Monday, June 24, 2002

This Week's Topic: Is this Munchausen's Syndrome

Question: I have an injured worker who between visits to my office, makes frequent visits to the ER. You cannot imagine the number of ER visits we have, and they are throughout the State. I believe this patient has Munchausen's Syndrome. Do you think this probable?

Dr. Adams Replies: It would not be my first area of concern. First let's redefine Munchausen's Syndrome as an individual with (Factitious Disorder with Physical and Psychological) Symptoms that warrant endless contact with the health care system.

These patients have a wide range of complaints, involving many organ systems of the body, and they will seek out painful and even dangerous diagnostic and invasive procedures so that this attention seeking process can continue.

While this often occurs, and a work related injury can be an opportunity for the Disorder to present itself, there is a greater concern - drug seeking.

Is this patient being medicated each time he/she is seen at the ER, and are the medications chiefly narcotics?

If you seek out and compile the records, you may find that not only is the patient being prescribed narcotics, but the patient is also reporting "allergies" to all but the most preferred narcotics. Thus, the patient states in the ER that he/she cannot tolerate "codeine" but can tolerate Percodan, Vicodin...OxyContin.

With further investigation, you may learn that the patient is exclusively receiving one narcotic or specific family of narcotics. You may also find that they refuse treatment in any ER where that narcotic is refused and return to those ERs where it is provided.

Having the patient evaluated for Munchasen's Syndrome can be valuable but concurrently examine the pattern of any narcotic seeking behavior.

Monday, June 17, 2002

This Week's Topic: Distrust and Mistrust

Question: “I am a case manager. I find a consistently recurring problem with trying to assist injured workers who develop these high levels of distrust despite all that I do for them. I do not know if this burns me up or burns me out. If you could assume for the moment that I am not doing anything wrong, what would account for their suspicion over my attempts to help them?”

Dr. Adams Replies: I refer to this as “the crisis of distrust and mistrust.” After an injury, a patient is placed in a helpless position and must invest trust in one or more people to insure that their needs are met. Often that trust is misplaced.

Ultimately, the trust needs to be placed in those attempting to treat and rehabilitate the patient. The only healthy assumption is that the patient wishes to, and is motivated for, recovery.

However, in reality, family, friends and others, may be invested with trust by patient without actually warranting this trust. There can be those close to the patient who manipulate him/her for their own gain. This gain can be a sense of control over them or the promise of a future financial reward.

The patient, in a position of vulnerability, places trust in those who have not earned it, and concurrently distrust those whose efforts would benefit them.

A case comes to mind in which an injured worker followed every medical visit with visits to his own physicians. He never invested trust in those providing care for his injury, and he consistently invested trust in those were often less skilled, and, in this case, gave him inaccurate information and ineffective care.

When you are attempting to manage such a case, it would be reasonable to state very early what your goals are, place it in the form of a contract so that the patient can review your goals for him/her. If you sense/detect that they patient is withdrawing trust and/or investing trust in counterproductive relationships, verbalize this observation to the patient. If he/she can accept redirection, then you can be of benefit to the patient. If data suggests that the patient has invested trust elsewhere in opposition to your efforts, you will certainly find yourself unsuccessful in rehabilitating the patient.

Monday, June 10, 2002

This Week's Topic: Too Much Time on Their Hands

Question: “I notice that injured workers whose cases I manage seem to be initially very aggressive in their compliance and urgency to return to work, but once you hit about 9 months post injury, they slow down, and after a year or so, you cannot get them to move forward regardless of injury. Has that been your experience and do you know the cause…and what to do about it?”

Dr. Adams Replies: Too much time and too few perceived options are at the core. For the first year, an injured worker may belief that rehabilitation, even with surgery, will be brief. As the bills continue to come in, as the children still have needs, as their mate has to shoulder the financial burden, as their pain continues, they begin to habituate to doing very little with their days.

Initially, they do home exercises and help around the house. Soon, they become discouraged, nap during the day, watch mindless TV, and they remain most often socially isolated. They begin to feel guilty, embittered, enraged, fearful and frustrated.

This is expressed as irritability. It is not discussed with family or friends, and, indeed, friends tend to disappear during times such as these.

The first order of business is to realize that there is a key anniversary response of these patients. When that first year comes around, discouragement will set in. Secondly, the less one does, the less one wants to do. And finally, if someone is not assisting them in mobilizing themselves, they become increasingly sedentary, gain weight, live for their medication which they insist does not help, and insure that their future holds no viable options.

Monday, May 27, 2002

This Week's Topic: Psychotherapy or Pills: We Want to Save Money

Question: It is cheaper for us to just medicate a patient rather than pay for even short term psychotherapy. Is not the prevailing opinion that pills are not only effective but cheaper?

Dr. Adams Replies: Many strongly believe and advocate medication, stating it is faster, cheaper and more effective. However, this is in contrast to some recent research findings.

A recent address at a mental health conference cited the consistent findings that cognitive therapy and antidepressants are equally effective for initial treatment of severe depression, but the enduring effect of cognitive therapy may prove to be more cost-effective in the long run.

Sixteen weeks after treatment, response rates were identical (57%) for both drug and cognitive therapy treatment. In one study, 75% of patients who received cognitive therapy avoided relapse, compared with 60% of patients receiving antidepressants. The effect of a brief course of cognitive therapy was better than a similarly brief course of medication in the year-long continuation phase of the study.

Results suggest that even after termination of treatment, a brief initial course of cognitive therapy may offer enduring protection comparable to that provided by continuing medication.

Over this particular 16-month study, antidepressant treatment cost $2590 on average compared with $2250 for cognitive therapy. This gap becomes greater because antidepressants must be administered continually to be effective.

Monday, May 20, 2002

This Week's Topic: Resistance to Recovery

Question: At what point do we order a psychological examination? After the patient seems depressed or when the patient requests it or when the primary provider thinks it is needed…?

Dr. Adams Replies: Those are not the ideal times.

Obviously, if the patient seems depressed to you or when the patient indicates he/she feels she needs assistance, you would investigate that need and refer accordingly. Similarly, if the primary provider, a surgeon for example, feels that it is indicated, it should be pursued.

However, the point at which *you* need to consider a psychological examination is when the patient’s injury complaints have continued beyond that which the objective clinical findings would indicate. Thus, if 30-60-90+ days after injury, and current clinical findings indicate the patient should be capable of returning to work, but the patient continues to complain of symptoms and resist return to work, psychosocial factors are at play.

These psychosocial factors will not subside. They most often become entrenched and/or expand. While you continue to authorize 2nd and 3rd opinions as well as more physical therapy and new medications, there may be no change in the patient’s willingness to mobilize.

This process can continue for months, if not years, and is not addressed until you determine what psychosocial factors are driving this resistance to recovery.

You may realize that this is occurring long before the patient and others directly request psychological examination. Indeed, the patient may strongly resist such an examination due to fear of revealing and dealing with the true problems that are creating their resistance to recovery.

Monday, May 13, 2002

This Week's Topic: Psychological Risks from Transitional Duty Work

Question: I had a patient working transitional duty (“light duty”) while waiting to recover. He appears to be an emotional mess. I cannot figure this out; is this common?

Dr. Adams Replies: Yes, it is quite common, and allow me to explain. Most injured workers are in an environment where there are not true light duty positions. These positions are (often reluctantly or certainly unskillfully) created by their employer.

Such transitional duty may be sitting at a desk, inactive and bored or monitoring an entrance to the building, in public viewing but social isolation. These types of “transitional” work place the patient at risk for two things: a. exposure to criticism by coworkers who resent the patient being paid for essentially non-productivity, and b. the patient’s own sense of humiliation at being disabled from doing his/her defined role.

I have found that injured workers, who continue (or return to) a light duty position, often become anxious and depressed. They lose faith in their employers, their coworkers and themselves. They anticipate that they will be fired, fear that they are resented, and they focus more upon their physical complaints as justification for being in that role.

However, the counterpart is that these same patients do very well in psychological care because they are holding these fears and resentments internally and are not dealing with them at home or at work.

As a result, those patients in transitional duty positions are often the most productive patients in short term psychological care.
From a physical standpoint pain and depression share much of the same biochemistry of the brain. Equally as important, they both interfere with sleep.

Monday, May 6, 2002

This Week's Topic: Pain and Depression

Question: What is the relationship, if any, between pain and depression?

Dr. Adams Replies: From a physical standpoint pain and depression share much of the same biochemistry of the brain. Equally as important, they both interfere with sleep.

The medication taken for pain also often disrupts sleep.

The inability to control pain leaves a patient with a sense of helplessness, and from a psychological standpoint, the learned helplessness is the cornerstone of depression.

Additionally, knowing that a patient is powerless even to sleep-away-pain, leaves the patient feeling powerless and out of control. The patient will then nap during the day due to sleep deprivation at night.

Since narcotic pain medication can result in unusual, if not bizarre, dream content, it is not unusual for pain patients to have nightmares in which they are being harmed or otherwise physically suffering.

Thus, sleep and pain become entangled. Upon awakening, they are still tired, and left with the aftermath of unpleasant dreams and a painful night.

Patients then become irritable toward family and health care providers, often driving away the very support they need.

Often an indirect, but effective means, of treating pain is treating the depression that accompanies it.

Monday, April 29, 2002

This Week's Topic: Developmental History & Failure to Recover

Question: I recently reviewed a psychological report, and there was no mention of any events in the patient’s life prior to injury. I gather you feel that the developmental history is important to understanding a patient’s pattern of recovery.

Dr. Adams Replies: The developmental history is critical for many reasons.
1. If the patient comes from a family with disabled parent(s), there has been role modeling early in life for acquiescing to the disability role.
2. If the patient’s marriages were unstable, the patient may have continuing instability and inconsistent support, both emotionally and financially
3. If the patient’s developmental history is characterized by poverty, adaptation to the low benefits inherent in workers’ compensation may too readily occur.
4. If the patient did not have a same sex role model who had a specific career or record of productivity, the patient’s expectations for/from a career may be quite low.
5. If the patient was a victim of trauma, abuse, abandonment or neglect, he/she may carry not only the trauma but the resultant distrust into situations that involve authority (Eg. Employers, doctors, insurers, etc).
6. If there was a family history of addictive and/or mood disorder, the patient’s vulnerability for these disorders is increased

…and there are truly numerous other developmental predictors of recovery. The best prediction of future behavior is past behavior. It is not possible to fully manage a case without knowing what developmental history led the patient into the injury situation.

Monday, April 22, 2002

This Week's Topic: Psych-IME as a Functional Capacity Exam

Question: I notice that you always check patients for arrest record, legal problems and/or criminal past. Is this truly related to work injury?

Dr. Adams Replies: You referred to a psychological consultation as a functional capacity examination, but this came at the end of the lecture. Can you explain this for us further?

Dr. Adams Replies: Certainly. Actually, I referred to it as “an in vivo mini-functional capacity exam,” and a side benefit for a Psych-IME.

As important as the results of a Psych-IME may be, the response of the patient to the scheduling and completion of the exam is also critical.

Patients who resist (anger and/or failure to show for) the exam, and obstruct it, are attempting to hide information.

Also, a patient may be told that he/she cannot sit for any more than very brief periods and, as a result, the patient is disinclined to consider transitional—duty work options, stating: “they want me to sit at a desk but even riding in a car for ten minutes is impossible.”

However, most of the patient sent for psychological IME, pre- or post-surgical exam, or for an initial psychological opinion, travel two hours to this office. They are then in the office from 4-6 hours, and then they drive or ride two hours in order to get back home.

Many/most of these patients decline breaks when offered, sit for hours at a time, exhibit no pain behaviors, and demonstrate that they have the functional capacity of performing clerical tasks (including travel) of 8-10 hour day.

Are these patients then malingering? Many are not malingering; they merely have misidentified their ability, their residual capacity, and while isolated in their homes, sedentary and medicated, they fail to recognize their own abilities.

Thus the psychological exam becomes not only a means of obtaining a better understanding of the patient’s motivations, it also permits the patient to witness their true limitations…and lack thereof.

It may also be the only setting in which their underlying concerns, frustrations, fears and expectations are openly presented by them.
 

Monday, April 15, 2002

This Week's Topic: Work Injury and Arrest Record?

Question: I notice that you always check patients for arrest record, legal problems and/or criminal past. Is this truly related to work injury?

Dr. Adams Replies: Definitely. Often a patient is forced into a semi-skilled or unskilled occupation due to criminal history. Thus, we see patients of above average intelligence, injured with no willingness to return to that line or work or even that employer. Why? The patient never wanted to work in such a setting but had no choice after release from jail/prison. They may be intellectually skilled and lacking education (or other credentials) to permit them employment commensurate with their intellectual potential.

Secondly, an individual with a history of DUIs, possession and/or sale of drugs, may be a decidedly complex case to manage when someone is considering medicating them with narcotics. Simply asking the patient “have you ever had a problem with drugs or alcohol,” the response will be “no.” As one patient remarked: “he (the doctor) asked me if I had problems with drugs and alcohol…I said “no”…it was no problem…as long as I could get some.”

Finally, a patient with a broad and consistent criminal history has learned how to inaccurately produce data…to lie to family, friends, law enforcement, attorneys, judges, cell mates…doctors and insurance companies. The average person is uncomfortable with being dishonest, but an individual with anti-social (Cf. sociopathic) personality characteristics, by definition, finds that dishonesty comes easily and without remorse.

Obviously, when asked directly, “have you ever been arrested,” most patients with a criminal past will simply reply “no,” and it them becomes a matter of clinical approach to obtain complete data from the patient.

Monday, April 8, 2002

This Week's Topic:  Occult Alcoholism? 

Question:  have an injured worker who is prescribed hydrocodone twice daily. He does not seem to be abusing it; I am certain he is dependent upon it. But lately he has been surly, nasty, hostile and verbally abusive when I talk to him. I really do not think he is depressed. Any ideas?

Dr. Adams Replies:  The abuse may not be of the hydrocodone per se but of the combination of hydrocodone and alcohol. Alcohol can potentiate not only the effects of hydrocodone but also its mood-related side effects such as irritability. 

Staying home all day, inactive, mobile only when physical therapy or monthly doctor visits are required…it is easy to fall into the habit of drinking beer and watching television. This feeds upon itself. 

The first order of business would be to differentiate between what is pain…what is depression…and what is alcohol abuse for this type of patient. Although direct questioning is usually met with denial, here are ways of obtaining the  data regarding what factors are causing the mood changes. 

Combine this with a deteriorating financial picture and appreciable tension in the household. Note that some of these patients are at home either with the children or when the children come home from school. They feel burdened by this added responsibility but more importantly that their adult role is impugned by being a non-working adult. 

Then there is the question of “why are they abusing any substance?”  Most often this is a futile attempt on the part of the patient to deal with the feelings of helplessness and mounting fear of the future.  

Do they need to “talk about this?”  Sometimes. Will adding an antidepressant to this picture be helpful. Usually not. Alcohol and antidepressants can result in severe consequences.  

It is like all of these situations, first you need to find out “why” and then determine “how.”

Monday, April 1, 2002

This Week's Topic: This Week's Topic: Positive Thinkings? 

Question: This week, rather than a question per se, I am forwarding the following journal article summary sent to me by Dr. John G. Keating. It appeared on WebMD. 

Dr. Adams Replies: This is what we have been discussing in our seminars and referring to as "Patient's Goals and Expectancies."

Injured Workers Who Believe They'll Get Better, Do Better

March 27, 2002 -- The power of thoughts like "I think I can, I think I can ..." may extend well beyond nursery rhymes. A new study shows positive thinking can help injured workers recover from their injuries faster and get back to normal activities. 

The study, published in the Canadian Medical Association Journal, tracked the progress of more than 1,500 injured workers after they filed a claim for their injury with the Ontario Workers' Compensation Board. Researchers questioned the workers at regular intervals about their recovery expectations for a year after the claim.  

They found factors such as the injured workers' perceptions about progress to date, expected change in condition, and expected length of time to return to normal activities were major predictors of how soon and how well the workers recovered. 

"Our study provides further evidence that patients' expectations have a direct influence on their recovery," says study author Donald Cole, MD, a senior scientist at the Institute for Work & Health in Toronto, in a news release. "We found that among the patients we followed, those who had a positive outlook returned to work sooner and reported feeling better than those who had more negative or uncertain expectations."  

For example, those who thought their recovery was going better than expected stopped receiving benefits 30% faster and likely went back to work quicker as a result. In addition, participants who said they were fully recovered or thought they would get better soon had a 25% faster recovery rate than those who thought they would never get or stay better.  

Researchers say the study suggests that healthcare providers should listen to their patients' expectations for recovery. Negative or uncertain expectations may indicate that the person has other personal, social, or work-related barriers that may make recovery more difficult.