PSYCHOLOGICAL EVALUATION IN REHABILITATION SETTINGS
Psychological disorders are highly prevalent among patients admitted to acute rehabilitation units. Soon after their medical event, patients are forced to quickly wrestle with myriad emotions, such as powerlessness, shock, demoralization, and loss, while often concomitantly experiencing a variety of physical discomforts. Many patients must also suddenly grapple with the reality of alterations in lifestyle and relationships, cope with stigma that may accompany their limitations or injury, and bear significant financial burdens. Particularly during the acute phase, physical and cognitive deficits, as well as the inability to perform basic activities of daily living, serve as a significant source of distress and irritation. Unanswered questions related to prognosis and quality-of-life issues fuel feelings of worry and unrest about the future, for both patients and caregivers.
Although many patients adjust well to their disability, others develop significant psychological distress, in a manner that goes beyond expected reactions to loss. Estimates of the prevalence of mood disorders among rehabilitation patients vary, ranging from 20% to a striking 64%. However, these disorders are common among a host of diagnostic categories, including spinal cord injury (SCI), burns, stroke, amputation, brain neoplasms, and traumatic brain injury (TBI). Identification and treatment of psychological disorders in patients with injuries such as SCI is particularly important, as psychological and biopsychosocial factors are often better predictors of adjustment or quality of life than biomedical variables, such as severity of injury. Emotional disturbances following acquired brain injury may be the result of a structural brain lesion or psychological reaction to the trauma, or some combination thereof. A psychologist skilled in assessment can be invaluable in determining the relative contributions of neurocognitive and emotional factors to a patient’s presentation. Discrimination of these factors can advance treatment strategies and facilitate successful postacute transition and care.
Psychological reactions or disorders commonly occurring in rehabilitation patients are summarized below.
Many patients admitted to rehabilitation units are confronted with medical events that may result in physical disfigurement, pain, psychological distress, cognitive dysfunction, and reduced functional independence; these events can be abrupt, unexpected, and have implications for change in life roles or plans (eg, inability to fulfill domestic responsibilities or return to work). Successful adjustment to a new disability requires the patient to acknowledge the functional consequences of the injury and incorporate these changes into his or her personal identity. Significant emotional reactions can occur that can lead to poor adjustment or more severe psychological disorders, such as depression or anxiety. According to the Diagnostic and Statistical Manual, Fourth Edition Text Revision (DSM-IV-TR)*, an adjustment disorder is present if the patient’s reaction to an identified stressor results in marked and excessive distress, or the reaction to this stressor causes significant impairment in functioning. An inability to adapt to injury can have an impact on quality of life, self-esteem, life satisfaction, or self-concept, and lead to increased subsequent hospitalization rates, longer hospital stays, and poorer functional outcomes.
*This chapter was completed prior to the release of the revised manual, DSM 5.
Depression is perhaps the most common neuropsychiatric manifestation in the rehabilitation setting. In addition to the typical features associated with depressed mood (eg, dysthymia, melancholia, anhedonia, decreased energy, perturbed sleep and appetite), depression can also result in diminished attention, memory, motor skills, processing speed, executive functions, initiation, and motivation, all of which serve as potential barriers for rehabilitation progress. Among rehabilitation patients, depression has also been linked to excess disability, slow physical recovery, poor quality of life, and increased mortality. A history of psychiatric illness, dysphasia, functional limitations, and social isolation are risk factors for depression in the rehabilitation setting.
The prevalence of depression varies somewhat for different diagnostic categories of rehabilitation patients, with some clinical populations being at very high risk. According to most studies, depression affects 30–50% of stroke patients within the first year and has been found to be associated with poorer functional scores up to 6 months following acute rehabilitation. Depression is estimated to occur in 11–40% of SCI patients and 33% of patients with lower limb amputations. Depression may be the most common psychological sequela following TBI, and depression in TBI has been associated with greater functional disability, poorer recovery and quality of life, and greater health care costs. A variety of somatic and cognitive indicators included in the DSM-IV-TR diagnostic criteria for depression overlap with symptoms found in nondepressed stroke, dementia, and TBI patients (eg, apathy, decreased motivation, fatigue, poor concentration); therefore, a thorough neurocognitive examination is recommended to evaluate the nature of these symptoms in such patients.
Anxiety among patients in rehabilitation settings is well documented in the literature. Reactions to disabling events are often marked by significant worry, tension, and feelings of loss of control. Patients diagnosed with inoperable cancers, as well as survivors of stroke, TBI, SCI, and burns, are sometimes confronted with the inevitability of death for the first time, resulting in increased rates of anxiety disorders, including generalized anxiety or post-traumatic stress disorder (PTSD). Rates of anxiety for various diagnostic groups can run very high; for example, some studies estimate up to 30% of stroke patients, 27% of TBI patients, 35% of burn patients, and up to 17% of SCI patients experience significant anxiety. Risk factors for anxiety disorders such as PTSD following a disabling event include preinjury psychiatric history, maladaptive coping strategies, perceived lack of social support, and high emotional distress.
Guilt is a painful emotion commonly experienced in rehabilitation settings and may result in heightened levels of depression. Guilt occurs when one imposes self-blame for his or her injury or disability. Stroke survivors, for example, may blame themselves for not immediately calling 911, abruptly discontinuing their hypertensive medications, or not taking adequate care of their health. Survivors of traumatic incidents that resulted in TBI or SCI may ruminate over choices or behaviors that led up to their injury, such as, “I could have prevented the accident by driving more slowly,” or “If only I did not go out that night.” Similarly, patients who have undergone limb amputations as a result of poorly controlled diabetes or other medical conditions may experience guilt over their disability.
Denial of illness is a psychological coping mechanism that may emerge following a threat to one’s identity and self-preservation, and is not uncommon among rehabilitation patients. Individuals utilizing this defense mechanism may deny the existence of the illness or minimize its nature, severity, and implications. In different phases of illness, denial may have an adaptive benefit, in that it serves to psychologically protect the patient, preserving optimism and hope, thereby allowing the individual to cope in the midst of a crisis. However, prolonged or excessive denial may be maladaptive, impeding rehabilitation activities and precluding the patient from adopting a more problem-focused orientation. Studies suggests that TBI patients evidencing denial are more likely to refuse rehabilitation therapies, are perceived as more difficult to work with, and are less likely to ask for help when needed. Denial has been linked to delays in seeking treatment and to negative treatment outcomes and survival.
A subtype of denial, anosognosia, is neurologically based and can serve as a significant barrier to rehabilitation. An individual with this neurologically acquired denial of illness may refuse to engage in therapies out of the belief that he or she is unimpaired. These patients may also attempt to leave the hospital or engage in unsupervised activities and thus pose a serious safety risk.
Personality disorders comprise a constellation of longstanding, persistent, maladaptive traits that are characteristic of the way an individual experiences and interacts with his or her environment. Several of the cluster B personality disorders described in the DSM-IV-TR involve impulsivity, unstable mood, suicidal gestures, and risky behavior as core criteria. Personality-disordered patients with limited judgment and impulse control at baseline are prone to higher rates of injury as a result of suicide attempts, assaults, and dangerous, sensation-seeking behaviors, and thus may constitute a higher percentage of rehabilitation patients. Individuals with personality disorders may pose a unique challenge in the rehabilitation setting by refusing to participate in therapies, smuggling illegal substances into the facility, or verbally abusing staff. Patients with personality disorders unfortunately show a tendency toward poor discharge outcome.
Acquired injury affects the family system in varying ways and degrees, as changes in family functioning and roles are almost inevitable. Emotional support, personal hygiene, ambulation, and feeding often become the primary responsibility of loved ones. The implications of acquired injury, including changes in the spouses’ perceived romantic relationship, sexual life, and changing role from partner to caregiver, may become more apparent in the weeks and months following the life-altering medical event. Owing to the demands involved in tending to their loved ones, caregivers are prone to experience a range of long-term difficulties, including depression, anxiety, decreased life satisfaction, and deterioration of health and social life. Identifying and treating emotional dysfunction in caregivers can contribute to improved outcomes for patients following discharge from postacute rehabilitation settings.
Psychological evaluations are frequently requested in rehabilitation settings to identify emotional dysfunction. As noted earlier, psychological disorders have been associated with poorer functional recovery and social outcomes, reduced quality of life, and increased frequency of cognitive impairment and mortality. Psychological distress can include feelings of helplessness, inertia, demoralization, and lack of motivation, which may reduce therapeutic compliance and, as a result, rehabilitation treatment efficacy. Thus, early identification of patients with emotional dysfunction is essential, as it can have a positive effect on recovery and long-term outcome.
Assessment of an individual’s psychological functioning requires a clinical interview with the patient and other informants, if possible. Information is gathered regarding the patient’s developmental, educational, and vocational history; social and medical history; prior psychiatric or psychological treatment; behavioral health issues (eg, substance abuse); and existing coping skills (eg, support network). For elderly patients, it is also important to inquire about preinjury functioning and to look for signs suggestive of premorbid cognitive decline or dementing conditions, which can complicate rehabilitation and disposition outcome. In these instances, neuropsychological assessment can be helpful in distinguishing dementia symptoms from other etiologies (eg, TBI, fatigue, medication effects).
Psychological assessment of emotional functioning is often supplemented by questionnaires and inventories. Assessment tools used in the screening, diagnosis, and assessment of psychiatric disorders can be classified into two basic types: self-report measures and observer-rating scales. Repeatable self-report measures for depression and anxiety are the Beck Depression Inventory–Second Edition (BDI-II) and the State Trait Anxiety Inventory (STAI), respectively. Brief questionnaires with a “yes–no” format, such as the Geriatric Depression Scale (GDS), are preferable for elderly patients with cognitive limitations. Assessment of coping strategies can yield important information regarding how an individual may adapt to a new injury or disability; instruments such as the Ways of Coping–Revised (WOC-R) or the Acceptance and Action Questionnaire (AAQ) can identify maladaptive coping mechanisms that can interfere with treatment and recovery. Lengthy inventories assessing personality and emotional functioning, such as the Personality Assessment Inventory (PAI) or Minnesota Multiphasic Personality Inventory, Second Edition (MMPI-2) are occasionally used with disabled patients who are largely cognitively intact.
Although the use of self-report measures to identify the presence and level of emotional distress has several advantages, it is not without limitations. Fatigue, pain, cognitive limitations, medications, and environmental noise can affect patients’ ability to participate in testing and the validity of the results. Moreover, some questionnaires contain several test items related to health, stamina, and physical functioning, which can be wrongly attributed to depression. Self-report measures also assume that patients have awareness into the nature and magnitude of their illness, which is not always the case.
The inclusion of neuropsychologists within a multidisciplinary rehabilitation team provides a valuable complement to other disciplines, as they are uniquely trained in the quantification of cognitive impairment following neurologic insult. Cognitive disability is present in a large proportion of rehabilitation patients, including individuals with TBI, stroke, and dementia. Acute and chronic health conditions can also have a negative impact on cognition (eg, cardiovascular disease, obesity, diabetes, cancer). Neuropsychological assessment offers an objective, valid, and reliable method for detecting and tracking brain impairment. It is often the only means of detecting impairment in higher cortical abilities and provides valuable information above and beyond neuroimaging techniques. Advances in structural and functional neuroimaging have provided a window into regions affected by brain injury but cannot quantify the magnitude of cognitive impairment nor predict the degree of functional disability experienced by the individual. Neuropsychological assessment identifies cognitive and behavioral barriers to patient care and predicts functional capacities postdischarge, such as the ability to live independently, resume driving, or return to work. Neuropsychological assessment can facilitate successful treatment strategies, assist with maintaining patient safety and compliance, and provide critical information related to discharge planning and outcomes.
Neuropsychological tests have strong psychometric properties that allow them to be used to assist with the diagnosis of brain pathology and to inform treatment. Evidence for brain dysfunction is determined by referencing a comparison standard. Specifically, neuropsychological tests allow for quantification of deficit by utilizing collected test data from reference groups. These data serve as a benchmark against which patient performance is statistically compared with that of other groups to determine if the respective cognitive domain signifies an area of strength or deficit. Patient performance can be compared against a healthy normative sample from the population, other clinical groups, or the patient’s previous test performance.
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