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
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?
IMPORTANT HISTORY 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
Functional Somatic Syndromes Several related syndromes characterized by: symptoms, suffering and disability rather than demonstrable tissue abnormality
Examples: chronic fatigue syndrome (CFS) chronic fatigue syndrome (CFS) multiple chemical sensitivities multiple chemical sensitivities sick building syndrome sick building syndrome fibromyalgia fibromyalgia silicone breast implant disease silicone breast implant disease chronic whiplash / other pain synd. chronic whiplash / other pain synd. irritable bowel syndrome irritable bowel syndrome others others
Characteristics: explicit and highly elaborated explicit and highly elaborated self-diagnosis self-diagnosis symptoms may be refractory to reassurance, explanation, and standard treatments symptoms may be refractory to reassurance, explanation, and standard treatments
Characteristics (cont’d) high rates of co-occurrence high rates of co-occurrence similar epidemiology similar epidemiology higher than expected psychiatric higher than expected psychiatric comorbidity comorbidity
Characteristics (concl’d): suffering worsened by “self-perpetuating, suffering worsened by “self-perpetuating, self-validating cycle in which common, self-validating cycle in which common, endemic, somatic symptoms are incorrectly endemic, somatic symptoms are incorrectly attributed to serious abnormality, attributed to serious abnormality, reinforcing the patient’s belief that he or she reinforcing the patient’s belief that he or she has a serious disease”. has a serious disease”. Barsky and Borus. Ann Intern Med 1999:130:910-921. Barsky and Borus. Ann Intern Med 1999:130:910-921.
Incidence of somatic symptoms: Incidence of somatic symptoms: Typical adult has one common symptom eg. Aching, every 4-6 days eg. Aching, every 4-6 days 81% of healthy college students report > 1 somatic symptom q3days.
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
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
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
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
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.
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
2. Chronic Fatigue Syndrome “…fatigue is very common, CFS is not ”. Caplan. CMAJ 1998;159(5):519-520.
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
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
3.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 *
*Additional tests as indicated: - ANA, RF, C 3, C 4, CH 50 - 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:
B. Chronic Fatigue > 6 mos.: Meet the CDC criteria? Yes: Do you really want to make this diagnosis? No: Idiopathic chronic fatigue.
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
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.
4.Treatment Strategies: 2. Treat psychiatric comorbidity. – Major depression, panic disorder – somatic symptoms = probability of psychiatric diagnosis
4.Treatment Strategies: 3. Form therapeutic alliance with patient –acknowledge and legitimize patient’s suffering. –discourage sick role. –reassure that you will not abandon.
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”
4. Treatment Strategies: 5. Provide limited reassurance – “no life-threatening illness found” – describe “amplification” process
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
THE STRESS REACTION CYCLE External Stressors Internal Stressors Perceptual Appraisal STRESS REACTION acute hyperarousal followed by normalization Disregualation Chronic = Chronic Hyperarousal Hyperarousal HBP Arrhythmias sleep disprders chronic pains chronic illness anxiety Maladaptive Coping Self-destructive behaviours overworking hyperactivity overeating harmful conditionings substance dependency Breakdown Physical exhaustion Psychological exhaustion loss of energy, enthusiasm depression genetic predispositions MI, cnacer, chronic illness (adapted from J. Kabat-Zinn)
Pain Centred Life Function Centred Life Adequate Analgesia Education Exercise Breath & Relaxation Increased Activities Improved Conditioning Improved Function Increased Control Improved Self-esteem Improved Motivation LETTING GO
Brain Muscle & Fascia Sensory Feedback Characteristics: blood supply metabolism resting tone contractility & power flexibility & elasticity Autonomic NS Central NS Hormonal system (sex hormone, cortisol, adrenaline, neuropeptides etc.) Trauma Emotions Posture Muscle tensionIncreased tone PAIN CHRONIC MUSCLE CONTRACTION Exercise, Stretching, Breathing & Relaxation Relaxation Practices Exercise, Stretching, Breathing & Relaxation Relaxation Practices
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
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
Depression in Medicine Depression more common in following illnesses: stroke dementia diabetes heart disease renal disease cancer
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
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
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
Cancer and depression estimates vary, but expect that depressed patients have mortality rates 10-20% greater than matched counterparts
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!)
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:
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
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
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
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
Treatment main modalities include psychotherapy drug treatment electro-convulsant therapy should be individualized
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
Medications three main groups of drugs: SSRI TCAs MAOI occasionally for refractive forms: lithium valproate thyroid supplementation
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
SSRI Most commonly used safer in overdose than TCAs some meta-analyses say less effective than TCAs: other say equal fluoxetine (Prozac) safe in pregnancy
SSRI - Common Side Effects GI: nausea, diarrhea, weight gain neuro: headache, sedation, paresthesia insomnia, poor memory, agitation other: sexual dysfunction
SSRI - Rare Side Effects Neuro: extrapyramdal - dystonias, akathesia b/c of serotonin mediated inhibition of dopaminergic pathways Cardiac case reports of a fib, bradycardia, syncope may have class 1,4 properties and be pro- arrhythmic SIADH
SSRI - Serotonin Syndrome Insidious, may be fatal usually seen when 2 or more drugs enhance serotonin activity present as: confused, agitated, fever, shivering, diaphoretic, diarrhea, ataxic, hyper-reflexic, myoclonus tx: stop meds +/- anti-sertoninergics (BB)
SSRI - OD Rarely fatal if fatal, usually b/c of what it is combined with moderate OD - 30* dose - are nauseated, drowsy high - 75* - may have seizures, ECG changes and further decreased LOC supportive care mainstay of treatment
TCAs until recently, most common drugs used to treat depression decrease use attributed to addition of SSRI to market very effective treatment approx. 50-60% improve may still be 1st line for severe depression
TCAs inhibit re-uptake of mono-amines, noradrenaline and serotonin at nerve endings many possible side effects, especially in the elderly
TCAs - Side Effects anti-cholinergic: dry mouth, nausea, constipation, urinary retention, mydriasis and cycloplegia cardiovascular: postural hypotension, tachycardia neurologic: fine tremor, dizziness, ataxia drowsiness
TCA - Overdose can be rapidly fatal were the 4th most common OD within 6 hours: CNS depression, seizures respiratory depression CVcollapse, QRS prolongation and VT quinidine like effects
MAOI increases levels of noradrenaline, dopamine and 5-hydroxytryptamine usually reserved for atypical depression: weight gain excessive sleep marked anxiety / obsessional features
MAOI - Side Effects common: weight gain drowsiness, agitation postural hypotension interactions may cause hypertension: tyramine in cheese, herring, red wines dopamine - other antidepressants must give at least 2 week wash-out period
ECT usually reserved for: imminent suicide psychotic depression catatonia very effective usually need 6-8 treatments over 3 weeks
ECT - Side Effects can develop short-term retrograde amnesia also can get hypertensive surge sympathetic mediated b/c done under general anaesthesia, other potential complications include aspiration pneumonia etc.
Special Considerations in Elderly age-related physiologic changes may alter pharmacokinetics reduce flow to liver, kidney decreased enzyme activity usually on multiple medications increases potential for drug interactions “start low and go slow”
Special Considerations in Elderly TCAs metabolized by P-450 common inhibitors cipro, biaxin, flagyl, amiodarone, fluconazole narrow therapeutic range increases possible side effects SSRI prozac, zoloft, paxil, luvox all inhibit P450 careful with haldol, coumadin, lithium
Conclusions depression is common in our patient population elderly, chronic illnesses often present with somatic complaints therapy is effective ideally managed by GP, or someone who can see patient frequently many side-effects, but SSRI generally well tolerated