Post-injury Obesity – Cause and Course? 

Question:  "As a nurse case manager, I note that most injured workers seem to gain a lot of weight after injury. I think this is significant at multiple levels."   

Dr. Adams responds: I certainly agree. Americans have poor health habits and as a society, obesity is an ever, increasing problem.  

However, obesity among injured workers has even greater implications: 

a.    Obesity arises out of inactivity that, in turn, may arise out of fear of pain or re-injury.

b.    Obesity arises out of boredom; many injured workers spending their days eating, sleeping and watching television

c.    Obesity becomes self-perpetuating and the eating of high caloric foods creates a cycle of short intervals between multiple meals and constant snacking

d.    Obesity taxes an already injured body, and very soon it is difficult to differentiate whether the pain is simply due to carrying the extra weight

e.    Obesity creates its own cycle of inactivity and arises not only from being sedentary but makes any activity more taxing

f.    Obesity can be a clinical significant sign of depression (called “hyperphagia”) 

When we note that a patient is rapidly (and/or progressively) gaining weight, it is important to determine not only causation but how that one problem will compound or even obstruct rehabilitation.  

Interestingly, once the cause of post-injury weight gain is determined, it may be more modifiable and rehabilitation may proceed more rapidly.

September 11, 2000

Treatment or Cure?

Question:  "Is the goal in treating injury-exacerbated psychological problems to cure them? This would seem futile since many of these people have had, and will continue to have, problems for years and years" 

Dr. Adams responds: The best we can do for a pre-existing problem (eg. Anxiety disorder or mood disorder) that has demonstrably been exacerbated by injury is to return the patient to baseline.

Baseline would be the level of functioning at which they were prior to injury.

A mistake many clinicians make is attempting, during the course of injury-related treatment, to address many or all of the problems that have disturbed the patient for years. This can include childhood abuse problems, educational/learning problems, marital problems, identity concerns, and long standing phobias, addictions and/or characterological traits.

In order to adequately treat those problems arising from injury, it must be established:

a.    What was the patient’s premorbid (pre-injury) status?

b.    What are attainable goals?

c.    Can the patient accept the limitations of care?

d.    Can the doctor accept that there are issues and concerns that are not to be addressed at this time?

e.    What is a reasonable treatment duration to determine the patient’s ability to improve versus the point at which no further improvement will occur?

Many patients have virtually no activities with which to fill their time other than their doctor visits. It becomes quite easy for them to allow care to languish for many months beyond that which is appropriate to treat their injury-related psychological disorder(s).  

If the doctor permits the patient to set the boundaries, he/she has essentially set aside a major responsibility in patient care…that is, determining when care should be ended.

September 4, 2000 

This Week's Topic: Can Injury-Related Stress Cause a Heart Attack?

Question:  "I have an injured worker, obese, smoker, drinker, high blood pressure...who sustained a back injury and then had a heart attack. He claims that the injury created his heart attack. Is this even logical?"   

Dr. Adams responds: The most common cause of heart attack (myocardial infarction) is not life stressors but a combination of genetics and poor health habits.  

However, results from a systematic review of quality-of-life studies in heart disease - connecting stress, depression and loneliness to coronary heart disease were presented during the XXII Congress of the European Society of Cardiology. The findings provide compelling evidence that psychosocial factors may be important determinants of heart disease. 

The reviewers noted that their analysis affirms that psychosocial factors exert effects above and beyond lifestyle factors, such as smoking.

The investigators noted that, "although psychological demand and high strain at work may be important determinants of coronary heart disease, the outcome was not statistically...” 

Thus, stress may be a factor, but the preponderance of evidence still suggests that physical self-abuse and self-neglect as well as inherited risk factors are the more likely cause of heart attack, not situational events. 

Question: Is Depression a Physical Result of Injury

August 28, 2000 

Question:  “If depression is caused by a chemical imbalance in the brain, then how can it possibly be tied to injury?" 

Dr. Adams responds: Excellent point, and often depression, that occurs after injury, is not at all related to the injury. The depression may have existed for a considerable period and simply not been detected.

Individuals with recurrent major depression have a series of major depressive episodes and will continue to have these episodes. Some personalities are more prone to these. 

There is a form of mild-to-moderately depressed mood, however, that does occur in some people after injury. This is “situational” depression and is tied to realistic worry, fear, pain, and uncertainty. This is called an adjustment disorder. 

There is also a form of depressed mood that is diagnosed when a person has had moderate depressive symptoms spanning at least two years. This is called dysthymic disorder as we have discussed in the past. 

As you noted, the physical symptoms, however, of major depressive disorder do arise from chemical changes in the brain. These may be of longstanding nature and simply not recognized until the person is receiving care for an injury.  

Adjustment to an injury, however, can amplify these physical symptoms of depression.

This is why it is imperative to have an early psychological examination and to determine what role, if any, an injury has in the development or perpetuating of depressed mood of the injured worker. 

For Whom is Brief Care Effective or Ineffective  

August 21, 2000

Question:  If someone truly does need psychotherapy following injury, what are the current standards of care...and why?"

Dr. Adams responds: For most injured workers, any emotional upheavals are transient and tied to pain, economic changes, relationship pressures and fears of the future.

The current treatment paradigm enforced by managed care is short-term -- a few sessions to relieve symptoms and quick termination. This treatment model assumes that emotional upset usually resolves quickly, especially with help. 

Patients may return for additional sessions if there is a recurrence of difficulty. 

For some patients, this model works quite well, is cost-effective, and avoids the stigma of mental or emotional problems. Even psychotropic medication can be added to the package, given the availability of relatively safe and efficacious selective serotonin reuptake inhibitors (SSRIs). The prescription most often comes from the patient's primary care physician.

The problem with this ubiquitous conceptualization and treatment of behavioral health patients is that it may mishandle some patients who suffer from chronic or relapsing behavioral health syndromes. 

Schizophrenic, bipolar patients, panic disorder, obsessive-compulsive disorder, anorexia nervosa, bulimia, generalized anxiety disorder, social phobia, chronic post-traumatic stress disorder (chronic), attention deficit disorder, dissociative disorders, sexual and gender identity disorders, and all severe substance abuse and personality disorders may not respond to the rigid boundaries required by managed care.

This leads us once again to the importance of accurate diagnosis and differential determination as to the true etiology (cause) of the psychological disorder.

August 14, 2000

Noncompliance Masking Domestic Violence

Question:  I have found that when an injured worker claims to have psychological problems as a result of physical injury, they often then are not compliant with a psychological referral. How do you explain this?

Dr. Adams responds: There are those patients for whom domestic violence may be the main issue. 

This violence can arise from substance abuse after injury and/or frustration in dealing with pain.

The pattern goes as follows:

• There is a violent outburst. 

• The patient (chiefly male) then asks their case manager, adjustor or primary provider for a psychological referral. 

• The referral is made, 

• The abused spouse feels "reassured" that the injured worker is no longer violent. 

• The pressure/urgency for the appointment is removed, and 

• the patient then fails to show. 

Most people are not skilled at identifying domestic violence. Recent research indicates that even after 3 hours of training on how to recognize women who are victims of domestic violence, not a single patient seen in the ob/gyn outpatient clinic (in one large study) had been screened for this problem. 

The reason why: Health care providers lack the confidence to intervene or provide appropriate help to victims.

When there is pain, financial problems, and substance abuse, the probability of masked-violence increases.

August 7, 2000

Psychology & Disabling Headaches

Question: "I have had injured workers who complain of severe headaches and say they cannot work. Often these individuals have had no head injury. The neurologists seem to feel the headaches are disabling, but I wonder what the research is on this…I mean – are there psychological factors in all of this?"

Dr. Adams replies: There is a recent article in the journal Headache. In that article, there is a lengthy discuss of depression and anxiety as being among the psychological symptoms that accompany frequent headache and headache-associated disability.

The presence of psychological comorbidity (that is, concurrent anxiety and depression as well as headache) with headache predicts a longer lifetime duration of headache and a poorer prognosis for headache reduction.  

Subjects who had headaches more than 4 days a week and those with headache-associated activity limitation for 3 or more days a week showed significantly greater depression and anxiety.  

Anxiety and depression were not believed to result from or cause the headaches but to co-exist in many headache sufferers. 

These symptoms were not directly associated with headache severity. However, compared with typically mild or moderate headache, severe headache was associated with reductions in role and social functioning. 

Frequent headache and frequent headache-associated disability were also linked to reduced quality of life in areas including physical and social functioning. 

The article concluded that that patients with such symptoms "should be further evaluated for the presence of psychological disturbance." Headache 2000;40:373-376.

July 31, 2000

Is Major Depression More Disabling? 

Question: "As I understand it, something called Dysthymic Disorder can only be diagnosed after an injured employee has been depressed for ~2 years. Major Depression is more frequently diagnosed after injury than this Dysthymic Disorder. Which is worse?  I would think that Major Depression is a worse and more disabling condition. What do I need to know other than whether they have major depressive disorder?" 

Dr. Adams replies: You are correct in one sense: Dysthymic (pronounced: diss-thy-mick) Disorder consists of waxing and waning depressive symptoms spanning a two year period. 

If a person has a situational depression as a result of an event in the past six months, it is called “Adjustment Disorder with Depressed Mood” and most often subsides as the event becomes further in the past. 

While the word MAJOR in Major Depressive Disorder sounds significant, those with a major depressive episode often recover quickly and may not be disabled by their symptoms. 

During the course of a recent study, the patients with dysthymic disorder had more symptoms, functioned worse, and were significantly more likely to attempt suicide and be hospitalized than were patients with episodic major depressive disorder.  

The estimated 5-year recovery rate for dysthymic disorder was 52.9%. For patients who recovered, the estimated risk of relapse was 45.2% during an average of 23 months of observation. Patients with dysthymic disorder spent approximately 70% of the follow-up period meeting full criteria for mood disorder. For patients with dysthymic disorder who never met the criteria for major depressive disorder before the study, the estimated risk of having a first lifetime major depressive episode in the 5-year period was 76.9%. 

As a result of their data, dysthymic disorder which usually pre-dates injury is a severe condition. Almost all patients with dysthymic disorder eventually develop major depressive episodes. Although the disorder by definition has only mild to moderate symptoms, this study shows that it is a chronic condition with a protracted course and a high risk of relapse. 

Thus, if you have an injured worker with diagnosed Major Depressive Disorder, it is important to find out if he/she had long been suffering from Dysthymic Disorder before the injury.

Men with PTSD? 

Question: “We keep receiving these claims of posttraumatic stress disorders in injured males. Is it more common in males than females?” 

Dr. Adams replies: Quite the contrary. Being exposed to a traumatic event can have serious psychological consequences for anyone, but women have a greater risk of developing post-traumatic stress disorder (PTSD) after an assault than men do. They had about the same risk as men when it came to coping with a trauma that did not involve assault, according to a recent study.

Experiencing such a trauma is more common than most people think. Nearly 80% of people in a Canadian community reported that they had been exposed to a serious traumatic event in their lifetimes. One of the interesting things is that, even in peacetime United States and Canada, the likelihood that any of us will be exposed to at least one traumatic event in our lifetime is very high.

Another important thing we learn from this study is that women are at greater risk of developing PTSD following an assaultive trauma situation, whether it's a sexual or nonsexual assault.

Post-traumatic stress disorder is the term doctors use for a variety of disturbing, intense psychological symptoms a person may experience following exposure to a traumatic event. These include a serious threat to life or physical health (such as rape or mugging) or involvement, either personally or through the experience of a loved one, in a major catastrophe. Affected individuals often report recurring nightmares or reminders of the traumatic event and may become emotionally numb.

Other symptoms include sleep problems, inability to focus intellectually, feeling anxious and jumpy, and constantly looking over the shoulder. These people can be quite difficult to help or live with and drinking behavior often increases.

Results of the study, published in the journal Behavior Research and Therapy, showed that 74% of the women and 82% of the men questioned had been exposed to at least one traumatic event. However, although post-traumatic stress disorder was relatively rare, women were four times more likely to report post-traumatic stress disorder than the men.

The adverse consequences of post-traumatic stress disorder can range from relatively mild or moderate symptoms that a person can live with in his or her everyday life to symptoms that are completely incapacitating.

Fibromyalgia?? 

Question: "What is your opinion on this concept of fibromyalgia arising from injury."?  

Dr. Adams replies: This is one of several "diagnoses" that concern many of us who have examined such patients and their families. 

A conference on this subject was reported in the May issue of the Journal of Rheumatology.  

Nine years of litigation over putative fibromyalgia said to be caused by a minor accident has yielded little satisfaction for any participants in the conference. One side insisted it is quite real; the other side stating that it exists to bolster legal claims and compensation.  

The Comprehensive Pain Program in Toronto, Ontario, Canada report on the experience of a family of six who began to report similar symptoms following consultation with a lawyer 5 months after a minor rear-end motor vehicle accident.  

Seven years after the accident, a "noted expert in chronic pain" diagnosed the entire family with fibromyalgia. That expert attributed the delayed onset of symptoms to fibromyalgia, explaining that "this disorder does develop over time." 

Six years after the accident, one of the clinicians examined the family, noting "a striking similarity of body pains and symptoms...in all family members." The diagnosis was pain disorder associated with psychological factors in the context of a dysfunctional family and in the setting of an emotionally charged legal battle, the report indicates.  

One of the other clinicians in the group examined the family 8 years after the motor vehicle accident. According to the report, "he concluded...that much information was feigned, distorted, or concealed by the family members in the context of the pending litigation."  

"After more than 9 years of legal battles," the report indicates, "the settlement, at less than 10% of the original claim, was consumed in legal bills."  

The issues of disability arising from fibromyalgia, as well as the relationship of fibromyalgia and trauma...are highly controversial, and this is also the case, with the concept of 'acquired brain damage' after minor accidents (even in the absence of head trauma or even loss of consciousness)."  

"This case illustrates the complex interplay and contributions of psychoemotional/socioenvironmental factors, litigational factors, and the medical system," the authors conclude.  

"All the usual villains are here: society, psychosocial status, psychological status, the legal system, unthinking medical experts, and a diagnosis of fibromyalgia writes on researcher in a related editorial.  

Based on the available evidence it is difficult to link fibromyalgia to trauma. "There are few useful scientific data regarding fibromyalgia and trauma. The reliability of our assessments of disability is poor."  

"But the case...serves to illuminate the incommensurable and often incompatible values and outcomes found within the litigation process. The long, 9-year case...should make us all think about fibromyalgia and the law, and may make it just a little bit less likely that another such case will happen."  

Additional Factors in Depression   

Question: "Can you expand upon the nature of stress and depression in injured workers?

Dr. Adams replies: Episodes of recurrent depression may lead to adverse economic, interpersonal, and medical consequences. For example, the impact of depression on a family can be detected not only during the depressive episode, but also years after symptomatic remission. Impairment of vocational functioning may similarly persist despite response to treatment. Complications such as alcoholism or substance abuse also may develop during an untreated depressive episode. In addition, depression complicates the course of chronic general medical illnesses such as diabetes and atherosclerotic heart disease.

Most initial depressive episodes are temporarily related to stress, which highlights the role of stress-diathesis vulnerability interactions, suggesting that certain critical factors impinge on a person's life, which may in turn become a catalyst for the development of an illness in those who are genetically predisposed.

Women have about 1.7 times the lifetime risk of developing a major depressive episode.Other relevant risk factors include a family history of affective disorder or alcoholism, a pattern of cognitive distortions, personality disorders, chronic medical problems, and a history of early trauma or abuse.

The relationship between stress and the onset of depressive episodes appears to become less pronounced in more highly recurrent episodes, and new episodes often begin to appear "out-of-the-blue." Some researchers have suggested that the apparent tendency for recurrent depressive episodes to become autonomous results from changes in brain stress-response mechanisms.

People with recurrent depression, for example, have a greater likelihood of hypothalamic-pituitary-adrenocortical dysregulation and more pronounced alterations of sleep neurophysiology.Other recurrent disorders have a seasonal pattern, with fall and winter more commonly associated with depressive episodes. Although the precise mechanism of seasonal vulnerability has not been elucidated, these recurrent depressions are thought to be triggered by changes in the length of the photoperiod (period of available sunlight).

Undifferentiated Somatoform Disorder 

Question: What is "undifferentiated somatoform disorder" and is this an injury related problem? 

Dr. Adams replies: When a patient complains of one or more (often multiple) physical complaints (eg. weakness, dizziness) for a period of at least six months, and the physical findings do not support the complaint, then undifferentiated somatoform disorder may be suspected. Also ruled out must be malingering, drug induced symptoms, or missed physical diagnosis. 

It can arise due to injury especially in anxious patients who are preoccupied with bodily function and who understand little about their diagnosis or treatment? 

This does not, however, often disappear with psychological care, and what the patient and his/her family may most need is a detailed explanation of what the injury caused...and what it did not cause.