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Chronic Medical Illness and Rehabilitation
Overview
Most of us take our ability to function physically (e.g., to open a tube of toothpaste, answer the telephone, tie our shoelaces, use the toilet, or comb our hair) and cognitively for granted. However, these capabilities can be lost suddenly after an accident (e.g., with a traumatic brain injury [TBI]; spinal cord injury [SCI]; an extensive burn); the onset of a debilitating chronic illness (e.g., cancer, multiple sclerosis, epilepsy); or an exacerbation of a pre-existing illness (e.g., an amputation associated with diabetes, seizures after an anoxic encephalopathy, stroke complicating lupus). For individuals with these conditions, rehabilitation is usually indicated to help restore lost function. However, despite rehabilitation, some aspects of everyday function never return.
Psychiatrists who consult such patients need to reconcile their need to offer such patients support with their limited personal experience with such sudden or chronic loss of function, as well as with the realism that complete recovery may not ultimately be obtained. This challenges the psychiatrist's ability to understand and to develop a therapeutic alliance with patients undergoing rehabilitation. In such cases, the psychiatrist needs to acknowledge this limitation and develop alternative strategies, such as recruiting assistance of others who have had personal experience with loss of function.
Further, the need to help patients maintain hopefulness, while accepting limitations and grieving losses of function, runs counter to the physician's typical focus on achieving a full recovery.
This chapter addresses such challenges faced by patients with chronic medical conditions and by the psychiatrists who treat them. The focus is on inpatient rehabilitation, though similar principles apply when consulting patients in other settings.
Diagnostic Considerations
While certain psychiatric conditions (depression, cognitive impairment, adjustment disorders, and behavioral difficulties) are more common in patients undergoing rehabilitation, diagnostic criteria are often not met because the symptoms of DSM-5 and ICD-10 are often similar to those associated with the patient's injury. As a result, diagnosis in rehabilitation focuses more on symptom constellations than it does in other settings.
Typically, symptoms are myriad in the rehabilitation setting ( Figure 33-1 ). When evaluating a patient undergoing rehabilitation, the psychiatric consultant should consider that the incidence rates of psychiatric syndromes are higher in this population. For example, depression, among amputees may be as high as 58%; for those with multiple sclerosis, it may be seen in up to 27%; and for those with cancer, it has been seen in up to 25%. Further, the prevalence of suicide and of suicidal intent is also substantially higher among patients undergoing rehabilitation. Individuals with cancer have suicide rates that are 15 to 20 times greater; those with spinal cord injuries have a rate 15 times greater; and those with multiple sclerosis have a rate 14 times greater, than those in the general population.
Phases of Rehabilitation
The phases of rehabilitation help to contextualize symptom presentation. As outlined in Figure 33-1 , patients' progression through rehabilitation can be viewed via a three-stage model. During the initial phase of inpatient rehabilitation (following one's transition from the acute medical hospital), psychiatric issues often arise, related to agitation and resolving states of physiologic hyperarousal.
During the middle phase, the rehabilitation patient's denial of a deficit related to his/her injury is the most common reason for psychiatric consultation. During this phase, patients often have difficulty accepting their deficit, either due to neurologically based anosognosia, or, more commonly, to anxiety about their deficits. This results in a need to re-visit the therapeutic contract and develop strategies to acknowledge deficits so that functional recovery can proceed. If denial of a deficit is not interfering with rehabilitation, it can generally be addressed later. Frustration related to the lengthy rehabilitation and uncertainty about long-term prognosis increases during the middle phase of treatment. Emotional stress in rehabilitation is typically highest during this phase and most discharges against medical advice (AMA) occur during this phase.
As rehabilitation progresses, patients start to focus on their anticipated loss of support from the hospital staff following discharge, their need for increasingly independent function, concern about whether outpatient care will be adequate to manage residual deficits, and increased concerns about anticipated gains that have not been met. During this phase, interventions that help with discharge-related anxiety include: bridging discharge plans (through active communication between inpatient and outpatient rehabilitation staff prior to discharge), focusing on gains that have been met, and tailoring the discharge planning to the patient's and/or family's particular concerns.
The progression through different rehabilitation settings and the phases of physical and emotional recovery during inpatient rehabilitation, parallels movement through Maslow's hierarchy of needs ( Figure 33-1 ). Considering the questions listed in Table 33-1 , can help to identify the basis for psychiatric symptoms seen during each phase of rehabilitation, whether they surround the formation of an initial contract, increased awareness of deficits during rehabilitation, or stress related to discharge.
Table 33-1
Key Questions in Developing a Treatment Plan for Psychiatric Symptoms Interfering With Goals of Rehabilitation
- 1.
Is the patient in agreement with the goals that the staff has in mind for the patient's rehabilitation?
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→ If yes go to question 2
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→ If no address reason for disagreement with noted concern before addressing question 2
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- 2.
Does the patient agree that the proposed intervention will help resolve the identified goal?
-
→ If yes move to question 3
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→ If no address reason for disagreement on usefulness of a rehabilitation intervention
-
- 3.
Does the patient agree that a potentially useful intervention should be undertaken?
-
→ If yes move to question 4
-
→ If no address why the patient objects to pursuing a treatment even though they feel it would result in improvement, before addressing question 4
-
- 4.
Is the patient motivated (does he/she want) to participate in the proposed intervention?
-
→ If yes go to question 5
-
→ If no address motivational issues for moving to question 5
-
- 5.
Does the patient participate in treatment?
-
→ If yes, no further intervention is recommended
-
→ If no, address resistance to participation in planned intervention
-
While progressing through rehabilitative phases, the patient and family typically experience an iterative process involving relief and discouragement. As with other developmental transitions, enthusiasm about functional improvements is often followed by sadness associated with an increased awareness of the deficit being remediated (e.g., after the amputee has gained the ability to walk with a prosthetic device there is increased awareness of the lost limb). The degree of sadness associated with the increased awareness of improvements during rehabilitation varies with how vital that function was for a given individual. For example, awareness of the lost limb often has more impact on a patient who had been athletic compared with one who was more sedentary. Thus, the psychiatric consultant should anticipate a higher degree of sadness and demoralization in the former patient than the latter. In contrast, for the patient with more sedentary and cognitively based interests, increased awareness of deficits during the phases of rehabilitation after a TBI may carry a particularly strong negative valence . Furthermore, the consulting psychiatrist should anticipate that a patient's tolerance for feelings of discouragement that accompany progress during rehabilitation will vary with the patient's level of pre-morbid stress tolerance. Less resilient patients are usually prone to greater exacerbations of pre-existing psychiatric symptoms during their hospitalization. Therefore, assessment of pre-morbid coping style and vocational/recreational interests will help the psychiatric consultant to contextualize levels of emotional distress during rehabilitation. These shifts in hopefulness that occur at the various stages are illustrated in the case example ( Case 1 ).
Case 1
Example of Psychiatric Consultation in a Patient With Traumatic Brain Injury
Ms. V, a 20-year-old woman, was admitted to the rehabilitation hospital following a severe motor vehicle accident (that led to multiple orthopedic injuries as well as TBI involving a frontal-temporal and thalamic intracranial bleed). Her presentation was complicated by a history of social service involvement and a history of disruptive behavior and substance use.
During the initial phase of recovery, psychiatric consultation focused on helping the family cope with anxiety as their focus shifted from relief that she had survived a near lethal injury to the fact that she was still minimally responsive 2 weeks after being brought out of a chemically induced coma. In addition to supportive interventions for the family, psychoeducation was provided to help them understand the steps that could be taken to help facilitate increased cognitive arousal. With their approval, amantadine was prescribed and gradually titrated to the maximum dose (150 mg BID), while a cognitive arousal protocol was implemented in speech, occupational, and physical therapy. On HD#3, the patient opened her eyes and began to show volitional eye tracking, non-verbal responses, and purposeful movements for the first time since the injury. Renewed relief ensued which was followed by discouragement that no verbal responses had returned. The patient was alert enough to participate in forming an initial contract about her treatment and both the patient and her parents, and family members agreed on the main goal in all three rehabilitation therapies. Further, agreement on addressing her still dysregulated sleep cycle and level of disorientation was agreed upon as part of the “initial contract”. Trazodone and melatonin were prescribed and insomnia improved, and behavioral strategies to facilitate orientation were initiated. On HD#7, she began to whisper non-meaningful sounds that progressed to two-word responses by HD#10. Increased relief and hopefulness during this period was followed by renewed anxiety and some pessimism about her recovery, as getting to longer verbal expressions was difficult and as short-term memory impairments became more apparent in assessments (could only hold one object in memory).
During the middle phase of rehabilitation, the discrepancy between the increased alertness but still limited short-term memory and other cognitive capacities was associated with a period of increased agitation, impulsivity, and perseveration. Some hypersexual behaviors (exposure of genitals in public) were also noted. As is typical during this period, there was increased tension between patient and staff, among family members, and among staff about why progress had slowed and how to manage the increased impulsivity, agitation, and perseveration. These issues were addressed with new approaches in rehabilitation (increased sensory focus in occupational therapy [OT] and physical therapy [PT] and shifting the focus to short-term memory deficits in speech). The agitated behavior scale was charted 5×/day in order to objectively track the effect of interventions on the target symptoms of impulsivity, aggression, and sensory-seeking behavior. Behavioral strategies to help with these symptoms were instituted through nursing and social work (e.g., use of a netbed to prevent her trying to walk to the bathroom when she had not yet recovered this function; use of abdominal binder to protect the G-tube; presenting her with a daily schedule before starting the day, with this divided so the length of information provided was appropriate to her cognitive capacity, and asking the patient to repeat back the information). Pharmacologic interventions during this phase were cross-tapering trazodone (50 mg) to quetiapine (50 qhs and 12.5 am) to address agitation and insomnia, low-dose SA methylphenidate (weaned up to 5/2.5 due to sensory and sleep side effects at higher doses), and clonidine 0.5 TID, and fluoxetine 10 mg qd was started as the agitation subsided. As the periods of agitation resolved, the alliance with the treatment team improved and the patient was able to re-engage in further therapy. Substantial gains accrued during this phase (HD #20–30). In speech, short-term memory, processing speed, and confabulation improved (earlier in this phase she would respond that the physical therapist [PT] was her gym teacher when she couldn't remember her name between sessions). In PT, she started to stand and then walk for short distances with minimal assistance, and in OT she was able to become independent with transferring from her wheelchair to the bathroom. Her mood improved and while she had periods of tearfulness and sadness about residual deficits, she gradually become less overwhelmed by these and the frequency and duration of euthymic mood states increased, and her affective state dysregulation decreased.
During the late phase of her rehabilitation, she started to engage with other patients during recreational therapy and tolerated successful visits from her best friend. This was timed with increased discharge planning about re-entry to her home environment, outpatient rehabilitation supports that would be needed, and home renovations that had to be made for wheelchair accessibility, as the patient was only beginning to regain walking at the time of discharge. Significant residual deficits remained that were addressed in outpatient long-term rehabilitation, as she entered the late phase of rehabilitation. At this point, the focus shifted to planning the appropriate supports for discharge to outpatient rehabilitation. Psychiatric consultation was provided to support the many gains that she had made during her rehabilitation while validating anxiety and sadness about coping with continued functional deficits with less supports than they had within the inpatient hospital.
Developmental Factors
In addition to the patient's phase of progression through rehabilitation, certain stages of childhood and adult development helped to contextualize the diagnostic questions posed for the psychiatric consultant. For example, functional losses from illness or injuries that occur during critical developmental periods in childhood are particularly refractory to rehabilitation (e.g., aphasia from a stroke occurring during the peak of language development). In contrast, illnesses that result in physical losses that occur outside of critical developmental periods are more responsive to rehabilitation when they occur proximal to the developmental period of that function (limb amputation due to congenital conditions has less psychiatric co-morbidity than when they occur after functional use of that limb has developed). Therefore, just as the patient with athletic interests may be more susceptible to distress associated with an amputation, an injury-based amputation will generally lead to greater emotional distress than in a patient whose amputation resulted from a chronic illness (such as diabetes) or a congenital abnormality.
Symptom Type and Intensity
Symptom type and intensity help distinguish normal from problematic adjustment reactions. As in most other areas of consultation–liaison (C–L) psychiatry, distinguishing “normal reactions” due to injury-related stress or illness-related stress is often vital. While this determination can be subjective, some general guidelines help to make this distinction.
Criteria that distinguish normal grief and normal stress reactions from pathologic grief or a stress disorder, help to separate normal from problematic adjustments during recovery. Specifically, self-blame, guilt, refusal to participate in a therapeutic rehabilitation or recreational therapy, agitation (that involves physical or verbal aggression), panic attacks, psychotic symptoms, and suicidal or homicidal ideation, usually suggest an atypical and problematic adjustment.
Prioritizing non-somatic over somatic symptoms of depression, as identified by the use of the Hospital Anxiety and Depression Scale, generally provides a more accurate assessment of depression and anxiety in rehabilitation patients. Still, a change in somatic symptoms, if it follows the trajectory of change in non-somatic depressive symptoms, should be part of this assessment.
Periods of sadness, tearfulness, anticipatory anxiety, resistance to participation in a therapeutic intervention (as long as it can be overcome with behavioral interventions), helplessness, and even hopelessness, are frequently normal reactions to the stress of adjusting to a physical impairment during rehabilitation. With regard to these latter symptoms, their frequency, intensity, and duration should decrease over time. While such symptoms wax and wane in intensity during treatment, they typically trend toward improvement as time passes. If symptom intensity is high or an overall trajectory of improvement is not apparent, then the consultant should consider whether an emotional response consistent with an adjustment reaction has developed into another syndrome.
Symptoms That Interfere With the Goals of Rehabilitation
Considering whether a particular symptom is impacting progression in rehabilitation helps to differentiate whether a symptom (such as tearfulness) is consistent with a normal adjustment reaction or at an intensity level that qualifies for a problematic adjustment. Asking rehabilitation staff about a change in a patient's motivation and their engagement in rehabilitation also helps in distinguishing normal from problematic adjustments. Finally, consideration of responses to reassurance, particularly from staff and/or family to whom the patient has previously responded positively, usually indicates that an adjustment reaction has evolved into something of greater concern.
Increased severity of symptoms during rehabilitation should be considered in light of the phases of rehabilitation (outlined in Figure 33-1 ). Namely, if symptoms of an adjustment reaction become more intense or impairing during the middle phase, they may be a response to issues during this phase, such as frustration about limited progress. If they appear in the mid-phase response, then the consulting psychiatrist would have a higher threshold for understanding symptoms as part of an evolving depression.
Psychiatric Look-Alikes
Psychiatric look-alikes are particularly important diagnostic considerations in rehabilitation. The psychiatric consultant needs to consider that symptoms (e.g., severe agitation, impulsivity, unprovoked aggression, or unusual levels of moaning) that indicate a problematic adjustment or another psychiatric syndrome have a higher-than-usual likelihood of arising secondary to a physiologic condition related to injury or illness. Here, the phases of rehabilitation outlined in Figure 33-1 can also be helpful. An overview of the brain circuits involved in response to and recovery from a physical injury or illness is shown in Figure 33-2 .
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