Gulf War and Health Treatment for Chronic Multisymptom Illness (2013) / Chapter Skim
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5 Review of Treatments for Comorbid and Related Conditions
5 Review of Treatments for Comorbid and Related Conditions
Pages 93-132
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From page 93... ...
In some cases, a common exposure can lead to more than one condition; for example, an explosion can cause a concussion, deafness, body injury, and pain. Different but similar conditions share symptoms; for example, cognitive impairment can be a feature of CMI and traumatic brain injury (TBI)
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From page 94... ...
The committee believes that symptoms shared between CMI and those treatments may respond to similar approaches in symptom management. Treatments that are recommended in evidence-based clinical practice guidelines or that have been found effective in systematic reviews are highlighted.
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From page 95... ...
CHRONIC PAIN Chronic pain is defined as pain that is associated with a chronic medical condition or that persists beyond the expected time for tissue healing and adversely affects the function or well-being of the person (American Society of Anesthesiologists Task Force on Chronic Pain Management and American Society of Regional Anesthesia and Pain Medicine, 2010)
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From page 96... ...
. The use of radiofrequency ablation of branch nerves to facet joints for low back pain is supported by results of multiple RCTs and meta-analyses (American Society of Anesthesiologists Task Force on Chronic Pain Management and American Society of Regional Anesthesia and Pain Medicine, 2010)
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From page 97... ...
Definitions of CFS used by CDC and UK National Health Service are included in Box 5-1. Chronic Fatigue Syndrome and Chronic Multisymptom Illness Much research on CFS has targeted infectious triggers associated with low-grade fever, adenopathy, and influenza symptoms.
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From page 98... ...
NOTE: CFS = chronic fatigue syndrome; NICE = National Institute for Health and Clinical Excellence.
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From page 99... ...
(CDC, 1994; Mayo Clinic staff, 2011; National Collaborating Centre for Primary Care, 2007)
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From page 100... ...
Among the many terms used in the literature to label these somatic presentations, somatization symptoms was the most common for decades. That designation has been gradually replaced with more descriptive terms, such as medically unexplained symptoms, unexplained symptoms, and functional somatic symptoms.
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From page 101... ...
Like CMI, sleep disorders are associated with fatigue, mood disturbances, cognitive difficulties, and other somatic symptoms; comorbidity with depression, anxiety, and substance abuse is common. Sleep Disorders and Chronic Multisymptom Illness Several types of sleep disorders are among the common symptoms associated with CMI.
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From page 102... ...
Treatments for Sleep Disorders Because of the large number of sleep disorders and evidence that effective treatment varies among them, it is vital to evaluate the patient adequately and accurately to characterize the specific symptoms, identify potential comorbid conditions or risk factors, and diagnose the specific type of disorder. Table 5-1 summarizes best-practice guidelines and recommendations for treatment for nightmare disorder and chronic insomnia.
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From page 103... ...
Functional Gastrointestinal Disorders and Chronic Multisymptom Illness The most common symptoms of IBS are abdominal pain or discomfort, diarrhea, constipation, and abdominal bloating, and common symptoms of FD are early satiety with upper abdominal fullness, burning, or pain -- all in the absence of other structural abnormalities that explain the symptoms. The symptoms are common in veterans deployed to the 1991 Gulf War (IOM, 2010)
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From page 104... ...
to respond to centrally targeted treatments that reduce symptom frequency and intensity and reduce such associated psychologic comorbidities as anxiety and depression. Treatments for Functional Gastrointestinal Disorders The general approach to treating IBS and FD is to look at the predominant symptom that requires treatment (for example, diarrhea, nausea, or pain)
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From page 105... ...
. After evaluation of that and other systematic reviews and studies, tricyclic medications and SSRIs have been endorsed by the Rome Foundation (Levy et al., 2006)
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From page 106... ...
are also common in severe depression and that depression is one of the clinical conditions most closely related to suicide, an outcome often reported in veterans returning from the Iraq and Afghanistan wars. Major depression often includes somatic disturbances (such as difficulty in sleeping, changes in appetite, changes in
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From page 107... ...
Proper management of CMI and depression requires a coordinated, well-integrated approach that should include medical and mental health specialists working together, i deally in a primary care setting. Treatments for Depression A number of treatment guidelines outline effective interventions for depression (APA, 2010; Gill et al., 2010; National Collaborating Centre for Mental Health, 2009a,b; Nieuwsma et al., 2012; Rimer et al., 2012; VA and DOD, 2009b)
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From page 108... ...
. Anxiety and Chronic Multisymptom Illness Anxiety disorders are frequent in primary care, often appearing with depression and unexplained physical symptoms.
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From page 109... ...
. Evaluation should also address comorbidities, including TBI, depression, other anxiety disorders, alcohol or substance abuse, and the presence of suicidality and risky behaviors (IOM, 2012)
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From page 110... ...
. Several investigations have suggested that posttraumatic stress symptoms correlate with 1991 Gulf War veterans' medically unexplained symptoms (Engel et al., 2000; Ford et al., 2001; Storzbach et al., 2000)
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From page 111... ...
, the UK National Institute of Health and Clinical Excellence Guideline (National Collaborating Centre for Mental Health, 2005) , the Australian National Health and Medical Research Council Guideline (Australian Centre for Posttraumatic Mental Health, 2007)
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From page 112... ...
Traumatic Brain Injury and Chronic Multisymptom Illness People who have TBI report a large variety of physical symptoms (such as loss of balance, pain, and fatigue) , cognitive symptoms (memory loss, word-finding difficulties, and reduced processing speed)
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From page 113... ...
Cicerone and colleagues in their three systematic reviews examined more than 370 studies and concluded that "there is substantial evidence to support interventions for attention, memory, social communication skills, executive function, and for comprehensive-holistic neuropsychological rehabilitation after TBI" (Cicerone et al., 2000, 2005, 2011)
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From page 114... ...
In the reorganization, substance abuse and dependence are combined into a single disorder of graded clinical severity, for which two criteria are required for a diagnosis. Substance-Use Disorders and Chronic Multisymptom Illness The co-occurrence of chronic medically unexplained symptoms and substance-use disorders -- including disorders of use of alcohol, opiates, and nicotine -- is common (Hasin and Katz, 2007)
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From page 115... ...
. It is a manual-based structured therapy that combines CBT strategies with methods that address relationship issues arising from alcohol misuse and more general relationship problems with the aim of reducing distress (National Collaborating Centre for Mental Health, 2011)
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From page 116... ...
. The ability of the screening measures to predict suicide attempts, particularly brief ones, has not been well studied (Haney et al., 2012; National Collaborating Centre for Mental Health, 2004)
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From page 117... ...
. Self-Harm and Chronic Multisymptom Illness The presence of physical symptoms is consistently associated with suicide attempts and suicide completion.
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From page 118... ...
. Treatments for Self-Harm The American Psychiatric Association practice guidelines (2003)
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From page 119... ...
. For patients who harm themselves repeatedly, dialectic behavior therapy, a form of CBT that teaches emotion-regulation skills, may be appropriate treatment because it is associated with decreased self-injurious behaviors, including suicide attempts (APA, 2003; National Collaborating Centre for Mental Health and National Collaborating Centre for Primary Care, 2011b)
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From page 120... ...
education, and self-help books • Pregabalin • Gabapentin Chronic pain • Tricyclic medications • Radiofrequency ablation of • SNRIs and SSRIs medial branch nerves to facet • NSAIDs joints for low back pain • Anticonvulsants • Acupuncture for headaches and • Opioids low back pain • Transcutaneous electric nerve stimulation for temporary relief of low back pain • Epidural steroids for leg pain • Physical or restorative therapy • Psychologic treatment (for example, CBT, biofeedback, relaxation training) • Botulinum-toxin injections for chronic migraines Chronic fatigue • NSAIDs for pain symptoms • CBT syndrome • Melatonin for problems in • Graded exercise therapy sleeping • Lifestyle changes (for example, • Antidepressants for depression regular sleeping schedule; and to improve sleep quality avoidance of caffeine, alcohol, and tobacco; and dietary changes)
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From page 121... ...
REVIEW OF TREATMENTS FOR COMORBID AND RELATED CONDITIONS 121 TABLE 5-3 Continued Condition Pharmacologic Nonpharmacologic Sleep disorders • For nightmare disorder, • For nightmare disorder, CBT, prazosin including image rehearsal therapy • For chronic insomnia, select pharmaceutical agent on basis • For chronic insomnia, stimulus of symptom pattern, treatment control therapy or relaxation goals, past treatment response, therapy, or combination CBT patient preference, cost, availability of other treatments, comorbid conditions, concurrent medication interactions, and side effects Irritable bowel • Tricyclic medications • CBT syndrome • SSRIs and SNRIs • Hypnosis Functional No treatments identified dyspepsia Depression • Tricyclic medications • CBT • SSRIs • Interpersonal therapy • Exercise • Acupuncture • Electroconvulsive therapy (for severe depression only) Anxiety • Antianxiety medications • CBT • SSRIs • Reassurance • Psychotherapy • Relaxation Posttraumatic • SSRIs • CBT stress disorder Traumatic No treatments identified • CBT brain injury continued
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From page 122... ...
• Methadone For tobacco-use disorders: • Buprenorphine • Individual and group behavioral • Naltrexone interventions focused on smoking cessation For opioid-use disorders: • Referral to a pain specialist or center that specializes in withdrawal treatment Self-harm • SSRIs • CBT, including dialectic behavior therapy • Interpersonal therapy NOTES: CBT = cognitive behavioral therapy; CPAP = continuous positive airway pressure; NSAIDs = nonsteroidal anti-inflammatory drugs; SNRIs = serotonin–norepinephrine reuptake inhibitors; SSRIs = selective serotonin reuptake inhibitors. There also is substantial evidence in guidelines and from systematic reviews that CBT is effective in managing more than one of the related conditions.
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From page 123... ...
2009. A randomized controlled trial of setraline for the treatment of depression in individuals with traumatic brain injury.
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From page 124... ...
2003. A random ized controlled trial of cognitive behavior therapy, relaxation training, and routine clinical care for the irritable bowel syndrome.
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From page 125... ...
2000. Relationship of physical symptoms to posttraumatic stress disorder among veterans seeking care for Gulf War-related health concerns.
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From page 126... ...
R 2001. Posttraumatic stress symptomatology is associated with unexplained illness a ttributed to Persian Gulf War military service.
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From page 127... ...
2011. Psycho physiologic treatment for patients with medically unexplained symptoms: A randomized controlled trial.
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From page 128... ...
:828-833. National Collaborating Centre for Mental Health.
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From page 129... ...
. National Collaborating Centre for Mental Health.
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From page 130... ...
Cochrane Database of Systematic Reviews Issue 7.
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From page 131... ...
2000. Psychological differences between veterans with and without Gulf War unexplained symptoms.
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From page 132... ...
1987. Hypnotherapy in severe irritable bowel syndrome: Further experience.
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