March 26, 2001

The Factitious Patient 

Question: "We have a patient I believe is malingering. She keeps finding people to do (sometimes painful) procedures on her, and she keeps refusing settlement. She has fired two attorneys already. How do we convince all involved that she is faking?" 

Dr. Adams Replies: "Your problem may be greater than you realize. While the malingering patient does want financial remuneration, they do not seek out painful and/or dangerous procedures, and they do not decline settlement. For the malingering patient, settlement is the goal. 

You may be looking at a case of factitious disorder that can present with psychological symptoms, physical symptoms or both. 

Your patient may be willing to run severe risk just to maintain herself in a patient role. For complex reasons, partially but not fully explained by dependency, she finds herself most comfortable when in a role of chronic disability. She likes the attention, the affection, the concern and the lack of more appropriate responsibility. 

It needs to be determined whether this is truly factitious disorder, and, if so, to insure that those treating her are aware that this is her goal. Only in this way can you assure her safety. Patients with factitious disorder will put themselves in harms way rather than relinquishing the patient role."

March 19, 2001

Cultural Differences 

Question: "We have an injured worker from the Middle East who can make no decisions in the absence of her husband. He dictates whom she sees, when she is seen, what she is prescribed and what procedures she has. Also, although she is MMI, he has determined that she cannot return to work because of her `pain.’" 

Dr. Adams Replies: "This question has arisen three times this week. With America as a cultural melting pot, we have to be prepared for differences in the ways cultures handle psychological and physical problems. And we must respect that. 

However, we are also governed by our standards of health care and our standards of the value of human life. If, for example, there is a culture that treasures death as a “reward” and views suicide as a favorable decision that does not mean that we should legalize suicide. Also, if a culture uses opium in religious ceremonies that does not indicate that we should freely distribute opiates. 

Being a patient in American health care not only has rewards but it has requirements.  

Whoever is seeing your patient(s) should have limits and boundaries. There should be a clear and firm clinical decision based upon objective evidence. We cannot allow a spouse to practice medicine. 

However, what is often not known is that these can be non-cultural issues. They are psychological issues between husband and wife and disguised as cultural issues. The husband may be a dictatorial, autocratic, suspicious and demanding individual who dominates his wife through intimidation. 

It is important to know whether the issue is cultural or psychological, but it is also important to set real, objective boundaries based upon American standards of health care.”

March 12, 2001

Amputation Psychology 

Question: "I have heard you lecture on the importance of a psychological examination for anyone who has suffered a work-related amputation. I believe you said the exam was mandatory. We see a lot of amputations, and we were wondering why you see evaluating an amputation patient as so psychologically necessary."

Dr. Adams Replies: “We all function within what is called our body-ego. This is how we see ourselves and determines the emotional comfort that we experience with our own physical appearance. It explains the differences between outer and inner beauty and why narcissistic preoccupation with our own appeal can lead to maladaptive personality development.

When we lose part of our body, suddenly and traumatically, our body is forever changed. Often a man losing a finger has less of an emotional impact than a woman losing a finger. Since a man may use even his non-dominant hand in his manual labor work, the loss of fingers or hand can be devastating for some males. They may feel that they have no employment options, they are “less of a man” and/or they are now helpless and dependent.

In general, men and women deal differently with amputation. And there are those for whom amputation is rapidly accepted, and those for whom amputation is incomprehensible and adjustment is extremely difficult.

What you are trying to determine with a psychological examination is whether the patient can, and will, adapt to the loss or whether they need some assistance in making that adjustment."

March 5, 2001

The Natural Course 

Question: "We have a patient who is abusing drugs and alcohol. She is volatile, rage-filled, and we get her new doctors, whom she likes for a few visits, and then she disparages.  

Her psychologist has diagnosed her with borderline personality, and even though she attempted suicide in the past, he says that her problems are now all from her work-injury. Is that an accurate assessment?" 

Dr. Adams Replies: "Quite unlikely. There is a natural course for personality disorders, and, as you know, personality disorders neither arise from, nor are made worse by illness or injury.  

Illness and injury merely become a means for the patient to account for their own behavior which they have rarely been able to control and which they poorly understand. 

Since the patient has been diagnosed with Borderline Personality Disorder, then we have a natural course for which we should be prepared. 

Two percent of the general population and 30-60% of clinical populations are diagnosed with Borderline Personality Disorder, and it is five times more common among first-degree biological relatives of those with the disorder. There is an increased risk Substance Related, Anti-social Personality and Mood Disorders.  

The most common course is one of chronic instability in early adulthood with episodes of serious lack of mood and impulse control as well as high utilization of health care resources.  

The tendency toward intense emotions, impulsivity and intensity in relationships is lifelong.  Recurrent job losses, interrupted education, and broken marriages are common. Premature death from suicide may occur especially with concurrent Mood and Substance-Related Disorders.  

Physical handicaps often result from self-inflicted abusive behaviors or failed suicidal attempts. Self-destructive acts most often result at times of threatened separation or rejection or by expectations that they assume increased self-responsibility. 

There are sudden and dramatic shifts in self-image, characterized by shifting goals, values and vocational aspirations, sudden changes in plans about a career. Their worse performance is in unstructured situations, and they have mood shifts associated with disillusionment with a doctor whose nurturing qualities have been idealized or whose abandonment is expected. 

In toto, these individuals suffer from recurrent major depressive episodes, biologically precipitated by what many believe to be a genetically based instability of neurochemistry.  

Attributing their impulsivity of mood and behavior and self-destructive tendencies to external events is the result of failure to accurately diagnose these individuals or failure to appreciate the implications of the diagnosis.”

February 26, 2001

Employer Interference & Disruption 

Question: “Dr. Adams, I am a nurse case manager for a self-insured company. Unquestionably, one of the greatest problems I have is employers trying to under-report, misreport, deny, and minimize injuries. Additionally, their panel providers become so invested in pleasing the employer that I cannot do my work and get an objective opinion. I am certain you feel this is not uncommon, but I am at a loss as to how to do my work because of it." 

Dr. Adams Replies: “I wish it were uncommon, but employers, both large and small, are often overly invested in minimizing an injury, asking the patient to work through the pain, access their private health insurance, or, in many case, simply stating that the employee’s injury occurred as a result of the aging process, the employee’s carelessness, or results from events outside the workplace.  

When the injury is a valid, work-related event, this places all involved in care and rehabilitation in to position of having to convince the employer of the necessity of care and also the impact of the employer on the aftermath of injury. 

In effect, the employee with a compelling work-related injury has four tasks immediately confronting him/her:

a.    Determine the severity of the injury

b.    Determining appropriate care for the injury

c.    Determining if there will be chronic residual limitations

d.    Convincing the employer of the need for care, modified duty, and emotional support. 

Unquestionably, employers, in some industries, and with some employee populations, become burdened with amplified or non-existent complaints. Nonetheless, assuming a position in which all injuries are a nuisance, and all injured workers are a burden rather than a responsibility, complicates and prolongs the recovery period. It does not decrease expense but extends and increases the financial burden to the employee and the employer. 

The solution? Ideally two-third of employers, with appropriate clinical and case management education can begin to understand their role. The employer can begin to identify how they may be creating the bulk of their own problems. For some employers, especially with changing staff or ongoing acquisition by other companies, these educational experiences must be repeated annually.  

A nurse case manager needs to insure that the employer has access to this education. Another viable approach is to provide a series of meetings throughout the year in which employers can discuss their injury management approaches, concerns and policies.  

Finally, it is often helpful to present to the employer one or more cases in which their standard, often constricted approach, has not limited but actually increased their financial exposure.  

February 19, 2001

Workplace Violence

Question: "Dr. Adams, what are the indices of workplace violence, and how do we prepare ourselves? I see this as increasingly common." 

Dr. Adams Replies: "Actually workplace violence has been decreasing, but each episode costs (on average) $5 million to the employer and untold costs upon society. 

Here are the warning signs:

a.    Actor Behavior: acting out anger such as pounding on desks

b.    Fragmentation behavior: taking no responsibility and blaming others

c.    Me-first behavior: doing things for self to detriment of company, coworkers or consumers

d.    Mixed-messenger behavior: undermining others behind their back while overtly appearing to be their friend

e.    Wooden-stick behavior: refusing to adapt to changes or attempting to control others

f.    Escape artist behavior: handling stress through lying, alcohol or drug dependency

g.    Shocker behavior: exhibiting changes in behavior or acting out of character

h.    Strange behavior: being remote, aloof, poor social skills, decrease in personal hygiene, and becoming fixated on a concept or a person 

Employers need means to encourage employees to report threatening instances, employers need to be supportive of those who express concern, the employer needs skill in disciplinary action, and the employer needs not only skills in emergency management but in recruitment screening.  

February 12, 2001

Idealism and Naivete

Question: "I am a surgeon, and I feel I can treat the injured body without concern as to whether the individual is involved in litigation or has psychological problems. I feel you likely disagree." 

Dr. Adams Replies: "In an ideal world, patients would tell us the truth and be motivated by nothing more than recovery and return to productivity.

In that ideal world, they would have healthy and supportive families, and the patient's themselves would be relatively problem free and have occupational options. They would be without deep resentment, financial problems and would have understanding and supportive employers. They would have received timely, appropriate, effective and immediate care for their illness or injury. They would have good health habits, take medication as directed and not be influenced by the manipulations of others.  

In the ideal world, patients would not be manipulative.

Clinically, I strongly believe that if a patient feels that his/her surgeon does not recognize or take into account their "other issues", the patient sees the doctor as a tool for things other than treatment. It may be a tool to access medication or time-off or to increase the financial value of their litigation.

Yes, I do believe you are best served by attempting to see the patient for a biological, psychological and social vantage point (the biopsychosocial model). It is not difficult, and it can make care more specific and permit you to objectively determine when care is complete. The alternative is to be buffeted by forces which you fail to recognize but which, in fact, drive the course of treatment and its outcome."

February 5, 2001

Injured women more likely to become depressed?

Question: "Dr. Adams, as an attorney, I seem to see more injured females who complain of depression than I see depressed, injured males. Is that a common finding?"

Dr. Adams Replies: "A significant number of women in the general population may have undiagnosed and untreated mood disorders and anxiety, a new study reports. Among an unselected group of gynecologic patients, Swedish researchers, reporting in the January issue of the American Journal of Obstetrics and Gynecology, found 30% had a psychological disorder.

Major depressive disorder was found in 10.1% of patients, whereas any mood disorder was found among 27.2% of patients. Previously reported prevalence rates of depression and depressive symptoms in patients seen by a gynecologist have varied between 11% and 50%, depending on the selection of patients and the diagnostic instruments used. An anxiety disorder was diagnosed in 12% of patients.

Fewer than 10% of women in whom depression was detected had received antidepressant therapy before the study began. Taking into account all psychological disorders detected, only 21% had received any form of treatment.

A similar study in the February reaches the same conclusion. Psychological disorders or substance abuse in 38% of an unselected population of women seeking prenatal care for example.

Making the screening tools easier and more convenient is no guarantee that if a disorder is detected it will be followed up and treated. You can't assume that just because the patient completes the questionnaire that an ob-gyn physician is going to pay attention to it. Many physicians feel it's something they don't want to get involved in. There has to be real changes in training and reimbursement and the system in general. There is a lot of evidence that having these questionnaires filled out doesn't modify physician behavior.

It is clear from current research that one should anticipate a high percentage of depressed women, higher still if they are pregnant, and that early diagnosis is unlikely to occur outside the psychologist's office."

Do Financially Compensated Patients Differ? 

Question: "Dr. Adams, I recently deposed a psychiatrist who said that treating a patient injured at work and/or who was suing for pain is no different than treating any patient in pain. He said that workers’ compensation and litigation make no different in the patient’s symptoms. What is the reality here?" 

Dr. Adams replies: “His statements are inaccurate and in contrast to research findings.  

In the January issue of American Journal of Pain Management (Vol. 11, No. 1, pp 21-29) Drs. Girondo and Clark, both Veterans Administration Hospital psychologists, found that family income, total pain sites, and pain hospitalizations were more frequent in those who were on workers’ compensation and those involved in lawsuits regarding their pain.

Also, it was found that pain duration, pain intensity, and interference with driving, sexual activity, and grooming were more frequent in those involved in litigation and/or being compensated for their pain.

Compensation-seeking individuals reported higher levels of pain interference and presented themselves as less able to engage in a range of behaviors necessary for independent functioning.

The authors state: “Therefore, these data indicate that individuals who are litigating or have a history of filing multiple compensation claims are likely to report more pain related impairment than individual with similar demographic characteristics, pain severity, and treatment histories who do not pursue financial compensation…

These results are consistent with evidence form previous investigations indicating that differences in clinical presentation between compensated and uncompensated patients…”   

January 22, 2001

This Week's Topic: Relentlessly Depressed Patients 

Question: "Dr. Adams, we have an injured worker who has repeated periods of depression, and just when she seems about to mobilize, she becomes depressed again. Is this a possibility or is something else going on?" 

Dr. Adams replies: "In a recent discussion of this topic, it was stated: "The lifetime risk of developing a depressive episode now approaches 15% and the World Health Organization ranks depression as the world's fourth greatest public health problem. This situation is growing even more problematic, because the age of onset of a first-episode depression is becoming progressively younger and, with early onset, comes greater risks of recurrence and chronicity. 

Between 50% and 70% of those who have experienced one episode of major depression will experience another at some later point, which represents a 5- to 10-fold elevation of risk when compared with the general population. Chronic minor depressive disorders (ie, Dysthymic Disorder) are similarly associated with a marked increase in the risk of subsequent major depressive episodes. 

Episodes of recurrent depression may lead to adverse economic, interpersonal, and medical consequences. 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.  

Depressive disorders themselves have an impact on sleep. Major depressive disorders can disrupt sleep continuity, resulting in increased sleep latency (i.e., trouble falling asleep), waking after sleep onset, early morning awakenings, decreased slow-wave or "deep" sleep, a shift of the rapid eye movement or REM phase of sleep to earlier in the night, and an increase in the length of REM sleep.  

Generally, antidepressants suppress REM-stage sleep, and that appears in a prolonged latency to REM sleep and a reduced percentage of REM sleep. There actually is a theory that it is the REM-deprivation that is the antidepressant effect of the drugs.  

But nefazodone (Serzone), an atypical antidepressant that is marketed in part for its sleep-aiding properties, is a notable exception because it helps users sleep better, even though it actually increases the percentage of REM sleep and decreases the time to onset of REM. Bupropion (Wellbutrin) and mirtazapine (Remeron) also appear to produce clinical improvement in sleep without favorably altering REM.  

Some antidepressants, such as certain tricyclic agents (amitriptyline, doxepin, desipramine), appear to have a beneficial effect on sleep in depressed patients by reducing the overall percentage of REM sleep and by increasing the number of minutes until the first REM period or REM latency.  

Other agents, such as venlaxafine (Effexor) and selective serotonin reuptake inhibitors (fluoxetine, paroxetine, et al.), also can shorten REM sleep and REM latency, but the stimulatory effects of these drugs actually may result in sleep fragmentation, worsening the efficiency of sleep and thereby canceling out the possible benefits.  

The SSRI's are currently the most commonly prescribed antidepressants. They are typically the first-line treatment for depression and anxiety disorders because of their 'benign' side-effect profile. Unfortunately, many patients taking these agents experience a worsening of their insomnia.  

January 8, 2001

This Week's Topic: But do we truly need it? 

Question:  "Last week, your Case Management Update, briefly discussed the MMPI. I can see what it does, but do we need it? Can the surgeon just simply ask a few key questions?"   

Dr. Adams responds: "Your concept is a good one. In the ideal world, where the surgeon has time not only to determine whether surgery is indicated and/or whether it has been successful, were he/she also to have to time to secure extensively psychological data, all could be accomplished by one provider and in one visit.  

But this ideal is unfeasible. Often when obtaining an orthopedic history, a patient becomes resistant to discuss family, personal or social problems. The frequent remark is “this has nothing to do with my back (knee, arm, ankle, etc),” and the patient becomes suspicious, guarded, and resentful. 

The patient expects such questions from a psychologist. Thus, two individuals asking the same questions will receive quite different verbal and emotional responses. 

But you also asked if the MMPI and similar standardized tests were necessary…mandatory. I strongly feel the answer is “yes.” While it would be theoretically possible to gather all the data by asking the precise questions, the MMPI is more cost effective, not prone to any intonation in the doctor’s voice when asking the same questions. 

More importantly, and for a variety of reasons, patients are often more candid and forthcoming when the questions are presented in written form. They do not process what the doctor is thinking or whether their answers are leading to other questions. In effect, it is more thorough, more efficient and certainly more accurate. 

A psychological diagnosis which is based solely upon verbal questioning and lacks appropriate psychodiagnostic tests is, at best, questionable."

January 1, 2001

What Does the MMPI Tell Us

Question:  "I am an insurance adjustor, and I receive requests from surgeons for an MMPI before any back surgery. What exactly is it, and why does he want it?" 

Dr. Adams responds: “The Minnesota Multiphasic Personality Inventory (currently the MMPI/2) was initially developed almost fifty years ago. It has been revised and is now the product of greater than twenty thousand scientific journal articles.

It not only provides objective information regarding the presence or absence of psychological disorder, it reveals underlying problems and runs internal checks to determine if the individual is exaggerating or minimizing complaints.

It is not only the greater than 550 test items and their content that are valuable to you, but this diagnostic inventory, when accurately scored and profiled provides you with clinical scales that reveal anxiety, depression, and even psychotic thought disorder.

There are continually new scales for the MMPI being developed, and not only does it provide raw data, but it provides profile configurations that help understand, predict and ideally control the behavior of a patient.

It is certainly not the only clinical diagnostic tool used to determine the suitability of a patient for surgery, but it is arguably the most commonly used. It is a very cost effective means of determining if this patient is emotionally capable of dealing with surgeries and their aftermath."