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به نام خدا

به نام خدا. Functional abdominal pain syndrome Irritable bowel syndrome Chronic pain disorder (Somatoform disorders) Depressive & Anxiety disorders. The gut and the brain are highly integrated, and they communicate in a bidirectional fashion, largely through the (ANS) and (HPA) axis.

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به نام خدا

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  1. به نام خدا

  2. Functional abdominal pain syndrome Irritable bowel syndrome Chronic pain disorder (Somatoform disorders) Depressive & Anxiety disorders

  3. The gut and the brain are highly integrated, and they communicate in a bidirectional fashion, largely through the (ANS) and (HPA) axis • Limbic system: • internal and external homeostasis of the organism • central role in emotionality, which is a nonverbal system that facilitates survival, threat-avoidance, social interaction, and learning • “mind/body interaction” may largely arise in this region • “top-down” modulation of visceral pain and visceral perception • cognitive/psychological factors, visceral perception, and motor abnormalities

  4. NTs for Depression NE – mostly located in the Locus Ceruleus 5-HT – mostly located in the Dorsal Raphe Brainstem area with pathways to the neocortex and limbic system, as well as down the spinal cord Anxiety Irritability Pain Mood Emotion Cog Function 5-HT affects: Impulsivity Aggression Appetite Sex NE affects: Vigilance Motivation

  5. Psychosocial correlates ofIrritable Bowel Syndrome

  6. Psychosocial correlates ofIrritable Bowel Syndrome

  7. Management of chronic functional abdominal pain • Set the agenda • Provide unambiguous information about findings • Time planning: a longer planned session may save time in long run-Regular visit • Identify psychosocial factors

  8. Empathy • Set limits for investigations Don't treat what patient doesn't have-Do not harm • Encourage patient to take responsibility • Med-psych interfere

  9. Approach to patients: Disease or illness oriented • Cognition: content, styles, questions. • Emotion • Function • Expectation • Concerns

  10. Pain perception: Cognition Ruminations Catastrophizing Selective perception Affect Depression Anxiety Fear Nociception

  11. Psychological Treatments: • Cognitive therapy • Behavioural therapy • Interpersonal therapy • Dynamic psychotherapy • Hypnotherapy • Psychological treatments should not be limitedto people with co morbid psychiatric disorders. • Psychological therapy already exists in routine clinical care and includes clear explanation and true reassurance, which helps patients cope better with their disorder.

  12. Cognitive behavioural approach to understanding health anxiety Probability x (perceived cost) awfulness Anxiety = Perceived ability to cope + chance of help (rescue)

  13. Antidepressant therapy: • Psychiatric and non psychiatric disorders: e.g. neuropathic pain syndromes. • The analgesic effect is independent and sooner than antidepressant effect. The time required to obtain analgesia : 1 day to 10 weeks. • Drug intolerance is a rule: Start low go slow (Low doses).

  14. Aware of potential adverse effects and be prepared to undertake either dosage adjustments or trials with other agents. • No FDA approved antidepressantfor IBS. • Different kinds of ADs: TCA, SSRIs, SNRIs, MAOIs.

  15. Tricyclic Antidepressants • Frequently used • In contrast, the effective dose range for TCAs in IBS appears to be about 30–50 (10-70) mg/day of amitriptyline or its equivalent. • Unclear mechanism of action • Antihyperalgesia • Improved sleep • Normalized bowel transit • Coexisting depression/anxiety at higher doses

  16. Tricyclic Antidepressants • Inconsistent data on efficacy • Improved abdominal pain, global symptoms seen in some RCT’s, systematic reviews • Evidence has significant limitations • Variable dosing • Small numbers • High discontinuation rates • Short duration • Poor/variable designs • May exacerbate constipation • Appears dose related • Might be more beneficial in patients with diarrhea • Decrease abdominal pain; no improvement in global symptoms • Few head-to-head trials with SSRIs

  17. SSRIs • None are FDA approved for IBS • Directly or indirectly affect gut function and motility. • Analgesic properties. • Effective in a variety of somatoform disorders and alleviate global distress. • Extra intestinal symptoms. • Affective memory bias towards positive material. • Few RCTs of use in IBS: suggest improvement well being, pain, QOL scores

  18. No superiority of one SSRIs. • Among SSRIs, evidence is available for paroxetine, paroxetine CR, fluoxetine and citalopram. • Target dose of SSRIs in IBS appears is in the range found to be efficacious in the treatment of depression. • SSRI trials should be at least 8–12 weeks in duration of IBS.

  19. If patients demonstrate clinical benefit; continue the medications for at least 6–12 months. A gradual reduction in dose: pay attention to withdrawal symptoms Close monitoring of patients for recurrence of symptoms-Withdrawal syndrome Co morbid anxiety or depression: long-term treatment with antidepressants. Failure to respond to one antidepressant, switchingto another antidepressant.

  20. SNRI • Effective in decreasing pain in other chronic conditions • No trials yet on effect in IBS Insufficient evidence to make recommendations about SNRIs (e.g. venlafaxine - doluxetine) in IBS. • Mechanisms of action: SER- NE Reuptake inhibition

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