A Neurophysiologic View of Functional Disorders: (A Contribution to Our Understanding and Management of Functional Illness)

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A Neurophysiologic View of Functional Disorders (A Contribution to Our Understanding and Management of Functional Illness) GEORGE

B. WHATMORE, M.D., PH.D.

Most physicians find themselves overwhelmed by the many confusing and conflicting opinions regarding the basic nature and treatment of functional disorders. There is, however, a perspective from which functional illness can be viewed which brings a measure of order into this confusion and facilitates the planning of treatment programs for individual patients. This perspective is a neurophysiologic one in which it is assumed that sensation, emotion, and thinking are all processes carried on by the nervous system and are not abstract spiritual entities existing separate from the nervous system. This is no mere assumption for there is good evidence to support the view that psychologic processes are activities carried on by the nervous system. , -n ,4" The nervous system is constantly reacting to information arriving via exteroceptors and interoceptors. But it also reacts to states of activity already present within the nervous system itself. That is, one part of the nervous system reacts to events occurring in other parts. Nervous system reactions are basically spatiotemporal patterns of activity in complex neuronal networks. There may also be other types of reaction not yet discovered. Mechanisms Underlying Functional Disorders

In the process of adjustment to our environments as well as to ourselves, the ability to learn is extremely valuable. Without it OUr adjustive capacities would be severely handicapped. For this reason, three nervous system processes that are readily modified by learning play a particularly important role in the adjustive process. These are 1) motor activity,

2) thoughts, and 3) emotions (or feelings). Each of them is composed of spatiotemporal patterns of activity in neuronal networks. Although sensory activity also participates in our attempt to adjust (by supplying some of the information upon which we are to act), it functions via fixed connections within the nervous system and does not exhibit the flexibility characteristic of motor activity, thoughts, and emotions. Older views held that thinking and emotion precede and are the initiators of motor activity. Newer concepts include that a fleeting sequence of motor activity, mostly in covert form (yet measurable with neurophysiologic techniques), makes up part of the very act of both thinking and emoting, and that in this form it pre'-1:: For this activity.'-I:: cedes overt motor activity. reason we can label thoughts, emotions, and motor activity as separate entities only for convenience, realizing always that they are not entirely separate. Motor activity consists of the presence of nerve impulses in motor and premotor cortical neurons and pathways extending to the peripheral musculature. Possibly the motor portion of the centrencephalic system should also be included. included." The occurrence of overt movement is not necessary. The limbic system occupies an important position in emotional experience, and the neopallium seems to be more important in ideational processes. H , II f;

Motor activity, emotions, and thoughts constantly interreact with one another as shown in Fig. 1. They also react to information arriving via sensory pathways (primary sensation). s(msation). Furthermore, one emotion can lead to another emotion, motor activity gives rise to further motor activity, and one thought elicits another

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thought. Learning, particularly the form known as associative conditioning,15 plays determining what rea prominent role in detennining actions are elicited in this interplay. That is, neurons can become able to activate other neurons as a result of having been set into action simultaneously with these other neurons. But the background activity into which a bit of information is fed also affects the magnitude and quality of the response to that information. For example, a learned response may not be elicited if the background activity interferes sufficiently, or the background activity may lead to an overreaction if it augments the learned response. In other words, the reaction elicited in one component of the interaction of Fig. 1 in response to nerve impulses arriving from another component of the system is partly

determined also by the ongoing activity at the moment of nerve impulse arrival. The interactions depicted in Fig. 1 are therefore in a constant state of flux as further learning takes place and as al· alterations in ongoing activity occur. This makes for a very complex system in which there is much opportunity for variation in reaction patterns. The very qualities that make for great variability and versatility in human reactions also set the stage for the development of functional illness. A system composed of several components, with complex interactions which can be modified by experience, provides much opportunity for disadvantageous events to develop. The neurons involved need not be strucabnormal. They can be normal turally abnonnal. neurons that have learned to fire off in

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spatiotemporal patterns detrimental to the organism or normal neurons that have failed to learn certain desirable patterns of activity.

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ances in autonomic function, although often resulting from emotions or thoughts, can also be the direct result of an effort state. Laboratory studies give support to the pronounced influence of motor activity elsewhere in the nervous system and on various physiologic processes. 8,17,2229 ,17,ZZZ9 Clinical studies, some employing electromyography, have demonstrated the presence of hyperponesis in patients with various functional disorders and its antecedency to the onset of symptoms. 8803.3 I-!5 These effects of effort states are probably mediated by way of the numerous collateral fibers given off by motor neurons both before and after they leave the cerebral cortex and through proprioceptive feedback. By means of excitatory and inhibitory influences exerted at various points within the nervous system, effort states can disturb usual patterns of activity in these regions and give rise to symptoms. Fatigue of neurons consequent to prolonged hyperponesis may also enter into symptom production}s.47 production. 46 .<7

Disturbed activity in one or more of the components of the interaction depicted in Fig. 1 can affect the entire nervous system, including the autonomic portion, and thus give rise to functional illness. The types of disturbed activity and the possible ways of production are so numerous that they cannot be discussed in detail in this brief presentation. Disturbances in the emotional sphere have received much attention in recent years in the American literature. Psychodynamic theories place great emphasis on unconscious emotions, unconscious emotional conflicts, and failure to satisfy emotional needs. Disturbances in the ideational sphere have been given less attention because of the belief that for the most part they are secondary to emotional factors. This neglect of ideational factors may not be entirely warranted. Neurophysiologically oriented physicians and research Treatment of Functional Disorders workers have begun to stress in addition Often the question confronting the phythe importance of disturbances in motor sician is not whether a given illness is activity, especially in its covert forms. functional or structural in nature but raOne of the reasons for this latter unex- ther, "How much of it is functional and pected emphasis is that motor activity oc- how much structural?" cupies a unique position in the interacDisorders and symptom-complexes contions of Fig. 1. A prerequisite for the oc- sidered by many physicians to be largely currence of thinking, emotion, or sensa- functional in origin include the tension tion is the presence of a certain minimum headaches, migraine headaches, certain activity.7,8,11,13,16 Quantities not types of backache, functional bowel disof motor activity.7,8,1l,13,16 detectable with the naked eye are suffi- tress (irritable colon, spastic colon, or cient and they need not be present in all mucous colitis), spastic esophagus, duoparts of the motor system. Consciousness denal ulcer, anxiety states, certain deitself is partly dependent upon motor ac- pressed states, many fatigue states, intivity for its maintenance, due probably somnia, the hyperventilation syndrome, to the effect of motor impulses on the re- hypochondriasis, phobic states, and obsesticular activating system. 8,30-42,44,45,47 sive-compulsive states. There is less Because of this relationship, a form of agreement regarding the magnitude of exaggerated motor activity called an ef- functional factors in essential hypertenfort state or hyperponesis, which is for sion, rheumatoid arthritis, myocardial inthe most part undetectable with the naked farction, certain skin disorders, asthma, eye, can give rise to disturbances of emo- schizophrenia, manic-depressive psychotion, thinking, and sensation. Disturb- sis, and excessive consumption of alcohol.

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It is to the functional components of

these illnesses that the present discussion of treatment is directed. A perspective from which to view the various treatment methods will be given, not a thorough discussion of technique. The relationships set forth in Fig. 1 provide a framework which enables us to telescope the many types of therapy for functional illness into a few basic processes and to understand better how to use them. Since functional disorders are basically disturbances in the equilibrium of a dynamically active system composed of several components (see Fig. 1), it is conceivable that stabilizing influences might be exerted at a number of different points within the system. This is one reason why there have come to be so many different forms of treatment for functional disorders. The effectiveness of any given treatment will depend upon the degree of its stabilizing effect on this equilibrium in the individual patient. Medication has been used widely. By acting upon metabolic processes within neurons it can temporarily increase or decrease the activity of particular neurons. By itself, medication cannot produce a permanent alteration in learned neuronal behavior. For functional disorders, it is at best a crutch. But crutches, of course, have their place. However, if a person has any potentialities for walking without them, these potentialities should be cultivated. Much has been written about the use of medication in treating functional illness, and this will not be discussed further here. Likewise the use of physical agents will not be discussed. Aside from medication and physical agents, the various types of therapy available today for the treatment of functional disorders seem to fall into four broad categories. Each of these four categories of treatment is directed toward a different component of the interaction illustrated in Fig.!. In selecting combinations of treatment for a given patient, it is therefore

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important to determine as accurately as possible the component or components of the interaction in which the basic disturbance lies. Then therapy can be directed where it is needed most. The four broad categories of therapy, in abbreviated form, are as follows: 1. Environmental Manipulation. Here the attempt is made to alter the input to the person's nervous system. Treatment is directed toward the environmental situation. The patient is told to change his job, go on a vacation, stay away from his in-laws, or make other alterations in his environment. This does not alter his way of reacting to environmental situations. It simply removes situations from his field of operation. When an environmental situation is a truly abnormal one, every attempt should be made to correct it. But often patients are overreacting to the ordinary stresses and strains of life, and what is needed is a change in the person's manner of reacting. Changing the environment cannot accomplish this. Environmental manipulation, as a form of therapy, has a limited application.

2. Ideational Re-education. In this approach the goal is to modify directly the patient's habitual patterns of thinking. Thinking is a complex sequence of neuronal events involving widespread portions of the nervous system, and the attempt is made to alter this neuronal activity directly by an educative process. The degree to which this change can be made to OCcur directly and the degree to which it can stabilize the interactions depicted in Fig. 1 determine the benefit to be derived. Here would be classified such procedures as reassurance, explanation, correction of patient misconceptions, giving the patient new knowledge about himself and the universe, clarifying the patient's goals in life, alteration of attitudes, cultivating habits of "positive thinking," developing an appreciation of interpersonal relationships, distraction, and suggestion (including hypnosis). The development of reli-

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gious faith of one kind or another would also be a form of ideational re-education. By altering his ways of thinking, a patient can reduce the stress-value of some of the situations or problems with which he is confronted. An example of ideational re-education would be correcting the misconception of a patient who has acquired the belief that because his mother became mentally ill at 40 years of age he is doomed to do likewise. The correction of this misconception can establish in a patient such sequences of neuronal activity as make up the thoughts "I am not so bad off as I thought I was; everything is going to be all right," and this pattern of neuronal activity can have a stabilizing influence on nervous system function. An important point to remember here is that a thought is a complex sequence of neuronal activity, and it is this sequence of neuronal activity which affects other neurons and gives a thought whatever stabilizing effect it might have on the interactions of Fig. 1. Ideational re-education is used widely in the practice of medicine and has a place in our armamentarium.

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3. Emotional Re-education. Many current forms of psychotherapy endeavor to accomplish an emotional re-education of the patient, but there are numerous variations in the manner in which it is carried out. The goals and methods are so complex, and so highly controversial at the present time, that only one will be selected for brief discussion here. This goal is to have the patient become able to recognize his real feelings about significant persons and events in his life, to become able to accept these feelings, and to learn to handle them in acceptable ways. As mentioned earlier, feelings (or emotiOl'lS) are basically spatiotemporal patterns of activity in neuronal networks. It is conceivable that such patterns of neuronal activity might be present without the person consciously noticing the emo-

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tion which they comprise, but we have as yet no objective neurophysiologic technique for detecting' them. Various psychological tests such as the Rorschach, TAT, Draw-A-Person, etc., have been used to obtain information about a person's real feelings, and can be of help. A careful study of a person's dreams will sometimes give clues. Free association is believed by the psychoanalyst to give such information. Hypnosis (in the form of hypnoanalysis) has also been used in attempts to determine a person's real feelings. The physician's interpretation of behavior and verbal material produced by the patient, although extremely subjective, is one of the common methods used to determine a patient's real feelings. Because of these difficulties in determining real feelings, it takes great perceptiveness and much experience on the part of the physician to become proficient in carrying out emotional re-education. Perceptiveness is required in judging what the real feelings are, when to make interpretations to the patient, or how to guide him to observe certain feelings for himself. Once a patient can recognize his feelings he is in a position to learn to handle them. Learning to recognize a real feeling may consist neurophysiologically of letting the pattern of neuronal activity comprising the feeling exist without an immediate elicitation of other distracting feelings in response to it. In this way the person experiences the initial emotional response to a situation without being distracted by a series of subsequent emotions. If a person finds emotions within himself which he does not want to experience or which he believes are wrong, he cannot simply cease them because these neurons are not under voluntary control. He must learn to accept them and to handle them effectively. The very act of of, recognizing and accepting an emotion tends to lessen its intensity. Verbal expression of emotions in the form of ventilation and abre-

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action have also been used in attempts to lessen the intensity of emotions. 4. Motor Re-education (or Effort Reeducation.) In this procedure, the origi-

nal form of which was worked out by Jacobson,s the patient is first taught to recognize accurately the specific efforts he makes that work to his disadvantage. They are referred to as misdirected efforts. Most of these efforts are undetectable with the naked eye, but they can be measured accurately by means of appropriate electromyographic techniques. The patient producing them does so unknowingly and it is necessary to open up for him step by step a whole new world of efforts. Effort consists of the initiation of nerve impulses (or action potentials) in that portion of the nervous system extending from the motor and premotor cortex to the peripheral musculature. The patient, in his attempt to adjust both to his environment and to himself and to meet their pressures successfully, has come to initiate nerve impulses that bring unwanted side effects progressing often to serious illness. It may take considerable training for the patient to learn to recognize these misdirected efforts. How this effort pattern began in a given patient is not considered important. More important is to recognize it as it now exists and proceed to correct it. To make a patient sufficiently cognizant of these misdirected efforts requires precise pedagogic techniques including electromyography as an audio-visual teaching device. The methods are a form of neurophysiologic engineering applied to man. Once a patient is able to detect his misdirected efforts, he is in a position to practice diminishing them. This is equally true of the misdirected effort component of both thinking and emotion. The patient thus learns to make his efforts work more to his advantage instead of to his disadvantage, and the goals he sets for himself are more successfully achieved. There are all degrees of skill in effort

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management, and there is no way of telling in advance how much skill a given patient will need to meet his own individual requirements or how long it will take to acquire that much skill. However, notable progress can be made in a year of well-motivated study and real interest in applying what he learns. After this the patient is in a position to participate in deciding when his technique is meeting his requirements. Some patients, when they see what they are accomplishing for themselves over and beyond their illness, and what the potentialities are for further accomplishment, will of their own choice continue instruction for variable periods up to several years. Proper teaching procedure requires that suggestion and reassurance be kept to a minimum. The patient is taught to observe for himself how he is misdirecting his efforts and to depend upon himself to correct it. Independence is cultivated. The quality of result will depend partly upon how successfully this is taught. The motor portion of the somatic nervous system is re-educated. This re-educative process possibly extends also into the motor portion of the centrencephalic system, a system hypothesized by Penfield and his associates. 6 A principle often overlooked in the carrying out of emotional re-education is that the accuracy with which a person observes his real feelings and the success he has in handling them is determined in part by how many misdirected efforts he makes in response to his feelings. Therefore effort re-education is a valuable preliminary to either emotional re-education or ideational re-education and accelerates the rate at which either of these can be carried out. Effort re-education is gaining momentum as a form of treatment since it is well-founded in precise laboratory and clinical studies, more so than any of the other methods for treating functional illness. The method has not been discussed

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in detail here, just the broad outlines have been given. The four different forms of therapy discussed in this paper can be used singly or in various combinations depending upon the requirements of the individual patient. But to overlook a need for any of them will bring an inferior quality of result.

SUMMARY There is a perspective from which functional disorders can be viewed which brings a measure of order into the many conflicting opiniol).s opinioJ?,s regarding the basic nature and treatment of these illnesses. It also facilitates the planning of treatment programs for individual patients. This perspective is a neurophysiologic one in which it is assumed, on good grounds, that sensation, emotion, and thinking are all processes carried on by the nervous system. Basically they are spatiotemporal patterns of activity in complex neuronal networks. These processes constantly interact with one another in an intricate manner shown in Fig. 1. Functional disorders are looked upon as disturbances in the neuronal activity making up one Or more of the components of this interaction. The neurons involved need not be structurally abnormal. Instead, they can be normal neurons that have learned to fire off in spatiotemporal patterns detrimental to the organism, or normal neurons that have failed to learn certain desirable patterns of activity. Such disturbances can affect all components of the interaction and the entire nervous system, including the autonomic portion. A form of covert motor activity known as an effort state, or hyperponesis, occupies a unique position in this relationship. Many forms of treatment have been proposed for functional disorders. Aside from medication and physical agents, they fall into four broad categories, namely: 1) environmental manipulation, 2) ideational re-education, 3) emotional re-edu-

cation, and 4) motor re-education (or effort re-education). Each of these categories of treatment attacks a different component of the dynamic equilibrium depicted in Fig. 1, hence exerts its stabilizing influence at a different point within the system. This must be carefully taken into consideration in selecting the combinations of therapy to be used for individual patients. 509 Medical and Dental Building, Seattle 1, Washington. BIBLIOGRAPHY

1. Cobb, Stanley: Arch. Neurol. &; Psychiat.) 67; 172, 1952. 2. Papez, J. W.: Arch. Neurol. &; Psychiat., Psychiat.) 38: 725, 1937. 3. MacLean, P. D.: Psychosom. Med., 11:338, 11 :338, 1949. 4. MacLean, P. D.: Psychosom. Med., 17 :3'55, 1955. 5. Heath, R. G., Monroe, R. R., and Mickle, W. A.: Am. J. Psychiat., 111: 862, 1955. C07·tex in 6. Penfield, Wilder: The Excitable Cortex Conscious Man. Springfield, Ill.: Charles C. Thomas, 1958. 7. Dement, William and Kleitman, Nathaniel: J. Exper. Psychol.) 53 :339, 1957. 8. Jacobson, Edmund: Progressive Relaxation. Univ. of Chicago Press, 2nd Ed. Chicago, Ill.: Dniv. 1938. 9. Shaw, W. A.: Arch. Psychol.) 35 :5, 1940. 10. Totten, E.: Compar. Psychol. Monographs, Monographs) 11: No.3, Serial No. '53,1935. 11. Vinacke, W. E.: The Psychology Of Thinki1~g. New York: McGraw-Hill Book Co., Inc., ir~g. 1952. 12. Sperry, R. W.: Am. Scientist, 40:291, 40 :291, 1952. 13. Max, L. W.: J. Compo Psychol.) 19 :469, 1935. 14. Eccles, J. C.: The Neurophysiological Basis of Mind. London: Oxford Dniv. Univ. Press, 1953. 15. Guthrie, E. R.: The Psychology of Learning. Revised Edition. New York: Harper & Brothers, 1952. 16. Kleitman, Nathaniel: Sleep and Wakefulness. Univ. of Chicago Press, 1939. Chicago, Ill.: Dniv. 17. Bernhaut, M., Gellhorn, E., and Rasmussen, A. T.: J. Neurophysiol., Neurophysiol.) 16:21, 16 :21, 1953. 18. Bremer, Frederic: The Neurophysiological Problem of Sleep. In: Brain Mechanisms and Consciousness. J. F. Delafresnaye, Ed. Springfield, Ill.: Charles C Thomas, 1954. 19. French, J. D., Hernandez-Peon, R., and Livingston, R. B.: J. Neurophysiol., 18 :74, 1955.

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20. Magoun, H. W.: The Waking Brain. Springfield, Ill.: Charles C Thomas, 19"58. 19158. 21. Roger, A., Rossi, G. F., and Zirondoli, A.: EEG & &; Olin. N europhysiol., 8: I, 1956. OUn. Neurophys22. Gellhorn, Ernst: EEG and Olin. N europhysiol., 10:697, 1958. A.M.A. Arch. Int. Med., 23. Gellhorn, Ernst: 102: 392, 1958. 24. Jacobson, Edmund: Ann. Int. Med., 12: 1194, 1939. 25. Jacobson, Edmund.: Ann. Int. Med., 13: 1619, 1940. 26. Jacobson, Edmund: J. Lab. & &; Olin. M,ed., 25: 1029, 1940. 27. Landau, William: J. Neurophysiol., 16 :299, 1953. 28. Miller, M.: J. Exper. Phychol., 9: 26, 1926. 108: 132, 29. Neufeld, William: Am. J. Psychiat., 108:132, 1951. 30. Barlow, Wilfred: Anxiety and Muscle Tension. In: Modern Trends in Psychosomatic Medicine. D. O'Neill, Ed. New York: Paul B. Hoeber, Inc., 1955. 31. Davis, F. H., and Malmo, R. B.: Am. J. Psychiat., 107: 908, 1951. 32. Dickel, H. A., Dixon, H. H., Stoner, W., and M·ed., 57: 14'58, Shanklin, J. G.: Northwest Med., 1958. 33. Holmes, T. H., and Wolff, H. G.: Psychosom. Med., 14 :18, 1952.

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34. Jacobson, Edmund: Am. J. Psychol., 55:248, 1942. 35. Kaufman, William: Missi.ssippi Valley Med. J., 73: 1951. 36. Lundervold, Arne: J. Nerv. & &; Ment. Dis., 115 :512, 1952. 37. Malmo, R. B., and Shagass, C.: Psychosom. Med., 11 :9, 1949. 38. Malmo, R. B., Shagass, C., and Davis, F. H.: Res. Publ. Ass. Nerv. & &; Ment. Dis., 29 :231, 1950. 39. Malmo, R. B., Shagass, S., and Davis, J. F.: J. Olin. & &; Exper. Psychopath., 12 :4'5, :415, 1951. 40. Shagass, C., and Malmo, R. B.: Psychosom. Med., 16 :295, 1954. 41. Watkins, A. L., Cobb, S., Finesinger, J. E., BraZier, M. A. B., Shands, H. C., and Pincus, G.: Arch. Phys. Med., 28:199,1947. 42. Whatmore, G. B., and Ellis, R. M., Jr.: A.M.A. Arch. Gen. Psychiat., 1 :70, 1959. 43. Weil, A. A.: Am. J. Psychiat., 113:149, 113 :149, 1956. 44. Wolf, S.: J. Olin. Investig., 26:1201, 1947. 45. Wolff, H. G.: Headache and Other Head Pain. London: Oxford Univ. Press, 1948. 46. Dixon, H. H., Peterson, R. D., Dickel, H. A., Jones, C. H., and West, E. S.: Western J. Surg., Obs. & &; Gyn., 60:327, 1952. 47. Whatmore, G. B., and Ellis, R. M., Jr.: Arch. 6:243, Gen. Psychiat., 6: 243, 1962.

Acknowledgment to the depressed patient with moderate retardation that some of his difficulty involves communication often makes him more available for cummunication. Exploring (these) ... difficulties often also mobilizes relevant experiences from his past. Coping explicitly with (them) ... reduces the patient's and the therapist's sense of helplessness and unproduetivity. Rose Spiegel

Specific Problems of Communication in Psychiatric Problems American Handbook of Psychiatry Basic Books, N. Y., 1959, Vol. I, p. 948