Chronic Illness: Psychological and Cognitive Issues

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Chronic Illness Psychological and Cognitive
Issues

• Scott N. Losk, Ph.D.
• Neurobehavioral Assessment Center and
• Summit Research Network
• Portland, OR

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Outline

• Review high frequency chronic disorders with
  significant psychological components
• Review chronic disorders that may have cognitive
  sequelae
• Address psychological issues that are common to
  these disorders
• Discuss the impact of psychological issues on
  functional ability
• Review interventions strategies that may be
  helpful for these patients

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Fibromyalgia

• Widespread musculoskeletal pain with multiple
  tender points, more than three months (11/18 for
  dx)
• 3-6 million Americans affected, womengtmen
• Sleep disturbance and depression common
• Other symptoms fatigue, anxiety, headache, IBS,
  reduced endurance, reduced social activity,
  cognitive deficits

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Fibromyalgia Cont

• 50-70 meet criteria for major depression
• Patient education critical
• Mild exercise critical
• Treat sleep disturbance and psychological issues
  symptomatically

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Migraine

• With or with out aura (classic versus common)
• 26 million Americans, 6 in men, 15-18 in women,
  although no gender differences noted until
  puberty
• Prophylactic, abortive, and symptomatic
  approaches to treatment

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Migraine Cont

• Depression and migraine - two-year follow-up
  study - 1) migraine 5x more likely to have first
  onset of major depression 2) major depression 3x
  more likely to have first onset of migraine
• Comorbidity with depression and anxiety - shared
  neurotransmitter dysregulation?

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Muscle Tension Headache

• 70 of men and 85 of women
• No greater likelihood of psychological
  complications unless chronic (chronic daily
  headache), severe and frequent

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Muscle Tension Headache Cont

• Chronic daily headache - 50-70 with comorbid
  psychiatric disorders, major depression,
  dysthymia, panic disorder and GAD most common
• Unresolved anger may also be present
• On exam, ask about more than stress, evaluate for
  psychiatric disorder presenting as chronic daily
  headache

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Musculoskeletal Pain

• Low back pain most common - no greater likelihood
  of psychiatric disorder or disability unless
  chronic, severe, and life-altering
• 80 of Americans at some point in life

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Psychological/Existential Issues Common to
Chronic Illness

• Loss
• Limitation
• Lability (unpredictability)

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Psychological Evaluation

• Detailed interview
• Emotional assessment - SCL-90-R
• Personality assessment - MMPI-II
• Functional assessment - ADL scales

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Pain Evaluation

• Ratings/questionnaires- frequency, duration,
  intensity, qualitative description
• Determine relationship between personality/emotion
  al issues and pain
• Relationship between personality/emotional issues
  and opiate use
• Relationship between problematic relationships
  and pain
• Functional limitations and secondary gain

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Role of Personality Factors

• Research suggests high number of personality
  disorders (PD) among chronic pain patients
• histrionic, borderline, dependent and others all
  represented - no predominant disorder
• 40-60 meet PD criteria

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Role of Personality Factors Cont

• Is PD cause or result of pain and limitation?
• unclear what percentage meets PD criteria before
  chronic pain
• Pain-related personality disorder may account for
  50 of PD

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Role of Pre-morbid Psychological Disorders

• Anxiety
• GAD, Panic, PTSD, Phobias, OCD, Social Anxiety
• Mood disorders
• depression, dysthymia, bipolar disorder
• Psychotic disorders
• schizophrenia, schizoaffective disorder

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Role of Somatoform Disorders

• Somatization disorder
• Multiple sxs before age 30
• Conversion disorder
• Pain disorder
• Hypochondriasis
• Preoccupation with fear of serious disease
• Body dysmorphic disorder

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Role of Stress

• Clear relationships with increased pain, distress
  and disability in chronic illness
• Damaged relationships and lack of social support

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Role of substance use

• Increased use of CNS depressants in chronic
  illness
• ETOH
• THC

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Cases

• Anxious hyperarousal
• Anger, idealization/devaluation, chronic pain,
  conversion?

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Anxious hyperaousal

• 62 yo married female with severe headache
  following rear-end MVA one month earlier
• Whiplash-type injury with no head injury, no LOC,
  and no immediate contact with medical
  professionals
• Immediate sxs pain in back of head and feeling
  wobbly
• 3 days after MVA saw insurance agent who said we
  should get checkedI started to get headaches,
  upset stomach and poor sleep.

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Anxious hyperarousal cont

• Treated by D.C. with no improvement, headaches
  worse
• Med Hx migraine (dormant for 30 years),
  hypoglycemia, overactive bladder, partial hyst,
  recent MRI of brain WNL
• Meds Ibuprofen, Centrum Silver
• MSE pleasant cooperative, anxious (in a crisis
  Im not a nonchalant personI yell and get
  upset), somatic focus, suggestible

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Anxious hyperarousal cont

• Sxs headache, return of migraines, R hip pain,
  poor sleep, nausea, ear ringing L, I forget
  thingsI couldnt remember my address, Im
  getting depressed
• Psych hx big time worry wart, Valium in 1970s,
  no other contact
• Psychsoc married, 5 children, 7 grandchildren, 5
  great grandchildren, 10th grade ed., only work
  was as apt. manager really stressful
• Habits none

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Anxious hyperarousal cont

• Testing cognition WNL, emotional/behavioral
  SCL-90-R GSI 1.4, BDI8
• Summary Psych Dx GAD, somatic, suggestible
• Treatment Detailed education as to the process
  of improvement in these conditions that the she
  will be expected to improve naturally over time

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Anger, idealization/devaluation

• 56 yo, married, female, no work, confined to
  wheel chair (only in doctors office), husband
  does everything at home
• Five PCPs in the last few years, multiple MVAs
  over a 20 year period, no psych contact
• Med hx ibs, fibromyalgia, arthritis, migraine,
  laminectomy x2

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Anger, idealization/devaluation

• MedsDuragesic Patch 100 mcg, Tylox 8 qd,
  Neurontin 600 bid, Lodine 400 tid, Soma 300 qid,
  Prozac 40 qd, Plaquenil 200 qd, Synthroid 0.112
  qd, Dyazide37.5/25 two tabs qd, Atrovent,
  Albuterol, Flonase
• Family med hx mother ibs, arthritis, pain, a
  lot like me.
• Testing MMPI-2 Conversion V, SCL-90-R
  GSI1.5, BDI18
• Summary psych distress channeled into physical
  sxs, mild depression

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Anger, idealization/devaluation

• Treatment
• Initial good rapport, manage stress, manage
  arousal, get spouse educated good results
  although she did fire referring PCP
• Continuing refer to accupuncturist, no
  wheelchair, reduce pain med use pt refused to
  return angry, I am just like all the others

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Cognitive Disorders

• Mild head injury - concussion
• Dementia - AD, VaD, Lewy Body Disease, Frontal
  dementias
• Parkinson Disease (PD)
• Multiple Sclerosis (MS)

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Mild Head Injury

• Concussion Mechanisms and post concussion
  syndrome (PCS)
• Blow or shaking
• Acceleration/deceleration, coupe/contra-coupe,
  orbital-frontal
• Diffuse axonal injury (DIA)
• Second Impact Syndrome
• Has a head injury occurred?
• Whiplash syndrome

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Is the brain damaged?

• Imaging - normal
• Neurologic exam - normal
• EEG-ERP - Variable
• Neuropsych - variable
• meta-analysis identifies subtle deficits in most
  cognitive domains

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Symptoms-PCS

• Physical
• Headache
• Sleep disturbance
• Musculoskelatal
• Cervical sprain/strain
• low back
• shoulder

• Cognitive
• Attention
• Divided attention
• Mental tracking
• Memory
• STM
• LTM

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Emotional Symptoms - PCS

• Irritability
• Decreased frustration tolerance
• Interpersonal conflict
• Decreased sexual interest
• Depression
• Anxiety - PTSD
• Decreased interest

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Personality issues

• 20-30 of PCS population, pre-TBI
• 60-70 of PCS population, post-TBI
• No specific personality disorder identified

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Variables

• Financial compensation
• typically perform one SD lower on neuropsych
  tests
• Litigation
• Pre-injury psychological issues
• Stress
• Previous MVA
• ETOH/Substances

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Dementia

• Causes
• Alzheimers Disease (AD) 50
• Cerebrovascular Disease (CVD) 10-15
• Lewy Body Disease (LBD) 15
• Frontotemporal Dementia (FTD) 15
• Other causes (ETOH, Head injury, etc. 5-10)

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Differential Diagnosis

• AD
• CVD
• LBD
• FTD
• Others

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AD - Risk Factors

• Age
• Family History
• Early onset PS-1, PS-2
• APOE 4,4
• Head Injury
• Down Syndrome
• MCI

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AD Course

• Gradual onset
• Progressive course

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AD - Presentation

• Memory impairment early (amnesia)
• Language impairment early (aphasia)
• Agnosia
• Apraxia

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CVD - Course

• Sudden onset
• Gradual or step-wise course
• Temporal association with vascular problems

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CVD - Presentation

• Gait Unsteadiness
• Neurological symptoms
• Forgetfulness early
• Imaging reveals strokes

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CVD Risk Factors

• Stroke history
• Cardiovascular disease
• Hypertension
• Smoking
• Peripheral vascular disease

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LBD Course and Presentation

• Generally more sudden than AD
• Fluctuation in cognition
• Psychiatric symptoms (visual hallucinations and
  delusions) early
• Parkinsonism

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FTD Course and Presentation

• Insidious onset
• Personality and behavioral changes early
• Disinhibition hypersexuality, poor hygiene,
  reduced social tact
• Depression apathy, aspontaneity
• Awareness and insight poor
• Hyperorality
• Memory spared early

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FTD Presentation Cont

• Left temporal lobe variant
• Language disturbance
• Depression
• Right temporal lobe variant
• Irritability
• Bizarre dressing
• Impulsivity

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ETOH Dementia

• Gradual onset
• May improve with cessation of ETOH
• Amnesia with confabulation early
• Visual-spatial deficits
• Poor insight and awareness

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Parkinsons Disease (PD)

• Bradykinesia
• Rigidity
• Resting tremor
• Gait disturbance

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PD - Cognitive Symptoms

• 35-55 may have dementia
• attention/ concentration deficits
• forgetfulness
• mental tracking deficits
• visual spatial deficits
• motor and mental slowing

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PD - Emotional Symptoms

• 40-60 meet criteria for major depression
• Depression may be the initial presenting
  complaint in 25 of PD
• Depression more common than in other medical or
  neurological disorders
• Level of depression does not correlate with
  degree of disability

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Multiple Sclerosis (MS)

• Unpredictable exacerbations and remissions of
  various CNS symptoms
• parasthesias
• weakness
• vision changes

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MS - Cognitive Changes

• Typically seen in more advanced disease
• decreased attention
• poor judgement
• memory difficulty

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MS - Emotional Changes

• Depression
• Emotional lability
• Euphoria
• Anxiety
• Psychosis

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Unpredictability

• Behavioral principles
• variable ratio reinforcement
• highest rate of responding
• results in highest utilization of medical
  resources
• Importance of early and detailed education
• the three Ls

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Intervention

• Psychotropics (as have been presented) for
  symptomatic treatment

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Intervention Cont

• Education - (may need to refer to mental health
  practitioner for this)
• importance of psychosocial support
• importance of physical activity
• importance of significant others not reinforcing
  pain behavior
• Arousal Management

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Intervention Cont

• Psychotherapy - beneficial effect of early
  referral
• If clearly depressed, anxious, or psychotic, get
  psych involved early in care
• explain the role of stress in chronic pain
• explain the routine nature of referral
• If exhibiting personality factors discussed
  above, get psych involved early

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Intervention Cont

• Check for Secondary Gain
• Incentives for maintaining illness or pain
• financial
• relational
• avoidance of conflict or stress
• maintaining an addiction

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Intervention Cont

• Cognitive disorders
• get neuropsychological consult
• educate patient and family
• treat dementia (e.g., cholinesterase inhibitors,
  etc.)
• treat problematic behaviors and emotional issues
  symptomatically

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Suggestions

• Use self-administered scales to assess
  psychological factors and stress - BDI, SCL-90-R,
  SF-36 etc.
• Use brief screening instrument to assess
  cognition - MMSE, NCSE, etc.
• Find a competent mental health professional that
  you can refer to early
• Set very clear boundaries e.g., call policies,
  med refill policies, splitting of staff

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• References
• Chronic Illness Psychological and Cognitive
  Issues
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  functional impairment, and psychological distress
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• Bolla, L.R., Filley, C.M. and Palmer, R.M. Office
  diagnosis of the four major types of dementia.
• Geriatrics, 2000, Volume 55, (1), 34-46.
• Bradley, L.A. and McKendree-Smith, N.L. Central
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• Caudill, M.A. Managing Pain before It Manages
  You. The Guilford Press 1995.
• De la Torre, J.C. Alzheimers Disease How does
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• Holroyd, K.A. et al. Management of chronic
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