Patient-Centered Diagnosis: a Cornerstone of Integrative Medicine

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

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 Foundation for Integrated Medicine

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 Foundation for Integrated Medicine

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 Foundation for Integrated Medicine

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 Foundation for Integrated Medicine

7. 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 Foundation for Integrated Medicine

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 Foundation for Integrated Medicine

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 Foundation for Integrated Medicine

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). Foundation for Integrated Medicine

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 effectsof sickness in this individual patient. Foundation for Integrated Medicine

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 Foundation for Integrated Medicine

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. Foundation for Integrated Medicine

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. Foundation for Integrated Medicine

15. Microbes Physical injury Allergens Chemical toxins Elemental toxins Radiation Social interactions Emotional injury Loss Anticipations of loss Memories Common Triggers of Illness Foundation for Integrated Medicine

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 Foundation for Integrated Medicine

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. Foundation for Integrated Medicine

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 Foundation for Integrated Medicine

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 Foundation for Integrated Medicine

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 effectsbecome antecedents for further illness. Foundation for Integrated Medicine

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. Foundation for Integrated Medicine

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 Foundation for Integrated Medicine

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 Foundation for Integrated Medicine

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? Foundation for Integrated Medicine

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? Foundation for Integrated Medicine

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 Foundation for Integrated Medicine

27. “Functional” Bowel Disorders:Mediators • Neurotransmitters: Ach, DA, 5-HT • Neuropeptides: CCK, VIP • Prostanoids: PGE2 • Anxiety, fear, appraisal • Fermentation by-products Foundation for Integrated Medicine

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 Foundation for Integrated Medicine

29. “Functional” Bowel Disorders:Precipitating Events • Foreign travel • Wilderness activities • Antibiotic exposure • Acute psychosocial distress • Change in diet Foundation for Integrated Medicine

30. “Functional” Bowel Disorders:Triggers • Food • Microbes • Psychosocial distress Foundation for Integrated Medicine

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 Foundation for Integrated Medicine

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 Foundation for Integrated Medicine

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 Foundation for Integrated Medicine

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 Foundation for Integrated Medicine

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 aerobe:anaerobe ratios and high stool PGE2 levels Alun Jones et al, Lancet, 1982 Foundation for Integrated Medicine

36. 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 Foundation for Integrated Medicine

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 > 10 foods 32% Foundation for Integrated Medicine

38. 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% Foods Provoking IBS Foundation for Integrated Medicine

39. 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% Foods Provoking IBS Foundation for Integrated Medicine

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 Foundation for Integrated Medicine

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) Foundation for Integrated Medicine

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