Herman Staudenmayer

Vocal cord dysfunction: The importance of psychologic factors and provocation challenge testing

We present three case reports involving patients with vocal cord dysfunction. The onset of symptoms in one case was coincident with a generalized cutaneous reaction to penicillin with laryngeal involvement. The other cases had been misdiagnosed as food allergy and chemical sensitivity. We describe the psychologic factors in these cases in terms of the primary and secondary gain operative in the somatoform disorder of conversion reaction and emphasize the importance of belief and learned sensitivity in the induction of symptoms. The necessity of considering psychologic factors and the use of blinded, controlled, provocation challenges to evaluate subjective symptomatology is underscored. This study emphasizes the heterogenicity of clinical presentations involving vocal cord dysfunction and illustrates the value of fiberoptic-assisted examination of laryngeal function in conjunction with provocation challenge testing in establishing causal relationships for specific clinical symptoms.

Baseline levels in muscle relaxation training.

Variations in the baseline levels of physiological measures, a familiar problem in psychophysiological research, can affect the results of clinical applications and research in the self-control of bodily processes. In this presentation, the problem is illustrated within the context of skeletal muscle relaxation training using continuous biofeedback(BF) based on surface electromyographic(EMG) activity. In terms of the Law of Initial Values(LIV), higher EMG levels are expected to be associated with greater decreases during training. The combined results of two studies documented an LIV-like effect for pretraining baseline levels with greater EMG decreases after training for subjects with the higher pretraining baselines. Left uncorrected, such baseline differences were shown to lead to discrepant results between two identical studies, and therefore to conflicting conclusions about the effectiveness of these procedures. The available methods suggested to correct for the biasing effect of baseline differences in research are described, with particular emphasis on the analysis of covariance.

Neuropsychophysiologic Observations in Patients Presenting with Environmental Illness

In 1975, the authors recognized a clinical syndrome that varied widely among patients but seemed to have certain common characteristics. The syndrome typically involved multiple systems, expressed with innumerable symptoms and a general malaise that could not be explained by any single etiological factor. Patients typically exhibited no objective physical or laboratory evidence of disease (Terr, 1986, 1989). The two most common characteristics were fear of xenobiotics (chemicals or drugs, food or water) and a belief that symptoms were directly attributable to environmental agents (Brodsky, 1983). Many of these individuals had been treated by clinical ecologists and this appeared to be the origin or reinforcement of their beliefs. In the ecology literature (Randolph and Moss, 1979), these patients were referred to as universal reactors.

Parents' subjective evaluation of a self-help education-exercise program for asthmatic children and their parents.

A self-help education-exercise program for asthmatic children and their parents was evaluated in Denver, Colorado. The objective of the program was to instill better self-care practices in the child which are expected to reduce utilization and cost of medical services and reduce the amount of interference in the childs normal activities. The program was designed to educate the family about the nature of asthma and its treatment, the importance of self-responsibility for the child, and the psychosocial aspects which may affect both the child and the parents in a family with an asthmatic child. The program also included specific lessons pertaining to self-care practices including general health exercises on land and in water, relaxation training, and diaphragmatic breathing. The results of subjective evaluations of the parents indicated that the program was successful in achieving its goals to: Reduce the number of severe attacks, reduce medication usage, improve compliance, reduce days of school missed, increase exercise activity, and control wheezing by the steps taught in the course. While the results are suggestive, a further, controlled evaluation of the program is recommended.

PSYCHOGENIC CHEMICAL SENSITIVITY: PSYCHOGENIC PSEUDOSEIZURES ELICITED BY PROVOCATION CHALLENGES WITH FRAGRANCES

A middle-aged woman with a 10-year history of disability attributed to chemical sensitivities complained that exposure to specific fragrances immediately elicited seizures. Video-EEG monitoring was performed in a hospital neurodiagnostic laboratory during provocative challenge studies employing fragrances identified by the patient as reliably inducing symptoms. The baseline clinical EEG was normal. Immediately after each provocation with air deodorant and perfume, she consistently showed both generalized tonic/clonic and multifocal myoclonic jerking, at times was nonresponsive, spoke with slurred speech, and complained of right-sided paralysis and lethargy. None of these events were associated with any EEG abnormalities. Psychological assessment (MMPI-2, MCMI-II) revealed personality traits that predisposed her to somatization and beliefs about environmental sensitivities. The convulsions were a manifestation of psychogenic pseudoseizures that had been iatrogenically reinforced.

Mass psychogenic illness: psychological predisposition and iatrogenic pseudo-vocal cord dysfunction and pseudo-reactive airways disease syndrome.

A multidisciplinary team assessed five patients who alleged chronic medically unexplained multiorgan system symptoms described by idiopathic environmental intolerance allegedly triggered by exposure to solvents used in membrane roofing repair work on an office building. The event precipitated an incident of mass psychogenic illness (MPI). Treating physicians diagnosed irritant-associated vocal cord dysfunction (IVCD) and reactive airways disease syndrome (RADS) resulting from exposure. The authors conducted medical, psychological, and industrial hygiene evaluations. Air monitoring data for total volatile organic compounds obtained during the 2-day exposure period, measurements of emissions during membrane roofing repair at a similar site, mathematical modeling of air contaminant concentrations, and injection of tracer gas into the incident building revealed exposure levels well below those doses anticipated to cause clinical symptoms. There was no objective medical evidence validating symptoms. Review of the medical records indicated that the video laryngoscopy data, pulmonary function tests, and medical examinations relied upon by the treating physicians were inconsistent with published criteria for IVCD and RADS. Psychological evaluation identified defensiveness and self-serving misrepresentations of exaggerated health concerns associated with somatization and malingering. Each case had personality traits associated with at least one personality disorder. Social histories identified premorbid life events and stressors associated with distress. This is the first study to assess psychological predisposition, social interaction among the plaintiffs, and iatrogenic reinforcement of beliefs by diagnoses of pseudo-disorders associated with patient misrepresentation of exaggerated health concerns in an incident of MPI.