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.pdf4.Aspegren D, Hyde T, Miller M. Conservative treatment of a female collegiate volleyball player with costochondritis. J Manipulative Physiol Ther. 2007;30(4):321–325.
CODES
ICD10
M94.0 Chondrocostal junction syndrome [Tietze]
CLINICALPEARLS
Acommon disorder, accounting for up to 30% of all cases of chest pain
Diagnosis is primarily clinical. Lab and other testing is done to exclude other conditions based on patient risk.
Self-limited (potentially recurrent) condition. Activity modification helps prevent recurrence.
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COUNSELING TYPES
William T. Garrison, PhD
BASICS
DESCRIPTION
Psychotherapeutic and counseling interventions play an important role in the management of chronic and acute-onset diseases and disorders. They are typically the primary initial mode of evaluation and/or treatment for most mild to moderate psychiatric disorders that reach criteria using the DSM-5 (1) or ICD-10 (2) diagnostic classification systems. It should be noted that the DSM system has recently been revised with significant changes in several disorder categories and their criteria. Treatment and successful control of either medical or psychological conditions require some form of professional counseling experience. Best outcomes occur when they are employed by a skilled practitioner. However, psychotherapy differs from generic counseling, which can take many forms and is delivered commonly in nonmedical settings, with mixed results.
Counseling approaches are usually tailored to the specific presenting problem or issue and serve educational and emotional support functions. Typically, such counseling in medical settings will be time-limited and problem-focused and often not intended to lead to major medical symptom relief or major behavioral changes.
The goals of psychotherapy range from increasing individual psychological insight and motivation for change to reduction of interpersonal conflict in the marriage or family, reduction of chronic or acute emotional suffering, and reversal of dysfunctional or habitual behaviors. There are several general types of psychotherapy, starting with individual, marital, or family approaches. In addition, a number of psychological theories guide various methods and treatment philosophies. The following is a brief overview of commonly used psychotherapeutic and counseling methods.
–Psychodynamic therapy: Unconscious conflict manifests as patient’s symptoms/problem behaviors:
Short-term (4 to 6 months) and long-term (≥1 year)
Focus is on increasing insight of underlying conflict or processes to initiate symptomatic change.
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Therapist actively helps patient identify patterns of behavior stemming from existence of an unconscious conflict or motivations that may not be accurately perceived.
–Cognitive-behavioral therapy (CBT): Patterns of thoughts and behaviors can lead to development and/or maintenance of symptoms. Thought patterns may not accurately reflect reality and may lead to psychological distress:
Therapy aims at modifying thought patterns by increasing cognitive flexibility and changing dysfunctional behavioral patterns.
Encourages patient self-monitoring of symptoms and the precursors or results of maladaptive behavior
Uses therapist-assisted challenges to patient’s basic beliefs/assumptions
May use exposure, a procedure derived from basic learning theories, which encourages gradual steps toward change
Can be offered in group or individual formats
Therapist’s role is suggestive and supportive.
–Dialectical behavior therapy (DBT): Techniques such as social skills training, mindfulness, and problem solving are used to modulate impulse control and affect management:
Derivative of CBT
Originally used in treatment of patients with self-destructive behaviors (e.g., cutting, suicide attempts)
Seeks to change rigid patterns of cognitions and behaviors that have been maladaptive
Uses both individual and group treatment modalities
Therapist takes an active role in interpretation and support.
–Interpersonal psychotherapy: Interpersonal relationships in a patient’s life are linked to symptoms. Therapy seeks to alleviate symptoms and improve social adjustment through exploration of patient’s relationships and experiences. Focus is on one of four potential problem areas:
Grief
Interpersonal role disputes
Role transitions
Interpersonal deficits: Therapist works with the patient in resolving the problematic interpersonal issues to facilitate change in symptoms.
–Family therapy: focuses on the family as a unit of intervention 
Uses psychoeducation to increase patient’s and family’s insight 
Teaches communication and problem-solving skills
–Motivational interviewing: focuses on motivation as a key to successful
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change process
Short-term and problem-focused
Focuses on identifying discrepancies between goals and behavior
“5 A’s” model is a brief counseling framework developed specifically for physicians to effect behavioral change in patients:
■Assess for a problem.
■Advise making a change.
■Agree on action to be taken.
■Assist with self-care support to make the change.
■Arrange follow-up to support the change.
–Counseling (heterogeneous treatment)
Often focuses on situational factors maintaining symptoms
Often encourages the use of community resources
–Behavioral therapy: relatively nontheoretical approach to behavioral change or symptom reduction/eradication through application of principles of stimulus and response
Pediatric Considerations
Important distinctions are made between psychotherapy and counseling for children/teens compared to adults/couples.
The focus of evaluation must include attention to parent and family processes and factors. Interventions typically include interactions and sessions with parents as well as collateral work with teachers and other school personnel. 
Younger children will often be evaluated and diagnosed through behavioral descriptions provided by parents and other adults who know them well as well as through direct observation and/or play techniques. Children of all ages should be screened using behavioral checklists that are norm-referenced for
age.
Any child or teenager who requests counseling should be interviewed initially by the primary care provider and referred appropriately. Most referrals will be in response to parental request, however.
Psychotherapeutic interventions with the strongest empirical basis with children include behavior therapy/modification, CBT, and family/parenting therapy. Play therapy has the least empirical support, and insight-oriented therapies appear to be more effective with older children (>11 years).
There is controversy regarding the efficacy of psychopharmacologic treatment in preadolescents, although clear benefits have been demonstrated in some studies. Treatment guidelines for mild to moderate depressed mood and/or anxiety disorders typically recommend pediatric CBT initially, and studies
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have typically supported this approach in preteen and milder cases.
EPIDEMIOLOGY
~18.8 million adults suffer from clinical depression, and 20 million suffer from a diagnosable anxiety disorder.
One in four Americans report seeking some form of mental health treatment in their adult life. This includes generic counseling in nonmedical settings such as work, clergy, or school settings and also includes visits to primary care providers. It is estimated that between 3.5% and 5% of adults in the United States actually participate in formal mental health psychotherapy annually.
Public health experts report that the majority of those adults with diagnosable psychiatric disorders, however, do not receive professional mental health services. This is due to multiple factors, including failure to identify, noncompliance with psychiatric referral, regional shortages of providers, economic barriers, and excessive time duration from referral to available service.
Alarge study conducted between 1987 and 1997 concluded that the percentage of adults in psychotherapy remained relatively stable over that decade, the use of psychopharmacology doubled, and older adults (aged 55 to 64 years) increasingly sought psychotherapy services. In that same study, it was found that psychotherapy duration (number of sessions) decreased substantially and about 1/3 of psychotherapy patients only attended one or two sessions.
RISK FACTORS
The need for psychotherapy or counseling services is directly and indirectly associated with a host of socioeconomic and biogenetic factors, including the general effects of poverty, family or marital dysfunction, life stressors, medical diseases or conditions, and individual biologic predisposition to mental health disorders.
GENERALPREVENTION
It is generally assumed that early identification and intervention of child and adolescent psychopathology increases the likelihood of reducing the risk for adult psychopathology, but this has not been sufficiently validated in all categories of psychological disorders. Data support such claims in disorders such as childhood ADHD, anxiety disorders, and habit disorders of childhood, however.
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TREATMENT
GENERALMEASURES
There is evidence of a “dose effect” in psychotherapy outcomes research, with some investigators suggesting that 6 to 8 sessions are necessary to yield positive initial effects and upward of 15 to 20 sessions for longer term, sustainable therapeutic effects. This dose effect may not be applicable to counseling services with primarily informational or emotional/supportive functions. Also, long-term therapy should be evaluated at 6- to 12-month intervals to determine efficacy.
MEDICATION
Psychotherapy is most likely to be accompanied by use of pharmaceutical adjuncts in moderate to severe cases of psychological dysfunction that do not respond to other therapies or in cases of extremely poor quality of life or high risk. The most common examples are in cases of clinical depression or anxiety that clearly incapacitates the patient or significantly reduces his or her quality of life. Patients at risk for suicide or who represent a danger to others are also candidates for acute psychopharmacotherapy. Studies suggest that verbal and behaviorally oriented therapies can add efficacy to medication treatment in both depression and anxiety.
There is controversy in the research field regarding the efficacy of medication alone versus psychotherapy alone versus combined treatments. The most recent consensus has been that combined treatments in moderate to severe psychological dysfunction are most likely to render positive short-term results and increase the likelihood that such effects can be sustained over time.
ADDITIONALTHERAPIES
Anxiety disorders
–Panic disorder with and without agoraphobia: CBT, psychodynamic therapy
–Generalized anxiety disorder: CBT
–Obsessive-compulsive disorder: CBT
–Posttraumatic stress disorder: CBT
–Specific phobia: CBT
–Social phobia: CBT
Mood disorders
–Unipolar depression: CBT, interpersonal therapy, psychodynamic therapy
–Bipolar disorder: family therapy, interpersonal therapy, CBT
–Schizophrenia: psychodynamic therapy, family therapy, CBT
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Eating disorders
–Binge eating disorder: CBT, interpersonal therapy
–Bulimia nervosa: CBT, interpersonal therapy
Personality disorders
– Borderline: DBT, CBT 
Substance-use disorders
–Alcohol: counseling, CBT, motivational interviewing
–Cocaine: CBT, counseling
–Heroin: CBT, counseling
–Smoking: 5 A’s
Somatoform disorders:
–Hypochondriasis: CBT
–Body dysmorphic disorder: CBT
COMPLEMENTARY& ALTERNATIVE MEDICINE
Ahost of nonempirically based psychological and nutritional therapies can be found outside of mainstream medicine and psychological science. Very little or no evidence exists to support such experimental therapies, but all have the considerable power of the placebo effect fueling their anecdotal supports or claims. Placebo effects are also thought to be powerfully enhanced by the use of ingested or applied substances that create real physiologic, although not therapeutic, changes in the patient. If it makes them feel different, they are more likely to believe it helps.
ONGOING CARE
FOLLOW-UPRECOMMENDATIONS
Patient Monitoring
There is evidence of a “dose effect” in psychotherapy outcomes research, with some investigators suggesting that 6 to 8 sessions are necessary to yield positive initial effects and upward of 15 to 20 sessions for longer term, sustainable therapeutic effects. This dose effect may not be applicable to counseling services with primarily informational or emotional/supportive functions. Because many patients cease attendance to psychotherapy sessions after one or a few sessions, most interventions of this type cannot be accurately evaluated by the referring
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provider. Long-term therapy should also be evaluated for effectiveness at regular periods.
REFERENCES
1.American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.
2.World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva, Switzerland: World Health Organization; 1992.
ADDITIONALREADING
Bortolotti B, Menchetti M, Bellini F, et al. Psychological interventions for major depression in primary care: a meta-analytic review of randomized controlled trials. Gen Hosp Psychiatry. 2008;30(4):293–302.
Eddy KT, Dutra L, Bradley R, et al. Amultidimensional meta-analysis of psychotherapy and pharmacotherapy for obsessive-compulsive disorder. Clin Psychol Rev. 2004;24(8):1011–1030.
Furukawa TA, Watanabe N, Churchill R. Combined psychotherapy plus antidepressants for panic disorder with or without agoraphobia. Cochrane Database Syst Rev. 2007;(1):CD004364.
Hunot V, Churchill R, Silva de Lima M, et al. Psychological therapies for generalised anxiety disorder. Cochrane Database Syst Rev. 2007; (1):CD001848.
CODES
ICD10
Z71.9 Counseling, unspecified
Z71.89 Other specified counseling
Z63.9 Problem related to primary support group, unspecified
CLINICALPEARLS
Combined medication and psychotherapeutic treatments in moderate to severe
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psychological dysfunction are most likely to render positive short-term results and increase the likelihood such effects can be sustained over time.
Relapse is common over time and/or as treatments are discontinued.
Children <10 years may benefit significantly from counseling or psychotherapy alone for symptom relief.
Older children and those with more severe symptoms typically require psychopharmacologic options in concert with counseling or verbal therapy approaches.
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CROHN DISEASE
Eric Ji-Yuan Mao, MD 
Samir A. Shah, MD, FACG, FASGE, AGAF
BASICS
DESCRIPTION
Achronic, relapsing inflammatory GI tract disorder, most commonly involving the terminal ileum (80%)
Hallmark features of Crohn disease (CD)
–Transmural inflammation resulting in fibrosis, stricture, and fissures with sinus tract, abscess, or fistula formation
–Noncaseating granulomas (30%), crypt abscesses
–Skip lesions: segmental distribution of disease; may affect multiple bowel segments, interspersed with areas of normal mucosa; can also be continuous, mimicking ulcerative colitis (UC)
–Diverse presentations: ileocolitis (50%); isolated colitis (20%) are most common.
Early disease
–Ulcerations: focal lesions with surrounding edema, resembling aphthous ulcers
–Perianal disease (pain, anal fissures, perirectal abscess) may precede intestinal disease.
–May present as wasting illness or anorexia
Developed disease
–Mucosal cobblestoning; luminal stenosis; creeping fat; fissures between mucosal folds result in strictures/adhesions and/or fistulae.
EPIDEMIOLOGY
Incidence
8 to 15 cases/100,000 North American adults; incidence rising in North America and Western Europe
Bimodal age distribution: Predominant age is 15 to 25 years, with a second smaller peak at 50 to 70 years.
Women slightly more affected than men; increased incidence in northern
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