Transcript Diapositiva 1 - WordPress.com

2nd
CME
Psychosomat
ic disorders
Headache
Insomnia
Pain Disorder
Doct. Jean-louis Aillon
04-11-10
Psychosomatic disorders
(Psychological factors affecting medical condition)
A general medical condition (coded on Axis III) is present.
B. Psychological factors adversely affect the general medical
condition in one of the following ways:
• the factors have influenced the course of the general medical
condition as shown by a close temporal association between
the psychological factors and the development or exacerbation
of, or delayed recovery from the general medical condition
• the factors interfere with the treatment of the general medical
condition
• the factors constitute additional health risks for the individual
• Stress-related physiological responses precipitate or exacerbate
symptoms of the general medical condition
Our datas
Association with Mental disorders
Association with Depression
Prevalence of sintoms
Gastric pain/problems: 58 pz:19,3 %
Headache: 40pz 13,3%
Pain how long? 29,2 months
Headache
Clinical assesment
• TIME: onset, frequency, patterns, duration
• CHARACTER: site, intensity, nature of pain
• CAUSES: predisposition, triggering,
aggravating, releaving factors
• RESPONSE: patient actions and limitations
during an attack, medications used
• INTERVALS: how does patient feel between
attacks; concern, anxieties and fears about
attacks
Chronic Headache
1.Migraine
2.Tension-type Headache
Migraine
World prevalence of migraine:
A disorder of First
World
Switzerland 13%
Denmark 10%
France 8%†
USA
12%
Italy 16%
Chile 7%
†Prevalence measured over a few years
Japan 8%
 1-year prevalence rates
 Population-based studies
 IHS criteria (or modified)
Rasmussen and Olesen (1994); Rasmussen (1995);
Lipton et al (1994); Lavados and Tenhamm (1997);
Sakai and Igarashi (1997)
Recognizing Migraine
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Pounding unilateral headache
Preceded by visual or other aura
Nausea, vomiting
Light and sound sensitivity
What is migraine?
Migraine without aura (MO)
At least five attacks fulfilling these
criteria:
• Headache lasting 4–72 h
(2–48 h in children)
• With at least two of:
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–
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unilateral location
pulsating quality
moderate/severe intensity
aggravated by activity
• Accompanied by at least one of:
– nausea
– vomiting
– photophobia and/or
phonophobia
• No evidence of organic disease
Migraine with aura (MA)
At least two attacks fulfilling these
criteria:
• At least three of the following:
– one or more fully reversible
aura symptoms
– gradually developing or
sequential aura symptoms
– no one aura symptom lasts
longer than 1 h
– headache shortly follows or
accompanies aura
• No evidence of organic disease
Headache Classification Committee of IHS (1988)
Aura
• Transient hemianopic disturbances prior to
headache, lastin 10-30 minutes (occasionally
up to 1 hour)
• A spreading scintillating scotoma (patiens may
draw a jagged crescent)
• Other reversibile focal neurological
disturbances (e.g. unilateral paraesthesiae of
hand, arm or face)
Diagnosis of migraine
• Diagnosis depends on patient history
• No specific tests or clinical markers
• Positive diagnosis if attack history fulfils IHS
criteria for migraine
Stress
Depression
Anxiety
Menopause
Head or neck traum
• Other pointers include:
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family history of migraine
age of onset <45
presence of aura
menstrual association
• Organic disease must be excluded
Cady (1999); Warshaw et al (1998)
Trigger
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Relaxation after stress
Change in habit: sleep, travel etc..
Bright lights/ loud noise
Diet: alcohol, cheese, citrus fruits, possibly
chocolate, missed or delayed meals
• Strenuous unaccustomed exercise
• Mestruation
WORRISOME HEADACHE RED
FLAGS
“SNOOP”
Systemic symptoms (fever, weight loss) or
Secondary risk factors (HIV, systemic cancer)
Neurologic symptoms or abnormal signs (confusion,
impaired alertness, or consciousness)
Onset: sudden, abrupt, or split-second
subarachnoid
hemorrhage (SAH)
venous sinus thrombosis,
arterial dissection, or
raised intracranial
pressure.
Older: new onset and progressive headache, especially
in middle-age >50 (giant cell arteritis)
Previous headache history: first headache or different
(change in attack frequency, severity, or clinical features)
Prevalence of migraine by
sex and age
Migraine prevalence (%)
30
Females
Males
25
20
15
10
5
0
20
30
40
50
60
Age (years)
70
The American Migraine Study (n=2479 migraine
80
100
Lipton and Stewart (1993)
Physiology
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Vasospasm – Lance
Spreading Wave of Depression – Leao
Trigeminocentric
Allodynia
Trigeminal Theory
• Serotonin again
• Trigeminal Afferents: sensory function of face
and meninges
• Trigeminal efferents to vessels
• Cause vessel spasm and sensitivity
• This theory primarily explains action of
Triptans: 5-HT 1b,d agonists
Vasospasm
• I. Aura: Arteries Spasm
– Visual and focal neurological symtoms
– Pial and Occipital small artery branches
• II. Headache: Compensatory Vasodilation
– Pounding unilateral sick headache
• III. Inflammation and muscle spasm: second
pain phase
Treatment
• Effective treatment of attack
• Prevention
• Address comorbidities
1 step
• Oral Analgesics
Paracetamol
Metoclopramide
Aspirin
Ibuprofen
Naproxen
±
Antiemetic
Domperidone
2 Step
Parenteral Analgesics
Diclofenac
Also suppositories
±
Antiemetic
Metoclopramide
Domperidone
Paracetamol 1 g Tid
3 Step
• Rizatriptan
• Contraindication:
Uncontrolled Hypertension
Risk factors for CHD or CVD
Children under 12
Diagnose ad-exiuvantibu
Mechanisms for treatment
Trigeminal
nerve
INHIBITION
5-HT1D
5-HT1F
CGRP triptan
NK
SP
CGRP
calcitonin gene
related peptide
NK
neurokinin A
SP
substance P
CONSTRICTION5-HT1B
Blood vessel
Adapted from Goadsby (1997)
Emergency
• Diclofenac IM
Or
• Clorpromazine IM
Prophilaxys
Atenolol
Even combined
in serious cases
Depression, another chronic pain, Disturbed Sleep, TTH
Tension-type headache (TTH)
• Episodic
• Chronic
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Bilateral
Also every day
No nausea or photophobia
No pulsation
Treatment
1) infrequent episodic TTH (-2 days/week)
Paracetamol, aspirine, ibuprofen
or Codeine
2) Chronic TTH
Sintomatic treatment only for short time
Consider a course of Naproxen
Prophilaxis with Amitriptiline (10-75 mg nocte)
Non drug intervention for
Migraine and TTH
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Improving physical fitness
Physiotherapy
Acupunture
Psychological therapy
Relaxation
Stress reduction
Coping Strategies
Biofeedback
Phisiotherapy and CBT
Relaxation exercise (once or twice a day)
Sit down on a comfortable armchair in a quiet room. Let the mandible drop in a
position of maximum relaxation for about 10-15 minutes. Apply warm pads on cheeks
and shoulders.
Posture exercises
8-10 times every 2-3 hours
1) Keep an erect position with the
tallons, the hips and the nape against the
wall. While the rest of the body does not
move bring the shoulders into contact
with the wall and release, rhythmically
2) While body and head are kept
against the wall, make horizontal
movements of the
head, forwards and backwards
3) After having cupped the hands behind the neck,
performs stretching movements of the head
backward, with forward counterpressure from the
hands. Relax after 2-3 seconds.
Visual feedback
Place colored labels in strategic sites to remind to keep muscle contraction at a normal level.
An Insomnia Typology
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Difficulty falling asleep
anxiety
Difficulty staying asleep
Depression, PTSD
Waking too early
Non-restorative poor quality sleep
Insomnia Mechanisms
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Disorders of circadian rhythms
Disordered homeostatic drive for sleep
Disordered sleep mechanisms
Dyssomnias & Parasomnias
Disordered arousal mechanisms
Medical & psychiatric disorders
Substance/medication-induced disorders
Sleep Disorder Classification
• Dyssomnias are disorders of initiating & maintaining
sleep, with Excessive Daytme Somnolence (EDS) – 3
types: intrinsic, extrinsic, and circadian
• Parasomnias - characterized by abnormal behavior
or physiological events at specific stages or sleepwake transitions, involving inappropriate activation
of autonomic & motor systems – usually with both
normal restful sleep & REM Latency, and without
EDS
Dyssomnias - Intrinsic
• Primary Insomnia – Psychophysiologic and
Idiopathic
• Narcolepsy
• Sleep Apnea
• Periodic Limb Movements
• Restless Legs Syndrome
Dyssomnias - Extrinsic
• Inadequate sleep hygiene
• Environmental sleep disorder
• Secondary to toxins & substance dependence
Dyssomnias - Circadian
• Time zone changes (jet lag)
• Shift work
• Changes in sleep phase – advanced & delayed
Parasomnias
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Sleep Terrors
Somnambulism
Nightmares
REM Sleep Behavior Disorder
Jactatio Capitis Nocturna
Bruxism
Enuresis
Medical & Psychiatric Causes
of Sleep Disorders
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Hyperthyroidism
Arthritis or any other painful condition
Chronic lung or kidney disease
Cardiovascular disease (heart failure, CAD)
Heartburn (GERD)
Neurological disorders (epilepsy, Alzheimer’s, headaches,
stroke, tumors, Parkinson’s Disease)
Diabetes
Pain Syndromes
Menopause
Cluster Headaches
Major Depression
Bipolar Disorder
Seasonal Affective Disorder
PTSD, anxiety
Common drugs that can cause
insomnia
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Alcohol
Caffeine/chocolate
Nicotine/nicotine patch
Beta blockers
Calcium channel
blockers
• Bronchodilators
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Corticosteroids
Decongestants
Antidepressants
Thyroid hormones
Anticonvulsants
High blood pressure
medications
Therapy of insomnia
1) Non-drug treatments
• Cognitive-behavioral therapy (CBT)
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Stimulus control
Cognitive therapy
Sleep restriction
Relaxation training
Sleep hygiene
How to keep track of your sleep
• Daily sleep diary or sleep log
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Bedtime
Falling asleep time
Nighttime awakenings
Time to get back to sleep
Waking up time
Getting out of bed time
Naps
Cognitive Therapy
• Identify beliefs about sleep that are incorrect
• Challenge their truthfulness
• Substitute realistic thoughts
False beliefs about insomnia
• Misconceptions about causes of insomnia
– “Insomnia is a normal part of aging.”
• Unrealistic expectations re: sleep needs
– “I must have 8 hours of sleep each night.”
• Faulty beliefs about insomnia consequences
– “Insomnia can make me sick or cause a mental
breakdown.”
• Misattributions of daytime impairments
– “I’ve had a bad day because of my insomnia.”
– I can’t have a normal day after a sleepless night.”
More common myths about
insomnia
• Misconceptions about control and
predictability of sleep
– “I can’t predict when I’ll sleep well or badly.”
• Myths about what behaviors lead to good sleep
– “When I have trouble getting to sleep, I should
stay in bed and try harder.”
Sleep Restriction - best if done
with a professional
• Cut bedtime to the actual amount of time you
spend asleep (not in bed), but no less than 4
hours per night
• No additional sleep is allowed outside these
hours
• Record on your daily sleep log the actual
amount of sleep obtained
Sleep Restriction (cont’d)
• Compute sleep efficiency (total time asleep
divided by total time in bed)
• Based on average of 5 nights’ sleep efficiency,
increase sleep time by 15 minutes if efficiency
is >85%
• With elderly, increase sleep time if efficiency
>80% and allow 30 minute nap.
Stimulus Control - You can do
this on your own
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Go to bed only when sleepy
Use the bed only for sleeping
If unable to sleep, move to another room
Return to bed only when sleepy
Repeat the above as often as necessary
Get up at the same time every morning
Do not nap
Relaxation training
• More effective than no treatment, but not as effective
as sleep restriction
• More useful with younger compared with older adults
• Engage in any activities that you find relaxing shortly
before bed or while in bed
– Can include listening to a relaxation tape, soothing music,
muscle relaxation exercises, a pleasant image
Exercise relaxion for insomnia and
anxiety
1) Take a deep breath. Breathe in through your nose and visualize the air moving down
to your stomach. Breathe out slowly through your mouth. As you breathe in again,
silently count to four. Purse your lips as you exhale slowly. This time count silently
to eight.
Repeat this process six to ten times.
2)Lay on your back on the floor with your feet slightly apart, your hands by your
sides, and your palms turned upward. Close your eyes and concentrate on every part
of your body.
Begin at the top of your head and work your way down to your toes.
Start by feeling your forehead tense, then your eyes, face, and jaw. Tense and
release each muscle group, such as your shoulders and neck.
Pay attention to each area of your body from the top of your head, down through
the trunk of your body, along your legs, and ending at the tips of your toes.
Stay in this relaxed condition for a few minutes. Concentrate on your breathing and
let all worry and stress dissipate from your mind and body. Make sure that your
breathing comes from deep in your stomach and flows slowly and evenly.
Stretch slowly before standing up.
Healthy sleep habits
(sleep hygiene)
• Avoid alcohol, nicotine, caffeine, chocolate
– For several hours before bedtime
• Cut down on non-sleeping time in bed
– Bed only for sleep and satisfying sex
• Avoid trying to sleep
– You can’t make yourself sleep, but you can set the stage for
sleep to occur naturally
• Avoid a visible bedroom clock with a lighted dial
– Don’t let yourself repeatedly check the time!
– Can turn the clock around or put it under the bed
More healthy sleep habits
• Expose yourself to bright light at the right time
– Morning, if you have trouble falling asleep at night
– Night, if you want to stay awake longer at night
• Establish a regular sleep schedule
– Get up at the same time 7 days a week
– Go to bed at the same time each night
• Exercise every day - exercise improves sleep!
• Deal with your worries before bedtime
– Plan for the next day before bedtime
– Set a worry time earlier in the evening
More healthy sleep habits
• Adjust the bedroom environment
– Sleep is better in a cool room, around 65 F.
– Darker is better
– If you get up during the night to use the bathroom, use
minimum light
– Use a white noise machine or a fan to drown out other
sounds
– Make sure your bed and pillow are comfortable
– If you have a partner who snores, kicks, etc., you may have
to move to another bed (try white noise first)
Farmacotheraphy for sleep disorders
Benzodiazepine
1) Difficult fall asleep, no anxiety during day
Ultra short-acting: Zolpidem 5-10 mg PO nocte
Less Dependence, Sedation
Short-acting: Alprazolam: 0,25 mg nocte, up to 2 mg
2) Early weakening:
Long acting: Diazepam: 2,5 mg PO nocte, up 5-10
mg .
Lowest effective dose for as short a period as possible (maximum 4
weeks)
better only when need it
Lower doses are generally advised in children and adolescents.
Contraindications:
1) VALIUM: Pregnancy and Breast feeding, Miastenia gravis, respiratory insuffic
2) ALPRAZOLAM, ZOLPIDEM: Pregnancy and Breast feeding
Somatoform disorders
“Hysteria”
Somatization Disorder
Conversion Disorder
Pain Disorder
Hypochondriasis
Body Dysmorphic Disorder
Dissociative Disorders (Amnesia,Fugue, identity, depersona
Histrionic Personality Disorder
Somatoform symptoms
• Symptoms suggest a physical disorder
• Symptoms cannot adequately be explained
physiologically
• Symptoms are often (but not always) described
in dramatic ways
• Other disorders, such as anxiety disorders,
mood disorders, and personality disorders,
often co-exist
Pain Disorder
• Main symptom is pain
• May be exacerbated by psychosocial factors
• May be maintained by gain: Eugene
– Primary gain
– Secondary gain
Unconscious conflict?
• Theraphy:
Psychological Therapy
Amitriptiline low dosage: 25 mg nocte
Somatization Disorder (Briquet’s
syndrome)
• Many physical complaints
• Beginning before age 30
• Must include
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Four different pains
Two gastrointestinal symptoms
One sexual symptom
One pseudoneurological symptom
• Symptoms are unfounded or exaggerated
Conversion Disorder
• Physical symptoms suggesting neurological
problems
– Sensory impairment: Any modality
– Paresthesias and paralysis (demonstrate)
• Sudden onset, sudden termination, sudden
reappearance
• Mostly women; men in combat
• Often misdiagnosed: Overpathologized
• La belle indifference: 1/3 of cases
Sometimes like epilectis convulctions
Hypochondriasis
• No physical symptoms are necessary
• Preoccupied with the possibility that normal
sensations are symptoms of serious disease
• Frequent visits to physicians
• Persists despite medical reassurance
• Over-report bodily sensations
Body Dysmorphic Disorder
• Excessive concern with real or imagined
defects in appearance, especially facial marks
or features.
• Frequent visits to plastic surgeons
• Culturally-influenced, but not culture-bound
• May be a symptom of more pervasive
disorders: Obsessive-compulsive or delusional
disorder, for example.
Asante sana for your
attention
http://www.who.int/mental_health/management/psychotropic/en/index.ht
Utopia lies at the horizon. When I draw nearer by two steps, it retreats two
steps. If I proceed ten steps forward, it swiftly slips ten steps ahead. No
matter how far I go, I can never reach it. What, then, is the purpose of
utopia? It is to cause us to advance.”
For any suggestion: [email protected]
0735525429
Eduardo Hughes Galeano