Funktionelle lidelser behandler vi patienterne ordentligt?

Funktionelle lidelser behandler vi patienterne ordentligt? Prof. Per Fink MD, PhD, Dr.Med.Sc.

Nej!

Reason for encounter and unmet need for care according to GPs Adequate More time in own practice Need referral to specialist n % n % n % Well-defined physical 949 95.3 20 2.0 27 2.7 Medically unexplained 119 53.6 55 24.8 48 21.6 Chi-2; p<0.001 Creed F, Henningsen P, Fink P. In Medically Unexplined Symptoms, Somatisation and Bodily Distress, Cambridge University press 2011

European prevalence rates for the last year across 21 studies (with a total of N = 65,000 subjects from national studies and N = 91,000 subjects from cross-national studies) Diagnosis (DSM- IV) Number of studies Combined N Number of combined cases 12-month prevalence range (%) Md Interquar tile range Alcohol dependence 12 60,891 2004 0.1 6.6 2.4 0.2 4.8 Illicit substance dependence 6 28,429 311 0.1 2.2 0.5 0.1 0.6 Psychotic disorders 6 27,291 231 0.2 2.6 0.8 0.2 2.0 Depression a 17 152,044 9739 3.1 10.1 6.9 4.8 8.0 Bipolar disorder 6 21,848 172 0.2 1.1 0.9 0.5 0.9 Panic disorder 12 53,597 880 0.7 3.1 1.8 0.7 2.2 Agoraphobia 11 43,489 797 0.1 10.5 1.3 0.7 2.0 Social phobia 11 43,489 1128 0.6 7.9 2.3 1.1 4.8 GAD 12 53,597 1066 0.2 4.3 1.7 0.8 2.2 Specific phobias 11 38,981 2188 0.8 11.1 6.4 3.4 7.6 OCD 9 38,886 401 0.1 2.3 0.7 0.5 1.1 Somatoform disorders 7 18,894 1215 1.1 11 6.3 2.1 7.8 Eating disorders 5 19,761 94 0.2 0.7 0.4 0.3 0.7 a Includes major depressive disorder, major depressive episode with and without diagnostic exclusions. H.Wittchen et al. Size and burden of mental disorders in Europe - a critical review and appraisal of 27 studies. European Neuropsychopharmacology 2005

Hvad er funktionelle lidelser? Fordomme og fakta.

Somatoform and related disorders ICD-10 (F45.X) Somatisation Disorder Undifferentiated SD Hypochondriacal Disorder Persistent Somato. Pain Disorder Somatoform Autonomic Dysfunction SD unspecified Dissociative Disorder Neurasthenia (F48.0) Factitious Disorder (F68.1)

Definition af somatoforme lidelser (ICD-10) gentagen forekomst af fysiske symptomer samt vedholdende anmodninger om lægelig undersøgelse på trods af, at der gentagne gange ikke er fundet noget galt og på trods af beroligelse fra læger om, at symptomerne ikke skyldes nogen fysisk sygdom. Patienterne er krævende er vedholdende kan ikke overbevises om, at de ikke fejler noget (fysisk)

We need to supply doctors with a valid diagnosis to give them an acceptable alternative to artificial syndrome diagnosis constructs. Fink and Rosendal; Current Opin in Psychiatry 2008

Editorial, JPR. Creed F, Guthrie E, Fink P, Henningsen P, Rief W, Sharpe M, White P. Møde i europæisk ekspertgruppe, maj 2009 gennemgang af termer Functional disorders and functional somatic syndromes Bodily distress disorder or bodily stress disorder Somatic symptom disorder Somatoform disorder

Definition af funktionelle lidelser (som sygdom) En funktionel lidelse er en sygdom, hvor man har fysiske symptomer, som gør det svært at fungere i dagligdagen. Den præcise årsag kendes ikke, men man kan forstå det som en sygdom, hvor hjernen og kroppen af forskellige årsager er overbelastet og ikke fungerer normalt. funktionellelidelser.dk 2011

Incidence of 10 common symptoms in 1000 internal medicine outpatients Chest pain Fatigue Dizziness Headache Edema Back pain Dyspnea Insomnia Abdominal pain Numbness Organic cause Total 0 2 4 6 8 10 12 % Kroenke & Mangelsdorff 1989

26-årig kvinde der klager over Infektionsmedicin Kronisk træthedssyndrom Almene symptomer Svimmelhed Voldsom træthed Generel utilpashed Hovedpine Koncentrations- & hukommelsesbesvær Gastroenterologisk afd. Irriteret tyktarm Mave- og tarmsymptomer Hvad fejler hun? Kvalme Opkastninger af og til Voldsomme mavekramper Halsbrand Oppustet, luft i maven, rumlen Vekslen mellem diarré & forstoppelse Reumatologisk afd. Fibromyalgi Muskel- og skeletsymptomer Smertende led Muskelsmerter Smerterne flytter sig rundt i kroppen Smerter i lænden og ned i benet Følelse af lammelse Dødhedsfornemmelse i huden Svaghedsfornemmelse Kardiologisk afd. i kroppen Ikke-hjerterelaterede brystsmerter Hjerte- og lungesymptomer Kan pludselig ikke få luft Hivende vejrtrækning Hjertebanken Trykken i brystet Sveder voldsomt PER FINK

Sygehistorie BDS, 26-årig kvinde Hun har fået diagnosen fibromyalgi og kronisk træthedssyndrom, ligesom mange andre sygdomme har været overvejet. Hun har været igennem alle tænkelige undersøgelser, selv de mest avancerede, der kun bruges i forskningsøjemed på universitetshospitalerne, men uden at et organisk grundlag er fundet. Kvinden har alarm i hjemmet samt diverse handicaphjælpemidler, og hun er tilknyttet hjemmesygeplejen. Hun står foran indstilling til pension. Ved undersøgelser stilles diagnosen somatiseringstilstand, som er den mest kroniske af de funktionelle lidelser. I dag Bodily distress syndrome, multi-organ type.

Functional somatic syndromes by speciality Gastroenterology Gynaecology Rheumatology Cardiology Respiratory medicine Infectious diseases Neurology Dentistry Ear, nose and throat Allergy Irritable bowel syndrome (IBS), non-ulcer dyspepsia Pelvic arthropathy, premenstrual syndrome, chronic pelvic pain Fibromyalgia, lower back pain Atypical or non-cardiac chest pain, syndrome-x Hyperventilation syndrome Chronic fatigue syndrome (CFS, ME) Tension headache, pseudo-epileptic seizure Temporomandibular joint dysfunction, atypical facial pain Globus syndrome Multiple chemical sensitivity (MCS)? Electricity hypersensitivity? Infrasound hypersensitivity Orthopaedics Anaesthesiology Psychiatry WAD whiplash ass. disorder Chronic benign pain syndrome Somatoform disorders, Neuroastenia, Dissociative (conversion)

The existence of specific somatic syndromes is largely an artefact of medical spezialization Wessely S et al., Lancet 1999

BODILY DISTRESS DISORDER / SYNDROME

Bodily distress syndrome = BDS Suggested diagnostic criteria No Yes Organ systems 3 Cardiopulmonary /autonomic arousal Palpitations, heart pounding, precordial discomfort, breathlessness without exertion, hyperventilation, hot or cold sweats, trembling or shaking, dry mouth, churning in stomach, butterflies, flushing or blushing 3 Gastrointestinal arousal Frequent loose bowel movements, abdominal pains, feeling bloated, full of gas, distended, heavy in the stomach, regurgitations, constipation, nausea, vomiting, burning sensation in chest or epigastrium 3 Musculoskeletal tension Pains in arms or legs, muscular aches or pains, feelings of paresis or localized weakness, back ache, pain moving from one place to another, unpleasant numbness or tingling sensations 3 General symptoms Concentration difficulties, impairment of memory, fatigue, headache, dizziness 1. Types 1. Multi-organ type >=3 symptoms from 3-4 organ systems 2. Single-organ type >=3 symptoms from 1-2 organ systems 2. Moderate to severe impairment (ICD-11 PC) 3. Relevant differential diagnoses ruled out (ICD-11 PC) 4. Duration > 6 mdr. (ICD-11 PC) Latent Class analyse: Test of model fit; Pearson s χ 2 (14)=16.35, p=0.2923 Fink P et al. Psychosomatic Medicine 2007 ICD-11 PC draft

Symptom clusters or factors in patients presenting with medically unexplained symptoms (exploratory and interview-based studies only) Cluster Robbins et al 1997 (prim.care, CIDI) N=686 Gara et al 1998 (prim.care, CIDI,DIS) N=1456 Liu et al 1997 (gen popul.dis) N=3000 Simon et al 1996 (prim.care, CIDI) N=? Fink et al 2007 (prim.care, SCAN) N= 986 Rosmalen et al 2011 (gen popul.) N= GI + + + + + Musc.skel./pain + + + + + + CP +* + + + + GU - + (+) - (+) Neurological - + + - Others + + - - High hierarchy cluster (i.e. multisympt.) na + + na + + * somatic anxiety Schröder & Fink J Psychosom Res 2009

Any somatoform disorder n=178 n=10 3.7 % n=8 2.9 % Any functional somatic syndrome n=220 Overall diagnostic agreement kappa 0.86 n=12 4.4 % n=4 1.5 % Explored functional somatic syndromes: fibromyalgia chronic fatigue syndrome n=148 54.4 % irritable bowel syndrome non-cardiac chest pain n=30 11.0 % n=60 22.1 % hyperventilation syndrome pain syndrome (e.g. low back pain or chronic pelvic pain) Bodily distress syndrome, n=250 Fink P. & Schröder A. J Psychosom Res 2010

Implications for new classification Bodily distress syndrome Severe (multi-organ system type) Moderate (single-organ system type) CP type GI type (incl. IBS) MS type (incl. Fibromyalgia) Others Health anxiety Others Factitious disorder (incl. Münchhausen s syndrome) Secondary to other mental disorder? Fink P et al. Psychosomatic Medicine 2007 Fink P. & Schröder A. J.Psychosom Res 2010

Fibromyalgia Wars Wolfe: J Rheumatol 2009 FM diagnosis offers short-term legitimacy and social benefit to patients Pharmaceutical companies, the pharmaceutical-academic complex, attorneys, and patient support groups have strong interests in continuing FM But their influence has distorted scientific and public information and institutions.

Annonce i Århus Onsdag

ETIOLOGY There are many causes for functional disorders.

Årsager Sårbarhed: Biologiske, psykologiske og sociale Arv, social indlæring, tidligere sygdom, seksuelle overgreb Sygdom Kronisk sygdom PER FINK PROF., DR.MED., PH.D.

Stress Cardio-pulmonary arousal Bodily distress Autonomic arousal & HPA axis hyperactivity Gastro-intestinal arousal Unspecific sensitivity to bodily symptoms General stress response Muskulosceletal tension

Biological factors Increased symptom production Pathological central processing and modulation of body signals

Årsager Sårbarhed: Biologiske, psykologiske og sociale Arv, social indlæring, tidligere sygdom, seksuelle overgreb Udløsende faktorer: Infektion eller anden fysisk sygdom Fysisk eller psykisk traume, stress eller belastning Lægen Tilfældigt fund ved undersøgelse Sygdom Vedligeholdende faktorer: Uhensigtsmæssige antagelser om symptomer og sygdommen Uhensigtsmæssig sygdomsadfærd Øget følsomhed af hjernen Sundhedssystemet Social og økonomisk afhængighed Kronisk sygdom PER FINK PROF., DR.MED., PH.D.

Consequenses Low health-related quality of life High use of health care Loss of working years due to sick leave, disability pension etc.

Part one; Somatoform disorder and multiple symptoms Sick leave and work disability in primary care patients 1. with somatoform disorders (SD) 2. with multiple symptoms 3. compared with patients with a well-defined Rask M et al., submitted

Somatoform disorders & multiple symptoms No multiple symptoms or somatoform disorder according to SCAN. Other main problem Well-defined according to physical FP disease (n=492) (n=833) Based on SCAN interview and FP rating of main problem (n=1785) Multiple symptoms (n=84) Somatoform disorders (n=183) Rask M et al., 33 submitted

Characteristics at index consultation Somatofo rm Multiple Referen p symptom ce Age (mean) disorder 41.4 n=84 38.5 n=833 37.7 p<0.01 Female (%) n=183 78.1 58.3 59.2 ns Labour market drop-out (%) Available 79.2 90.5 93.3 p<0.00 Disability 19.1 8.3 3.5 1 pension Age 1.6 1.2 3.5 Chronic retirement illness Comorbidity (%) (%) 61.3 34.5 23.8 p<0.00 1 Depression 14.8 15.5 0.8 p<0.00 Anxiety 29.0 9.5 1.7 p<0.00 1 SF-36 (median) 1 Physical 42.5 50.9 51.9 p<0.00 health Mental health 44.4 42.0 56.5 p<0.00 1 1 34 Rask M et al., submitted

Labour market drop-out during ten years of follow-up Rask M et al., submitted 35

Paper III Risk of new awards of full or partial disability pension during ten years of follow-up Hazard ratios Reference (95%CI) group (n=775) Multiple symptoms Somatoform (n=76) disorder (n=145) Crude Adjusted* 1 1 2.15 2.28 4.04 (1.08;4.27) (1.14;4.55) 3.26 (2.55;6.40) (1.93;5.51) *Adjusted: Age, gender, chronic illness, major depressive episode, anxiety disorder and intervention Rask, M. et al. submitted 36

Treatment of functional disorders

Udfordringer Sikre patienter med funktionelle lidelser den samme behandlingskvalitet som alle andre patienter.

Bodily Distress Syndrome Assumption The patients misinterprete normal physical sensations as indication of severe disease Preoccupation with their physical health and bodily sensations High health care use frequent attenders Reality The case in health anxiety but not in BDS. The patients have their symptoms Suffering from symptoms The patients cannot get any help or explanations A problem of the health care system It is a chronic illness The same spectrum as in other disorders/diseases Unresponsive to therapy The symptoms represent a (disguised) mental disorder Quite good treatment results even in the chronic group The problem is physical symptoms. It is a distinct disorder of its own

Misforhold mellem patientens forventninger og det lægen tilbyder Hvad patienten vil Kende årsagen Have forklaringer og information Have råd og behandling Have beroligelse Tages seriøst af en forstående og kompetent læge Ønsker emotionel støtte Hvad patienten får Ingen diagnose Dårlige forklaringer, der ikke omhandler deres behov eller bekymringer Utilstrækkelige råd Manglende beroligelse En følelse af, at lægen er uinteresseret eller mener symptomerne ikke er vigtige Ingen emotionel støtte

Funktionelle tilstande et spektrum 6 mdr. Normale fysiologiske reaktioner Forbigående symptomer Lette funktionelle symptomer Bodily distress syndrome = BDS Let grad af funktionelle symptomer Svær grad af funktionelle symptomer

Den somatiske afdelings/læges rolle i behandlingen af patienter med funktionelle lidelser Ekskludér (inden for rimelighedens grænser) somatisk lidelse eller skader, der kan behandles. Giv på empatisk måde patienten klar besked om, at der er/ikke er fundet tegn på organisk sygdom inden for ens eget speciale. Forklar patienten, at der ikke er lægelig indikation for flere somatiske undersøgelser. Sober og professionel behandling. Stil diagnosen funktionel tilstand (eller lignende betegnelse). Undgå at påføre patienten skader eller gøre denne mere syg. Forsøg at respondere på patientens udtalte og uudtalte spørgsmål og forventninger. Koordiner behandlingen med egen læge og evt. andre behandlere, patienten er i kontakt med. Overvej henvisning til psykiatrisk vurdering eller specialenhed. Se i øvrigt råd ved kroniske tilstande. Modificeret efter Fink P. Somatoforme lidelser og funktionelle syndromer. Med Kompendium 17 (in press)

www.funktionellelidelser.dk PER FINK PROF., DR.MED., PH.D.