OVERVIEW

Rehabilitation and rehabilitation hospitals aim to restore a patient’s physical and mental function following serious illness or injury; when this is not possible, efforts focus on helping the patient to adjust to his or her condition and to function as well as possible in all important domains (including vocational, educational, social, psychological, and physical). In the United States, many individuals undergo some type of rehabilitation. According to Schoenborn and associates,¹ in 2000, although about 7 out of every 10 persons reported excellent or very good health, about 31 million people (11%) had limitations in their usual activities due to one or more chronic health conditions, and about 3 million people (2%) required assistance with activities of daily living (ADLs).

Those physicians with specialty training in physical medicine and rehabilitation (commonly referred to as “PM & R”) are called physiatrists, and, according to the Association of Academic Physiatrists (www.physiatry.org), they provide services in three major areas of medical care: diagnosis and treatment of musculoskeletal injuries and pain syndromes; electrodiagnostic medicine (including electromyography [EMG] and nerve conduction studies); and rehabilitation of patients with severe impairments either caused by one or more medical conditions (e.g., stroke, myocardial infarction [MI], brain injury, and spinal cord injury) or that occur as a consequence of medical or surgical treatments (e.g., amputation, cardiac surgery, and neurosurgery).

Because successful rehabilitation requires the cooperation of many professionals (e.g., physical therapists, occupational therapists, nurses, physicians, social workers, clergy, psychologists, and speech-language pathologists), the physiatrist is likely to direct a unique, large, multidisciplinary team that is expressly assembled to deal with the specific needs of each patient receiving PM & R care. Therefore, the psychiatrist asked to treat a patient undergoing rehabilitation must be prepared and willing to work closely with the entire team by doing the following: demonstrating his or her willingness to consult with any and all team members who feels their input might be important; understanding that each member of the team “holds different pieces” of the patient (e.g., because a physical therapist might spend a lot of time with a particular patient, he or she may have observed more depressive symptoms, witnessed more frequent fluctuations in attention, or had more frequent contact with family members, thereby making his or her observations and inferences essential to a better understanding of the patient); and appreciating and appropriately responding to patients receiving rehabilitation services who need psychiatric care and may require more frequent contact with the psychiatrist than do other patients.

For most people, normal physical functioning is an expected and regular occurrence; routine tasks (such as opening a tube of toothpaste, answering the telephone, tying shoelaces, using the toilet, or combing hair) take place without much conscious thought or effort. However, these learned behaviors took considerable time and effort to master, and for most adults they are well “programmed,” and require little if any thought.

Good physical health is the norm for most adults. This is often not the case for a person in a rehabilitation hospital or for someone who is receiving rehabilitation services elsewhere (e.g., a skilled nursing facility [SNF]). Such an individual may be adjusting to a life-altering change (e.g., disfigurement following burn injuries, learning to walk [again] with one or more prosthetic devices after amputation, or trying to adapt to a progressive disease such as cystic fibrosis).

PSYCHIATRIC COMPLICATIONS THAT ARISE IN THE CONTEXT OF CHRONIC MEDICAL ILLNESS AND REHABILITATION

In the United States, rapid discharge of patients from acute care facilities is the rule rather than the exception. Moreover, there is an increasing tendency to divert patients from acute care hospitals to other (lower-cost) facilities in order to cut costs.^2,³ Thus, there is a growing need for appropriate aftercare following acute treatment. Many larger hospitals have rehabilitation facilities attached to them or close by; smaller hospitals often rely on distant rehabilitation centers to provide the specialized, long-term care that they cannot offer.

Many types of patients who require rehabilitation are at significant risk for the development of one or more psychiatric complications. For example, for persons with traumatic brain injury (TBI), the prevalence of depression may be as high as 40% to 50%,^4,⁵ of fatigue, 43% to 73%,⁶ and of anxiety, as high as 77%⁷; in those with cancer, rates of depression vary according to the type of cancer, with higher rates associated with cancer of the oropharynx (22% to 57%), pancreas (33% to 50%), and lung (11% to 44%), whereas colon cancer (13% to 25%) and lymphoma (8% to 19%) have lower rates⁸; in those with multiple sclerosis, depression ranges from 22% to 46%,⁹^–¹¹ and, for these and other conditions, diagnosis and treatment are often inadequate.¹² In addition, thoughts of suicide¹³ are more common among those with chronic illnesses compared to those without such conditions; compared to those without chronic illness, people with cancer have suicide rates that are 15 to 20 times greater, those with spinal cord injuries, 15 times greater, and those with multiple sclerosis, 14 times greater.¹⁴

PROBLEMS THAT MAY OCCUR DURING REHABILITATION

Patients who receive rehabilitative treatments tend to spend a large portion of their time worrying about the future. Such individuals may anticipate (correctly or incorrectly) difficulties that they will face while adjusting to their new (more medically compromised) lives. Among the domains a patient may worry about are problems with returning home, obtaining financial independence, driving, returning to work, adjusting to changes in appearance, socializing, dealing with stigmatization, engaging in sexual activities, and managing decreased functional capacity.¹²^–¹⁶

Rehabilitative services may be obtained in a rehabilitation hospital or as an outpatient. Rehabilitation may continue for months or years, a span much longer than the acute treatment, and it may seriously disrupt a person’s usual schedules. During this phase of treatment, patients are usually exposed to a variety of new caregivers (including physiatrists, nurses, occupational therapists, physical therapists, social workers, vocational therapists, recreational therapists, psychologists, clergy, and psychiatrists). In addition, patients receiving rehabilitative treatments are often exposed to many new, uncomfortable, or painful procedures.

At times challenges arise for clinicians and patients that may affect empathic connectedness. Cultural differences may play a role in this regard as it takes time to learn to trust a new consultant. Table 88-1 lists some characteristics of patients and caregivers that should be considered when a clinician, especially a psychiatrist, tries to make an empathic connection with a patient undergoing rehabilitation.

Table 88-1 Some Differences between Psychiatrist and Patient That May Affect the Quality of the Interaction

Adapted from Rabinowitz T: Approach to the patient requiring rehabilitation. In Stern TA, Herman JB, Slavin PL, editors: The MGH guide to primary care psychiatry, ed 2, New York, 2004, McGraw-Hill.

THE REHABILITATION ENVIRONMENT

Patients must adapt to a large number of rehabilitation personnel and to the rehabilitation setting, which is often dramatically different from the acute hospital setting. Perhaps one of the most important issues for the rehabilitation patient is the possibility of physical displacement. With separation from loved ones and from familiar objects and surroundings, treatment received far from home for an extended period may be particularly troublesome; it may lead to depressed mood, apathy, or hopelessness.

Other problems experienced during rehabilitation may hinder timely and successful recovery and produce long-term negative effects (including disruptions in school, work, marriage, partnership, and parent-child relationships) for a recovering patient as a direct result of prolonged hospitalization or incapacity. Patients may also believe that they and their illnesses have caused a financial or emotional burden for loved ones and may feel guilty about the large blocks of time spent on them and the care they require.

COMMON PSYCHIATRIC PROBLEMS IN PATIENTS UNDERGOING REHABILITATION

Any psychiatrist who provides care in a rehabilitation setting should expect to encounter the full spectrum of psychiatric conditions. However, certain psychiatric diagnoses and conditions (e.g., depression, cognitive dysfunction, adjustment disorders, and behavioral difficulties) are more common than others.^2,¹³^–¹⁵

Although diagnostic criteria for these conditions remain unchanged in the setting of chronic illness or among those receiving rehabilitative services, it often is more difficult to obtain sufficient data to satisfy the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria in this setting. Although a large proportion of patients who receive rehabilitative care and who are coping with chronic medical illnesses appear to be depressed, confused, or anxious, when widely used clinical assessment instruments are employed in hopes of reaching a less “biased” diagnosis, a large proportion of these patients do not meet diagnostic criteria for the suspected condition. This inability to reach a diagnostic threshold may be due in part to shared communication deficits between clinician and patient. Many of the conditions that afflict rehabilitating patients wreak havoc on their ability to communicate their most basic emotions. Likewise, clinicians may be fooled because the usual affective “music” associated with various mood states in healthy people may not sound the same in patients with chronic illness.

Therefore, clinical experience dictates that, in these circumstances, it is most appropriate to treat symptoms rather than diagnoses, and to treat them early and aggressively, as it is too often the case that more (and more severe) symptoms appear quickly rather than disappear, and are more difficult to manage once they have developed fully; it appears that it is far better to err on the side of too much treatment rather than too little treatment.

Delirium (see Chapter 18) is of particular importance in rehabilitation patients. This condition, commonly referred to as an “acute confusional state,” can arise during an acute hospitalization and may “follow” the patient to the rehabilitation center; unfortunately, it may have gone undetected, or if detected, go inadequately treated. Its presence may adversely affect prognosis, as well as length of stay, need for a nursing home placement, or disability.¹⁶

Marcantonio and co-workers ¹⁷ reported that, among 551 adults age 65 and older transferred from an acute care facility to a post–acute care facility (i.e., a rehabilitation hospital or a SNF), 23% had symptoms of delirium on admission, and 1 week later, 12% had more symptoms of delirium. In addition, of those with no symptoms of delirium on admission, 4% developed new symptoms 1 week later. New-onset delirium may occur during rehabilitation when, for example, changes to medications take place or an infection develops.²

Several important predisposing and precipitating risk factors for the development of delirium are often present among patients undergoing rehabilitation and with chronic illness (including visual or hearing impairment, cognitive impairment, history of stroke, presence of an intracranial lesion, ongoing infection, regular use of psychotropic drugs, polypharmacy, and greater medical complexity).¹⁷

SOME DISABLING NEUROLOGICAL CONDITIONS AND THEIR POTENTIAL IMPACT ON PSYCHIATRIC DIAGNOSIS AND TREATMENT

Co-occurrence of certain conditions in patients receiving rehabilitation can make it more difficult to perform a psychiatric examination, thus confounding diagnosis and treatment. For example, strokes (depending on their location) can interfere with cognitive or affective expression, key components required to make an accurate diagnosis. In addition, psychiatric treatment may be affected, for example, when acute cervical spinal cord injury is accompanied by psychosis or delirium.

Strokes and some general neurological conditions can generate disorders of communication that can mislead treating physicians. Expressive aprosodia is an under-appreciated example of dysfunctional post-stroke communication. It involves an impaired ability to convey affect through inflection, gesture, and facial expression ¹⁸^–²¹; the damage is to the nondominant-frontotemporal region, which creates an analog of aphasia (which is associated with the frontotemporal region on the dominant hemisphere). Expressive aprosodia disrupts the “feeling” or “music” of communication that supports the words or “lyrics” that are affected by aphasia (see Table 88-2 for definitions of some common neuropsychiatric conditions seen in patients receiving rehabilitation).

Table 88-2 Definitions of Some Common Neuropsychiatric Conditions Seen in Patients Receiving Rehabilitation

Medical Term	Greek (Gr.) Meaning; Medical Definition	Usual Location of Brain Lesion
Abulia	Gr. a-, not, + boule, will; absence or inability to exercise willpower	Nonspecific
Anosognosia	Gr. a-, not, + nosos, knowledge; real or pretended ignorance of the presence of disease, especially paralysis	Nondominant parietal
Aphasia	Gr. a-, not, + phasis, speech; inability to express oneself properly through speech, or loss of verbal comprehension; loss or impairment of ability to produce or comprehend language	Dominant frontotemporal
Aprosodia	Gr. a-, not, + prosodia, voice modulation; lacking emotional intonation and having a monotone quality; absence of normal pitch, rhythm, and variations in stress	Nondominant frontotemporal
Dyskinesia	Gr. dys, bad, + kinesis, movement; defect in voluntary movement; difficulty or distortion in performing voluntary movements	Nonspecific
Pseudobulbar affect; also called emotional lability, pathological laughter or crying; involuntary emotional expression disorder (IEED)	Affect apparently, but not really, due to a bulbar (i.e., medullary) lesion; the pathological expression of laughter, crying, or smiling	Nonspecific; may be a manifestation of stroke, brain trauma, motor neuron disease, multiple sclerosis, or dementia
Telegraphic speech	Speech consisting of only certain prominent words and lacking articles, modifiers, and other ancillary words; simple, noun-verb sentences: “Drink water;” “Take bath;” “Read book”	Nonspecific

Patients with aprosodia sometimes have depressive cognitions but cannot convey their depressed mood; this leads to underdiagnosis of depression. On the other hand, a patient with an expressive aprosodia may be misdiagnosed as having depression when the patient’s unemotional, apathetic speech is misinterpreted as a sign of a mood disorder. Several approaches can detect defects in prosody. First, one wants to know if the nondominant hemisphere is damaged; this can be gleaned from detection of hemiplegia and from findings of a magnetic resonance imaging (MRI) scan. Further, the examiner can ask to the patient to repeat a neutral sentence, such as “I am going to the store,” in a tone that signifies happiness, sadness, and anger in succession. Failure to do these well suggests expressive aprosodia. If the patient cannot detect changes in tonality of the examiner when reciting the phrase (when the patient cannot see the examiner’s face), a receptive aprosodia is suggested. In patients with aprosodia, careful observation of vegetative signs (such as decreased appetite) takes on a greater significance, as does a personal and family history of depression.

Strokes in the nondominant parietal lobe can produce anosognosia, as originally described by Babinski. This condition usually involves the denial of deficits, most often paralysis; however, it can also involve irritability, crying, and denial of depression that are obvious to family and staff. The patient’s inability to report depressive experience in the context of anosognosia can also lead to underdiagnosis of this condition and to a missed opportunity to help.

Dominant hemisphere lesions generate confounds (such as aphasias) for psychiatric diagnosis as well. Fluent aphasia (e.g., Wernicke’s aphasia) manifests with well-articulated incoherent speech and failure to comprehend, without a motor or sensory deficit. This disordered speech can be confused with loose associations, a common characteristic of thought disorders and schizophrenia. History is the key to differentiating a fluent aphasia with sudden onset from the speech pattern of someone with schizophrenia, where an insidious onset and chronic course along with emotional and social impoverishment are evident. It is common for psychiatrists to be asked to see a post-stroke patient with a fluent aphasia to rule out schizophrenia, or to see an aphasic patient with a history of schizophrenia, though long quiescent, to treat an exacerbation of schizophrenia.

Nonfluent aphasia, such as seen with a Broca’s aphasia, features slow, telegraphic speech with impaired word-finding ability. Through yes/no questions, such patients can express their feelings. Facial expressions associated with depression remain intact.

The presence of strokes, multiple sclerosis, or amyotrophic lateral sclerosis (ALS) can lead to the overdiagnosis of major depressive disorder (MDD).²² For example, lesions of the frontal lobe can produce abulia, a syndrome featuring apathy, loss of motivation, and a loss of goal-directed behavior. Because all these conditions may have abulia as a symptom, its presence may lead to the misdiagnosis of depression as the cause of the observed lack of motivation or apathy.

A careful history and mental status examination can reduce the likelihood of diagnostic error in abulia. Sudden onset is characteristic of cerebrovascular accident (CVA)–related abulia, but not of MDD. Abulic, but not depressed, patients may display a wide affective range despite lacking motivation. They are also less likely to be preoccupied with suicide. As is often true of the aprosodias, careful observation of vegetative symptoms along with knowledge of the patient’s history can help to differentiate between neurological and psychiatric conditions.

Pathological crying or laughter and pseudobulbar affect can mislead clinicians and patients regarding the presence of MDD. This often-inappropriate affect is spontaneous and may be incongruent with the patient’s thought content; neurovegetative symptoms of depression may be minimal or absent between affective displays. For unclear reasons, pathological crying is sometimes ameliorated with use of low-dose tricyclic antidepressants (TCAs), even in the absence of a mood disorder. However, although many different classes of psychotropic agents have been reported as useful in the treatment of this condition, none has been shown to be effective in large, well-controlled trials.²³

Other brain-related disorders (e.g., Parkinson’s disease [PD], Alzheimer’s disease [AD], and temporal lobe epilepsy [TLE]) also create perplexing problems for the diagnosis and treatment of depression. Apathy, masked facies, cognitive slowing, sleep disturbance, and fatigue are features of both PD and depression that complicates diagnosis. In addition, there is a significant co-morbidity with respect to the presence of depressive symptoms and PD, with 20% to 40% of those with PD meeting criteria for MDD,²⁴^–²⁶ and several investigations have shown that in general, the presence or absence of neurovegetative symptoms does not help separate depression from underlying PD. However, two symptoms (appetite disturbance and early-morning awakening) have discriminative power for the diagnosis of depression. The symptoms that correlate most significantly with depression in those patients with PD, as measured by the Hamilton Depression Scale,²⁷ were suicidal thoughts and feelings of guilt.²⁸ The highest correlations using the Montgomery-Asberg Depression Rating Scale²⁹ were observed for depression (0.75) and anhedonia (0.74).³⁰

The pathophysiology of PD also overlaps with that of MDD. Reduced catecholamine neurotransmitter release in the midbrain is implicated in both conditions; thus, interesting possibilities for treating both conditions with the same medication are raised. Unfortunately, convincing evidence regarding the notion that improvement in dyskinetic movements with dopaminergic treatment lessens depression is lacking. Selective serotonin reuptake inhibitors (SSRIs) can lessen depression in this population; however, they may worsen dyskinesia through reduction of dopamine release that accompanies increased serotonin receptor activity. However, conclusive evidence that dyskinesia worsens in PD with the use of SSRIs is lacking. Electroconvulsive therapy (ECT) is effective in both MDD and PD,³¹^–³³ relieving depression, and reducing parkinsonian symptoms for several weeks or longer.

Alzheimer’s disease shares several features with PD and MDD.³⁴ All three have depleted brainstem aminergic nerve cell function. This common pathology contributes to apathy, impaired concentration, and reduced short-term memory that is seen in all three. The high co-morbidity of MDD in AD and PD is also understandable. MDD may be the initial presentation in late-life AD and is prominent in the differential diagnosis for reversible dementias.³⁵ In addition, depression at any time in life appears to increase one’s risk for AD.

Those with AD and MDD are less apt to experience excessive guilt, disturbed sleep, and feelings of worthlessness; however, they are more apt to describe indecisiveness and an inability to concentrate, which is consistent with cognitive decline. It is noteworthy that there is no change in the frequency of the features of MDD with the severity of AD, except for psychosis, which increases with the severity of AD.

Successful treatment of MDD in AD can reduce agitation, improve quality of life, and reduce caretaker stress. Antidepressants, such as TCAs, with significant anticholinergic properties should not be used because they undermine the already depleted cholinergic reserves seen in those with AD. In apathetic AD patients it is reasonable to use antidepressants that increase synaptic catecholamines, such as bupropion and venlafaxine; however, caution against overstimulation of the adrenergic system is advised. For those who are anxious and agitated, mirtazapine or an SSRI is appropriate, although definitive studies to support these choices are lacking.

TLE, including complex partial seizures, is the type of epilepsy most commonly (approximately 20%) associated with psychiatric findings; 14% of these patients exhibit psychosis during postictal and interictal states.^18,²¹ Care is needed to make psychiatric diagnoses associated with TLE while the patient has a clear sensorium, not when the patient is ictal or in a postictal state.

Psychopathology often exists during interictal periods in people suffering from TLE. The interictal syndrome features hypergraphia, seriousness, humorlessness, and an intense interest in philosophical, moral, or religious issues. In addition, affected individuals tend to be viscous, that is, they have a tendency to talk on-and-on and circumstantially about a restricted range of topics; Dostoyevsky is one famous person thought to have had TLE.

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