Posts tagged: Stroke

The Psychological Model

Dr. Holzmacher's Business Logo for online psychotherapyThe medical versus psychological models of treatment are often discussed during psychological training.  The word “model” refers to the theoretical framework that each profession uses as their guiding principles.  Both medical and psychological models focus on signs and symptoms of illness.  The medical model relies heavily upon independent tests to prove or disprove if a patient is ill.  The psychological model also uses tests to prove or disprove whether a patient is ill.  It is at this point of agreement that the two models diverge.

The chasm that divides one model of treatment from the other is the subjective experience of the patient.  To most medical doctors, if the tests do not reveal a problem, then the patient is often perceived as hypochondriacal or even malingering.  To a psychologist, if the patient believes they have a problem, then they really do have a problem.  The subjective experience of the patient is considered most important, and objective measures less so.  For example, people often claim they are experiencing pain, even though objective tests did not discover damage to the organism.  The psychologist will note that there does not appear to be organic damage, yet the patient remains in obvious distress.  Psychologists are trained in the scientific method, which encourages constant skepticism.  A well trained psychologist should always keep in mind that no test is one hundred percent reliable, and there are always limitations regarding the extent of their validity.  In the example above, there may be actual organic damage to the patient causing their pain, but the current state of the art lacks a test to reliably identify the organic damage.

An obvious limitation to the psychological model is a patient that is unconscious, or their communication ability is compromised to the extent that they are unable to make their needs known to others.  Both medical and psychological models must rely upon objective tests to evaluate these type of patients.  There is no alternative.  When the patient regains consciousness, and is at least vaguely aware of their environment, then their subjective experience again becomes very important.  For example, patient’s who wake from a stroke to discover that they are unable to communicate often manifest great agitation.  Quite often, they are not aware of their own lack of expressive ability and believe others are making a game of pretending to not understand their verbiage.  The objective tests qualify and quantify the extent of damage to their brain, but the subjective experience is that loved ones and staff are playing an elaborate trick.

The explosion of “alternative” medicine suggests that traditional medicine might be missing something.  Those patients that are attracted to alternative medicine do not completely eschew the traditional medicine model.  Consumers of alternative medicine still believe that substances outside our bodies have curative powers.  They tend to avoid products of traditional pharmaceutical companies in favor of medicinal preparations from other cultures or even antiquity.  The model of treatment is essentially the same, it is merely a change in the manufacturing and distribution of the medicines.  Clearly this group of consumers has health needs not adequately addressed by the traditional medical model, yet it remains to be seen if the “alternative” style of medical treatment is any more effective.

To paraphrase Andrew Still, anyone can find disease, but it takes a healer to find health.  The various qualities and techniques to become a “healer” are still less than scientific.  The failure of traditional and alternative medical models to address the subjective needs of the patient may be the missing link that completes the true healer.  Twenty years of clinical practice have convinced the author that people’s complaints are only loosely based upon reality, and this holds true for the author as well.  Humans have resisted efforts to equate mental and physical health with empirical evidence reminiscent of mechanical laws.  Empirical evidence should be the cornerstone of medical and psychological practice, yet the entire edifice is not created with these laws alone.  Understanding the subjective experience of the patient is a gift, both to the patient and their family.

A Stroke of Bad Luck

Business Logo for Psychological and Neuropsychological IssuesThe term “stroke” is a fitting name for a sudden unexpected happenstance.  In medicine the term “stroke” applies to the sudden onset of symptoms after circulatory problems arise in the brain.  The movies typically portray the sudden devastation to one’s physical functioning; for example the paralyzed father in “Legends of the Fall.”  The slow insidious onset of symptoms from circulatory problems is neither as dramatic or pictorial as the sudden manifestation, but it may cause as much or more functional impairment.  The sudden classic middle cerebral artery stroke with left or right paralysis may be diagnosed by many non-professionals.  The slow manifestation is often overlooked or misidentified by professionals.

Neuropsychological and medical training instills the belief that the former type of stroke is much more common than the latter; that the sudden “stroke” is much more common than the slowly evolving cerebral damage from altered circulation.   Given the unique and dramatic symptoms of a stroke are much easier to diagnose than the slowly evolving, it is likely that the figures taught to doctors are less than accurate.  Slowly evolving symptoms of stroke are directly related to uncontrolled high blood pressure.  While one would think that a slowly evolving hemorrhagic stroke (leaking blood vessel) would be more common than a blockage, this does not appear to be the case.   Most hemorrhagic strokes are of sudden onset, and are often difficult to differentiate from a blockage in a cerebral artery.

Most slowly evolving events related to blood pressure present with decreased attention, a decreased level of arousal, and an overall slowing of thoughts and actions.  There may be signs often considered focal or localized; for example speech and visual deficits, but this is hardly universal.  Family history often identifies a day or two where the patient had been inattentive or even partially paralyzed, but the symptoms tended to abate.  I recently interviewed a man with many years of uncontrolled high blood pressure.  The man had refused treatment for high blood pressure because he was convinced the issue was touted by physicians to increase their income.  His family noticed a few days of poor attention and impaired speech a year or two back, but his apparent rapid recovery dissuaded them from seeking medical consultation.  The symptoms returned and abated over a course of years, but the overall picture was of functional decline.  Diagnostic imaging of the brain was not remarkable, yet his performance on neuropsychological tests was indicative of one or more strokes.  As is often the case, one of his arms was significantly stronger than the other, but not affected to the point it was noticeable to the patient or his family.  He lost the power to ambulate as both legs became progressively weaker; not just the one side typically associated with a blockage of a cerebral artery.  Notice that not only were both sides effected, but the damage increased over time.  This is at odds with what most people would consider a cerebral vascular accident.

Another difficulty in the diagnosis of slowly evolving strokes is the overlap with other conditions.  The sudden dramatic onset of focal paralysis is not present in any other physical condition known to this clinician.  The clinician must differentiate between a stroke and a psychological conversion reaction producing the symptoms, and the latter is fortunately very rare.  The slow onset of bilateral weakness in the legs, as in my patient above, may be secondary to a host of factors other than brain damage.  The unfortunate person may have generalized weakness due to malnutrition, dehydration, anemia, a systemic infection or metabolic/endocrine disorders.  Bilateral weakness in the legs may be secondary to damage in the spinal column, a muscular dystrophy, arthritis or even an unwillingness to walk.  Regardless of age, failure to bear weight on one’s hips and legs quickly leads to muscular atrophy.  The burden on the physician is much greater when the symptoms are not focal and slowly evolving.  It is no wonder that statistics regarding different kinds of strokes may be unavoidably inaccurate.

Given these hurdles experienced by trained professionals, what is an educated layman to do?  The most practical and effective measure is to watch one’s blood pressure.  Over the course of my training and twenty years of practice, I have observed many medical “facts” and “breakthroughs” fall by the wayside for a lack of evidence and efficacy.  The evidence favoring control of blood pressure and its positive effects on health and overall well-being has only increased over the years.  Regardless of age, if you are a female smoker and use birth control, I suggest close monitoring of your blood pressure.  If you are older than 50, I suggest checking your blood pressure regularly; especially important if one has episodes of feeling dizzy and flush.  Please leave comments regarding this post in the space provided below.

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