Managing Psychosocial issue Psychiatric illnesses in Family Practice Lena Gowharji

Psychiatry in family practice BIO-PSYCHO-SOCIAL Interaction between body and mind Why are psychological issues so important? 1- Preventing preventable deaths 2- Time off work

BATHE Technique B: Background A: Affect Troubling Handling Empathy T: H: E:

Background *Assessment of the patients background situation *Done by asking a simple statement: “ Tell me what has been happening?”

Affect The patient's affect Done by asking the patient : “ How do you feel about that?”

Troubling The problem that is most troubling for the patient Done by asking the patient: “ What troubles you most about this?”

Handling The manner in which the patient is handling the problem Done by asking the patient: “ How are you coping with this?”

Empathy The technique concludes with an empathetic response by the physician Done by saying: “ That must have been difficult” or “ I can understand that you would feel angry”

Different approaches according to the type of patient: 1- over talkative patient 2- silent and angry patient 3- those who insist that they can’t handle their problem

The BATHE technique fulfills the essential elements of successful psychotherapy which are: 1- establishment of therapeutic alliance 2- empathy on part of the clinician( the Dr. puts himself in the patient’s shoes) 3- identification of the central conflict 4- the development of insight and awareness 5- the discouragement of dependency

Challenging patients 1- Poor social skills 2- Chronic pain 3- Learned helplessness

Patients with poor social skills Referral to life skills programs ( not always successful ) because : 1- family physician not always familiar with these resources or 2- patients may refuse attending these services

Illustrative Case A 23 year old single parent was seen by her family physician for psychotherapy. No history of mood or anxiety disorder could be elicited. This patient described difficulties caring for her two preschool- aged children. Her childhood included many years of moving back and forth from home to foster homes because her parents were unable to provide for the family consistently.

Patients with Chronic pain Dealt with by: 1- the physician expressing meaningful empathy and 2- helping the patient deal with grieving process. Without this, the patient may easily develop intractable anger or depression

Illustrative case A 46 year old man was followed by his family physician for problems related to Tranverse Myelitis. The patient was the only child of hard-working immigrant parents, and his identity revolved around his career. His brief but regular visits with the physician allowed him to express his anger and sadness about his disability. The most troubling aspects of the patient’s situation were his loss of productive employment, self-respect and self-esteem. Eventually, the patient was able to channel his anger and his drive to work into a successful woodworking business. Clearly, validation of the patient’s feelings by the physician assisted in the restoration of self-esteem.

Learned helplessness These patients are best dealt with by refractory to 1- conventional antidepressant drug therapy 0r 2-psychotherapy. The BATHE technique can be adapted to help patients with learned helplessness.

Illustrative case A 42 year old women was followed for depression and marital discord. Unipolar depression was diagnosed, and an antidepressant was prescribed. In the follow-up visits, the patient described a current abusive relationship, as well as severe physical and sexual abuse in the past. She was most troubled by her belief that she had no way out– no escape. The patient related that when she was a child, she was locked in a closet for long periods. She remembered feeling powerless and fearful.

Final comment Effective physician: 1- listens to the patients current reality 2- works with the patient to identify the predominant feelings and central conflict. *this facilitate empathy and positive regard for the patient *the responsibility for handling the problem remains with the patient 3- the physician may validate the patient’s existing strategies or work with the patient to come up with new methods.

Staging of consultation (PRACTICAL) 1. P… prior to consultation. 2. R…relationship. 3. A…anxieties. 4. C…common language. 5. T…translating. 6. I…interacting. 7. C…converting insight into action. 8. A…agreement check, safety netting. 9. L…leave from consultation. The BATHE technique 1. B…background. 2. A…affect. 3. T…troubling. 4. H…handling. 5. E…empathy.

Criteria for the diagnosis of depression include:  Major criteria… Anhedonia (loss of ability to experience pleasure). Anhedonia (loss of ability to experience pleasure). Dysphoria (feeling of depression). Dysphoria (feeling of depression).  Minor criteria… Sleep (early awakening or excessive sleeping). Sleep (early awakening or excessive sleeping). Interest (motivation to take an action). Interest (motivation to take an action). Guilt (hopeless, helpless, worthless feeling). Guilt (hopeless, helpless, worthless feeling). Energy (fatigue in morning, may improve in evening). Energy (fatigue in morning, may improve in evening). Concentration (includes short-term memory problems). Concentration (includes short-term memory problems). Appetite (overeating or under-eating). Appetite (overeating or under-eating). Psychomotor agitation (irritability or anxiety) or retardation (slowed speech, movement, depressed affect). Psychomotor agitation (irritability or anxiety) or retardation (slowed speech, movement, depressed affect). Suicidal ideation or planning. Suicidal ideation or planning. Depression

Anxiety, panic disorders and agoraphobia. Anxiety, panic disorders and agoraphobia. Depression. Depression. Alcoholism. Alcoholism. Sexual dysfunction. Sexual dysfunction. Eating disorders. Eating disorders. Sleep disorders. Sleep disorders. Drug misuse disorders. Drug misuse disorders. Common psychosocial problems in the family practice

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