Approach to the patient with chronic polyneuropathy

Background –  Chronic polyneuropathy is a common disorder with heterogenic clinical presentation and many different etiologies. Diagnostic investigation is challenging.
Materials and methods –  An algorithm for diagnostic investigation of chronic polyneuropathy is presented. It was designed to secure practical usefulness for general neurologists, identification of the most common causes with an adequate number of laboratory tests, and more focused investigation when necessary. The proposal is based on review of articles found by PubMed search using the terms 'peripheral neuropathy, cause, and investigation', relevant book chapters, and own clinical experience.
Results –  All patients should undergo a routine investigation for the most common causes of polyneuropathy by asking for diabetes, heredity, alcohol abuse, toxic medications and agents, symptoms of Sjögren's syndrome, renal failure, and the following laboratory tests; glucose, haemoglobin, leucocytes, thrombocytes, ESR, creatinin, ALAT, GT, vitamin B12, serum electrophoresis, TSH and thyroxin. If routine investigation is negative, a targeted approach based on clinical type and electrophysiological findings is recommended. The most common type with slowly progressive, symmetric sensory symptoms beginning in the feet can often be classified as cryptogenic without further investigation. Polyneuropathies with subacute onset, progressive weakness, asymmetric symptoms, proximal weakness, selective involvement of sensory fibers or demyelinating pathology, or other organ manifestations, have various etiologies that necessitate individual focused investigation.
Interpretation –  Diagnostic investigation of polyneuropathy can be simplified and systematized.     

A patient classification system for the chronic psychiatric patient

Classification of chronic psychiatric patients to determine staffing needs is an emerging issue confronting many psychiatric nurses. This paper follows the development of a patient classification system for chronic psychiatric patients in the United States. Few tools are available and those cited in the literature tend to report minimal validity and reliability and lack applicability to the setting or for the purpose desired. The tool demonstrated use and acceptance by nurses and was found to meet the comprehensive needs of patients it was designed to serve.     

Productive activities for the chronic patient

This paper examines the common characteristics of chronic psychiatric patients and the principles that should guide the development of any program of activities designed to promote their rehabilitation. A range of productive activities in each segment of a support network is described, and an example from Oregon is presented to illustrate how different levels of activities can be used to meet rehabilitation goals.This work is supported in part by an NIMH Grant.     

Reframing to deal with patient resistance: practical application

Patient resistance presents many therapeutic challenges. Reframing has proven to be a potent method of circumventing such issues. The present article describes methods of constructing, cultivating, and delivering reframes. Several examples of this intervention strategy are provided.     

The cancer patient with chronic pain due to herpes zoster

Postherpetic neuralgia (PHN) is the most common complication of herpes zoster, and as such has been an area of extensive medical research for the past three decades. The patients at highest risk for PHN include those older than 50 years, those with severe acute cases of zoster, and those with shingles in a trigeminal distribution. As persons with malignancy are at a high risk for developing zoster itself, PHN is a complication that will be faced by many of these patients and their caregivers. This article reviews the available treatments and preventative measures for this debilitating condition.     

Response to methotrexate in a chronic inflammatory demyelinating polyradiculoneuropathy patient

We report a patient with chronic inflammatory demyelinating polyradiculoneuropathy and progressive resistance to standard treatment who showed a striking response to methotrexate, 20 mg/week. The improvement, which started 5 months after initiation of therapy, was consistent and permanent. It allowed the previously wheelchair‐dependent patient to achieve pharmacological remission. The 2‐year follow‐up of this case further illustrates the role that methotrexate may play as a treatment option for CIDP patients. Muscle Nerve 39: 386–388, 2009     

The disculturation hypothesis and the chronic patient syndrome

Summary Goffman (1961) and others have hypothesized that the experience of being a patient in the traditional type of mental hospital leads to negative consequences for the personality system of the inmate. Rather than being seen as purely a manifestation of internal psychopathological processes, patient behavior is seen, from this perspective, as a response to a peculiar sort of social environment. This environment is seen as disruptive of a positive sense of self in the individual and also as conducive to regressive behavior in several dimensions, including the adoption of a passive, dependent orientation towards the institution. — From a population of psychiatric crisis patients seen at the Emergency Room of Yale-New Haven Hospital, some are sent to the Emergency Treatment Service of the Connecticut Mental Health Center. A small, short term treatment facility, the E.T.S. was designed to avoid many of the negative features of the traditional hospital environment. The small size of the unit leads to a situation where some patients, considered by the reviewing resident to be appropriate E.T.S. candidates, cannot be accommodated because the unit is frequently filled to capacity. A high percentage of these cases are sent to State, a traditional type of public mental hospital. By taking measures on a sample from each of these groups at admission and discharge, it would seem possible to determine the impact of the hospital environment on certain aspects of patient personality and self-image. — The major findings of the study indicate that the traditional hospital environment does, in fact, engender and encourage dependency but that there is a complex interrelation between institutional demands and personality predispositions. Individuals who become long-term mental patients seem to be characterized by a high degree of dependency and a negative definition of self. The hospital environment is thus congruent with certain of their personality demands while it also may serve to emphasize these particular demands from a broader possible range of personality components. Conversely, autonomous individuals seem not to be easily molded by the hospital demands and seem able to vacate the patient role very quickly.

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Zusammenfassung Goffman und andere haben angenommen, daß die Erfahrung des Patientenstatus im traditionellen Typ des psychiatrischen Krankenhauses zu negativen Konsequenzen für die Persönlichkeit des Insassen führt. Von diesem Blickpunkt her wird das Verhalten des Patienten nicht nur als Manifestation der inneren psychopathologischen Prozesse gesehen, sondern vielmehr als Reaktion auf eine besondere Form sozialer Umgebung. Gemäß solcher Ansicht zerstört diese Umgebung das positive Selbstgefühl des einzelnen und verführt zu regressivem Verhalten in verschiedenen Dimensionen, einschließlich der Annahme einer passiven abhängigen Haltung gegenüber der Institution. — Aus einer Population psychischer Krisenfälle, die beim Notfall-Dienst der Yale-New Haven-Klinik gesehen wurden, werden einige zum Notfallbehandlungsdienst des Zentrums für seelische Gesundheit in Connecticut geschickt. Eine kleine Einrichtung für Kurzzeitbehandlung, die E.T.S., wurde geschaffen, um viele der negativen Merkmale traditionellen Klinikmilieus zu vermeiden. Die Kleinheit der Einrichtung führt zu der Situation, daß einige Patienten, die vom untersuchenden Assistenzarzt als geeignete E.T.S.-Kandidaten angesehen werden, nicht untergebracht werden können, weil die Einheit häufig voll besetzt ist. Ein hoher Prozentsatz dieser Fälle wird zur staatlichen Klinik, dem traditionellen Typ eines öffentlichen psychiatrischen Krankenhauses, geschickt. Indem man ein Sample aus jeder dieser Gruppen bei der Aufnahme und bei der Entlassung einschätzt, erscheint es möglich, die Entwicklung der Klinikumgebung auf bestimmte Aspekte der Patientenpersönlichkeit und des Selbstbildes zu bestimmen. — Die Hauptergebnisse der Untersuchungen zeigen an, daß die traditionelle Krankenhausumgebung tatsächlich Abhängigkeit erzeugt und fördert, aber daß eine komplexe Wechselwirkung zwischen institutionellen Anforderungen und Persönlichkeitsneigungen besteht. Leute, die Langzeitpatienten werden, scheinen durch einen hohen Grad von Abhängigkeit und eine negative Selbsteinschätzung charakterisiert zu sein. Die Klinikumgebung entspricht also gewissen Forderungen ihrer Persönlichkeit, während sie zugleich dazu dienen kann, diese besonderen Forderungen aus einem möglichen breiteren Spielraum von Persönlichkeitskomponenten hervorzuheben. Umgekehrt scheinen selbständige Menschen nicht leicht durch Klinikforderungen umgeformt zu werden und können offenbar die Patientenrolle sehr schnell aufgeben.

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Résumé Goffman (1961) et d'autres auteurs ont émis l'hypothèse que l'expérience vécue par un patient dans un hôpital psychiatrique de type traditionnel amène des conséquences négatives pour la personnalité de celui qui y est interné. Dans cette perspective, le comportement du patient est considéré comme une réponse à un type particulier de milieu social plutôt que comme une simple manifestation des processus psychopathologiques internes. Ce milieu est considéré comme perturbant le sens positif du Moi de l'individu et conduisant à des comportements régressifs dans plusieurs directions, y compris l'adoption d'une orientation passive, dépendante, à l'égard de l'institution. — Parmi une population de patients en phase psychiatrique aiguë examinés à la salle d'urgences du Yale-New Haven Hospital, quelques-uns sont envoyés au Service de traitement d'urgence (E.T.S.) du Centre de santé mentale du Connecticut. Petit service de traitement à court terme, l'E.T.S. a été conçu de façon a éviter beaucoup des aspects négatifs du milieu hospitalier traditionnel. Vu la faible capacité de ce service, un certain nombre de patients, qui sont pourtant considérés par l'assistant examinateur comme étant des cas appropriés à l'E.T.S., ne peuvent y être admis parce que le service est fréquemment complet. Un grand pourcentage de ces cas est alors envoyé à l'hôpital d'Etat, type traditionnel de l'hôpital psychiatrique public. En comparant un échantillon de chacun de ces groupes à l'admission et à la sortie, il semble possible de déterminer l'impact du milieu hospitalier sur certains aspects de la personnalité et de l'image du Moi du patient. — Les résultats principaux de cette étude indiquent que le milieu hospitalier traditionnel, en effet, engendre et encourage la dépendance, mais qu'il y a une interrelation complexe entre les exigences institutionnelles et les prédispositions de la personnalité. Les cas qui deviennent chroniques semblent être caractérisés par un degré élevé de dépendance et une définition négative du Moi. Le milieu hospitalier satisfait ainsi certains besoins de leur personnalité, comme il peut aussi les exagérer. Au contraire, les individus autonomes ne semblent pas être facilement influencés par les exigences de l'hôpital et semblent être capables d'abandonner leur rôle de patient très rapidement.

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This paper is based on a section of a dissertation presented to the Faculty of the Graduate School of Yale University in candidacy for the degree of doctor of philosophy. During the period of the research, the author was supported by an N.I.M.H. predoctoral research fellowship.     

A view from Riggs: treatment resistance and patient authority--VI. Working with family resistance to treatment

Resistance to treatment is not only seen in the therapeutic dyad of patient and therapist. It can also be manifest in the interaction between the family, the patient, and the clinicians providing treatment. Psychodynamic and family systems perspectives can be useful in understanding the systemic and unconscious dynamics that comprise this form of resistance. Family therapy may be an effective modality for addressing family resistance, can be integrated with a psychodynamic approach, and may facilitate establishing a working alliance that allows therapeutic change and growth.     

A view from Riggs: treatment resistance and patient authority--VII. A team approach to treatment resistance

Treatment resistant patients frequently require treatment modalities beyond combined psychopharmacology and individual psychotherapy. They often require a team effort to manage crises, contain anxiety, and create a psychological space for examining the impact and meaning of behavior. The use of a treatment team as an adjunctive therapeutic modality helps individual team members understand regressions as repetitions of family dynamics, unearths the underlying meaning of behavior, engages patients' authority, and prioritizes the importance of relationships in effecting change. Through engagement with team members and with the team leader's authority, patients may assume responsibility for their behavior, reevaluate familiar roles, and increase self-awareness and psychological integration. The team helps its members identify, bear, and metabolize negative countertransference, address associated anxieties realistically, and optimize the environment for change.     

The drug addict as chronic patient

From the above discussion, it is clear that the chronic drug addict is in need of a careful diagnostic work-up, a team approach, a highly sophisticated model of illness, and treatment targeted to his or her special needs. . Given the high prevalence and social costs of addictions, it is obvious that increased support for training and research, prevention, and treatment is needed within psychiatry and medicine.