Patient-Centered%20Diagnosis:%20a%20Cornerstone%20of%20Integrative%20Medicine

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Patient-Centered Diagnosis a Cornerstone of
Integrative Medicine

• Leo Galland M.D.
• Foundation for Integrated Medicine

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It is more important to know what person has the
disease than what disease the person has.Sir
William Osler
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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 persons illness is unique
• The healers 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 Disease-Specific

• 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

• Microbes
• Physical injury
• Allergens
• Chemical toxins
• Elemental toxins
• Radiation

• 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

• 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 disease-related, iatrogenic,
  cognitive or social

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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?

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Functional Bowel DisordersEffects

• 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 DisordersMediators

• Neurotransmitters Ach, DA, 5-HT
• Neuropeptides CCK, VIP
• Prostanoids PGE2
• Anxiety, fear, appraisal
• Fermentation by-products

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Functional Bowel DisordersAntecedents

• 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 DisordersPrecipitating Events

• Foreign travel
• Wilderness activities
• Antibiotic exposure
• Acute psychosocial distress
• Change in diet

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Functional Bowel DisordersTriggers

• 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 aerobeanaerobe
  ratios and high stool PGE2 levels
• Alun Jones et al, Lancet, 1982

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The Addenbrookes 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 gt 10 foods 32

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Foods Provoking IBS

• Wheat 60
• Milk 44
• Corn 44
• Cheese 39
• Oats 34
• Coffee 33
• Rye 30
• Eggs 26

• Tea 25
• Butter 25
• Yogurt 24
• Citrus 24
• Barley 24
• Chocolate 22
• Nuts 22
• Preservatives 20

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Foods Provoking IBS

• Potatoes 20
• Cabbage 19
• Sprouts 18
• Peas 17
• Beef 16
• Carrots 15
• Lettuce 15
• Rice 15

• Pork 14
• Broccoli 14
• Soy 13
• Chicken 13
• Spinach 13
• Yeast 12
• Lamb 11
• Sugar 12

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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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