Are Constant Nightmares A Sign Of Mental Health Problems?

Author Article

Constantly having nightmares can be very stressful on mental health. It disrupts your sleep; your mind doesn’t get the rest it needs and you could wake up feeling down, tired or sleep-deprived, which in turn affects your day-to-day activity. But why do these unhelpful dreams sneak their way into your head and are they a sign that something bigger is going on in your life? It can be particularly difficult to deal with a barrage of nightmares if you aren’t aware of any mental health issues that you’re suffering, because you might not have tools to deal with these issues. We find out what having consistent nightmares can be an indication of and how to manage them (so that you can finally get a good night’s rest). What causes nightmares? Nightmares usually occur during REM sleep – similar to dreams – and although they can be a sign of an underlying issue, they’re not always this complex. According to WebMD, having a snack late at night can trigger nightmares as it boosts your metabolism and tells your brain to ‘be more active’. Taking medication or coming off medication can also stimulate nightmares, as can alcohol withdrawal. You get less REM sleep when you drink, and although it may seem tempting to have a nightcap, reduced REM sleep also means your mind’s ability to process dreams is impaired – so you might not be able to deal with what you’re dreaming about. Interestingly, sleep-deprivation in itself can also lead to nightmares, meaning you’re effectively stuck in a loop of bad sleep. A study from 2016, which measured the role of insomnia, nightmares and chronotype (essentially your biological clock) in relation to mental illness revealed that 8% to 18% of the population is ‘dissatisfied’ with their quality of sleep, and between 6% to 10% suffer with some form of insomnia disorder. The same study showed that a disruption in sleep patterns ‘commonly presents prior to acute psychiatric difficulties’, such as a manic episode, paranoia or ‘transition to major depression’. (Picture: Ella Byworth for Metro.co.uk) Lola, 21, is currently going through a phase of sleep disruption – she’s only sleeping a few hours per night and when she does, her sleep frequently consists of nightmares. ‘After every night’s sleep, I wake up and remember the wholly vivid nightmares I’ve just had’, she tells Metro.co.uk. ‘They vary from being a mash-up of several short intertwined dreams about people, some good that I don’t want to wake up from, but mostly horrible ones. ‘Sometimes they involve people from my life, sometimes faceless figures, which makes it even more creepy. Mostly I will wake up intermittently throughout the night. ‘I’ve had dreams of my teeth crumbling out of my mouth and anxiety nightmares, where I spend the entire time feeling anxious within the dream. ‘When I wake up, I’m worn out and extremely tired, which makes me not want to get out of bed – it’s paralysing. I’ve pretty much had nightmares my whole life, but they never used to be as frequent as they are now. They definitely happen more when I’m stressed or anxious, but I’ve never spoken to anyone about them because I’m so used to it.’ When should you seek help for your nightmares? Just like mental health problems are very individual, so are nightmares, and having the occasional one doesn’t automatically mean you also have a mental health problem. Therapist Sally Baker tells Metro.co.uk it’s how these affect you that could be a sign of something troubling underneath the surface. ‘Occasional nightmares are completely normal and many people experience them,’ she said. ‘It is how you feel about having those nightmares and the judgements you make about them that indicates how you are feeling about yourself and can give you insights into whether you are feeling emotionally balanced and okay, or may need to seek professional help. ‘Dreams and nightmares are one of the ways the sub-conscious mind processes emotional challenges, so recurring nightmares can be a clue that your mind is struggling to cope with real life negative emotions or events. ‘The nightmares may even vary with different narratives but if they engender the same feelings on waking from them such as heightened anxiety or feeling of dread you are definitely struggling to process.’ How can you deal with constant nightmares? Hayley, 30, has suffered from night terrors for years and tells Metro.co.uk these are similar to nightmares, but completely ‘take over’ her mind. ‘It’s hard to deal with them, as I’m not sure when they will happen,’ she said. ‘I can go for nights without anything and then bam, suddenly I’m screaming in my sleep. The main difference between nightmares and night terrors is that night terrors completely take over. I also remember them a lot more vividly than nightmares. ‘They’re always the same – someone is trying to kill me. ‘Counselling helps and communicating what happens in my night terrors helps too, as it allows me to process and understand what’s happening in my head. ‘For example, whenever they happen, it’s always in the flat I lived in with my mum and I have a lot of negative emotions and memories in that place that I’ve never addressed. ‘The night terrors have actually allowed me to understand this and address these fears directly. ‘I often find if I’m relaxed or I’ve done a workout in the evening, this will rest my mind but ironically, my night terrors seem to be worse when things are going great – it’s a cruel twist.’ Sally also recommends speaking with a therapist about your nightmares, especially if you experience persistent after effects or if they’re anxiety-inducing. ‘If you are left with heightened anxiety or depression after recurrent nightmares, you can work with a therapist to resolve the negative emotions even when you are not sure what is bothering you,’ she said. ‘Be your own detective and focus on the feelings you’re left with, not the storyline of your nightmares as that will be more helpful in finding out what is at the root of your scary or disturbing dreams. ‘Also ask yourself what you may have been ignoring in your life or overlooking. ‘Your intuition or your gut reactions are always on your side and are your best friend, so ask yourself what have you been overriding in your life that in your heart of hearts you’re not really sure about.’ MORE: HEALTH You Don’t Look Sick: ‘I have MS but I get told to give up my train seat’ Will a CBD spree of workouts, croissants, and high tea get rid of your stress? Teenager uses coffee to colour her hair after dye left her looking ‘like a monster’ Having singular nightmares are usually not a sign of mental health problems. But if you’re having trouble falling asleep or staying asleep and suffering from nightmares or even night terrors, it’s worthwhile speaking to a medical or mental health professional about it. Don’t ignore your sub-conscious mind – it can be just as telling as your conscious one.

 

Read more: https://metro.co.uk/2019/02/17/constant-nightmares-sign-mental-health-problems-8649694/?ito=cbshare

Twitter: https://twitter.com/MetroUK | Facebook: https://www.facebook.com/MetroUK/

The Role of Mental Illness in Mass Shootings, Suicides

See Author Article Here
By Amy Swearer

This week marks the one-year anniversary of the horrific Parkland school shooting. That tragedy sparked an intense national debate over how best to protect our children from school shootings.

Some have pushed for more restrictions on the constitutional rights of law-abiding citizens. Among them are the American Federation of Teachers and the National Education Association. These groups released a new set of proposals on Monday that they say “can prevent mass shooting incidents and help end gun violence in American schools.”

Unfortunately, these proposals miss the mark by neglecting to focus on the real problems, including, among other things, the role of mental illness in certain types of firearm-related violence.

How does serious mental illness factor in? And what steps can government take to mitigate the role of untreated mental illness in producing violent threats?

These questions merit deliberate, thoughtful examination, not reflexive calls for broad gun control.

For that reason, The Heritage Foundation recently published a legal memorandum, “Mental Illness, Firearms, and Violence,” as part of a series of papers by John Malcolm and myself exploring some of these deeper issues.

The paper makes clear that, while most mentally ill individuals are not and never will become violent, certain types of serious mental illness—especially when untreated—are associated with a higher prevalence of certain types of firearm-related violence.

In particular, individuals with serious mental illness are at a greater risk of committing suicide and are responsible for a disproportionate number of mass public killings.

Mass Public Shootings

There’s no evidence that all mentally ill people constitute a “high risk” population with respect to interpersonal violence, including firearm-related violence against others.

In fact, most studies indicate that mental illness is responsible for only a small fraction (about 3 percent to 5 percent) of all violent crimes committed in the United States every year, and most of those episodes of violence are committed by individuals who are not currently receiving mental health treatment.

There is, however, a strong connection between acts of mass public violence—including mass public shootings—and untreated serious mental illness.

While acts of mass public violence are extraordinary and rare occurrences, they are often high-profile events that deeply affect the national view of violent crime trends. Mass public shootings in particular stoke national conversations on gun violence and gun control, for understandable reasons.

The majority of all mass public killers (some studies estimate as many as two-thirds) likely suffered from a serious mental illness prior to their attacks, and often displayed clear signs of delusional thinking, paranoia, or irrational feelings of oppression associated with conditions such as schizophrenia and bipolar-related psychosis.

This includes many individuals who committed atrocious attacks on students, including the Parkland shooter, the Virginia Tech shooter, and the Sandy Hook shooter—all of whom had long histories of untreated mental health problems.

Unfortunately, hardly any of these individuals were receiving psychiatric treatment at the time of their attacks.

Even without access to firearms, individuals with untreated serious mental illness can and do find ways to commit mass public killings.

Activist groups and politicians who point to mass public shootings as a reason for broad restrictions on firearm access by the general public largely miss the underlying reality: The real problem is not the prevalence of firearms among the general public, but the prevalence of untreated serious mental illness that causes some individuals to become violent in catastrophic ways, regardless of lawful access to firearms.

Suicide

The most significant link between mental illness and firearm-related violence is suicide, which accounts for almost two-thirds of all annual firearm-related deaths in the United States.

Of course, not every suicide is necessarily related to an underlying mental illness, but there is little doubt that the presence of a mental illness substantially increases a person’s risk for committing suicide.

The most common method of suicide in the U.S. is through the use of a firearm, an unsurprising reality given that the U.S. has the highest per-capita number of privately owned firearms in the world.

Despite the nation’s exceptionally high rate of suicide by firearm, however, it does not have a particularly high overall suicide rate, compared with other countries.

Our national suicide rate stands at roughly the world average and is comparable to the rate experienced by many European countries with significantly lower rates of private firearm ownership.

At the same time, a number of countries with severely restrictive gun control laws have much higher rates of suicide than the United States, including Belgium, Finland, France, Japan, and South Korea.

The connection between general measures of firearm access and general suicide rates is limited, at best. The U.S. suicide rate has remained relatively stable over the past 50 years, even though the number of guns per capita has doubled.

Moreover, the percentage of suicides committed with firearms has actually decreased since 1999, even though the number of privately owned firearms has increased by more than 100 million.

As this data suggests, broad restrictions on firearm access are unlikely to have a meaningful effect on general suicide rates, and there are other socioeconomic factors beyond firearm availability that better account for differences in suicide rates.

These factors largely include measures of “social cohesion,” such as divorce rates, unemployment, poverty, past trauma, and family structure, and it’s increasingly clear that more socially integrated communities also tend to have lower suicide rates.

Access to firearms may, however, exacerbate the danger for people who are already at a heightened risk for committing suicide. For example, when individuals have a serious mental illness, access to firearms appears to increase their risk of committing suicide.

But it’s also more complicated: While individuals with serious mental illness may have an increased risk of committing suicide when they have ready access to firearms, they may also be less likely than the general population to commit suicide with firearms.

Why? Because they often have greater barriers to legal firearm access, including disqualifying mental health histories under state or federal law, and concerned friends or family members who may limit their unsupervised access to firearms.

Several studies suggest, then, that reducing unsupervised access to all commonly employed means of suicide (including firearms, but also sharp objects, medications, and rope material) for at-risk persons reduces their individual risk of suicide.

In short, broad limitations on firearm access for individuals who are not necessarily at heightened risk for committing suicide are unlikely to meaningfully affect overall suicide rates and should be viewed with a heavy dose of skepticism, but policies designed to limit firearm access for individuals with serious mental illness may be an important step in the right direction for reducing state and national suicide rates.

Policy Implications

It is clear that mental illness—especially untreated serious mental illness—plays a significant role in certain types of firearm-related violence that cannot be ignored.

This is not to suggest that individuals with mental illness should be treated as community pariahs or that they are even the cause of most firearm-related violence in the United States. But any holistic approach to reducing suicide and violent crime rates in our communities must account for the role played by serious mental illness.

The reduction of suicide rates requires a comprehensive approach that addresses all of the various factors related to suicide risk, including mental illness, socioeconomic variations, and access to a support system.

Similarly, policies to reduce the rate of mass public shootings in the United States must account for the significant role played by untreated serious mental illness in such killings.

The broad-scale disarmament of the general population is an inappropriate and unnecessary substitute for dealing with the underlying problems.

CBD Oil for Depression, Schizophrenia, ADHD, PTSD, Anxiety, Bipolar & More

Psych Central Article Here
By John M. Grohol, Psy.D.

You can extract more than 70 different components from a marijuana plant, technically known as cannabis sativa. Two of the most common constituents are delta-9-tetrahydrocannabinol (known colloquially as THC) and cannabidiol (CBD).

Because CBD is not as regulated as THC (though it may be technically illegal under federal laws), nor does it provide any accompanying “high” as THC does, it has become increasingly marketed as a cure-all for virtually any ailment. You can now find CBD oil products online to treat everything from back pain and sleep problems, to anxiety and mental health concerns.

How effective is CBD oil in the treatment of mental disorder symptoms?

Unlike it’s sister THC, CBD doesn’t have any of the associated negative side effects of tolerance or withdrawal (Loflin et al., 2017). CBD is derived from the cannabis plant, and shouldn’t be confused with synthetic cannabinoid receptor agonists like K2 or spice.

Because of its relatively benign nature and more lax legal status, CBD has been more widely studied by researchers in both animals and humans. As researchers Campos et al. (2016) noted, “The investigation of the possible positive impact of CBD in neuropsychiatric disorders began in the 1970s. After a slow progress, this subject has been showing an exponential growth in the last decade.”

Research has shown that CBD oil may be effective as a treatment for a variety of conditions and health concerns. Scientific studies demonstrate the effectiveness of CBD to help relieve some of the symptoms associated with: glaucoma, epilepsy, pain, inflammation, multiple sclerosis (MS), Parkinson’s disease, Huntington’s disease, and Alzheimer’s. It appears to help some people with gut diseases, such as gastric ulcers, Crohn’s disease, and irritable bowel syndrome as well (Maurya & Velmurugan, 2018).

You can find low-end and high-end CBD oil products. The most popular CBD oil product on Amazon.com retails for around $25 and contains only 250 mg of CBD extract.

ADHD

In a pilot randomized placebo-controlled study of adults with attention deficit hyperactivity disorder (ADHD), a positive effect was only found on the measurements of hyperactivity and impulsivity, but not on the measurement of attention and cognitive performance (Poleg et al., 2019). The treatment used was a 1:1 ratio of THC:CBD, one of the common CBD treatments being studied along with CBD oil on its own. This finding suggests more research is needed before using CBD oil for help with ADHD symptoms.

Anxiety

There are a number of studies that have found that CBD reduces self-reported anxiety and sympathetic arousal in non-clinical populations (those without a mental disorder). Research also suggests it may reduce anxiety that was artificially induced in an experiment with patients with social phobia, according to Loflin et al. (2017).

Depression

A review of the literature published in 2017 (Loflin et al.) could find no study that examined CBD as a treatment for depression specifically. A mouse study the researchers examined found that mice treated with CBD acted in a way similar to the way they acted after receiving an antidepressant medication. Therefore, there is virtually little to no research support for the use of CBD oil as a treatment for depression.

Sleep

Loflin et al. (2017) only found a single CBD study conducted on sleep quality:

Specifically, 40, 80, and 160 mg CBD capsules were administered to 15 individuals with insomnia. Results suggested that 160 mg CBD was associated with an overall improvement in self-reported sleep quality.

PTSD

There are two human trials currently underway that are examining the impact of both THC and CBD on post-traumatic stress disorder (PTSD) symptoms. One is entitled Study of Four Different Potencies of Smoked Marijuana in 76 Veterans With PTSD and the second is entitled Evaluating Safety and Efficacy of Cannabis in Participants With Chronic Posttraumatic Stress Disorder. The first study is expected to be completed this month, while the second should be completed by year’s end. It can take up to a year (or more) after a study has been completed before its results are published in a journal.

Bipolar Disorder & Mania

The depressive episode of bipolar disorder has already been covered in the depression section (above). What about CBD oil’s impact on bipolar disorder’s manic or hypomanic episodes?

Sadly, this has not yet been studied. What has been studied is cannabis use on the effect of bipolar disorder symptoms. More than 70 percent of people with bipolar disorder have reported trying cannabis, and around 30 percent use it regularly. However, such regular use is associated with earlier onset of bipolar disorder, poorer outcomes, and fluctuations in a person’s cycling patterns and severity of manic or hypomanic episodes (Bally et al., 2014).

More research is needed to see whether supplementing CBD oil might help alleviate some of the negative impact of cannabis use. And additional research is needed to examine whether CBD oil on its own might provide some benefits to people with bipolar disorder.

Schizophrenia

Compared to the general population, individuals with schizophrenia are twice as likely to use cannabis. This tends to result in a worsening in psychotic symptoms in most people. It can also increase relapse and result in poorer treatment outcomes (Osborne et al., 2017). CBD has been shown to help alleviate the worse symptoms produced by THC in some research.

In a review of CBD research to date on its impact on schizophrenia, Osborne and associates (2017) found:

In conclusion, the studies presented in the current review demonstrate that CBD has the potential to limit delta-9-THC-induced cognitive impairment and improve cognitive function in various pathological conditions.

Human studies suggest that CBD may have a protective role in delta-9-THC-induced cognitive impairments; however, there is limited human evidence for CBD treatment effects in pathological states (e.g. schizophrenia).

In short, they found that CBD may help alleviate the negative impact of a person with schizophrenia from taking cannabis, both in the psychotic and cognitive symptoms associated with schizophrenia. They did not find, however, any positive use of CBD alone in the treatment of schizophrenia symptoms.

Improved Thinking and Memory

There is little to no scientific evidence that CBD oil has any beneficial impact on cognitive function or memory in healthy people:

“Importantly, studies generally show no impact of CBD on cognitive function in a ‘healthy’ model, that is, outside drug-induced or pathological states (Osborne et al., 2017).”

If you’re taking CBD oil to help you study or for some other cognitive reason, chances are you’re experiencing a placebo effect.

CBD Summary

As you can see, CBD research is still in its early stages for many mental health concerns. There is limited support for the use of CBD oil for some mental disorders. Some disorders, including autism and anorexia, have had little research done to see whether CBD might help with the associated symptoms.

One of the interesting findings from research to date is that the dosing found to have some possible beneficial effects in research tends to be much higher than what is found in products typically sold to consumers today. For instance, most over-the-counter CBD oils and supplements are in bottles that contain a total of 250 to 1000 mg.

But the science suggests that an effective daily treatment dose might be anywhere from 30 to 160 mg, depending on the symptoms a person is seeking to alleviate.

This suggests that the way most people are using CBD oil today is not likely to be clinically effective. Instead, at doses of just 2 to 10 mg per day, people are likely mostly benefiting from a placebo effect of these oils and supplements.

Before starting or trying any type of supplement — including CBD oil or other CBD products — please first consult your prescribing physician or psychiatrist. CBD may interact with psychiatric medications in a way that is unintended and could cause negative side effects or health problems.

We also do not really understand the long-term effects and impact of CBD oil use on a daily basis over the course of years, as such longitudinal research simply hasn’t yet been done. There have been some reported negative side effects experienced in the use of cannabis, but it’s hard to generalize such research findings to CBD alone.

In short, CBD shows promise in helping to alleviate some symptoms of some mental disorders. Much of the human-based research is still in its infancy, however, but early signs are promising.

 

For further information

Reason Magazine: Is CBD a Miracle Cure or a Marketing Scam? (Both.)

Thanks to Elsevier’s ScienceDirect service in providing access to the primary research necessary to write this article.

 

References

Bally, N., Zullino, D, Aubry, JM. (2014). Cannabis use and first manic episode. Journal of Affective Disorders, 165, 103-108.

Campos, AC., Fogaça, M.V., Sonego, A.B., & Guimarães, F.S. (2016). Cannabidiol, neuroprotection and neuropsychiatric disorders. Pharmacological Research, 112, 119-127.

Loflin, MJE, Babson, K.A., & Bonn-Miller, M.O. (2017). Cannabinoids as therapeutic for PTSD
Current Opinion in Psychology, 14, 78-83.

Maurya, N. & Velmurugan, B.K. (2018). Therapeutic applications of cannabinoids. Chemico-Biological Interactions, 293, 77-88.

Osborne, A.L., Solowij, N., & Weston-Green, K. (2017). A systematic review of the effect of cannabidiol on cognitive function: Relevance to schizophrenia. Neuroscience & Biobehavioral Reviews, 72, 310-324.

Poleg, S., Golubchik, P., Offen, D., & Weizman, A. (2019). Cannabidiol as a suggested candidate for treatment of autism spectrum disorder. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 89, 90-96.

Which Mental Illness Is Most Disabling?

Psychology Today Link Here

While there is no consensus on the exact definition of disability (especially psychological disability), there is greater recognition these days that, like physical disease, psychological conditions can cause functional impairment and dysfunction—some more so than others. In a paper, published in the November issue of Social Psychiatry and Psychiatric Epidemiology, Edlund et al. conclude that among the 15 mental health conditions examined, mood disorders (e.g., depression) are associated with the greatest functional impairment and disability.1

The Mental Health Surveillance Study
Data for the present research came from the Mental Health Surveillance Study (MHSS). The MHSS is a sub-sample of 2008-2012 National Survey on Drug Use and Health (NSDUH), an annual survey of non-institutionalized US civilians 12 years or older. MHSS, however, includes only individuals aged 18 and over.

For the Mental Health Surveillance Study, researchers conducted phone interviews with participants, utilizing the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-IV-TR. Of the original NSDUH 2008-2012 sample of 220,000 adults, 5,653 completed the MHSS interview (48% men; 67% White, 14% Latino/Hispanic, and 12% Black).

Using these interviews, researchers attempted to determine if participants met the criteria for any of the following 15 psychiatric conditions:

Mood disorders (major depressive disorder, mania, and dysthymic disorder), anxiety disorders (post-traumatic stress disorder, panic disorder, agoraphobia, social phobia, specific phobia, obsessive-compulsive disorder, and generalized anxiety disorder), alcohol use disorder, illicit drug use disorder, intermittent explosive disorder, adjustment disorder, and psychotic symptoms.

Other conditions (e.g., eating disorders) were not examined because of their low prevalence in the sample.

Three measures of disability
Functional impairment was assessed using three measures (modified for this investigation):

Global Assessment of Functioning (GAF)
Days-out-of-role (DOR)
World Health Organization Disability Assessment Schedule 2.0 (WHODAS)
Scores for GAF range from 0 to 100 (higher means better functioning). GAF scores are based on both functional impairment and symptom severity (whichever happens to be worse).

StockSnap/Pixabay
Source: StockSnap/Pixabay
Unlike GAF, which is determined by clinical judgment and thus has a subjective element, WHODAS and DOR are based strictly on objective criteria and the patient’s responses.

DOR measures the number of days in the past year when an individual could not function at all because of mental health issues.

WHODAS assesses cognitive abilities (e.g., memory, concentration), social relations, social participation, self-care, and ability to do one’s duties (whether related to work, home, or school). In this study, a 0-24 score range was used, with the higher score meaning worse functioning.

Mental illness and disability: Results
Descriptive statistics revealed the sample’s average…

GAF = 74.1 (median 75)
WHODAS = 3.5 (median 1)
DOR = 6.7 (median 0)
Researchers performed a series of regression analyses, and concluded that among 15 mental health conditions, mood disorders were associated with the greatest functional impairment; anxiety disorders, with intermediate functional impairment; and substance use disorders, with less functional impairment.

For instance, in the fully adjusted model, the greatest decrease in GAF scores was seen in psychotic symptoms (22), followed by depression (16), and mania (13). In WHODAS modeling, mania (9), depression (6), and social phobia (5) had the largest coefficients. And, in the final analysis, only depression, adjustment disorder, and panic disorder, had a significant association with DOR.

These results are comparable with those of a 2007 study, which also included a nationally representative sample, used DOR, and employed similar statistical methods. In that investigation, mood disorders resulted in higher days-out-of-role than most other disorders examined.2

Commentary on use of disability measures
Aside from suggesting that mood disorders are associated with the greatest disability among conditions examined, the present investigation highlights the importance of using multiple measures in determining disability.1

Employing a single measure paints a misleading picture. For instance, as mentioned above, the median value for days-out-of-role was zero. Indeed, 70% of participants with one mental disorder, and over half of those with two disorders, had zero days-out-of-role. Only 3/15 disorders were statistically linked with DOR scores (8/15 with WHODAS; all 15 with GAF).

Therefore, DOR was the least sensitive of the three measures used. If we were to rely only on days-out-of-role numbers, we would miss significant dysfunction and disability.

darkerstar/Pixabay
Source: darkerstar/Pixabay
While GAF is likely the most sensitive of the three measures, it does not always assess functional status. As mentioned, GAF scores depend on functional impairment and symptom severity; when there is disagreement between the two values, GAF score is determined by the worse of the two. For instance, if symptoms are severe but functioning is okay, GAF scores will still be low.

Thus, it is important to use complementary measures of disability; doing so allows clinicians to achieve greater accuracy in determining a patient’s needs and in monitoring a patient’s progress. Use of complementary measures can also inform public policy and resource allocation. Physicians, politicians, and the public cannot make informed decisions about how to improve functional impairment if they fail to recognize disability in the first place.