Transdiagnostic Treatment Approaches in Primary Care

I learned a new word recently: Transdiagnostic, which refers to something that is applicable across a spectrum of conditions. It seems that this is becoming an increasingly popular concept in treating anxiety disorders.

No wonder. As I researched this word, I read this:

“As of 2013, there are twelve anxiety-disorder diagnoses and over twenty-five subtypes and categories of these disorders, with specific treatments for about half of them. Research has demonstrated that these treatments, particularly cognitive behavioral ones (Hofmann and Smits 2008; Norton and Price 2007), help most people recover from anxiety disorders. Over the last few years, however, researchers have studied the effectiveness of general, rather than specific ones for anxiety disorders. These new treatments target core factors thought to maintain anxiety disorders in general (Erickson 2003).”

It struck me how much this fits into my work as a primary care physician:

The three major diseases I deal with on a daily basis, Type 2 Diabetes, cardiovascular disease and obesity really respond to the same dietary and lifestyle interventions (low carb, high good fat, moderate exercise), and now we even have drugs with transdiagnostic benefits: Jardiance (empagliflocin), an SGLT2 inhibitor, makes you excrete more sugar in the urine (like one of my recent patients did on her own) and also happens to lower the risk of cardiovascular death by 38%.

Another example of transdiagnostic therapies in primary care is the fact that SSRI antidepressants are now first line treatment for anxiety, depression and irritable bowel syndrome. I am not smart enough to know where IBS ends and anxiety begins, but I do believe they are not one and the same.

Fibromyalgia and other neuropathic pain syndromes like postherpetic neuralgia and sciatica respond to SNRI antidepressants (duloxetine), which are also obviously useful tools in depression treatment.

Metformin is another example of a transdiagnostic medication treatment, used for diabetes and polycystic ovary syndrome, conditions that have similarities but also several differences.

This brings me back to the notion I was introduced to in medical school:

Be familiar with many medications, but develop expert, in-depth knowledge about the use of a few select ones with particular efficacy or breadth.

My new word reminded me of that.

And when it comes to the two dozen subtypes of anxiety, that just reminds me of the absurdity of ICD-10 codes, like “accidental drowning and submersion due to fall in (into) bathtub (W16.211)”

Drowning is pretty much drowning. And I refuse to believe that there is any practical need to have 25 different types of anxiety.

Transdiagnostic treatments eliminate the need for obsessive-compulsive diagnosticism.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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