Is your practice really that predictable? Nonlinearity principles in family medicine

,

Applied Evidence

Is your practice really that predictable? Nonlinearity principles in family medicine

J Fam Pract. 2005 November;54(11):970-977

PDF Download

References

1. Freeman W. Physiology of perception. Sci Am 1991;264:78-85.

2. Barton S. Chaos, self-organization, and psychology. Am Psychol 1994;49:5-14.

3. Guastello S. Chaos, Catastrophe, and Human Affairs. Mahwah, NJ: Erlbaum, 1995.

4. Dendrinos D, Sonis M. Chaos and Socio-Spatial Dynamics. New York: Springer Verlag, 1990.

5. Cheng Y, Van de Ven AH. Learning the innovation journey. Organization Sci 1996;7:593-614.

6. Dooley K, Johnson T, Bush D. TQM, chaos, and complexity. Hum Syst Mgmt 1995;14:1-16.

7. Dooley K. Complex adaptive systems model of organizational change. Nonlinear Dynamics, Psychology, and the Life Sciences 1997;1:69-97.

8. Arthur WB. Economy and complexity. In: Stein DL, ed. Lectures in the Sciences of Complexity. Redwood City, Calif: Addison-Wesley, 1989;713-740.

9. Gottschalk A, Bauer MS, Whybrow PC. Evidence of chaotic mood variation in bipolar disorder. Arch Gen Psychiatry 1995;52:947-959.

10. Goldberger AL. Nonlinear dynamics for clinicians. Lancet 1996;347:1312-1314.

11. Hull RL. Chronobiology and chronotherapeutics in disease states. Drug Benefit Trends 2002;14:31-42.

12. Breier A, Charney DS, Heninger GR. Agoraphobia with panic attacks. Arch Gen Psychiatry 1986;43:1029-1036.

13. Sheridan MS, Kostlany F. SIDS and chaos. Med Hypotheses 1994;42:11-12.

14. Wilson T, Holt T. Complexity and clinical care. BMJ 2001;323:685-688.

15. Rado JP. Change in antikaliuretic response to potassium-sparing diuretics in patients with cirrhotic ascites. J Am Geriatr Soc 1976;24:340-343.

16. Kraft M, Martin RJ. Chronobiology and chronotherapy in medicine. Dis Mon 1995;41:503-575.

17. Nagayama H. Influences of biological rhythms on the effects of psychotropic drugs. Psychosom Med 1999;6:618-629.

18. Pruessner HT, Hensel WA, Rasco TL. Scientific basis of generalist medicine. Acad Med 1992;67:232-235.

19. Miller WL, Crabtree BF, McDaniel R, Stange KC. Understanding change in primary care practice using complexity theory. J Fam Pract 1998;46:369-376.

20. O’Connor PJ, Crabtree BF, Yanoshik MK. Differences between diabetic patients who do and do not respond to a diabetic care intervention. Fam Med 1997;29:424-428.

21. Jarvis AN. Taking a break. Dissert Abstr Intl 1997;57(10-B):6605.-

22. Boughton MA. Premature menopause. J Adv Nurs 2002;37:423-430.

23. Forsyth DM. Families and the life transition of first time mental illness. Dissert Abstr Intl 1995;56(4-B):1935.-

24. Goldberger AL, Bhargava V, West BJ, Mandell AJ. Nonlinear dynamics of the heart beat. Physica 1985;17D:207-214.

25. Moleiro F, Misticchio F, Mendoza I, Rodriguez A, Costellanos A, Myerburg RJ. Paradoxical behavior of PR interval dynamics during exercise and recovery and its relationship to cardiac memory at the atrioventricular node. J Electrocardiol 2001;34:31-34.

26. Warren K, Sprott JC, Hawkins RC. Spirit is willing. Nonlinear Dynamics Psychol Life Sci 2002;6:55-70.

27. Weiss MJS, Wagner SH. What explains the negative consequences of adverse childhood experiences on adult health? Am J Prev Med 1998;14:356-360.

28. Campbell WG. Is self-organized criticality relevant to alcoholism? J Addict Dis 1997;16:41-50.

29. Pincus D. Framework and methodology for the study of nonlinear, self-organizing family dynamics. Nonlinear Dynamics Psychol Life Sci 2001;5:139-173.

30. Koopmans M. Chaos theory and the problem of change in family systems. Nonlinear Dynamics Psychol Life Sci 1998;2:133-148.

31. Piqueira JRC, Monteiro LHA, De Magalhaes TMC, Ramos RT, Sassi RB, Cruz EG. Zipf’s law organizes a psychiatric ward. J Theor Biol 1999;198:439-443.

32. Christini D, Collins J, Linsay P. Experimental control of high dimensional chaos. Physical Rev E Stat Nonlin Soft Matter Phys 1996;54:4824-4827.

33. Regalado A. Gentle scheme for unleashing chaos. Science 1995;268:1848.-

34. Kauffman SA. Origins Of Order. New York: Oxford University Press; 1993.

35. Klinkman MS, Schwenk TL, Coyne JC. Depression in primary care-more like asthma than appendicitis. Can J Psychiatry 1997;42:966-973.

36. Wells KB, Burnam A, Camp P. Severity of depression in prepaid and fee-for-service general medical and mental health specialty practices. Med Care 1995;33:350-364.

37. Katerndahl D, Realini JP. Patients with panic attacks seeking care from family physicians compared with those seeking care from psychiatrists. J Nerv Ment Dis 1998;186:249-250.

38. Reis SE, Holubkov R, Edmundowicz D, et al. Treatment of patients admitted to the hospital with congestive heart failure. J Am Coll Cardiol 1997;30:733-738.

39. Schulberg D, Gottlieb J. Dynamics and correlates of microscopic changes in affect. Nonlinear Dynamics Psychol Life Sci 2002;6:231-257.

40. Ehlers CL. Chaos and complexity: can it help us to understand mood and behavior? Arch Gen Psychiatry 1995;2:960-964.

41. Wilder J. Modern psychophysiology and the law of initial value. Am J Psychother 1958;12:199-221.

42. Uhlenhuth EH, Matuzas W, Warner TD, Paine S, Lydiard RB, Pollack MH. Do antidepressants selectively suppress spontaneous (unexpected) panic attacks? J Clin Psychopharmacol 2000;20:622-627.

43. Nash JS, Carrato RR, Dlutowski MJ, O’Connor JP, Nash DB. Generalist versus specialist care for acute myocardial infarction. Am J Cardiol 1999;83:650-654.

44. Chen J, Redford MJ, Wang Y, Krumholz HM. Care and outcomes of elderly patients with acute myocardial infarction by physician specialty. Am J Med 2000;108:460-469.

45. Katon W, Von Korff M, Lin E, et al. Collaborative management to achieve treatment guidelines. JAMA 1995;273:1026-1031.

46. Lyketsus CG, Taragano F, Triesman GJ, Paz J. Major depression and its response to sertraline in primary care versus psychiatric office practice patients. Psychosomatics 1999;40:70-75.

47. Thomas L, Mulsant BH, Solano FX, et al. Response speed and rate of remission in primary and specialty care patients with depression. Am J Geriatr Psychiatry 2002;10:583-591.

Alcoholism serves as an attractor, controlling not only the patient’s behavior, but the behavior of the family.¹⁸ Attractors limit the range of possible behaviors and thereby resist or limit changes in a patient’s course. Attractors may be internalized models or belief systems that lead to recurring patterns of behavior, even though sensitivity to initial conditions prevents one from predicting the specific path the system will follow; patterns are predictable, the path followed is not. The combination of attractors and sensitivity to initial conditions ensures nonlinearity.

Alcoholism is not the only example of a factor that molds behavior and resists change. Our lives are governed by repeating patterns of behavior. Lifestyle routines are deeply ingrained and resist change even for medically important reasons. These lifestyle patterns may be due to attractors and may explain the resistance to change that many of our diabetic patients exhibit. Similarly, dysfunctional families often display counterproductive patterns of behavior that are resistant to even the best counseling.

Implications for management. The presence of attractors suggests several implications for patient management.

FAST TRACK

Patterns are predictable; the path that will be followed is not

First, we should anticipate resistance and not be frustrated when it occurs.

Second, we can attack the attractor itself,¹⁹ by identifying another, more positive attractor in the patient’s life and reinforcing it to diminish the negative attractor’s impact. For example, instead of simply criticizing the inactive lifestyle ingrained in a hypercholesterolemic patient, we reinforce the positive attractor of the patient’s affection for his grandchildren and use that attractor to get the patient to exercise.

For strongly negative attractors (eg, alcohol use), we could simply attack the attractor itself without providing an alternate attractor. Though this approach is more risky because of the unpredictability of what the patient will substitute, if the attractor is bad enough, we may be willing to allow the patient to choose any other attractor, assuming that it must be more positive than the original.

For the patient above, simply attacking the negative attractor may lead to other negative behaviors (eg, smoking). The best approach may be to focus on positive attractors (ie, wife, children, social relationships, hobbies), perhaps even positive attractors for the entire family, to move him or them away from the negative attractor.
For the practitioner, it is imperative to identify the attractors producing recurrent detrimental behaviors that need to be changed. Using attractors for management means that potential positive attractors need to be identified through exploration with patients and reinforced while attacking the negative attractors currently producing the unhealthy behavior.

Case 3: Bifurcation effects

B.I. is a 50-year-old plumber who has had type 2 diabetes for more than 10 years. Though he has regularly seen his physician and taken his medications, his diabetes control has been poor (hemoglobin A_1c=10.2). He admits that compliance with his diet and exercise has been “spotty” at best. Six months ago, his older brother began dialysis for end-stage renal disease secondary to diabetes. Within 1 week of his brother’s first dialysis session, B.I. began walking 30 minutes each night and eliminated evening snacks. Consequently, he has lost 22 pounds, and his hemoglobin A_1c has dropped to 8.1.

FAST TRACK

Sudden dramatic changes can occur in a nonlinear system as it reaches a “tipping point”

Sudden dramatic changes (bifurcations) can occur in nonlinear systems as the system reaches a “tipping point.” In this case, chronic noncompliance suddenly changed to compliance after a meaningful event.²⁰ These bifurcations represent a qualitative change in behavior linked to a change in an attractor. Hence, epiphanies may represent behavioral bifurcations.²¹ Such epiphanies are important in premature menopause²² and initial family decisions to hospitalize a mentally ill relative.²³

Bifurcations have been best documented in cardiovascular disease. Pulsus paradoxicus, pulsus alternans in congestive heart failure (CHF), and cardiac movement in tamponade reflect bifurcations in the system as minor changes cause the system to cross a “tipping point” and produce sudden drastic effects.¹⁰ Similarly, bifurcations in heart rhythm are seen in sick sinus syndrome and ST-T alternans in ventricular tachycardia.²⁴ Paradoxical behavior of the PR interval²⁵ and the disastrous effect of the R-on-T phenomenon are other examples. However, bifurcation dynamics are also important in psychosocial behavior. Sudden drastic changes in mood have been documented in patients with generalized anxiety disorder.²⁶

Implications for management.

For the patient above, we can first look for events that could serve as epiphanies (eg, development of lung cancer in a relative of our tobacco-dependent patient) and use them to alter behavior. Many physicians already look for consequences of diabetes in friends and relatives to motivate their patients.
For the practitioner, the existence of bifurcations implies that sudden unforeseen behavior should be expected and should not be a source of frustration. From a management perspective, drastic changes in patient behavior can be achieved by exploring patients’ lives and recognizing and reinforcing epiphanies.