MIND & MEDICINE
Vo l u m e 1 Issue 2
Q u a r te r l y b u l l e t i n o f t h e D e p a r t m e n t o f P s yc h i a t r y
October-December
MAHATMA GANDHI MEDICAL COLLEGE & RESEARCH INSTITUTE ● PONDICHERRY ● INDIA
2013
In this issue:
THE BIOPSYCHOSOCIAL CONCEPT OF PAIN DEPRESSION AND CHRONIC PAIN REFERRAL FACILITATION CASE REPORT (DELIRIUM OF MIXED ORIGIN)
In commemoration of WORLD MENTAL HEALTH DAY (10-10-2013), the following events were organized, between 07-10-2013 & 10-10-2013: A mental health awareness talk for the public A short play highlighting the significance of geriatric mental health A poster competition Chancellor’s medal elocution contest A live radio talk A guest lecture by Dr. Raguram R., Professor and Head of the Department of Psychiatry, KIMS, Bangalore
EDITORS Dr. Abu Backer S Dr. Sivaprakash B ASSOCIATE EDITORS Dr. Eswaran S Dr. Sukanto Sarkar
The Department of Psychiatry, MGMCRI is on Facebook. To connect with us, please visit www.facebook.com/PsychiatryMgmcri
MIND & MEDICINE ● 2013 ● Volume 1 ● Issue 2
THE BIOPSYCHOSOCIAL CONCEPT OF PAIN The biopsychosocial concept of pain integrates the key findings of the past 50 years of research, namely, that the relation between pain and injury is variable; pain may persist or occur in the absence of injury; pain is not a single sensation but has many dimensions; there is no adequate treatment for many types of pain; there are multiple ascending pathways that can carry pain information to the brain; and there are multiple areas of the brain that process pain information. The biopsychosocial understanding of pain has been particularly valuable in helping to understand the persistent and intractable nature of chronic somatic pain. Known relations between somatic sensation, catastrophic thinking, negative affect, and pain have led to suggestions that emotional and cognitive inputs from higher neural centers can expand, amplify, or create chronic pain symptoms. Source: Lane RD. The rebirth of neuroscience in psychosomatic medicine, Part II: Clinical applications and implications for research. Psychosomatic Medicine 2009;71:135-151.
Source: Klossika et al. Emotional modulation of pain: a clinical perspective. Pain. 2006 Oct;124(3):264-8. Legend: Red arrows - Direct corticolimbic pathways processing somatosensory aspects of pain; Blue arrows - Corticolimbic pathways integrating sensory, cognitive & affective aspects of pain; Purple arrow - Direct thalamic activation of amygdala
DEPRESSION AND CHRONIC PAIN Depression and chronic pain are linked, and are known to occur together. Chronic pain can worsen depression symptoms and is a risk factor for suicide in people who are depressed. Bodily aches and pains are a common symptom of depression. Studies show that people with more severe depression feel more intense pain. According to recent research, people with depression have higher than normal levels of cytokines. Cytokines send messages to cells that affect how the immune system responds to infection and disease, including the strength and length of the response. In this way, cytokines can trigger pain by promoting inflammation. Many studies are finding that inflammation may be a link between depression and illnesses that often occur with depression. Further research may help us understand this connection and find better ways to diagnose and treat depression and other illnesses. One disorder that has been shown to occur with depression is fibromyalgia. Fibromyalgia causes chronic, widespread muscle pain, tiredness, and multiple tender points. People with fibromyalgia are more likely to have depression and other mental illnesses than the general population. Studies have shown that depression and fibromyalgia share risk factors and treatments. Source: http://www.nimh.nih.gov/health/publications/depression-and-chronic-pain/index.shtml Department of Psychiatry
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MIND & MEDICINE ● 2013 ● Volume 1 ● Issue 2
REFERRAL FACILITATION About one-third of people attending medical and surgical outpatient clinics have a psychiatric disorder. However, reluctance of patients & physicians to utilize mental health care services may hinder the referral process. Five common reasons due to which patients may object to physician’s suggestion of psychiatric referral: (1) Stigma, (2) Damage to one’s self-esteem, (3) Lack of knowledge about mind-body interactions, (4) Feeling rejected by the treating physician, (5) Psychopathology The goal of a referral is not to merely coerce an unwilling & unprepared patient to visit a psychiatrist. It would be of little value if the patient arrives too frightened, angry, confused, or defensive to be able to cooperate for a psychiatric consultation. A few extra minutes spent by the treating physician could help the patient visit the psychiatrist with hope and an open mind.
Practical ways of facilitating a psychiatric referral -
The referral can be discussed over the course of several visits and need not be forced as the only option. If the patient feels the referral is premature, he/she will feel ignored and short-changed.
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The patient’s lack of knowledge about the role of psychological factors in overall health & physical suffering can be managed through simple explanation. Educate the patient that physical and emotional factors interact through established physiological pathways; improvement in one usually accompanies improvement in the other.
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Communication & Empathy: Understand & let the patient know he is being heard and understood. ("Now, when I suggest a psychiatrist, I understand that you are surprised. You might think that I am implying that it’s all in your head. It is not really true and I am not giving up on you.”)
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Roll with resistance: Acknowledge the patient’s ambivalence and refrain from confronting. (“Now, I understand that you are confused; you might think why a psychiatric consultation is needed. I am not suggesting that there is nothing wrong with you physically. I hope you can agree with me that all illnesses have a psychological impact. Likewise, psychological stress can prolong or aggravate physical illnesses. Psychiatrists can help you in managing your stress.”)
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Support self-efficacy: Elicit and reinforce statements of self efficacy from the patient. (“I am happy that you are keen on getting back to work in good health. I can see that you have put up bravely during this time of sickness. I want you to understand that psychological symptoms are neither signs of personal weakness nor do they lead to social disgrace.”)
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Address the discrepancy: Highlight the contrast between the patient's current behavior & his/her values & goals. (“It seems to me that you are still hesitating, despite your need to recover from this suffering. Would you still consider a psychiatric referral as a disgrace and deprive yourself of the benefits it may offer? I hope you know that this referral would help me to help you better.”)
Addressing stress & mental health issues of patients with physical disease through a timely psychiatric referral can improve overall health outcomes. Bibliography • • • •
Cowen P, Harrison P, Burns T. Shorter Oxford Textbook of Psychiatry. 6th edition. United Kingdom: Oxford University Press; 2012. Bursztajn H, Barsky AJ. Facilitating patient acceptance of a psychiatric referral. Arch Intern Med. 1985 Jan; 145(1):73–5. Miller WR, Rollnick S. Motivational Interviewing: Preparing People for Change. 2nd edition. New York: Guilford Press; 2001. The management of patients with physical and psychological problems in primary care: a practical guide [Internet]. London: Royal College of Psychiatrists; 2009. Available from: http://www.rcpsych.ac.uk/files/pdfversion/CR152x.pdf
Department of Psychiatry
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MGMCRI ● Pondicherry 607402
MIND & MEDICINE ● 2013 ● Volume 1 ● Issue 2
CASE REPORT Mr. S, a 35-year-old married male, a farmer from a rural background, presented with history of alcohol use for the past 15 years. Over the years, he had developed tolerance and experienced withdrawal symptoms. He resorted to daily drinking over the past 2 years. Patient had a fall from an electrical transformer, while under the influence of alcohol, in September 2013. He sustained multiple injuries over the arms, shoulder & head. He was immediately admitted at a hospital nearby, but got discharged against medical advice. Later that day, in a confused state, the patient removed the plaster casts and wound dressings, following which he experienced severe pain. He was then brought to MGMCRI, on the fourth day after the fall. He was admitted in Department of Orthopedics for the management of trauma. Following an evaluation by the Department of Psychiatry, a diagnosis of alcohol dependence syndrome (ICD-10 F10.2) was noted, and detoxification measures were initiated. Two days following the admission, the patient showed signs of disorientation. He was pale, restless, irritable, and aggressive. He complained of hearing voices of unseen people. He was fearful & suspicious about the surroundings. Profuse sweating & tremulousness of the arms were evident. Investigations revealed anemia, hyponatremia, hypoproteinemia and fracture-dislocation of the left humerus. An MRI scan revealed fracture of the orbit, both nasal bones and bony part of the nasal septum. In accordance with the ICD-10 classification, a diagnosis of delirium of mixed origin (F05.8) was recorded. Over the course of stay in hospital, patient was managed in various settings, including the critical care unit. A multidisciplinary approach was required. In addition to correction of physiological parameters, plaster casts for the fractured arm and dressings for the facial wounds, psychiatric management of delirium was implemented. Non-pharmacological measures such as reassurance, demonstration of empathy, communicating through clear and short messages, providing cues about the time, the date and the surroundings were instituted. Aggression and sleep cycle disturbances were managed through appropriate psychopharmacological strategies. Subsequently, the patient became more amenable to treatment and showed global improvement in all critical health parameters over a period of 2-3 weeks. Delirium occurring in the alcohol withdrawal state is well documented. However, in this patient, a diagnosis of delirium of mixed origin was more appropriate due to the presence of multiple etiological factors such as trauma, pain, systemic inflammation, multiple drugs, sleep deprivation, dehydration, anemia and alcohol use. Many of these factors are known to cause changes in neuronal membrane function and neurotransmitter aberrations. This leads to a domino-like effect. As one neuron loses membrane integrity and stability, neighboring neurons have more difficulty in maintaining physiologic integrity and functioning. This spreading instability of neurons is postulated to progress from hippocampus to neocortex, subcortical nuclei, brain stem, gray matter, cerebellar cortex, and finally affecting the spinal cord. The complex interplay between alcohol dependence, trauma, metabolic changes, anemia, and alcohol withdrawal state contributing to the delirium posed a challenge in the management of this patient. A well-designed multidisciplinary treatment approach addressing all etiological factors simultaneously is mandatory in the treatment of delirium.
Bibliography • • •
World Health Organization. The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines [Internet]. Geneva: World Health Organization; 1992. Available from: http://www.who.int/classifications/icd/en/bluebook.pdf Maldonado JR. Pathoetiological model of delirium: a comprehensive understanding of the neurobiology of delirium and an evidence-based approach to prevention and treatment. Crit Care Clin. 2008 Oct; 24(4):789–856, ix. Maldonado JR. Delirium in the acute care setting: characteristics, diagnosis and treatment. Crit Care Clin. 2008 Oct; 24(4):657–722.
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Department of Psychiatry
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