Monday,
September 16, 2002
This Week's Topic: Out
of Focus
Question: “The
majority of claimant’s that I see are confused about their
condition, what to do, what to tell the family, how to handle
matters before them. I guess some are depressed, but I think many
are just bewildered. I was wondering if psychological care could be
used for injured workers who are not depressed or even anxious?”
Dr. Adams Replies:
Many patients I see are depressed. All the patients I see are in
pain. Many chronic pain patients are depressed. Some are not. Some
are simply concerned about that which they are to do next.
You are correct. They do not
understand their condition. They misinterpret what the are told.
They seek the “magic bullet”, some surgery, procedure, or medication
that will resolve all of their complaints.
They permit way too much time
to pass during which they are increasingly inactive, increasingly
bored, and increasingly destitute. They then believe that their only
viable option is “settlement” and that some amount of money will
restore quality of their life and function to the family. In
reality, the money goes quickly, and there are then no future
options.
They get caught up in appeals
for their Social Security benefits as though that small amount of
money can not only support their families but can compensate their
endless days at home and bored.
These individuals need
psychological care not because they are depressed but because they
have not fully committed themselves to responsibility for their own
future, created their own options and opportunities, and have not
yet been confronted with the permanence of their own complaints.
They are still running from the reality of their situation, angry
and resentful, but have not as yet focused. In that case, the
purpose of psychological care is to permit that focus to occur.
Monday,
September 9, 2002
This Week's Topic:
“Cyberchondriacs”
Question: “I am a
nurse case manager. An increasing number of my cases are complicated
by injured workers going to the internet, getting either incomplete
or inaccurate data, and then attempting to coordinate their own
care, including their medications. Is this a concern others have
expressed?
Dr. Adams Replies: I
refer to many of these patients as “cyberchondriacs.”
They find a disorder or
condition that somewhat resembles their symptom pattern and then
they fill in the blanks. That is, while they may not have all the
symptoms for the disorder, they begin to focus upon the potential
for these symptoms and believe they are occurring. They then search
for an “expert” based upon their internet reading and become
convinced that only a specific person or specific procedure will
assist them.
They cannot easily be
dissuaded.
Further, they read about all
potential side effects of their medications and often refuse to take
what is prescribed and/or misinterpret the response to the
medication as an adverse reaction.
These patients tend to be
very vulnerable to “neologisms” (new terms) which, to them, seem to
uniquely describe their condition. They then obsessively read about
“X.Y.Z. Disorder” and develop complaints that coincide with that
diagnosis. Since some of these diagnoses are broad and ill-defined
with flexible diagnostic boundaries, the patient can readily adapt
their own symptoms to meet that diagnosis.
On the one hand, we have the
patients that have not a clue as to what is wrong with them no
matter how carefully or how often it is explained while on the other
hand we have the competent patient who is misled by what he/she has
read.
There is no simple solution.
They are going to read, and they have abundant time available to do
so. On-line information ranges from brilliant to dangerous. All that
can be done is to insure that they are provided all reasonable and
accurate data by those who are delivering care. Our greatest concern
is when their reading creates hypochondriacal symptoms and/or leads
them to seek ineffective or risky treatment.
Monday, September, 2002
This Week's Topic:
When Wives Attack
Question: “I am a new
workers’ compensation claims adjustor. Twice now in the middle of
helping an injured worker, I have had to deal with their wives. The
men are very nice, but the wife puts herself in the path and blocks
my communication. I feel like I can’t get my work done. Is this
common and is there a reason for this intrusion?”
Dr. Adams Replies:
Doctors and nurse case manager have similar problems with patient’s
wives.
It is quite common, and the
reasons are multiple, and none of those reasons are positive:
a.
The wife may have a pattern of never
relinquishing control to another woman, and she sees his dependency
upon you as a threat to her power base in that home.
b.
His relationships with other women have
always been a problem in this marriage, and as unbelievable as it
may seem to you, she sees you as one more woman going after her
husband.
c.
The wife may have tolerated a great
deal from this man over the years, and now that he is compromised,
she takes over the control/power that she has long wanted.
d.
The wife may have plans for what she
feels will be the “settlement” of this claim, and she wishes to
insure that she controls that outcome.
e.
To the wife, it may be far preferable
to have a dependent and helpless husband rather than the one who has
been so aggressive toward her
Often it is a combination of
these factors which conspire to mobilize the wife to take control of
her husband’s case.
Her filtering all
communication, dictating care, and blocking direct interaction with
the patient makes the patient increasingly passive, dependent and
ultimately insures that he will receive suboptimal care.
There are two approaches:
1. I will be better able to
assist your husband if I deal with him directly, and if this fails,
2. “your husband is the
claimant, and I cannot meet his needs by communicating through you.
To insure that his needs are met, I must communicate directly with
him.”
If you feel their
relationship is particularly pathological, you may wish to have the
patient psychologically evaluated with this “wife-involvement” as
one of you primary questions.
Monday, August 26, 2002
This Week's Topic: The
Pattern
Question: “What is the
pattern or profile of the `problematic rehabilitation
candidate’…what I am asking is whether there is a certain list of
features that are associated with not returning to work even though
physically capable.”
Dr. Adams Replies:
There are actually several groupings, but two may be of immediate
interest to you, and they are divided by gender”
1.
Females in their
mid-to-late 40s who have worked all of their lives due to low family
income or single parenthood. They have worked in labor intensive,
often repetitive and boring jobs. Their children, for whom they had
insufficient time, are now grown, and they have grandchildren. Their
income under workers’ compensation provides meets basic needs, and,
for the first time, they are able to be homemakers. They can take
care of their home, relax, be with grandchildren, and motivation to
return to work is largely absent. Most often they do not realize
this. They retreat to physical complaints to justify their enjoyment
of the secondary gain (freedom, etc). With assistance, they are able
to see that their goals in life have changed. While this does not
return them to work, it assists them in relinquishing their
somatizing (focusing upon bodily complaints to account for their
largely unconscious decision that a return to work will entail a
loss of this long-wanted lifestyle.
2.
Males in their mid-to-late
40s who quit school due to the allure of income when they were teens
and the freedom to “not sit behind a desk.” They have worked
strenuous, labor intensive, and sometimes high risk semi-skilled
work. While they may have valid orthopedic problems resulting from
injury, it is the realization of fleeting youth and lack of
marketable skills that deters them from considering return to work.
When they do consider return to work, it involves often unrealistic
fantasies such as gun repair and taxidermy; long held wishes that
are in the absence of a true available job market. They are now at
home; often their wives are overly attentive. Their grown children
provide various forms of support. They have no marketable skills,
and they retreat to their physical complaints to cover their lack of
future options. Again, with minimal assistance they are able to
understand their actions and that options, other than relying upon
amplified physical complaints, are needed.
Monday, August 19, 2002
This Week's Topic: Scandalous and Dangerous Doctors
Question: “We have a very difficult problem: there is a
doctor who diagnoses and treats a questionable post-injury
condition. The doctor uses “new” tests, implements “new” and often
radical procedures (some of which are invasive) and prescribes truly
incredible levels of medications. We know the patients are being
harmed, but we appear powerless to stop this from occurring. Have
you seen this, and what is the cause and solution before someone is
seriously harmed?”
Dr. Adams Replies: This kind of provider is actually rare,
but when they do arise they tend to assume responsibility for those
cases which others wish to avoid and/or feel cannot be directly
helped.
So when someone comes into an area and offers to treat the
untreatable, other providers are usually relieved to no longer have
the responsibility for the patients and willingly step aside.
There are those patients who fit the diagnosis, and there are soon
patients who become included in a far reaching (if not farfetched)
definition of the diagnosis. Thus, the “disorder” may occur in 1 of
every 1,000 injuries but soon you will note that it is increasingly
and more broadly defined and now 5-10 of every 100 now receive the
diagnosis.
The patient becomes a victim of this process since patients are most
often passive and accept what they are told, especially if told they
have severe problems which no one wishes to address, which will only
get worse, and only this provider has the skill to treat.
The provider then creates his/her own patient base which becomes
very large and very vocal. Those with administrative capacity and
responsibility, respond with “well at least he/she is willing to try
to help these people.”
What you are saying is that you are aware that overtime the patients
are not helped, but increasingly harmed. They become dependent upon
their ever increasing number of medications, spend the entirety of
their days tracking medication, and now need care for adverse
effects arising from treatment. They go from being capable of
modified duty to obtunded in wheel chair and bed.
Their family and friends do not know how to assist and participate
in the patient’s now entrenched perception of invalidism. Family may
fatigue with the process, leaving the patient even more vulnerable
to, and dependent upon, "care."
This happened a decade ago with “chronic fatigue syndrome” which was
broadly applied to large numbers of patients.
So we can now expect that
such diagnoses and self-appointed experts will arise and fill the
void left by others who treat the patients conservatively.
Eventually, what is occurring…the over-diagnosis, over-treatment and
iatrogenic disabling of the patient becomes well known, and the
offenders see less and less cases as new and more appropriate
differential diagnosis and effective care arises.
The most immediately available alternative is to find an examiner
who can accurately diagnose the patient and explain to him/her the
cause of the symptoms and the safest and most effective means of
dealing with them. In smaller communities, this solution becomes
more difficult.
Monday, August 12, 2002
This Week's Topic: Fear of Failure
Question: “Not all of those who fail to return to work are
unmotivated or manipulative. So why do not the majority of the
return to work?”
Dr. Adams Replies: Assume for a moment that the employer does
not have a position available within their physical limitations.
Also assume that any replacement job would lack the seniority that
they are leaving behind and with that seniority was also their level
of income. Then ask yourself `how many of those for whom you have
cared have stated that they would not go work for (example)
McDonald’s at (minimum wage).
A large number of injured workers fear their own future. They may
lack education, training and interest in work other than that which
they performed before injury. If it is the common injury scenario,
they were performing work with a highly than average probability of
injury (Eg. Lifting, pulling, carrying, etc). However, by doing such
work, they were making more money than many of their contemporaries.
Their income, while likely stretched, enabled them the lifestyle
they were living at the time of injury.
Upon injury, there is immediate financial impact and loss of
material items (vehicles, etc.) Then within months they are existing
on an ever dwindling income base. Concurrently, they see that they
will never be fully pain-free.
They then examine “what to do next” and find that they have no
interests, skills or training that would permit alternate work at
their pre-morbid income level. They become fearful of their own
future, a sense of desperation ensues, and with that comes
distortions of both future threats and potential solutions.
They cease to see their futures accurately. They do not clearly
perceive their options. But most importantly, they stagnate waiting
futilely for “something to happen” without knowing what that will be
or even considering that nothing is likely to happen until they
mobilize.
Family and friends either participate in the distorted believes
and/or become exasperated and impatient.
What the patient needs at that stage is someone who directs them to
look at the reality of their situation, the valid options (and lack
thereof) and the compromises that are already built-into their
future. The patient must work through the anger and resentment, the
shame and guilt and ultimately their own fear of failure. The anger
toward others is most often a defense for the close-to-the-surface
realization that they had not prepared for such a situation and had
left themselves few residual and marketable skills.
Monday, August 5, 2002
This Week's Topic: Caffeine
Question: “I notice that as part of an exam you also get a
history of caffeine consumption. Is not a reasonable amount of
coffee okay for injured workers?”
Dr. Adams Replies: Perhaps not, and it is not just coffee.
Caffeine may come from tea, colas (and Mountain Dew), chocolate and
others sources of caffeine.
These patients complain of problems with sleep (see below) and pain,
and while many “pain centers” immediately halt their caffeine
intake, more often than not, these treatment facilities fail to do
so.
In a recent article (Psychosom Med 2002;64:593-603) People who
consume caffeine may experience an increase in blood pressure, feel
more stressed and produce more stress hormones than on days when
they opt for decaf, US researchers report.
The effects of caffeine appear to persist until people go to bed,
even if they do not consume any caffeine after 1 pm.
Given the long-lasting effects of caffeine, the authors suggest that
regular consumption of the substance could contribute to the risk of
heart disease and any condition influenced by stress could also be
aggravated by caffeine.
For example, in people with type 2 diabetes stress can worsen the
condition by influencing glucose metabolism. People with
stress-related conditions, such as post-traumatic stress disorder or
social anxiety, could also experience adverse effects from caffeine
consumption.
Any stress-related disease could be aggravated by caffeine.
In the current study, 47 regular coffee drinkers consumed 500
milligrams of caffeine in the form of two pills, the rough
equivalent of the amount of caffeine contained in four 8-ounce cups
of coffee. The second pill was taken no later than 1 pm. Each
participant took caffeine pills or placebo on alternate workdays,
and frequently recorded their levels of stress. The participants did
not know if the pills contained caffeine or placebo.
The researchers monitored the participants' blood pressure and heart
rate, and performed urinalyses.
The subjects had slightly higher blood pressure levels, produced 32%
more of the stress hormone epinephrine, and felt more stressed on
the days they took the caffeine pill compared with the days they
took placebo.
The effects of caffeine likely persist because it has an average
half-life of 4 hours.
When these people are home, alone, bored and nonproductive, they not
only eat too much, but they consume caffeine throughout the day and
evening. They misinterpret the caffeine agitation as “energy” when,
in reality, they are likely further agitating themselves and both
their injury condition and unrelated underlying medical problems
including heart disease, diabetes and high blood pressure.
Monday, July 29, 2002
This Week's Topic: The Cloak of Depression
Question: “Do you not think that depression would be readily
apparent to a patient’s family or surgeon and that it is certainly a
less important concern than the orthopedic injury?”
Dr. Adams Replies: It is difficult to separate depression
from the orthopedic condition since the former can unquestionably
complicate or obstruct the treatment of the latter. Depressed
patients do not full cooperate with therapies and when not in a
doctor’s office, they are sleeping, eating or watching television;
thereby, gaining weight and increasingly de-conditioned.
Depression is very often presented as irritability, and as a result,
the surgeon may find the patient merely unpleasant and noncompliant.
The surgeon may recommend that the patient lose weight since weight
gain can complicate their recovery. However, the patient
compulsively eats as a marker of their depression and as a means of
attempting to offset their dysphoria with the pleasure of eating.
The pre-surgical patient is told to quit smoking and knows he/she
should do so but depression patients are less likely to successfully
quit smoking.
Rehabilitation also involves intense future planning since career
alterations resultant from injury are not uncommon. However, a
depression individual avoids thoughts of the future, avoids future
planning. He/she avoids dealing with the immediate consequences of
the injury upon their lives, thinking exclusively in terms of pain
and financial losses rather than mobilizing for that future.
We are finalizing next year’s seminar which deals with pain and
depression and the recent findings that almost two-thirds of injured
workers have symptoms rising to the diagnosis of mood and/or anxiety
disorder.
Monday, July 22, 2002
This Week's Topic: The Work History
Question: “Can you
tell me the subtle ways in which a work history is important?”
Dr. Adams Replies: Excellent question. Many workers
terminated their education in order to have access to more money
than adolescence usually provides. They then toil at labor
intensive, often physically demanding and risky jobs for decades.
Others complete high school only with difficulty and follow the same
basic sequence of jobs, moving rapidly in housing construction,
warehouse work, production work and/or heavy equipment operation.
In that history, there may be a series of job losses due to conflict
with authority. There may well be concurrent difficulties in the
current job dealing with supervisors, foremen and coworkers.
Following injury in which there will even be mild
restrictions/limitations, there is no true job to which to return.
The employer may not want them back, or the employer may not have
work within those limitations. Worse still, the employer may have
token work available for which the patient is ridiculed by coworkers
and resented by the employer.
The patient’s perception of the injury may be less a matter of
objective findings and more a matter of the patient’s assessment of
future employability. The injury may be seen, by the patient, as an
aggression against the employer and coworkers.
While the patient may appear to have decades of employability, the
patient may perceive that productive years have ended.
The work history must be combined with intellectual and academic
functioning along with feelings of resentment and helplessness. This
combined with the patient’s perceptions of future options lets you
know to what extent this patient will mobilize for future work. The
patient’s future plans can only be known through an assessment of
the intricacies of a work history.
Monday, July 15, 2002
This Week's Topic: Dealing in Drugs
Question: “When I
finally got through paying for all the medications, I realized that
this patient was on seventeen different drugs and checking with a
pharmacy, I found that several of them cannot be combined. What is
the cause and solution for this?”
Dr. Adams Replies: The primary provider should be dispensing and
tracking the medication, but quite often he/she will simply state
“this is not my field (referring to a class of drugs) and allow
someone else to prescribe.
The secondary provider(s) then may cross boundaries and refer a
second or third narcotic, second or third antidepressant,
anti-inflammatory, etc.
There are obvious and there are subtle concerns:
a. Obvious: This unmonitored avalanche of medications can be a
source of harm and/or abuse for the patient
b. Subtle: The patient can spend much of his/her day just keeping
track of medications
The solution lies in being certain that someone evaluates the
patient, not the medication:
1. Does the patient know his/her medications and why they are
prescribed?
2. Does the patient take the medication as directed?
3. Does the patient recognize adverse side effects?
4. Is the patient able to recognize when redundant medications are
being prescribed?
5. Is the patient able to communicate his/her concerns and physical
responses to those who are prescribing?
Part of this evaluation must also be a determination whether all of
those prescribing are willing to re-examine and alter their
prescribing behaviors.
Unfortunately, the feelings, thoughts and behaviors of the patient
are not often independently and formally examined.
Monday, July 8, 2002
This Week's Topic: Distorting the Facts
Question: “I read a
recent consultation you had performed. All sorts of data were
obtained which did not exist in the records prior to the evaluation.
Do you think that the patient simply lied to everyone else?”
Dr. Adams Replies:
Deliberate omission of data is referred to as malingering by
dissimulation, but that is not the most common reason that
information is missed.
Remember that physical symptoms due to psychological factors are
often unconscious. Patients may have no way to evaluate whether
events in their present or past are influencing their current
physical symptoms.
Patients fail to see how their symptoms are solving problems that
they were unable to solve through other means (primary gain) and/or
enabling them attention/affection/support that they could not
otherwise receive (secondary gain).
As a result, clinicians often do not know the questions to ask, and
patients do not know that they are supposed to reveal non-injury
information.
Obviously an injury is a problem, but quite often an injury solves a
problem. Our responsibility is to determine:
a. which problems are solved or set aside because of injury
b. what is the best method to communicate that reality to patients
c. how do we get those involved in his/her care to be aware of this
The latter is especially of concern since those involved in care may
be unaware of the patient’s longstanding problems and potentiating
them.
Monday, July 1, 2002
This Week's Topic: Nurturance or Nonsense?
Question: We have a
case manager working with an injured worker and frankly we are
concerned that she is making the patient worse. She says she is
being supportive and making certain he gets the right care, but I
think he is simply becoming dependent upon her. What do you think?
Dr. Adams Replies: I
do not know this specific case, and it could well be that the
patient needs more advocacy than he is receiving. But allow me to
give you some guidelines:
• Anyone put in a patient role can become mildly to moderately
manipulative
• Patients can learn to be demanding and “entitled” very rapidly
• Meeting a patient’s dependency needs often does not enable the
patient to recover
• The ultimate goal of any relationship is to have the patient
become self-sufficient
• Patients can have financial, drug, and even criminal concerns that
they do not share but will use their illness role to their own
advantage
• It is easier to drug-seek when you have someone whom you have
convinced that you cannot function without narcotics
• There is always the potential for counter-transference in which
the case manager or even the primary physician becomes overly
identified with the patient’s plight and loses objectivity while
concurrently lacking all of the data.
By way of analogy, I recent saw a patient whose concept of
disability was being strongly advocated by a pain clinic which was
providing him with high levels of OxyContin. The pain clinic,
however, was sorely lacking in data regarding the patient’s
criminal, economic, addictive, and social past. This included his
dishonorable discharge from the military, drug convictions,
alcoholism, past prison terms, estimated eight divorces and other
data which suggested that he had poor impulse control and perhaps
incapacity to benefit from his own experiences.
While becoming supportive of a patient is appropriate, it quite
often occurs with decidedly poor understanding as to what is truly
operating the patient.
If the case manager appears overly involved, she should be
redirected as to whether she has a full and accurate understanding
of the patient.
