Patient-Centered Diagnosis - What is Integrated Medicine?

Patient-Centered Diagnosis: a Cornerstone of Integrative

Medicine

Leo Galland M.D.

Foundation for Integrated Medicine


“It is more important to know what person has the disease than what disease the person has.”

Sir William Osler


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


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


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


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


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


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


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


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 ).


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.


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


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.


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.


Common Triggers of Illness

• Microbes

• Physical injury

• Allergens

• Chemical toxins

• Elemental toxins

• Radiation

• Social interactions

• Emotional injury

• Loss

• Anticipations of loss

• Memories


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


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 .


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


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 diseaserelated, iatrogenic, cognitive or social

3


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.


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.


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


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


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?


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?


“Functional” Bowel Disorders:

Effects

• Pain

• Diarrhea, constipation, urgent bowel movements

• Distension, flatulence, eructation

• Fatigue and symptoms of co-morbidity

• Anxiety

• Health care seeking behaviors



Mediators

• Neurotransmitters: Ach, DA, 5-HT

• Neuropeptides: CCK, VIP

• Prostanoids: PGE2

• Anxiety, fear, appraisal

• Fermentation by-products



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



Precipitating Events

• Foreign travel

• Wilderness activities

• Antibiotic exposure

• Acute psychosocial distress

• Change in diet



Triggers

• Food

• Microbes

• Psychosocial distress


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


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


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


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


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


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


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%


Foods Provoking IBS

• Wheat 60%

• Milk

44%

• Corn 44%

• Cheese

39%

• Oats 34%

• Coffee

33%

• Rye30%

• Eggs

26%

• Tea

• Butter

25%

25%

• Yogurt

• Citrus

24%

24%

• Barley

• Chocolate

24%

22%

• Nuts 22%

• Preservatives

20%


Foods Provoking IBS

• Potatoes 20%

• Cabbage 19%

• Sprouts 18%

• Peas 17%

• Beef 16%

• Carrots 15%

• Lettuce 15%

• Rice 15%


• Pork

• Broccoli

• Soy

• Chicken

• Spinach

• Yeast

• Lamb

• Sugar

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


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)



Patient-Centered Diagnosis - What is Integrated Medicine?

SBBO AND IBS:

CONCLUSIONS

Low Fermentation Diet

Outcome of Exclusion Diet in 182 IBS Patients

Foods Provoking IBS

Foods Provoking IBS

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Patient-Centered Diagnosis - What is Integrated Medicine?

SBBO AND IBS:

CONCLUSIONS

Low Fermentation Diet

Outcome of Exclusion Diet in 182 IBS Patients

Foods Provoking IBS

Foods Provoking IBS

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