• Become familiar with the biopsychosocial approach in patient care
• Understand common patient concerns and stress factors involved in being ill
• Be able to undertake a psychosocial assessment on patients

Psychosomatic illnesses vs. Psychosomatic approach to illness

• "Holy 7"
• Psychological factors play very significant role in onset, maintenance or exacerbation of certain physical complaints
• Eg. Skin problems - emotional upheavals aggravate skin problems
• Eg. Children can precipitate an asthma attack but getting 'worked-up'
• Wrong in that it limits attention to only 7 types of problems
• Case-oriented vs. illness-prognosis (1) Illness - many different clinical outcomes, often unexpected (2) Do not determine prognosis on illness alone
• Extent of injury does not predict subsequent adjustment (eg. Hill-fire victims)

• Not restricted to 7 types of illnesses
• All illnesses have potential to be affected by psych factors
• Therefore understand how psych factors can alleviate/ exacerbate illnesses

• Pt have no moral to continue, feel Px is bad
• Eg. Burns victims - all in stable condition
• One died overnight (sudden infection)
• The physical condition of all other Pt's started to deteriorate rapidly
• Then put these Pt's near Pt's with better Px - able to halt their physical deterioration

• One of the leading causes of death
• Both chronic and disabling diseases
• Eg. Suicide, work-related, house-hold accidents for children, violence, gang-war, MVA, smoking, sexual behaviour (HIV epidemic in China)

• Spread and control of parasitic and infectious diseases (eg. Mosquitoes and Dengue fever)
• Diabetes, respiratory diseases, hypertension, ischaemic heart disease, cancer, sexually transmitted diseases: bad eating behaviours, abuse of alcohol and tobacco, dangerous and unhealthy behaviour
• Injuries and accidents
• Intentional violent behaviours

• 30%-50% in industrialised countries
• 20%-35% in developing countries:
• Patients complain of discomfort and dysfunctioning with: (1) No ascertainable organ pathology (no physical Dx), or (2) Where identified organ pathology is disproportionate to their physical problems

• Structure and staff our present day health care systems such that:
• The psychosocial and behavioural factors involved are timely detected, adequately treated, and wherever possible prevented from (re)occurring.

1. Problems with primary support group - Death of family member, health problems, disruption: separation, divorce, estrangement, removal from home, child problems, etc.
2. Problems related to social environment Death or loss of friend, inadequate social support, estrangement, adjustment to life-cycle transition
3. Educational problems - illiteracy, academic problems
4. Occupational problems - unemployment, threat of job loss, stressful work, insecurity, conflict
5. Housing problems - homelessness, inadequate housing, problem with neighbours
6. Economic problems - transportation unavailable, long waiting list
7. Problems with access to health care services
8. Problems related to interaction with legal system/ crime - litigation, victim of crime
9. Other psychosocial and environmental problems

Vulnerability to illness

• 1/3 succumb
• 1/3 borderline
• 1/3 untouched

• The higher the score, the better the functioning

Prerequisites for +ve psych Dx (regardless of symptoms)

1. Significant deterioration in Pt's role functioning - eg. Son, med student, parent, spouse, worker
2. Symptoms cause the afflicted person significant pain, stress and suffering

Life circumstances characterised by:

• Perceives social and interpersonal environment as being highly unsatisfactory
• A number of major life changes in a short time (whether +ve or -ve)
• Separation and loss experiences (eg. Death of family member, broken love affairs)
• Prolonged state of helplessness and hopelessness (eg. Depression - see following)
• Sense of isolation
• Loss of real, threatened, or symbolic "objects" of great value (object - anything outside of us which we invest yourself in - eg. Studying for distinctions)

Depression convictions

1. I am bad/ inferior
2. World is against me

3. My condition is forever

• Loss, Conflict, Change, Maladjustment, Stress, Isolation, Failure

• "Understand the whole of his patient's communication, so that he could assess the whole person and be able to consider the effect of any intervention in an illness on the whole life of his patient"

• Problem definition
• Management
• Caring/support
• Prevention and health education

• Nearly all problems presented to the doctor have a psychological element to them and this needs exploring
• The doctor has feelings in the consultation. These need to be recognised and can be used to the benefit of the patient
• The doctor has a positive therapeutic role in all consultations, not only in those with a defined disease process - "a dose of doctoring

Cues: (1) From patient (2) N-v behaviours (3) Context of consultation (4) Previous knowledge of patient

Formulating hypotheses - common pitfalls: (1) Fail to hear or observe cues (2) Focus only on one hypothesis and exclude others (3) Limited range of hypothesis

• What to ask - how to ask:
• How best to encourage the patient to give information
• Specific Q: is your pain made worse or better by anything?
• Open Q: tell me about your pain
• Closed Q: do you get the pain on exertion?
• Seeking concerns: (1) Are you frightened of heart disease? (2) What are you concerned that this might be? (3) Many men like you are worried about ... (4) You look anxious (use nv cues) (5) You make me feel anxious - I wonder what's bugging you (use own feelings as a diagnostic tool)
• Listening: (1) Observe nv cues (2) Congruity of nv with v cues (3) Relating Q and explanations to (4) Information already obtained (5) Express interest - eye contact (6) Appropriate use of silence (7) Avoid unhelpful interruptions
• N.B. try not to argue even in your heart
• Physical examination/s: (1) All examinations are selective (2) Make selection with a clear understanding of the purpose to be achieved (3) Reassurance (4) Meeting expectations (5) Communicating concern (6) Acceptance of patient by physical contact

• Keeping medical records
• Psychosocial issues arising from illness and treatment (Axis 4 list)

• Patient needs to remember the agreed plan
• Understanding
• Knows basis of actions recommended
• See how it relates to own ideas and expectations
• Be able to implement plan
• Improving recall: (1) Aware of your use of jargons (2) Use short words and sentences (3) Be specific (4) Recall best what they are told first (5) Repetition of important points (6) Explicit categorisation (7) Use diagrams and leaflets

• Elicit and build upon patient's own ideas and beliefs
• The whole consultation (eliciting, organising, and reflecting the information the patient is giving) can be a learning experience for the patient

• Provides clear information about what he should do in any given situation and what results are to be expected
• Gives ample feedback with results
• Focus on anticipating and overcoming problems which might arise
• Needs to have goals + skills to reach them
• Encourages monitoring success of own management
• "Exploring and using the patient's own ideas and expectations of management ... choosing a management with the patient that is appropriate not only for the particular problem, but also for the patient's situation, available support and normal coping mechanisms ... achieving a fully shared understanding of the nature of the problem and the proposed management, so that the patient can be in a position to make a truly informed choice"

• Determine attendance reasons at start
• Structure consultation session appropriately
• Determine patient's own ideas before giving explanation
• Understand patient's expectations before management
• Inverse relationship between length of time a doctor allows for the consultation and the average no. of times a patient consults him each year
• Know your limits: know when to refer

• Waiting time
• Seating position can affect consultation even before it begins
• Initial phase of greeting and putting patient at ease (e.g. research in Parkinson's patients)
• Demonstrate interest in patients as people as well as problems

• Offer appropriate sympathy and support
• Questioning
• Note patients' expectations
• Make encouraging noises and gestures
• Demonstrate acceptance of patient's ideas and feelings

• Maintain eye contact
• Ensure compatible nv and v messages
• Offer reward and encouragement to patient when appropriate

Possibly the most crucial skill, for the doctor, is for him/her to be able to observe the effect of his/her own behaviour on the patient, and be able to choose strategies and skills that are appropriate to the individual doctor, the patient, and the problem.