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CHRONIC FATIGUE/DEPRESSION THE MIND BODY CONNECTION

CHRONIC FATIGUE/DEPRESSION THE MIND BODY CONNECTION. AIMGP Seminar Series 2003-2004 Tim Cook (H. Abrams). OUTLINE. Case Functional Somatic Syndromes CFS Diagnostic Criteria CFS Diagnostic Strategy CFS Treatment Strategy: Evidence? Depression Epidemiology Depression Management .

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CHRONIC FATIGUE/DEPRESSION THE MIND BODY CONNECTION

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  1. CHRONIC FATIGUE/DEPRESSIONTHE MIND BODY CONNECTION AIMGP Seminar Series 2003-2004 Tim Cook (H. Abrams)

  2. OUTLINE • Case • Functional Somatic Syndromes • CFS Diagnostic Criteria • CFS Diagnostic Strategy • CFS Treatment Strategy: Evidence? • Depression Epidemiology • Depression Management

  3. CASE • 33 yo woman VP HR • Referred from FDr c/o fatigue X 18 mos • MEDS • multivits, CoE Q10, Gingko, glucosamine • Prn Zomig, Tylenol, Zelnorm • Non-smoker, daily glass wine, quit exercising

  4. Case Cont’d • P/E – fit looking woman • Few tender, “shotty” cervical nodes • 5 trigger points tender • Upper abdo quadrants tender • Remainder normal What additional history would be helpful? What investigations should be done?

  5. FATIGUE Onset Duration Severity (% of N) Provoking Factors (exercise?) Relieving Factors (wkends, sleep?) OTHER SYMPTOMS Arthralgia, myalgia, sore throat, neuro, depression bowel habits, SLEEP Duration Quality Restorative? Use of ETOH, caffeine Narcolepsy “flags” Daytime napping Hypnagogic hallucin. Cataplexy Sleep paralysis IMPORTANT HISTORY

  6. Functional Somatic Syndromes • Several related syndromes characterized by: symptoms, suffering and disability rather than demonstrable tissue abnormality

  7. Examples: • chronic fatigue syndrome (CFS) • multiple chemical sensitivities • sick building syndrome • fibromyalgia • silicone breast implant disease • chronic whiplash / other pain synd. • irritable bowel syndrome • others

  8. Characteristics: • explicit and highly elaborated • self-diagnosis • symptoms may be refractory to reassurance, explanation, and standard treatments

  9. Characteristics (cont’d) • high rates of co-occurrence • similar epidemiology • higher than expected psychiatric • comorbidity

  10. Characteristics (concl’d): • suffering worsened by “self-perpetuating, • self-validating cycle in which common, • endemic , somatic symptoms are incorrectly • attributed to serious abnormality, • reinforcing the patient’s belief that he or she • has a serious disease”. • Barsky and Borus. Ann Intern Med 1999:130:910-921.

  11. Incidence of somatic symptoms: Typical adult has one common symptom eg. Aching, every 4-6 days 81% of healthy college students report > 1 somatic symptom q3days.

  12. Amplification and Maintenance of Somatic Symptoms Five Factors: 1. The belief that one is sick 2. Future expectations and the Role of Suggestion 3. The Sick Role 4. Stress and Distress. 5. Political, Economic, and Legal issues

  13. Amplification and Maintenance of Somatic Symptoms 1. The belief that one is sick • Effect of cognitive beliefs on interpretation of current symptoms. e.g. hypertension and absenteeism • Effect of cognitive beliefs on interpretation and recall of past symptoms e.g. healthy volunteers given imaginary diagnosis • Amplified through self-scrutiny, medical scrutiny, media / public health attention, advocacy groups

  14. Amplification and Maintenance of Somatic Symptoms 2. Future expectations and the Role of Suggestion • Cognitive processing of current bodily sensations guided by expectations of what we will experience next. e.g. ASA for UAP – 6 X dropouts for GI symptoms (- endoscopy) if consent form explicitly mentioned

  15. Amplification and Maintenance of Somatic Symptoms 3. The Sick Role • social labeling theory: “… the connotations and implications of the label we apply to a condition or state influence the outcome of that condition or state.” - changes interactions with family, employer & physician

  16. Amplification and Maintenance of Somatic Symptoms 4. Stress and Distress. • Exacerbates and perpetuates physical symptoms • lowers threshold for medical help seeking • ambiguous body sensations more likely attributed to disease.

  17. Amplification and Maintenance of Somatic Symptoms 5. Political, Economic, and Legal Issues • political climate of entitlement • sense of belonging to a group • secondary gain e.g. prolonged rehab. in workers compensation

  18. 2. Chronic Fatigue Syndrome “…fatigue is very common, CFS is not ”. Caplan. CMAJ 1998;159(5):519-520.

  19. CDC Criteria for CFS: 1. Fatigue > 6 mos., resulting in decrease in activities of > 50%. and 2. All of: - New or definite onset - Not from ongoing exertion - not alleviated by rest and

  20. CDC Criteria for CFS (concl’d): > 4 of the following, present con- currently for > 6 mos.: - impaired memory/concentration - sore throat - tender cervical/axillary lymph nodes - myalgias - arthralgias - new headache - unrefreshing sleep - Post-exertional malaise

  21. Diagnostic Strategy • A. Prolonged fatigue > 1 mo., < 6 mo. • - Hx and Px • - Mental status, psych, neuro as indicated • - Lab: CBC, lytes, urea, Cr, glucose, Ca++, phos, ALT, ALP, protein, albumin, TSH, urinalysis, ?ESR ?Fe Sat • - Additional tests as indicated*

  22. *Additional tests as indicated: • - ANA, RF, C3, C4, CH50 • - Quantitative Ig’s (serum, urine) • Cortisols, CK’s • HCV, HBV, HIV, CMV, toxo • TB skin test • Lyme serology • Sleep Study • Other cause of disease Identified? • YES: Manage as per disease • NO:

  23. B. Chronic Fatigue > 6 mos.: Meet the CDC criteria? Yes: Do you really want to make this diagnosis? No: Idiopathic chronic fatigue.

  24. 4. Treatment Strategies: 1. R/O diagnosable disease as per diagnostic strategy. 2.Treat psychiatric comorbidity. 3. Form therapeutic alliance with patient 4. Make restoration of function the goal of treatment 5. Provide limited reassurance 6. Cognitive Behavioral therapy? 7. Other options

  25. 4. Treatment Strategies: • 1. R/O diagnosable disease (diagnostic strategy) • Try not to foster sick role • negative findings rarely reassure these patients • risk of iatrogenesis.

  26. Treatment Strategies: • 2.Treat psychiatric comorbidity. • Major depression, panic disorder •  somatic symptoms =  probability of psychiatric diagnosis

  27. Treatment Strategies: • 3. Form therapeutic alliance with patient • acknowledge and legitimize patient’s suffering. • discourage sick role. • reassure that you will not abandon.

  28. 4. Treatment Strategies: • 4. Make restoration of function the goal • coping rather than curing • realistic, incremental goals, • i.e. gently graduated exercise • active rather than passive role • “not waiting to be cured” but “taking control of self-cure”

  29. 4. Treatment Strategies: • 5. Provide limited reassurance • “no life-threatening illness found” • describe “amplification” process

  30. 4. Treatment Strategies: • What’s the Evidence? • 6. Cognitive Behavioral therapy • Positive and negative randomized trials of varying • quality, and relatively small numbers. • reexamines health beliefs and expectations • explores effects of sick role and stress on symptoms • muscle relaxation, graduated exercise, desensitization

  31. THE STRESS REACTION CYCLE (adapted from J. Kabat-Zinn) External Stressors Perceptual Appraisal Internal Stressors STRESS REACTION Physical exhaustion Psychological exhaustion loss of energy, enthusiasm depression genetic predispositions MI, cnacer, chronic illness Breakdown acute hyperarousal followed by normalization • Self-destructive • behaviours • overworking • hyperactivity • overeating • harmful conditionings • substance dependency HBP Arrhythmias sleep disprders chronic pains chronic illness anxiety Disregualation = Chronic Hyperarousal Maladaptive Coping

  32. Improved Self-esteem LETTING GO Increased Control Improved Motivation Function Centred Life Improved Function Pain Centred Life Improved Conditioning Adequate Analgesia Education Exercise Breath & Relaxation Increased Activities

  33. CHRONIC MUSCLE CONTRACTION Trauma Emotions Posture Brain PAIN Sensory Feedback Autonomic NS Central NS Hormonal system (sex hormone, cortisol, adrenaline, neuropeptides etc.) Muscle & Fascia Characteristics: blood supply metabolism resting tone contractility & power flexibility & elasticity Increased tone Muscle tension Exercise, Stretching, Breathing & Relaxation Practices

  34. 4. Treatment Strategies: • 7. Other options: • low dose SSRI’s, TCA’s: no consistent response • modafinil (alertec): few studies • complementary therapies. No evidence from RCT’s

  35. Depression • Very common problem in primary practice • 10% of men over lifetime • 20% of women over lifetime • May be even more prevalent in medical patients • up to 40% with chronic illness

  36. Depression in Medicine • Depression more common in following illnesses: • stroke • dementia • diabetes • heart disease • renal disease • cancer

  37. Depression and Drug Tx • certain drugs have been linked to onset of depressive symptoms • common offenders: • steroids, calcium channel blockers, digoxin • cohort studies • withdrawal of psycho-stimulants • benzos, barbituates, morphine, levo-dopa • perhaps ACEi, statins • B-blockers controversial

  38. Why should we care? • Prognosis of medical diseases worse in depressed patients • 15 months post onset of depression, mortality rates are 4 times that of age matched controls!!! • Depressed patients admitted to NH are 1.5 times more likely to die within a year

  39. Post MI, depression is an important marker of prognosis • as important as LV function • incidence in stroke patients very high • between 25-80% • range is large b/c difficult to make diagnosis

  40. Cancer and depression • estimates vary, but expect that depressed patients have mortality rates 10-20% greater than matched counterparts

  41. Diagnosis • often difficult • medical patients often have somatic complaints • GI upset, headache, fatigue etc. • important to r/o other causes for complaints • hypothyroid, anemia etc. • rating scales available (+ we have them!)

  42. DSM 4 Criteria • Must have one of: • depressed mood most of the time • decreased interest/pleasure in nearly all activities • Plus, must have 5 of the following during a 2 week period:

  43. DSM 4 Criteria • weight change • sleep change • observed agitation or retardation • fatigue or loss of energy • feelings of worthlessness or excessive guilt • unable to concentrate / indecisiveness • recurrent thoughts of death

  44. Minor Depression • patients and doctors may want to attribute mood to current life stress • I.e. adjustment disorder • this is characterized as a minor depression • most common type of depression • becomes problematic if leads to social dysfunction, or persists longer than 2 months

  45. Course and Prognosis • untreated major depression: • 40% resolve spontaneously • within 6 - 12 months • 20% resolution is incomplete • sub-clinical symptoms persist for years • 40% depression continues • depression is usually recurrent

  46. Course and Prognosis • depression is usually recurrent • 70% recurrence after 2 episodes • 90% recurrence after 3 episodes • thoughts of death are common • 1 in 8 suicide attempts are successful • risk factors for suicide: • medical illness, ETOH, male, Caucasian, presence of psychotic symptoms, social isolation, history of previous attempts, and a plan

  47. Treatment • main modalities include • psychotherapy • drug treatment • electro-convulsant therapy • should be individualized

  48. Psychotherapy • recent studies do show it to be as effective as medication • 40-50% improve • BMJ 2000;320:26-30 • perhaps best suited to less severe forms of depression in a highly motivated patient

  49. Medications • three main groups of drugs: • SSRI • TCAs • MAOI • occasionally for refractive forms: • lithium • valproate • thyroid supplementation

  50. Medications • in general, need 6 week trial to see effect • try to adjust dose to achieve benefits at lowest possible dose • usually continue therapy for 6 months to 2 years • relapses usually occur within 2 months of discontinuation; taper slowly

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