Tuesday, May 5, 2009

Toilet ...

3 comments:

  1. This is clearly designed as exercise for those of Prof Weasly's patients who somatise IBS & M.E. as the same aberrant illness belief!

    What a considerate, caring, thoughtful doctor he is to have designed this treatment after years of intensive scientific research.

    It saves on lithium prescriptions when they are all cured too! Praise be to Prof Weasel & his cronies!

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  2. Detection of herpes viruses and parvovirus b19 in gastric and intestinal mucosa of chronic fatigue syndrome patients.

    Journal: In Vivo. 2009 Mar-Apr;23(2):209-13.

    Authors: Fr=E9mont M, Metzger K, Rady H, Hulstaert J, DE Meirleir K.

    Affiliation: Protea Biopharma, Z.1-Researchpark 100, 1731 Zellik, Belgium


    NLM Citation: PMID: 19414405


    BACKGROUND: Human herpesvirus-6 (HHV-6), Epstein-Barr virus and parvovirus B19 have been suggested as etiological agents of chronic fatigue syndrome but none of these viruses is consistently detected in all patients. However, active viral infections may be localized in specific tissues, and,
    therefore, are not easily detectable. The aim of this study was to investigate the presence of HHV-6, HHV-7, EBV and parvovirus B19 in the gastro
    -intestinal tract of CFS patients.

    PATIENTS AND METHODS: Using real-time PCR, viral DNA loads were quantified in gastro-intestinal biopsies of 48 CFS patients and 35 controls.

    RESULTS: High loads of HHV-7 DNA were detected in most CFS and control bi
    opsies. EBV and HHV-6 were detected in 15-30% of all biopsies. Parvovirus
    B19 DNA was detected in 40% of the patients versus less than 15% of the
    controls.

    CONCLUSION: Parvovirus B19 may be involved in the pathogenesis of CFS, at
    least for a subset of patients. The gastro-intestinal tract appears as an important reservoir of infection for several potentially pathogenic viruses.

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  3. http://www.psychiatrictimes.com/dsm-v/article/10168/1171223?pageNumber=3D=
    2

    01 August 2008
    Psychiatric Times. Vol. 25 No. 9
    Special Report

    PSYCHIATRY AND MEDICAL ILLNESS
    Unexplained Physical Symptoms
    What's a Psychiatrist to Do?

    Humberto Marin, MD and Javier I. Escobar, MD

    Dr Marin is assistant professor in the department of psychiatry and Dr Es=
    cobar
    is associate dean of global health and professor of psychiatry and family
    medicine at the University of Medicine and Dentistry of New Jersey-Robert=
    Wood
    Johnson Medical School in New Brunswick. Dr Marin reports that he has rec=
    eived
    research support from Eli Lilly and Pfizer. Dr Escobar reports that he ha=
    s no
    conflicts of interest concerning the subject matter of this article.

    The psychogenic view generally considered somatic presentations as ancill=
    ary
    manifestations of psychological discomfort. The more direct and pragmatic
    approach to somatization that would eventually lead to the atheoretical f=
    rame of
    modern nomenclatures began with French psychopathologist Pierre Briquet,3=
    who,
    in 1859, brought an observational or experiential perspective to the stud=
    y of
    hysteria during the golden age of French psychopathology. His description=
    of a
    syndrome inclusive of multiple motor and sensorial symptoms (pseudoneurol=
    ogical
    symptoms) made possible the separation of somatization from conversion.

    In the 1950s, a group of investigators at Washington University-Renard Ho=
    spital
    in St Louis resurrected Briquet's concept of hysteria in several clinical
    studies. They formulated criteria for the diagnosis of hysteria that requ=
    ired
    the presence of a specified number of symptoms from a comprehensive list =
    that
    included physical and psychological manifestations, personality traits, a=
    nd
    behavioral expressions, in addition to the neurological symptoms from the
    traditional French definition.4,5

    With a few modifications, these were the criteria for somatization disord=
    er
    proposed by Feighner and colleagues6 in 1972 in their seminal paper, "Dia=
    gnostic
    Criteria for Use in Psychiatric Research." After Robert Spitzer and his
    colleagues7 coined the term "somatoform disorder" (inclusive of the Greek=
    soma
    and the Latin form), it officially entered American and world psychiatric
    terminology with the publication of the International Classification of D=
    iseases
    criteria in the late 1970s and the DSM-III in the 1980s.

    Somatoform Disorders in DSM

    Following the publication of DSM-III in the 1980s, somatization disorder =
    (SD)
    became the key somatoform diagnosis. In DSM-III and its subsequent revisi=
    ons, SD
    turned into a simple somatic symptom list that contracted or expanded rat=
    her
    capriciously. Partly because the atheoretical perspective of DSM discarde=
    d any
    presumptions of causality, other manifestations of the syndrome were not
    included in the criteria.

    The list of somatoform disorders kept expanding with the addition of vagu=
    e
    categories, such as "undifferentiated somatoform disorder" or "somatoform
    disorder NOS [not otherwise specified]," which, unfortunately, are the mo=
    st
    common diagnoses within the somatoform genre. These terms failed to trans=
    cend
    specialty boundaries. Perhaps as a corollary of turf issues, general medi=
    cine
    and medical specialties started carving these syndromes with their own to=
    ols.
    The resulting list of "medicalized," specialty-driven labels that continu=
    es to
    expand includes fibromyalgia, chronic fatigue syndome, multiple chemical
    sensitivity, and many others (Table 1).

    Table 1

    Functional somatic syndromes34

    Irritable bowel syndrome

    Chronic fatigue syndrome

    Fibromyalgia

    Multiple chemical sensitivity

    Nonspecific chest pain

    Premenstrual disorder

    Non-ulcer dyspepsia

    Repetitive strain injury

    Tension headache

    Temporomandibular joint disorder

    Atypical facial pain

    Hyperventilation syndrome

    Globus syndrome

    Sick building syndrome

    Chronic pelvic pain

    Chronic whiplash syndrome

    Chronic Lyme disease

    Silicone breast implant effects

    Candidiasis hypersensivity

    Food allergy

    Gulf War syndrome

    Mitral valve prolapse

    Hypoglycemia

    Chronic low back pain

    Dizziness

    Interstitial cystitis

    Tinnitus

    Pseudoseizures

    Insomnia

    Systemic yeast infection

    Total allergy syndrome


    These labels fall under the general category of functional somatic syndro=
    mes and
    seem more acceptable to patients because they may be perceived as less
    stigmatizing than psychiatric ones. However, using DSM criteria, virtuall=
    y all
    these functional syndromes would fall into the somatoform disorders categ=
    ory
    given their phenomenology, unknown physical causes, absence of reliable m=
    arkers,
    and the frequent coexistence of somatic and psychiatric symptoms.
    Epidemiology

    Medically unexplained physical symptoms are extremely common in adults. T=
    hey are
    more frequently seen in females, in persons from lower socioeconomic
    backgrounds, and in certain ethnic groups. These symptoms are also fairly=
    common
    in childhood and adolescence; a recent study showed that 10% of children
    surveyed had unexplained headaches, 9% had unexplained abdominal pain, an=
    d 4%
    had unexplained pain in the extremities.8

    The Epidemiological Catchment Area Survey of Mental Disorders in the Unit=
    ed
    States reported that fewer than 0.1% of respondents met strict DSM-III cr=
    iteria
    for SD, and about 5% met criteria for abridged SD, a less restrictive con=
    struct
    of somatization.9 In Germany, about 20% of a community sample met criteri=
    a for
    undifferentiated SD, but very few (about 1%) met criteria for the more sp=
    ecific
    somatoform disorders.10

    The prevalence of unexplained physical symptoms is much higher in primary=
    care
    and medical specialty settings. A World Health Organization (WHO) study a=
    t 14
    primary care sites in Asia, Europe, and the Americas showed that the rate=
    s for
    abridged SD differed widely across countries. They were lowest in Nigeria
    (7.6%), Italy (8.9%), and the United States (9.8%) and highest in Germany
    (25.5%), Brazil (32%), and Chile (36.8%).11

    In a North American study, patients with SD reported spending an average =
    of 8.8
    days sick in bed per month, compared with half a day for those without th=
    e
    disorder. More than 80% of patients with SD stopped working because of "p=
    oor
    health" and their per capita yearly health costs were 9 times higher than
    average.12 A study of patients with SD who attended a university outpatie=
    nt
    service in London showed that 61% were receiving disability benefits, 64%=
    had
    been treated for spurious physical disorders, 60% had had surgeries with =
    no
    pathology found, and 16% were using either wheelchairs or crutches withou=
    t any
    evidence of organic disorder.13

    Unexplained physical symptoms tend to have a chronic, protracted course. =
    For
    example, in the South London Somatization Study, most patients had a chro=
    nic
    unremitting course. About 80% of these persons still qualified for a soma=
    toform
    diagnosis 4 years later.14 A follow-up in the WHO study showed that, 1 ye=
    ar
    later, somatization persisted in about half of the patients.11

    The causes of SD are multifactorial. Although no consistent biological (b=
    rain)
    markers have been documented, genetic factors may play a role. Findings f=
    rom
    studies of adopted females with SD suggest excessive alcoholism or violen=
    t
    behavior in the biological fathers.15 More recent studies have shown that=
    there
    is familial clustering of functional syndromes such as fibromyalgia.16 A =
    large
    number of studies have shown a frequent association between unexplained p=
    hysical
    symptoms and early traumatic experiences; medical illness with long
    hospitalizations; serious medical illness of a parent; natural disasters;=
    or
    psychological factors such as sensitization processes, specific cognitive
    styles, or benefits derived from the sick role (secondary gain).17-23

    The most common psychiatric conditions that coexist with unexplained phys=
    ical
    symptoms are major depression, anxiety, substance use, personality disord=
    ers,
    and posttraumatic stress disorders.24 Averaging data from several studies=
    , about
    two-thirds of patients with unexplained symptoms also met criteria for at=
    least
    one of these psychiatric disorders and a large portion of the remaining
    one-third, who did not fully meet the criteria, had significant symptoms,=
    mainly
    depression or anxiety.25

    Diagnosing and Managing SD

    Not surprisingly, patients with unexplained physical symptoms are first s=
    een by
    primary care or nonpsychiatric specialists, who usually make the initial
    diagnosis. Unfortunately, only about 1 of 4 primary care physicians ackno=
    wledge
    feeling confident about their ability to treat these patients. The percen=
    tage of
    primary care practitioners who report confidence in managing other mental
    disorders, such as depression or anxiety disorders, is much higher.26

    Assisting primary care providers through instructional sessions and manua=
    ls or
    simply by using a consultation letter has proved to be useful.27,28 Refer=
    ral of
    these patients to mental health services is generally unsuccessful unless=
    proper
    bridges between primary and mental health care are built. This requires p=
    atient
    preparation, careful teamwork, and the presence at the primary care site =
    of
    trained mental health personnel.

    Because of the high level of discomfort associated with unexplained sympt=
    oms, to
    be told that "there is no physical problem" is disconcerting to many pati=
    ents.
    For the provider, however, finding no physical abnormality generally brin=
    gs a
    sense of relief. In building a good therapeutic relationship, it is impor=
    tant
    for the therapist not to downplay the patient's discomfort at being told =
    "there
    is no problem" or "your symptoms are all psychological." As in any other =
    field
    of medicine, empathy and acknowledging the patient's distress are essenti=
    al
    ingredients for a sound therapeutic relationship. Table 2 provides a step=
    wise
    list of suggestions for communicating a diagnosis of SD to the patient.

    Table 2

    Communicating a diagnosis of somatoform disorder

    1. Convey clearly, succinctly, and in a positive, supportive way that the
    physical examinations and laboratory tests show no physical abnormality
    2. Tell the patient that he or she has a relatively common disorder with =
    no
    clear basis but which may cause severe discomfort and dysfunction
    3. Explain that despite the lack of physical findings, the physical sympt=
    oms are
    not intentionally produced and cannot be eliminated by an act of will
    4. Let the patient know that there are treatments that can provide relief=
    but
    require the close collaboration of the patient and all health care provid=
    ers
    5. Do not use psychological or psychodynamic terminology or jargon (eg, d=
    enial,
    resistance) because most of these patients are not psychologically minded

    If properly communicated, the diagnosis of SD may offer relief and encour=
    agement
    to the patient. For example, in a recent study, patients with unexplained
    symptoms felt that receiving such a diagnosis after a time of worry and
    uncertainty was an important factor in successfully managing the disorder=
    .29

    Regular patient visits should be scheduled (eg, monthly or bimonthly)
    independent of fluctuations in symptoms. Treatment goals must be concrete=
    ,
    stepwise, and realistic. Do not aim for an all-or-nothing result, but con=
    sider a
    gradual and incremental response. The goal is to progressively decrease
    emergency visits and calls.

    A routine examination is recommended at every visit to reassure the patie=
    nt and
    to ensure that there are no physical abnormalities (remember that paranoi=
    d
    people may have real enemies). However, no new tests or consultations sho=
    uld be
    ordered unless there is a clear indication. Rather than reassuring patien=
    ts,
    unwarranted consultations or tests may feed their belief that they have a
    serious physical illness.

    During the visit, the patient can be allowed to play the "sick role." All=
    ow him
    or her to verbalize complaints and concerns without entering into needles=
    s
    arguments on issues related to the reported symptoms. The objective is no=
    t to
    negate the symptoms but to improve functionality and well-being. Briefly =
    discuss
    current stress factors and other important circumstances, and make sure t=
    he
    patient understands that the unexplained symptoms are elements of a
    biopsychosocial illness. Table 3 presents a list of goals to work toward.

    Table 3

    Suggested goals in treatment of somatoform disorder

    . Encourage the patient to decrease or (ideally) stop making emergency
    department visits
    . Address specific psychiatric comorbidities, such as depression, anxiety=
    ,
    alcohol or substance use disorders, and other lifestyle measures (eg, die=
    t,
    excessive use of stimulants, smoking)
    . Improve sleep with sleep hygiene measures and, if necessary, add a brie=
    f
    course of nonaddictive hypnotic medication
    . Address fatigue with an aerobic exercise program (eg, walking, jogging,
    biking, swimming) at least 4 days a week but ideally, every day; exercise=
    should
    be sustained rather than intensive (a half hour walk is better than sprin=
    ting or
    lifting weights for 10 minutes) and should start at a comfortable level f=
    or the
    patient
    . Discourage secondary gains such as missing work or class or avoiding ho=
    me
    chores

    Treatment Options

    Evidence is rapidly growing for the usefulness of modified cognitive-beha=
    vioral
    therapies for somatoform syndromes.30,31 A comprehensive model successful=
    ly
    applied in several studies included relaxation training, behavioral manag=
    ement,
    cognitive restructuring, emotion identification, emotion regulation, and
    interpersonal skills training.32 Other types of psychotherapy have not be=
    en
    tested in well-controlled studies. However, it is our impression that int=
    ensive
    or exploratory therapies that focus on internal conflict and mental chang=
    e may
    be counterproductive.

    As mentioned, mental disorders such as significant depression and anxiety=
    are
    common in those with SD and should be specifically addressed. However, th=
    ere is
    no clear evidence from randomized clinical trials demonstrating the effic=
    acy of
    psychotropic drugs for the treatment of unexplained physical symptoms. Th=
    e
    benefit observed in some studies has been attributed to the effect of
    medications on anxiety or depressive symptoms and not to a direct effect =
    on
    somatic symptoms.

    On the basis of our clinical experience, patients with SD accompanied by
    significant depression and anxiety symptoms can be initially treated with=
    an
    SSRI or a serotonin norepinephrine reuptake inhibitor. Mirtazapine seems =
    to be a
    reasonable first option for patients with unexplained symptoms who have
    significant insomnia or anorexia because of the drug's positive effects o=
    n sleep
    and appetite. In patients with significant fatigue/sleepiness or poor
    concentration, or those in whom the avoidance of sexual adverse effects i=
    s
    paramount, bupropion may be a good first-line agent.

    Because patients with SD may be at a heightened risk for addiction or
    dependence, caution must be exercised when prescribing medications with
    addictive potential, such as opiate analgesics and tranquilizers such as
    benzodiazepines. In patients with SD, pain complaints are very common and
    include headaches, and joint, abdominal, and pelvic pain. NSAIDs should b=
    e used
    whenever possible for pain relief.

    FDA-Approved Medications

    The anticonvulsant pregabalin and the antidepressant duloxetine have been
    recently approved for the treatment of fibromyalgia. Pregabalin has analg=
    esic
    properties, especially for neuropathic pain, and has also shown some anti=
    anxiety
    effects in randomized clinical trials. Duloxetine, a dual action antidepr=
    essant,
    also seems to exert some analgesic properties similar to those reported f=
    or
    other dual action drugs as well as tricyclic antidepressants.

    Lufriprostone has been approved for clinical use in irritable bowel sympt=
    oms
    alternating with chronic idiopathic constipation syndromes. This drug app=
    ears to
    exert a laxative action by increasing the secretion of chloride and fluid=
    in the
    intestinal epithelium.

    Fluoxetine, paroxetine, and sertraline have been approved for the treatme=
    nt of
    premenstrual dysphoric disorder/premenstrual syndrome, which have a numbe=
    r of
    somatic manifestations and also include anxiety and depression symptoms. =
    A
    recent meta-analysis found that all SSRIs seem to be about equally helpfu=
    l for
    premenstrual symptoms, their continuous use is better than intermittent u=
    se, and
    their clinical effect on symptoms seems to be relatively small.33

    The Future Definition of SD

    As we prepare for the new edition of DSM-V, we suggest the following:

    . Consider a dimensional approach for unexplained physical symptoms with
    differences in severity.
    . Avoid further expansion of somatoform categories and the mechanistic co=
    unt of
    symptoms and systems. There is a need for evidence-based, inclusive, and =
    simpler
    definitions.
    . Do not devalue the psychological, cultural, and social aspects in patie=
    nts
    with somatoform disorders; instead, emphasize their character as complex
    expressions of distress and sickness.
    . Do not subordinate somatic presentations to other mental disorders or t=
    o
    purely mental mechanisms. Acknowledge the unique and independent nature o=
    f
    somatoform disorders.

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