Download Free Medical Fibromyalgia and the Social Construction of Disease PowerPoint Presentation

Fibromyalgia and the Social Construction of Disease PowerPoint Presentation

DOWNLOAD MEDICAL POWERPOINT PRESENTATION

About This Presentation

Description : This medical presentation titled "Fibromyalgia and the Social Construction of Disease" talks about fibromyalgia, a syndrome of widespread pain associated with characteristic tender points.

Tags : Principles, Practice Strategies, Fibromyalgia, functional somatic syndromes, diagnosis, treatment, rheumatology, Chronic Pain, Suffering Syndromes

Published on : Apr 26, 2021 | Views : 2735 | Downloads : 4

Shareable Url :

Embed Code :

Comment

Transcript

Slide 1-

Fibromyalgia and the Social Construction of Disease Salahuddin Kazi, MD
Slide 2-

In 1990 the American College of Rheumatology published criteria for the classification of fibromyalgia Fibromyalgia was defined as a syndrome of widespread pain associated with characteristic tender points
Slide 3-

ppt slide no 3 content not found
Slide 4-

ppt slide no 4 content not found
Slide 5-

ppt slide no 5 content not found
Slide 6-

Fibromyalgia is a controversial disorder Valid Disease Construct OR Universal Stress + Doctor + Social Sanction “Fibromyalgia”
Slide 7-

Doctors are ambivalent about fibromyalgia Diagnosed by self-report Objective findings limited to tender points No characteristic laboratory or imaging abnormalities Overlap with other syndromes No specific treatment
Slide 8-

The argument If fibromyalgia is a true disease, there ought to be observable pathologic lesions But what do we mean by “disease”?
Slide 9-

Fibromyalgia – key features Fibromyalgia is characterized by widespread chronic muscle pain The pain worsens with activity Patients cannot distinguish well between myalgia and arthralgia often describe joints as being swollen burning, numbness, tingling and heaviness of the limbs are common complaints
Slide 10-

Fibromyalgia – key features Fatigue is very frequent (90%) and may be the presenting complaint Sleep disorders are universally reported Mood disturbance, cognitive impairment, headache, Raynaud’s phenomenon and pre-syncope are also very prevalent Some patients meet formal criteria for depression
Slide 11-

Fibromyalgia – key features Many individuals meet criteria for other unexplained clinical syndromes irritable bowel syndrome, chronic fatigue syndrome, migraine headaches and interstitial cystitis Physical examination is largely normal except for the finding of characteristic tenderness at defined points Laboratory studies are within normal limits
Slide 12-

Fibromyalgia - epidemiology Fibromyalgia is more common in women Prevalence increases linearly with age 2% at age 20 and 8% at age 70 Peak presentation is in the fourth and sixth decades of life In 50%, onset is attributed to trauma or a flu-like illness
Slide 13-

Chronic fatigue syndrome
Slide 14-

Unexplained clinical syndromes Fibromyalgia Chronic fatigue syndrome Irritable bowel syndrome Multiple chemical sensitivity Migraine headaches Interstitial cystitis Chronic nonbacterial prostatitis Chronic pelvic pain Chronic low back pain Post-concussion syndrome Interstitial cystitis Temporomandibular disorder
Slide 15-

ppt slide no 15 content not found
Slide 16-

The history of fibromyalgia and chronic fatigue syndrome 1869 Neurasthenia 1904 Fibrositis 1930’s Epidemic neuromyasthenia Benign myalgic encephalomyelitis Post viral syndrome 1938 Referred muscle pain 1976 Fibromyalgia 1980’s Chronic EBV infection Chronic fatigue syndrome 1990’s Fibromyalgia – ACR definition Myofascial pain syndrome
Slide 17-

Pathophysiology of fibromyalgia: evolving views Disease of muscle Psychiatric disorder Disease of pain perception Neuroendocrine disease
Slide 18-

Pathophysiology of fibromyalgia: evolving views Disease of muscle Psychiatric disorder Disease of pain perception Neuroendocrine disease
Slide 19-

Is there muscle pathology in fibromyalgia? Stockman,1904 - biopsy studies of palpable tender nodules in patients with fibrositis “inflammatory hyperplasia” Two subsequent studies could not confirm these findings
Slide 20-

Is there muscle pathology in fibromyalgia? Collins,1940 - review of original specimens found no evidence of inflammation Contemporary muscle biopsy studies have revealed either normal findings or nonspecific ultrastructural changes Studies of muscle metabolism and MR spectroscopy have also failed to demonstrate abnormalities in muscle metabolism
Slide 21-

Pathophysiology of fibromyalgia: evolving views Disease of muscle Psychiatric disorder Disease of pain perception Neuroendocrine disease
Slide 22-

Is fibromyalgia a psychiatric disorder? Prior to the 1980’s the concept of “psychogenic rheumatism” was prevalent: dramatic urgency to be seen by the doctor written list of complaints large volume of previous investigations brought to the first clinic visit
Slide 23-

Fibromyalgia and the MMPI Payne, 1982 - higher MMPI scores in fibromyalgia patients when compared with patients with arthritis Fibromyalgia patients scored higher on the hypochondriacal and hysteria scales but not on the depression scale
Slide 24-

Fibromyalgia and the MMPI Smythe suggested that the MMPI will rate any patient with chronic pain high on the hysteria and hypochondriasis scales Pincus reported that elevated MMPI scores for hypochondriasis, depression and hysteria correlated with disease activity in patients with rheumatoid arthritis
Slide 25-

Fibromyalgia - history of depression Clarke - fibromyalgia patients from general practice No increase in rates of psychologic disturbance 50%-70% of patients with fibromyalgia report a personal history of depression Current major depression is found in not more than 36% of patients
Slide 26-

Fibromyalgia and depression: prospective data A prospective study of 175 women with self-reported pain designed to examine etiologic factors in the onset of fibromyalgia Depression developed in 25% of this cohort after a period of 5.5 years Self-reported depression was the single strongest predictor (six-fold) of new-onset fibromyalgia
Slide 27-

Fibromyalgia and depression:prevailing views Depression and fibromyalgia are associated, but the nature of the association and the temporal relationship are unclear Fibromyalgia and major depression may share a common etiologic abnormality The greater frequency of depression in fibromyalgia patients in referral-based practices versus fibromyalgia patients in the community reflects differences in health-seeking behaviors
Slide 28-

Fibromyalgia + Depression Health Seeking Community Clinic Fibromyalgia Fibromyalgia + Depression
Slide 29-

Is fibromyalgia a somatization disorder? Severe fatigue Abdominal pain Diarrhea Headaches Dizziness Jaw pain Paraesthesia Raynaud’s phenomenon Dysuria Patients have multiple somatic complaints that suggest organic disease:
Slide 30-

Fibromyalgia and somatization Most patients with fibromyalgia would not satisfy diagnostic criteria for somatization disorder Do these patients may have a subsyndromal somatization state?
Slide 31-

Critics point to the circular nature of the definition of somatization disorder: “a psychiatric diagnosis that depends on the presence of physical symptoms that suggest organic disease and are not explained by a general medical condition would become a nonpsychiatric diagnosis once the general medical condition adequately explains the symptoms”
Slide 32-

Pathophysiology of fibromyalgia: evolving views Disease of muscle Psychiatric disorder Disease of pain perception Neuroendocrine disease
Slide 33-

Fibromyalgia as a chronic pain disorder: epidemiology the number of tender points correlated best with depression, fatigue and poor sleep
Slide 34-

Fibromyalgia as a chronic pain disorder: epidemiology Wolfe – rural Kansas widespread pain was more common in women increased in prevalence with age peak 23% by the seventh decade
Slide 35-

Depression The pain-fibromyalgia spectrum Chronic Pain Fibromyalgia Sleep Disorder Fatigue
Slide 36-

Fibromyalgia: abnormal central sensory processing Non-nociceptive pain (NNP) pain elicited by stimulation of fibers that usually relay non-painful signals to the spinal cord non-noxious stimuli are subverted by abnormal central processing resulting in the experience of pain
Slide 37-

Chronic pain in fibromyalgia Several studies of chronic pain in fibromyalgia patients compared with controls show: dolorimetry reveals a lower pain threshold elevated substance P levels in the CSF with isometric muscle contraction, the pain threshold decreases rather than showing the expected increase seen in controls somatosensory-induced potentials demonstrate increased amplitude following laser stimulation of skin distinctive regional cerebral blood flow abnormalities
Slide 38-

Pathophysiology of fibromyalgia: evolving views Disease of muscle Psychiatric disorder Disease of pain perception Neuroendocrine disease
Slide 39-

The hypothalamic-pituitary-adrenal (HPA) axis Primary endocrine stress axis Adaptational response to stressors Patients with fibromyalgia have abnormal stress activation
Slide 40-

Neuroendocrine abnormalities in fibromyalgia Elevated cortisol levels with a flattened diurnal pattern that are not suppressed by dexamethasone administration Low 24 hour urinary free cortisol suggesting elevated cortisol secretion during the day and suppressed secretion at night Markedly enhanced ACTH release when CRH is injected, but with no increase in cortisol levels (suggesting adrenal hyporesponsiveness)
Slide 41-

Significance of HPA abnormalities Chronic CRH hyperactivity is driven by stress and pain CRH is a pleiotropic hormone changes in the set points of other hormonal axes like growth hormone, gonadotropin and thyroid stimulating hormone may also be of significance
Slide 42-

Significance of HPA abnormalities Whether somatic symptoms in fibromyalgia are caused by these abnormalities is unclear Is the link between somatic complaints and central nervous system changes bidirectional?
Slide 43-

Genetic vulnerability Stressful life event Abnormal central sensory processing Chronic pain Psychosocial distress Secondary somatic symptoms Somatosensory amplification HPA Axis Acute Pain
Slide 44-

Summary of the current concept of fibromyalgia Theories of the pathophysiology of fibromyalgia have moved from a disorder of soft tissues to one of chronic pain Diagnosis is largely based on patient self-report but an increasing body of literature points to measurable phenomena in the central nervous system and HPA axis Psychologic disturbances are common in patients with fibromyalgia but the temporal association with disease onset is still unclear
Slide 45-

ppt slide no 45 content not found
Slide 46-

Foucault’s “spaces” Primary spatialization: disease is described and ordered as a concept Secondary spatialization: disease is given a place within the body Tertiary spatialization: the disease and the diseased individual are located within the societal body
Slide 47-

The birth of biomedicine Turn of the 18th century French revolution Restructuring of French society Parallel restructuring of the medical paradigm
Slide 48-

The birth of biomedicine Medicine changed from a study of symptoms to the precise mapping of signs and symptoms to observable pathologic lesions Doctors began to care for indigent patients in a hospital setting The doctor became dominant in the doctor-patient relationship
Slide 49-

The biomedical model of disease Disease is caused by an observable pathologic lesion in the body The presence of a pathologic lesion is revealed in two ways: symptoms, the patient’s perception that body function is not normal signs, the physician’s observation that signifies that an underlying lesion exists
Slide 50-

Assessing symptoms Patients subject their symptoms to some form of evaluation prior to seeking medical advice Community surveys suggest that the ratio of symptom episodes to consultation is much higher than one would expect
Slide 51-

Symptom : consultation ratio
Slide 52-

The active decision to seek medical advice for symptoms is known as illness behavior Trivial symptoms Trivialize symptoms
Slide 53-

Decision to see the doctor Perceived interference with vocational or social activity Perceived interference with social or personal relations The occurrence of an interpersonal crisis Failure of symptoms to resolve by the end of a self-determined arbitrary period Coercion from friends or relatives (sanctioning)
Slide 54-

Not all persons with fibromyalgia are “patients” Community surveys: fibromyalgia non-patients > fibromyalgia patients A history of depression > current depression history of depression is a marker for persons more likely to seek health care The “onset” of fibromyalgia following an interpersonal crisis a stressful life event, and not the disease itself, precipitates a consultation
Slide 55-

Parson’s “sick role” Strong position of social authority of the doctor to legitimize illness Allows the patient to ease from a “well person” to a “patient”
Slide 56-

Benefits of the “sick role” The patient is temporarily excused from performing his or her normal social role The patient is not held responsible for his or her illness
Slide 57-

Sick role: patient’s obligations The patient must want to get well (the sick role is of temporary status) The patient must cooperate with the treatment plan
Slide 58-

Parson’s model fails in chronic illnesses Inability of the patient to fulfill the two obligations The sick role is not temporary Lack of cure makes cooperating with treatment difficult to sustain
Slide 59-

Parson’s model also fails when: Patients have multiple complaints without a readily identifiable lesion The patient does not accept a shared belief in the biomedical model of disease
Slide 60-

The doctor as an agent of social control Doctors utilize the biomedical rule of medicine to judge patients as ill or well Conferring/withholding “sick role” status This judgment occurs independently of the patient’s own beliefs
Slide 61-

The doctor as an agent of social control Patients may be judged ill even though they may view themselves as well screening asymptomatic patients judged to be well, even when they see themselves as ill no biological explanation for the patient’s symptoms
Slide 62-

Good patients, bad patients and great patients Lober-1975: study of inpatients in a general hospital good patients trusting, cooperative, non-complaining, non-demanding great patients seriously ill patients who were cheerful, cooperative, uncomplaining, and objective about their illness difficult or problem patients not seriously ill but were demanding, emotional, and uncooperative frequently discharged early, given sedatives, or referred to psychiatry
Slide 63-

“Difficult patients” in primary care Hahn-1996: 15% of patients were viewed by doctors as difficult patients More likely to have: psychiatric disorder functional impairment greater health-care utilization higher dissatisfaction with their care
Slide 64-

So, what’s “difficult”? “Difficult” because patients have presented with “problems of living” rather than defined diseases The question of secondary gain the hope of attaining the benefits of the sick role The doctor is reticent to exercise his or her unique social authority to grant these benefits The doctor views such patients as “difficult” because they do not fulfill the construct of the biomedical model
Slide 65-

Patients with fibromyalgia are “difficult” A chronic illness without a readily identifiable lesion Multiple somatic complaints Higher incidence of psychiatric disorders Greater health care utilization Dissatisfaction with their care Advice of the doctor is often not followed
Slide 66-

The patient with fibromyalgia may present with a comprehensive belief system that rivals the biomedical scientific belief system of the doctor
Slide 67-

While on the surface the doctor-patient relationship is seemingly about common interests and goals cause diagnosis therapy cause diagnosis therapy Medical epidemiology Lay epidemiology
Slide 68-

Disease and labeling theory A doctor’s decision to interpret an individual’s particular biologic state as being abnormal (diseased or ill) constitutes a label (diagnosis) In social theory, labeling has a negative connotation Individuals deemed abnormal are labeled “abnormal” If this abnormality is also socially abnormal, it can cause deviance
Slide 69-

Deviance Primary deviance defining a biologic state as abnormal Secondary deviance change in patient behavior as a consequence of labeling (diagnosis) Strong social pressures to conform to the label reinforce secondary deviance “self-fulfilling prophecy”
Slide 70-

Fibromyalgia the label Patients with widespread pain and multiple tender points labeled as suffering from fibromyalgia Social meaning and significance of the applied label (secondary deviance) change in behavior pressure to conform to the diagnosis
Slide 71-

Is fibromyalgia a deviant label? Critics of fibromyalgia, the label: The doctor is creating secondary deviance The labeled patient falls into a self-fulfilling prophecy trap The label (not the underlying biologic state) perpetuates the illness behavior By declaring “normal aches and pains” a disease, doctors are promoting the sick role and creating unnecessary somatization
Slide 72-

Patients may also reject fibromyalgia Avoidance of stigmatization Adoption of a more “acceptable” disease “Systemic lupus erythematosus” Fibromyalgia + positive ANA “Lyme disease” Fibromyalgia + positive Lyme titre
Slide 73-

Fibromyalgia: a useful construct? Patients are comforted when they can give their symptoms a name The conferring of the sick role relieves them of personal responsibility for the cause of their symptoms These set of symptoms can be studied in a uniform manner
Slide 74-

Is fibromyalgia a disease, a syndrome or an assortment of unexplained symptoms? What is disease? The traditional view: disease is a biological problem excludes conditions without known biological mechanisms assumes that the line between physiology (normal) and pathology (abnormal) is well-demarcated
Slide 75-

Are psychiatric conditions diseases? No clearly defined biological mechanisms Manifestations are principally in altered behavior Cause or consequence of labeling? Szasz has argued that psychiatrists do not identify real disease, they simply label inappropriate behavior and call it disease
Slide 76-

Is disease dis-ease? Dis-ease: lack of feeling well constitutes disease Unacceptable to doctors because Definition of disease is firmly in the grasp of the patient Synonymous with the lay concept of illness Objectivity succumbs to subjectivity Presymptomatic disease states cease to exist
Slide 77-

Disease as social variance Variation from normal is only a disease if it creates social disadvantage Normal Abnormal Abnormal Disease Social Disadvantage
Slide 78-

Disease and social norms Osteoarthritis may be viewed as a normal consequence of aging Dyslexia would not be a disease in a pre-literate society Is obesity a disease? How is insanity defined?
Slide 79-

Fibromyalgia can be viewed as a disease based on the social construct (because it causes social disadvantage) BUT Fibromyalgia is typically considered a non-disease because it resists biologic reductionism and is often viewed as a collection of unexplained symptoms
Slide 80-

The usual fate of unexplained symptoms Referral to psychiatry Patient wants to avoid the stigma of a psychiatric label Join an advocacy group lobby for reform Adopt a disease with a more socially acceptable label Doctor shop Dissatisfaction with care Secondary deviance Unexplained symptoms
Slide 81-

Explaining unexplained symptoms One third of all symptoms in primary care settings are unexplained Unexplained symptoms were originally considered functional disturbances of the brain reversible
Slide 82-

Explaining unexplained symptoms Unexplained symptoms became the province of psychiatry hardwired Somatization was proposed as the mechanism by which mental disorders became physical symptoms Sharpe has suggested that we resurrect the original meaning of the term “functional”
Slide 83-

It is difficult to accommodate fibromyalgia in the biomedical disease construct since it is a subjective diagnosis Biomedical science thrives on objectivity But is biomedicine itself influenced by social forces?
Slide 84-

Is the biomedical model impervious to social forces? Paradigms vs. independent scientific inquiry (Kuhn vs. Popper) “Reality” and the “knowledge” that explains it - is socially determined
Slide 85-

Paradigms vs. independent thought Scientific inquiry is based on prevalent paradigms Prevailing paradigms are subject to social influence Unexplained phenomena are “puzzles” not independent “problems” New paradigms are adopted when the unexplained is explained A new cycle starts
Slide 86-

Kuhn vs. Popper Scientific growth is a journey towards an infinite absolute truth The scientist functions in an atomistic, individualistic fashion Truth is absolute Scientific growth is series of temporarily valid solutions that provide successively better explanations The scientist is one of many working to validate an established paradigm Truth is relative and it subject to newer, better paradigms when appropriate
Slide 87-

Neurasthenia and chronic fatigue: a biosocial model
Slide 88-

Conclusions Fibromyalgia is a complex biosocial construct shaped by the interaction between biology and sociology It can only be resolved by creating an alliance between classical biomedical thought and the forces that influence the expression of illness in society
Slide 89-

Conclusions Fibromyalgia Search for Pathology Biosocial Model of Disease Neurobiology of pain HPA axis Social Factors