Transcript Patient-Centered Diagnosis - What is Integrated Medicine?

Patient-Centered Diagnosis:
a Cornerstone of Integrative
Medicine
Leo Galland M.D.
Foundation for Integrated Medicine
Foundation for Integrated Medicine
“It is more important to know
what person has the disease than
what disease the person has.”
Sir William Osler
Foundation for Integrated Medicine
Diagnosis
• Greek for “knowing through”
• Underlies all human problem-solving
activity
• Is goal-oriented; diagnosis is the basis of
treatment
• Diagnostic systems are attempts to separate
two kinds of information: signal and noise
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The Disease Model of Illness
• People become sick because they contract
diseases
• Each disease is a distinct entity with its own
natural history
• Each disease can be coded and understood
independently of the person who is sick or
the context in which the illness occurs
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Conventional Medicine
• The leading clinical question is, “What
disease does this person have?”
• The treatment that results from answering
this question is, first and foremost, the
treatment of the disease
• Education, research, “scientific evidence,”
health policy and insurance are all built on
this model
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Disease vs. Illness
• Disease is what the doctor observes
• Illness is what the patient experiences
• In conventional diagnosis, disease and
illness are related but separate constructs
with trajectories that may be totally
independent of one another
• In conventional medicine, physiologic and
psychosocial domains may barely overlap
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The Biographical Model of
Illness
• Illness is an event in the life of an individual
• Illness results from disharmony or
imbalance
• Each person’s illness is unique
• The healer’s job is to help the individual
restore harmony and balance, not to
suppress disease
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Integrated Medicine
• Integrates modern science with the ancient
biographical model of illness
• The foremost question is, “What are the
disharmonies and imbalances contributing
to illness in this person?”
• Uses the process of Person-Centered
Diagnosis to answer that question and guide
therapy
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Modern Science and the Origins
of Disease
• Etiologic agents: the infectious, toxic, or
allergic triggers of illness
• Chemical and psychosocial mediators of
tissue injury and distress
• Risk, the cornerstone of preventive
medicine
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Science and the Biographical
Model
• What we call a “disease” is a pattern of
signs, symptoms, pathological changes in
tissue, and behavioral changes that appears
coherent to the observer.
• Clinical disease and illness result from the
interaction of mediators, triggers and risk
factors (antecedents).
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Person-Centered Diagnosis
• The individuality of each patient is foremost.
• Disease and illness, physiologic and psychosocial
functional domains are integrated.
• The fundamental diagnostic question is what are
the mediators, antecedents, triggers and effects
of sickness in this individual patient.
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Mediators
• Biochemical: prostanoids, cytokines,
neurotransmitters, reactive oxygen species,
ions, electrons…
• Psychological: fear, anger, denial,
expectations, perceived self-efficacy,
motivation, conditioning, personal beliefs
• Social: reinforcement, support, cultural
beliefs, relationship with a healer
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Mediators are not DiseaseSpecific
• They are organized into circuits and
cascades that sub-serve homeostasis and
allostasis.
• Each mediator is multi-functional.
• Each function involves multiple mediators.
• Redundancy is the rule, not the exception.
• Biochemical, psychosocial and cultural
mediators interact continuously.
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Mediator Flow
• There is a natural flow of mediator activity
which is strongly influenced by the
common components of life: diet, sleep,
exercise, hygiene, social interactions, solar
and lunar cycles (circadian, menstrual,
annual) and the effects of age and sex.
• Ripples, currents and maelstroms result
from the effect of triggers.
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Common Triggers of Illness
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Microbes
Physical injury
Allergens
Chemical toxins
Elemental toxins
Radiation
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Social interactions
Emotional injury
Loss
Anticipations of
loss
• Memories
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Antecedents, the Flip Side of
Risk
• Those factors that predisposed this person
to this illness
• Congenital: genetic or acquired in utero
• Developmental: the result of nutrition,
trauma, stress, toxins, social learning or
symbiosis
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Symbiosis
• Greek for “living with”
• We live with our families.
• We share our bodies with microbes. There
are as many microbial cells as mammalian
cells in the average human body.
• Beneficial symbiosis is eusymbiosis or
mutualism.
• Harmful symbiosis is called dysbiosis.
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Precipitating Events
• Lie between antecedents and triggers
• Initiate a change in health habits
• Common events include severe
psychosocial distress, acute injury or
infection, large toxic exposure or a period of
nutritional deprivation
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The Effects of Illness
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Symptoms
Pathological and chemical changes in tissue
Laboratory and physical signs
Changes in behavior and social
relationships
• Altered susceptibility to future illness
through mechanisms that are diseaserelated, iatrogenic, cognitive or social
Foundation for Integrated Medicine
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The Anatomy of an Illness
• Antecedents influence exposure and sensitivity to
triggers and the nature of the mediator response.
• Precipitating events initiate a change in health.
• Triggers maintain mediator activation.
• Mediators produce the effects of illness.
• The effects become antecedents for further illness.
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Causation of Disease/Illness
• Disease/illness is not caused by
mediators, antecedents, triggers or
their effects but rather by the
dynamic interaction of all four.
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Practical Approach to Patients
with Chronic Illness
• Describe the effects of illness, especially
functional and social disabilities.
• Investigate the antecedents of illness. What
was this person like before?
• Search for a precipitating event. “When is
the last time you felt really well?” may
yield a different answer than “How long
have you had this problem?”
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Practical Approach, continued
• Inquire about the possible triggers of
symptoms: food, drugs, supplements,
environment, activity, sleep, social
interaction.
• Think about the possible mediators:
metabolic, neuro-endocrine, inflammatory,
psychological, social, cultural and spiritual.
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Medical History: Key Points
• When is the last time you felt completely
well?
• What was your health/life like during the
years before that time?
• What happened in your life during the six
months before that time?
• What treatments have you received? How
have you responded to each?
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Medical History, continued
• How are your symptoms affected by...sleep,
food, activity, work, stress, supplements,
medication, seasons, etc.
• How has this illness affected your life?
What do you most fear about this illness?
• How much control do you believe you have
over your symptoms?
• What kind of treatment are you looking for?
Foundation for Integrated Medicine
“Functional” Bowel Disorders:
Effects
• Pain
• Diarrhea, constipation, urgent bowel
movements
• Distension, flatulence, eructation
• Fatigue and symptoms of co-morbidity
• Anxiety
• Health care seeking behaviors
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“Functional” Bowel Disorders:
Mediators
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Neurotransmitters: Ach, DA, 5-HT
Neuropeptides: CCK, VIP
Prostanoids: PGE2
Anxiety, fear, appraisal
Fermentation by-products
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“Functional” Bowel Disorders:
Antecedents
• Familial predisposition
• Trait anxiety predisposes to seeking medical
evaluation and treatment
• Co-morbidity is common: migraine,
fibromyalgia, pelvic pain, vulvodynia,
asthma, atopy, latent tetany
• GI infection, antibiotic use
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“Functional” Bowel Disorders:
Precipitating Events
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Foreign travel
Wilderness activities
Antibiotic exposure
Acute psychosocial distress
Change in diet
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“Functional” Bowel Disorders:
Triggers
• Food
• Microbes
• Psychosocial distress
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BACTERIAL OVERGROWTH IS
MORE COMMON THAN
SUSPECTED
• 202 patients with IBS underwent
hydrogen breath testing
• 157 (78%) had SBBO and were treated
with antibiotics
• 25/47 patients had normal breath tests
at follow-up
• Diarrhea and abdominal pain were
significantly improved by treatment
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SBBO AND IBS:
CONCLUSIONS
Elimination of SBBO eliminated IBS in
12/25 of patients:
48 % of patients with IBS and abnormal
breath tests who responded to
antibiotics with normal breath tests no
longer met Rome criteria for IBS
Pimentel M et al, AM J Gastroenterol
2000
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MANAGEMENT OF UGI
BACTERIAL OVERGROWTH
INVOLVES DIET, ANTIBIOTICS
• Low fermentation diet
-restrict sugar, starch, soluble fiber
• Antimicrobials (in select cases):
– Metronidazole (anaerobes)
– Tetracyclines (anaerobes)
– Ciprofloxacin (aerobes)
– Bismuth
– Bentonite
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Low Fermentation Diet
• Basic diet: no wheat, sucrose, lactose
• Additional restrictions
-no glutinous grains
-no cereal grains, potatoes
-restrict fruits, juices, honey
-avoid legumes
-cook all vegetables
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IRRITABLE BOWEL SYNDROME
IS ASSOCIATED WITH SPECIFIC
FOOD INTOLERANCE
• Specific food intolerance, present in 48%
of patients with diarrhea and pain, is
associated with unstable fecal flora, high
aerobe:anaerobe ratios and high stool
PGE2 levels
Alun Jones et al, Lancet, 1982
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The Addenbrooke’s Hospital
Exclusion Diet for IBS
• 1-2 meats:
lamb, turkey, fish, chicken, beef
• 1 fruit:
pears, pineapple, banana, apple
• Rice, water
Commonest diet was lamb, pears, rice
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Outcome of Exclusion Diet
in 182 IBS Patients
• No improvement after 7 days: 38 (21%)
• Improved after 7 days: 144 (79%)
-Provoking foods identified, established
dietary control of IBS: 122 (67%)
-Intolerant of one food
5%
-Intolerant of 2-5 foods 28%
-Intolerant of 6-10 foods 35%
-Intolerant of > 10 foods 32%
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Foods Provoking IBS
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Wheat
Milk
Corn
Cheese
Oats
Coffee
Rye30%
Eggs
60%
44%
44%
39%
34%
33%
26%
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Tea
Butter
Yogurt
Citrus
Barley
Chocolate
Nuts
Preservatives
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25%
25%
24%
24%
24%
22%
22%
20%
Foods Provoking IBS
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Potatoes 20%
Cabbage 19%
Sprouts 18%
Peas
17%
Beef
16%
Carrots 15%
Lettuce 15%
Rice
15%
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Pork
Broccoli
Soy
Chicken
Spinach
Yeast
Lamb
Sugar
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14%
14%
13%
13%
13%
12%
11%
12%
Food Intolerance in IBS Is not
Associated with Atopy
• Only 10% of patients were atopic
• 40% could relate onset of symptoms to:
-A course of antibiotics (11%)
-A bout of gastroenteritis (12%)
-Abdominal or pelvic surgery (15%)
• Unstable fecal flora was common
Hunter et al,Topics in Gastroenterology, 1985
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IBS with Food Intolerance Is
Associated with Excess
Fermentation, Corrected by Diet
• 6 patients, 6 controls, whole body chamber
• Total body hydrogen production greater
with IBS, fell with exclusion diet. (No
grains except rice, no dairy or beef, restrict
yeast, citrus, caffeine, tap water)
King et al, Lancet 352: 1187-1189 (1998)
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Foundation for Integrated Medicine