Hvornår skal man overveje om patienten har en funktionel lidelse?
Program Velkommen Hvad er en funktionel lidelse? Fakta om bodily distress syndrom I almen praksis den nyeste forskning Diagnostisk udredning gør det ikke i sig selv! Tak fordi I medvirkede
Lene Toscano del 1 HVAD ER EN FUNKTIONEL LIDELSE?
Definition Funktionelle Lidelser - En sygdom, hvor man er belastet af fysiske gener, som gør det svært at fungere i dagligdagen - Ingen oplagte patologiske fund, som kan forklare symptomerne - Man kan forstå det som en tilstand, hvor hjernen og kroppen er overbelastet og ikke fungerer normalt
Funktionelle syndromer (Lancet 1999) Gastroenterologi Colon irritabile, non-ulcus dyspepsi Gynækologi Kroniske bækkensmerter Reumatologi Fibromyalgi Kardiologi Atypiske/non-kardiogene brystsmerter Lungemedicin Hyperventilationssyndrom Infektionsmedi Kronisk træthedssyndrom (CFS, ME) Neurologi Spændingshovedpine, pseudo-epileptiske anfald Tandlæge Temporomandibulær dysfunction, atypiske ansigtssmerter Øre, næse, hals Globulus syndrom Allergologi Duft- og kemikalieoverfølsomhed (MCS) Ortopædkirurgi Kronisk whiplash, WAD whiplash ass. disorder Anæstesiologi Kronisk smertesyndrom Psykiatri Somatoforme tilstande, neuroasteni, dissociative tilstande
Anna Budtz-Lilly: Den nyeste forskning! FAKTA OM BDS I ALMEN PRAKSIS
Forskningsdiagnose Etablerede diagnoser Bodily distress syndrome Svær Moderat Somatoforme lidelser Funktionelle syndromer Let Symptom diagnoser Symptom diagnoser: fx. træthed, hovedpine, svimmelhed Funktionelle syndromer: fx. colon irritabile, fibromyalgi, kronisk træthedssyndrom Rask, 2013
Diagnosekriterier: 1) 3 symptomer fra en af grupperne eller 4 symptomer i alt 2) Funktionspåvirkning 3) Relevante differentialdiagnoser udelukket Nej Ja Symptomgruppe 3 symptomer fra Hjerte & Lunger 3 symptomer fra Mave & Tarm 3 symptomer fra Muskler & Led 3 Almene Symptomer 4 symptomer fordelt på Symptomgrupperne Fink et al., 2007
Single organ BDS Multi organ BDS Fink et al., 2007
Table 1.2 Symptom clusters or factors in patients presenting with bodily distress Study Simon et al. (1996) (8) Liu et al. (1997) (45) Robbins et al. (1997) (46) Gara et al. (1998) (44) Fink et al. (2007) (7) Rosmalen et al. a (2011) (47) Kroenke et al. (1998) (48) Lee et al. (2011)(49) Whitthöfft et al. (2012) (55) n=na n=3000 n=686 n=1456 n=978 n=964 n=1000 n=3014 n=414 b, n=308 c Assessment intrument CIDI DIS CIDI CIDI, DIS SCAN CIDI PHQ-15 PHQ-15 PHQ-15 Symptom cluster Setting Gastrointestinal Symptom cluster Primary care General population Primary care Primary care Primary care, neurological, internal medicine General population Primary care General population Gastrointestinal + - + + + + + + + Musculoskeletal/pain Musculoskeletal/pain + + + + + + + + + Cardiopulmonary Cardiopulmonary + - + d + + + + + + Fatigue/ general - + - - + - + Fatigue/ general Neurological + + - - - + - Urogenital - (+) - + (+) - - Neurological Headache - - - + - - - - General population, primary care, CIDI, Composite International Diagnostic Interview; DIS, Diagnostic Interview Schedule; SCAN, Schedules for Clinical Assesment in Neuropsychiatry; PHQ, Patient Health Questionnaire. Urogenital a Confirmatory analyses of 3 and 4 factor models previously reported by Kroenke et al. and Fink et al. b General population. c Primary care. d Somatic anxiety Headache
Table 1.2 Symptom clusters or factors in patients presenting with bodily distress Simon et al. (1996) (8) Study Simon et al. (1996) (8) Liu et al. (1997) (45) Robbins et al. (1997) (46) Gara et al. (1998) (44) Fink et al. (2007) (7) Rosmalen et al. a (2011) (47) Kroenke et al. (1998) (48) Lee et al. (2011)(49) Whitthöfft et al. (2012) (55) n=na n=3000 n=686 n=1456 n=978 n=964 n=1000 n=3014 n=414 b, n=308 c Assessment intrument CIDI DIS CIDI CIDI, DIS SCAN CIDI PHQ-15 PHQ-15 PHQ-15 Setting Symptom cluster Liu et al. (1997) (45) Robbins et al. (1997) (46) Gara et al. (1998) (44) Fink et al. (2007) (7) n=na n=3000 n=686 n=1456 n=978 n=964 CIDI DIS CIDI CIDI, DIS SCAN CIDI Primary care General population Primary care Primary care General Primary care population Primary care Primary care Rosmalen et al. a (2011) (47) Primary care, neurological, internal medicine General population Primary care Primary care, neurological, internal medicine General population General population Gastrointestinal + - + + + + + + + Musculoskeletal/pain + + + + + + + + + Cardiopulmonary + - + d + + + + + + Fatigue/ general - + - - + - + Neurological + + - - - + - Urogenital - (+) - + (+) - - Headache - - - + - - - - General population, primary care, CIDI, Composite International Diagnostic Interview; DIS, Diagnostic Interview Schedule; SCAN, Schedules for Clinical Assesment in Neuropsychiatry; PHQ, Patient Health Questionnaire. a Confirmatory analyses of 3 and 4 factor models previously reported by Kroenke et al. and Fink et al. b General population. c Primary care. d Somatic anxiety
Table 1.2 Symptom clusters or factors in patients presenting with bodily distress Study Simon et al. (1996) (8) Liu et al. (1997) (45) Robbins et al. (1997) (46) Gara et al. (1998) (44) Fink et al. (2007) (7) Rosmalen et al. a (2011) (47) Kroenke et al. (1998) (48) Lee et al. (2011)(49) Whitthöfft et al. (2012) (55) n=na n=3000 n=686 n=1456 n=978 n=964 n=1000 n=3014 n=414 b, n=308 c Assessment intrument CIDI DIS CIDI CIDI, DIS SCAN CIDI PHQ-15 PHQ-15 PHQ-15 Setting Symptom cluster Primary care General population Primary care Primary care Kroenke et al. (1998) (48) Primary care, neurological, internal medicine General population Primary care Lee et al. (2011)(49) General population Gastrointestinal + - + + + + + + + Musculoskeletal/pain + + + + + + + + + Cardiopulmonary + - + d + + + + + + Fatigue/ general - + - - + - + Neurological + + - - - + - Urogenital - (+) - + (+) - - Headache - - - + - - - - General population, primary care, CIDI, Composite International Diagnostic Interview; DIS, Diagnostic Interview Schedule; SCAN, Schedules for Clinical Assesment in Neuropsychiatry; PHQ, Patient Health Questionnaire. a Confirmatory analyses of 3 and 4 factor models previously reported by Kroenke et al. and Fink et al. b General population. c Primary care. d Somatic anxiety Whitthöfft et al. (2012) (55) n=1000 n=3014 n=414 b, n=308 c PHQ-15 PHQ-15 PHQ-15 Primary care General population General population, primary care,
Table 1.2 Symptom clusters or factors in patients presenting with bodily distress Study Simon et al. (1996) (8) Liu et al. (1997) (45) Robbins et al. (1997) (46) Gara et al. (1998) (44) Fink et al. (2007) (7) Rosmalen et al. a (2011) (47) Kroenke et al. (1998) (48) Lee et al. (2011)(49) Whitthöfft et al. (2012) (55) n=na n=3000 n=686 n=1456 n=978 n=964 n=1000 n=3014 n=414 b, n=308 c Assessment intrument CIDI DIS CIDI CIDI, DIS SCAN CIDI PHQ-15 PHQ-15 PHQ-15 g y pp y y pp y pp p Symptom cluster Setting Symptom cluster Primary care General population Primary care Primary care Primary care, neurological, internal medicine General population Primary care General population Gastrointestinal + - + + + + + + + Musculoskeletal/pain + + + + + + + + + Cardiopulmonary + - + d + + + + + + Fatigue/ general - + - - + - + Neurological + + - - - + - Urogenital - (+) - + (+) - - Headache - - - + - - - - General population, primary care, Gastrointestinal + - + + + + + + + Musculoskeletal/pain + + + + + + + + + Cardiopulmonary + - + d + + + + + + Fatigue/ general - + - - + - + CIDI, Composite International Diagnostic Interview; DIS, Diagnostic Interview Schedule; SCAN, Schedules for Clinical Assesment in Neuropsychiatry; PHQ, Patient Health Questionnaire. a Confirmatory analyses of 3 and 4 factor models previously reported by Kroenke et al. and Fink et al. b General population. c Primary care. d Somatic anxiety
Fælles diagnose Explored functional somatic syndromes: fibromyalgi kronisk træthedssyndrom iritabel tyktarm ikke kardiogene brystsmerter hyperventilationssyndrom smertesyndrom (f. eks. lændesmerter eller kroniske bækkensmerter) Fink P. & Schröder, 2010
Eksklusionskriterie Afhængig af lægen forståelse og tilgang Dualistisk Overlap i sygdoms-definitionerne Udviklet i højt selekterede patientpopulationer Milde lidelser bliver ikke dækket Fink P, Rosendal M (2008). Recent developments in the understanding and management of functional somatic symptoms in primary care. Curr Opin Psychiatry 21, 182-188. Hansen HS, Rosendal M, Oernboel E, Fink P (2011). Are medically unexplained symptoms and functional disorders predictive for the illness course? A two-year follow-up on patients' health and health care utilisation. J Psychosom. Res. 71, 38-44. 17
Indeks konsultation Baseline 2 år Tidslinie Praktiserende læger Patienter Registre Patienter
Resultater 1/6 har BDS Efter to år 50% fortsat BDS
Resultater Dårligt fysisk og psykisk helbred Læger><patienter Ofte angst og depression Social marginalisering Stort sundshedsforbrug
Medicinforbrug Antal AP patienter Antal BDS + N n % of N Crude OR Justeret OR* (95%CI) 1356 230 17.0 Opioider 132 52 39.4 3.8 3.6 (2.2;5.7) Protonpumpehæmmere 160 50 31.3 2.6 2.1 (1.3;3.3) *Justeret for alder, køn, boform, uddannelsesniveau, arbejdsmarkedstilknytning, angst og depression
Cardiopulmonary Gastrointestinal Musculoskeletal General Budtz-Lilly, 2015
Risiko for flexjob/førtidspension, 10 års follow-up Hazard ratios (95%CI) Crude Justeret* Reference 1 1 BDS, single organ 5.8 (3.6 ; 9.3) 4.9 (2.8 ; 8.4) BDS, multi organ 8.0 (3.8 ; 16.9) 8.7 (3.7 ; 20.7) *Justeret for alder, køn, kronisk lidelse, angst, depression og intervention Mette Rask, 2014
Perspektiver Forbedret diagnosticering Skærpet fokus på funktionelle lidelser Diagnosen omsat til praksis
Lene Toscano del 2 DIAGNOSTISK UDREDNING GØR DET IKKE I SIG SELV!
Funktionelle lidelser -et spektrum
Symptom Differentialdiagnose Funktionel lidelse/ Bodily distress syndrome Somatisk sygdom Lokalisering Vag, diffus, skiftende Veldefineret, konstant lokaliseret Intensitet Vag, uklart definerede niveauer, få variationer, ofte maksimal hele tiden Veldefinerede ændringer og niveauer i intensiteten Periodicitet Diffus, vanskeligt afgrænsbare Typisk veldefinerede perioder med forværring eller forbedring Antallet Behandling og medicin Talrige, ofte fra flere organsystemer Ofte ingen eller kun forbigående effekt af symptomspecifik medicinsk eller kirurgisk behandling Få, veldefinerede Ofte god effekt af symptomspecifik medicinsk eller kirurgisk behandling Symptomerne er Udtryk for en ændret perception (central sensibilisering) Udtryk for (strukturelle) patologiske forandringer i de berørte organer
Boom and bust
Ætiologi og udvikling
Multifaktorielt bio-psyko-socialt
Zone modellen
Gradueret genoptræning
Mere viden? Hjemmeside: www.funktionellelidelser.dk E-læring: www.laeger.dk Kurser: Lægeforeningen, 12-mandsforeninger kommuner, hospitaler mm.
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