Monday, September 29, 2003 

(CASE MANAGEMENT UPDATE #254)

This Week's Topic: “After the Initial Exam” from PsychIME.com 

Question:  “You said in a seminar that few injured workers truly want psychological care due to social embarrassment and cultural bias, but what about those that do want care…how much care do they need?” 

Dr. Adams Replies:  There are three factors to consider:

a.    Has anyone separated injury related problems from problems in personality development?

b.    Are the problems chiefly or solely financial and marital?

c.    Has the patient been informed as to the limited scope of care related to injury? 

Frequently, what I see is that the initial exam itself resolves the bulk of the patient’s problems. Often, they want nothing more than to verbalize their anger, resentment and fear.  While they believe that they want care, after venting their frustrations in the initial exam, those emotions dissipate.  They do not pursue care for more than one to two visits. As indicated, this is a very frequent outcome. 

For those who do wish to pursue care, as long as visits are held to once every 2+ weeks (or even monthly), few visits are required (or desired by the patient). The problems emerge when someone begins seeing these patients 1-2 times per week (!) and delving into longstanding problems in their family, their addictions, and their interpersonal problems.

Monday, September 22, 2003 

(CASE MANAGEMENT UPDATE #252)

This Week's Topic: “Pre-existing Problems” from PsychIME.com

Question:  “These injured workers complain of a host of problems, some of which I do not believe come from their injury. How do you determine pre-existing problems?” 

Dr. Adams Replies:  I will always be rather amazed that prior to my seeing a patient, no one, even if they are already in psychological care, has obtained a complete history of these injured workers. 

It appears that everyone proceeds from what the patient says is wrong with them, rather than attempting to determine if there may not be multiple other causes or contributors to their complaints.  

As you know, a negative MRI or CT scan (etc) will not stop a patient from complaining. So we need to know what the source of these complaints. 

I recently saw an injured worker who had been in psychological care for two years at the request of her orthopedist. During my IME of her, she objected to my obtaining a past developmental and health history. Her foundation: “no one else ever had.” 

Yet, she has prior unreported MVA’s and lawsuits, prior problems with addiction, disabled parents and sister, and had been abused as a child, been a repeated and recent victim of domestic violence, and was receiving as much on disability as she had when she was working. And…she had only been in the workforce for three years, had five jobs during that time, was about to remarry and did not want to ever return to work. 

She did not need psychological care for her injury, and the care she was receiving was for her numerous past problems.   

Until a truly thorough history is obtained, care cannot be targeted solely to the injury.

Monday, September 15, 2003 

(CASE MANAGEMENT UPDATE #252)

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

Question:  “Well, it is clear that some injured workers will return to work in great pain while others with lesser pain elect never to return to work. Is there a way to predict who will do what?” 

Dr. Adams Replies:  Yes, there is. Achievement motivation can arise from several sources, but the two most common are:

* Fear of financial destitution and its effect upon patient and family And/or
* Perceptions of having a focused career 

Those who believe that their job entails their “life’s work,” that it defines who they are, that there identity and that of their coworkers is contingent upon quality work completion are more likely to return to work…in pain and with limitations.  So, it is imperative that it be determined if this patient’s job established for him/her a particular role in their society.  

Equally as important, if the patient perceives that some/any form of employment is mandatory in order to maintain the financial functioning, if not survival, of family and self, he/she has a higher probability of returning to productivity. This, it is equally imperative to determine if this patient is experiencing financial concern or whether the combination of compensation and spouse returning to work does not meet or exceed what the patient was earning when working.  

In summary, the patient who feels minimal financial pressure and who was largely indifferent to what type of job he/she was performing is the least likely to return to work. We need those data as soon as they can be obtained.

Monday, September 8, 2003 

(CASE MANAGEMENT UPDATE #251) 

This Week's Topic: “Injury and Intimacy” from PsychIME.com 

Question:  “A problem we have is the injured workers’ marriage and how it interferes with recovery.  What are the chief causes of these problems?” 

Dr. Adams Replies:  The most obvious, of course, is financial. They may have significant debt going into injury and begin to spiral downward after injury. 

However, an equally complex area is that of physical intimacy.  After injury, the patient is often disinterested in physical contact. This may occur because of pain, but it also can occur as a result of side effects of medication.  Decreased libido is also a symptom of depression as we have discussed.  

The most interesting and important aspect is that whether the injured worker is male or female, they are convinced that their partner will not remain with them if they continue to have a low drive level: 

The female patients believe that their husbands will not tolerate it.

The male patients believe that their masculinity is now impugned.  

In the marriage of an injured worker, regardless of which partner has been injured, this becomes a source of fear, anxiety and combined with financial concerns, marital discord (which may have already been present) escalates.  

Importantly, the patients rarely tell their primary treating physician of this concern. Perhaps this is because of brief office visits, but more likely, it is because the patient perceives that pain is the sole reason for the visit. 

The concerns for physical intimacy complicates, and at times, full obstructs the recovery process, leads to further retreat to pain medications to “feel better” and increases depressive symptoms.

Monday, September 1, 2003 

(CASE MANAGEMENT UPDATE #250) 

This Week's Topic: “Anxiety & Paranoia” from PsychIME.com 

Question: “…we sent this claimant [back and shoulder injury] to a very good orthopedist and a very good neurologist…but he does not trust either of them. I cannot see this is warranted and wonder if this guy is paranoid…”   

Dr. Adams Replies:  Paranoid? Unlikely.  Distrustful, suspicious, frightened and uninformed…highly probable.  

Likely, he spends his days with pain and anxiety as his only companion. Without the emotional and intellectual resources to resolve his physical, financial, marital and future occupational fears, he processes each office visit as a disappointment. 

He tells a friend or relative that he is in pain. The response he receives is similar to `what kind of doctor is this?  Who sent you there?  He doesn’t care about you.  He just wants you to go back to work. Etc” 

The patient’s memory becomes selective. He believes he has been told he has a surgical condition (where none exists) or that there are specific diagnostic findings (when all have been negative).  

Months pass, and he is unimproved. He is de-conditioned, napping during the day, overeating, socially isolated and intellectually deprived.  His anxiety becomes complicated by depressive thoughts and increasing doubt that anyone has his best interests in mind.  

If he does not discuss these perceptions, beliefs and fears, they become expressed by an increase in physical symptoms, increased reliance upon narcotics and decreased compliance with physical therapy and motivation to mobilize.

Monday, August 27, 2003 

(CASE MANAGEMENT UPDATE #249) 

This Week's Topic: “Primary vs. Secondary Gain” from PsychIME.com

Question: “What is the difference between primary and secondary gain as it applies to personal injury?”   

Dr. Adams Replies:  Most involved in case management and patient care are familiar with secondary gain.  It occurs when a patient’s symptoms are maintained because of the impact of attention, affection, remuneration, access to medication and other incentives. Sometimes the patient is aware of these sources of secondary gain, but often they lack insight that it is occurring and need to be shown the ways in which they are gaining from their injury. 

Primary gain is quite different. It occurs when the injury solves an internal conflict for the individual. For example, the patient may have a fear or aversion to something at work (or at home) and their symptoms prevent them from having to be exposed to it. These may range avoiding intimate contact with their spouse to avoiding work tasks over which they are phobic (heights, closed spaces, etc). 

Quite often there are elements of both primary and secondary gain occurring at the same time. In a recent case, a patient with a minor injury was able to use his injury to: a. manipulate his girlfriend into marrying him (secondary gain), b. avoid a physical relationship with her (primary gain), c. gain access to narcotics (secondary gain) and d. avoid competing in the workforce (primary gain).

Monday, August 18, 2003 

(CASE MANAGEMENT UPDATE #248) 

This Week's Topic: “Finding the Truth” from PsychIME.com 

Question: “My problem is what I call a “hunch.”  I suspect that a claimant is not being honest, often about their history, sometimes about their injury, many times about their care, and frequently about their limitations. I feel one way; someone else seeing the patient feels another way. How do you get to the bottom line reality?”   

Dr. Adams Replies:  No choice: a third party. You must provide to a neutral party all of the medical records including pharmacy records. That examiner must have access to the primary physician’s notes and often to the primary physician him/herself. 

Patients often erroneously believe that there is no communication between offices. If they distort information in one way in one office, they think they can then change those data in the next office. 

An ideal exam entails not only a complete history of development, work, injury and care, but it also feeds back to the patient the discrepancies noted and asks for an explanation.  

Patients may become angered and defensive, but they are also aware that that the altering of information between offices is ineffective.

Monday, August 11, 2003 

(CASE MANAGEMENT UPDATE #247) 

This Week's Topic: “Immigrants and Workers’ Compensation” from PsychIME.com 

Question: “When we, as nurse case managers, are assigned an injured worker who is a refugee from South America, Mexico or Africa, we almost always feel that there are factors influencing recovery that we do not understand. This is also true for those immigrating from Bosnia and similar settings. I do not believe that this is a language barrier or difference. Do you know what is going on in these situations?”   

Dr. Adams Replies:  Yes, they are carrying trauma from their past lives. For example, about half of Latino immigrants to Los Angeles have post-traumatic stress disorder (PTSD), depression and chronic pain upon arrival. This high prevalence of symptoms is caused by political violence and torture prior to their arrival in the US. They enter the workforce in the U.S. with these pre-existing problems.  

There is a similarly high prevalence of psychological disorder among Guatemalan refugees living in camps in Mexico. In contrast, Israeli citizens exposed to terrorism appear to exhibit relatively low rates of mental illness.

The difference between populations is due in large part to the breakdown of social support systems among refugees, who often flee to "an environment that is hostile to them. 

The association between political violence and chronic pain, functional impairment and decreased health-related quality of life is substantial. Only 3% of those exposed to political violence had discussed their experiences with a healthcare provider after their arrival in the US. 

JAMA 2003;290:612-620,627-642.

Monday, August 4, 2003 

(CASE MANAGEMENT UPDATE #246) 

This Week's Topic: “What is Pain Management” from PsychIME.com 

Question: “Many of these injured individuals will have chronic and perhaps severe permanent pain. They seem to float from one pain management program to the next…is that wise?”   

Dr. Adams Replies: There is a difference between pain “treatment” and pain “management.” 

A pain treatment programs with its various procedures and medications seeks to lower the pain that the patient experiences. By contrast, true pain management would teach the patient how to cope with chronic pain and life a functional life, not merely seek seemingly endless care.  

Ideally pain treatment programs would have a specified end-point.  When a patient is told that they are being sent to a “pain center,” they either believe that their pain will be completely resolved and/or they will meet in groups with similar patients to share their common concerns. 

What we most often see, however, is that the patient is treated with a variety of procedures:

a. Without being prepared for the permanence of their condition

b. Without being taught what they can do to minimize their own experience of pain.

The latter is especially critical. If they are in a pain program, passively responding to seemingly endless treatment, they are not assuming responsibility for their own existence when that treatment ends.  

Most of these patients are deconditioned, laying about watching television, developing even worse health habits.  What needs to be done is to teach these patients what they can do with their time, their family relationships, their own (often distortion) thinking and the productive activities that enables them a functional existence.

Monday, July 28, 2003 

(CASE MANAGEMENT UPDATE #245) 

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

Question: “As a nurse case manager, I see a fair number of injured workers who believe, and tell others, that they have, for example, a herniated disc, even when the diagnostic findings are negative. I do not think these people are malingering but cannot figure out why they do this.”   

Dr. Adams Replies: You are going to have a fair number of claimants who will (for reasons outlined below) cling to a belief even in the absence of findings to support that belief. The concept of the hypochondriac is quite real.  

They may not have the pain complaints to support the diagnosis to which they cling. Nonetheless, they tell family, friends and each new doctor, that this is their diagnosis. They may also offer that they have been encouraged to have a procedure (EG. spinal fusion) and have not as yet acted upon that recommendation.  

In these cases, the patient is not deliberately trying to lead mislead you. They are dealing with their own morbid fears of their future, their financial insecurity, the growing unwillingness of the family to be supportive and their perception of a future without options. 

You will find that merely providing them with more and more data that counters their belief has no positive effect. They have begun a lifestyle that they believe is warranted by the “diagnosis” to which they cling. 

They may be successful in finding a surgeon to perform a procedure (or procedures) based upon their continued subjective complaints. It is this latter possibility that is truly alarming, and this is where they run their greatest risk. 

There are three things that can be done for them:

a.    Once the objective findings are established, be certain that treatment is tied to those findings, not to the patient’s disortions

b.    Be certain that the patient has been evaluated and hypochondriasis, not depression, is the true source of these unsubstantiated complaints

c.    Have the patient consistently engage in productive activities within their functional capacity, rather than allow daily activities to be determined by distorted beliefs. These may include:

1.    Volunteer activities

2.    Regular gym/spa involvement (Eg. WMCA)

3.    Ideally assistance from family to insure that they remain active.

Monday, July 21, 2003 

This Week's Topic: “Should We Be Prepared” from PsychIME.com 

Question: “Should we expect depression in all patients with chronic pain?”   

Dr. Adams Replies: No, but you should test for it. Approximately one-quarter of all chronic pain patients develop a (mood) depressive disorder With early and effective intervention, the vast majority of them improve rapidly. 

However, many injured workers had legal, financial, marital, occupational, interpersonal, addictive, and a variety of family problems prior to injury. Indeed, many of them have been depressed recurrently and/or for extended periods prior to injury. 

In some cases, the injury exacerbates the pre-existing depression. However, in the majority of cases, the patient (and family) focus upon the injury while knowing full well that the depressive symptoms have been a longstanding problem. 

In other case, the family knows that the patient has long been irritable, difficult to please, restless, and having problems with sleep and appetite. They did not know that these were symptoms of depression. 

It is important to determine how the patient was coping in the months (and years) prior to injury and whether any depressive symptoms seen now are part of unrelated (to injury) problems.

Monday, July 14, 2003 

(CASE MANAGEMENT UPDATE #243) 

This Week's Topic: “But There is Absolutely Nothing Wrong” from PsychIME.com 

Question: “This is a frequent occurrence for us. We see to it that the injured worker receives immediate and exceptional care. We pay for repeat MRIs. We fund physical therapies over…and over…and over. Their complaints continue in the absence of any hard findings. I can only conclude that they are malingering, but they seem like they are being genuine. What is the problem?”  

Dr. Adams Replies: This is called “somatization” (so-mutt-is-a-shun). This is seen when a patients complaints do not correspond with the objective findings, and the complaints continue even when the patient is reassured that there are no positive findings. 

This emerges from the patient over-interpreting essentially normal bodily responses or excessively dwelling and monitoring mild-to-moderate discomfort.  

A patient told me that he needed a lumbar fusion (no positive findings) although he is able to stand, lift, bend, stoop, and ambulate without observed difficulty. He *believes* that he has a surgical lesion despite reassurance that no further care is indicated. 

This focusing upon one’s body arises out of anxiety and depression associated with the *fear* that “something is wrong and they can’t find it.” 

Since the patient is at home, often watching television, gaining weight, insufficiently tired to promote effective sleep, then up at night bored and worried…the focusing upon remote, obscure and modest bodily complaints becomes an obsession.  

This problem needs to be directly confronted. It will not resolve with yet another opinion or diagnostic study. Rather than being appreciated, you will be accused of “not understanding.”  

Have the surgeon collaborate with a psychologist in your area so that a clear picture of somatization can be determined. Then efforts must be extended to engage the patient in behaviors (YMCA, volunteer work, etc) that reduce his/her incessant focusing upon bodily functions.

Monday, July 7, 2003 

(CASE MANAGEMENT UPDATE #241) 

This Week's Topic: “Why now?” from PsychIME.com 

Question: “This is one that I know you have seen…the back injury that has been under treatment for several years, surgery was never indicated. All of a sudden, the claimant sees a new doctor and is all hot-to-trot to have surgery.  What is this all about, and what do we do?”  

Dr. Adams Replies: This is actually quite common.  

The condition has not changed, but the recommended treatment has suddenly gone from conservative to invasive.

And it is the fact that the condition has not changed which is the driving force behind the sudden introduction of surgery into the picture.  

The reason?  Dependent, uninformed, and desperate patients who know very little about their condition despite the years of pain, and they know even less about the recommended procedure. 

When intellectually tested, you learn that they may not have the capacity to fully understand the surgery they are now seeking.  

This is compounded by the belief, held by too many, that patients cannot learn to tolerate/manage/cope with pain further. It is complicated by the belief that “something must be done as long as the patient has complaints.” 

Additionally, someone…somewhere…has told them that surgery will eliminate all of their complaints and that a lumbar fusion is quite common, not terribly complex and certainly “has few risks” of its own…and that the probability of negative outcome is low. 

Solution: Have the patient assessed for intelligence, dependency and fear. Then have the patient talk with someone about their condition, to discuss what they believe they will accomplish with surgery and their other options for dealing with pain that is most likely chronic.  

I recall a patient who said that when his case settled he would try to live with the pain for a few months and then was certain he could not go on.  That was 11 years ago. He called to say that he was working part time.