1	Patient-Centered Diagnosis: a Cornerstone of Integrative Medicine Leo Galland M.D. 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
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
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
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
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
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
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
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
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).
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 effects of sickness in this individual patient.
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
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.
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.
15	Common Triggers of Illness Social interactions Emotional injury Loss Anticipations of loss Memories Microbes Physical injury Allergens Chemical toxins Elemental toxins Radiation
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
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.
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
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
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 effects become antecedents for further illness.
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.
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?”
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.
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?
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?
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
27	“Functional” Bowel Disorders: Mediators Neurotransmitters: Ach, DA, 5-HT Neuropeptides: CCK, VIP Prostanoids: PGE2 Anxiety, fear, appraisal Fermentation by-products
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
29	“Functional” Bowel Disorders: Precipitating Events Foreign travel Wilderness activities Antibiotic exposure Acute psychosocial distress Change in diet
30	“Functional” Bowel Disorders: Triggers Food Microbes Psychosocial distress
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
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
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
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
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
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
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%
38	Foods Provoking IBS Tea 25% Butter 25% Yogurt 24% Citrus 24% Barley 24% Chocolate 22% Nuts 22% Preservatives 20% Wheat 60% Milk 44% Corn 44% Cheese 39% Oats 34% Coffee 33% Rye 30% Eggs 26%
39	Foods Provoking IBS Pork 14% Broccoli 14% Soy 13% Chicken 13% Spinach 13% Yeast 12% Lamb 11% Sugar 12% Potatoes 20% Cabbage 19% Sprouts 18% Peas 17% Beef 16% Carrots 15% Lettuce 15% Rice 15%
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
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)
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