Who Will Not Return to Work?
Question: How do you
determine who will not be returning to work, independent of the extent of their
injury?
Dr. Adams replies:
During the course of my clinical examination, I look for and inquire about the
following factors:
a. Does the individual have
a role-modeling adult authority in their past who has lived on disability
benefits?
b. Has the patient truly a
career path or simply worked for sheer financial survival?
c. If this is a female
patient, has she worked since adolescence to support children while males have
been transient sources of financial support?
d. Has the patient applied
for social security benefits soon after injury?
e. Has the patient had a
series of brief employments; this being the most recent?
f. Does the patient feel
he/she can financially survive for 400 weeks on the current level of
compensation?
g. Does the patient have a
family member who has plans for any cash settlement?
h. Does the patient refer to
return to work as "I wish I could" do so rather than "I must" do so?
i. Does the patient refer to
the residuals from the injury as something that he/she must learn to manage
rather than something that must completely disappear?
There are actually numerous
other considerations, but when lecturing or authoring articles for
psychologists, these are the beginning concepts I encourage them to utilize.
Who Should Be Treated?
Question: How do you
determine who should receive psychological care related to work injury?
Dr. Adams replies: If
formal psychological diagnostic exam reveals that a psychological disorder
exists that has resulted from injury or been exacerbated by injury, then the
following series of decisions must be made:
a. Is the patient
sufficiently motivated for change?
b. Is the patient
intellectually capable of understanding their role in the process of change?
c. Is secondary gain from
the symptoms likely to erode attempts to help the patient?
d. Is the family invested in
the patient improving or merely fostering pathology?
e. Does the patient’s
culture support him/her receiving psychological care?
f. Can care be delivered
that does not foster dependency upon the doctor?
g. Can psychological care be
delivered that facilitates care for the physical injury?
h. Can we be assured that
the patient will comply?
i. Can we be assured that
the patient is being forthright and honest?
j. Can psychological care
reach completion concurrent with administrative closure on the injury?
k. Are all attempts being
made to insure that variables unrelated to injury are not becoming the focus and
goal of treatment?
Although every clinician has
his/her own practice statistics, within my own practice, less than 5% of those
seen in evaluation are shown to be capable of benefiting from care. However, it
is important to document early in the injury process who it is that needs and
can benefit from psychological care.
Net Gain = Zero
Question: In a recent lecture, you made
the comment (I am paraphrasing): `for some injured workers when they ask the
question "WIFM", they come out with a net gain of zero.' I could not follow
that. Please clarify.
Dr. Adams replies:
Certainly. The term "WIFM" refers to
"what's-in-it-for-me."
For many patients, the question can be stated:
"If I cannot get a whole lot better...and I really do not know what to do with
my life...what possible advantage is there in seeing or presenting myself as
maximally medically improved."
And for some of these patients, they may be quite
correct.
After all, with the absence of education, absence
of a viable (or appealing) future employment, what is the gain to setting aside
disability income, whether that comes from workers' compensation and/or from
social security?
For these individuals, the relinquishing of the
patient-role involves a net gain of zero. They have essentially nothing to gain
by the process of recovery.
They lack the skills and training that would
enable them employment options. They may have investigated the salary levels of
the jobs they could now secure and have decided that their current disability
income provides more for them...and requires much less from them.
When looking at a case in which the patient
"should have" reached MMI and now be returning to productivity, it may be past
time to investigate whether there the resistance to mobilizing might be arising
from the patient's erroneous perception that there is no gain in returning to
work. Then they must be assisted in seeing that such gain does exist.
Belligerence
Question: "I see my
fair share of belligerent patients. They are best described as `plain old
nasty.' Do you think this can be explained in terms of their pain?
Dr. Adams replies:
In a word? No. Patients can become frustrated with their symptoms or delays in
their care. They can become irritable. They can become aggrieved. Such patients
most often calm rapidly when reassured, their needs are understood and attempts
are made to meet those needs.
Belligerent patients,
however, cannot be soothed. Just when you think that you have made headway, and
they are about to be reasonable, they become abusive. They have no boundaries
and will abuse you, your staff and even those upon whom they are knowingly
dependent.
Such individuals will not
display this in merely one setting although they will try to pit individuals
against each other. They will tell you that they disliked their last surgeon and
document the reasons. They are never at fault in their stories.
They fire their lawyers, and
they change providers, and even those whom they say they trust and respect you
will find have been treated poorly.
This becomes a
characterological pattern quite early in life. You will find it in the patient’s
employment history. You will find it within their family relationships. You will
find it in their tenuously held social relationships.
Belligerent individuals are
so impressive in their lack of diplomacy that we often create television and
movie characters from this mold, and then have them punished in the story line.
The only individuals who are
comfortable around belligerent patients are those who naively feel they are
immune from the attacks and/or that the attacks will serve some greater good. In
reality, these “supportive/encouraging” individuals ultimately wind up being
denigrated by the belligerent patient at some point.
Remember, in their minds, these patients are never
wrong. You are. And you cannot sympathize or empathize sufficiently to halt
their belligerence. The only option is to deal with the most concrete aspects of
their demands and minimize the contact time you have with them. The more time
you attempt to invest, the more contempt you will evoke.
Sexual Abuse
Question: I note in
your diagnostic reports that you question a patient regarding instances of
sexual or other abuse. Can you explain why those data are important when looking
at a current work-related injury?
Dr. Adams replies:
At the combined annual meeting of the Pediatric Academic Societies and the
American Academy of Pediatrics Adolescents, it was reported that patients who
say they were sexually abused are more likely to drink, smoke, use illegal
drugs, exhibit eating disorders or report that they have contemplated suicide.
As a risk factor for mental health problems, "sexual abuse stood out apart from
financial status, physical abuse or age," it was found.
Those who acknowledge sexual
abuse are also more likely to say that they have missed needed medical care and
are in fair to poor health. But only 27% of girls and 26% of boys have ever
discussed the abuse with a physician or other healthcare provider.
These results are noteworthy
because very few studies have been done on sexual abuse in boys. Yet among male
injured workers, I am finding a high level of sexual abuse.
Thus, we
can extrapolate that those injured workers, especially males, who were sexually
abused, are likely to have the most problematic lives, especially after injury.
While we focus on the physical injury, the underlying, unreported sexual abuse
from earlier in life may be the real problem.
Risk Factors
Question: I
hear about a "crisis in mental health." Does this effect my work and my
decisions as a risk management supervisor.
Dr. Adams replies:
Yes, it does. The probability of psychological disorder pre-existing or even
causing injury has increased.
Mental disorders are
becoming more widespread, beginning as early as the teens, according to the
results of an international study. Most individuals with mental health problems
are not treated at all, and nearly half do not seek treatment.
The study group determined
that 48% of the subjects from the United States experienced at least one
disorder in their lifetime, compared with 40% in the Netherlands, 38% in
Germany, 37% in Canada, 36% in Brazil, 20% in Mexico and 12% in Turkey.
Disorders associated with
anxiety, substance abuse and moods are widespread among the poor and
disadvantaged sections of society. Those with below-average education and those
who are unemployed or unmarried are more likely to experience mental illnesses.
The
researchers calculated that the median age for the onset of anxiety disorders is
15 years. For substance abuse it is 21 years, and for mood disorders it is 26
years. Individuals who show symptoms early on tend to delay treatment to the
greatest extent. Women experience anxiety and mood disorders to a greater extent
than men, while men are more prone to substance disorders. Anxiety disorders are
most likely of all to become a chronic illness.
DEPRESSION SCREENING
Question: Do you know a quick and dirty
way to screen for depression and a means to help us remember what to look for?
Dr. Adams replies:
Certainly, here is a mnemonic that I came across that effectively screens a
patient for Major Depression:
S.P.A.C.E - R.A.G.S
S: Sleep disorder (increased
somnolence or insomnia)
P: Pleasure (lack of = anhendonia)
A: Appetite (decreased or increased)
C: Concentration (decreased)
E: Energy (low)
R: Retardation (movement,
thinking, etc. vs. agitation)
A: Agitation
G: Guilt
S: Suicidal Ideation
Sleepless in Atlanta?
Question:
"As a surgeon, is there one simple question I can ask
patients to determine if the patient has underlying or concurrent psychological
problems that are disrupting recovery?"
Dr. Adams:
Actually, there are two such questions:
1. "Do you ever wake up between 2am and 4am and are unable to fall back to sleep
for reasons other than pain?"
2. "Have you noticed or been told you are forgetful and/or irritable?"
Either of these can arise
from inappropriate medication use (for example narcotic analgesia disrupts sleep
and give rise to irritability and forgetfulness), clinical depression (gives
rise to sleep, appetite and changes in thought process), generalized anxiety
(fear of the future, worry about finances, concern for marriages/children) and
underlying resentment (with employer, insurer, doctors, attorneys, family).
Deprived of sleep, the
patient is less likely to put forth effort (or even comply with) physical
therapies, return appointments, weight loss attempts, light duty release or
search for alternate employment.
Irritability winds up
alienating most involved in care and tests the limits of indulgence of the
family.
Once you have determined that there is a
psychological component, then its source and solution must be determined. If you
ignore irritability and sleep disorder during the course of care, progress is
often either slowed or halted.
Why Work?
Question:
“When we see injured workers, we are always trying to get
them back to work. That is our job, but recently, I wondered if we do this
arbitrarily. If work is solely for money, then money can replace work. Why not
give them money instead of trying to facilitate a return to work?"
Dr. Adams:
When an individual is out of work, his/her role in the family
and society changes.
Not aggressively returning a
patient to productivity is arguably the greatest disservice we can do to them.
Most of us spend the first 2+ decades learning how to work, the next 4+ decades
performing that work, and the final stage of life determining our own sense of
accomplishment for having done the work.
Work is not simply
productivity for the sake of society. Work is also where the individual learns
social skills, emotional interaction, economic planning, cooperation in task
completion, a sense of purpose and a meaning to his/her existence.
I do not see us as
arbitrarily attempting to return patients to work because it is our job to do
so. I see it as universally true of humans that work creates a mission to life.
For some, it is simply the creation of income so that the individual and family
can survive.
For many, however, the
entirety of life, from choosing a career path to determining when/if retirement
occurs, is based upon the concept of work. Work adds meaning and identity to
life.
How often do we ask “now,
what is it that you do?” Or even more often, “oh, so you are a dentist…an
architect…a plumber…” We define people by the tasks they complete. And we define
ourselves in the same terms.
If the
patient’s mission in life is to be the work he/she performed, then our mission
in life is to insure that their mission is complete.
Disabling Conditions?
Question:
(paraphrased) "Which psychological disorders, arising from
work-injury, are considered permanently and/or totally disabling?"
Dr. Adams:
Thank you for submitting this question. It is an excellent
one and will be part of an expanded reply in a forthcoming Psychological Letter
(the practice’s newsletter).
In very brief response, the
Diagnostic & Statistics Manual of Mental Disorders lists the known psychological
disorders and the symptoms that are necessary for that diagnosis to apply.
In the introduction of that
manual, it clearly states: “…mental disorders may not be wholly relevant to
legal judgments…individual responsibility, disability determination and
competency.”
Adjustment Disorders, anxiety disorders, mood
disorders and addictive disorders are the most common consequence of injury. BUT
the mere diagnosis of a disorder does not mean that the individual cannot,
should not, and/or would not benefit from working. Indeed, often return to work
is the most therapeutic offering we can make to the patient.
The most potentially disabling disorders such as
schizophrenia and other psychotic disorders are highly improbable to arise as a
result of industrial injury.
Impotent Rage
Question:
"In one of your lectures, you referred to injured male
workers suffering from impotent rage. I did not have a chance to ask you to
clarify. What does impotent rage mean?"
Dr. Adams:
Certainly. For many males working in blue collar,
labor-intensive positions, their power, strength, stamina and (often) tenuous
financial position is the only evidence of their masculine identity.
They are angered that this
has been “taken away” by their injury. They are angry with their doctors, angry
with their nurse case manager, angry with their adjustor…angry with their
family. Often, the anger is due to their belief that they are now seen as less
masculine, as weak, as dependent, and they feel their masculinity has been
impugned.
However, they are, in fact,
now quite dependent upon others, and this often enrages them. But they can do
little with their rage since to express the anger would threaten their needs
being met.
So they sit on the anger and
are often misidentified as being depressed because the symptoms (irritability,
sleeplessness, overeating, etc) are similar.
If the underlying problem were impotent rage,
treating it as though it were depression would not be effective.
Alexithymia (ah-lex-eh-thy-mee-uh)
Question: "Can we predict
which injured workers will be more likely to focus upon mild symptoms?”
Dr. Adams: Many individuals
(males more than females) cannot express their feelings verbally. They either
act them out (destructively) or hold them in (equally destructive).
These people are referred to
as “alexithymic.” They are more prone to somatoform (excess focus upon bodily)
complaints. They are also more prone to psychosomatic (physical destruction
arising from psychological) disorders.
It is possible to
psychologically examine these patients and determine that they have a pervasive
pattern of inability to healthily express emotions. Family members will often
refer to the patient having this problem. For many of these patients, their
bodily focus will decrease when they have the opportunity (with assistance) to
discover what they truly feel and how to appropriately deal with these feelings.
Defense Mechanisms
Question: "Briefly what are defense mechanisms
referred to in reports, and what relevance do they have to work-related injury?"
Dr. Adams: Defense mechanisms are (largely)
unconscious ways we use to defend ourselves against anxiety. Simply “not
thinking” (repression) about our bad marriage or failing to accept we drink too
much (denial) keeps us from becoming upset.
Somatization, the act of focusing upon bodily
complaints rather than dealing with real life issues, is common among injured
workers. They become angry at doctors and employers/insurers rather than
themselves.
Their bodily complaints are either unfounded or
grossly exaggerated.
Their unconscious goal is to keep themselves from
realizing and dealing with what they may have done to their own lives: They
never achieved enough education or pursued a career path that would support them
in event of lost time from work or job change. They (somatize) focus upon their
injury as a way of repressing the fact that they are ultimately responsible for
their own lives and their own future.
Anti-Depressants
Question: "We denied a
prescription for anti-depressants for a patient with a back injury. We felt that
if the patient was depressed, it was pre-existing and do not feel we are
responsible for the medication. Do you have any input?"
Dr. Adams: Many back injured
patients become depressed. Some would say that most become depressed. However,
very few seek treatment for their depression.
Even if they were depressed
prior to injury, and, again, there are data to support that pre-existing
depression increases the risk of injury, you are responsible for exacerbation of
the depression caused by the injury. Once again, few of these patients would
want/accept care even if offered.
When in pain, the individual
sleeps poorly, concentration is impaired, they eat out of boredom, they are
irritable and very little of life is enjoyable to them. Anti-depressants have
become an effective way of helping patients cope with pain.
Often antidepressants are
sufficiently therapeutic that the patient can come off their narcotic pain
medication (which itself can trigger depression).
Thus, antidepressants can be
a very cost effective way of dealing with the painful residuals of work-injury.
The Exceptional Patient
Question: "What do you
consider to be the exceptional patient…the one for whom injury or disability is
most complex?"
Dr. Adams: Some would argue
that the patient who wants to return to work is the exception. However, the true
exception is the highly educated, managerial-executive patient who is unprepared
for the nature of the workers’ compensation system.
Such individuals are not
familiar with a health care system in which they have so little input, in which
records are not privileged, and in which the rate of reimbursement is
impressively far from their pre-injury income.
These patients are not
familiar with a passive role in their health care, with providers being assigned
to them, with authorization being required for treatment or with increasing
financial limitations.
For the white collar,
managerial/executive worker, industrial injury is fraught with frustrations and
disappointments. They most often seek psychological care during their injury
because of a sense of helplessness and fear of an uncertain future.
The Enmeshed Family
Question: "What does the term
enmeshed family mean and how does that pertain to injured workers or those
claiming disability from work?"
Dr. Adams: A distorted
perception of the world, society, responsibility and goals can be created and
maintained by a family.
With injured or ill
individuals, the family can readily become a subculture which encourages the
patient to perceive that he/she is incapable of any productive return to work.
The family can encourage the patient to believe that doctors are indifferent or
incompetent, and that almost everyone is “out-to-get-you.”
By taking away
responsibilities from the patient, the family can encourage grossly exaggerated
perceptions of disability and effectively block any motivation and attempts to
mobilize.
I do not know of a case
where the patient’s perceptions of disability was not substantially determined
by the views of the family. The role of the family needs to be determined and is
often a critical factor in determining whether the patient is
motivated-to-recover.
Precious Time Lost
Question: “I am not I
understand this “diagnosis-by-exclusion” and why it would be such a concern?”
Dr. Adams: If a patient has
complaints that are not readily verified, there are three choices:
a.
Assume the patient is malingering
b.
Assume other factors are forcing the patient to somatize (emphasize minor
physical complaints/sensations)
c.
Assume that more or repeated diagnostic studies should be ordered
The concept of
diagnosis-by-exclusion is when we fail to consider the patient’s role in the
complaints and look exclusively for physical causation. We do not look at the
psychosocial variables until we have excluded every possible, even obscure,
physical causes regardless of how improbable.
Case managers often do not
consider the impact of other variables (marriage, drugs, crime, financial
problems, depression, boredom, personality, etc etc) which are giving rise to
the physical complaints until the patient makes consideration of such issues
unavoidable. Since the patient most often lacks insight, the patient will
continue to submit to repeatedly nonproductive diagnostic tests rather than deal
with the true underlying reason they do not wish to return to work.
Once the pattern of
diagnosis-by-exclusion has become the problem solving approach of an individual
or a company, it is quite difficult to change, and a great deal of time and
nonproductive expense is lost.
Self Medication
Question: What is the biggest problem with
medicating a patient for pain? It would seem that as long as you tracked how
much medication you were giving the patient, there would be no problem at all?
Dr. Adams: It is extremely important to determine
to what degree a patient is self-medicating and complicating his/her own
recovery process
In the
acute (short term) treatment of pain, aggressive pain management can prevent the
patient from developing fear and hopelessness regarding the future. However,
many patients will attempt to adjust their own dosage levels, borrow medication
from friends/relatives and mix the medication with alcohol and other agents (eg.
marijuana, cocaine, etc).
Patients believe that the goal for chronic pain
is to eliminate all experiences of discomfort rather than beginning the
difficult process of adjusting to residual pain and building a life that does
not have its basis in a pain-free existence.
I believe our greatest error is not discussing
with a patient the concept of residual pain, means of coping with that pain, and
adjustments to life style that may be required. We often leave patients with the
belief that there will be no discomfort in the future, and while awaiting that
day to arrive, the patients may engage in a process of counter-productive
self-treatment.
Clinical versus Administrative Decisions
Question: "I have claimants
who appear to languish in care moving from orthopedic care to pain management to
psychological care with no end in sight and yet it is hard to believe that most
of them have significant problems arising from their injury. Is there something
I am overlooking?"
Dr. Adams: Assuming that the
clinical problem has been diagnosed and appropriately treated, we occasionally
have a clinician who feels uncomfortable simply releasing the patient and,
therefore, feels that there is always “one more” referral that needs to be
made.
But there is a more
compelling problem and that is administrative. The patient believes that
they must be out of work for a specific period for their injury to “be worth” a
specific sum of money.
My experience has been that
after a case is ~12-18 months old, a patient readily acclimates to
nonproductivity, and the focus of their attention becomes solely financial.
It is important to identify
the patient’s goals rather than merely our own.
America Today
Question: "Many of my patients are divorced and
many have, or have had, sexual problems or conflicts. Do you have any statistics
of American marriages, sexual preference and other demographics of the American
family?"
Dr. Adams: In 1997, there were 2.3 million
marriages. Sixty percent of Americans were married at that time, 23% had never
married, 9% were divorced, and 7% were widowed. Fifteen percent of Americans are
single parents, 45% rely upon dual income and only 20% maintain the traditional
breadwinner/homemaker roles. Fifty-three percent of couples have no children.
The average is 1.84 children per family. Sixty-eight percent live with mom and
dad; twenty-four percent live with their mother; 4% live with their father. Six
percent of families have incomes above $100k and sixteen percent have incomes
below $10k. Eleven percent of males had been sterilized as compared to 28% of
females. Seven percent of women are homosexual, and thirteen percent of males.
Of the 1.3 million prostitutes in the U.S., 500 thousand were under the age of
18, and 100 thousand of all prostitutes had been arrested. Thirty-eight percent
of girls under sixteen years of age were sexually active; 20% become pregnant.
Handling the Truth
Question: "I am an orthopedic surgeon, and I am not
certain many of my back injured patients understand or are capable of
understanding their complaints. They actually seem offended by their diagnostic
information and distrustful that it is even accurate."
Dr. Adams: At the request of an orthopedic surgeon,
I recently saw a patient who had two prior, unsuccessful back surgeries. His
third surgeon told him that he had significant scar tissue and that further
surgery would be counterproductive.
The surgeon recommended that the patient consider
conservative care and also at the possibility that he would have to learn to
cope with the pain; that the pain may be chronic.
The patient became angered, told me that the
surgeon was "not being positive enough". This meant, in actuality, that the
patient was frightened by the information and was blaming the messenger
(surgeon) for the message.
We talk about psychological diagnosis, but I
should note that the goal of PSYCHOLOGICAL CARE with back-injured workers is to
insure that they:
a. truly understand their condition,
b. realize their capacities not just their
limitations,
c. seek some degree of productivity for their
lives and
d. learn not to be frightened (and avoidant) by
their pain.
Diffuse Complaints
Question: "I have a patient that complains of a
range of physical complaints that do not logically follow from her injury. She
injured her knee and hip, but she has chest, abdominal, arm, neck, head and
urinary complaints. Every few weeks more complaints emerge. I do not think she
is malingering, but I am baffled by her behavior."
Dr. Adams: There are a range of somatoform
disorders in which the expression of fears and needs are expressed through
bodily complaints. Soma means body. Thus, somatoform, in essence, means
"taking the form of bodily complaints." What is missing is your having access to
that which is truly bothering her. Is she frightened of the original complaint
and its consequences. Is she fearful of recovery and its responsibilities or
does she need her complaints in order to cling to one or more relationships that
would otherwise fail? These are the things for which she would need to be
examined.
Pain: Physical and Psychological
Question: "I was told there were two
psychologically based pain disorders. Can you tell me what they are and what
percentage of the population suffers from them?"
Dr. Adams: "Pain Disorder Associated With
Psychological Factors" is diagnosed when psychological factors play a major role
and medical condition plays minimal or no role.
"Pain Disorder Associated With BOTH Psychological
Factors and a General Medical Condition" is quite often diagnosed in
work-related injuries in which psychological factors impact the onset, severity,
exacerbation or maintenance of pain.
It is a quite common disorder with 10-15% of
American's claiming disability each year due to back pain alone.
Free-Floating Fear
Question: "I have an injured worker whose attorney
says suffers from injury related anxiety. If he means that the woman is
"nervous", I say "big deal everyone gets nervous." Maybe I do not understand the
concept of anxiety because I cannot see where it would be disabling and/or
contribute to problems with a case."
Dr. Adams: Anxiety is a fear that has become
diffuse. It is normal to become concerned after an injury, concerned about the
discomfort, about one's career, about finances and about the family. In some
cases, the anxiety becomes more of a problem than the injury.
The individual becomes so anxious that they
cannot understand what they are told about their injury and their need for care.
They cannot make effective decisions, cannot sleep, have problems with appetite
and the anxiety itself can cause physical problems which the patient then
believes are injury related.
It is not uncommon for people to assume that a
patient understands what is physically wrong and what will be the course of
care. In reality, often the patient does not understand, is embarrassed (or
lacks the skills) to ask about treatment, and often the patient will not
willingly discuss with the treating doctor, the underlying family and financial
concerns.
Anxiety is a treatable symptom. When anxiety
characterizes and impedes daily functioning, it can precipitate a variety of
psychological disorders and associated physical complaints. It is best to check
out what, if any, impact anxiety has upon an injured worker. It is not typically
disabling, but left unaddressed, anxiety itself become the problem which
interferes with recovery.
The Proverbial Can of Worms
Question: "I am certain you hear this all the time,
but do you feel that having a psychological evaluation on every injured worker
potentially opens a can of worms? That is, does it not run the risk of
revealing problems that ordinarily we could avoid addressing?"
Dr. Adams: "Thank you for the question. Yes, that
is arguably the most common concern, and it is partially accurate but likely not
for the reasons you suspect.
In fact, the impact of a psychological exam is
the opposite of what you would anticipate. It does not expand the scope of a
complaint; it focuses it upon the real underlying issues.
Psychological factors driving a “case” are going
to be operational whether you discover what they are or whether they blind-side
you and emerge when you are least prepared. Ignoring them does not make them
less of an issue.
The “can of worms” that is opened during
exhaustive psychodiagnostic examination is not problematic for the
employer/insurer/nurse-case-manager, but it may be problematic for the patient.
Most often there are factors (addiction, martial
problems, legal conflicts, financial difficulties, etc) that are the true cause
of why a patient elects to remain in the patient role.
Once others become aware of these factors, the
patient is required to address them and accept them as unrelated to injury.
The patient does not want to address such issues,
and/or the patient is fearful that he/she is incompetent to address them.
Thus, the psychological data revealed in
examination are issues that clarify, not complicate, case management."
Sexual Dysfunction: Injury/Illness
Related?
Question: "As a nurse case
manager, I frequently hear, even from my female claimants that since their
injury, they have had very upsetting sexual problems. For me it is difficult to
determine the source of these problems. Can you run through some of the causes
and how we determine which factors are operating in a given case?"
Dr. Adams: “At one level, this
can be a simple problem, but globally it is actually quite complex. In training,
they referred to this as “multiple co-existing factors” so let’s look at a few
of the factors to consider:
1.
Depressed individuals have decreased libido (sexual drive), and the
patient may be referring more to his/her depressive symptoms than to a sexual
dysfunction. It may actually be a decrease in sexual desire.
2.
As we have discussed in the past, sexual desire is quite often influenced
by mechanical pain from injury. It is simply painfully unpleasant to engage in
any sexual activities since it requires mobility that the patient may not have,
or has only with painful difficulty.
3.
There are two important groups of medications that frequently impact
sexual functioning, one is the narcotic pain medications and the other is the
SSRI antidepressants. Indeed, there are recent articles regarding the use of a
supplemental medication when using SSRI antidepressants to deal with the sexual
complaints that occur.
4.
Conflicts regarding self-image, sexual attractiveness or longstanding
problems in a relationship may surface at many levels after injury (or physical
illness) and decreased sexual response, intentional or involuntary, may be a
means for the patient to respond to those relationship issues.
It is often quite difficult
to determine which of these important variables are influencing a given patient
without thorough evaluation of the patient. This is an important and excellent
question.
I hope
that the above four factors will give you a place to begin in order to determine
if more extensive diagnostic examination is indicated.”
RAGE
Question: "I read in a report
that a workers’ depression was no more than anger toward himself. Could this be
true…and if so, how is it addressed?"
Answer: "It was once believed
that all depression was nothing more than rage directed against the self. We now
know it is, for some, a great deal more complex.
However, when an individual
realizes that he/she has not completed an education, has not worked toward a
career goal, has placed himself/herself in harm’s way by having to work
semi-skilled and potential dangerous jobs, such injured workers often blame
themselves.
Since such self-blame is
intolerable, they become sullen, withdrawn, irritable and defensive. They are
loathe to admit to friends and family that “this is really all of my own
making…I should have never put myself in this position”
Instead, they become
accusatory, self-righteous, defensive and blameful of others.
The resolution of this is to
insure that the patient not become fixed in self-blame and begin to aggressively
examine available options.
The one option that is not
available to anyone is the capacity to change what has already occurred.
The option that is available
is that directed to insure maximum utilization of the future. Few patients
initially realize either of these, but can rapidly learn to do so.”
