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

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


1
Patient-Centered Diagnosis a Cornerstone of
Integrative Medicine
  • Leo Galland M.D.
  • Foundation for Integrated Medicine

2
It is more important to know what person has the
disease than what disease the person has. Sir
William Osler
3
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

4
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

5
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

6
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

7
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

8
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

9
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

1
10
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).

11
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.

12
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

2
13
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.

14
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.

15
Common Triggers of Illness
  • Microbes
  • Physical injury
  • Allergens
  • Chemical toxins
  • Elemental toxins
  • Radiation
  • Social interactions
  • Emotional injury
  • Loss
  • Anticipations of loss
  • Memories

16
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

17
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.

18
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

19
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

3
20
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.

21
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.

22
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?

4
23
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.

5
24
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?

25
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?

26
Functional Bowel Disorders Effects
  • Pain
  • Diarrhea, constipation, urgent bowel movements
  • Distension, flatulence, eructation
  • Fatigue and symptoms of co-morbidity
  • Anxiety
  • Health care seeking behaviors

27
Functional Bowel Disorders Mediators
  • Neurotransmitters Ach, DA, 5-HT
  • Neuropeptides CCK, VIP
  • Prostanoids PGE2
  • Anxiety, fear, appraisal
  • Fermentation by-products

28
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

29
Functional Bowel Disorders Precipitating Events
  • Foreign travel
  • Wilderness activities
  • Antibiotic exposure
  • Acute psychosocial distress
  • Change in diet

30
Functional Bowel Disorders Triggers
  • Food
  • Microbes
  • Psychosocial distress

31
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

32
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

33
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

34
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

35
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

36
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

37
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

38
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

39
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

40
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

41
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)

42
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