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Consultation LiaisonPsychiatry

( C-L-P )

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

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BIOPSYCHOSOCIAL

GEORGE L ENGEL

CLP

QOL, BRIEF,EFFICIEN,FRIENDLY

S. SOCIAL

S. PSYCHOLOGY

S. BIOLOGY

MEDICAL SERVISMEDICAL ASPECS+ PSYCHIATRY

CLP fungsinya untuk meningkatkan kualitas hidup, brief (lbh singkat tatalaksananya),efisien (biaya lbh murah)

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The earlymovement? Development PM

The holistic paradigm ofmedicine (Thure von

Uexkll)

The bio-psycho-social

paradigm (George L. Engel)

Paradigm of object relationsin medicine (Michael Balint)

The Physician,

the Patient,

and his Illness

Michael Balint

1957

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In the 50ies and 60iesof the last century, the holistic approach in internal medicine and the object relationsapproach 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

Uexklltogether withWolfgang Wesiackcreated a theoretical foundation of medicine that overcomes the old

dualistic hydra and includes an explanantion of the interdependence of somatic, psychological, relational, andsocial 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 modelin 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 thecrucial 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 researchersin the US some of them internists and others

psychiatrists started to conduct empirical research. Some of this research like the studies of Mirsky & Weiner onpeptic ulcer (to my knowledge the first prospective study in PM)

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AIM AND TARGETS

General : role CLPHolistic medical services

managementQOL

Spesific: Theory:

CLP implementation - med & psy field

Technic:

Learning CLP.

Practices CLP Paradigma holistikadanya gangguankrn faktor biopsikososial shgtatalaksananya dgn biopsikososial jg.

Tujuan clp: holistik, beri pelayanankedokteran u/ ningkatin kualitas hidup.

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C-L-P

DEFINITIONS

DIAGNOSIS

GENERALMANAGEMENT

COMMUNICATIONS

INTERVENTION

CASE FINDING

HISTORY

TREATMENT

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Sternberg Nature Reviews Immunology6, 318328 (April 2006) | doi:10.1038/nri1810

Stimulus luarkortek, lewat 3 jalur:-aksis hpa-hormonal

-aksis sistem imun

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(Hawkley)Mana yg bereaksi thd stressor ditentukan o/ hipotalamus dan amygdala.

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

Dottedlines:negativeregulatorySolid llines:positive

regulatory

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JALUR TANTANGAN MENTAL DANRESPONS KARDIVASKULER

AMIGDALA

Lateral

periaqueductalgrey

Sympatheticautonomic

activation

Cardiovascularrespons

Dorsal motor

nucleus of thevagus

Parasympatheticnervous system

activation

Bradycardia

Lateral

hypothalamus

Sympatheticnervous system

activation

Tachycardia,Increased blood

pressure

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CONSULTATIONLIAISON PSYCHIATRY

BAB -I

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UNDERSTANDING AND DEFINITION

CLP definition develop side by side with the developmentof 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 physicalillness,

Psychological factors that influence physicalconditions,

and interrelations somatopsychic and psychosomaticDiagnosisfaktor pasien sndiri kooperatif/ tdk.

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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 asknowledge for helping psychologist, psychiatric, andpsychophysiology co morbidity in medical field.

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Definition at IndonesiaBased on meaning of CLP term it self :

Consultation- clinical references for examination andmanagement suggestion.

Liaison- connector.

Liaison Psychiatryknowledge that develop for thatpurpose.

Liaison Psychiatrist- conector psychiatrist that do thetask psychiatry liaison.

Consultation-Liaison Psychiatryterm based onpractice clinical need (companion).

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Based on opinion of Pasnau and Lipowski thandefine CLP as:

Subspecialist psychiatry knowledge root thatintense psychiatric aspect from another medicalcondition, including evaluation, diagnosis,therapy, prevention, study and education.

Clpapproach pasien medis dan bedahdgn psikiatri.

Definisi: pendekatan holistik pd pasienmedis dan bedah

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C-L-P

Development of psychiatry in relations withanother general medical field/another connectedfield.

Connect medical knowledge with psycho-social/behavioral aspect.

Point at final purpose therapy: recover goodquality of life (not only cure fromsymptom/disease).

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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.

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1) Karena merupakan subspesialisasi yang kompleks dan luas, CLP tidak dapatdipelajari/dikuasai dalam waktu yang singkat. Presentasi seperti sekarang ini hanyamerupakan introduksi.

2) Kesulitan pertama adalah pemahaman konsep CLP. Masih banyak salah pengertianbaik dari kalangan psikiatri sendiri, apalagi dari bidang medik lain.3) Perlu persiapan dan kesiapan dari bidang/pihak psikiatri sendiri baik dalamilmunya, waktu dan tenaga. Memerlukan junlah SDM yang cukup banyak danpendalaman khusus pada bidang-bidang tertentu yang menjadi fokus liaison.4) Di lain pihak perlu pengertian dan kesiapan dari bidang medik yang akan bekerja-

sama. Bagi bidang-bidang spesialistik lain, tidak mudah menerima konsep liaison inibila mereka sendiri belum memahami dan tidak merasakan kebutuhan untuk itu. Halini akan sulit bila tingkat profesionalisme masih kurang, lebih kearah business danbukan ke kepentingan pasien. Dalam hal demikian maka konsep liaison ini akan terlihatsebagai 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 sepertikerajaan sendiri-sendiri. Konsep teamwork dan melihat tujuan terapi secara menyeluruhbagi kepentingan pasien, masih merupakan hal langka.5) CLP memerlukan keterlibatan bidang medik lain, tidak dapat dipaksakan.Penggalangan kerjasama merupakan proses panjang yang perlu persiapan.

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CLP GENERAL MANAGEMENT

1. Liaison psychiatry working consept

Primary, secondary, tertiary prevention

Detection & Diagnosing (CLP vs. ConsultsPsi)

Health services evaluation (groupresponsible)

Giving authority to non psychiatry staff

Develop new knowledge

Change health service structure ( Modern

Service )

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2. CL preparation and aplication (atIndo)?

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

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3. Organization Structure CLP Service

General organization field

Group practice CLP with another specialist

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EXT

INT

Healthservices

SICK,DISORDER QOL

Health services as system

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CASE FINDINGAPPROACH

Liaison approach direct to medical staffsensitivity increasing, so that its canproduct more effective budget

management and early detection atpatient services.

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Approach Method

1. Non structure interview

2. Structure interview

3. Self-report

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MANAGEMENT SYSTEM

CASE FINDING

OPERATIONAL PROCEDURE

HEALTH SERVICES

QUALITY OF LIFEPATIENT

MEDICAL SERVICESEFFECTIVITY

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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

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Categories of Psychiatric Differential

Diagnoses in the General HospitalPsychiatric presentations of medical conditionsPsychiatric complications of medical conditions or treatmentsPsychological reactions to medical conditions or treatments

Medical presentations of psychiatric conditionsMedical complications of psychiatric conditions or treatmentsComorbid medical and psychiatric conditions

Source: Adapted from Lipowski 1967

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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.

S A O

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Case Finding Role

Active

Pasive

Team work

Service system

INSTRUMENT THAT OFTENUSED AT SCREENNING

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DIAGNOSIS

Prof.Dr.M.Syamsulhadi,dr,Sp.KJ ( K )

Consultation-Liaison Psychiatry

LAB/SMF PSIKIATRI FK UNS-RSUDDR.MOEWARDI SURAKARTA

2009

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A. LANGKAH MENUJUDIAGNOSIS YANG TEPAT

DIAGNOSIS

ANAMNESIS

Pemeriksaanpenunjang

Sulitditegakkan

Ketrampilandokter

Ketersediaan alatpenunjang Dx

Faktor pasiensendiri

PemeriksaanStatusMental

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EFFECTIVE DIAGNOSTIC& COSTEFFECTIVE

Case finding

Anamnesis

SkreeningDaftar isian-latar belakangsosiodemografik

-kel somatis-Perub emosional-RPD-R.penggunaan zatLaboratoriumPmx penunjang lain

Kemampuanmengarahkan

& menilai

Pmx PenunjangFx (MRI, CT-

Scan, EEG)

Pmx kimiawi(Kdr obat,

estrogen, tiroid,ureum, kreatin)

Psikometri(MMPI, MMSE,

Wwcrterstruktur)

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Diagnosis yg tepat & intervensi yg

efektif

Menekan biaya & prosedur yang tidakperlu

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6 bidang yg sering menjadigarapan bersama

1. Efek psikologis akibat menderita penyakit fisikatau prosedur terapi

2. Gangguan somatoform

3. Perilaku yang membahayakan4. Kedaruratan psikiatrik yang datang ke rumahsakit

5. Keadaan gangguan fisik dan psikologis akibatterapi psikiatrist

6. Gangguan fisik dan perilaku akibat tindakkekerasan termasuk yang bersifat seksual

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Ruang lingkup CLP1. Apakah ggn medis yg muncul didasari oleh

ggn mental atau bukan (gejala depresi bisa diakibatkanprimer akibat hipotiroid shg beda penangananya dengan depresiakibat stresor psikososial )

2. Apakah ggn mental yang menyerupaigangguan fisik namun sebenarnya bukangangguan mental( delusional parasitosis, body dysmorphicdisorder)

3. Gangguan medis yang muncul adalah akibatketerlibatan proses psikologis (psoriasis,neurodermatitis, hyperhidrosisdll)

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4. Gangguan psikiatri yang timbul

merupakan sekunder akibat isolasi sosialatau stigmatisasi dari gangguan kondisimedis ( depresi pada penderita kusta )

5. Baik ggn psikiatri maupun ggn kondisimedis ttt sama-sama timbul akibat dariadanya faktor genetik dan lingkungan(mania dan psoriasis, keadaan hipo atau hipertoroid, autismepada anak)

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6. Ggn kondisi medis ttt yg muncul akibatkronisitas gangguan psikiatri ( dehidrasi, giziburuk pada skizofrenia katatonik, infeksi kulit akibat higiene yangburuk pada skizofrenia )

7. Gangguan psikiatri timbul akibatpenggunaan obat-obat untuk penyakittertentu ( reserpin dan kortikosteroid yang dapatmemunculkan gangguan mood)

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8. Gangguan kondisi medis tertentu yangtimbul akibat penggunaan obatpsikotropika ( distonia, parkinsonisme,tirotoksikosis,agranulositosis, aritmia, hipotensi postural, SNM )

9. Gangguan psikiatri yang disebabkan

oleh penyakit medis kronis ( stroke )

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Komponen Pemeriksaan StatusMental

KOGNITIF

Tingkat kesadaran &kewaspadaan

Perhatian Kemampuan berbicara &

berbahasa

Orientasi

Memori

NON KOGNITIF

Penampilan umum danperilaku

Afek dan Mood

Proses fikir dan isi fikir Persepsi Kemampuan abstraksi Daya nilai

Tilikan diri

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DD D li i ( I WATCH DEATH )

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DD Delirium ( I WATCH DEATH )Infection : Encephalitis,Meningitis,HIV,Syphilis,sepsis

Withdrawal : Alcohol,Barbiturates,Sedative-hipnoticsAcute metabolic : Acidosis,alkalosis,hepatic failure,renal failure

Trauma : Closed-head injury,severe burns,postoperative

CNS pathology : Hemorrhage,hidrocephalus,seizure,sroke,tumorsHypoxia : 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

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Medications and Psychoactive

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Medications and Psychoactivesubstances assosiated with depression

AntihypertensiveReserpinMetyldopa-Blockers

Streroids

Oralcontrasceptives

Cancer chemotherapeuticagentsVincristin

VinblastinProcarbazineAmphotericin BInterferon

Histamine resceptorantagonistsCimetidine

Ranitidine

Psychoactive substanceAlcoholOpiate

Amphetamine/ cocaine

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Kesimpulan

Keefektifan konsultasi psikiatriketrampilan klinis serta kemampuanmengintegrasikan berbagai informasi mjd

suatu Diagnosis Ketrampilan esensial dlm CLP :

kemampuan melakukan pmx statusmental scr komprehensif ( Kemampuan

kognitif ) serta melakukan pmx neurologissingkat & berfokus pada pmx fisik

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Lanj Kesimp.

Formulasi diagnosis dibuatberdasarkan data tentang riw penyakit(riw psi & medikasi, hasil pmxpenunjang), ggn psikiatri, defensemechanisms , kepribadian, sertapemeriksaan status mental scr

komprehensif

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INTERVENSI

Langkah antara diagnosis & penerimaanpasien terhadap pengobatan

Persiapan pasien thd suatu pengobatan

Komunikasi dokter-

Pasien

Ketrampilan

komunikasi

Pasien mampu menerima diagnosis

& pengobatan yang diberikan

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Strategi FRAMES

F = Feedback on the patients risk or impairmentR = Responsibility for change belongs to the patientA= Advice to change should be specific and

nonambiguous

M= Menu of alternative strategiesE = Empathetic rather than confrontational

counselingstyle

S = Self-efficacy : a positive view of patientsability tochange and the treatments efficacy

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Kotak dialog :Pasien rawat inap laki-laki pecandu alkohol danhepatitis

Tn C, Saya pikir kebiasaan anda minumalkohol adalah penyebab penyakit liver anda(feedback), dan anda perlu untuk menghentikan

minum alkohol sebelum liver anda menjadilebih buruk (advice).Saya harap andamembicarakan dengan Dr X untukmendiskusikan apa yang dapat anda lakukanmengenai kebiasaan anda minum alkohol

tersebut (responsibility). Saya sudah minta diauntuk menengok anda hari ini. Saya pikirbeliau dapat membantu problem anda (empathydan self efficacy).

K t k di l P i t i

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Kotak dialog: Pasien rawat inap perempuandengan gejala angina dan depresi

Ny D, Saya pikir problem anda yaitu insomnia,

saat-saat sedih dan menangis, serta kelelahanmungkin disebabkan oleh depresi (feedback)karenakondisi jantung anda. Saya harap anda berbicaradengan Dr Y (advice), seorang yang ahli dalambidang ini untuk melihat apakah kami dapatmembantu anda dengan gejala-gejala ini (empathy).Saya sudah membicarakan dengannya agar datangsegera dan melihat anda hari ini. Inilahkesempatan yang baik dimana anda akan merasa

lebih baik (self efficacy). Jika anda depresi danmeneruskan pengobatan. Saya senang andamerasa lebih baik dan melakukan lebih banyakdalam hidup anda (empathy).

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Intervensi

Ketrampilan komunikasi

Perilaku yg positif

Ketekunan & latihan Menilai keberhasilan pengobatan drsegi kepuasan pasien, kesehatan &fungsi pasien yg meningkat

Nilai usaha : kepuasan profesional ygbertambah

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INTERVENSI PSIKIATRI PADA LINGKUNGANMEDIS PASIEN RAWAT INAP

Intervensi :

Mengerti kebutuhan kebutuhan

psikiatri dan psikososial pasien yangdirawat di rumah sakit

Pengobatan (terapi)

Memperkecil morbiditas fisik Mengurangi LOS (Length of Stay)

Faktor Psikiatri & Psikososial

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Faktor Psikiatri & Psikososialberlaku pd tiap fase dari episode

suatu penyakit

1. Sebelum perawatan sebagai sebab atau

tekanan untuk pengakuan2. Selama perawatan di rumah sakit

3. Selama keputusan yang mempengaruhi

pemulangan dan penempatan sesudahperawatan

Intervensi liaison bedanya dgn

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Intervensi liaison, bedanya dgnpendekatan konsultasi

1. Mendeteksi DSM-III-R secara signifikan(American Psychiatry Association 1987)morbiditas Psikiatrik (56%).

2. Menghasilkan lebih sedikit depresi danpenurunan kognitif pada pemulangan.

3. Mengurangi LOS sampai 2 hari.

4. Mempersingkat hari-hari rehabilitasi5. Tidak menyebabkan rawat inap kembalidalam periode follow-up 12 minggu.

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Penelitian intervensi LaisonPsikiatri

Pendekatan liaison menghasilkanpeningkatan kesehatan psikiatrik danpenurunan penggantian kerugianbiaya yang signifikan

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Kesimpulan

Intervensi mrpk Langkah antaradiagnosis & penerimaan pasienterhadap pengobatan

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A. MIND AND BODYINTERACTION

Problem :

Modern medical practice become somethingthat mechanic, technically, and divided. Our

rationalistic view and divided makedifficult to do integral approach that aim tocure sick people.

(Fountain,2002)

A. MIND AND BODY

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A. MIND AND BODYINTERACTION

PERSON

Sex

Constitution

Lifeexperience

Age

Life phase

Religion

Culture

Believe

Strengthresources &

othersupport

(Wibisono, 2007)

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A. MIND AND BODY INTERACTION

ExternalStimuli

ImmuneFunction

Physiological

State

Neurological

Activity

MentalState

(diadaptasi dari Duncan Smith-Rohrberg,2000)

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Thouhgt-desease pathway

American Medical Association, 1998

RepetitiveNegative Thought

Body Becomes LockedInto a Chronic

Sympathetic/StressState

Negative ThoughtForm

DESEASE

Frozen EmotionalState

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Thougth-healing pathway

Affirmation

Positive Thought Form______________

Negative ThoughtForm

Positive Thought Form_________________

Fleeting Negative ThoughtsHEALTH

Body Relaxes andMoves Into a

ParasympatheticState

Release of FrozenEmotional State

American Medical Association, 1998

B CLP TREATMENT

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B. CLP TREATMENTGUIDELINES

The site of psychiatric treatment and the useof psychiatric consultants is currently amatter of :

1. preference,

2. the patient's acuteness,3. risk factors,4. availability of local resources.

C-L psychiatrists usually use biological andpsychotherapeutic treatments that havedemonstrated efficacy.

(Westphal J.R dan Freeman A.M, 2000)

a BIOLOGICAL/PHARMACHOTHERAP

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a.BIOLOGICAL/PHARMACHOTHERAPY TREATMENT

Treatment principle in CLP :1. Remember that discontinue treatment

sometimes is a beneficial action

2. If possible, need to avoid recipe if neededtreatment

3. If there is a require to give if needed treatmentdose, observe using frequency to decide precise

dose level

4. That is important to use minimum dose inmaintenance the targets response

5. Change one drug in one time

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Treatment principle in CLP cont

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

7. Keep to make simple mixed drug8. Dont give prophylaxis drugs except there is a rational

reason9. Use drugs with proved efficacy10. 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 thebioavailability may low12. Consider that each patient show a new experience

(Jachana, Lane, dan Gelenberg, 1996)

Principle in choosing drugs

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Principle in choosing drugs

1. Effect on clinical problems.

2. Effect on basis desease.

3. Implication side effect figure.

4. Interaction with somatic drugs.

5. Oral or parenteral drugs.

6. Lever or kidney function and dose.

7. Biological matching?

(Malt, 2006)

FACTORS THAT INFLUENCE ADHERENCE

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Insight into illness

Perception of severity ofillnessPerception of tendency to

relapseAcceptance of illnessType / symptoms of illness

Degree of supportStability of familyDoctor-patient relationshipType of administrationMethod of prescription

Psycho-educationTherapy supports:

symptom diary, textmessages to a mobilephone

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

FACTORS THAT INFLUENCE ADHERENCE

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b. Psychotherapy

1. Dynamic psychotherapy.

2. Humanistic-experiencepsychotherapy.

3. Cognitive-behavior psychotherapy.4. Ecletic and integration

psychotherapy.

(Nash, 2000)

Prime form psychotherapy

There is some adaptation for

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ppsychotherapy technique at patient with

medical illness

1. Focus on supportive than conflict, built therapeutic relationsthat 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)

Life event(s)Ill P lit f tAdjustment to illness

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W. Sllner, Lausanne

2006

Illness

Vulnerability

Stress

Adjustment

disorder

Personality features,previous experiences,psychiatric disturbance

Interpersonalrelationships,social support

Adaptation of cognitions,behaviour

Coping

Recurrent/chroniclife events

Recognition,professional support,treatment

Adjustment to illness

Successfuladjustment

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Adjustment to illness depends on various factors:

-the severity of distress

-The kind of the LEcausing distress the (kind and severity of the somatic illness): it is acompletely 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 classifythis as a AD.

-This figure shows that a couple of psychological and social factorscontribute to the

development of an AD as well as somatic factors. The debate on diagnosiswhether it

is an affective disorder or an AD is often academic. It is important that severely ill

patients have specific psychological threats and needs.

St h i l f

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Stage psychosocial care formedical illness

Emotional support fromphysician & paramedic

W. Sllner, Lausanne 2006

Psychotherapy, konseling

Pharmacology therapy

Emotional support from patiensocial environment

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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 BiopsychosocialModelAcademic Psychiatry, 31:5, September-October 2007

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PATIENT

CARE TEAMSIGNIFICANT

PEOPLE

O O

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FOUNDATION

PSYCHO

BIO

SOCIAL

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PENDEKATAN KOMUNIKASI

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PENDEKATAN

EXAMINATION

MODEL

SKILL AID

CONSULTATION PROCESS

GROUPPRACTICE

ANOTHERDEPARTMENT

SUMMARY

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SUMMARY

PATIENT

Treatmentintegration

Interdiscipline

collaboration

Intradiscipline

collaboration

Collaborationbetween

department