III. PSYCHOLOGICAL testING

A.  Experiential Index
1. Somatic anxiety score is 8, indicating the probability of an unfavorable response to conventional treatment as the score is greater than the average urban female.
2. The profile support the patient's complaints of depression and (generalized) anxiety.  The response pattern also verifies a tendency to be non-disclosing about emotions and use of defenses to offset awareness of non-rational anxieties.

 B. Psychiatric Screening Profile
                        1. Type: ANXIOUS DEPRESSION

 C. Psychogenic Health Analysis

• Intense feelings that she has no control of her health situation and a Very High sense of control lying beyond her personal resources.

• Stress symptoms:  suggest the presence of shock and high arousal.

• Marked Musculoskeletal  Cluster System and Depression scales and Severe Anxiety.

• Severe Scales: Coordination, Dysphoria, Headache: Tension, Phobic, Pain, Self-consciousness, Anxious, Headache: Migraine

• Marked Scales: Despondency, Obsessive Worry, Faintness, Sleep Disturbance, Fatigue/Malaise

• Moderate Scales: Muscle Tension, Gastric, Clench/Spasm, Elimination

• Response pattern:  Somewhat higher response frequency than the norm. May be interpreted as an emotional reaction to questions on symptoms, especially physical symptoms.

 D. Murray Personality Assessment

• Validity scale indicates results are reliable and valid, the patient showing no unusual test-taking attitude that would distort results.

• Tendency toward avoiding self-disclosure. Possible are broad deficits in introspectiveness and psychological-mindedness

• Severity of Disturbance:  moderately severe mental disorder.  

Summary: Patient is characteristically non--disclosing about emotions and weaknesses. Prone towards understatement and may minimize her actual physical or emotional needs. Personality traits indicate predominant dependency, hysteria and compulsive tendencies.  Axis I syndromes indicates clear, clinical levels of anxiety and depression, with a tendency to somatize resulting from her internalization of emotions.

Faced with interpersonal tensions, she tries to maintain an air of  buoyancy, denying all disturbing emotions and concealing inner  discomforts with short-lived pleasantries and enthusiasms.

To secure strong dependency needs, this woman is has become exceedingly responsive to the needs of others. She seeks harmony with others, even at the expense of her views and beliefs.  Basically unsure of her strengths and lacking in self-confidence--despite superficial appearances to the contrary--she seeks to avoid situations that may involve personal conflict, preferring to smooth matters over as best she can.

She is experiencing clinical signs of generalized anxiety of an uncharacteristic nature. 

Agitated and apprehensive, she may report physical discomforts such as headaches, gastrointestinal symptoms, fatigue, insomnia, jitteriness and diffuse fears.

Events of the recent past are likely to have prompted a dysthymic syndrome in this otherwise controlled woman who declines self-disclosure.  A depressive pattern of  diminished security and self-deprecation has emerged, especially in regard to matters of  personal worth, effectiveness and physical attractiveness.

E. Ramstead Health Inventory

    Another valid profile, Mrs. Smith is described as introversive yet showing confidence. NOTEWORTHY RESPONSES included  HEALTH PREOCCUPATIONS PSYCHIATRIC POSSIBILITY DEPRESSIVE FEELINGS, but no ILLNESS OVERREACTIONS or (tendencies to magnify illness consequences) .

 F. Minnesota Multiphasic Personality Inventory-2

Validity scales are all within normal limits.

She is experiencing low morale and a depressed mood.  She is preoccupied with  feeling guilty and unworthy.  She feels regretful and unhappy about life, and  seems plagued by anxiety and worry about the future.  She feels hopeless at  times and feels that she is condemned.  She has difficulty managing  routine affairs, and the item content she endorsed suggests a poor memory,  concentration problems, and an inability to make decisions.  She appears to  be immobilized and withdrawn and has no energy for life.  She views her  physical health as failing and reports numerous somatic concerns.  She feels  that life is no longer worthwhile and that she is losing control of her  thought processes.  According to her self-report, there is a strong  possibility that she has seriously contemplated suicide.  She is rather  high-strung and believes that she feels things more, or more intensely, than  others do.  She feels quite lonely and misunderstood at times.

She views herself as having so many problems that she is no longer able to  function effectively in day-to-day situations.  Her low mood and pessimistic outlook on life weigh heavily on her and seemingly keep her from acting to  better her situation.  Her negative self-attitudes and sense of frustration  may be very detrimental to treatment and require attention early in therapy. 

G. post traumatic stress disorder.

Based upon the results of the MMPI 2,without revealing the purpose of the questioning, Mrs. Smith was asked to describe whether or not she experienced any of the symptoms of PTSD. She was positive for the following 11 of 17 symptoms of post traumatic stress disorder.

• Intrusive recollections

• Distress at reminders

• Avoids thoughts/feelings

• Loss of interest/anhedonia

• Feelings of estrangement

• Foreshortened future: "I feel like I'm going to die."

• Irritability/anger

• Difficulty concentrating

• Hypervigilance

• Exaggerated startle reaction: "I'm paranoid someone will hit me in my car."

• Physical reaction to reminders: frightened, headaches.

H. Neuropsychological Screening
1. Screening Test for the Luria-Nebraska Neuropsychological Battery: Adult Form  
2. Bender Gestalt Test of Visual-Motor Functioning
3. Summary:

• Bender Gestalt figures are adequately executed and support the above indications that gross neurological deficits are not apparent. 

• These neuropsychological screening tests were administered to rule out  gross neuropsychological dysfunctioning.  Based upon prior testing, medical reports and clinical observations, negative results were anticipated.  In fact, the Luria-Nebraska screening test (with a cutoff of 8) reached only three.  The errors demonstrated appeared to the related more to difficulties with concentration and attention than cerebral dysfunctioning.

• As suspected, any neurological problems appeared to be specific and quite possibly localized to the inner ear apparatus, visual motor apparatus and possible undetectable cranial nerve lesions.

Analysis Response Bias: Reliability & Validity 

COMMENTS
Results support the truthfulness and accuracy of  Mrs. Smith's statements. She shows no variation in her reliability on the tests and meets the honesty model criteria.
 

III. PSYCHOPHYSIOLOGY

    A. PATIENT results (Ranges/hemisphere)
1. Medications: Nuprin
2. Handedness: Right

B. Procedure
1. Bilateral measurements were used as a means of assessing left and right hemispheric effects upon autonomic activity. After establishing a baseline EMG and EDR (see pt. 1 DP 0-12) Mrs. Smith was interviewed.

C. PHYSIOLOGICAL READINGS Part 1

              1.  0-12     eyes closed sitting
2. 12-28   eyes open sitting
3. 29-36   eyes closed, standing in place. Needed to open eyes. Claims to feel loss of orientation and anxiety.
4. 36-45   eyes open, standing. Still demonstrates corrections in orientation, although not as apparent.
5. 46-53   eyes open with sunglasses. Allowed her to sit and quiet down.
6. 55-60   eyes open, removed sunglasses and sit. Incandescent lighting.
7. 60-64   eyes open, ceiling fluorescent lights on. Gaze straight ahead.
8. 65-68   without sunglasses, looking up towards light. (Worst!)
9. 68-71   look down right, then left. No discomfort, but moderately disorienting.   

Part 1 EDR RANGES

Average left           1. 86 mho
average right         1.83 mho

 D. Qualitative Interpretation
1. Caution must be taken while interpreting this data. Mrs. Smith took Nuprin (2) prior to this meeting. However, some conclusions may be drawn from this information. It is also conceivable that elevations may occur beyond those levels recorded here.
2. Although the average conductivity of both hands is similar, of even greater interest is a comparison of the autonomic reactivity to each condition. It is clearly demonstrated that  Mrs. Smith, while sitting with eyes open or closed (with sunglasses) operates within  normal limits of nervous system arousal. However, there is a dramatic shift in autonomic reactivity upon standing with eyes closed as measured and reported by other sources. The photophobia appears to play little role here as her eyes were closed in a dimly lit room, yet within seconds she swerved, then reached out for an object to support herself.
3. The next condition enabled her to open her eyes while standing. This enabled her to utilize vision to fixate and stabilize, with only minor adjustments that were still beyond the norm.

4. Permitting her to sit and relax resulted in a noticeable decrease in reactivity.
5. When asked to remove her sunglasses with only 2 incandescent lights lit, little reaction was demonstrated. However, when fluorescent ceiling lights were turned on, a reaction was elicited. This was worsened when asked to look up at the light.
6. Superimposing one profile upon the other, there is considerable symmetry noted with the exception of the following conditions: eyes closed standing, eyes open standing, removal of sunglasses, and looking up at fluorescent light. The greatest asymmetry is demonstrated with eyes closed standing. Since right hand conductivity is associated with left hemispheric activity, this verifies that Mrs. Smith was using conscious controls to compensate for unconsciously related disequilibrium and attempting (as she did under other conditions) to maintain emotional composure under adverse circumstances.
7. The results support Mrs. Smith's statements. She is physiologically reactive to head and body movements, whether eyes are open or closed, although she is better able to compensate when using her eyes. Sitting or reclining reduces her ANS activity to normal limits.

IV. MENTAL STATUS
1. General description:
a)              Physical Appearance
    (1)     Attire, Neat, Haggard,  Hygiene good, Tearful, Anxious, frustrated, angry.
    (2)     Psychomotor activity: Normal to agitated.
    (3)     Attitude toward examiner:  Cooperative, direct, decisive, pleasant.

            2. Mood and affect
a)              Angry, Anxious,  Depressed, Distressed, Emotional
b)             Affect:  Appropriate.

            3. Appropriateness:  Appropriate.

            4. Attitude/Manner: Cooperative, Direct, Rapport--Good, Resentful, Straightforward

            5. Task Orientation: Attentive, Distractible, Scattered, Tired

            6. Speech: Articulate, Detailed, Goal-Directed, Informative, Pressured,  Self-Initiating, Talkative

            7. Perceptual disturbances:  None

            8. Thought Processes: Thinking was largely logical, relevant and goal-oriented with indications of thought blocking and avoidance.

            9. Content:  Centered about the impact of her illness upon employment and its sequelae.

            10. Alertness and level of consciousness:  Alert.

            11. Orientation: X 3

            12. Memory:  Long-term intact; short-term somewhat impaired due to emotional factors.

            13. Concentration: Some impairment due to emotional reactions.

            14. Abstract thinking:   Appropriate for age and education.

            15. Fund of information and intelligence:  Appears of at least average intelligence with fund of   information consistent with age and background.

            16. Impulse control: Appears adequate.

            17. Judgment and insight:   Patient appears somewhat insightful; judgment is adequate.

            18. Reliability:  Patient assessed as reliable informant.

V. DIAGNOSIS 

VI. Summary

A. Historically, Mrs. Smith has been an industrious worker and devoted mother. In addition, she was working towards an Associate's degree in insurance and holds an agent's license.

B. Mrs. Smith has suffered from an unspecified viral infection that has afflicted her with photophobia, nystagmus, and vertigo. Consequently, she must avoid sunlight, wear dark glasses and rest extensively. She has continual pain in her eyes (and with eye movement), headaches, nausea, blurred vision, dizziness, pulsing in eyes, muscle tics, disequilibrium worsening later in the day. Occasional morning awakenings with  dizziness. Highly sensitive to body movements and those of objects around her.

C. Since my initial contact with Mrs. Smith, I have referred her for:

1. Neurophysiological testing

2. Audiological examination

3. Psychiatric/neuropsychiatric examination

4. Neurotological examination

D. SUMMARY OF MEDICAL FINDINGS

1. OPTOMETRY

a)      Detached vitreous leading to conjunctivitis which became keratoconjunctivitis.

b)     Permanently scarred corneas.

c)       Alteration in eye dominance from right to left eye. This may have also caused a shift in her perceptual field contributing to her symptoms.

d)       Considered unemployable.

2. AUDIOLOGY

a)       Upbeating nystagmus with eyes closed.

b)       Brief upbeating nystagmus with changed direction of gaze from center to 30 degrees up.

c)              Severe, subjective vertigo immediately following the initial right Dix-Hallpike positioning.

d)       Positional testing was remarkable for upbeating nystagmus in the right lateral positions.

e)       Nystagmus may be associated with central dysfunction.

f)        Extreme nausea and dizziness following rotation and refused counter-clockwise stimulation.

g)       Normal peripheral hearing

h)       Bilateral reduced labyrinthine function.

i)        Spontaneous nystagmus induced after strain of 40 minutes of visual/auditory testing.

3. NEURO-OPTHALMOLOGY

a)       Viral keratoconjunctivitis in July, 1996, first in right eye, then left.

b)       Episodes of transient diplopia and impaired vision.

c)       Five changes in prescription.

d)       No longer able to read or carefully track with her eyes. Images become distorted, taking on different shapes. Reading up close, she becomes dizzy, feels off balance and slightly nauseated. Persistent pain in both eyes and sensitivity to light. When dizzy symptoms are at their worst, she feels as though she is leaning off to the left.

e)       Multiple subepithelial defects in right cornea. A few  evident on the left.

f)        Normal mental status.

g)       The Romberg sign is said to be positive when unsteadiness is increased by closure of the eyes; the sign is present in diseases affecting the posterior column or polyneuritis in which there is loss of proprioception in the muscles of the lower extremities. The Romberg test is not performed when the patient has vestibular dysfunction or cerebellar disease with ataxia, because the results will obviously be positive. Romberg testing showed "quite a bit of swaying and fell to the left a few times."

h)       Visual distortions are likely related to cornea defects.

i)        Symptoms are referable to either a post- viral acute disseminated encephalomyelitis or a viral vestibulitus. ENG showed upbeat nystagmus with the eyes closed, a left deviation in right lateral position.

4. RADIOLOGY

a)              Normal MRI

5. NEUROLOGY

a)              Visual distortions explained due to corneal scarring.

b)             Vestibular rehabilitation recommended.

6. NEUROPHYSIOLOGY

a)      Pre-and post chiasmal potentials normal. Twenty channel topography normal. Digital EEG normal. BAEP, P300 normal.

7. PSYCHIATRY

a)      Dr. Bartle:

(1)      No prior psychiatric involvement.

(2)     Could not retain balance with eyes closed (this corresponds with my observations and the Romberg test).

(3)     Good informant.

(4)     Difficulty concentrating and grasping the meaning of what she is reading.

(5)     Axis I diagnosis of Adjustment Disorder, Depressed Affect and Axis III pathology of the eyes and neurological deficits of undetermined origin.

(6)     Patient  severely stressed by  circumstances, not know what is wrong with her, physicians have not been able to definitively diagnose condition.

b)             Dr. Millar

(1)     Major Depression with symptoms of PTSD

(2)     Subclinical personality features exacerbated by Axis III conditions.

                 8. NEUROTOLOGY

a)              Psychogenic dizziness associated with chronic anxiety, panic and phobia.

b)             No objective evidence of peripheral vestibular system or central vestibular system involvement at present.  

c)              Abnormal control of maintenance of upright stance in the sagittal plane as found in individuals with significant psychologic overlays.

d)             It is reasonable to consider an initial viral insult secondary to other evidence of viral infection that was occurring at the time causing insult to the vestibular portion of the inner ear.  While not  ongoing, the damage may then cause  symptoms when head movements are made.

e)              Significant reactions as depression, anxiety, and panic,  can disrupt the normal compensation process and create a significant exacerbation to minor symptoms  with ongoing head movements.

f)               Vestibular rehabilitation therapy is appropriate for helping to habituate the responses to head movements. However, in this case it would be adjunctive to behavioral, psychological, and possibly medical psychiatric treatment for the other associated conditions. There is no doubt, considering all of the medical reports, observations and testing, that Mrs. Smith is experiencing major stress and depression in combination with PTSD relative to the undiagnosed medical condition from which she is suffering.

E. Mrs. Smith's statements during medical examinations and psychological testing have been reliable and consistent . Empirical medical and psychological data indicate that she was afflicted by a viral infection that doubtlessly affected her eyes and may have impacted her vestibular system, at least temporarily. She compensated by reducing her activity level, which  exacerbated her sensitivity to head movements. The pain in her eyes remains to be explained medically.

F. Psychiatric and psychological evaluations verify severe stress symptoms. This is exacerbated by postural changes (as verified by physiological data-EDR), emotional stress, and eye use. Medical symptoms have aggravated/exacerbated earlier underlying personality tendencies.

G. The continuity of symptoms involving use of her eyes in combination with disequilibrium militates against employment, restricts her transportation capability and social activities and contributes towards daily headaches, anxiety and frustration.  These factors certainly mount to cause a substantial detriment to the quality of her life. Consequently, Mrs. Smith is presently unemployable.

Mrs. Smith has experienced--and continues to experience—emotional consequences due to the effects of this illness: loss of employment, inactivity, income and other enduring sequelae. These have directly and negatively impacted finances, family, socialization and self-esteem. Considering her personal career investment over many years, unless there is a radical improvement in her condition she may never again enjoy the same quality of life and sense of well being as prior to being driven into despair by the present illness.