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Psychiatric Approach to Morgellons Disease and Other Poorly Defined

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Psychiatric Approach to Morgellons Disease and Other Poorly Defined Somatopsychic, Psychosomatic or Multisystem Illness Bursting the Bubble: Challenging the Misconceptions and Misdiagnoses of Neuropsychiatric and Pathogen-Triggered Disorders: AONM Robert C Bransfield, MD, DLFAPA London, England Nov 18, 2018 Disclosure Statement Robert Bransfield, MD, DLFAPA • Patients pay me money in return for trying to help them and this is most of my income. • I have no contract with any insurance company or other payer that might restrict or alter patient care in return for referring patients or providing other benefits. • I do not have any financial arrangements or affiliations with any commercial entities whose products, research or services may be discussed in these materials. Outline • Case presentation • What Causes Illness and Mental Illness? • Brain & Body Interaction • DSM-5 Definitions • ICD-11 • Making the Diagnosis • Consequences of Diagnostic Errors • Discussion & Summary • Conclusion Case Presentation Case Presentation: History • The patient is an 18 y/o white female with multiple symptoms who had previously been adept at Taekwondo. She had a bulls eye rash, a Bell’s palsy, became increasingly debilitated over 4 years, was in a wheel chair and had seizure episodes. • Prior diagnoses included “wanting attention,” fibromyalgia, chronic fatigue, hypoglycemia and pseudoseizures. Case Presentation: symptoms • The major symptoms included cognitive impairments (attention, memory, processing speed, concentration/executive functioning), tactile hypersensitivity, sun sensitivity, orthostatic hypertension, weight loss fatigue, non-restorative sleep, pelvic pain, difficulty urinating, headaches peripheral neuropathy, muscle atrophy, cervical radiculopathy, hair loss costochondritis, subluxation of multiple joints and generalized pain. Case Presentation: Lab • Lyme IgG Wb: 93 and 41 and IgM 41 • Lyme IgG Wb: 31 IND, 34 IND, 39+, 41+, 56+ IGeneX • HGE IGM + 1:20 • ANA 1:640, later negative • EBV VCA IGG AB 1.44 (0.0-0.9), EBV nuclear AB (EBNA) IGG 3.36 (0.0-0.9) • Parvovirus b19 (IGG) 5.9 (0.0-0.89) • Brain SPECT: moderate to severe decreased cerebrocortical perfusion, heterogeneous pattern Case Presentation: Diagnosis? • A) Somatic symptom disorder • B) Hysterical conversion reaction • C) Bodily distress syndrome • D) Medically unexplained symptoms • E) Factitious disorder (Munchausen’s) • F) Lyme borreliosis • G) Other medical condition(s) • H) Other medical condition(s) and Lyme borreliosis Case Presentation: Diagnosis? • A) Somatic symptom disorder • B) Hysterical conversion reaction • C) Bodily distress syndrome • D) Medically unexplained symptoms • E) Factitious disorder (Munchausen’s) • F) Lyme borreliosis • G) Other medical condition(s) • H) Other medical condition(s) and Lyme borreliosis Case Presentation: Diagnosis • The diagnosis was late stage Lyme borreliosis with multisystemic symptoms, porphyria, Ehlers-Danlos/ALPIM syndrome (Anxiety-Laxity-Pain-Immune-Mood) with seizures caused by increased intracranial pressure from cranio-cervical instability. • The patient did not have “pseudoseizures.” • Patient was treated, is physically active, married and leading a productive life. What Causes Illness and Mental Illness? Complex & Poorly Defined Diseases • Poorly understood illnesses are often considered “psychogenic” until the pathophysiology is better understood. • Complex diseases require complex explanations. • When dealing with poorly defined conditions, begin by defining it. Defining Mental Health • Mental functioning (cognitive, emotional and vegetative) facilitates adaptive and productive activities, fulfilling relationships and the capacity to enjoy the activities of life; the capacity to contend with adversity and the mental flexibility to adapt to changing life circumstances. Bransfield R What Causes Illness and Mental Illness? • Everything is caused by something • Nothing is caused by nothing. • Illness is from an interaction of contributors and susceptibilities resulting in a pathophysiological process. • We can categorize types of mental illness, but we often do not know the cause. • Mental illness is never a diagnosis by default. Multi-Systemic Disease Model Disease Disease Progression Recovery Time • Predisposing & precipitating factors • Infections • immune & other reactions • Pathophysiological processes • Dysfunction • Symptoms & Syndromes • Ineffective Treatment • Disease Progression Research & Clinical Observation: Microbes & TBD Cause Mental Illness • Thousands of peer-reviewed journal articles demonstrate the causal association between infections, somatic illness and mental illness. • Viral, venereal, vector-borne diseases are associated with persistent infections (Most notably arachnid, tick-borne diseases). • 400+ peer reviewed scientific articles demonstrate the causal association between tick-borne disease and mental illness. • Clinical observation by front line physicians also supports this view. Dysregulated Aversive Emotional States • Environmental phobias—agoraphobia, claustrophobia, acrophobia, etc. • Interpersonal—paranoia, social anxiety, body dysmorphic disorder, pathological jealousy • Body integrity—somatic symptom disorder, illness anxiety disorder • Traumatic perception—posttraumatic stress • Alarm—panic disorder • Doubt—obsessive compulsive disorder • Futility—depression (often comorbid) Brain and Body Interaction Comorbidity: Psychosomatic, Somatopsychic or Multi-systemic? • Psychosomatic: Mental distress results in somatic symptoms. • Somatopsychic: Somatic distress results in mental symptoms. • Multi-systemic process adversely affecting the brain and body causing both psychiatric and somatic symptoms. • Or a combination of the above. Psychosomatic Disorders • Somatic illness caused or aggravated by mental distress. High levels of stress &/or high reactivity to stress may contribute. • Diagnosed by a psychiatric & medical evaluation, not a diagnosis of exclusion from inadequate assessment or diagnose or inability to understand the pathophysiology. • The term is not included in DSM-5. Psychosomatic Disorders II • The list keeps shrinking as scientific knowledge advances. Tuberculosis, hypertension, stomach ulcers were once considered “psychosomatic.” Now it is rare to name a illness that is purely psychosomatic. However many diseases are made worse by stress and anxiety such as psoriasis, eczema, heart disease, irritable gut and skeletal muscle guarding. Even, Naïla & Devaud, Jean-Marc & Barron, Andrew. (2012) Stress &/or Stress Reactivity • Shift: sympathetic-parasympathetic tone, HPA axis • Increased: blood pressure, heart rate, breathing, blood flow to skeletal muscle, skeletal muscle guarding, blood sugar, inflammation • Decreased: regenerative activity, blood flow to prefrontal cortex, digestive activity Psychosomatic: Cardiovascular • Chronic stress activates the hypothalamic-pituitary- adrenal axis (HPA) and the sympathetic branch of the autonomic nervous system, reduces vagal tone, increases plasma catecholamines, elevates heart rate, causes vasoconstriction, activates platelets and reduces heart rate variability. • Associated chronic increases in proinflammatory cytokines contribute to endothelial damage, plaque formation, atherosclerosis thrombus formation, vascular occlusion, endothelial damage of the cerebral vasculature and acute coronary syndromes. • These autonomic and immune system changes, singly and additively, exert adverse effects resulting in high CV morbidity and mortality. Halaris A. Psychocardiology: Understanding heart brain connection. Psychiatric Times. 9-20-18 Multisystemic vs. Psychosomatic • A person is reasonably healthy throughout most of their life, and then there is a point in time where a multitude of symptoms progressively appear. The number and complexity of these symptoms may be overwhelming and illness may be labeled hypochondriasis, somatic symptom disorder, or psychosomatic. However, both hypochondriasis and psychosomatic illnesses begin in childhood and are life long conditions which vary in intensity depending upon life stressors. If a complex illness with both mental and physical components begins in adulthood, the likelihood that this is psychosomatic is very remote. “Functional Disorders” • Historically a ”functional disorder” (not in DSM) is a medical condition that impairs normal functioning of bodily processes that remains largely undetected under examination, dissection or even under a microscope. At the exterior, there is no appearance of abnormality. This stands in contrast to a structural disorder (in which some part of the body can be seen to be abnormal) or a psychosomatic disorder. • Generally, the mechanism that causes a “functional disorder” is unknown, poorly understood, or occasionally unimportant for treatment purposes. “Functional Disorders” II • Since the development and expansion of brain imaging, neurochemistry, microarray technology and other advances; pathological changes can be identified in psychiatric disorders and “functional disorders” is no longer a valid concept. “Primary Psychiatric Illness” • This category of mental disorders includes all those not believed to be associated with a medical condition. • Like “functional disorders,” it is an outdated and invalid term since medical, physiological changes are associated with psychiatric illnesses. "Compensation neurosis". An invalid diagnosis. • “Compensation neurosis:“ Sometimes called by numerous synonyms has been used for many years in discussing the emotional sequelae of accidental injury. The clinical validity of these terms has
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