Psychodiagnostic Evaluation in Neurological Presentations

Report
An Emergency Department and Centre for Emotions and
Health Collaboration
Contact: Allan Abbass 902473-2514, [email protected]
www.istdp.ca
Emotion
Dysregulation
Physical Symptoms
Physical Illnesses
Low self care
Self Injury
Relationships
Low Compliance
Complaints
Hospital Days
Emergency use
Medical Visits
Tests + Procedures
Excess Medications
Poor Outcomes
Disability
Morbidity
Mortality
Great Overlap Between Common Problems
Irritable Bowel
Dyspepsia
Abdominal pain
Chemical
Sensitivity
Fibromyalgia
Fatigue
Headache
Confusion
Bladder dysfunction
Pelvic Pain
Hypertension
Chest pain
Psoriasis
Dermatitis
Depression
Anxiety
Panic
Conversion
Pseudoneurological
Phenomena
Great Overlap Between Common Problems
Irritable Bowel
Dyspepsia
Abdominal pain
Headache
Confusion
Bladder dysfunction
Pelvic Pain
Chemical
Sensitivity
Fibromyalgia
Fatigue
Emotion
Dysregulation
Psoriasis
Dermatitis
Depression
Anxiety
Panic
Hypertension
Chest pain
Conversion
Pseudoneurological
Phenomena
Specialty
Gynecology
Neurology
Gastroenterology
Chest Clinic
Rheumatology
Total
% with 1 or more
unexplained symptoms
66
62
58
51
45
52
Emergency use: ~15-20,000 visits/yr
Hospital Days: ~13,000 days per year
Medical Visits: 25-50% of all new consults
Excess Tests + Procedures: ?
Excess Medications: ~$150,000/yr in Hospital
Suboptimal Outcomes: ? Cost
Excess Side effects: ? Cost: many admissions
Disability: ~$6,000,000/ year in Capital Health
Mortality: a measurable excess in reviews
Info from Emergency Database, Decision Support, Occupational Health and Pharmacy
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Unexplained Chest Pain, Headache, Panic,
Abdominal Pain account for 16% of all
CDHA ED Visits each year
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75% of all Chest Pain complaints come
out with no diagnosis: 9000 visits
88% of all Abdominal Pain complaints
come out with no diagnosis: 7000 visits
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   Wait
Times
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A method based on videotaped research to
diagnose and address problems handling
emotions
Effective with broad range of physical and
psychological problems
Actively researched and taught in our Centre
More information
http://www.istdp.ca/whatis.htm
Physical Problems treatable with ISTDP
Voluntary Muscle Tension
 Fibromyalgia, chest pain, abdominal
pain, hyperventilation, panic attacks
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Involuntary Muscle Tension
 Hypertension, IBS, Dyspepsia, Urinary
symptoms, pelvic pain, migraine
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Cognitive-perceptual Disruption
 dizziness, fainting, weakness, memory
problems, accidents, injury, psychotic
features
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Motor Conversion
 Falling, loss of speech, spasm,
weakness
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How Effective is ISTDP
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21 published outcome studies
Effective with multiple medical conditions and
physical symptom syndromes
Marked drop in Dr and Hospital costs
Majority stop psychiatric medications
Around 85% of treated patients return to work
from disabilities (several studies)
Single session brings 25% symptom reduction
on average
Saves approximately 10 times what it costs each
year through service use and disability
reduction.
ISTDP reduced Repeat Emergency Visits for Medically
Unexplained Symptoms Abbass, Campbell et al, Can J Emerg Med,
2009, 2010a, 2010b
7
Emergency Visits/yr
6
p =0.2
Control
5
p <.01
4
ISTDP
Control
3
p <.001
2
ISTDP
1
0
1 Year Pre
1 year Post
 Innovation Grant to staff ED with Diagnostic Clinicians
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Established long term relationship between CEH
and ED
Provided videotape based education sessions to the
emergency staff
Developed an information pamphlet for patients.
Introduced rapid access referrals to the service
where emergency patients were seen in less than 2
weeks when possible.
Showed videotape of the emergency-referred cases
we had seen.
Provided literature to emergency physician and
other staff.
Provided a month of on-site consultation and
liaison with emergency physicians.
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3.8 sessions average
Significant Improvement on symptom measure
(BSI)
High Patient Satisfaction ratings (~8/10)
Marked increase in referral rates by more
Emergency Doctors
Major reduction in repeat Emergency Use (65-70%
reduction)
“Net Cost saving” of 500 per patient
Funding received for 1.2 FTE Psychologists to
staff the ED
Named Canadian Leading Practice by
Accreditation Canada 2010
Nova Scotia expected to roll this program out to
other emergency departments
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Simply understanding that emotional factors
were responsible for symptoms was enough to
reduce symptoms and ED use. Only 2 returned
to ED, after assessment and during course of
clinic.
Almost all patients were suitable referrals for
service. Only 2 or 3 did not fit the service.
More complex patients needed coordinated Tx
While all had multiple issues, at the core of the
problem was some form of attachment trauma
in early life.
Nearly all were moderate resistant, highly
resistant or fragile
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The service is widely acceptable and well
used
Patients benefit with reduced ED visits
Service use reduction can help to reduce
wait times
This service matches meeting the patient at
point of entry, and
Exemplifies patient-centred care at Capital
Health
Canadian Journal of Emergency Medicine
2009 article:
http://www.istdp.ca/docs/CJEM_2009.pdf
 Journal of Academy of Medical Psychology
articles on Cost Effectiveness and
Implementation
http://www.istdp.ca/docs/Cost%20Saving%20E
D%20Treatment.pdf
http://www.istdp.ca/docs/Implementing%20IS
TDP%20in%20the%20ED.pdf
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