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CASE MANAGEMENT UPDATE |
Dr. Adams’ Case Management Update
This is the 441st
Weekly Issue
This Week's Topic: "Major Depressive Disorder
and Generalized Anxiety Disorder"
Question:
"If a worker is injured and is very anxious, could this
anxiety lead to becoming depressed?'"
Dr.
Adams replies:
"Research indicates that people with
generalized anxiety disorder can, indeed, develop a
major depressive disorder.
Allow me to outline generalized anxiety disorder:
-
Excessive anxiety and
worry about a number of events.
-
Difficulty controlling
this anxiety
-
Restlessness, easily
fatigued, difficulty concentrating, irritability, muscle
tension and sleep disturbance
Symptoms of major depressive
disorder include:
-
depressed mood
-
markedly decreased
interest in almost all activities
-
significant weight gain or
loss, sleeping too much or too littler
-
notable agitation or
slowing
-
loss of energy
-
feelings of worthlessness
-
decreased ability to
concentrate or make decisions
-
preoccupying thoughts
about death
The co-existence of both
disorders (referred to as "comorbid") can be a significant
impairment in even daily functioning.
These symptoms are not
difficult to detect, and the disorders are not difficult to
diagnose. If they are not addressed, the course and rate of
recovery from a physical illness will be significantly
prolonged."
Monday,
June 18,
2007
Dr. Adams’ Case Management Update
This is the 440th
Weekly Issue
This Week's Topic: "The Candidate"
Question:
"If a patient is diagnosed with PTSD, should he or she
immediately be referred for psychological care?'"
Dr.
Adams replies:
"PTSD [posttraumatic stress disorder] can be an
impressively disabling disorder with the injured
worker awakened by frequent nightmares, plagued by
intrusive thoughts of the accident, easily startled
and attempts at avoidance of anything that reminds
him/her of the injury. This can generalize in
severe cases in which the individual may have lost a
finger in an accident involving a specifically
defective piece of equipment. Over time the
patient cannot tolerate the sounds of similar or
even remotely similar equipment. The patient may
begin to avoid using knives, scissors or even using
eating utensils.
However, not every trauma, even a severe trauma,
results in PTSD. For a variety of reasons, some
individuals are more prone to develop PTSD.
Two individuals may encounter the same trauma; one
develops the disorder and one does not.
Additionally, the disorder may develop many months
after the traumatic event (called delayed onset PTSD).
There are a variety of medications that will help
the patient deal with not only the anxiety
associated with the event but deal with anxiety over
their own symptoms. That is, quite often patients
develop "anticipatory anxiety" in which they become
anxious as night falls, and they fear the occurrence
of their nightmares.
In true cases of PTSD, the patient may be
embarrassed by their own symptoms, fearing that
others will ridicule their avoidant or anxious
behavior.
With regard to treatment, there are desensitization
procedures that will reduce the individuals
anticipatory and reactive anxiety. But not all
patients are responsive to psychological care. They
may only partially invest in the treatment process,
not fully comply with what they are instructed to
do, and when they are being financially compensated
for their symptoms, they are not always faithfully
honest about the severity of the symptoms.
Much depends upon the patient's intentions with
regard to their job: Do they plan to, wish to, or
work toward returning to the job? Or has the
injury become their exist strategy to a job they did
not like, help briefly or for which they had grown
weary? Again, it is important to
determine the patient's motivation before assessing
whether care will benefit them."
Monday,
June 11,
2007
Dr. Adams’ Case Management Update
This is the 439th
Weekly Issue
This Week's Topic: "Poor Foundations"
Question:
"Could you briefly explain personality disorders versus
character disorders and why it is important that we know about
them?'"
Dr.
Adams replies:
"Personality disorder is the current
terminology for what we once called character
pathology. A personality is the sum total of
how we think, feel and behave, and it is the
foundation from which we operate both socially and
occupationally.
A personality disorder, however, is a developmental
defect. It disrupts how a patient deals with
relationships, life's demands and how the patient
perceives and reacts to stressors.
There are groups (called clusters) of personality
disorders that represent the severity of this
developmental defect. On the one extreme you
may have a dependent personality disorder in which
the individual is unable to deal independently with
life and defers even minor decisions to others,
continually seeking approval. On the other
extreme are disorders such as paranoid personality
disorder in which the individual lives a life of
continual distrust of the motives of others.
Suspicious and guarded, these latter individuals are
watchful for even the slightest signs of betrayal.
About 10 percent of the population may have symptoms
and signs of a personality disorder. It is
generally believed that personality disorders are
much more prevalent among injured workers, and,
indeed, that the personality disorder may lead the
person to a line of work in which injury is more
probable. In either case, we are often dealing
with a developmentally compulsive or negativistic or
avoidant or even a chaotic individual. The
injury did not cause this, but the personality
disorder will definitely complicate the treatment of
the patient.
Thus, it is imperative that we determine when a
patient is responding inappropriately due to the
co-existence ("co-morbid") personality disorder.
We cannot change that disorder, but we can then base
even orthopedic treatment upon the limitations
imposed by the disorder."
Monday,
June 4,
2007
Dr. Adams’ Case Management Update
This is the 438th
Weekly Issue
This Week's Topic: "Different Priorities"
Question:
"Orthopedic surgeons make psychological referrals when they
suspect that their patient is depressed, right?'"
Dr.
Adams replies:
"That is often true. Almost two-thirds of
surgeon-instigated psychological referrals are for
(correctly) suspected depression.
However, not infrequently, the surgeon has before
him a patient for whom surgery went well, yet the
patient is not mobilizing.
The patient returns to the surgeon repeatedly with
unusual, unlikely, vague or even suspicious
complaints. The patient may request more,
different or specific medication. The patient may
seek repeated reassurance that the surgical outcome
was a success.
The patient may not respond to reassurance or
attempts to put closure on care. He/she may
not fully participate in physical or occupational
therapies and may request second or third opinions.
Often the surgeon does not know whether the patient
has job skill sets that would permit alternate duty
work.
In fact, such concerns are not surgical and do not
fall within the surgeon's area of practice.
Are these patients simply depressed? Many are,
but some are not. Some have increasing
problems emerging with their employer, former
coworkers or family. Giving up their physical
complaints may represent relinquishing control.
The injury has become a tool with which they attempt
to solve other problems of living.
The surgeon's practice will not permit him to sit
and ask probing questions that appear wholly
unrelated to the orthopedic injury or surgical
outcome. Indeed, the patient may be quite reluctant
to talk about matters that are non-surgical even
though these are the very factors that are impeding
recovery and closure.
The surgeon is left with no viable option other than
to leave the psychological probing to others and to
focus upon the course of orthopedic care and
recovery."
Tuesday,
May 29,
2007
Dr. Adams’ Case Management Update
This is the 437th
Weekly Issue
This Week's Topic: "Evil Exacerbation"
Question:
"Is it not true that even if a condition is pre-existing,
the injury can always cause an exacerbation of the problem.
Injury is a stressor. So if someone has always been depressed,
the injury, by definition, is then a contributing cause to the
depression at this time, correct?'"
Dr.
Adams replies:
That is actually not correct.
There are many forms of depression as explained
previously. Some are related to the current
situation and are called adjustment disorders.
However, there are some depressions that are the
result of genetic and familial patterns. These
very often occur in families that have histories of
other mental disorders ranging from depressed
relatives, to schizophrenic and addicted family
members.
These chronic and recurring depressions are going to
occur independent of external events. However, the
patient will try to attribute everything to an
injury either as a form of malingering or due to
poor understanding of their own psychological
condition.
A careful history will reveal whether there has been
a long (often never formally diagnosed) history of
depression. That depression will have
presented itself over and over and led to very
maladaptive life patterns and often past suicidal
attempts. The individual may have been medicated
with little if any change. They may have seen
numerous doctors for vague complaints that
suggested, but may not have been diagnosed as,
depression.
Injury becomes a way for the patient to explain the
most recent dysregulation in mood. It is a
grave disservice to the patient to attribute a
chronic problem to a recent event since it may block
the patient from seeking care for what may be a
lifelong problem.
Just because someone has not been in psychological
care does not mean that they have not long suffered
from depression. And just because someone is said to
have successfully completed psychological care does
not mean that they may continue to suffer from
depression but present the depression as physical
complaints.
Dr. Adams’ Case Management Update
This is the 435th
Weekly Issue
This Week's Topic: "Much Better than Nothing"
Question:
"Has anyone ever written about the philosophy of injury? I
mean `what does injury mean in the course of one's life?'"
Dr.
Adams replies:
"I have written about this extensively and
perhaps others have as well, but it is clear that we
are just one of the creatures in the animal kingdom
that defines ourselves by what we create.
Life is fairly meaningless unless we have a purpose,
goal, direction, motivation and determination to
accomplish.
When someone is injured, their immediate purpose
becomes that of recovery, and it is often many
months before some realize that "recovery does not
mean returning to how things once were."
Indeed, many injuries result in permanent changes
with which one will live forever.
Some would have you believe that this means that the
individual's goal then becomes that of being
financially remunerated for limitations. Our
society, and, indeed, the world, does not operate in
this fashion.
Injury is a barrier, but it is not a terminal
endpoint. A person poorly serves him/herself
by assuming a role of total disability and ending
all attempts at productivity.
Living a disability role is not only a burden upon
your family but upon those (children, grandchildren,
etc) who look to you as a role model. If you
care, it is also a burden upon society.
Thus, your philosophy of American life and of your
role in family and society determines what you
ultimately do with an injury.
I have had many severely injured patients who
attempted to assume the stance that, because they
had appreciable limitations and no training for
alternate work, they would never work again.
However, following up on these patients after
administrative closure has almost always
demonstrated that they found some form of
remunerated productivity to fill their days.
The problem has been is that the patient is placed
in a role governed by two opposing forces, one which
attempts to minimize their limitations and the other
attempts to exaggerate it. What almost every
patient needs is someone who helps them recognize
that there are productive things that they can do
with their remaining years...even with pain."
Monday,
May 7,
2007
Dr. Adams’ Case Management Update
This is the 434th
Weekly Issue
This Week's Topic: "How Can You Tell?"
Question:
"Is there a simple formula to identify those injured
workers that will, and those who will not ever, return to work?"
Dr.
Adams replies:
"Actually there is a way (an algorithm if you
will) that can help you determine who will (and will
not) return to work. It is not necessarily
related to the type or severity of the injury.
If the injured worker is asked "Will you ever be
able to work again?" the following responses can be
categorized:
a. "They tell me that I won't ever be able to" - the
patient has accepted, appropriately or not, that a
return to work will not occur.
b. "Well, I would like to, but I don't see how" -
the patient has become fixed in a perception that
his/her limitations preclude any productive return
to the workforce.
c. "Well, I can't return to work doing what I used
to do." - the patient wishes to return to work but
is uncertain of his/her options.
d. "If they have another job for me (at the company
where injured)." - the patient anticipates that,
with assistance, he/she can work modified or
alternate duty work for the current employer or
another.
e. "I have no choice; the family needs the money (or
"I would not know what to do if I was not working"
or "I have to because sitting at home is miserable")
- the patient is committed to finding work within
his/her objective limitations.
Part of this decision-making process is determined
by the individual's personal work ethic and
motivation as well as education and definable career
path. If the individual has consistently worked,
seen their work as a career, and finds self-esteem
in a sense of accomplishment and productivity,
he/she is likely to return to work in some capacity.
But an equal part is shaped by the perceptions of
those around them. Thus, the earlier in the recovery
process that this question is asked, and the higher
the expectation of health care personnel that an
injured worker should strive for productivity, the
more they will incorporate return to work into the
mental process of recovery.
Conversely, the more that treatment drags on, the
more changes of physicians, and the more
nonproductive the course of care, the easier that
patient will settle into a self-concept of
disability regardless of age or education.
Monday,
April 30,
2007
Dr. Adams’ Case Management Update
This is the 433rd
Weekly Issue
This Week's Topic: "So Many Drugs...So Little
Time "
Question:
"Does it ever occur to you that many injured workers are
taking a medicine chest worth of medication or what this does to
them?"
Dr.
Adams replies:
"All drugs have side effects. Take many
drugs, and you have many side effects. Take a
whole lot of drugs and...well, you get the picture.
Post-injury patients may have a myriad of physical
complaints. They may be prescribed
anti-inflammatory drugs, muscle relaxers and
narcotic pain killers by multiple physicians as
their care moves from occupational medicine to a
series of specialists. There is no policy or
program whereby they "turn-in" their old drugs
before receiving the new medications.
Similarly, there is often no screening for patients
who continue to take the old drugs in combination or
in lieu of the new drugs largely due to personal
preference for one drug over another.
Side effect profiles become quite complex and range
from dry mouth to day time sedation to dizziness,
stomach pain, constipation and nausea. Many of
these patients are on so many drugs that the better
part of their day is spent watching their drug
schedule or anticipating when it is acceptable for
them to take more narcotics.
This becomes all the more complex because a large
number of these patients are understandably
depressed. Their careers may have ended, their
income is severely curtailed and they are in pain.
Someone may put them on multiple antidepressants,
highly sedating anti-anxiety agents, various
(hypnotics) sleep agents and these may be prescribed
at maximum dosage level or at insufficient levels.
Patients most often blindly comply with prescribed
medication, but they rapidly learn to prefer one
drug over another, to avoid some because of GI
complaints, and will often take one medication to
counteract the adverse side effects of another drug.
Importantly, it is rare that someone sits down with
the patient and asks what they have experienced
while on each drug and whether any individually, or
in combination, are a cause for discomfort or
concern.
The best source of information as to whether a
medication is appropriate is the patient taking that
medication. But it is a source that is rarely
utilized."
Monday,
April 23,
2007
Dr. Adams’ Case Management Update
This is the 432nd
Weekly Issue
This Week's Topic: "The Abused Patient"
Question:
"Why are you concerned whether a patient was abused as a
child and/or in their marriage? This is not related to
their injury."
Dr.
Adams replies:
"That is quite accurate. It is not related to
their injury, but it will most often determine the
compliance with treatment, the effort put forth in
rehabilitation and ultimately their use of narcotics
and willingness to ever return to work.
Abuse occurs when we are vulnerable. Arguably there
is nothing more horrible than the concept and
reality of child abuse. Only second to that is
spousal abuse.
In both situations, the individual is left
powerless, helpless and often hopeless. They rapidly
lose the capacity to trust, feel betrayed by
authority and feel alone and abandoned by their
world. There is shame, embarrassment and unresolved
rage.
This formerly (or sometimes currently) abused
individual is injured at work. Indeed, sometimes
they are only working because the abusive individual
in their life insists that they do. They become
injured and are fearful of the response at home when
they are no longer financially productive. The
workers' comp system does not probe this area, and
the patient is shuttled between clinic, providers
and treatment regimen. Someone may note that
they are depressed, withdrawn and "not putting forth
full effort." Yet no one will ask if they have
been, or are currently being, abused.
If the abuse is current, the patient may need to
enter a shelter along with dependent children.
If the abuse is part of a distant past, the
patient's fear of mistreatment and abandonment by
treating physicians, there needs to be very specific
and targeted reassurances and demonstration that the
fears are unfounded.
These factors are, unfortunately, not rare when
treating industrially injured workers.
Individuals from such a background often quit school
and marry to flee abuse. Or if the abuse has
occurred during adulthood, they will desperately
seek any, even high risk, employment just to escape
an oppressive situation.
Thus, you need to determine if the patient selected
this particular job largely because of abuse, has
poor relationship with you and others because of
abuse and fully expects (and will create) failure
since this has so much been a part of life."
Monday,
April 16,
2007
Dr. Adams’ Case Management Update
This is the 431st
Weekly Issue
This Week's Topic: "Managing the Burdensome
Compulsive Patient"
Question:
"We have an injured worker who is a burden to our practice
(and likely to the employer and insurer as well). She
calls repeatedly and demandedly. She wants copies of all medical
notes and records and then edits them for the smallest detail,
calling attention to what she feels are inconsistencies and
inadequacies. How do we stop all of this? We need a
practical solution."
Dr.
Adams replies:
"The case you describe should lend itself to
the following approach:
a. Ask the patient to maintain copies of all medical
records and to meticulously note all errors,
inaccuracies and perceived inadequacies in the form
of a journal.
b. Ask the patient to "maintain a perfectly
organized" copy of this journal in their home
and to provide the office with monthly copies.
c. Maintain a second patient folder that remains
part of the patient chart (as per HIPPA), and that
folder contains solely copies of the journal that
the patient is maintaining.
d. Have the patient also maintain a chronological
outline of all symptoms, signs and concerns and to
keep this in annotated form and to, again, provide
you with a copy of this secondary journal.
e. Also inform the patient that he/she should create
a list of ten questions, in writing, per week that
is submitted along with their monthly compilation
but with which they call you weekly at a precise
time for an exact ten minute presentation of these
questions to you.
f. Remind the patient that this must be carefully
and accurately created and maintained and be able to
be presented in a ten minute telephone interchange.
This places the entire burden of organization within
the scope of the patient's obsessive thoughts and
compulsive behaviors and permits him/her to
discharge anxiety in an effective and productive
fashion. It also creates that second chart
that clearly illustrates the profoundly
obsessive-compulsive drive of the patient.
Finally, it restricts the infringement upon the
practice to a specific time, time span and schedule.
Remember that personality ("character") disorders
are developmental defects. You will not change
them, and most often the patient feels that they are
without fault. In their thinking, it is the world
that is defective, inadequate and in need of
modification.
This perception of the flawless self and the
imperfections of others will not be altered.
To manage such patients, you must function within
the system that they have built.
The compulsive patient is arguably among the easiest
to modify but only after you understand the ways in
which their needs-for-control manifest themselves.
Monday,
April 7,
2007
Dr. Adams’ Case Management Update
This is the 430th
Weekly Issue
This Week's Topic: "Suicide"
Question:
"How do you separate between someone who is suicidal and
someone who is just manipulating?"
Dr.
Adams replies:
"A great deal is known about suicide, but
clearly, it is always better to assume that the
threat is quite real. That said, I have seen
more than a few patients who use suicidal threats to
control family, doctors and inflate the value of
their insurance settlement.
However, here are some of the factors that need to
be weighed when assessing suicidal threat:
1. Does the patient currently have a diagnosable
mental disorder - examples include mood disorders,
substance abuse disorders, and some of the more
severe personality disorders?
2. Does the patient have a personal history that
would lead to suicidal concerns - examples include
prior suicidal attempts, aborted attempts or other
forms of self harm?
3. Does the patient have a current medical diagnosis
- examples would include orthopedic and pain
disorders?
4. Is there a family history of suicide, suicidal
attempts or mental disorder?
5. What are the patients individual strengths as
well as vulnerabilities?
6. What are his/her coping skills, personality
traits, past responses to stress, capacity for
reality testing and history of tolerance of
emotional pain?
7. What is the patient's current psychosocial status
- for example are there chronic and acute stressors,
a recent change in status, the quality of the
support system and the patient's religious beliefs?
8. What is the nature of the suicidal ideation,
plan, behaviors, intent, and method being considered
(Eg. do they have access to a firearm)? Is the
patient joyless, anxious and does the patient
believe that they have a reason for living?
Are they currently substance abusing? Do they
also have homicidal ideation?
This is the briefest of overviews, but suffice it to
say that despite the use of such threats as a form
of malingering, all suicidal threats need to be
taken seriously and assessed professionally."
Monday,
April 2,
2007
Dr. Adams’ Case Management Update
This is the 429th
Weekly Issue
This Week's Topic: "Self-Talk, Distortion,
Pain & Depression"
Question:
"We have this injured worker who was assaulted in the
workplace. He has treated with a certain surgeon for five
years. He has undergone many procedures which we felt were
unnecessary, some were actually dangerous and none produced
relief. He is a very dependent and not well-educated
individual. We put in and were awarded a
change-of-provider. Now, the patient is angry at us; go
figure."
Dr.
Adams replies:
"Many/most patients who are injured are
immediately placed in a position of helplessness.
Those who have been assaulted are also frightened
and angered at their assailant. Since most employers
do not respond effectively to the assaulted patient,
the patient then becomes angry and alienated from
the employer no matter how long they have been
employed.
The patient has only two advocates: their physician
and their attorney. If the attorney does not
have their best interests at heart, wishes only to
build the value of the "case" and is not completely
honest with information imparted, the patient
typically is unaware that this is occurring.
So when the insurer (or employer) questions
care-related charges, the patient is solely reliant
upon the attorney for interpretation of why this is
happening. The attorney does not typically
calm the patient and most often does not have the
requisite skills and may not recognize the need to
do so.
The treating physician is either an individual of
great suspect or great trust by the patient. His
feelings toward the physician are unlikely to
change. The patient may trust or suspect his doctor
independent of reality. That is, the patient
may distrust anyone to whom they have been sent by
the employer. Or conversely, the patient may
completely trust anyone to whom their attorney has
sent them. These are emotional responses and are
quite often not based upon any real data or good
reality-testing.
If the treating physician is a charming, persuasive
and manipulative individual, the patient will invest
undeserved trust in him/her. The patient
becomes protective of the doctor even though the
doctor is not providing effective or even
appropriate care. The patient may even know
that he has more pain (or other limitations) over
time while under this doctor's care.
Nonetheless, he continues to believe in the doctor
and becomes entrenched in that care and quite
resistant to leave.
When you intervene, even on behalf the patient's
best interests, the patient immediately distorts
what is happening. His self-talk sounds much
like: "Dr. Jones has recommended some painful
and difficult procedures. I am in worse pain.
But my pain is worse because I have so many
injury-related problems, and they only want me away
from Dr. Jones to save themselves money. Dr. Jones
is the only one who understands how badly I have
been hurt, and how I suffer. I cannot stop
them from taking me away from Dr. Jones, and,
therefore, I now feel totally helpless. I am
now depressed solely because of not being able to
see Dr. Jones. I feel all of this is hopeless,
and I hate these people who are keeping me from
seeing him."
It is critical to the management of these patients
that you determine whether the doctor-patient
relationship is becoming dysfunctional, whether the
patient is distorting the nature and value of care
and whether the patient should not be moved to
another provider before further pathological
attachments occur."
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