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2	4 Type of Claims The Ideal The Tragic The Unreal The Real: Injury Related Injury Exacerbated “WTF is going on”
3	Why Does Adjustor/ Nurse Need Psychological Findings Needs to know what the claimant is going to do…the motives and the goals Needs recommendations for effective case management and what is to be “resolution” Needs to determine appropriateness of current care Central Concern: Needs data to clinically validate their own concerns and suspicions.
4	Your Hunches Are Not Data Injury is falsely reported Problems seem pre-existing New problems are unrelated to injury Patient is being untruthful Patient is case-building Patient is drug seeking Patient does not want to work Wife (or husband) is the problem Problems are more financial than physical The treating doctors are the problem
5	Simple Case Management Axiom If you do not have all of the information, you will never have control of the case.
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8	Pain & Depression The International Association for the Study of Pain gives this definition: Pain has 6 aspects: Biological – a signal Psychological – suffering & fear Behavioral – movement & actions Cognitive – thoughts & beliefs Spiritual – reminder of mortality Cultural – test of fortitude
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10	Psychological Statistical Review Most injuries occur in semi-skilled, intensive labor positions, requiring overtime for financial stability with an absence of career or economic plan. Most have no viable future plans, economic support, and most do not fully understand injury or treatment options. Most have marginal education and training; many have subaverage intelligence Many have unrealistic expectancies of treatment or case outcome. Most lost time cases have agenda that complicates or obstructs the course of recovery.
11	Two Chronic Pain Cases Depression & Surgical Outcome Two patients with HNP at L4/5, both seeking spinal fusion Case One: 38 yo male, ambulates with observed difficulty, working since injury, fully understands and fears procedure Case Two: 36 yo female, no apparent discomfort, states she will not work again, husband and then boyfriend left her, no fear or understanding of procedure
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20	Brief Symptom Checklist Has the patient lost or gained significant weight? Is the patient complaining of specific sleep problems? Is the patient irritable? Is the patient forgetful, have difficulty concentrating and/or have trouble making decisions? Does the patient feel guilty and/or worthless? Does the patient become readily tearful? Does the patient cease to enjoy hobbies or interests? Has there been a decrease in libido? Is there psychomotor agitation or retardation? Does the patient express thoughts about death?
21	Psychological Red Flags In All Case Management
22	Psychological Red Flags
23	The Synonyms for “Psychological” Functional Overlay Conscious Embellishment In excess of objective findings Non-physiologic Indicators Symptom Amplification Inconsistent Effort (“positive Waddell”) Secondary Gain Faking/malingering – pure or partial “Crock, Gomer, Troll, Troglodyte, Burnout, Drug Seeker, Scammer,” and other unpleasantries
24	Three Types of Depression Adjustment Disorder with Depressed Mood – occurs within three months of an event, excess distress or impairment in social/occupational functioning, depressed mood, tearfulness or feelings of hopelessness. After 6 months, it is referred to as chronic. Dysthymic Disorder – almost every day for at least two years, has had two of the following: eating problems, sleeping problems, low energy, low self esteem, difficulty making decisions or hopelessness. Never symptom free for greater than two months. Major Depressive Episode* - for two weeks, nearly every day, depressed mood or loss of interest plus: >5% weight loss or gain, motor changes, feelings of worthlessness or guilt, indecisiveness, thoughts of death, sleep disruption
25	Pain, Medication & Depression Does the patient suffer from Opioid induced mood disorder Does the patient spend his/her days tracking their own medication? Has the patient been tried on antidepressants as a means of coping with pain? Is medication intended to resolve/cure chronic pain?
26	Concluding Concepts
27	Psychological Exam is Needed in: Assault Cases Amputation cases Chronic Pain & Depression Surgical Candidacy Suspected Medication Misuse Questionable surgical outcome When Complaints Exceed Findings When Employment Has Been Brief When There is a Catastrophic Claim
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