http://villamar.ipower.com/State of the Art Reviews Abstracts & Chapt Links.htm
State of the Art Reviews
in
Physical Medicine and Rehabilitation
16: 1, Feb 2002
Hanley & Belfus
(Publisher Has Discontinued Science Division)
Phone: 215-546-7293
Fax: 215-790-9330
PREFACE TO
FUNCTIONAL MEDICAL DISORDERS IN REHABILITATION
MEDICINE
Edited By
Nathan D. Zasler, M.D., Michael F. Martelli, Ph.D.
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. Laurence 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 He ushers in a volume that is unencumbered by outdated models of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.
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TABLE OF CONTENTS
Introduction
Nathan D. Zasler, MD and
Michael F. Martelli, PhD
http://villamar.ipower.com/FDIntro.pdf
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. .
http://villamar.ipower.com/FD1Miller.pdf
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.
http://villamar.ipower.com/FD3Merskey.pdf
THE ROLE OF
NEURODIAGNOSTICS IN FUNCTIONAL DISORDERS
A.
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 .
http://villamar.ipower.com/FD6Chuadhuri.pdf
OBJECTIVE ASSESSMENT
IN SOFT TISSUE INJURY
G.
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.
http://villamar.ipower.com/FD7Sella.pdf
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.
http://villamar.ipower.com/FD9RuchinskasMaitin.pdf
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
http://villamar.ipower.com/FD10JohsonGreene.pdf
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.
http://villamar.ipower.com/FD8Cripe.pdf
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.
http://villamar.ipower.com/FD12Martelli.Zasler.pdf
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.
http://villamar.ipower.com/FD4TeasellShapiro.pdf
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.
http://villamar.ipower.com/FD5SpeedMooney.pdf
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.
http://villamar.ipower.com/FD11MailisNicholson.pdf
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.
http://villamar.ipower.com/FD2DeVore.pdf
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.
http://villamar.ipower.com/FD13RoperMartelli.pdf
APPENDIX A
Survey
of indicators suggestive of non-organic presentations and somatic,
psychological and cognitive response biases.
Michael F. Martelli, PhD
and Nathan D. Zasler, MD
http://villamar.ipower.com/FDAppendix.pdf
INDEX
http://villamar.ipower.com/FDIndex.pdf