Nathan D. Zasler, M.D., Michael F. Martelli, Ph.D.
State of the Art Reviews
Physical Medicine and Rehabilitation
16: 1, Feb 2002
Hanley & Belfus
210 S. 13th Street, Phila, PA.19107
We are very proud to bring you this issue of State of the Art Reviews in Physical Medicine and Rehabilitation on the topic of functional disorders. As practitioners in the "trenches," we felt that there was a lot of misunderstanding regarding this special group of patients, particularly in the rehabilitation context. We often see patients who have unclear medical presentations, are recalcitrant to treatment, and appear to have significant psychological disturbances that are uncertainly intertwined with medical symptoms. Such patients typically end up with some type of "functional" diagnosis and are labeled as "chronic" and beyond help. As practitioners, we believe that it is important to not only better understand this patient population, but also be able to provide more effective rehabilitation services. We hope that this special issue of State of the Art Reviews serves to enlighten fellow readers regarding functional disorders in terms of both diagnosis and treatment.
We lead off with a general introduction to the topic of functional disorders with an insightful perspective by Dr. Lawrence Miller regarding the true spectrum of functional disorders. He ushers in a volume that is unencumbered by outdated models of mind body dualism. An interesting historical perspective on conversion disorders, as related to the issue of pain and hysteria, is then offered by Dr. Merskey. Next, English neurologist, Dr. Chaudhuri examines the clinical indications for neurodiagnostic tests in the evaluation of persons with functional disorders. Dr. Sella then provides us with an up-to-date review of objective assessment of soft tissue injuries given their propensity for being labeled as "functional disorders." Response bias detection in sensory disorders is then reviewed by Dr's. Ruchinskas and Maitan. More general symptom validity testing is subsequently reviewed by Dr. Johnson-Green.
Dr. Cripe then shares with us some of his perspectives on false psychonomies as they relate to differentiating organic from non-organic disease in the context of functional disorder assessment and treatment. Dr's Martelli and Zasler follow by discussing a brief biopsychosocial model of assessment and relevant psychological instruments that can provide information about a person's physiological, behavioral, and cognitive-affective vulnerabilities and strengths and guide treatment planning. Dr's Teasell and Shapiro provide us with a Canadian perspective on treatment of disorders by elaborating an inpatient program for treatment of conversion disorders. Some of the interdisciplinary challenges facing the treatment team providing rehabilitation services to persons with functional disorders are reviewed with in a chapter by Dr's. Speed and Mooney. An interesting and important chapter on the use of Amobarbital in pain and functional disorder assessment and management is then provided by Dr. Mailis and Dr. Nicholson.
Next, Dr. DeVore discusses emerging psychophysiologic models and methods for diagnosis and treatment. Finally, Dr's Roper and Martelli offer useful guidelines for providing feedback and making psychological treatment referrals to persons with functional medical disorders.
TABLE OF CONTENTS
WHAT IS THE TRUE SPECTRUM OF FUNCTIONAL DISORDERS?
Laurence Miller, PhD
Functional disorders in rehabilitation can cause diagnostic confusion, may result in ineffective or improvper treatment, and often contribute to lengthy and constly litigation in compensation and other forensic cases. This introductory chapter outlines the main diagnostic categories of psychological syndromes that may complicate rehabilitation cases, including somatization, conversion disorder, hypochondriasis, body dysmprphic disorder, factitious disorder, chronic pain, the postconcussion syndrome, posttraumatic stress disorder, personality disorders, and malingering. The chapter then elaborates a neuropsychological model that characterizes many of these disorders as neurosensitization syndromes that develop out of predisposing trait factors and exposure to traumatic and other life experiences. Neurosensitization may explain why many of the traumatic disability syndromes we see in rehabilitation seem to be so entrenched and difficult to treat. Finally, clinicians are urged to take a broad and educated view in diagnosing psychological syndromes in the rehabilitation setting and in planning effective treatments. .
TIME AND MEANING IN THE HISTORY OF PAIN AND HYSTERIA:
Harold Merskey, M.D.
The meaning of hysteria has changed from time to time throughout its long history. Some of these changes of meaning are described. Pain has often been entangled with the concept of hysteria, although some part of pain has always been recognized as physical in origin. The extent to which this has happened in different periods is outlined. Currently there are still concepts of pain and hysteria which are applied in standard diagnostic volumes although identification of much, if any, pain with hysteria has become increasingly suspect.
THE ROLE OF NEURODIAGNOSTICS IN FUNCTIONAL DISORDERS
A. Chaudhuri, MD
Neurological symptoms are common in functional disorders. Comparable functional symptoms in organic neurological or systemic medical disorders are also well recognized. Proper clinical assessment and use of appropriate technology reduces the risk of possible misdiagnosis. This review focuses on the evaluation of common pseudoneurological symptoms due to an underlying dissociative, conversion or somatizing disorder. The emerging role of functional neuroimaging in improving the understanding of hysterical neurologic syndromes is discussed and a hypothetical neuroanatomic template of hysteria is presented.
OBJECTIVE ASSESSMENT IN SOFT TISSUE INJURY
G. Sella, MD
Soft tissue injury is a subject of great relevance in the field of physical medicine.1 A number of parameters of clinical presentation of soft tissue injury, namely muscle and the myofascial mantle will be discussed in the present chapter. A specific focus on investigative methodology in terms of assessment of soft tissue injury symptoms parameters is the subject of this chapter. A special focus is intended for the documentation of the intensity of the symptomatology and the differential diagnosis of true soft tissue injury symptoms from those involving symptom magnification or functional overlay.2 The main parameters of focus of soft tissue injury & dysfunction are related to the presence of pain, functional loss of ROM and strength, muscular activity dysfunction, myofascial development and pain syndrome symptoms as well as radiation of the symptoms and dysfunctions. A number of objective tests are discussed within the context of soft tissue injury evaluation. These are: algometry, dynamometry, goniometry, S-EMG and myofascial pain syndrome investigative methods. The various methodologies are described within the detail necessary to stress the strengths and limitations of each method and the strength of testing with several methods, whenever necessary.
THE DETECION OF EXAGGERATED SENSORY SYMPTOMS?
Bob Ruchinskas, Psy.D. and Ian Maitan, MD.
Disorders of sensation that have no readily apparent cause are seen as part of everyday rehabilitative practice. We describe methods to detect obvious symptom exaggerations that defy known neuroanatomical facts. The detection of more complex cases often requires the use electrodiagnostic procedures or the use of forced-choice methods. Once identified, the treatment of such disorders is briefly described. Both the psychiatric and emerging neurological/biological models of causation of non-physiologic sensory symptoms are discussed.
SYMPTOM VALIDITY TESTING IN THE REHABILITATION SETTING:
Doug Johnson-Greene, Ph.D
Health professionals are often called upon to assess the validity of patient's symptoms and self-report. It has become increasingly clear that the question of symptom validity and patient self-report is complex and is mitigated by a multitude of factors, including facilitation due to secondary gain. Capitalizing on forced choice tasks and patient performance that is beyond the range of probability, symptom validity assessment has been shown to be a useful paradigm for evaluating the validity of patient self-report and symptoms. The approach has served as the genesis for many of the psychometric instruments that have been developed to measure patient motivation and symptom validity. The paradigm has been lauded for its empirical focus, superiority to traditional clinical judgment, and its ability to be tailored to characteristics of individual patients, making it a highly flexible tool for evaluating complex patient complaints in rehabilitation settings. The chapter concludes with practical considerations for utilizing symptom validity assessment in rehabilitation patients with emotional, cognitive, and somatic concerns
MALADY VERSUS MALINGERING: A TRICKY ENDEAVOR
Lloyd Cripe, Ph.D.
This chapter discusses the challenges of the diagnostic relationship in the detection of somatization and malingering. The general process of the diagnostic relationship, the doctor-patient relationship, the limits and hazards of detecting somatization and depception, the problems with psychological assessment procedures, and the complexities of the medicolegal diagnostic relationship in detecting somatization and malingering are discussed. It is concluded that the search for malingering is a tricky endeavor fraught with many challenging pitfalls. Guidelines for more effective diagnostic relationships in comoplicated cases are given. It is recommended that researchers and doctors put their energies into understanding the complex interaction of a person's psychology with disease and in developing positive diagnostic relationships rather than pursue a few potential malingerers.
USEFUL PSYCHOLOGICAL INSTRUMENTS FOR ASSESSING PERSONS WITH FUNCTIONAL MEDICAL
Michael F. Martelli, PhD and Nathan D. Zasler, MD
Functional medical disorders, defined in this volume as physical disorders and presentations in which psychological disturbances primarily influence symptomatology, are a prevalent and costly health care problem. Variability is the more the rule than the exception in terms of related outcomes. Clearly, psychological factors such as depression, anxiety, post traumatic stress, somatoform disorders, a variety of psychiatric syndromes, and more stylistic predispositions such as excessive somatic vigilance and external locus of control, are recognized as actively contributing to a patient's perceptions and responses to physical status and can represent significant impediments to optimal physical functioning and health and adaptation. As a result, it is becoming increasingly common for individuals who seek treatment for medical conditions with unclear etiology or symptoms or nonorganic manifestations to undergo a comprehensive assessment that evaluates, in addition to medical findings, psychoemotional status and personality variables, coping style and strategies, interpersonal relationship patterns, beliefs about one's health and physical condition, activity level and quality of life, among many other nonmedical variables. Psychological assessment instruments that provide information about a person's physiological, behavioral, and cognitive-affective functioning in terms of vulnerabilities and strengths can, in the hands of experienced clinicians, be a valuable tool for treatment providers. In the present chapter, a brief biopsychosocial conceptual model is offered, along with descriptions of a representative list of methodological instruments that have utility for evaluating relevant variables in persons with conditions that have significant psychological contributions.
A TREATMENT MODEL FOR CONVERSION DISORDER
Robert Teasell, MD and Allan Shapiro, PhD
A unique rehabilitation program has been developed to treat patients with conversion disorders presenting as either paralysis or ataxic-like (astasia-basia) complaints and signs. Treatment with a standard rehabilitation approach is only successful in those patients who suffer from acute conversion disorders, defined as signs and symptoms lasting less than one month. An alternative "strategic-behavioral" rehabilitation approach was developed for intractable cases utilizing the "double bind" as its primary method of behavioural modification. This program has proven to be successful, particularly for the very difficult chronic conversion disorder patients, where the standard rehabilitation program failed to provide a benefit.
INTERDISCIPLINARY CHALLENGES IN TREATMENT:
John Speed, MBBS and George Mooney, PhD.
This chapter describes some of the barriers to successful treatment that sometimes arise when conversion disorder is treated within an interdisciplinary treatment context. Common interdisciplinary barriers to treatment can occur in some of the following areas: negative emotional reactions on the part of clinical staff toward conversion disorder patients, staff misunderstandings and resentment toward patients, skepticism about symptom legitimacy, misunderstandings about the unconscious nature of symptoms, and concern about overlooked, underlying organic disease. Issues of staff communication and consistency of how the treatment approach is applied and also consistency about how the diagnosis is discussed with the patient can also be important interdisciplinary topics in successful treatment. Management strategies intended to cope with these obstacles to treatment are proposed. Through an awareness of some of the interdisciplinary barriers to treatment and by initiating strategies to mitigate those barriers, more successful treatment outcomes can probably be achieved for patients with conversion disorder.
THE USE OF SODIUM AMYTAL IN THE ASSESSMENT AND TREATMENT OF FUNCTIONAL OR OTHER DISORDERS
Angela Mailis, MD and Keith Nicholson, PhD
The literature concerning the use of sodium amytal (SA) in the assessment and treatment of functional and other disorders is reviewed. Whereas there are numerous case-series or case reports indicating that SA may be useful for a wide variety of purposes, few controlled studies exist. Particular attention is paid to the issue of chronic pain and research conducted at the Toronto Western Hospital, Toronto, Canada, where SA infusion has been found to produce dramatic resolution of certain types of chronic pain, and modify a variety of somatosensory abnormalities. Possible mechanisms of effect of sodium amytal are explored. We conclude that SA may be useful in demonstrating the functional nature of a wide variety of disorders and that it is a particularly useful diagnostic tool in chronic pain patients. Its value as a therapeutic tool in functional and pain disorders, however, is unclear, while its mechanisms of action remain speculative. The issue of organic versus functional disorders is revisited and recommendations for future research are made.
APPLIED PSYCHOPHYSIOLOGY: STATE OF THE ART
Jerry R. Devore, PhD, ABPP
Nearly everyone has read something about biofeedback; the term became a household word in the late 1960s and early 1970s. Applied psychophysiology and biofeedback have a broad scope ranging from the clinical settings of psychotherapy and health care to a number of areas including performance enhancement and ergonomic applications to increase work efficiency and worker productivity and to decrease injury. This chapter explores the history of biofeedback and applied psychophysiology, the various modes used, clincal areas, neurologic disorders, and future directions.
PROVIDING USEFUL DIAGNOSTIC FEEDBACK TO PATIENTS WITH FUNCTIONAL MEDICAL DISORDERS AND MAKING REFERRALS FOR TREATMENT
Brad L. Roper, PhD and Michael F. Martelli, PhD
Persons with functional medical disoders typically present with somatic focus and entrenched belief systems. The process of providing diagnostic feedback and making referrals for psychological treatment can be an especially challenging task. Taking advantage of an appreciation of the complex interactions that occur in functional medical disorders, the authors present a useful model and explicate a method designed to optimize this process.
SURVEY OF INDICATORS SUGGESTIVE OF NON-ORGANIC PRESENTATIONS AND SOMATIC, PSYCHOLOGICAL AND COGNITIVE RESPONSE BIASES.
Michael F. Martelli, PhD and Nathan D. Zasler, MD