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Monday,
December 27, 2004
This is the 317th Weekly Case Management Update
This Week's Topic: “S.A.D.”
Question: “I heard that this seasonal affective disorder
(SAD) where you get depressed because you don’t get enough
daylight may be more prevalent among injured workers. How can
that be?”
Dr. Adams Responds: Many injured workers seek outdoor
employment because they feel they must be in the sun and fresh
air. When offered indoor factory/production work, they become
lethargic and irritable.
Some people suffer from symptoms of depression during the winter
months, with symptoms subsiding during the spring and summer
months. This may be a sign of Seasonal Affective Disorder (SAD).
SAD is a mood disorder associated with depression episodes and
related to seasonal variations of light.
SAD was first noted before 1845, but was not officially named
until the early 1980’s. As sunlight has affected the seasonal
activities of animals (i.e., reproductive cycles and
hibernation), SAD may be an effect of this seasonal light
variation in humans.
As seasons change, there is a shift in our “biological internal
clocks” or circadian rhythm, due partly to these changes in
sunlight patterns. This can cause our biological clocks to be
out of “step” with our daily schedules. The most difficult
months for SAD sufferers are January and February, and younger
persons and women are at higher risk.
Symptoms Include:
• regularly occurring symptoms of depression (excessive eating
and sleeping, weight gain) during the fall or winter months.
• full remission from depression occur in the spring and summer
months.
• symptoms have occurred in the past two years, with no
nonseasonal depression episodes.
• seasonal episodes substantially outnumber nonseasonal
depression episodes.
• a craving for sugary and/or starchy foods.
Possible Cause of this Disorder:
Melatonin, a sleep-related hormone secreted by the pineal gland
in the brain, has been linked to SAD. This hormone, which may
cause symptoms of depression, is produced at increased levels in
the dark. Therefore, when the days are shorter and darker the
production of this hormone increases.
Treatments:
Phototherapy or bright light therapy has been shown to suppress
the brain’s secretion of melatonin. Although, there have been no
research findings to definitely link this therapy with an
antidepressant effect, many people respond to this treatment.
The device most often used today is a bank of white fluorescent
lights on a metal reflector and shield with a plastic screen.
For mild symptoms, spending time outdoors during the day or
arranging homes and workplaces to receive more sunlight may be
helpful. One study found that an hour’s walk in winter sunlight
was as effective as two and a half hours under bright artificial
light.
If phototherapy does not work, an antidepressant drug may prove
effective in reducing or eliminating SAD symptoms, but there may
be unwanted side effects to consider.
Monday,
December 20, 2004
This is the 316th Weekly Case Management Update
This Week's Topic: “Doldrums”
Question: “OK, we are seeing the same holiday doldrums in
these injured workers. You said last year that this was largely
due to financial constraints and guilt over not having enough
for the family. We have made certain that all checks have been
mailed in a timely fashion, but we are still seeing psych
requests prior to Christmas. What causes that?”
Dr. Adams Responds: Check into the surgery schedule.
Those who are contemplated a first or repeat procedure after the
holidays are often agitatedly depressed due to not only fear of
the procedure (and that includes anesthesia) but fear of
negative outcome.
Those who have had past surgeries are concerned that “this one
will not help either.” There is also the fear of anesthesia,
additional pain, winter months confined to bed, a new year with
no more hope than the preceding year, and sometimes a discomfort
with their surgeon.
All of these can be addressed rapidly and effectively since they
often escalate after the holidays.
Equally as important, and it is to some degree true for all of
us, post-holiday blues occurs when we realize we have an entire
year of work ahead of us and the festivities are now past.
On a much more positive note, we can all learn from these
patients that it is critical that we focus on what we can
achieve for families, our patients, and ourselves during the
next year. The greatest weapon against depressed mood is
investment in a productive future.
December
13, 2004
This is the 315th Weekly Case Management Update.
This Week's Topic: “Just Makes It Worse”
Question: “I know that you have written about the high
incidence of psychological trauma in the histories of many
injured workers. I think we get stuck paying for these, and
there is no way to avoid that.”
Dr. Adams Responds: Yes, it is true. A very large
percentage (I would venture an estimate of 2/3 or more) of
injured workers are the victims of past trauma. That includes
all forms of physical and emotional abuse; often beyond our
comprehension. Many of these adults were also abandoned as
children, grew up with abusive relatives or in foster homes.
Many have harbored emotional problems for years and
self-medicated with substance abuse and/or chaotic
relationships; never fully accepting the source of their
problems.
It is also true that should some psychologist get involved in
these past problems, the patient will remain in care
indefinitely (most often with little or no improvement). Then
the psychologist labels them as emotionally disabled from ever
working again and attributes this to the recent injury rather
than realizing that the patient was never functional, and his
keeping the patient in open-ended care has merely made the
injured worker worse.
However, there are quite a few injured workers who are quite
aware of the their own traumatic past. They know, and will
readily state, that many of their problems have long existed and
are not related to a recent injury. They simply want assistance
in dealing with that injury and can be concurrently (or
subsequently) directed to private or community mental health
care for past problems.
I have found that there are some injured workers for whom their
past trauma serves as a conviction that they have “gotten
through it” before, and that they can do so again.
It always comes down to accurate assessment of the patient and
revealing/understanding the role of past trauma in today’s
complaints.
December
6, 2004
This is the 313th Weekly Case Management Update.
This Week's Topic: “Marital Bliss”
Question: “I believe that the injured worker who is
married is much easier to deal with than one who is single or
divorced. Agree?”
Dr. Adams Responds: “I hate to disagree (well actually, I
rather enjoy it), but I find that among workers, marriage is
often more problematic than helpful. This is especially true for
the female patient. Please follow me:
1. For the young, married, female, injured-worker, her marriage
is often based upon a husband who is working skilled or
semi-skilled labor. They live paycheck to paycheck, and she is
working in order to keep things financially afloat.
2. He is often quite young in thinking, has single friends and
still enjoys youthful hobbies which the family cannot readily
afford. His interest in the children and greater
responsibilities is less than ideal.
3. When she is injured, his interests are now secondary at best.
Additionally, she is quite "not in the mood" to meet his other
insistent and often incessant demands for affection.
4. She begins to fear abandonment, made to feel guilty because
she does not physically recover rapidly and is reminded
continually that she does not meet his needs (or those of their
children).
5. For the young female injured worker, this becomes inseparable
(to her) from her pain. It is all one and the same since
"everything was fine before I got hurt."
6. For the older female injured worker, there are often even
greater financial needs. Children are grown and have their own
problems. He has extended their indebtedness by owning several
vehicles. They are refinancing their home. He has a series of
health problems arising from increased risk (obesity, smoking,
drinking, etc), and he expresses his resentment that he now
works two shifts while " you just stay at home and watch TV."
For the injured female worker, the husband is quite often
working against recovery. We are not aware of this until the
patient is directly asked in depth about her marriage and her
husband’s response to her limitations.
Monday, November 29, 2004
This is the 312th Weekly
Case Management Update.
This Week's Topic:
“Amputation”
Question: “What sort of
psychological problems should we expect when an individual loses
part of his/her body in an accident?”
Dr. Adams Responds:
“Many are able to lose toes with no complaints other than
initial pain and readjusting to difficulties in mobility.
As you can well imagine
even if a patient loses his non-dominant hand or arm, there are
many things that require the use of both hands, and there are
many things for which it is embarrassing, if not humiliating)
with which that patient then needs to seek assistance.
A case in point is a
patient who lost his non-dominant hand prior to his work related
injury. He adjusted to that loss quite well. However, when he
sustained a neck injury at work with resultant dominant arm
pain, he became very depressed and extremely anxious. Everyone
assumed it was simply the pain which troubled him. In reality,
it was his now needing to ask his wife to assist him with
toileting. This was a temporary problem, but his fear was that
it would become a chronic need.
Many are least prepared
for the inordinate problems which arise with finger amputation.
For females this can be even more severe because of our
culture’s emphasis upon a woman’s hands/fingernails.
But even for men, the
loss of a finger implies a disfiguring outcome, and the patient
is certain that everyone is staring and disgusted by the site of
the loss. As a result, seeing a patient with a finger
amputation, attempting to hide his/her hand is the first
indication that problems are arising. Additionally, if they are
around small children (who most often will innocently focus upon
anything unusual in their environment, the patient may be
exposed to questions or looks of interest.
However, even adults can
be thoughtless in their need at a cash register (for example)
inquiring of the patient what had happened.
Thus, you should watch
for adjustment problems, most often transient depression, in
patients who sustain even finger amputation.
Monday, November 22, 2004
This is the 312th Weekly Case Management Update.
This Week's Topic: “Let’s Drink to That”
Question: “What is the Effect of Alcohol on Case
Resolution?”
Dr. Adams Responds: “Arguably, one of the highest
predictors of poor outcome is alcohol abuse and dependence.
This is something that the patient shields and can arise as an
attempt to self-medicate for pain, but more often, it is a
continuation and increase of an already deeply entrenched and
untreated problem.
Recently, I saw a patient who was college educated, working
consistently since he got his degree, was single and financially
solvent.
However, I determined that he had also drunk heavily every
night, without exception, for fourteen years.
This has never directly interfered with work, but it is the
factor that has resulted in his having little ambition to do
more than the basic tasks of his job (thus, no promotions) and
his lack of upward mobility (absent motivation) as well as his
being easily fatigued (hung over).
After his work injury, he has, indeed, returned to modified
duty, but his emotional investment in his job, coworkers or
career is very low. His follow through on orthopedic care is
inconsistent. And, expectedly, his request for narcotics is
quite high.
The only thing that will help this man is involvement in A.A.
He has one advantage: he refers to himself as having “a very bad
problem with alcohol…I am really hooked.” However, he has no
true motivation to change, and he has no friends and/or family
to encourage/force him to do so.
Alcohol for many injured workers becomes an obstacle that is
impossible to overcome, and there is little we can do except to
document it and accept the limitations it imposes upon recovery.
Monday, November 15, 2004
This is the 311th Weekly Case Management Update
This Week's Topic: “How to Be Incompetent”
Question: “I want to re-address the issue of these people
who have complaints even though the doctor we use says that they
are fine. Are these complaints ever valid? They do not appear to
be valid to me.”
Dr. Adams Responds: “One of the consistently alarming
trends that I see is that following an injury, the worker is
permitted care along the lines of an (often arbitrary)
assumption as to how the injury occurred and what physical
damage took place.
There is very rarely a thorough history taken of the complete
nature of the injury.
Let me give you an example: A patient this week was struck by a
falling object and suffered severe orthopedic injuries. Thus, he
was seen by an orthopedist.
From the orthopedic standpoint, the patient had now recovered.
He has returned to work half-time and was seeking a release to
return to work full time.
However, he had irregular heart beat and rapid fluctuations in
blood pressure that a consulting cardiologist said “well it
could have existed before injury.”
He also had periods of dizziness, loss of consciousness several
times a day, and visual disturbances which the company’s
neurologist said “oh that’s probably nothing.”
So there he was, at work, using potentially hazardous tools,
alone in a shop, dizzy, falling, losing consciousness 3-5 times
per day while working half-days, about to be released to full
time work (60 hours per week in two separate job sites).
During psychological exam, he was asked if he had struck his
head when the machine struck him. He indicated that he had
turned his head to avoid it being struck. He noted that that
when he arrived in the hospital, his neck was very sore from the
suddenness of being thrown forward, and his right ear canal was
deeply impacted with mud from the impact of his right cheek
striking the ground.
In short, there were multiple, unaddressed, potentially serious,
physical problems which could be life-threatening in his
work-setting (or certainly the potential for further injury)
that were simply being set aside because his initial shoulder
complaints were resolving.
Instead, he was being told he was simply depressed. While he may
be mildly depressed, he is more clearly terrified of attempting
to live his life in a world where he loses consciousness and
falls for no apparent (to him) reason.
A more thorough history could/can protect this man and others
from additional injury.
Monday, November 8,
2004
This is the 310th Weekly Case Management Update
This Week's Topic: “Foreign Bodies”
Question: “Is there a difference in response to injury
among recent immigrant employees?”
Dr. Adams Responds: “There are unquestionably cultural
patterns that we see emerge.
Asians, for example, are often quite stoic, suffer inwardly and
do not readily acknowledge the impact that an injury has upon
them. They are less likely to ask for psychological support
and/or medication despite having anxiety and depressive
symptoms.
Spanish workers, especially those with little English, tend to
respond with a sense of defeat. They do not fight against their
limitations, often become depressed and withdrawn and dependent
upon some perceived authority to make decisions for them. They
often do not participate in that decision making.
Workers coming here from the strife encountered in the break up
of the U.S.S.R. are often angry and distrustful. Many feel as
though they have had enough misery in one lifetime and readily
express frustration, anger and distrust.
While all may have similar types of psychological symptoms, they
are not equally motivated to address them directly and must be
assisted by first accepting their value system and cultural
expectations.
Monday, November 1,
2004
This is the 308th Weekly
Case Management Update
This Week's Topic:
“Staying Unprepared?”
Question: “At
what point does a patient become prepared…or a doctor prepare a
patient…for chronic problems. I mean some degree of pain
remains with many injuries so at what point is chronic pain
discussed with the patient?”
Dr. Adams Responds:
“There are two problems here and two types of pain:
a.
There is the sensory/physical pain
from a trauma which in many cases never fully resolves. Few if
any talk to the patient about the possibility. It is often said
that this takes away hope. In reality, what takes away hope is
the patient being led to believe that this next surgery or next
series of injections or next medication will resolve all
remaining pain. When this does not occur, the patient is often
devastated and feels he/she has nowhere to turn.
b.
The psychological/emotional pain
that arises from severe scarring, paralysis or loss of limb is
typically not addressed until the patient appears so depressed
that “something must be done.” The patients in this case will
state “I have felt this way for over a year, and no one wanted
to do anything about it.”
In both cases, the
patient must be prepared (by others) for some degree of
permanency (chronicity) of their injury. It simply will never
completely resolve.
A patient once told me
that he would commit suicide (due to back pain) as soon as his
settlement was received (for his family) since no one could live
with this pain.
That was 12 years ago. He
coped quite well after administrative closure and
understanding/accepting that life with pain is more than
possible.
Monday, October 25,
2004
This is the 308th Weekly
Case Management Update
This Week's Topic:
“Wearing A Mask; Having No Gun?”
Question: “I am a
nurse case manager, and I was discussing this with an
adjustor...neither of us is depressed. But we do have some
problems in common.
She does not have much of
an appetite but has always been heavy. She is now losing weight,
and I, who have always been thin, am gaining weight. Unlike
her, I am hungry all the time.
We are both forgetful and
do not sleep well, and we are personal friends and go out
shopping together. That is a sight to see; neither of us can
make a decision what to buy. And I do not believe that either
of truly enjoy shopping although we used to love to do so.
I am not tense, but my
husband would say that I am irritable. He tells me that it is
“raging hormones and menopause.” I am 38 years old, not
likely.
I have seen these same
problems in our injured workers, but I always assumed that this
was due to their pain and money problems.
Opinion or input?
Dr. Adams Responds: It
is likely, if not highly probable, that your line of
investigation and concern should include “clinical depression”
which is often masked by physical symptoms such as low energy,
absent mindedness, weight and sleep changes, decreased libido
and nagging irritability, pessimism and doubt.
It is easy to test for
depression and aside from going “to talk with someone,” your
primary care physician can start you on one of a number of low
side effect agents which can remarkably impact those nagging
symptoms.
If you come to recognize
this depression in yourself, be vigilant of its occurrence in
friends, family and…patients.
Monday, October 18,
2004
This is the 307th Weekly
Case Management Update
This Week's Topic:
“How Much is Too Much?”
Question: “I am a
rather new nurse case manager. I accompany injured workers to
their doctors’ appointments. I was in the office of (pain
clinic) and while we were sitting there, I listened around the
room. Most of these people had been coming to this practice for
years. Their discussions were about how much they would get when
they settle, and those that weren’t discussing money, seemed so
gorked out that they did not know what was going on. This was
the first visit of the woman I was accompanying, and it all made
me very uncomfortable. What do I do?”
Dr. Adams replies:
“My experiences are very similar to your own: a patient is
either not a surgical candidate or surgical options have been
exhausted. The patient is still in pain. The pain is moderated
by a small drug regimen that leaves them functional enough to
enjoy parts of their day and be a viable member of their family.
They are not, and cannot, return to work.
Rather than release MMI
with a PPD rating, they are referred to an office where they are
then prescribed numerous and ever increasing/changing
medications that make them decreasingly functional. The sleep
much of the day away, cannot concentrate, remember, decide or
readily verbally relate.
They go through a series
of injections which provide minimal or no relief, and after
months or years, there is no end in sight.
How did this occur? My
belief is three fold:
a. The surgeon did not
take the responsibility to made the MMI and PPD determination
and instead punted the case to someone else
b. The pain management
center had no gatekeeper who determined the patient’s goals,
pain tolerance and (if any) concurrent mental and physical
problems
c. There is no specific
treatment plan individualized for this patient, and, thus, there
is no endpoint to care.
A patient last week said
that she felt sitting in the office waiting for injections,
listening to the other patients (some of whose complaints she
doubted) “was a good way to learn how to look like you are in
pain and score some good drugs.” That is, of course, the other
concern.
The important things to
do are:
1. Work closely with the
surgeon and be certain he understands the patient’s needs (not
just the cause of pain) and whether a pain center is truly what
is indicated.
2. For any pain center,
be certain that there is a gatekeeper, preferably external, who
screens these patients for their appropriateness for treatment
3. Work with pain centers
that have specifically stated protocols and timeframes so that
the patient…and you…know how treatment will progress and when it
will end.
Monday, October 11, 2004
This is the 306th Weekly Case Management Update
This Week's Topic: “Makes No Sense to Me”
Question: “We insure several employers who are robbery
prone. We insure several others where there is a lot of
potentially high risk production work. We have injured workers
who a couple weeks or a couple months after injury have gotten
themselves convinced that they have this posttraumatic stuff,
and we have a horrible time getting them back to work.”
Dr. Adams replies: “In reality, anxiety disorders
(including PTSD) are rather common after robbery, assault, and
severe (burn, amputation, etc) injury.
Several things complicate dealing with the employee, and in
order, they are:
• Symptoms may not emerge for several weeks (and sometimes for
several months)
• Their emotional complaints are ignored by those treating the
injury
• The employer and coworkers minimizes and sometimes mock such
complaints
• The patient and his/her family lack understanding as to why
these symptoms occur.
• Diagnosis and treatment are almost always postponed to save
costs.
Most often, these patients should not return to the store,
department, area, building or site of the trauma.
There is a process called redintegration in which a small cue
(sound, smell, sight of location or equipment) can and will
trigger overwhelming anxiety.
It is far easier to have this patient work at a different Burger
King, a different company location or even a different job.
At the same time, they need to be desensitized so that it is the
*event* and not the setting that threatens them.
October 4, 2004
This is the 305th Weekly Case Management Update
This Week's Topic: “Carrying the Whole Burden”
Question: “If an injured worker has pre-existing mental
problems…are they always made worse by injury…and how much of
this are we responsible for…I do not know how to read this
“exacerbation” stuff.”
Dr. Adams replies: “I had a patient last week who did not
work until she was 38 years old. She then had ~20 jobs in the
next four years; all were brief and there was no career pattern.
She also had a long drug history, is currently drinking heavily,
was in two abusive marriages, had two hospitalizations (1+
years) for suicide attempt…and it gets worse from there.
She now has PTSD from a work-related injury.
Did the injury make her worse? Likely it did. But here is the
most important part:
• Treating her emotional problems under workers’ compensation
would be doing her a disservice
• She has bipolar disorder which coexists with, and contributes
to, her PTSD. The bipolar disorder would be ignored if she were
treated solely for injury related PTSD.
• She has a clear history suggesting of addictive disorder
driven by borderline personality disorder. Neither of these
would be addressed under workers’ compensation.
• Injury related psychological care would be inadequate to deal
with her more pressing and potentially self-destructive
pre-existing disorders.
In conclusion, treating an injury related psychological problem
in patients with pre-existing severe emotional and addictive
disorder is not only ineffective, it is unfair to the patient.
When there are data indicating past diagnosed (or even
undiagnosed) and significant psychological problems, you must
insure that such problems be addressed first and often
separately from injury related problems. In doing so, you often
find that the injury related “exacerbation” then is no longer
present.
Contact the
Practice |
Atlanta Medical
Psychology The clinical
practice of Dr. David B. Adams is located in The Medical Quarters in
the northside of Atlanta at the junction of Scottish Rite, Northside
and Saint Joseph's Hospitals. Dr. Adams consults to occupational
medicine, surgeons, nurse case managers, insurers and employers
regarding the psychological impact of work-related injury and the
role of psychological factors in short- and long-term
disability.