGEMENT SYSTEM CASE FINDING


OPERATIONAL PROCEDURE HEALTH SERVICES

QUALITY OF LIFE PATIENT

MEDICAL SERVICES EFFECTIVITY

Criteria for Identification of an Emergency by Consultation-Liaison Psychiatrists


1. Psychiatric antecedents 2. Agitation 3. Suicidal thoughts and attempted suicide 4. Confusional state 5. Other symptoms indicating a serious psychiatric state (depression, anxiety, state of shock, borderline state, or catatonic state) 6. Substitute treatment (methadone) for a drug-dependent patient 7. Forensic problem 8. Transfer to a psychiatric ward 9. Psychiatric symptoms linked to the perspective of somatic treatment 10. Patient should be seen before the weekend

Categories of Psychiatric Differential Diagnoses in the General Hospital


Psychiatric presentations of medical conditions Psychiatric complications of medical conditions or treatments Psychological reactions to medical conditions or treatments Medical presentations of psychiatric conditions Medical complications of psychiatric conditions or treatments Comorbid medical and psychiatric conditions
Source: Adapted from Lipowski 1967

Procedural Approach to Psychiatric Consultation


Speak directly with the referring clinician. Review the current records and pertinent past records. Review the patients medications. Gather collateral data. Interview and examine the patient. Formulate diagnostic and therapeutic strategies. Write a note. Provide periodic follow-up.

INSTRUMENT THAT OFTEN USED AT SCREENNING


Case Finding Role
Active Pasive Team work Service system

Consultation-Liaison Psychiatry

DIAGNOSIS
Prof.Dr.M.Syamsulhadi,dr,Sp.KJ ( K )
LAB/SMF PSIKIATRI FK UNS-RSUD DR.MOEWARDI SURAKARTA 2009

A. LANGKAH MENUJU DIAGNOSIS YANG TEPAT


ANAMNESIS

DIAGNO SIS
Pemeriksaan penunjang

Sulit ditegakkan
Ketrampilan dokter Ketersediaan alat penunjang Dx Faktor pasien sendiri

Pemeriksaan Status Mental

EFFECTIVE DIAGNOSTIC& COST EFFECTIVE


Case finding
Anamnesis
Skreening Daftar isian -latar belakang sosiodemografik -kel somatis -Perub emosional -RPD -R.penggunaan zat Laboratorium Pmx penunjang lain Kemampuan mengarahkan & menilai
Pmx Penunjang Fx (MRI, CTScan, EEG) Pmx kimiawi (Kdr obat, estrogen, tiroid, ureum, kreatin) Psikometri (MMPI, MMSE, Wwcr terstruktur)

Diagnosis yg tepat & intervensi yg efektif

Menekan biaya & prosedur yang tidak perlu

6 bidang yg sering menjadi garapan bersama


1. Efek psikologis akibat menderita penyakit fisik atau prosedur terapi 2. Gangguan somatoform 3. Perilaku yang membahayakan 4. Kedaruratan psikiatrik yang datang ke rumah sakit 5. Keadaan gangguan fisik dan psikologis akibat terapi psikiatrist 6. Gangguan fisik dan perilaku akibat tindak kekerasan termasuk yang bersifat seksual

Ruang lingkup CLP


1. Apakah ggn medis yg muncul didasari oleh ggn mental atau bukan (gejala depresi bisa diakibatkan
primer akibat hipotiroid shg beda penangananya dengan depresi akibat stresor psikososial )

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,

tirotoksikosis,agranulositosis, aritmia, hipotensi postural, SNM )

9. Gangguan psikiatri yang disebabkan oleh penyakit medis kronis ( stroke )

Komponen Pemeriksaan Status Mental


KOGNITIF Tingkat kesadaran & kewaspadaan Perhatian Kemampuan berbicara & berbahasa Orientasi Memori NON KOGNITIF Penampilan umum dan perilaku Afek dan Mood Proses fikir dan isi fikir Persepsi Kemampuan abstraksi Daya nilai Tilikan diri

Komponen Non Kognitif


Lebih sulit subyektif

DD Delirium ( I WATCH DEATH )


Infection : Encephalitis,Meningitis,HIV,Syphilis,sepsis Withdrawal : Alcohol,Barbiturates,Sedative-hipnotics Acute metabolic : Acidosis,alkalosis,hepatic failure,renal failure Trauma : Closed-head injury,severe burns,postoperative CNS pathology : Hemorrhage,hidrocephalus,seizure,sroke,tumors Hypoxia : Anemia,hypotension,pulmonary or cardiac failure Deficiencies : Vit B , folate,niacin,thiamine Endocrinopathies : Hyper/hypoglycemia,myxedema Acute vascular : Hypertensive encephalopathy,shock,arrhytmia Toxin or Drugs : Medications,pesticides Heavy metals : lead,manganese,mercury

Medical condition etiologically related to depression


Neurologycal disorders Stroke Parkinsons disease Multiple sclerosis Epilepsy Hutingtons disease Dementia Endocrine disorders Hyperthyroidism Hypothyroidism Cushings syndrome Addisons disease Hyperpharathyroids m Hyperprolactinemia

Cancer

Medications

Medications and Psychoactive substances assosiated with depression


Antihypertensive Reserpin Metyldopa -Blockers Cancer chemotherapeutic agents Vincristin Vinblastin Procarbazine Amphotericin B Interferon

Streroids
Oral contrasceptives

Histamine resceptor antagonists Cimetidine Ranitidine


Psychoactive substance Alcohol Opiate Amphetamine/ cocaine

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

Pasien mampu menerima diagnosis & pengobatan yang diberikan

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 PSIKIATRI PADA LINGKUNGAN MEDIS PASIEN RAWAT INAP

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

Intervensi liaison, bedanya dgn pendekatan konsultasi


1. Mendeteksi DSM-III-R secara signifikan (American Psychiatry Association 1987) morbiditas Psikiatrik (56%). 2. Menghasilkan lebih sedikit depresi dan penurunan kognitif pada pemulangan. 3. Mengurangi LOS sampai 2 hari. 4. Mempersingkat hari-hari rehabilitasi 5. Tidak menyebabkan rawat inap kembali dalam periode follow-up 12 minggu.

Penelitian intervensi Laison Psikiatri


Pendekatan liaison menghasilkan peningkatan kesehatan psikiatrik dan penurunan penggantian kerugian biaya yang signifikan

Kesimpulan
Intervensi mrpk Langkah antara diagnosis & penerimaan pasien terhadap pengobatan

A. MIND AND BODY INTERACTION


Problem : Modern medical practice become something that mechanic, technically, and divided. Our rationalistic view and divided make difficult to do integral approach that aim to cure sick people. (Fountain,2002)

A. MIND AND BODY INTERACTION


Sex

Constitution
Strength resources & other support Life experience

PERSON

Age
Life phase

Religion
Culture Believe
(Wibisono, 2007)

A. MIND AND BODY INTERACTION


External Stimuli

Mental State

Neurologi cal Activity

Physiolo gical State

Immune Function

(diadaptasi dari Duncan Smith-Rohrberg,2000)

Thouhgt-desease pathway
Repetitive Negative Thought

Frozen Emotional State

Negative Thought Form


DESEASE

Body Becomes Locked Into a Chronic Sympathetic/Stress State

American Medical Association, 1998

Thougth-healing pathway
Affirmation Positive Thought Form ______________ Negative Thought Form Release of Frozen Emotional State

Body Relaxes and Moves Into a Parasympathetic State

Positive Thought Form _________________ Fleeting Negative Thoughts

HEALTH
American Medical Association, 1998

B. CLP TREATMENT GUIDELINES


The site of psychiatric treatment and the use of psychiatric consultants is currently a matter of : 1. preference, 2. the patient's acuteness, 3. risk factors, 4. availability of local resources. C-L psychiatrists usually use biological and psychotherapeutic treatments that have demonstrated efficacy.
(Westphal J.R dan Freeman A.M, 2000)

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

Treatment principle in CLP cont


6. If possible, used only one drug to treat patient disorders

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

(Jachana, Lane, dan Gelenberg, 1996)

Principle in choosing drugs


1. 2. 3. 4. 5. 6. 7. Effect on clinical problems. Effect on basis desease. Implication side effect figure. Interaction with somatic drugs. Oral or parenteral drugs. Lever or kidney function and dose. Biological matching?
(Malt, 2006)

FACTORS THAT INFLUENCE ADHERENCE


Insight into illness Perception of severity of illness Perception of tendency to relapse Acceptance of illness Type / symptoms of illness Degree of support Stability of family Doctor-patient relationship Type of administration Method of prescription Psycho-education Therapy supports: symptom diary, text messages to a mobile phone Side effects Primarily critical attitude Lack of symptom control Complex therapy regimen Type of therapy

Changes in lifestyle
Substance abuse Stigmatisation Package insert

Fenton et al 1997; Lacro et al 2002

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

Life event(s) Illness

Personality features, previous experiences, psychiatric disturbance

Stress

Adjustment disorder Successful adjustment

Vulnerability
Recurrent/chronic life events

Adaptation of cognitions, behaviour

Coping

Interpersonal relationships, social support


W. Sllner, Lausanne 2006

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.

Stage psychosocial care for medical illness


Pharmacology therapy
Psychotherapy, konseling Emotional support from physician & paramedic

Emotional support from patien social environment


W. Sllner, Lausanne 2006

c. Relation between psychopharmaca and psychotherapy


Psychopharmaca have different effect and pathway compare with psychotherapy. Psychotherapy and psychopharmaca effective but the effect that give is not amazing (there is no panacea).

(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

Collaboration between department

PATIENT

Inter discipline collaboration

Intra discipline collaboration