Transcript No Slide Title

THE FOLLOWING LECTURE HAS BEEN APPROVED FOR
ALL STUDENTS
BY BIRMINGHAM CITY UNIVERSITY
This lecture may contain information, ideas,
concepts and discursive anecdotes that may be
thought provoking and challenging
Any issues raised in the lecture may require the
viewer to engage in further thought, insight,
reflection or critical evaluation
Psychological
Assessment
of
Irritable Bowel Syndrome
Dr. Craig Jackson
Senior Lecturer in Psychology
Faculty of Education Law & Social Sciences
BCU
Birmingham
www.hcc.bcu.ac.uk/craigjackson
[email protected]
Dualism
“If you are distressed by anything external, the pain is not due to the
thing itself, but to your estimate of it; this you have the power to
revoke at any moment”
Marcus Aurelius 180BC
Dualism
Mind & Body Divided
Unification
Mind & Body are One
BioPsychoSocial Unification popular in last 10-15 years
Rene Descartes
Traditional model of Disease Development
Pathogen
Disease (pathology)
Modifiers
Lifestyle
Individual susceptibility
Dominance of the biopsychosocial model
Mainstream in last 15 years
Hazard
Illness (well-being)
Psychosocial Factors
Attitudes
Behaviour
Quality of Life
Rise of the patient
as a psychological
entity
Mental States & Physical Well-being
Triggering Hypothesis
Chinese # 4
Phillips et al. 2001
World cup 1998
Carroll et al. 2002
Stressful events and Breast Cancer
Chen et al. 1995
Scottish Heart Attack Deaths
Evans et al. 2002
Baskerville Effect
Conan-Doyle
Is disease real or is it in the mind?
Linking Emotions with Physical Symptoms
Rome Criteria
Irritable Bowel Syndrome
Chronic or Recurrent
Lower Abdominal Pain
Disturbed Defecation
Bloating
NOT EXPLAINED BY STRUCTURAL OR KNOWN BIOCHEMICAL
ABNORMALITIES
Symptoms / Side Effects
Abdominal pain
Limited social life
Inability to travel
Flatulence
Bloating
Diet restriction
Discomfort
Unexpected onset
Constipation
Distended abdomen
Embarrassment
Diarrhoea
Sleep disturbance
Explosive movements
Lack of energy
Depression
Nausea
Noisy Intestines
Lethargy
Interruptions at work
Mental anguish
Inability to concentrate
56.6%
38.3%
24.8%
21.5%
18.6%
14.8%
9.4%
7.6%
7.1%
6.9%
6.7%
6.5%
6.2%
5.6%
4.5%
4.3%
4.1%
3.5%
3.3%
3.2%
2.5%
2.4%
IBS Bulletin, 1995
Irritable Bowel Syndrome
Common digestive disorder
Functional syndrome
(No organic cause)
Traumatic life events
Personality disorders
Stress
Anxiety
Depression
Somatization
Not a psychological disorder!
Psychological Consequences of Irritable Bowel Syndrome
• Distress
• Reduced Quality of Life
• Delay in seeking help
• Fear
• Denial
• Depressed / Anxious
• Increased somatic complaints
• Pain
• Fatigue
• Breathlessness
• Seeks help too readily
Adjustment Disorder – commonest psychiatric diagnosis
Increased risk of suicide in early stages (of some) conditions
Global Epidemiology
Drossman et al. 1997
Help Seeking Behaviour
Sandler et al. 1984
Psychological / Perceptual Process of Illness
Internal Processes
“Do
I notice internal changes?”
“Should

I interpret them negatively?”
“Should I think they are important?”
External processes

“Do I notice external sources?”

“What should I believe about it?”

“What should I do about it?”
MENTAL SCHEMA
Internal representation of the world
(knowledge, attitudes, beliefs)
What do we believe about health?
What do we believe affects health?
Factors Influencing Symptom Development
Selective Internal Attention
Tedious & un-stimulating environment
Little communication
Stressful environment
Learned behaviours
“Negative Affectivity”
OVER FOCUS ON SYMPTOMS
Comparisons
Attributions
Responses
Blame
Pessimism
Factors Influencing Symptom Development
Selective External Attention


Heightened concern about risk
involuntary
uncontrolled
lack of information
dreaded consequences
Mistrust of government / industry
 Attitudes about medicine

Political agenda

Legal agenda

Social and political climate

Media and pressure group activity
OVER FOCUS ON SYMPTOMS
Comparisons
Attributions
Responses
Blame
Pessimism
Irritable Bowel Syndrome
Occupational Link - Night-workers
Personality Link - Loners
Not life threatening
Embarrassment
QoL
Anguish
Pain
Discomfort
Debilitation
1 in 5 of population suffer IBS-type symptoms
Females more prone (80%)
Stress considered to play important role in triggering some IBS symptoms
Psychology important in how symptoms are perceived and reacted to
Can poor QoL Become a predictor of who will suffer in advance?
Psychosocial Balance
Whitehead et al. 1988
Psychological Treatments
Drossman et al. 1995
Prevalence among Twins
Levy 2001
Prevalence of Non-Specific Symptoms
Symptom
Prevalence %
Stuffy nose
46.2
Headaches
Tiredness
Cough
Itchy eyes
Sore throat
Skin rash
Wheezing
Respiratory
Nausea
Diarrhoea
Vomiting
33.0
29.8
25.9
24.7
22.4
12.0
10.1
10.0
9.0
5.7
4.0
Heyworth & McCaul, 2001
Modern day complaints
Multiple Chemical Sensitivity
Chronic Fatigue Syndrome
Sick Building Syndrome
Gulf War Syndrome
Low-level Chemical Exposure
Electrical Sensitivity
Historical complaints
Railway Spine
Neurasthenia
Combat Syndrome
Non-Specific Symptoms
Often missed in clinical assessments
“Cultural” Bowel Syndrome
Women in western societies in general seem more willing than men to seek
medical attention for a whole variety of disorders
Indian sub-continent:
IBS is more common in men than women
In Indian society men are known to consult doctors more often than women
In this region of the world women also suffer from IBS symptoms but are not
seeking help for their problem
Case #1 – Laura’s Weblog
“Hello. This is a series of postings about my adventures, and trials, with
irritable bowel syndrome (IBS). IBS is not a well defined disease. In fact most
MDs don't define it as a disease at all; it is defined as a syndrome composed
of varied and multiple symptoms. Traditional doctors either refuse to address
it (it's all in your head) or call it what it is - a dysfunction of the digestive
system, particularly the intestinal tract, that has no cure.”
“I refuse to define it as a syndrome. Too much stigma for my brain. I need to
work with a definition that allows for positive future energy. I haven't come
up with one yet. In the meantime I consider IBS to be this large intestinal
gnat.... sometimes, when the weather is just right, it doesn't bother me at all.
The rest of the time I keep swatting at it. One of these days I will make it
disappear altogether. Hence this blog.”
Laura
Case #2 – Mike’s Nirvana of Peristalsis
Tuesday, August 31, 2004
Dinner: leftover grilled chicken, chopped up with some baby zucchini, grilled
poblano chile, and cheddar cheese. Lunch: tunafish salad, tossed salad, organic
peaches. mhs@19:12
Friday, August 27, 2004
Lunch: leftover sautéed cauliflower and onion, grilled sausages, and cheese.
Breakfast: homemade yogurt, fresh fruit, Lois Lang's nut bread, and some flax seed
oil. mhs@14:00
Thursday, August 12, 2004
Breakfast: homemade applesauce, homemade yogurt, fresh blueberries, and some
honey. A wonderful way to start the morning! mhs@06:27
Sunday, August 01, 2004
Dinner, yesterday: A feast with family and friends! Grilled salmon, grilled red
snapper, grilled Cajun-rubbed catfish, and grilled shrimp with cumin, lime, and green
chillies; tossed salad, roasted eggplant salad, asparagus. mhs@05:57
Case #3 - Kate
“I have had IBS since I was a child. I remember always having stomach ache,
sometimes quite severe, that no one could find the cause of. I was always at the
doctor's or hospital being investigated. Finally, at age about 10, I went into hospital
for a few days for tests. I think they thought I had a problem with my kidneys (I have
three), but after observing me and my bowel movements for a few days they
concluded that I had "irritable bowel syndrome". I don't remember having any
treatment recommended at that time (this was the early 70s). I think it was just a case
of "go away, your illness is not life threatening and there is nothing we can do for
you". The trouble was that, apart from the bowel symptoms, I just never felt well
anyway. I felt tired and mildly depressed all the time.
I was okay for a few years and just suffered occasional problems. Then in my midtwenties the IBS seemed to get worse. I had a couple of attacks in which I passed
out. One time this happened in a restaurant, just after eating the first course. I had to
rush to the loo as well. I saw an allergy doctor who tried to say that I was passing out
to get attention! I can think of better, less painful ways, of getting attention. I went for
more examinations and investigations but again I was diagnosed with IBS and sent
away. I think it was about this time that I was prescribed anti-spasmodic drugs which
I have been taking on and off for years. Violent attacks”
Case #3 - Kate
“In my early-thirties it started to get worse again. I had more episodes of violent
attacks in which I would have terrible pain and often pass out. I began to be scared to
go out the house or anywhere that it might be difficult to find a toilet. I would wake up
tired and go to bed feeling tired. It would be a struggle to get through the day,
especially if I was also suffering from stomach cramps or other IBS symptoms. These
symptoms were not restricted to my bowels. I also felt nauseous a lot of the time, and
had general malaise. I started to get panic attacks when out in busy places. I became
too frightened to even consider travelling anywhere, whether for work or a holiday.
Even socialising became a nightmare and I started to want to stay in all the time. I also
began to lose weight because I felt too nauseous to eat.
I saw yet more doctors who gave me the all clear for various things such as stomach
ulcers or cancer. But they couldn't (or weren't able to) help with the IBS. I was even
referred to a psychiatrist, who suggested counselling. I found this helpful in some
ways (we all enjoy talking about ourselves) but didn't get at the root of the problem,
the IBS.”
The Brain-Gut Axis
A variety of features that effect function of the central nervous system or
brain have now been shown to effect, by virtue of the connections of the
brain gut axis, the symptoms described above at the 'end organ' level
This could be caused by psychological factors for example:
Stress
Anxiety
Depression
Or by psychological trauma such as:
Verbal abuse
Physical abuse
Emotional abuse
Sexual abuse
The Role of the Brain
Modern strategies / treatments that have been developed for IBS reflect
researchers’ understanding of the important role that the brain gut axis plays
in causing symptoms
In treatment of IBS variants, a concept of centrally and end organ treatment
has been developed
Centrally targeted treatments include therapies to counter the influence of:
Stress, Anxiety and Depression
Including:
1) physiological explanation of symptom generation
2) various forms of counselling
3) simple relaxation therapy
4) gut-focused hypnotherapy
5) cognitive behavioural therapy
6) use of tricyclics / MAOIs
Stress Factor
Many sufferers consider stress an important factor responsible for flare ups
IBS may be a primary disorder of the brain/gut axis
Psychological factors that influence the mental state of IBS sufferers are
thought to cause chemical changes or imbalances in the brain that may in
turn influence motility e.g. 5HT
Stress-related chemical changes may influence perception of pain signals
sent to the brain from sensory nerve endings that respond to events
occurring in the intestines
70% of the non-patient population suffer changes in bowel
function as a reaction to stressful situations
Drossman 2001
Stress Factor
Such 'gut reactions' tend to occur more frequently and more severely in those
with IBS
Half of IBS patients reporting stress believe their psychological situation
helped contribute to their initial IBS (Summer 1999)
IBS sufferers have a lower threshold for coping with stressful situations and
are more likely to react to negative events that in turn, can have catastrophic
effects on the workings of the gut
The relationship between life events and gastrointestinal symptoms has long
been accepted
Environmental stresses can be common causes - childhood stress, early
parental loss, parental alcoholism, unsatisfactory parent- relationships,
sexual and physical abuse
Case Summary of an “IBS Patient”
Date
Symptoms
Referral
Investigation
Outcome
1980 (18)
Abdominal pain
GP --> surgical OP
Appendicectomy
Normal
1983 (21)
Pregnancy
(boyfriend in prison)
GP --> obs and gynae
OP
1985-7
(23-25)
Bloating, abdominal
blackouts (divorce)
GP --> Gastro and
neurology OP
1989 (27)
Pelvic pain
(wants sterilisation)
GP --> obs and gynae Sterilised
OP
Pain persists for 2 years
1991 (29)
Fatigue
GP --> infectious
diseases unit
Diagnosis of ME by patient
and self help group
1993 (31)
Aching muscles
GP --> rheumatology Mild cervical
clinic
spondylosis
1995 (34)
Chest pain, breathless A&E --> chest clinic
(child truanting)
Termination
All tests normal
Nothing abnormal
IBS diagnosis
unexplained syncope
Pain clinic - Tryptizol
Nothing abnormal
Refer to psychiatric services
poss hyperventilation
Screening Questionnaires
Self-report screening instruments
Beck Depression Inventory (BDI)
General Health Questionnaire (GHQ)
Hospital Anxiety Depression Scale (HAD)
“How have you been feeling recently?”
“Have you been low in spirits?”
“Have you been able to enjoy the things you usually enjoy?”
“Have you had your usual level of energy, or have you been feeling tired?”
“How has your sleep been?”
“Have you been able to concentrate on your favourite tv shows?”
Persistent low mood and lack of interest and pleasure in life cannot be
accounted for by severe physical illness alone
A Profile of IBS Sufferers?
No such thing as a “typical” IBS patient
How valid is this profile?
Personality:
introvert
Occupation:
night-time
Sex: female
sedentary
Increased risk
of IBS
History of
History of
anxiety
depression
Food allergy /
intolerance
Epidemiology of Chronic Patients
4% of general population
• 9% of admitted patients
• 10-15 per GP
• Mostly female
• Recurrent depressive disorder
• Longstanding difficulty in personal relationships
• Possible substance misuse
• Associated with emotionally deprived childhood, physical & sexual abuse
• Some personality disturbance
Iatrogenic harm issues
Increased investigations + Increased treatments = Increased risk of harm
Common Chronic Ill-Health Complaints
• Low Back Pain
• Carpal Tunnel Syndrome
• Cumulative Trauma Disorders
• Tendonytis
• Repetitive Strain Injury
• Fibromyalgia
• Irritable Bowel Syndrome
• Chronic Fatigue
FORMS OF
CHRONIC PAIN
& FATIGUE
Those with heightened symptoms choose attributions to match concepts of
what is currently acceptable in medicine
External cause for illness preferred - patient becomes a helpless victim
“O R G A N I F I C A T I O N”
Chronic Patients’ Attributions of Ill-Health
• Work
Stress
• Environment
Chemicals
Toxins
Virus
Allergies
• Traumatic injury
• Anatomy / Ergonomic
Cognitive Model of Physical Symptoms
Measuring the Impact of IBS
The IBS-QOL scale (Patrick & Drossman, 2004)
Self-Completion questionnaire
10 minutes to complete
34 Items
5-Point likert scale
1. Not at all
2. A little
3. Moderately
4. Quite a bit
5. Extremely
1-100 score: Greater score = Better QoL
8 sub-scales:
Dysphoria, Activity, Body image, Health worries, Food avoidance,
Social reactions, Sexual activity, Relationships
Compensation Neurosis
Improvement in health.....
...may result in loss of status
Patient compelled to guard against getting better
Financial reward for illness is a powerful nocebo
Exacerbates illness
In a litigious society, will compensation neurosis become more widespread?
Abnormal Illness Behaviour after Compensable Injury
Accident neurosis
Aftermath neurosis
Attitudinal pathosis
Compensatory hysteria
Compensation neurosis
Functional overlay
Greenback neurosis
Justice neurosis
Post accident anxiety syndrome
Postaccident fibromyalgia
Profit neurosis
Railway spine
Traumatic hysteria
Traumatic neurasthenia
Triggered neurosis
Vertebral neurosis
Whiplash neurosis
Accident victim syndrome
American disease
Barristogenic illness
Compensationitis
Fright neurosis
Greek disease
Invalid syndrome
Perceptual augmenter
Pensionitis
Post-traumatic syndrome
Psychogenic invalidism
Secondary gain neurosis
Symptom magnification syndrome
Traumatic neurosis
Unconscious malingering
Wharfie’s back
Mendelson, 1984
Secondary Gain Pre-disposition
Motivation
• Desire for attention
• Punish spouse / others
• Solve life’s problems
• Cry for help
• Diversion from work
• Socially approved task avoidance
sex with spouse
work
military duty
Behavioural Yellow Flags of Irritable Bowel Syndrome
Indicative of long term chronicity and disability
•
Negative attitude – some food is harmful and disabling
•
Fear avoidance
•
Reduced activity
•
Expects passive treatment to be better than active treatment
•
Tendency to low morale, depression and social withdrawal
•
Social / Financial problems
Returning to Work
10 20 30 40 50 60 70 80 90 100
% returning to work
Longer off work = Less likely to return to work
<1 2 4 6 8 10 12 14 16 18 20 22 24
months not working
Waddell, 1994
Conclusions
• IBS influenced by numerous factors – no single cause established
• Some acknowledgement that brain / mood / personality effects IBS
• Treatments focus equally on physiological and psychological
• “Fashionable” diagnoses have considerable overlap
• Environmental syndromes – sufferers often seek “organification”
• Overlap with prior depression, anxiety, and history of unexplained complaints
• Psychology plays a role in the cause, the toleration and the cure
• Society is more “Accommodating” to chronic ill-health than ever before
• Psychological assessment for the affects of IBS on the patient are important
• Longer-term IBS patients may slip into the “chronic patient role”
Some References
Corazziari E. Definition and epidemiology of functional gastrointestinal disorders. Best
Pract Res Clin Gastroenterol. 2004 Aug; 18(4):613-31.
Drossman DA. The "organification" of functional GI disorders: implications for
research. Gastroenterology. 2003 Jan; 124(1): 6-7.
Gralnek IM, Hays RD, Kilbourne AM, Chang L, Mayer EA. Racial Differences in the
Impact of Irritable Bowel Syndrome on Health-Related Quality of Life. J Clin
Gastroenterol. 2004 Oct; 38(9):782-789.
Isolauri E, Rautava S, Kalliomaki M. Food allergy in irritable bowel syndrome: new
facts and old fallacies. Gut. 2004 Oct; 53(10):1391-3.
Patrick DL, Drossman DA. Re: Groll et al.--Comparison of IBS-36 and IBS-QOL
instruments. Am J Gastroenterol. 2002 Dec; 97(12):3204
Malingering: Definition
Intentional production of false or grossly exaggerated physical or
psychological symptoms or signs
for external gain (avoiding responsibility, or obtaining financial reward
or drugs)
not a medical diagnosis but a form of deviant behaviour
ICD-10 Z76.5
Includes:
Excludes:
+ Munchhausen’s syndrome
- Somatoform disorder (hysterical conversion)
- Hypochondriasis
- Factitious Disorder – intentional production of false
or grossly exaggerated physical or psychological
symptoms or signs for internal gain (the sick role)
ICD-10 F68.1
Historical Context
Bible
Several references e.g. King David; feigns
madness when frightened by Saul’s military
success (Samuel I, 21)
Ancient Greece
Punished malingerers in the military, by death
War
Combatants feign illness to avoid battle/ hard labour
Workmen’s Compensation Act 1908
State sickness benefits, pension schemes, injury litigation
Historical Context
Epidemics of illness deception
Telegraphists’ cramp
Railway spine - Chicago
Repetitive strain disorder – Australia
Back pain and incapacity benefit – UK
Whiplash syndrome - USA
Ill health retirement
Enhancements in benefits
An estimated £3billion in UK Social Security fraud 2001
Patient Identification and Motivation
0 to 10% of consultations according to practice
Need for primary or secondary gain
4 criteria –
(i) intentional
(ii) false, exaggerated or misattributed complaints
(iii) volitional
(iv) non-trivial consequences
Custom and practice in some workplaces / industries
Entitlement
Patient Identification and Motivation
Desire to outwit those in authority
Successful malingerers are likely to repeat behaviour
Illnesses relying on subjective symptoms for diagnosis easiest to
simulate
Doctors are not trained or prepared for patient deception
Doctors and lawyers may collude either actively or passively against a
third party
Whiplash
Professional Meddling?
Professional Meddling?
Deception and the Occ Health Professional
Dynamics of the doctor - patient relationship is different
Inconsistencies in history, examination or investigations
History -
Vague details
Time lag
Incongruity between work and social impairments
Assurances of veracity
Ingratiates
Easily takes umbrage
Performance or interpersonal problems at work
Refuses rehabilitation
Self-depiction in excessively +ve terms prior to trauma
Deception and the Occ Health Professional
Examination
Sub-optimal effort
On-off muscle power
Global or inappropriate weakness
Abnormal behavioural signs (eg Waddell back pain)
Declared disability disprop. / inconsistent with pathology
(eg foot drop, reflex sympathetic dystrophy)
Non-anatomical sensory loss
(eg carpal tunnel)
Case History – 39 year old police officer
•
•
•
•
•
not worked for two years due to pain and weakness left arm
following injury at work
receiving full pay and Industrial Injury Benefit
requesting IHR with 100% injury award
diagnosed as having reflex sympathetic dystrophy
(complex regional pain syndrome type I)
•
•
held left arm in fixed adduction
analgesics guanethidine infusion EUAs x2
psychologists
physiotherapist
occupational therapist
cried during consultation
apparent allodynia
no signs of RSD
threatened suicide, complained to Trust
covert surveillance
•
•
•
•
•
Not THAT kind of Health Surveillance
Investigation
•
•
•
findings inconsistent with history or examination
scores on neuropsychiatric testing worse than random
high coefficient of variation (CV) for muscle power testing
Case History – 56 year old labourer
Not worked for 2 years
Due to non-specific back pain
Holidaying abroad and playing squash
Diagnosed with HAVS, 3V 3SN after standardised tests
Jamar dynamometer for grip strength:
right hand 19, 16, 24 kg (mean normal 46 kg) CV 21%
left hand 36, 24, 30 kg (mean normal 38 kg) CV 20%
(131 normal subjects, median CV = 4.0, 95 centile <12.1%)
Case History – 56 year old labourer
Case History – 55 year old Teacher
Seeking IHR on grounds of deafness
ENT consultation
given hearing aid
normal conversation in clinic and during audiometry testing
Case History – 46 year old FLT driver
Plastics factory
Diagnosed with occupational asthma
No symptoms or signs of asthma witnessed
Spirometry normal on 12 days in five locations
in factory and also in clinic
How ye shall identify them . . .
medical records
employment records
covert surveillance
vindictive actions
(complaints and shootings)
Often n pursuit if that “one enlightened doctor”
Vindictive Actions
Brisbane Courier Mail
26 November 1955
“Told ‘Fit for Work’ Patient Shot Doctor”
“…a few minutes before the shooting the doctor informed the man
identified as the killer that an elbow injury was healed and that he
was ready for work…”
Factitious Disorders
Beverly Allitt, 1991
Harold (Fred) Shipman, 2000
associated with women and health care workers Ben Green, 2006
simulated illness
chronic wounds
surreptitious self-medication
self-induced infections
Colin Norris, 2008
personal stresses
maladaptive coping strategy
immature, passive and manipulative personalities
confront with the evidence in a supportive way
Reich P et al Annal Int Med 1983; 99: 240-7
Pre-Employment
Screening!!!
Chutzpah!
1)
Ward sister comes to work with shaved hair and scarf round head
Declaring she has a pituitary tumour
Requiring treatment with radiotherapy
Third marriage is failing
2)
Staff nurse tells colleagues she has breast ca with only months to live
No scar – says had keyhole surgery through axilla
Leaves job after consultation and disappears
Hysterical monoparesis at previous hospital
NMC informed
Registration suspended but does not respond to letters.
Chutzpah!
3)
Gardener declares she is deaf and blind
Passed pre-employment assessment two years previously
Social services provide signer and carer
Behavioural inconsistencies at work and in clinic
Long psychiatric history to include repeated self-harm
Given hearing aid and a dog
6/60 VA but normal visual evoked potentials
Patient ambivalent to OHP’s observations tho carers and GP angry
4)
Staff nurse says she is unable to work night shifts
Due to recurrent urinary infections and urinary retention
Previous auto-renal transplant for loin pain and haematuria
Angry, manipulative and complains.
Summary
Be alert to the possibility of illness deception
Do not use the term “malingering” either verbally or in writing
Use terms such as
“inconsistencies”
“abnormal illness behaviour”
“symptoms disproportionate to objective physical findings”
“more disabled than I would expect”
The term “functional illness” is liked by patients but its meaning is
misunderstood by most
Warn employer of potential for complaints
Confirm that they want you to identify patients with illness deception
An undesirable task but part of occupational health