Recognizing and Treating Major Depression in Fibromyalgia: A Narrative Primer for the Non-Psychiatrist.

Fibromyalgia (FM) affects 2% to 8% of the general population. FM patients often experience self-stigma and feel rejected by healthcare providers and families, resulting in isolation and distressing symptoms of pain, fatigue, and poor cognitive functioning, increasing the risk of depressive symptoms. Major Depressive Disorder (MDD) is the most common comorbidity in FM patients (Any depression: 43%; MDD: 32%). Genome-wide association studies (GWAS) have identified a common genetic risk loci for major depression and fibromyalgia. Given that even minor symptoms of depression worsen the outcomes of FM patients, clinicians are challenged to identify and manage depression in these patients. However, due to overlapping symptoms, limited screening, and contamination bias, MDD often goes undiagnosed and presents a critical challenge. Unrecognized and untreated MDD in FM patients can exacerbate fatigue, sleep disturbances, and pain, reduce physical functioning, and increase the risk of developing comorbid conditions, such as substance abuse and cardiovascular disease. These comorbidities are associated with a lower treatment response rate, a higher dropout rate, and a greater risk of relapse. Clinicians may effectively identify and treat MDD in FM patients with appropriate pharmacologic agents combined with aerobic exercise and cognitive-behavioral therapies for core FM symptoms, thus significantly reducing symptom severity for both MDD and FM. Such a comprehensive approach will result in a much-improved quality of life. MedLine content was searched via PubMed to identify eligible articles between 1995 and 2023 using search terms fibromyalgia, major depressive disorder, and treatment of depression in fibromyalgia, and the most current information is presented. In this primer for clinicians caring for FM patients, we describe clinically relevant pharmacologic and non-pharmacologic management approaches for treating MDD in FM patients.

Institutionalized Adoption of a Protocol for the Management of Median Arcuate Ligament Syndrome Correlates with Improved Surgical Outcomes.

INTRODUCTION: Median arcuate ligament syndrome (MALS) is a rarely diagnosed and treated etiology of abdominal pain with no established diagnostic approach. The effectiveness of our institutional protocol in identifying these patients was investigated by analyzing their surgical outcomes. METHODS: A retrospective review was conducted of patients treated for MALS at our institution from 2001 to 2022. Patients were considered for a diagnosis of MALS if there was evidence of abdominal pain (unprovoked, provoked by eating and physical activity) and celiac artery dynamic compression on diagnostic imaging. During the study period, an institutionalized management protocol was developed for these patients. Patients were then categorized as having positive surgical outcomes if their symptoms improved or resolved entirely during the latest follow-up visit, while those whose symptoms remained unchanged or worsened were classified as having negative outcomes. Of the patients considered for MALS diagnosis, a patient was confirmed positive if there is either a positive provocative mesenteric angiogram, celiac plexus block, or both, along with a negative gastroenterology workup. Comparative analysis was performed using a chi-square test. Multivariable logistic regression models were performed to evaluate the association between risk factors and symptom relief with the adjusted follow-up length. All tests were two-sided, with p-value <0.05 considered statistically significant. RESULTS: A total of 163 patients with a mean follow-up duration of 17.7 + 23.4 months were included in the study. Patients who were part of the protocol had a higher rate of improvement in their abdominal pain (65.9% vs 50.0 %, p < 0.04). Furthermore, patients diagnosed positive by the protocol experienced greater relief of abdominal pain compared to patients with a negative diagnosis (77.8% vs 52.5%, p = 0.014). CONCLUSION: By using a standardized protocol, patients who received a positive diagnosis demonstrated symptomatic improvement in their outcomes. Further investigation is warranted on a larger scale to assess its generalizability for the management of this challenging patient population.

High overlap in patients diagnosed with hypermobile Ehlers-Danlos syndrome or hypermobile spectrum disorders with fibromyalgia and 40 self-reported symptoms and comorbidities.

Background: Joint pain is a common symptom in patients with hypermobile Ehlers-Danlos Syndrome (hEDS), hypermobility spectrum disorders (HSD) and fibromyalgia. The goal of this study was to determine whether symptoms and comorbidities overlap in patients diagnosed with hEDS/HSD and/or fibromyalgia. Methods: We retrospectively examined self-reported data from an EDS Clinic intake questionnaire in patients diagnosed with hEDS/HSD, fibromyalgia, or both vs. controls with an emphasis on joint issues. Results: From 733 patients seen at the EDS Clinic, 56.5% (n = 414) were diagnosed with hEDS/HSD and fibromyalgia (Fibro), 23.8% (n = 167) hEDS/HSD, 13.3% (n = 98) fibromyalgia, or 7.4% (n = 54) none of these diagnoses. More patients were diagnosed with HSD (76.6%) than hEDS (23.4%). Patients were primarily White (95%) and female (90%) with a median age in their 30s (controls 36.7 [18.0, 70.0], fibromyalgia 39.7 [18.0, 75.0], hEDS/HSD 35.0 [18.0, 71.0], hEDS/HSD&Fibro 31.0 [18.0, 63.0]). There was high overlap in all 40 symptoms/comorbidities that we examined in patients diagnosed with fibromyalgia only or hEDS/HSD&Fibro, regardless of whether they had hEDS or HSD. Patients that only had hEDS/HSD without fibromyalgia had far fewer symptoms/comorbidities than patients with hEDS/HSD&Fibro. The top self-reported issues in patients that only had fibromyalgia were joint pain, hand pain when writing or typing, brain fog, joint pain keeping from daily activities, allergy/atopy and headache. Five issues that significantly and uniquely characterized patients diagnosed with hEDS/HSD&Fibro were subluxations (dislocations in hEDS patients), joint issues like sprains, the need to stop sports due to injuries, poor wound healing, and migraine. Conclusion: The majority of patients seen at the EDS Clinic had a diagnosis of hEDS/HSD plus fibromyalgia that was associated with more severe disease. Our findings indicate that fibromyalgia should be routinely assessed in patients with hEDS/HSD and vis-a-versa to improve patient care.

A retrospective analysis of the prevalence and impact of associated comorbidities on fibromyalgia outcomes in a tertiary care center.

Background: This retrospective study was designed to analyze the prevalence and impact of associated comorbidities on fibromyalgia (FM) outcomes (functionality, pain, depression levels) for patients who participated in an intensive multicomponent clinical program in a tertiary care center. Methods: Participants included a sample of 411 patients diagnosed with FM at a large tertiary medical center using the 2016 ACR criteria. Patients completed an intensive 2-day cognitive behavioral treatment (CBT) program, filled out the Fibromyalgia Impact Questionnaire Revised (FIQR), the Center for Epidemiologic Studies Depression Scale (CES-D), the Pain Catastrophizing Scale (PCS), and were followed for 6 months after treatment completion. T-tests were performed to analyze differences between the presence or absence of select comorbidities for the three outcomes at follow-up. Statistically significant comorbidities (p < 0.05) were used as predictors in multivariable logistic regression models. Results: The FM associated comorbidities in this cohort that had significant impact on the measured outcome domains after treatment program completed were Obesity (FIQR p = 0.024), Hypothyroidism (CES-D p = 0.023, PCS p = 0.035), Gastroesophageal reflux disease GERD (PCS p < 0.001), Osteoarthritis (CES-D p = 0.047). Interestingly, Headache, the most frequent FM associated comorbidity in this cohort (33.6%), did not have a significant impact on the outcome domains at follow-up. Obesity (18.2%) was the only FM associated comorbidity significantly impacting all three outcome domains at follow-up. Conclusion: The present study suggests that addressing obesity may significantly impact outcomes in FM patients.

Sinus Tachycardia: a Multidisciplinary Expert Focused Review.

Sinus tachycardia (ST) is ubiquitous, but its presence outside of normal physiological triggers in otherwise healthy individuals remains a commonly encountered phenomenon in medical practice. In many cases, ST can be readily explained by a current medical condition that precipitates an increase in the sinus rate, but ST at rest without physiological triggers may also represent a spectrum of normal. In other cases, ST may not have an easily explainable cause but may represent serious underlying pathology and can be associated with intolerable symptoms. The classification of ST, consideration of possible etiologies, as well as the decisions of when and how to intervene can be difficult. ST can be classified as secondary to a specific, usually treatable, medical condition (eg, pulmonary embolism, anemia, infection, or hyperthyroidism) or be related to several incompletely defined conditions (eg, inappropriate ST, postural tachycardia syndrome, mast cell disorder, or post-COVID syndrome). While cardiologists and cardiac electrophysiologists often evaluate patients with symptoms associated with persistent or paroxysmal ST, an optimal approach remains uncertain. Due to the many possible conditions associated with ST, and an overlap in medical specialists who see these patients, the inclusion of experts in different fields is essential for a more comprehensive understanding. This article is unique in that it was composed by international experts in Neurology, Psychology, Autonomic Medicine, Allergy and Immunology, Exercise Physiology, Pulmonology and Critical Care Medicine, Endocrinology, Cardiology, and Cardiac Electrophysiology in the hope that it will facilitate a more complete understanding and thereby result in the better care of patients with ST.

Depression: A Modifiable Risk Factor for Poor Outcomes in Fibromyalgia.

BACKGROUND: About 4 out of 10 fibromyalgia patients suffer from depression. The European Alliance of Associations for Rheumatology (EULAR) guidelines recommend using antidepressants to treat fibromyalgia. OBJECTIVE: To determine predictors of improved outcomes following a multicomponent treatment program. DESIGN: We designed this longitudinal treatment outcome study to evaluate the prevalence of depression symptoms in patients diagnosed with fibromyalgia at a tertiary care facility, and the impact of depression on functional outcomes after completing a multicomponent fibromyalgia treatment program. SETTING: Tertiary care center. PATIENTS: This study included 411 adult patients with fibromyalgia who completed a multicomponent treatment program for fibromyalgia. Expert physicians performed comprehensive evaluations following American College of Rheumatology (ACR) criteria to confirm fibromyalgia before referral to the program. INTERVENTION: An intensive outpatient multicomponent treatment program consisting of 16 hours of cognitive behavioral strategies served as the intervention. MEASUREMENTS: Functional status was assessed using the Fibromyalgia Impact Questionnaire Revised (FIQR). Depression was evaluated with the Center for Epidemiologic Study of Depression (CES-D) measure. Measures were administered prior to participation in the program and approximately 5 months following completion of the program. RESULTS: The cohort had a high prevalence of depressive symptoms (73.2% had depression at admission). Higher depression scores at baseline predicted poorer outcomes following multi-component treatment. Effectively treated depression resulted in improved functioning at follow-up. LIMITATIONS: Findings limited to tertiary care center cohort of fibromyalgia patients. Patients did not undergo a structured clinical diagnostic interview to diagnose depression. CONCLUSIONS: The current data links depression to poorer outcomes in patients with fibromyalgia. Depression is an important modifiable factor in the management of fibromyalgia. Guidelines should reflect the importance of assessing and effectively treating depression at the time of diagnosis of fibromyalgia, to improve functional outcomes. REGISTRATION: Specific registry and specific study registration number-Institutional Review Board-(IRB# 19-000495). FUNDING SOURCE: No funding.

Intensive Multicomponent Fibromyalgia Treatment: A Translational Study to Evaluate Effectiveness in Routine Care Delivery.

OBJECTIVE: The current study was designed to evaluate the translation of clinical trial outcomes and clinical guidelines for the treatment of fibromyalgia (FM) into an intensive multicomponent clinical program embedded in routine care delivery. The study aimed to assess the adaptation of these recommended strategies into routine clinical care while evaluating their effectiveness and durability in improving functional status and level of distress in a large clinical sample of FM patients. METHODS: Four hundred eighty-nine patients with FM completed a 2-day program that incorporated best practice recommendations for the treatment of FM. Patients completed the Fibromyalgia Impact Questionnaire-Revised, the Center for Epidemiologic Studies Depression Scale, and the Pain Catastrophizing Scale at admission to the program and at follow-up on average 5 months posttreatment. RESULTS: Significant improvements were seen in functional status (p < 0.0001), depressive symptoms (p < 0.0001), and pain catastrophizing (p < 0.0001) after participation in the intensive multicomponent treatment program. CONCLUSIONS: The present study shows that an intensive multicomponent treatment program embedded in routine care delivery is effective in significantly improving functional status and psychological distress in a large sample of FM patients. The significant improvements were durable and maintained at follow-up.

Opioid Use in Fibromyalgia Continues Despite Guidelines That Do Not Support Its Efficacy or Risk.

BACKGROUND/OBJECTIVE: The aim of this cross-sectional study is to determine the prevalence of opioid use in a large sample of fibromyalgia (FM) patients and examine the factors associated with opioid prescription/use despite multiple clinical guidelines that do not recommend opioid use in this population. METHODS: Data were collected from a convenience sample of 698 patients admitted from August 2017 to May 2019 into an intensive 2-day Fibromyalgia Treatment Program at a tertiary medical center in the United States after FM diagnosis. Patients were administered the Fibromyalgia Impact Questionnaire-Revised, the Center for Epidemiologic Study of Depression Scale, and the Pain Catastrophizing Scale upon admission to the program. Demographic information and opioid use were self-reported. Logistic regression analysis was utilized to determine associations between patient-related variables and opioid use in this prospective study. RESULTS: Of 698 patients, 27.1% (n = 189) were taking opioids at intake. Extended duration of symptoms (>3 years), increased age, higher degree of functional impairment, and increased pain catastrophizing were significantly associated with opioid use. CONCLUSIONS: Opioids are not recommended for the treatment of FM under current guidelines. Greater burden of illness appeared to be associated with the prescription and use of opioids in this population. These findings suggest that some providers may not be aware of current recommendations that have been found to be effective in the management of FM that are contained in guidelines. Alternative approaches to the management of FM that do not involve opioids are reviewed in an effort to improve care.

Improving Distress and Behaviors for Parents of Adolescents With Chronic Pain Enrolled in an Intensive Interdisciplinary Pain Program.

OBJECTIVES: Intensive interdisciplinary treatment is emerging as an effective treatment of chronic pain in youth. These programs often include a parental component with the belief that targeting parental distress and responses to a child's pain will improve outcomes. However, few studies have evaluated the impact of a parental intervention in the interdisciplinary treatment of pediatric chronic pain. The present study consists of a nonrandomized pre-post design to evaluate change in psychological and behavioral functioning of parents who participated in intensive parent programming that utilized cognitive-behavioral therapy and acceptance and commitment therapy, delivered within the context of an interdisciplinary intensive 3-week pain treatment program for youth with chronic pain. MATERIALS AND METHODS: Two hundred twelve parents and their children participated in the study, with 116 participants completing 3-month follow-up measures. Parents completed measures of depressive symptoms, pain catastrophizing, protective responses, and psychological flexibility at admission, discharge, and 3 months after the program. Child functional disability was assessed at the same time points. We examined change in parent factors over time, while controlling for change in child distress. RESULTS: Parents reported significant improvements in all areas of functioning from admission to discharge and improvements were maintained at 3-month follow-up. DISCUSSION: This study provides evidence suggesting parent interventions can be effective in reducing parent distress and behaviors known to be associated with child outcomes.

Executive Functioning in Pediatric Chronic Pain: Do Deficits Exist?

Objective: Despite ample research documenting deficits in executive functioning for adults with chronic pain, the literature on pediatric patients with chronic pain is limited and provides mixed results. The current study sought to further investigate the nature of executive dysfunction in this population and also examine the relationships between pain intensity, duration, and catastrophizing with sustained attention, working memory, and self- and parent-report of executive functioning. Settings: Pediatric pain clinic and rehabilitation program. Participants: Forty adolescents with chronic pain and their parents participated in this study. Methods: Participants completed neuropsychological measures and standardized self-report questionnaires during a 45- to 60-minute testing session. Results: Fifty percent of this sample of adolescents with chronic pain demonstrated significant difficulties on at least one measure, with nine participants indicating difficulties on multiple measures. Pain significantly increased during the testing session. Pain variables of intensity, duration, and catastrophizing are related to sustained attention and working memory. Conclusions: This study adds support to previous findings suggesting subclinical struggles with executive functioning for adolescents with chronic pain. One-half of the sample indicated difficulties in either sustained attention and/or working memory. Future studies that would more thoroughly examine more complex executive functioning skills in this population would be helpful to further guide multidisciplinary treatment of these patients, particularly regarding whether or not school accommodations are warranted.

Getting Back to Living: Further Evidence for the Efficacy of an Interdisciplinary Pediatric Pain Treatment Program.

OBJECTIVE: This study examined key functional outcomes following a 3-week interdisciplinary pediatric pain rehabilitation program for adolescents with chronic pain. Maintenance of gains was evaluated at 3-month follow-up. METHODS: Participants included 171 adolescents (12 to 18 y of age) with chronic pain who completed a hospital-based outpatient pediatric pain rehabilitation program. Participants completed measures of functional disability, depressive symptoms, pain catastrophizing, opioid use, school attendance, and pain severity at admission, discharge, and at 3-month follow-up. RESULTS: Similar to other interdisciplinary pediatric pain rehabilitation program outcome studies, significant improvements were observed at the end of the program. These improvements appeared to be maintained or further improved at 3-month follow-up. Nearly 14% of the patients were taking daily opioid medication at admission to the program. All adolescents were completely tapered off of these medications at the end of the 3-week program and remained abstinent at 3-month follow-up. DISCUSSION: This study adds to the available data supporting interdisciplinary pediatric pain rehabilitation as effective in improving functioning and psychological distress even when discontinuing opioids. Implications for future research and limitations of the study are discussed.

Eating Disorders in Adolescents With Chronic Pain.

INTRODUCTION: Given that youth with chronic pain frequently experience disruptions in eating patterns that may place them at risk for disordered eating, the purpose of this study was to examine the clinical characteristics and illness course of adolescents with chronic pain and comorbid eating disorders. METHODS: Using a retrospective chart review, 34 adolescents with chronic pain and concurrent eating disorders were identified. These adolescents were compared with 34 age-, gender-, and eating disorder symptom-matched adolescents who had an eating disorder without chronic pain. RESULTS: The majority of adolescents with chronic pain and an eating disorder had a primary medical diagnosis of abdominal pain (n = 14), followed by autonomic dysfunction (n = 10) and headache (n = 6). Although in 41.2% of teens with chronic pain, eating disorder symptoms developed after the onset of their pain, 35.3% reported having eating disorder symptoms before they experienced chronic pain. Body mass index did not differ between the groups, but the duration of eating disorder symptoms was significantly longer for the chronic pain group (p < .001). DISCUSSION: Despite comparable severity, eating disorders are undetected for longer periods in patients with chronic pain, which may contribute to a poorer prognosis. Implications for eating disorder conceptualization, detection, and treatment are discussed.

Development of an Interdisciplinary Pediatric Pain Rehabilitation Program: The First 1000 Consecutive Patients.

OBJECTIVE: To describe the development of a clinically and financially successful interdisciplinary pediatric pain rehabilitation program at a large tertiary academic medical center and present demographic and clinical information on the first 1000 patients. PATIENTS AND METHODS: All patients who were consecutively admitted to this program between October 1, 2008, and March 31, 2015 were included in this review. The patients ranged in age from 9 to 24 years. The program is a 3-week, hospital-based outpatient treatment program that requires substantial parental involvement. At admission and discharge, patients completed the Center for Epidemiologic Studies of Depression Scale for Children, the Functional Disability Inventory, and the Pain Catastrophizing Scale for Children. Opioid use was also assessed. RESULTS: At admission, patients reported substantial pain-associated disability and depressive symptoms; they had elevated pain catastrophizing scores, and 16% were taking opioids. Primary sites/types of pain included head, abdomen, and generalized. Functional disability scores decreased significantly, from 27 to 9 after the program (P<.001). Depression scale scores improved from 27 to 14 (P<.001). Pain catastrophizing scores decreased significantly, from 26 to 14 (P<.001), at discharge from the program. All but 4 patients successfully tapered off of all opioid use by the conclusion of the program. CONCLUSION: Participation in a multidisciplinary pediatric pain rehabilitation program can be successful, with significant decreases in disability, depression symptoms, and pain catastrophizing, as well as discontinuation of opioid use.

Improvement in Functioning and Psychological Distress in Adolescents With Postural Orthostatic Tachycardia Syndrome Following Interdisciplinary Treatment.

Significant functional impairment and psychological distress have been observed in adolescent patients with postural orthostatic tachycardia syndrome (POTS). Interdisciplinary rehabilitation programs have been shown to be beneficial in the treatment of chronic pain in adults and adolescents. Only preliminary data have examined interdisciplinary rehabilitation efforts in patients with POTS. This study evaluated the impact of an interdisciplinary rehabilitation program on the functional impairment and psychological distress in 33 adolescents diagnosed with POTS. Patients included in the study were adolescents ages 11 to 18 diagnosed with POTS. Measures completed at admission and discharge from the program included the Functional Disability Index, Center for Epidemiological Studies-Depression-Child scale, and the Pain Catastrophizing Scale for Children. After participation in the 3-week program, adolescents with POTS demonstrated a significant increase in overall functional ability and significant reductions in depression and catastrophizing.

Interdisciplinary Treatment of Maladaptive Behaviors Associated with Postural Orthostatic Tachycardia Syndrome (POTS): A Case Report.

The prevalence of postural orthostatic tachycardia syndrome (POTS) in adolescents and young adults has been increasing during the past decade. Despite this increase, documentation regarding treatment of these patients is just beginning to emerge. In addition, despite a call for a multidisciplinary or interdisciplinary approach, no studies have examined the efficacy of such an approach to treatment. This paper describes a case study of a 19-year-old male with debilitating POTS seen at a tertiary clinic for evaluation and subsequent intensive interdisciplinary treatment. The treatment approach is described and outcomes are presented.

Adolescent fatigue, POTS, and recovery: a guide for clinicians.

Many teenagers who struggle with chronic fatigue have symptoms suggestive of autonomic dysfunction that may include lightheadedness, headaches, palpitations, nausea, and abdominal pain. Inadequate sleep habits and psychological conditions can contribute to fatigue, as can concurrent medical conditions. One type of autonomic dysfunction, postural orthostatic tachycardia syndrome, is increasingly being identified in adolescents with its constellation of fatigue, orthostatic intolerance, and excessive postural tachycardia (more than 40 beats/min). A family-based approach to care with support from a multidisciplinary team can diagnose, treat, educate, and encourage patients. Full recovery is possible with multi-faceted treatment. The daily treatment plan should consist of increased fluid and salt intake, aerobic exercise, and regular sleep and meal schedules; some medications can be helpful. Psychological support is critical and often includes biobehavioral strategies and cognitive-behavioral therapy to help with symptom management. More intensive recovery plans can be implemented when necessary.

Pain relief as a primary treatment goal: at what point does functioning and well-being become more important? A case study of an adolescent with debilitating chronic pain.

BACKGROUND: Pediatric chronic pain is a common problem with significant economic implications and devastating consequences on quality of life. The present report describes a case involving a 15-year-old girl with severe and debilitating chronic pain. RESULTS: Before her referral to a pain rehabilitation program, the patient saw numerous specialists who treated her with an aggressive medical regimen and two spinal cord stimulators. She was then referred for intensive interdisciplinary treatment and, after three weeks of rehabilitation, she reported clinically significant changes in anxiety, pain catastrophizing and functional disability. The patient was successfully titrated off all of her opioid medications and, eventually, both neurostimulator implants were removed. DISCUSSION: Interdisciplinary pain rehabilitation is a useful treatment for patients with chronic pain. With its primary emphasis on functional restoration as opposed to strictly pain reduction, patients can regain a higher quality of life with reduced pain and fewer medications, surgeries and hospitalizations.

Acceptance of pain: associations with depression, catastrophizing, and functional disability among children and adolescents in an interdisciplinary chronic pain rehabilitation program.

OBJECTIVES: The aims of this study were: (1) investigate relations between pain acceptance, depressive symptoms, catastrophizing, and functional disability in pediatric patients in an interdisciplinary chronic pain rehabilitation program, (2) examine changes in acceptance from pre- to posttreatment, and (3) test if changes in acceptance predict changes in depressive symptoms, catastrophizing, and functional disability from pre- to posttreatment. METHODS: 112 participants, ages 11-18 years, completed the Chronic Pain Acceptance Questionnaire, Adolescent Version, Center for Epidemiological Studies-Depression-Children's Scale, Pain Catastrophizing Scale for Children, and Functional Disability Inventory on admission to and completion of the program. RESULTS: Significant and strong relations between acceptance, depression, catastrophizing, and functional disability were demonstrated. Participants demonstrated significant increases in acceptance and decreases in depression, catastrophizing, and functional disability. Finally, changes in acceptance significantly predicted changes in depressive symptoms, catastrophizing, and functional disability. CONCLUSIONS: Pain acceptance is an important variable in the treatment of pediatric chronic pain.

Covert video monitoring in the assessment of medically unexplained symptoms in children.

OBJECTIVE: Diagnosis of medically unexplained symptoms (MUS) occurs after thorough evaluations have failed to identify a physiological cause for symptoms. However, families and providers may wonder if something has been missed, leading to reduced confidence in behavioral treatment. Confidence may be improved through the use of technology such as covert video monitoring to better assess functioning across settings. METHODS: A 12-year-old male presented with progressive neurological decline, precipitated by chronic pain. After thorough evaluation and the failure of standard treatments (medical, rehabilitative, and psychological) covert video monitoring revealed that the patient demonstrated greater abilities when alone in his room. Negative reinforcement was used to initiate recovery, accompanied by positive reinforcement and a rehabilitative approach. Covert video monitoring assisted in three subsequent cases over the following 3 years. RESULTS AND CONCLUSIONS: In certain complex cases, video monitoring can inform the assessment and treatment of MUS. Discussion includes ethical and practical considerations.