Transcript OTH

Field test version-1.00 May 2012
DO NOT UPLOAD ON THE INTERNET
Base Course
Other Significant
Emotional or Medically
Unexplained Complaints
(OTH)
Contents (Other Complaints)
A. Introduction 5 min
B. Learning objectives
C. Key actions
1. Establish communication and build trust 8 min
2. Conduct assessment 15 min
3. Plan and start management 55 min
4. Link with other services and supports 3 min
5. Follow up 3 min
Total time: 90 min
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Introduction
• OTH = Other Significant Emotional or Medically Unexplained
Symptoms
• OTH involves common conditions not covered in the mhGAPIG
• "Medically unexplained" means "no underlying physical
condition can be identified"
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What is covered in OTH?
• “Normal” distress/sub-threshold disorders
– i.e. symptoms do not amount to a clear diagnosis
• Medically unexplained somatic complaints when these are
not part of moderate severe depression
• Some mental disorders not covered in mhGAP-IG
– Adjustment disorder
– Somatoform disorder
– Mild depression, dysthymia
– Anxiety disorders
Note:. mhGAP OTH does not differentiate among the above.
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Somatic presentations in primary care setting.
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The single most common reason why mental illness goes undetected in PHC
It often occurs in conjunction with physical disease processes.
George Cheyne 250y ago saw its association with dysphoric affect
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Once established,
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However somatisation can occur in the absence of dysphoria
it secures advantages from spouse, family and employers;
it tends to be encouraged by MDs - differentially reward somatic symptoms.
Somatic presentation seems to have three functions
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it allows people who are unsympathetic to psychological illness, or who live in
cultures where mental illness is stigmatised, to nonetheless occupy the sick-role while
psychologically unwell
it is blame-avoiding: instead of being responsible for the mayhem, one is cast in the
role of the suffering victim.
by reducing blame, it appears to save patients from being as depressed as they
might otherwise have been.
J Psychosom Res. 1988;32(2):137-44.
Somatic presentations of psychiatric illness in primary care setting.
Goldberg DP, Bridges K.
biological substrates
for somatoform disorders
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somatoform disorders may hide an undiagnosed disease.
four ways in which unrecognized diseases get labeled as somatoform
disorders:
 missed diagnoses (in a small sample of fatigued breast cancer patients, 40%
had undiagnosed thyroid disease);
 new diagnostic tests reveal surprisingly prevalent diseases (e.g., celiac disease,
once considered rare and diagnosed primarily in childhood is quite common);
 new insights about fatigue and pain (e.g., sleep disruption contributes to pain
and fatigue);
 new, previously unknown diseases are discovered (e.g., SARS, hepatitis C).
Joel Dimsdale, MD (La Jolla, CA)
Ricardo Araya MD (Bristol, UK)
association of somatoform disorders and common mental disorders in
community and primary care settings
THE absence of a medical explanation should not confer automatic psychiatric labeling.
it is impossible not to approach depression and anxiety without considering the presence of
unexplained physical symptoms.
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1) somatoform disorders are highly comorbid with depression and anxiety in most
community and primary care studies
a small group of individuals present with a somatoform disorder alone;
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2) in the WHO-PHC study, mood, anxiety, and somatoform symptoms loaded into one
common factor ('internalizing' disorders) in all countries surveyed
3) a large longitudinal community survey in Germany found there was marked mobility
over time between somatoform diagnostic categories.
Diagnosis-related research planning conference focusing on Somatic presentations of mental disorders in Beijing, China, on September 6-8, 2006
Prepared by Michael B. First, M.D., DSM Consultant to the American Psychiatric Institute for Research and Education (APIRE)
http://www.dsm5.org/Research/Pages/SomaticPresentationsofMentalDisorders(September6-8,2006).aspx
Features of assessment and
management of OTH
Management (safe & simple)
• Avoid medications
• Give psychosocial support
• Follow up
• Refer as needed
Assessment
• Is based on excluding
physical causes
• Is based on excluding
mhGAP priority disorders
• Will not identify a specific
syndrome
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Knowledge and skills necessary before
receiving training on the OTH module
• Ability to rule out any physical condition
– OTH is not used if a physical condition fully explains the
symptoms
• Ability to identify or rule out moderate-severe depression
– OTH is not used in the presence of moderate-severe
depression
• Ability to suspect mhGAP priority disorders
– OTH is not used when there are mhGAP priority disorders
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Contents (Other Complaints)
A. Introduction
B. Learning objectives
C. Key actions
1. Establish communication and build trust
2. Conduct assessment
3. Plan and start management
4. Link with other services and supports
5. Follow up
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Learning objectives
• To be able to assess for Other Significant Emotional or
Medically Unexplained Complaints (OTH)
• To be able offer basic psychosocial support
• To be able to avoid (self-)medication
• To be able to manage unexplained somatic symptoms
• To be able to follow up and refer appropriately
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Contents (Other Complaints)
A.
B.
C.
Introduction
Learning objectives
Key actions
1. Establish communication and build trust
2. Conduct assessment
3. Plan and start management
4. Link with other services and supports
5. Follow up
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What can be difficult when communicating with
people with OTH
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They may insist on tests and medications
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They may take a lot of time
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You may become frustrated
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Your attempts to help may fail
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How can we build trust
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Try not to judge the person or yourself
Make the person feel welcome and accepted
Listen carefully
Do not dismiss the person's concerns
Acknowledge that the symptoms are real
Be conscious of your feelings in case you become frustrated
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Contents (Other Complaints)
A.
B.
C.
Introduction
Learning objectives
Key actions
1. Establish communication and build trust
2. Conduct assessment
3. Plan and start management
4. Link with other services and supports
5. Follow up
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Process of assessment
Does the presentation
suggest a priority condition
according to the master chart?
NO
End assessment
Go to relevant module(s)
Conduct assessment according to the module
Identify the condition and treatment
Develop a management plan
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If the person is presenting
with multiple possible
conditions, all must be
assessed.
Assessment
Tasks to identify OTH
Rule out physical conditions
How?
Medical history
Physical examination
Rule out moderate-severe
depression
Ask first 3 questions in DEP
module (mhGAP-IG, p. 10)
Rule out mhGAP priority
disorder
Check Master Chart
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In case of OTH, there are 3 possible clinical scenarios
Scenario
1 OTH General
2 OTH Prominent somatic symptoms
3 OTH Recent trauma and loss
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Case 1: Ms Sousa
1.
2.
3.
Ms Sousa, 34-years old, presents with severe anxiety and
occasionally headaches. After your history and physical
exam, you do not suspect any physical condition. She
reports during the interview that her life has been boring
recently.
When using the mhGAP-IG, what is the first step
Go to the master chart, which suggests the need to assess
for depression.
What is the next step
Go to the depression module
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Ms Sousa does not have moderate-severe
depression. What is the next step
Tasks to identify OTH
How?
Rule out physical conditions
Medical history
Physical examination
Rule out moderate-severe
depression
Ask first 3 questions in DEP
module (mhGAP-IG, p. 10)
Rule out mhGAP priority
disorder
Check Master Chart
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Ms Sousa has (OTH). Which scenario fits Ms Sousa
Scenario
1 OTH General
2 OTH Prominent somatic symptoms
3 OTH Recent trauma and loss
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Case 2: Mr Assad
Mr. Assad, 25 years old, sees you for the first time reporting
abdominal bloating and excess gas
• He has seen two other doctors who investigated
• They both concluded it must be “nerves”
• The last doctor prescribed vitamins
• Mr. Assad wants another opinion
•
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Mr Assad (continued)
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He asks for blood tests and ideas for further investigation
Your assessment does not suggest a physical condition
Mr. Assad insists on tests and “some kind of medication”
He does not have depression
You do not suspect any of the other mhGAP priority
conditions
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Which scenario applies to Mr Assad
Scenario
1 OTH General
2 OTH Prominent somatic symptoms
3 OTH Recent trauma and loss
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Contents (Other Complaints)
A.
B.
C.
Introduction
Learning objectives
Key actions
1. Establish communication and build trust
2. Conduct assessment
3. Plan and start management
4. Link with other services and supports
5. Follow up
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Three OTH management scenarios
(open mhGAP-IG, p. 80-81)
Scenario
Management
1 OTH General
p 80: 3rd col. 3rd box
2 OTH Prominent somatic symptoms
p 80: 3rd col. 3rd box
+
p 81: 3rd col. 1st box
3 OTH Recent trauma and loss
p 80: 3rd col. 3rd box
+
p 81: 3rd col. 2nd box
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Managing scenario 1: General
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Avoid inappropriate medications
• Correct inappropriate self-medication
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Do not prescribe
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Antidepressants
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Benzodiazepines
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Placebos
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Irrelevant injections or treatments (e.g. vitamins)
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These medications can have significant side effects and
contribute to the person's idea of being sick
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How to identify and manage
psychosocial stressors
• Offer the person an opportunity to talk in private
• Ask about current stressors
• Assess for abuse (e.g. domestic violence) and neglect
• Brain storm together for solutions or for ways of coping
• Involve supportive family members as appropriate
• Encourage involvement in self-help and family support groups
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How to identify and manage psychosocial stressors
in children and adolescents
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Group discussion: What would you do for Mr Assad?
This will be taken up as a forum on the VC
• Would you prescribe a blood test and a colonoscopy to
reassure Mr. Assad?
• Would you dismiss Mr. Assad's request and prescribe an
antidepressant because it seems to be all in his head?
• Would you prescribe placebo vitamins to calm him down?
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Managing Scenario 2: Prominent Somatic symptoms
• Same as for the scenario for psychological symptoms
– Address inappropriate self-medication
– DO NOT prescribe antidepressants, benzodiazepines,
injections or vitamins
– Address psychosocial stressorss
• In addition, mhGAP–IG offers some specific advice on how to
manage somatic symptoms
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Managing unexplained somatic symptoms
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Acknowledge that the symptoms are real
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This action helps to build trust
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Ask the person to explain the symptoms with questions
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Ask "What might be causing these sensations?"
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Explain that pain can be related to emotions due to the
stress hormones that are released
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Ask "Are there problems in your life causing you stress?"
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Managing unexplained somatic symptoms
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Avoid unnecessary tests, referrals and medications
• You would contribute to people's idea that they are sick
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Even if all results are normal, do not disregard symptoms
• The person in your room still needs help
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Tell the person to come back if symptoms worsen
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Case 3
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Mr. Granflor
Slides 37 – 51 are not in the original slide kit provided by the
WHO.
We have added these slides to introduce the notion of anxiety
disorders and their overlap with unexplained somatic
complaints
We also wanted to specifically discuss trauma-related somatic
symptoms.
Case 3
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Mr. Granflor
This 36 y.o. does road works and an excavation caved in,
killing his partner and injuring him.
He presents 2 weeks later with some lateralized motor deficits,
GI complaints, severe headaches, and insomnia.
Neurological exam reveals neurological findings explaining
only the motor deficits but not the other complaints
He is hyperalert, and describes waking up at night with cold
sweats, gasping for air and with his heart racing.
He keeps re-imagining the accident and this worsens his
abdominal pain and intense headaches.
He has been unable to do almost anything in the past weeks.
Diagnosis: Anxiety
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Fear or Worry
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Inappropriate thoughts or actions
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Unexplained somatic complaints
Diagnosis: Anxiety – step 1
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General medical condition?
Substance induced
 Alcohol?
 Drugs?
 Medication?
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Due to other mental disorders?
Anxiety – Not so severe
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Anxiety is due to psychosocial stressor (e.g. not due to
physical causes)
Anxiety is still more severe than expected
Adjustment
 With
disorder
anxiety, depressed, or behavioural changes
Anxiety – Very severe
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Recurring anxiety attacks
Panic
 Can
attack or disorder
occur with other anxiety disorders
Anxiety with Traumatic Re-experiencing:
Brief or Prolonged?
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Re-experiencing highly traumatic events
<
4 weeks:
Acute
>
Stress Disorder
4 weeks:
Post
Traumatic Stress Disorder
Which scenario applies to Mr Assad
Scenario
1 OTH General
2 OTH Prominent somatic symptoms
3 OTH Recent trauma and loss
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Treatment of Anxiety Disorders
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Psychotherapy:
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Support and psychoeducation are very useful
Cognitive behavioral therapy can be indicated
Group therapy for some disorders
Pharmacologic is not always indicated
If you use pharmacotherapy, only do so for the short-term
 If symptoms remain, consult a specialist
 Benzodiazepines: high potential for tolerance and abuse; if
used, do so carefully and for short periods < 2 weeks
 Also used are SSRIs, B-blockers (for specific performance anxiety)
and TCAs

Kessler et al. Arch Gen Psychiatry 1995;52:1048
Kessler et al. Arch Gen Psychiatry 1994;51:8
Panic
Disorder
PTSD
30
25
20
15
10
5
0
Any
Anxiety
Disorder
Lifetime Prevalence (%)
Prevalence of Anxiety Disorders
Algorithm: Anxiety
Re-experience
traumatic events
Fear, avoidance:
Phobias
Anxiety
General medical
condition
Anxiety
Substance
Induced
Other mental
disorders
Recurrent anxiety
attacks:
Panic attacks
Obsessions,
compulsions
OCD
E.g.: adjustment
disorder
< 4 weeks
Acute Stress
Disorder
> 4 weeks
PTSD
Post-Traumatic Stress Disorder
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Literature states up to 25% of those experiencing trauma
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Symptoms “often begin immediately after the event”
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~30% of all Vietnam war veterans
Watch for the 1-month criterion
Can be delayed for many years, however
Core symptoms
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Re-experience traumatic event
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Avoidance of reminders of trauma
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Vivid and distressing
People, situations, circumstances, memories
Other symptoms
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Hypervigilance
Exaggerated startle responses
Difficulty concentrating
Recognizing PTSD
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Screening for PTSD using debriefing must not be routine
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For high-risk populations only
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Screen using a short questionnaire 1 month after disaster
Note people who have symptoms
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If mild and < 4 weeks, simply use watchful waiting
Follow up these people in 1 month
Contents (Other Complaints)
A.
B.
C.
Introduction
Learning objectives
Key actions
1. Establish communication and build trust
2. Conduct assessment
3. Plan and start management
4. Link with other services and supports
5. Follow up
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What community supports are available?
• In case of
– Domestic violence
– Unemployment
– Bereavement
– Caring for a person with mental, neurological or substance
use disorder
Note: people with major stressors in their life are more
likely to have a range of mental health problems,
especially OTH
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Contents (Other Complaints)
A.
B.
C.
Introduction
Learning objectives
Key actions
1. Establish communication and build trust
2. Conduct assessment
3. Plan and start management
4. Link with other services and supports
5. Follow up
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Follow up
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Regular follow up is essential
The person may have an as yet undiagnosed disorder
The person may need referral if things are not improving
Regular follow up helps the person feel secure and may
reduce presentations to your clinic
• Regular follow up builds trust
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What would you do at follow up
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Ask about well-being and symptoms
Explore psychosocial stressors
Discuss problems and brainstorm for solutions
Link with other available support resources
Assess progress and refer as needed
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Refer
•
•
If there is no improvement
If the person of family asks for more intense treatment
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Key messages
• OTH is a guide to managing mental health symptoms that do
not meet criteria for a mhGAP priority condition
• Always take a medical history and do a physical exam
• Do not prescribe placebos, benzodiazepines or antidepressants
• Offer basic psychosocial support and follow up regularly
• Refer if people do not improve or want more intense treatment
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