Key words
comorbidity - psychotherapeutic approaches - multimodal psychotherapy - bio-psychosocial
approach - interdisciplinary
Psychotherapy: A Task of Neurorehabilitation
Psychotherapy: A Task of Neurorehabilitation
The high prevalence of comorbid mental disorders requires psychiatric-psychotherapeutic
and psychosomatic measures that go beyond the original purpose and bio-psychosocial
orientation of rehabilitation. In addition, damage to the CNS can directly affect
emotional, cognitive and social functions and thus impair a person’s expressive behavior
and coping mechanisms. Unlike other medical disciplines, neurology is characterized
by a close interconnection of somatic and psychological functions – as well as reciprocal
influences [1].
Psychological disturbances in neurologically ill patients have an impact on compliance,
length of hospital stay, achievable functional and socio-medical outcome as well as
the quality of life [2]. Likewise, there is suggestive evidence that disease risk and mortality are adversely
affected by the presence of psychological disorders [3]. A targeted treatment of mental disorders, including psychotherapeutic measures,
is therefore indicated, if only from a purely neurological perspective.
Due to their specific competence, neurologists play a role that is both central but
neglected in the treatment of mental disorders in neurologically ill patients as well
as in clinical practice. Differentiated psychotherapeutic treatment designed to take
into account individual neurological findings is rare. The extensive lack of systematic
scientific studies and related well-founded information is an expression of this situation
while maintaining it. Therefore this overview is intended to focus attention on activities
to improve this situation as well as outline the clinical foundations that facilitate
direct integration of psychotherapeutic measures into neurorehabilitation. The results
of a literature search using the terms “neurology”, “psychiatric illness”, “neurorehabilitation”
and “psychotherapy” should serve as an introduction.
Comorbidity of Neurological and Psychiatric Disorders
Comorbidity of Neurological and Psychiatric Disorders
Data regarding the prevalence of comorbid mental disorders are largely available for
the most frequent neurological disorders – with significant differences depending
on the population being studied, the size of the sample, the nature and severity of
the neurological disorder and the method of examination used ([Table 1]).
Table 1 Prevalence of comorbid psychological disorders among selected neurological illnesses
in %.
|
Neurological illness
|
Depression
|
Anxiety
|
Other
|
|
Seizure disorders
|
11–80 [4]
|
10–25 [5]
|
Schizophrenic psychosis: 2–9.1 [4]
Bipolar disorder: 12 [6]
|
Addiction: 3 [7] (marijuana)
ADHD: 12–37 [4]
|
|
Parkinsonism
|
20–50 [8]
|
25.7–49 [9]
[10]
|
Apathy: 12–45 [8]
[10]]
Hallucinations: 15–40 [11]
Impulse control disorders: 6–36 [10]
[12]
|
|
MS
|
4.8–46.9 [13]
[14]
|
8.7–54.1 [14]
[15]
|
Schizophrenic psychosis: 0.8–4.7 [15]
[16]
Bipolar disorder: 0.5–5.8 [16]
[17]
|
Alcohol: 13.6–14.6 [17]
[18]
Other substances: 1.5–7.4 [16]
[19]
|
|
Dementia
|
32–77 [20]
[21]
|
62 [21]
|
Apathy: 36–71 [20]
[21]
|
|
Brain tumors
|
2.5–44 [22]
[23]
|
5–12 [24]
[25]
|
Acute stress disorder: 19 [25]
Adjustment disorder: 15 [25]
|
Apathy: 35.2 [26] Schizophrenic psychosis: 22 [23]
|
|
Stroke
|
16.8–47
[27]
[28]
[29]
|
20–29 [28]
[30]
[31]
|
Apathy: 36.3 [32]
Fatigue: 25–85 [33]
PTSD: 23 [34]
|
|
Subarachnoid hemorrhage
|
5–50 [35]
[36]
|
27–54 [35]
|
PTSD: 18–37 [36]
|
|
Traumatic brain injury
|
27 [37]
|
37 [38]
|
Chronic pain: 51.5 [39]
Sleep disorders: 25–29 [40]
Schizophrenic psychosis: 1.35–9.2 [41]
|
|
Chronic back pain
|
2.5–13.7 [42]
[43]
[44]
|
0.2–9.5 [42]
[43]
[44]
|
PTSD: 0.0–7.4 [44]
Somatization: 14.9 [42]
|
Sleep disorders: 10 [43]
Alcohol: 0.0–5.1 [44]
|
|
Migraine
|
16.8–47 [45]
[46]
|
30.1–31.2 [45]
[46]
|
PTSD: 25–40 [45]
[47]]
Bipolar disorder: 5.9–9 [48]
|
The prevalence of depressive and other psychological disorders in neurology patients
treated on an inpatient and on occasion on an outpatient basis is higher than in the
general population [15]
[49]. The order of magnitude may be questionable, but the need for specific treatment
is undeniable [3]
[50]
[51].
Depression and anxiety are frequent, so to speak appropriate accompanying symptoms
of neurological disorders. Situation-dependent phobic and social phobia anxieties
revolving around functional impairments are frequently found, as well as addiction
and pain. Trauma- or stress-response disorders can occur, depending on the origin
of the illness and impairment. Physical manifestations and health problems can take
the place of psychological symptoms, especially as amplifications of neurological
functional impairment [52]
[53]
[54]
[55]
[56]. Likewise, purely functional neurological impairments should be anticipated. Primary
and secondary pain disorders represent an additional field of inquiry. Etiologically,
both organic mental and functional psychological disorders should be expected. Possible
side effects of drug treatment must be also be taken into account.
Suicidal ideation and behaviors are frequent [13]
[57]
[58]
[59]. More than the etiology of the disease, the type and extent of the impairment and
its subjective assessment influence the occurrence of suicidality which can be masked
by just neurologically-appearing symptoms, such as fatigue [60].
Functional neurological disorders in particular evidence the close interconnection
of neurological and psychological aspects in neurological disorders makes it obvious
how diagnostics and therapy require both neurological and psychiatric-psychotherapeutic
and psychosomatic competence. The current high scientific and clinical interest in
this topic is shown by the fact that a separate volume, “Functional Neurologic Disorders”
(139) has recently appeared in the “Handbook of Clinical Neurology” [61].
Psychotherapeutic Procedures in Neurology
Psychotherapeutic Procedures in Neurology
Psychotherapy in neurological rehabilitation is characterized by a wide variety of
concepts and procedures ([Table 2]), which makes the recommendation of certain procedures more difficult, especially
since there are no conclusive comparative studies.
Table 2 Frequently identified psychotherapeutic procedures.
|
Cognitive behavior therapy
|
|
Psychodynamic therapy
|
|
Psychodrama
|
|
Interpersonal psychotherapy
|
|
Narrative psychotherapy
|
|
Client-centered psychotherapy
|
|
Mindfulness-based psychotherapy
|
|
Biofeedback
|
|
Auto- and heterosuggestive techniques
|
|
Relaxation techniques
|
|
Music therapy
|
|
Art therapy
|
|
Body-oriented psychotherapy
|
In the case of frequently missing or weak effects, existing therapy studies particularly
show the efficacy of cognitive behavioral therapy-oriented interventions [62]
[63]
[64]
[65]. Psychodynamically-oriented procedures can however be primarily indicated and useful
with respect to personality or conversion disorders, and in the treatment of existential
issues [66]
[67]. Recent decades have seen the development of targeted therapeutic approaches due
to a growing focus on the needs of patients suffering from chronic illness and disability.
In narrative procedures, disease and disability are treated in the context of life
history [68]
[69]
[70]. Interpersonal psychotherapy also supports focusing on the challenges posed by the
illness [71]. Body-oriented psychotherapy, music therapy, art and creative therapy are advantageous
for physically ill people with communication disorders or whose perception of illness
is primarily somatic [72]
[73]
[74]
[75]. In addition to auto- and heterosuggestive approaches, a variety of complementary
procedures are used [76]
[77]
[78]. Mindfulness-based interventions provide an obvious benefit [79]
[80]
[81]
[82]
[83]. Neurological functional therapies benefit from incorporation of psychotherapeutic
aspects [84]
[85]. Neuropsychological treatment integrates psychotherapeutic approaches [86]. In addition, counseling of family members and, where necessary, couples and family
therapy interventions are a complement.
However, the variety of approaches and procedures and their overall unsatisfactory
evidence do not necessarily represent a shortcoming. Illnesses of the CNS are complex
disorders, made even more complicated by the occurrence of psychiatric disorders [87]. It is therefore not to be expected that a single psychotherapeutic approach will
cover all essential therapeutic needs. An acknowledged model of psychotherapy after
brain damage is based in important aspects on concepts of analytical psychology, but
also relies on behavioral therapy and cognitive elements [88]. Integrative treatment models that combine different approaches are obviously advantageous
[89].
The Psychotherapeutic Approach
The Psychotherapeutic Approach
To date, there is still insufficient research and conceptualization regarding the
adaptation of psychotherapeutic procedures to neurological functional impairments.
Nevertheless, some recurring tasks can be formulated which have to be taken into consideration
during treatment.
Where established criteria indicate a definable psychiatric disorder, consequent therapy
will primarily be based on relevant guidelines and treatment recommendations. The
sooner the psychological disorder is understood as an autonomous disease independent
of the neurological event, the better psychotherapy can be added as a prime adjunct
which is complementary to neurorehabilitative treatment. Even then psychotherapy will
have to be adapted to the complexity of the condition. Compared to working with physically
healthy people, an approach offering more structure is needed, as well as an active,
involved and emotional support. In particular psychotherapeutic interventions must
be oriented to the individual patient’s functional limitations, which frequently include
limited psychophysical resilience. Regardless of the procedures eventually used, it
is important to take into account certain recurring tasks arising from the combination
of neurological and psychological disorders.
Treatment Begins With the Diagnosis
Treatment Begins With the Diagnosis
Without targeted diagnostic attention, mental disorders remain easily undetected in
physically ill patients. Criteriologically, sub-threshold psychiatric disorders should
be expected [90]. Numerous overlaps on the symptom level complicate the differentiation of symptoms
which can be explained as a direct physical consequence of organic damage. At the
same time, lack of a somatic disease origin cannot be relied on as a criterion. For
the patient, the coincidence with physically-induced complaints facilitates somatization;
for the therapist, the clinically obvious focus on the physical disorder and disability
compromises the recognition of the elements of the psychosomatic disorder.
It is true that a single influencing factor such as organic brain damage can dominate
the clinical picture. The patient’s problems are generally better understood if the
therapist presumes a combination of clinical issues, variously presenting as proportions
of cognitive deficits and the loss of other instrumental abilities, of brain-related
disturbed behavior and interaction. The approach should also be based on understanding
the functional psychiatric or psychosomatic components of the disorder, as well as
the biography and personality of the patient, the patient’s preferred management strategy
and other contextual influences. Preparation for psychotherapy should include the
neurological and psychological findings, supplemented by a differentiated functional
and social-medical assessment, which takes into account the treatment context.
Illness and Life Management
Illness and Life Management
Managing an illness goes beyond improvement and compensation of the consequences of
the disease and the psychological processing of disorder-related events. Personal
reorientation is indispensable if the patient’s relationship to the self and the world
are doubtful, and its success may require clarifying unrelated, even long past life
experiences and events. Existential questions, guilt and shame, anger and bitterness,
fragile self-esteem and vulnerable autonomy present persistent challenges [91]. The understanding the patient has of the illness and his/her future as a patient
constitutes an important primary starting point for therapy [92]. As the duration of the illness and disability increases, coping with residual impairments
and best possible participation in life activities increasingly becomes the focus
of therapy.
Coping behavior itself can be a reason for an intervention. When managing severe impairments,
a frequently observed “forced management attitude” with active negation of emotional
(psychological) neediness, high need for control and information and high activity
level can offer a great advantage. In the long run, however, this can be sustained
only at the price of increased psychophysical exhaustion, and will ultimately lead
to manifest psychological problems [93].
Traumatising psychological experiences occuring or reactivated in context of the illness
may require targeted interventions. In addition to full-blown post-traumatic stress
disorder, seemingly nonspecific complaints should be expected, with pain or somatoform
symptoms as the main focus [94]
[95].
Changes in the Personal Environment
Changes in the Personal Environment
Even though the patient succeeds at managing the illness and personal issues, stressful
changes can occur in the patient’s personal environment. Including close relatives
makes sense not only regarding joint daily coping with the illness and its consequences,
but also takes into account shared psychosocial burdens while opening up possible
treatment resources [96]. Other aspects include past conflicts, relationships and partnerships, and, especially
among young people, sexuality.
Direct involvement of the patient in the sense of shared decision-making or empowerment
is a necessity, especially in the case of chronic physical illness, not only with
regard to medical treatment – the clarification of relevant issues regularly extends
into psychotherapy. Since chronic illness is accompanied by a medicalization of everyday
life, patients and their relatives need to learn how best to deal with issues of care
and treatment [97]. Psychotherapeutic need for action is also found regarding socio-medical questions
requiring active utilization of adapted occupational therapy measures.
Organic Psychiatric Disorders
Organic Psychiatric Disorders
When planning and implementing psychotherapeutic measures, reduced psychophysical
resilience and other limitations that hinder adequate cooperation must be anticipated,
particularly regarding executive impairment, motivational problems, emotional disorders
and understanding of the illness, as well as other impairments [98]. However, the presence of organic brain damage does not rule out psychotherapeutic
intervention – on the contrary. Mental disorders can sometimes also manifest themselves
in the form of functionally altered emotional or cognitive impairments, and in any
case affect the course of the disease as well as neuropsychological diagnosis and
therapy. A differentiated behavioral analysis or a psychodynamic model also creates
the prerequisites for an optimal use of action-oriented methods [88].
The Sick Body
The body plays a significant role in the psychotherapy of neurologically ill patients
beyond an attempt to alleviate symptoms and improve management of the disability.
Physical disabilities determine a framework for experience and action in which patients
or disabled persons will preferentially express their psychological condition as well
as their personality and life experiences. This is especially true of chronic pain,
which may originate from psychic trauma tied to bodily experiences, but applies variously
to all physical symptoms, and even more so with respect to functional neurological
disorders. Once understood, the expressive and interactive aspects of the body can
properly guide the direction of the psycho- and functional therapy [99]
[100]. These aspects must be kept in view for all therapeutic and neurorehabilitative
measures and should likewise be targeted in functional therapies. Body psychotherapeutic
procedures address them right from the start [101].
Integrated Therapy
To the extent possible, integration of neurological, neuropsychiatric, functional,
neuropsychological and psychotherapeutic measures is necessary in the disorder-specific
treatment of comorbid psychiatric disorders. Based on individual need, the multimodal
psychotherapeutic intervention should combine information, education and exercise,
more narrowly defined individual psychotherapy as well as complementary approaches.
Physical illness and functional disabilities allow ample scope for action, causing
psychotherapists with little experience in neurology to easily lose the necessary
broader perspective. Psychotherapeutic work with neurological patients requires thorough
medical knowledge as well as openness to psychosocial issues. Given the complexity
of the task, the treatment of comorbid mental disorders necessitates interdisciplinary
teamwork. The findings of all disciplines define a complex of conditions containing
the possible influencing factors which form the basis for functional impairments and
symptoms. Relying on this, hypotheses are generated as to the possible interaction
of different elements in the manifestation of the disease – mutually reinforcing or
mutually weakening – and as to which diagnostic and therapeutic requirements may result
from the individual findings and hypotheses and their aggregation. In the form of
a continuous feedback process, the results of the treatment measures based thereon
are then included into the narrowing and updating of the complex of conditions and
consequently into the resulting diagnostic and therapeutic interventions [102]. An overarching conceptual framework for this work is provided by systems theory
comprehension and action models, including the investigator’s own role as well as
that of his/her phenomenological modeling [103]
[104]
[105].
Summary and Outlook
Psychotherapy in neurorehabilitation is a developing discipline, tasked with managing
a wide variety of clinical objectives. Only broadly-based, bio-psychosocial models
and treatment approaches can adequately take into account the mostly complex illness
cases – both diagnostically and therapeutically. Furthermore, development and application
of specific psychotherapeutic interventions which are geared to the needs and abilities
of neurologically ill patients are a necessity. Finally there is a need for training
and continuing education for all therapists engaged in neurorehabilitation.
The interdisciplinary approach of neurorehabilitation itself creates favorable conditions
for the direct integration of psychotherapeutic measures. However, it is necessary
to utilize them. Thus the special role of psychotherapy in neurorehabilitation, requiring
an integration of different models of comprehension and action, creates a field for
the further development of psychotherapy as a whole.
