Monday, December 30, 2002

This Week's Topic: What’s Related?

Question: Where do you draw the line between psychological problems that arise from injury and those that either pre-existed or are coming from other sources unrelated to injury…and how do you address all of that?

Dr. Adams Replies:  Psychological problems arising from injury are almost the norm. The patient is in pain, become anxious, depressed and confused. 

However, in an equal number of cases, the psychological problems take on a life of their own and suddenly the doctor is presented with a barrage of personal, social, family, and interpersonal problems which the patient would like to address…and which may have nothing whatsoever to do with injury.  

It is important, therefore, to tell the patient from the onset that “you will be seen for 8 return appointments…during that time, other problems may arise that are not related to your injury. For those unrelated problems, I shall refer you to someone in your community that can address those issues since they are not our domain in this setting.” 

It is important that the patient be reassured that his/her problems are recognized and of concern but that he/she must differentiate them from the problems that have arisen solely because of injury.  

If one allows those boundaries to become blurred, the patient will form a dependent attachment and begin to believe that all problems are the domain of treatment. 

Let me give you an example: A patient was referred after she injured her neck. She had the option of dealing with the pain or considering a cervical surgery which her condition did not mandate but which was an option. After she had dealt with that decision, she wanted to discuss the critical health problems of her diabetic son…the recent shooting of her son in a carjacking situation…the unhealthy alliance between her sister and mother…the drug seeking behavior of her daughter-in-law…  All are valid concerns, none were related to her injury.

Monday, December 23, 2002

This Week's Topic: One size fits all? 

Question: In a recent lecture you made reference to the "one size fits all mentality of workers' compensation."  Could you clarify that concept for me?

Dr. Adams Replies:  The nature of health care provided is likely not significantly different between private pay patients and workers' compensation patients. 

There are vast differences, however, in the way the worker' compensation system is structured when comparing highly educated managerial type patients and marginally educated semi-skilled labor workers. 

I have treated a fair number of claims adjustors, nurse case managers, and college educated injured workers in general. In all cases, they feel a sense of lack of control over their care, feel that they are former gatekeepers now locked outside the gates.  

They cannot financially manage on $400 per week, cannot readily adjust to having to have medical procedures authorized before being delivered and know enough about how they, themselves, have managed claims to feel apprehensive now that they are in the patient role. 

More importantly, when you are educated enough to understand diagnostic and therapeutic procedures, you are most often uncomfortable with not having control over when, how, who or even if such procedures are provided.  

These highly educated injured workers feel a great lack of control. They feel powerless in a system that is structured for the passive, compliant or even indifferent patient. Also, most often, injuries among managerial staff are characterized by an intense need to return to work. While a semi-skilled laborer may be accustomed to months in which there is no available work, managerial employees have consistently worked and are ill prepared for the weeks-on-end of nonproductivity. 

While the educated worker often benefits more from psychological care, they also more often require it. They are quite often highly verbal and expressive individuals who are expected to remain passive in the patient role.

The injured worker with appreciable education represents a management dilemma that is uniquely different, and the nature of workers' compensation does not readily fit with their needs.

Monday, December 16, 2002

This Week's Topic: How Dangerous is Dangerous?

Question: Twice during my career, I have been threatened by an injured worker. Nothing has come of either incident, but I wonder if there is a way to determine true danger.

Dr. Adams Replies: First, obviously you must consider all threats credible. Dangerousness has always been very difficult to predict. However, there are some factors to bear in mind. 

As with suicide, if the person distortedly perceives that their situation is somehow improved by aggression against someone else, the probability of an attack is increased. 

If the person perceives that others see them as weak, powerless, and ineffectual, this can motivate them to demonstrate there “power” regardless of consequences. 

An individual with past criminal history who is already familiar with the judicial system and defending themselves within it, are more probable to see their aggression as something for which they will not ultimately be punished. 

If the injured worker sees his plight as hopeless, and believes there is nothing to lose, then the probability of an aggressive act is higher especially among those with history of such things as domestic violence. 

The attacker is more likely to be male, and in the case of injured workers, the victim is more likely to be female (but certainly not always). 

There is a final thing to consider: The threat of violence can be a powerful manipulative tool to gain control just as the threat of suicide can be. While both must be taken seriously, there is always a high probability that the threats are manipulations used to control the direction of their “case.”   

I recall a patient who tore up my office in what his attorney called “psychotic depression.”  The reality is that he did not receive the settlement offer he had expected, had gone home and beat his wife and now needed to appear psychotic so that he would be hospitalized rather than punished.  

You need to be aware that even people who would not follow through upon a threat can still create

Monday, December 9, 2002

This Week's Topic: The Drama Queen

Question: Repeatedly, I have had cases in which the patient is very dramatic about their symptoms, almost as though performing in front of a camera. They tend to do a large number of inappropriate things…they flirt with staff, they sometimes dress inappropriately, they have rapidly changing mood and anything they are asked about their condition, they immediately take on that symptom. What is this…what does it mean?

Dr. Adams Replies: A pervasive pattern of attention seeking and excessive emotional expression is characteristic of what was once called “hysterical conversion” but is now referred to as “histrionic personality.” 

In brief, these individuals are much as you describe:  

a. they have strong, dramatically stated opinions, but they have no supporting facts or details. Their reason for their melodramatic statements are vague and diffuse.

b. In the office, they are often inappropriately flirtatious

c. They express a “familiarity” in interactions that is inappropriate to the relationship (Eg. Hugging staff or making personal references as though this is a close personal relationship when it is not).

d. Their moods are rapidly shifting, shallow and often we feel a combination of being annoyed with them and embarrassed for them. They make us uneasy. And their emotions seem exaggerated and theatrical.

e. They appear to continually crave attention, and

f. They are highly suggestible. 

It is the last two elements that are truly critical. If told that they have symptoms “much like…” or which “look like”…or are “similar to…” some condition, they behave as though they have that condition and exhibit physical symptoms that represent that condition.  

Their symptoms afford them with secondary gain (attention, affection, remuneration, and avoidance of responsibility) and sometimes primary gain (the symptoms, while largely imagined, resolve problems in their lives). 

Until you are certain that this is what is occurring, you find that much time is being expended chasing down the patient’s emotional concerns, only to learn that the emotions were brief and shallow.

Monday, December 2, 2002

This Week's Topic: The Explosive Individual 

Question: I am a nurse case manager and was excused from a case in which a claimant was verbally abusive and physically threatening to several people. He appeared to have no boundaries. His attorney said he was “psychotically depressed.”  Is this accurate? 

Dr. Adams Replies: Extremely unlikely. Highly probable is that he suffers from longstanding Intermittent Explosive Disorder. This could be determined by determining if he has had recurrent physical confrontations and destruction of property when provoked.  Such individuals often have a history of domestic violence recurrently in their lives. 

While depressed people can be irritable and overly responsive, and they may even launch into brief verbal tirades for which they feel guilt and remorse, those with intermittent explosive disorder simply do not tolerate disappointment or frustration. 

I have seen this occur when a patient is offered a settlement amount that was not what he expected.  

Some patients will attempt to cover their explosiveness and assaultive behaviors by stating “I was depressed” to avoid responsibility. Also, they may quickly learn that to try to claim it as due from injury may increase the perceived financial value of their claim.  

Such patients rarely want to be in a mental hospital and fail to see that this will be the consequences of their aggressiveness. If they are admitted to a hospital with those who are truly ill, they seek rapid release since, for them, it is an unpleasant experience. 

The Key Point:  Major Depressive Disorder is far different from Intermittent Explosive Disorder.

Monday, November 25, 2002 

This Week's Topic: Return to Baseline 

Question: “Personality disorders are interesting, but since they cannot arise from injury, why would we care if the patient has one?” 

Dr. Adams Replies: You are responsible for attempting to return a patient to baseline functioning…how they were before they were injured. 

If they have a personality disorder of which you are unaware, your efforts to return them to what you consider to be “normal” will ultimately fail. 

Thus, if they are pathologically dependent or pathologically avoidant by virtue of a developmental personality disorder, and you are unaware of this, you can exhaust yourself in an attempt to restore them to a level of functioning which they have never had. 

Additionally, if they have even more dysfunctional personality disorders such as paranoid, schizoid or borderline, much of what you believe is arising from injury is actually the way they have (poorly) functioned for much, if not all, of their adult lives. 

Think of personality is a foundation upon which our lives are built. A personality disorder can then be considered a weak foundation for the development of adequate social and occupational functioning.  

If you have a patient assessed for existence of a personality disorder, you are attempting to establish what was their functional capacity prior to injury and, thus, what is the best you can expect from care associated with injury.  

It also alerts the primary treating physician as to what to expect from the patient.

Monday, November 18, 2002 

This Week's Topic: Bad Personality? 

Question: “I have a claimant who is hostile, abusive on the telephone, accuses me of absurd things, wants even minor things in writing, has an attorney but insists on calling me anyway, and tells me that his doctors discuss him, laugh at him and that he “will fix them.” Don’t some of these people just have a bad personality?   

Dr. Adams Replies: Personality is merely a term used to describe the sum total of characteristics that make us each unique. We each have a personality which is our style of interacting with our world. 

There are, however, “personality disorders” in which the individual has developed a pattern of maladaptive ways of interacting that results in some degree of occupational and social impairment.  

People with a personality disorder do not feel that they necessarily have a problem. They do feel that there is something wrong with everyone else.  

The individual you describe may have a paranoid personality disorder. Such individuals, when injured, expect the worst and look for it continually. They hire a lawyer to protect themselves and end up not trusting the lawyer. They anticipate betrayal from family, friends and doctors.  

They live in a world where they are defending themselves against others whom they perceive undermines their authority. They attribute to others the very characteristics that actually may define themselves. They believe that others are scheming against them. They feel that they will have to defend themselves, and they cannot readily relinquish control to others. 

Once you have had this personality disorder documented, and you are certain that is what you are confronting, then you can establish a clear line of communication. Keep conversations brief and always directed toward the point/topic. Do not respond to accusations because defending yourself will have no positive impact. Anticipate that you will not be trusted no matter what you do and be prepared to document all of your actions.  

Be certain that the primary treating physician is aware of this pattern of behavior so that he/she can assure that he does not fall prey to the same chaotic interactions. 

Be aware that you will not be successful in changing a personality disorder, but you can learn to anticipate how someone with a paranoid personality disorder does respond.  

And, by the way, a personality disorder cannot be caused by injury, but it can certainly complicate your management of that injury.

Monday, November 11, 2002 

This Week's Topic: Head Injury but not Brain Injury 

Question: “We have a significant number of workers with very mild head injuries that go on to be diagnosed with post-concussive disorder when their symptoms do not go away. Are there other explanations for their complaints?   

Dr. Adams Replies: Closed head injury can be a significant and serious concern, but quite often there are other factors, and more accurate diagnoses, are not being considered.  

For example, highly anxious individuals will have problems with attention, concentration and memory. Depressed individuals will have problems with decision making and recent memory.  

Individuals with uncertain occupational future may have periods of confusion, irritability and even uncharacteristic swings of mood and displays of temper. 

“Somatizing” (Cf. somatoform disorders) individuals (those who convert emotions into bodily symptoms) can and do falsely believe in their symptoms in the confirmed absence of any physical problem.  

Humans are highly suggestible. If someone asks a patient repeatedly if he/she is having memory problems or problems with concentration, this redirects the individual to self-examine such symptoms.  

As you know, some patients become obsessively preoccupied with even minor symptoms.  They become fixed in their belief that they have a condition even though all diagnostic studies have been negative.  

Before assuming that all of a patient’s symptoms are due to brain trauma, be certain that they are evaluated for other factors that could give rise to identical symptoms.

Monday, November 4, 2002 

This Week's Topic:  Psychological not Psychopathological

Question:  I am a nurse case manager, and the surgeon seeing one of my clients said that he wanted a psychological evaluation of the patient. This made no sense to me since the patient is not depressed. He simply has a back injury and is in pain. Why do these surgeons feel that all of these people are "mental."

Dr. Adams Replies: Let's back up a few stages:

a. Unless he told you that he felt the patient was anxious or depressed or suffering from some thought disorder, it appears that he is not seeking a diagnosis so much as he is seeking a sense of direction.

It may be that he has done everything that is usual and customary to manage the patient's complaints, and, yet, the complaints persist. This is not only troubling and discouraging, it is also something that needs to be explained.

If a patient is unimproved after reasonable standards of care have been applied, then something else is going on which has not been fully explored. This may be related to family, financial, legal or other problems.

The surgeon has neither the time nor the situation in which to explore these issues, and, indeed, exploration of such factors may interfere with his clinical relationship with the patient.

b. Secondly, "psychological" simply means a full examination of how/why the patient thinks, feels and behaves as he does. It is not the same of "psychopathological" (meaning "mental disorder").

Securing a psychological exam is a means of completing your database on the patient and understanding why you wish/need to do next to move the case along.  For most of these patients, the major issue is not whether they are depressed or anxious. The major issues are related to aspects of their lives of which we have insufficient information (i.e. data).

It would appear that the surgeon is telling you that he needs more information and does not feel that it is within his domain to secure those data. It does not appear that he is dismissing the patient as simply depressed or simply anxious.

Monday, October 28, 2002 

This Week's Topic: The Normal Response 

Question: “Is it not a normal response to be depressed by a significant injury?  You lose fingers, or injury your back, or have a shoulder or knee injury…your income goes down, you are in pain…I mean maybe we should not intervene at all…I am thinking it is normal to get depressed and normal to recover on your own. 

Dr. Adams Replies: Excellent point, and this point was also made by an astute case manager several days ago.  

However, let me point out three things: 

1.    Most importantly, the goal of a psychological exam is *not* to determine if someone is depressed. The purpose of a psych. exam is to determine the, often incredible, number of *other* factors that are operating in the patient’s life, that have not been reported/recorded, and need to be separated from those that are truly injury related. 

2.    Secondly, please do not confuse depression with sadness. When a person is sad, they are tearful, glum, and discouraged. However, when they are clinically depressed, not only is their mood effected, but they are irritable, have difficulty making decisions, have thoughts about death, are pessimistic, worried, preoccupied and derive little pleasure, if any, from their lives. Sadness is an emotional response to a sudden event, and it dissipates rather rapidly. Depression is a biological change and may not abate unless treated.  

3.    Finally, in the case of injured workers, it is imperative that once detected, by whatever means, depression is seen as a disorder that may complicate the course of recovery.  

What may frustrate you in case management may simply be the multiple ways in which a depressive disorder expresses itself in the months following injury.

Monday, October 21, 2002 

This Week's Topic: Offensive Employers? 

Question: "What makes me so tired of dealing with w.c. more than anything is some of these employers. They want employees back at work right away, or they want me to deny a claim on the basis of an injury being unrelated, but they have no evidence of this; they just want to save money. Or they want me to ask the treating physician for a work release when the patient is in the middle of getting care. I shouldn’t have to be in this position. The good doctors are offended by requests like this. The ones that go along with the employer's request aren't doctors I want to deal with anyway." 

Dr. Adams Replies: I hear this all the time. TPA’s have to answer to employers in a way that insurance companies do not, and adjustors and case managers are often caught in the middle.  

There is no doubt that some doctors believe that if they please the employer they can maintain a better referral base. In reality, this is not effective since it becomes clear to the injured worker that the doctor is attempting to meet employer, rather than patient, need.  

Employers can be amazingly supportive, helpful and benevolent. They can just as often be manipulative, rejecting and accusatory, sacrificing the patient in some vain attempt to save seemingly little money. 

The only safeguard is working with doctors whose opinion you can trust, that are swayed only by objective findings. These doctors will not always tell you what you “want” to hear, and that is how it should be. The objective doctor will tell you what the patient truly needs, provide reasonable care with a defining endpoint, and be prepared to release the patient when objective data supports that capability.  

At the point of objective MMI, if the patient resists release, it is time for a psych eval to find out why.

Monday, October 14, 2002

This Week's Topic: Offensive Employers?

Question: "What makes me so tired of dealing with w.c. more than anything is some of these employers. They want employees back at work right away, or they want me to deny a claim on the basis of an injury being unrelated, but they have no evidence of this; they just want to save money. Or they want me to ask the treating physician for a work release when the patient is in the middle of getting care. I shouldn’t have to be in this position. The good doctors are offended by requests like this. The ones that go along with the employer's request aren't doctors I want to deal with anyway."?

Dr. Adams Replies: I hear this all the time. TPA’s have to answer to employers in a way that insurance companies do not, and adjustors and case managers are often caught in the middle.  

There is no doubt that some doctors believe that if they please the employer they can maintain a better referral base. In reality, this is not effective since it becomes clear to the injured worker that the doctor is attempting to meet employer, rather than patient, need.  

Employers can be amazingly supportive, helpful and benevolent. They can just as often be manipulative, rejecting and accusatory, sacrificing the patient in some vain attempt to save seemingly little money. 

The only safeguard is working with doctors whose opinion you can trust, that are swayed only by objective findings. These doctors will not always tell you what you “want” to hear, and that is how it should be. The objective doctor will tell you what the patient truly needs, provide reasonable care with a defining endpoint, and be prepared to release the patient when objective data supports that capability.  

At the point of objective MMI, if the patient resists release, it is time for a psych eval to find out why.

Monday, October 14, 2002

This Week's Topic: What Evidence Do You Have?

Question: As a nurse, I too see a lot of chronic pain injuries who are also depressed, but how do we know this is not just coincidence and a select few…what evidence do we have?

Dr. Adams Replies: Does chronic pain cause the depression or does depression cause the pain? Current evidence indicates that both are occurring in our cases. Research shows that patients with persistent or chronic pain are at risk for developing an anxiety or depressive disorder and that those genetically predisposed to anxiety and depression are prone to experience pain more intently.  

A recent analysis of data from the World Health Organization, found that 22% of primary care patients complained of persistent pain, which was defined as experiencing at least 6 months of pain plus disability because of the pain and/or receipt of medical care for the pain. Those with persistent pain were 4 times more likely to have an anxiety or depressive disorder than were pain-free individuals. 

* Pain is as strongly associated with anxiety as with depressive disorders;

* The number of pain sites (diffuseness of pain) and the extent to which pain interferes in daily life are the characteristics that most strongly predict depression;

* Certain psychological symptoms of depression, including low energy, sleep disturbances, and worry, are common among pain patients whereas guilt and loneliness are not; and

* Psychological distress and disability often surface and resolve early during the course of a pain disorder that evolves into a chronic condition. 

Based upon their findings, researchers proposed 3 theories about the mechanisms underlying the co-existence of pain and depression:

(1) some individuals are genetically susceptible to both physical and psychological symptoms

(2) some are prone to psychological distress which amplifies any unpleasant physical sensations, including pain;

(2) the physical and psychological stress of pain itself  may induce or aggravate psychological a psychological disorder 

As is indicated and explained in this year’s seminar, there is increased evidence that pain and depression share common physical causes. 

Psychotherapy and behavioral modification, either alone or in combination with medication, has been shown to be an effective and important part of the successful treatment of comorbid pain and depression.  Patients, however, must be directed to actively participate in their own recovery rather than passively await change to occur. 

Monday, October 7, 2002

This Week's Topic: Distortion

Question: In my surgical practice, I had not paid a great deal of attention to the recounting of how an injury occurred. However, when I saw patients distorting what I told them about surgery, I began to wonder if they are accurate in their details of the injury. Thoughts?

Dr. Adams Replies: In contrast to remembering the ages of their parents or spouse or knowing which jobs they have held, patients are very specific as to day, date, time and minute circumstances of not only the injury but what preceded and what followed. 

This can be quite striking. They minimize the importance of education, training or health problems (outside injury), but they are meticulous in detailing who was at fault, how poorly things were managed, and from where their distrust arose.  

Quite often, this is because their case has been mismanaged from reporting and documenting the injury to timeliness and structure of care.  

However, these distortions and alterations of reality may also arise from attempts to manipulate and deceive.  

This can be a central point in case management since it extends to what they report they were told about their diagnostic findings as well as distorts what they either believe and/or recount is the planned course of care. 

As part of a psychological exam, I review all medical records. It is surprising or perhaps alarming that different versions of the injury and its aftermath have been recounted to each individual seen since the date of injury.