Q^uestion:
"We have a patient with cervical injury. We dropped the ball on this, being told it was neck strain and a series of administrative difficulties. Anyway, his checks were not sent out, prescriptions not authorized...our bad.  Now his attorney is claiming that he is depressed. Any thoughts?"

D^{r. Adams replies:}

He may well be clinically depressed.  His symptoms will tell you that (sleep, eating, cognitive, mood) whether a mood disorder like depression is the cause of his current behavior.  But he may just as likely be inordinately angered at what has occurred.

He has lived with appreciable pain which has been trivialized.  He has been financially dependent upon you.  He cannot readily select his own doctor.  He likely cannot afford his own prescriptions. And he battles to convince others, including you, that his pain is more than a cervical strain.  This reliance upon you is sometimes referred to as "hostile dependency."  Interestingly, you see this also in teenagers who seek to, but cannot really afford to, be independent.

So let us assume that he is quite angry. Anger will resemble depression in several important ways:  In both depression and anger, the individual is sullen, often withdrawn and brooding, restless and agitated, and likely no one who wants to listen to what seems like endless complaining.  He feels helpless, powerless and has ceased to be hopeful that things will change in the short run.

The problem with misidentifying an angry person as depressed is that the treatment for clinical depression is not benign. The drugs used to treat depression can interact with other drugs, can lead to symptoms (side effects) of their own, and are not inexpensive. More importantly, antidepressants are not a solution to anger.

Whether the authorized treating physician or the nurse case manager, someone needs to spend some time differentiating (and helping the patient separate) between anger and depression.  Anger can be resolved with reassurance that amends will now be made. Depression, by contrast, requires treatment.

Q^uestion:
"Is the purpose of psychological testing to confirm a diagnosis or to make one in the first place?"

D^{r. Adams replies:}

The purpose of psychological testing in worker’s compensation is to determine what, if any, disorder is giving rise to the patient's behavior following injury. 

A disorder is a combination of symptoms that often occur together and define a behavior as a departure from normal functioning.  A disorder interferes with a person’s usual process of adaptation to stress.  It interferes with occupational and social functioning. The process of defining or classifying that disorder, and separating it from other disorders, is called "differential diagnosis."

For example, being sad or frightened after injury is not a disorder. However, a combination of problems with sleep, eating, energy, irritability, memory, and concentration, may well be symptoms of a mood disorder such as major depressive disorder.

You can verbally ask a patient a range of questions in an organized fashion and make a reasonable diagnosis, but many patients will respond more openly to questions presented to them in written form, especially those questions which they feel are embarrassing.  

It is also quite difficult to insure that you ask every patient, every question, in a form to which they will respond.  It is difficult to insure that all questions are asked in such a way as to not offend, threaten or frighten a patient when they are presented in verbal form.

Written questions can insure that the same questions are asked in the same way of all patients. This removes a source of bias (error).

The responses are then correlated with the information obtained in a clinical interview, and the two response sets are compared for consistency.  The combination of the two produces greater validity than either as a stand-alone form of evaluation.  If a patient responds differently when the questions are asked verbally versus when they are presented in written form, this can provide us with additional information.  

Putting together the right combination of psychological tests can provide critical data in determining how best to help mobilize a particular patient.

Q^uestion:
"I have this claimant who seemed nice enough in the beginning, but over time he’s getting harder to deal with, but he never comes and says what’s wrong.  Do you have any suggestions?"

D^{r. Adams replies:}

Anger is an insidious process.  Expressed or held in check, it influences what a patient says and does.  What the patient does not express often emerges in new or increased physical symptoms often seemingly unrelated to injury.

When anger is unsafe to verbalize, the patient feels extremes of frustration and is preoccupied with an unfulfilled need to retaliate.  Ultimately helpless to either resolve or discharge the aggression, the patient becomes physically symptomatic.  

Case in point: The patient has a lumbar injury and six months later, winds up in the ER with chest pain, headaches and/or GI distress.  He wants cardiology, neurology and gastroenterology consults, believing that these new symptoms are part of previously undiagnosed but injury-related problems or, at a minimum, he believes that the symptoms are arising from adverse side effects of prescribed medication. 

In the ER, no one asks the patient, "are you depressed....are you angry...are there problems that you cannot resolve..."  Instead, numerous, unnecessary and expensive diagnostic studies are ordered, and the patient is sent home with more prescriptions for symptomatic relief of the new complaints. 

The patient arrives home, has worse injury-related pain from sitting in the ER, is frustrated by these new diffuse symptoms, feels powerless to address the underlying cause. He arises the following day and repeats the same process.  

When these new symptoms do not improve, they become evidence to the patient that no one cares about him and/or it is impossible to have adequate care if you have been injured at work. Until/unless credence is given to the patient's anger and frustration, and the causes are addressed, this becomes a cycle.   

In the arena of work injuries, the person most likely to receive blame is the adjustor and nurse case manager followed by the primary provider who does not “fix” them.  Unfortunately, many patients feel that the solution to their problems, whether financial or medical, is being intentionally withheld from them.  Asking direct questions can communicate a message of caring, as long as you are prepared to hear the answer and deal with it.

Q^uestion:
"At a pain center, one of our patients was told not to discuss his pain except when at the center.  That is, he should avoid discussing the pain with family and friends and reserve those discussions for when he is seen at the pain center every three weeks.  Is that a valid approach?"

D^{r. Adams replies:}

No, it is not. A recent study at Duke University (Pain Prevention and Treatment Research Program) suggests that avoiding open discussion of pain and limitations actually exacerbates, or worsens, the pain experience. 

When the patient or the spouse feel unable to discuss the changes brought about by pain or injury, the patient then dwells on the experience internally.  This increases the perceived intensity of subjective pain.

Research indicates that both patient and family members benefit from being able to discuss pain its effect upon their lives.  Direct communication helps prevent the commonly seen passive behaviors utilized by patients to control their environment, and helps the patient become an active manager of their disorder, rather than a victim.

Communication also increases the likelihood that a patient will try something new to manage their pain, such as biofeedback, relaxation therapies, change in medications etc. rather than attempting to convince others that nothing can help them feel better.

Learning to change the way one thinks about pain has been successfully approached through CBT (Cognitive Behavioral Therapy).  CBT is utilized to restructure how one thinks about and interprets pain.  Curbing negative thinking is critical to changing perceptions.  Instead of catastrophizing an acute flare up as a sign of permanent decline, patients can learn to see this for what it is – a temporary and manageable event that will subside.

Along with CBT, patients benefit from becoming aware of how they communicate distress.  Habitual grimaces, moaning, groaning and limping are sometimes just that – habits which do not reflect how they feel at a given point in time, but communicate dire distress to family and others. 

Rather than see themselves as victims of pain or injury, patients undergoing Cognitive Behavior Therapy can learn ways to control the experience of pain and moderate their expression to family.  This, in turn, changes how they see themselves.

Q^uestion:
"In your lectures, you emphasize the importance of the first year following a lost time injury. Why do you feel that the first twelve months are so crucial?"

D^{r. Adams replies:}

"Within the first twelve months of injury:

1.      The patient has become increasingly alienated from coworkers and the employer whom they now strongly feel has abandoned him/her

2.      The patient’s expectancy that this would be short term medical care has been quashed

3.      The patient’s relationship with nurse case manager and his/her own family will increasingly become strained or compromised

4.      The patient has seen multiple providers, sometimes with conflicting goals, and may now have incompatible diagnoses

5.      The patient has become concurrently irritable but also both passive and dependent

6.      The financial picture has become very bleak and is worsening

7.      The patient has become sedentary, de-conditioned and unmotivated

8.      The patient spends increasing time counter-productively, over-medicating, sleeping and over-eating

9.      The patient has become focused upon issues of rights and authorization of care rather than issues of improvement

10.  The patient now has developed no clear career alternatives, conceived goals or direction

11.  The patient has become very conflicted as to where to invest trust and hope

12.  All holidays, special events and other meaningful landmarks of time have now passed with the patient in a disability role

Within those first twelve months, the patient has all but established a new personal identity.  Their values and belief systems have been altered, and their belief that they can change the course of their future have eroded.

The best time to mobilize these patients is before the end of that first year, and the best way to do so is to help them challenge these developing, faulty belief systems.

Q^uestion:
"What is the relationship, if any, between pain tolerance and smoking cigarette smoking?"

Q^uestion:
"...then how do we predict who will abuse narcotics that are prescribed for pain?"

Q^uestion:
"Pain is just an experience.  Pain itself does no damage...I mean no physical damage....right?"