role of the psychologist in rehabilitationvillamartelli.com/psych_in_rehabssmpr2pp.pdfdefined as the...

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Role of the Psychologist inRehabilitationRehabilitation::Appreciating and Countering MultipleAppreciating and Countering MultipleContributors to Impairment & DisabilityContributors to Impairment & Disability

Michael F. Martelli, Ph.DConcussion Care Centre of Virginia, and Tree of Life10120 West Broad Street, Suites G - HGlen Allen (Richmond), Virginia 23060

Email: [email protected] /VillaMartelli Disability Resources Website

http://villamartelli.com

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Recovery & AdjustmentRecovery & AdjustmentFollowing Insult or IllnessFollowing Insult or IllnessIf the Structure Tests say they Can, They Might NotIf the Structure Tests say they Can, They Might NotIf the Structure Tests say they Can't, They MightIf the Structure Tests say they Can't, They Might

Injury

ExceptionalExceptional

PremorbidPremorbidVulnerabilitiesVulnerabilities

ComorbidComorbidVulnerabilitiesVulnerabilities

ExpectedExpected

ContextualContextualFactorsFactors

AtrociousAtrocious

Removing Obstacles toRemoving Obstacles toIndependenceIndependenceAccessing Opportunities forAccessing Opportunities for

Stepwise AchievementsStepwise Achievements (Of Desired(Of Desired

Goals)Goals) in the areas of Love, Workin the areas of Love, Workand Play!and Play!Changing Destiny!Changing Destiny!

REHABILITATIONREHABILITATION

The Systematic Process of:

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CatastrophicCatastrophicReactionReaction

Early: AcuteOverwhelming

Anxiety /Distress

COPINGSuccessful -

MaximalRecovery/

Adaptation

Unsuccesssful

FailureProducing/ProgressBlockingAttitudes

Deterioration

Catastrophic Reaction: Goldstein's term for theextreme depression he observed after left-hemisphere lesions.

"We have characterized the conditions of brain-injured patients, when faced with solvable andunsolvable tasks, as states of ordered behavior andcatastrophic reaction. The [latter] show all thecharacteristics of anxiety."

Organism in struggle to cope with the challenges ofenvironment and own body.

Whole; Cannot be divided into "organs" or "mind" &"body"

"Disease" = changed state with the environment.Healing comes not through "repair" but through

adaptation to conditions causing the new state

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Common PersonalityDisturbances Following TBI(Prigatano, 1987)

Anxiety & the Catastrophic Reaction cf Chronic Compensatory Effort Syndrome (Hopewell, 2001)

Denial of Deficits (Anasognosia / Anosodiaphoria)

Paranoia and Psychomotor Agitation (cf

Bateson)

Depression, Social Withdrawal &Amotivational States (cf Seligman; Taub)

Other Neurobehavioral InfluencedPsychoemotional Patterns & Factors

Behavior Disorders Irritability / Reduced Frustration Tolerance, Impulsivity, Reduced

Insight, Social Inapproriateness, Reduced Motivation, IncreasedEmotionality

Executive Disorders Initiation, Planning, Problem Solving, Self Regulation

Psychosocial Disorders Substance Abuse Physical DysfunctionCognitive Dysfunction Psychoemotional Dysfunction Psychosocial Changes / Disruption Self / Identity Changes / Disruption

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Evidence for Rehabilitation Suppression by CatastrophicEvidence for Rehabilitation Suppression by CatastrophicReaction:Reaction: CONSTRAINT INDUCED MVMT TXCONSTRAINT INDUCED MVMT TX

Converging Lines of Evidence: Nonuse of a Single DeafferentedLimb is a Learned Conditioned Suppression of MovementNeurologic injury --> Depressed motor or perceptual

functionLasts 2-6 months; progressive regaining of movement

followsInitial attempts to use limb failBegins to function adequately with 3 limbs, reinforcing 3

limb useContinued attempts to use deafferented limb produces

failure, pain, incoordination, falling --> punishment andsuppressionNonuse response tendency persists, preventing monkeys

from learning that after several months, the limb isPotentially UsableConclusion: Animals never learned they could eventually use

the limb (Learned Nonuse)

Evidence for Rehabilitation Suppression by Catastrophic ReactionEvidence for Rehabilitation Suppression by Catastrophic Reaction::ConstraintConstraint--Induced Movement TherapyInduced Movement Therapy (CIMT)(CIMT)

To date, CIMT (Taub, 1966-present) used effectively for:Upper paralytic/ paretic limb of Chronic , Subacute CVA, TBI, LE

CVA, Focal hand dystonia, Phantom limb painUse Dependent Cortical ReorganizationNumerous efficacy studis, 5+ TMS, EEG, MEG studies with humans, 2+

studies of monkeys indicate: Cortical reorganization associated with TXSeveral Converging Lines of Evidence:Nonuse of a Single Deafferented Limb is a Learned Conditioned Suppression

of Movement...efforts to use limb during initial post trauma period are unsuccessful(due to diaschesis, etc.), painful, anxiety and failure inducing and result in LearnedNonuse (cf. Learned Helplessness, Catastrophic Reaction) persisting when cerebralreorganization possible.

Mechanism of Action(1) Changing learning contingencies reinforces Use Learning, inhibits "Nonuse

Learning Phenomenon" (cf. Henr Meige (1904): "functional motor amnesia")(2) Sustained, repeated practice of functional arm movements induces expansion

of contralateral cotical area controlling movement, and recruitment of newipsilateral areas.

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Injury

ExceptionalExceptional

PremorbidPremorbidVulnerabilitiesVulnerabilitiesComorbidComorbidVulnerabilitiesVulnerabilities

ExpectedExpectedContextualContextual

FactorsFactors

AtrociousAtrocious

Recovery After InjuryRecovery After Injury...and Adaptation to Impairment...and Adaptation to Impairment

M.F. Martelli, Ph.D.: 1999

Empirical Predictors of PoorEmpirical Predictors of PoorAdjustment Following InjuryAdjustment Following Injury

Previous Treatment Failures (esp. if surgical)Length/Duration of ComplaintsVagueness or Inconsistency of ComplaintsPresence of Serious Psychopathology, and, to a lesser degree,a Personality DisorderRepressive and Somatization Defenses, including strongHypochondriacal (e.g, MMPI scale 1) and Hysterical Traits(e.g., MMPI Scale 3)Dependency TraitsDepressionEmotional Immaturity/Inadequacy & Poor Coping Skills

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Empirical Predictors of PoorEmpirical Predictors of PoorAdjustment Following InjuryAdjustment Following Injury

Greater reinforcement for "Illness" vs "Wellness" behaviorAbsence of Signficant Supportive Other(s)Anger or Resentment or Perceived MistreatmentFear of Failure Or Rejection (e.g. damaged goods; fear ofbeing fired after injury)Loss of Self-confidence and Self-efficacy associated withResidual ImpairmentsExternal (health, pain) Locus of ControlFear of Pain (Kinesophobia, Cogniphobia) Re-injury/ Exacerbation of Injury

CCCV

Other Specific Impediments (cont)Other Specific Impediments (cont)

Discrepancies between Personality / Coping StyleBehaviors and Injury ConsequencesInsufficient Residual Coping Resources / SkillsDisuse AtrophyFear of Loosing Disability Status, Benefits, Safety NetPerceptions of High Compensability for injuryPreinjury Job (task, work environment) DissatisfactionCollateral Injuries (especially if "silent")Inadequate and/or or Inaccurate Medical InformationMis- or Late diagnosis and Mis- or Late TreatmentDichotomous (organic vs. psychologic)Conceptualizations of injury and symptoms

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KinesiophobiaKinesiophobia**

Defined as the unreasonable or irrational fear of pain andpainful reinjury upon physical movement.Phobic responses to pain (or pain phobias), as unhealthypain maintaining habits, are a major contributor to painrelated disability, or Avoidance Conditioned Pain RelatedDisability (ACPRD).After R/O malingering, Combination TX:Reeducation, countering maladaptive phobicresponses and promoting adaptive attitudes andtreatment participation/ cooperation

*cf Cogniphobia

Fishbain (2000) MetaanalysisFishbain (2000) Metaanalysison Waddell signs:on Waddell signs:Not correlated with psychological distress orsecondary gainDo not discriminate organic from nonorganicproblemsMay represent an organic phenomenonAssociated with greater pain levels andpoorer treatment outcomes

Other False Positives Indicators:Pain Relief by DISTRACTION, FBS, etc.!!!

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146/155 =

94%43/57 =

75%6/39 =

15%

9/155 =

6%14/57 =

25%33/39 =

85%

Mensana Clinic Test Discrimination Success:Mensana Clinic Test Discrimination Success:"Organic" versus "Functional" Back Pain"Organic" versus "Functional" Back Pain(X(X22 = 133: p<0.0001)= 133: p<0.0001)

0 Objective 17 Mixed 21 Exaggerating 30

Test Scores - Categories

P Fh iy ns di ic na gl s

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0

Longitudinal study of PI MVA litigants (Evans, 1994)Strongest predictors of successful outcome wereInclusion of psychological services in the Tx planReceipt of immediate intervention, with return to work(RTW) treatment focusRTW at reduced status or modified duties

>= 6 months: uncooperativeness and delayed bill paying ofmedical insurance carriers (vs. medical symptoms) was mostfrequently reported stressor.Insurance carrier bill payment very strongly predicted RTWPrompt ( <=30 days): 97% had returned to work.Delayed ( > 90 days): 4% had returned to work.

ExtraExtra--medical Factors andmedical Factors andRehabilitation OutcomeRehabilitation Outcome

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Incidence & claim closure speed of Whiplash injury after change tono-fault in Saskatchawan, CA (Cassidy, et al, 2000)

Claims dropped by 28%Time to claim settlement was cut by 54%.Intensity of neck pain, level of physical functioning, depressive symptoms,having attorney increased claim closure for bothTheir Conclusion: Compensation for pain and suffering increasesfrequency, duration of claims and delays recoveryNote: No-fault system eliminated most court actions, income replacementand medical benefits were increased and medical care became universal,without barriersPre-injury anxiety was associated with delayed claim closure onlyunder the tort system

More Valid Conclusion: removal of financial disincentives andmedicolegal associated treatment barriers and anxiety provocationhas a facilitative effect on post-injury recovery.

ExtraExtra--medical Factorsmedical Factors (cont)(cont)

PSYCHOLOGIC ASSESSMENTPSYCHOLOGIC ASSESSMENT

Domain Specific Pain Coping MeasuresMultidimensional Pain Inventory (MPI)

ƒSection 1 assesses pain severity, interference,support, pain severity, life control and affectivedistress.

ƒSection 2 assesses significant others' responses withpunishing, solicitous, and distracting responses.

ƒSection 3 assesses activity levels with householdchores, outdoor work, activities away from home,social activities and general activities

CCCV

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PSYCHOLOGIC ASSESSMENTPSYCHOLOGIC ASSESSMENTDomain Specific Pain Coping MeasuresCogniphobia Scale (Sample Items)

ƒI'm afraid that I might make the cause of my head pain worse if I concentratetoo much

ƒMy head pain is telling me that I have something dangerously wrongƒMy accident/injury has put my head & brain at risk for the rest of my lifeƒHeadaches always mean I have an injury or have done something to make itworse

ƒI'm afraid that I might make my medical condition worse by concentrating toomuch or being too mentally active

ƒSimply being careful not to concentrate too hard or too long is the safest thingI can do to prevent my pain from worsening

ƒPain lets me know when to stop concentrating so that I don't injure myselfƒIt's really not safe for a person with a condition like mine to engage in toomuch thinking and concentrating

ƒNo one should ever concentrate on difficult mental tasks when s/he is in pain

PSYCHOLOGIC ASSESSMENTPSYCHOLOGIC ASSESSMENT

Psychoemotional MeasuresZung Depression Inventory

ƒMeasures Cognitive, Affective, Psychomotor and NeurovegetativeSymptoms of Depression

MMPI (Sample Derived Information):ƒPattern 1:Willingness to Emit Pain BehaviorsƒPattern 2: Distress/Discomfort About Illness ("How comfortablysick?")

ƒPattern 3: Poor General Coping Skills (Are other problems makingpain behaviors reinforcing?)

ƒPattern 4: Depression Complicating Pain Symptoms (mostly in theelderly)

ƒPattern 5: Tension (and sympathetic arousal) contributing to PainƒPattern 6: Predicting Treatment Outcome

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ASSESSMENT OF PSYCHOLOGICALASSESSMENT OF PSYCHOLOGICALMEDIATORS OF PAIN:MEDIATORS OF PAIN:A STRESS & COPING MODELA STRESS & COPING MODEL

INDIVIDUAL PATIENT VARIABLESINDIVIDUAL PATIENT VARIABLESComorbid Coping VulnerabilitiesComorbid Coping Vulnerabilities

ƒƒPTSDPTSDƒƒReactive Depression, Anxiety, etc.Reactive Depression, Anxiety, etc.ƒƒAssociated Psychosocial StressesAssociated Psychosocial StressesPremorbid Coping VulnerabilitiesPremorbid Coping Vulnerabilities

CCCV

Practitioners in the "trenches," often see patients with:ƒ Unclear medical presentationsƒ Recalcitrance to treatmentƒ Significant psychological disturbancesƒ Uncertain intertwining of psychological and medicalTypically diagnosed "functional"Often labeled "chronic" & beyond help

Better Uunderstanding Needed for More Effective RehabilitationƒFactitiousƒSomatoformƒPsych Factors Affecting A GenMed ConditionƒFunctional AmnesiaƒPsychogenic Seizures, etc.

FUNCTIONAL MEDICAL DISORDERSFUNCTIONAL MEDICAL DISORDERS

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Vulnerable Personality StylesVulnerable Personality StylesStyle Premorbid traits Post morbid reactionsOverachiever Sense of self derived from driven

accomplishments, which isfrequently accompanied byobsessive compulsive traits

Catastrophic reaction if drop inperformance is perceived

Dependent Excessive need to be taken careof, frequently leading tosubmissive behaviors and a fear ofseparation

Paralyzed by symptoms if criticalerosion of independence occurs

Borderlinepersonality traits

Pattern of instability ininterpersonal relationships andself-image with fear of rejection orabandonment

Exacerbation of personalitydisorganization, includingdespair, panic, impulsivity,instability, and self-destructiveacts

General Insecurity Weak sense of self, which caninclude shame, guilt, anddependency needs

Magnification of symptoms

Grandiosity Overestimation of abilities andinflating accomplishments; caninclude need for admiration andlack of empathy

Minimization or denial ofsymptoms. If failure results,crash of self-esteem can result incatastrophic reaction

from Ruff, RM, Mueller, J and Jurica, P. (1996). Estimation of Permorbid Functioning after traumatic brain injury. NeuroRehabilitation, 7, 39-53

Vulnerable Personality StylesVulnerable Personality Styles (Cont.)(Cont.)

Vulnerable Personality StylesStyle Premorbid traits Post morbid reactionsAntisocial traits Tendency to be manipulative or

deceitful, temperamental, impulsiveand irresponsible; lacks sensitivityto others

Possible exaggeration ormalingering, increased risk taking,irritability, takes littleresponsibility for recovery

Hyperactivity Restless, unfocused and sometimesdisorganized

Attentional difficulties andimpulsivity may be compounded;possible oppositional behavior

Depressed Mood fluctuations dominated bynegative affect

Increase of depressive symptoms,despondency

Histrionic style Emotionality and attention seekingbehavior

Dramatic flavor to symptompresentation; blaming behavior

Somatically focused Preoccupation with physical wellbeing, reluctance to acceptpsychological conflicts.

Endorsement of multiplepremorbid physical symptomsintermixed with new or changingpost morbid residua

Post traumatic stressdisorder

Prior stressors produced anemotional reaction of fear andhelplessness

Decreased coping ability,cumulative effect of traumas withexaggerated reaction to currentcrisis

from Ruff, RM, Mueller, J and Jurica, P. (1996). Estimation of Permorbid Functioning after traumatic brain injury. NeuroRehabilitation, 7, 39-53

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TheVulnerability To Disability Rating

ScaleGeneralVersion

Increased ComplaintDuration

Complaint Inconsistency /Vagueness

Previous Treatment Failure Collateral Injury /Impairment

Pre/ Comorbid MedicalHistory

MedicationReliance

0= <6Months 0=Little 0=Insignificant 0=Insignificant 0=Insignificant 0=Little1= <12Months 1=Mixed 1=Mixed 1=Mild/Moderate 1=Mild to <Moderate 1=Moderate

2= >12Months 2=Mostly Inconsistent 2=Mostly or All Failures 2=Significant 2=Significant 2=Significant

Especially with expectation ofchronicity, poor understandingof symptoms;

Multiple, vague, variable sites; anatomicallyinconsistent; Sudden onset without accidentor cause; not affected by weather;performing no work or chores, or avoidingeasy tasks but performing most hobbies,enjoyments; pain only ocassional;

Especially with complaint of treatmentsworsening pain or causing injury, andexpectation that future treatments willfail;

Especially if silent andinvolving adaptationreducing impairments;

Seizure disorder; Diabetes;Hypertension; Brain injury orstroke or other neuro- logic insultor vulnerability (esp. ifundiagnosed); Pre- injurymedication reliance; Older; Etc.

>4X/Week Narcotic,Hypnotic or Benzo-diazepine tranqulizer;Perceived inability tocope without medication;

Severity of CurrentPsychosocial Stress

Psychological CopingLiabilities

Victimization Perception SocialVulnerability

Illness Reinforcement VULNERA-BILITY SCORE

0=Non-significant 0=Few 0=Little 0=Little 0=Little1=Mild/Moderate 1=Mild/Moderate 1=Mild/Moderate 1=Mild/Moderate 1=Mild/Moderate _____ Total Points

(Max: 22)

2=Significant 2=Significant 2=Significant 2=Significant 2=SignificantSum of Personal, Social,Financial, Emotional, Identity,Activity Stresses, LifeDisruption, Premorbid CopingStyle Disruption, etc. andincluding Injury/ Impairment XCoping style incongruence;Persistent premorbidpsychosocial stress levels;

Premorbid, Comorbid: Depression; Post-Traumatic Anxiety; Somatization (&Repressive) Defenses; Emotional Immaturity/Inadequacy With Poor Coping Skills;Hypochondriacal Traits (e.g., post-injuryMMPI-3 > 85; preinjury > 70); PassiveCoping Style; Childhoo

Externalized "Blame" for accident,disability, etc.; Percieved Mistreatment;Anger, Fear, Resentment, Distrustregarding accident, treatment,understanding (family, employer,doctors, etc - esp. given charactero-logic tendencies regarding victimization,

Lack of Family Support,Resources, Romantic Support(esp if recent conflict,divorce); Lack of CommunitySupport / Resources /Involvement; Lack ofEmployer, Co-worker,Insurance Manger Support;Etc.

Secondary Gain: Attention, supportin a dependency prone person;Avoidance of stressful ordispleasing life or jobresponsibilities or demands (espwith recent or imminent job / jobduty changes or reorganization);Financial Compensation (esp. iflitigati

Preliminary InterpretiveGuidlines Scores of 13or Above Suggest HighVulnerability to ChronicDisability

Martelli, 1996

Neurosensitization Syndrome (NSS)Syndrome of Subjective Discomfort and ObjectiveFunctional DisabilityOften appears Excessive in Duration and Severity (vs.initiating event)May be Resistant to Conventional Medical andPsycholgical interventionsHypothesized to Develop from Progressively EnhancedSensitivity / Reactivity of CNS mechanisms

More Evidence for Biopsychosocial Effectsof Catastrophic Reaction: Traumatic Disability& NEUROSENSITIZATION Syndromes(e.g., Miller, 1997; 1998; 1999; 2000)

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Frequently Comorbid and Treatment RefractorySyndromesPersistent Post Concussion SyndromePost Traumatic Stress DisorderChronic PainDepressionTrait Anxiety DisordersVestibular DisordersNeurogenic FatigueHyperacusis, TinnitusFibromyalgiaChronic FatigueMultiple Chemical Sensitivity

Traumatic Disability & NEUROSENSITIZATIONTraumatic Disability & NEUROSENSITIZATIONSyndromesSyndromes(Miller, 1997; 1998; 1999; 2000)(Miller, 1997; 1998; 1999; 2000)

Effect of Repeated Stimulation on CNSKindling vs. HabituationHabituation: continuous or short interval stimulationeffectKindling: extended interval subthreshold stimulationsummating as seizure, with permanent changes in CNSexcitability resulting in susceptibility to intermittentstress, and spontaneity (amygdala)

Traumatic Disability & NEUROSENSITIZATIONSyndromes (Miller, 1997; 1998; 1999; 2000)(Miller, 1997; 1998; 1999; 2000)

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Psychological reaction to Extremely Distressing EventExperience intense fear, terror, and helplessness

(Loss of Control)Recurrent and Intrusive Recollections of eventDistressing Dreams Re-experiencing eventDeliberate Avoidance: associated thoughts, feelings, activities orsituationsMTBI like symptoms: Concentration difficulties, Forgetfulness,Sleep difficulties, Irritability, and Poor frustration tolerance.,frequent Depression, AnxietyCognitive Problems secondary to emotional and psychologicaldistress (ACC, HPA activation)

PostPost--traumatic Stress Disordertraumatic Stress Disorder

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Psychotropic and Pain Medications are often First StopGap MeasuresPsychotherapy is the Treatment of Choice for most casesof Traumatic Disability SyndromesDubovsky (1997): psychotherapy relationship "splints" theneurophysiological regulatory mechanisms, providing arepeated corrective stabilization that eventually allowsnormal functioningMartelli (2000): "Calming the Catastrophic Reaction"through Integrated Combination TreatmentsCf EMDR, Accupuncture, Biofeedback, Grad Exposure,Teasell Physical Rehab Beta-blockers, AEDs, Amytal,Tizanidine, etc.

NEUROSENSITIZATION Syndromes: Treatment ImplicationsNEUROSENSITIZATION Syndromes: Treatment Implications(Miller, 1997; 1998; 1999; 2000)(Miller, 1997; 1998; 1999; 2000)

Resolving the PersistentCatastrophic Reaction

Confront Fears/ Deficits:Without being Overwhelmed by distressWith a Conceptual Framework and RehabMethodolgy that Bolsters and Supports and offersHope Conceptually and Through GraduatedSuccessesWith a Calmer CNS and Decreasing CatastrophicReactions (emotional, cognitive,neurophysiologic) that would block optimalrecovery

ƒCf EMDR, Accupuncture, Biofeedback, GradExposure, Teasell Physical Rehab Beta-blockers,AEDs, Amytal, Tizanidine, etc.

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Plan:Plan: A strategy or design for stepwise progress toward a desiredA strategy or design for stepwise progress toward a desiredoutcome. Most plans are based on task analyses, or breaking seeoutcome. Most plans are based on task analyses, or breaking seeminglyminglycomplex tasks down into simple component steps, and proceeding icomplex tasks down into simple component steps, and proceeding in a listn a listwise fashion. Clearly, the more specific, concrete, and obviouswise fashion. Clearly, the more specific, concrete, and obvious, the more, the morelikely the plan will work.likely the plan will work.

Practice:Practice: Repetition is the cement for learning which makesRepetition is the cement for learning which makescomplex and cumbersome and boring tasks more automatic and efforcomplex and cumbersome and boring tasks more automatic and effortless.tless.With practice and repetition, even complex tasks become automatiWith practice and repetition, even complex tasks become automatic andc andhabitual. That is, a habit, or automatic robots, performs the thabitual. That is, a habit, or automatic robots, performs the tasks for usasks for uswithout special effort, energy, concentration, memory, and so onwithout special effort, energy, concentration, memory, and so on..

Promoting Attitude:Promoting Attitude: A facilitative attitudeA facilitative attitudeprovides the motivation that fuels persistence & mobilization ofprovides the motivation that fuels persistence & mobilization of energyenergynecessary for accomplishment of a progressive series of desirablnecessary for accomplishment of a progressive series of desirable bute butchallenging goals.challenging goals.

Holistic Habit RehabilitationHolistic Habit RehabilitationIngredients:Ingredients: The 3 P'sThe 3 P's

M.F. Martelli, Ph.D.:1999

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TA: Breaking a task into single, logically sequenced steps &recording in a Checklist and then checking off each step as it is completed.TA's always make task initiation, completion & follow

through much easier....greatly improveperformance despite limitations inmemory, attention, energy, initiative, ability to sustain performance, organization...anyother difficulty.TA's reduce demand and energy consumed by reasoning and

problem solving associated with planning, organizing & having to recall, make decisions &prioritize appropriate steps and sequences for both basic & complex tasks.TA's (re)establish efficient habit routines that make up normal everyday activity.30 to 1000 consistent repetitions produce automatic habits

Ingredients for (re)building automatic habits are the 3 P's: Plan, Practice,Promoting Attitude. The result is (re)habilitation, or increased efficiencyaccomplished by removing obstacles to independence.

Task Analysis:The Building Block of LEARNing

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The FiveCommandmentsof Rehabilitation:of Rehabilitation:Incorporating Cognitive Behavioral Psychotherapy toConquer the Catastrophic Reaction

Thou Shall Learn New Ways to Do OldThings.

Thou Shall Make Only Accurate

Comparisons. Thou shall not make false comparisons.

Thou Shall Not Beat Thyself Up...Instead,Thou Shall Build Thyself Up!

Thou Shall View Progress as a Series ofSmall Steps

Thou Shall Expect Challenge & Strive toBeat IT


I

II

V

IV

III

Shaping via Reinforcement ofSuccessive Approximations of DesiredBehavior:This involves successively rewardingthe smallest movements (baby steps) inthe desired direction with carrots (i.e.,verbal rewards, expressions of approval &appreciation, smiles & nonverbal gestures ofapproval, physical/tangible rewards, jumping upwith joy, etc.)Each successful small step is rewarded, whichteaches graduated successes.

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Psychologically BasedPain ManagementRelaxation trainingBiofeedbackVisualization/hypnosisAttention focus/distractionGraduated Exposure/ Activity ProgrammingContingency ManagementCognitive Behavioral PsychotherapyTreatment of comorbid depression, etc.Multidisciplinary and Interdisciplinary TreatmentCOMBINATION TREATMENTS

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Desensitization Procedure OptionsƒDesensitizing Medications

ƒCentral Nervous System (CNS) Medications: Anti-epiletic drugs, Tizanidine HCL, Amytal, etc.

ƒPeripheral Nervous System (PNS) Medications:muscle relaxants; homeopathics?

ƒDesensitizing CNS NeurophysiologicProcedures: EEG Biofeedback or EEG Driven Stimulationand adjunctive procedures such as sound and light(AudioVisualStimulation) and CranioElectrotherapyStimulation), Transcranial Magnetic Stimulation, BrainElectrical Stimulation

ƒDesensitizing PNS Procedures: EMG, Temp.Biofeedback; Various Relaxation Procedures; TENS

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Desensitization Procedure Options (cont)

ƒDesensitizing Behavioral Activity Procedures:Graduated Exposure / graduated activity programs; variousexposure desensitization nterventions, systematicdesensitization, etc.; Pacing

ƒDesensitizing Psychotherapeutic Procedures:Emotional desensitization of catastrophic reaction to injuryand pain and other fears and trauma; splinting ofemotional reactions; calming the catastrophic reaction;emotional reaction systematic desensitization; sensorydesensitization / reprocessing psychotherapy

..

Powerful PsychotherapyPowerful PsychotherapyInterventionsInterventions

RelaxationRelaxation ProcProc’’ss, Biofeedback, Hypnosis, etc., Biofeedback, Hypnosis, etc. Cognitive Behavioral PsychotherapyCognitive Behavioral Psychotherapy Desensitization ProceduresDesensitization Procedures ShapingShaping Behavioral ProgrammingBehavioral Programming SchwartzSchwartz (1996) 4(1996) 4--Step OCD TX MethodStep OCD TX Method Holistic Habit Retraining & PracticalHolistic Habit Retraining & Practical

AdaptationsAdaptations Combination InterventionsCombination Interventions Network TherapyNetwork Therapy Group / Family TherapyGroup / Family Therapy


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Effective Behavioral Medicine Group Studies

*Shapiro, Teasell (in press). Brit J PsychiatryDesign: 39 Conversion / Factitious motor disorder patientsStandard Behavioural Rehabilitation program8 of 9 acute, 1 of 28 chronic pts improvey

Strategic-behav TX for NonimproversFrame: Full recovery = Organicity; Nonrecovery = Psychiatric13/21 chronic pts symptom-free at d/c

Conclusions: Strategic intervention superior with chronic pts. Other Txcomponents (wellness reinforcement, skills training) may be unnecessary.

*Barsky, Ahern (2004) JAMA. 2004;291:1464-1470Design: RCT of 187 hypochondriacal pts & volunteersIntervention: 6-session, individual CBT vs usual medical careResults at 12mo f/u:Less Hypochondriacal symptoms, beliefs, attitudes, health anxietyLess Impairment of social role functioning and ADL'sNo change in Hypochondriacal somatic symptomsConclusion Brief, individual CBT designed to alter hypochondriacal thinking and

restructure beliefs, produces beneficial long-term effects.

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..

BiofeedbackVisual and/or auditory information about bodily functionsMuscle tensionSkin temperatureHeart rateBlood pressureBreathingSweat gland activityEEG (Brain waves)

Commonly treated conditions:Hypertension–Feedback on blood pressure, heart rate, and skin

temperature (fingers, toes)Headaches–Feedback on muscle tension in the face and neck musclesOther chronic pain conditions, esp back, shoulders

..

PHYSIOLOGIC STRESS RESPONSE

EVENT

Perception

HeartRateRX: Relaxation

BloodPressureRX: Relaxation

Breathing

Glucose Secretion

EEGDesynchronization

RX: Relaxation

GI SecretionsRX: Relaxation

PeripheralVasoconstriction

RX: Relaxation

Muscle Tone

Medical & Rehabilitation Neuropsychology ServiceConcussion Care Centre of Virginia

Autonomic

Nervous

Ssytem

= InterventionPossibility

RX: Modify Event

RX: RelaxationRX: Relaxation

RX: Relaxation

RX: ReinterpretProblem Solve

or Environment

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PATTERNING:PATTERNING:Physiologic Response HabitsPhysiologic Response HabitsType IType I (Good)(Good) versus Type IIversus Type II (Bad)(Bad) StressStressType I versus Type II Stress Response HabitType I versus Type II Stress Response Habit

Chronic Stress and DiseaseChronic Stress and DiseaseModelsModels

Pathophysiologic Resetting

© 1996: M.F. Martelli, Ph.D

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PAIN

STRESS& SleepDisorder,

Etc.

MUSCLETENSION

& MuscleFatigue

PAIN PERPETUATION CYCLES:Resetting Physiological Function


PAIN

STRESSand/orPoorPosture& SleepDisorder,Etc.

MUSCLETENSION,& Muscle Fatigue

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PAIN PERPETUATION CYCLES:PAIN PERPETUATION CYCLES:Resetting Physiological FunctionResetting Physiological Function

PAIN

PhysicalActivityAvoidanceDisuse

Atrophy


HA PAIN

CognitiveActivity

AvoidanceDisuseAtrophy

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PAIN PERPETUATION CYCLES:PAIN PERPETUATION CYCLES:OverOver--UnderUnder--Activity Disability PatternActivity Disability Pattern

HA PAIN

Time I: Overactivity

Time I: Re-injury

Time II: Disuse Atrophy

Time II: Underactivity

RX:

RECOVERY

RESTING Baseline

REACTIVITY

Better

Worse

Worse

Worse

Better

Better

The Basics: The 3 R's of Self ControlRESTING Baseline refers to the usual state ofphysiological & emotional arousal - for example, level ofmuscle tension, heart rate, electrical activity in thebrain, or more general level of stress or emotionaldistress. Decreasing resting baseline level of physiologicalor emotional arousal provides increased protectionagainst the harmful effects of stress by establishing ahealthier regular resting state and a buffer against futurestresses.

REACTIVITY to stressful events refers to thestrength of increases in physiological variables such asheart rate, muscle tension or blood pressure, or thelevel of increased emotional arousal in response tostressful events. Decreasing our reactivity to stresses inthe environment by controlling elevations in individualphysiological channels & emotional status is anotherway of reducing the harmful effects of stress on ourbodies and emotions.

RECOVERY refers to the length of time required forreducing physiological and emotional reactions to normallevels after stress responses. Learning to more quicklyreduce our physiological and emotional responses reducesthe harmful effects that come from prolonged stressfulreactions and helps produce greater rebound &restoration of general physiological and emotional health.More importantly, it facilitates a habit of healthyrecovery after stress that will lower long term physicaland emotional distress and promote improved health andresistance to continuing streaawa are encountered ineveryday life.

Time

Time

Time

Healing Harm

Healing Harm

Healing Harm

© 1996: M.F. Martelli, Ph.D

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E. Brenner: Prof Psychol Res Pr, Volume 34(3). June 2003. 240–247

Downloadable ReferencesMartelli, M.F., Zasler, N.D. & LeFever, F.F. (2000) Consumer Guidelines for Choosing a Well SuitedNeuropsychologist. Brain Injury Source, 4, 4, 36-39. http://villamartelli.com/PsychConsumGuides2001.pdfBOOK - ND Zasler and MF Martelli (Eds): Functional Medical Disorders in Rehabilitation, State of the Art Reviewsin Physical Medicine and Rehabilitation. Phila.: Hanley and Belfus.http://villamartelli.com/STARSAbs&ChapLnks.htmMartelli, MF and Zasler, ND (2002). Appendix: Survey of indicators suggestive of non-organic presentations andsomatic, psychological and cognitive response biases. http://villamartelli.com/STARSAbs&ChapLnks.htmMartelli, MF and Zasler, ND (2002). Useful psychological instruments for assessing persons with functionalmedical disorders. http://villamartelli.com/STARSAbs&ChapLnks.htmRoper, BL and Martelli, MF (2002). Providing useful diagnostic feedback to patients with functional medicaldisorders and making referrals for psychological treatment. http://villamartelli.com/STARSAbs&ChapLnks.htmOther Chapters...

Martelli, M.F., Zasler, N.D. & Bender, M.C. (2004). Psychological, neuropsychological and medical considerations inthe assessment and management of pain. Jl Head Trauma Rehab, 19, 1, 10-28.http://villamartelli.com/JHTR191MFMZBNPainBrain.pdfMasquerades of Brain Injury Article Series (j Controv Med Claims): Part I to V. http://villamartelli.com/#MBI

Martelli, M.F., Zasler, N.D., Nicholson, K. and Hart, R.P. (2001). Masquerades of Brain Injury. Part I: Chronicpain and traumatic brain injury. Journal of Controversial Medical Claims, 8, 2, 1-8.Martelli, M.F., Zasler, N.D., Hart, R.P., Nicholson, K., and Heilbronner, R.L. (2001). Masquerades of Brain Injury.Part II: Response Bias in Medicolegal Examinees and Examiners. JCMC, 8, 3, 13-23.Martelli, M.F., Zasler, N.D., Nicholson, K., Hart, R.P. and Heilbronner, R.L. (2002). Masquerades of Brain Injury.Part III: Critical Examination of Symptom Validity Testing and Diagnostic Realities in Assessment. The Journalof Controversial Medical Claims, 9, 2, 19-21.Heilbronner, R.L., Martelli, M.F., Nicholson, K. & Zasler, N.D. (2002). Masquerades of Brain Injury. Part IV:Functional Disorders. The Journal of Controversial Medical Claims, 9, 3, 1-7.Martelli, M.F., Bender, M.C., Nicholson, K., and Zasler, N.D. (2002). Masquerades of Brain Injury. Part V: Pre-injury Factors Affecting Disability Following Traumatic Brain Injury. JCMC, 9, 4, 1-7.

Martelli, Siegal, Zasler (2002). Grand Rounds: Frontal Lobe Syndromes Following Neuro Insulthttp://host69.ipowerweb.com/~villamar/NANBullFrontal.pdfZasler, N.D., Martelli, M.F. and Bender, M.C. (2003). Assessing Impairment in Traumatic Brain Injury. The AMAGuides Newsletter, Sept/Oct, 1-9. http://villamartelli.com/AMA_Guides_TBI_Eval_Sep-Oct2003

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THETHEENDEND

That's all Folks!!

APPENDIXAPPENDIX

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Acquisition of Coping: Resilience(Optimal Learning)


Poor Acquisition of Coping:(Suboptimal Learning: Traumatization)


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Poor Acquisition of Coping:Poor Acquisition of Coping:(Suboptimal Learning: Overprotection)(Suboptimal Learning: Overprotection)


Graduated Exposure Programs in Rehabilitation

Exposure to distressful emotional, physiological and sensoryreaction situationsIncremental increases in tolerance (and incremental compensatorylearning, anxiety extinction, sensory interpretation distress)without experiencing significant anxiety or sensory distress.Requires person Not experience distressful reactions or experiences.Examples: anxieties, phobias & distressful emotions and sensoryreactions related to the following:

ƒNoise and/or light (when not mediated by headaches, etc.)ƒCrowds and public places (e.g., stores, malls, sporting events)ƒOverwhelming visual stimulation and patternsƒDriving (especially in traffic)

METHOD: Schedule Gradually Increased Exposure / AssignedActivities, Incremented in Time and/or Distance and/or Intensitythat are followed Exactly

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Lisa's Graduated Exposure Driving Program(Beginner's Version)

Level/Step

Activity Time Frequency SUDS

1-1 Sit in and Start Car <= 2 min. 1-3 X/day1-2 Start Car, Back up slightly, then pull forward

in driveway, going no further than iscomfortable

<= 2 min. 1-3 X/day

1-3 Start Car, Back up all the way to street, thenpull forward, going no further than iscomfortable, and repeat one or two times.

<= 2 min. 1-3 X/day

2-1 Start Car, Back up all the way to street andthen slightly into street, then pull forward,going no further than is comfortable, andrepeat one or two times.

<= 2 min. 1-3 X/day

2-2 Start Car, Back up all the way to and one fullcar length into the street and then then pullforward, going no further than iscomfortable, and repeat one or two times.

<= 2 min. 1-3 X/day

RULES:Stop the activity if you begin to feel even a little shaky.Do not progress to next level previous level completed for all exposures for 2 consec. daysEmail feedback to MFM re: progress, any shakiness you experienced, when level completed


Graduated Exposure Sensory Tolerance Program

Level/Step

Activity Time Frequency SUDS

1-1 Stand on stepladder or chair for 3 Sec's (s 3 Sec. 3 X/day1-2 Perform a visuomotor scanning computer

exercise30 Sec 4 X/day

2-1 Listen to radio while driving 1 Min 1-3 X/day2-2 Track 2 persons talking at same time 2 Min. 1-3 X/day

3-3 Visit Clover Mall (9-11am, 2-4pm, Main ent.) 10 min. 1-2 X/day


Sample Rationale: "Like Breaking a Bronco, you can't learnto ride until you can get in the saddle. You can't get inthe saddle until the horse believes it won't die ifsomething gets on its back. Similarly, You can't increaseyour tolerance for (sounds, etc.) unless your systemlearns that it can tolerate some level of that (noise, etc.)without great (distress, pain, fatigue, etc.)."

role of the psychologist in rehabilitationvillamartelli.com/psych_in_rehabssmpr2pp.pdfdefined as the...

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