June 30, 2003 

(CASE MANAGEMENT UPDATE #241) 

This Week's Topic: “Psychotherapy Rather than Fusion?” from PsychIME.com 

Question: “Was there not a recent study that compared psychological care for lumbar injury to spinal fusion?” 

Dr. Adams Replies: “A Norwegian study has shown that patients with chronic lower back pain get as much benefit from behavioural therapy as they do from spinal fusion surgery.

Dr. Jens Ivar Brox, from the National Hospital in Oslo randomly assigned 64 patients to either cognitive behavioural therapy or lumbar fusion and followed their level of disability for the following year. He presented his results at the Annual European Congress of Rheumatology.

The study aimed to rigorously test the surgical technique. Although it is not well understood why the operation only works for some people, it is increasingly popular in some places, he said.

"In California for example, the number of back fusions was 15,000 in 1995 and in 1999 was 21,000. At the same time the price for each operation increased from $35,000 to $46,000."

All the patients in the study had back pain that had lasted for more than a year, and evidence of disc degeneration. The cognitive therapy involved identifying the patient's thought and behaviour patterns about their pain, and helping them overcome them, including specific exercises.

"According to an independent observer, the success rate was 70 percent after surgery and 76 percent after cognitive intervention and exercise," Dr. Brox said. "We had expected that surgery would be better than the non-surgical treatment," he told reporters at the conference. "But the outcome was similar."

The measurement of disability was made with the Oswestry Disability Index. The ODI score was reduced from 42 to 30 in the cognitive intervention groups and 41 to 26 in the surgery group.

"This difference between the two groups was not significant," the researcher said. "However, this study shows clearly that simple cognitive intervention can be both physically- and cost-effective in patients with chronic low back pain."

He said his group was conducting a followup study, and hoped that other groups would conduct similar research to see if they achieved similar results.”

June 23, 2003

This Week's Topic: “The Masquerade” from PsychIME.com 

Question: “I do not think the cases I see are unusual…usually they involve a male, back injury, relentless complaints of pain, and high levels of prescribed narcotics with no improvement. At what point should we expect these people to roll back on their narcotics…or someone take a role in seeing to it that medication is reduced before addiction occurs?”  

Dr. Adams Replies: Likely, the addiction process is already at work.  

Drug addiction, drug abuse, drug dependence and drug dealing are often masqueraded as unrelenting pain for which the patient justifies as desperate drug-seeking pattern. 

I suspect, with your patients, that no one has determined if this patient and/or members of the patient’s family have had substance abuse problems. This is the most common piece of missing information and is the cornerstone for suspected drug problems.  

You have a man with multiple past DUIs, who has friends and family with whom he has used recreational drugs in the past, and who now has rather open-access to narcotics both to use and to sell.  

Patients will also potentiate their narcotics by mixing them with alcohol. They may share the drugs with friends, swap drugs with friends and family and, as you know, find multiple prescribers. 

It is important that the primary treating physician be made aware of the potential drug abuse of a patient. This is accomplished by an independent examination whose goal is chiefly to examine the drug use/abuse issue.

Monday, June 16 2003

This Week's Topic: “My Job Stress” from PsychIME.com 

Question: “Our office really appreciated the brief discussion on burnout, and we wish you had a seminar or workshop in that area… what we most often feel is extreme and relentless job stress. In our jobs, what do you think contributes most to our vulnerability to burnout?” 

Dr. Adams Replies: I believe there are actually two experiences that erode you:

1.    Lack of Appreciation

2.    Lack of Faithfulness 

You pride yourself in job completion.  Your job requires that you insure adequate diagnosis and treatment to an individual concurrently with assuring that benefits his/her are paid, bills are covered, treatment is timely, and, where possible, the individual returns to productivity. 

Are you consistently appreciated by those for whom you work and those you are trying to assist? 

Your tasks are is thwarted by scheduling problems, noncompliance, and interference from outside sources. Thus, by definition, you lack control of the way you spend your workday and how efficiently others permit you to be. 

Your job requires communication with individuals whose education level and socialization processes may differ greatly from your own. You may be blind-sided by values that conflict with your own and/or even appear to be counterproductive and self-destructive. 

Are those for whom you work and those whom you try to assist faithful to you? 

That is, do they consistently provide you with accurate information? Do they come to you with their concerns or go elsewhere?  Do they defend you if someone is critical of your attempts to assist them? 

Emotional erosion occurs when an individual feel decreasing appreciation and lacking fidelity from those whose approval is most needed.

Monday, June 9 2003 

This Week's Topic: “Burnout? Us?” from PsychIME.com 

Question: “Does the term “burnout” apply to job stresses in claims management?”  

Dr. Adams Replies: “Burnout” was a term created by the late Dr. Herb Freudenberger in 1974 to describe the decrease in quality of output and decrease in quality of product among workers. Dr. Freudenberger was a disnguished practitioner of the National Academy of Practice in Psychology into which I was admitted close to the time of his death in 2000.

As a teenager in Nazi Germany, Herb Freudenberger put on his boy scout uniform, got on a train, passing through Switzerland he jumped off and made his way to Paris. He managed to exist by his wits until he obtained a visa to the United States.

He arrived in this country alone, nobody met the boat, he knew no English. He had relatives in the Bronx but he had no way of knowing who or what the Bronx was or how to get there. His reception when he did arrive was quite poor and rather than be neglected and mistreated he took to the streets ultimately going to school and working in a factory.

Burnout is a process that occurs when workers perceive a discrepancy between their work input and the output they had expected from work. For example, a claims adjustor or nurse case may perceive herself to be a caring, committed professional willing to spend long hours and become personally invested in the progress of her claimants; however, over time she may become disillusioned and exhausted by excessive case loads, lack of progress by her claimants, and insensitivity of the bureaucracy. Among the symptoms associated with burnout are feelings of helplessness and hopelessness, physical and psychological depletion, a sense of unending stress, development of a negative self-concept, and the perception of little to no "payoff" in terms of job outcomes and achievements.

This arises in all involved in workers’ compensation and all for the same reasons:

a.    The cases are not purely medical; there are legal, political and financial components that drive the claim at each stage.

b.    While receiving care at no cost, the patient is not consistently (or even often) appreciative. Instead, they are often angry, resentful and distrustful

c.    The decisions made on behalf of the patient are often then redirected by others so that there is a sense of minimal control

d.    Rarely do most involved in a claim have an understanding of what is truly motivating the patient 

The end result of burnout can be mitigated by providing the adjustor and nurse case manager with more “tools” to understand what is truly happening with a claim. Ideally, a company would also provide a support group where the issues of burnout could be discussed as they emerge.

Monday, June 2 2003 

This Week's Topic: “Posttraumatic Stress Disorders” from PsychIME.com 

Question: “We have a worker who lifted a machine part and strained his back at work two weeks ago. His attorney says that he needs care for posttraumatic stress disorder. Howe do you find if the claimant has the disorder before you start treating it?”  

Dr. Adams Replies: Simple answer, he does not have it. 

Could he develop PTSD? It is highly improbable, but without examining him, I can state unequivocally that he does not as yet have it. 

There are psychological tests that measure the presence of PTSD, but the least accurate form is to ask the patient whether he/she feels she has the disorder. 

In your case, the fatal flaws in the diagnosis arise from two sources:

a. He must have symptoms for at least a month to receive the diagnosis yet was injured only two weeks ago

b. The injury must have involved threatened death or threat to physical integrity and created intense fear, hopelessness or horror.

That would not seem to describe the injury in question. 

Someone with true PTSD symptoms spanning at least a month would have recurrent dreams or intrusive thoughts and may respond strongly if exposed to the same setting in which the traumatic setting.  Again, this would not appear to apply to your patient. 

He would extend appreciable efforts to avoid thinking of the event, show diminished interest in his life, seem detached and/or fail to recall aspects of the injury.   

He would also have sleep problems, irritability, and/or problems with concentration.  

The injured worker should be evaluated. The diagnosis does not appear to apply to him.

Monday, May 27, 2003 

This Week's Topic: “Settlement & Open Medical” from PsychIME.com 

Question: “If an injured worker settles his/her case, and we provide open-medical for a year, we are afraid of being bitten by weekly psychological visits or even a hospitalization after settlement.”  

Dr. Adams Replies: Settlement is itself an interesting topic for which there is not enough discussion. For example, even brutally honest and high integrity people seem to set aside their moral values when the “value” of their claim becomes a focus. 

However, back to your question:  In the last 5,000 cases I have seen, there has only been three individuals who used their open medical for psychological visits, and even then, it was a visit every three weeks (or less frequently). 

Additionally, even those patients did not continue care for the full (six months) or year of open-medical. They most often ask for reassurance that I would still see them and then settlement occurs and after a very few visits, they do not return for care. 

This is logical in that for many of them, the anxiety, helplessness and anger has now been resolved by a financial agreement in which they have participated. They have participated in their own decision-making and whatever PPD was assigned is now, to them, a fixed “quantity” with no needed additional efforts to demonstrate their limitations.  

Thus, at least in my practice, it is exceedingly rare for a patient to return to psychological care after settlement has occurred.

Monday, May 19, 2003 

This Week's Topic: “Drugs and Pain” from PsychIME.com 

Question: “We find that these pain centers are pushing pills like there is no tomorrow. They have patients on 5-10-20 different medications and the patients are strung out, dependent, and I do not see them as better. How many addicts get started this way?”  

Dr. Adams Replies: Many of these people have positive drug and alcohol histories prior to injury that, for reasons unclear, do not appear in their records. At least one in four people enrolled in substance abuse treatment programs have experienced chronic severe pain as a foundation for their addiction. 

24% of inpatients enrolled in short-term substance abuse treatment programs said they experienced persistent pain that interfered with their daily activities. Up to half of these patients--especially inpatients--said they self-medicated with illicit drugs and alcohol. 

The two disorders, addiction and chronic pain, complicate each other. Surveys have indicated that more than 70 million adults in the US have chronic pain.

Most report that the chronic severe pain interfered with their sleep, and many patients said it disrupted their work, mood, and general activity. 

Patients with chronic pain were more likely to report using illicit drugs to get relief from chronic, severe pain. Thirty-five percent of subjects said they used alcohol, 29% said they used cocaine and 26% percent said they used opioids and marijuana, respectively. Furthermore, 30% of patients in the methadone treatment programs used opioids--the most frequently used illicit drugs in this group. 

Study results suggest that chronic pain contributes to illicit drug use behavior among persons who were recently using alcohol and/or cocaine. 

There may not be adequate screening or goal setting for these chronic pain patients who anticipate that treatment for their pain will resolve all of their complaints, and they quickly become reliant upon short acting opioid medications. Addiction then becomes the consequence of care.  

JAMA 2003;289:2370-2378.

Monday, May 12, 2003 

This Week's Topic: “Distortion” from PsychIME.com 

Question: “Do you find a discrepancy between the injury as it is reported and the injury as it is retold by the employee?”  

Dr. Adams Replies: Almost always.  Injuries reported or summarized by the surgeon often simply state that a patient sustain a specific injury with little or no detail as to context of the injury. 

What is more important:

Does the injured worker believe that the injury:

·         was preventable and occurred because of the carelessness of others

·         was due to poor safety standards or protective equipment

·         occurred on machinery that patient feels he/she should not have been working

·         resulted from being “forced” to work extra hours or the wrong shift 

And/or does the worker feel:

·         obstructed (or unassisted) in getting timely care

·         poor quality-of-care was provided

·         that he/she was actively discouraged from reporting the event  

Does the injured worker sense that he/she is

·         unsupported by superiors once injured

·         not being offered transitional duty work although it is available

·         now a target of disciplinary action designed to terminate employment 

When the patient believes that one or more of these are occurring, recovery slows or halts. The recovery process begins when these are identified and addressed.

Monday, May 5, 2003 

This Week's Topic: “Liars” from PsychIME.com 

Question: “How do you know when someone is lying about their injury, their symptoms or their limitations?”  

Dr. Adams Replies: A study by the Research Council in 1996 demonstrated that “build up fraud” in automobile accidents is reported as high as 33%. In another study, 17-25% of claimants admitted to lying about their level of disability in order to remain out of work.  

We are concerned about malingering – the volitional fabrication of physical and psychological symptoms to achieve an external goal.  We are also concerned about distortion – an intentional or nonintentional style of minimizing or maximizing complaints. And we are concerned about deception – distortion of symptoms to achieve some larger goal.  

Malingering is clinically defined (DSM-IVTR) as occurring in a medicolegal context (“the person is referred by an attorney to the clinician for examination”), characterized by lack of cooperation, a discrepancy between subjective complaints and objective clinical findings and associated with anti-social personality. However, with regard to anti-social personality, it should be pointed out that malingering also occurs in other personality types as well. For example the pathologically dependent, passive-aggressive or paranoid (etc) personalities. 

In a 2003 article, Tearman notes: Understanding the honesty, accuracy and completeness of a patient’s  self-report (of pain) is essential. It is important that the clinician reach diagnostic and treatment decision with an understanding of the truthfulness of the pain patients’ self-report. 

Since deceptive patients report that treatment is inadequate, that they are suffering and that there is a high level of disability, it is important to examine the thoughts, behaviors, moods and beliefs to determine the patient’s goals and objectives have, not only for their care but for their disability role.

Monday, April 28, 2003 

This Week's Topic: “Not Far From the Tree” from PsychIME.com 

Question: “What are the important data that we receive from a family history of an injured worker?”  

Dr. Adams Replies: There are many critical data in the patient’s developmental and family history that do (should?) appear in a psychological IME.  

In order of importance, they are:

·         Was the patient’s primary role model missing or maladaptive during the developmental period?

·         Is there a pattern of disability in family members, especially same gender role models?

·         Was the patient reared in a household in which the source of income was disability payments?

·         Do same gender role models work in unsatisfying jobs?

·         Did the family relocate frequently, obviating the formation of peer relationships?

·         Did the family relocate due to head-of-household inability to generate income?

·         Was the family income supplemented by settlement of personal injury litigation?

·         Does the patient have sibs whose physical or mental disorders have adversely influenced their productivity?

·         Did the patient have a pattern of discipline problems in school?

·         Did the patient terminate education early due to lack of motivation?

·         Was the patient’s education adversely influenced by learning disabilities or mental retardation?

·         Does the patient have a past history of arrest?

·         Does the patient have a past history of violent acts?

·         Does patient or 1^st degree relatives have history of addictive disorder?

·         Do the patient or 1^st degree relatives have history of mood or anxiety disorder?

·         Was the patient abused during the developmental period?

·         Did the patient receive a medical, general or dishonorable military discharge?

·         Has the patient had dependent children for which the patient has provided no support?

·         Has the patient had three or more primary relationships ended because of dysfunctional behavior patterns?

·         Are there primary relationship conflicts which are the true source of concern?

·         Are the patient’s problems primarily financial?

·         Do disability benefits approximate the patient’s pre-injury income?

·         Are there exogenous-to-injury problems which are influencing patient behavior?

·         Does the patient spend days with one or more disabled friends?

Monday, April 21, 2003

This Week's Topic: “Persecution”  

Question: “I am treating an injured worker. He questions my motives, questions my methods, questions my integrity…before I boot him from the practice, I would at least like to attempt understanding what his problem is…(sic)”  

Dr. Adams Replies: Paranoid thinking presents in two ways: grandiosity in which the individual feels that they are uniquely gifted or persecution in which they feel they are the target of oppression. 

Many injured workers are given data that increase their perceptions of persecution. They are told that panel providers are both lacking in competence and lacking in concern. They receive this misinformation from a variety of sources. It does little to help them and much to increase their anxiety. 

However, there is another concern when dealing with the highly distrustful and suspicious patient and that has to do with a concept called “projection.”  There are untrustworthy people who then project their own lacking integrity upon others. They accuse others of that which they would do given the opportunity. Knowing that they personally cannot be trusted, they then distrust the motives and intentions of others.  

Thus, the patient may be portraying a series of distortions provided him by others, or he may be accusing you of the dishonesty that may be representative of him.  

The best management in such cases is to put the burden of the decision back upon the patient: “This is how I do my job; I can see that it does not please you. You can either begin to invest trust in me or can seek care in another office. What will not work, however, is this attitude which you bring to the office. I have the option of treating you, and you have the option of finding someone else whom you may prefer.” 

Repeated reassurance and repeated subjecting of yourself to attack will not itself calm the patient. You provide boundaries of your practice, limits on what is acceptable behavior and then accept the patient’s decision.  

Monday, April 14, 2003 

This Week's Topic: “Welcome to the Theater”  

Question: “I just saw a patient, and I swear she thought she was onstage. She was truly theatrical…wild gestures, sudden and brief tearfulness, overly appreciate and equally overly-accusatory… Surely you have seen these patients, have a handle on them and can give some recommendations.”  

Dr. Adams Replies: This behavior does not occur to this extent in “normal” individuals. It is seen in flagrantly histrionic (often referred to as hysterical) individuals (most often women, but certainly not always) in which there is a pattern of rapidly shifting and shallow emotions. These are the patients who can be agonizingly tearful and suddenly calm and equally as suddenly repentant or angry or briefly sullen.  

You will find that they are uncomfortable if they are not the center of attention. They are highly suggestible, and when you offer a symptom to them, they are immediately convinced that they have this symptom and any other you care to mention.  

They will offer a great deal of verbiage, length and dramatic explanations, yet you find that there is no substance or helpful data in what they provide.  

Emotions seem exaggerated as though they are performing in a play. They will be overly familiar with staff in offices and often overly demonstrative seeking to hug, touch and otherwise treat relationships as though they are more intimate than they actually are.  

The best management for such patients is brief, direct, concrete, communication without excessive latitude within which they can become overly dramatic. Be matter-of-fact, objective and avoid the tangents that the patient will attempt to introduce. 

For these patients, an injury (as an illness) provides a stage on which they can perform and feed what is often an insatiable need for attention.

Monday, April 7, 2003 

This Week's Topic: “Psychopath” from PsychIME.com 

Question: “I have a real problem claimant. He not only has been caught getting prescriptions from multiple doctors, but he has been working part time for his brother-in-law, appears to be married to two women, and I have reason to believe that this may be his third or fourth claim in as many States. How do I determine if this is a psychopathic liar?”  

Dr. Adams Replies: To clarify terms first, you are likely referring to what is called anti-social personality disorder. That is the diagnostic category that refers to individuals who since at least the age of fifteen have shown a clear pattern of both disregard and violation of the rights of others:

·         Repeatedly engaging in acts that are grounds from arrest

·         Deceitfulness, conning others, use of false identities for personal profit and pleasure

·         Lack of future planning

·         Impulsive behavior

·         Reckless disregard to the safety of self or others

·         Failure to sustain consistent work behavior

·         Failure to honor financial obligations

·         Lack of remorse for having hurt, deceived or mistreated others  

You will not succeed in redirecting or even punishing such individuals since they feel no guilt or shame.  

Also they surround themselves with a combination of others just like them and those who are vulnerable to them.  

Once you can document that this is what is occurring (i.e. this is their diagnosis), then you must insure that boundaries are well maintained to protect yourself and others from the inevitable and typically relentless manipulations.