D^{r. Adams replies:}

This is a significant problem and complication to much of case management.  Quite often the injury has become an opportunity to control a family member. Sometimes the person to be controlled is the patient him/herself by others who may have a host of goals and objectives of which we are largely unaware.  However, those hidden agenda are not difficult to anticipate, and fall into six major categories:

a. Where there were marital problems, the injury may serve as a distraction from them, yet the emotions tied to those problems now emerge in the management of the injury and are, thus, excessive.

b. If there were infidelity or problems with intimacy, the injury becomes a means of justifying past misdeeds or current inadequacies.

b. If employment prior to injury had been brief and prior employment inconsistent, a stable weekly check offers financial stability to the family.

c. If there were appreciable and mounting financial problems, the injury erroneously looks like a monetary windfall which will work against the patient mobilizing.  And in some cases, a spouse remains only until those financial goals have been realized.

d. Where there were occupational limitations, including lack of education and training, and/or where there was the absence of a career path, the injury becomes a justification to the family for not seeking an functional future goal.

e. The family is likely to be more forgiving of work that is halted by injury even though the true cause was that the job was unclean, unrewarding, filled with interpersonal conflict and physically exhausting.

Using physical complaints to solve specific psychological problems is engrained in us early in life.  A stomach ache obviates our need to go to school. A headache or cramps enable us to avoid tasks in which we do not wish to engage.  Humans use everything from fatigue to pain to escape life's demands...and quite often others benefit from those physical complaints.

D^{r. Adams replies:}

There is a diagnosis (316.0 Maladaptive Health Behaviors Affecting Physical Condition) which addresses the self-abuse through which we place our bodies.

A significant number of injured workers are obese, de-conditioned with high levels of nicotine, caffeine and/or alcohol intake. They are genetically predisposed to hypertension and diabetes, and many are already undiagnosed cases of Type II Diabetes prior to injury.

After injury, they are sedentary, diet is unhealthy, and their underlying problems worsen. They do not have regular mammography or prostate exams, and I have seen numerous cases where, during the case of recovery from injury, they develop lung, breast or prostate cancers. Some develop peripheral neuropathies from their undiagnosed diabetes. The only health care they receive is that related to their injury, and their authorized treating (orthopedist for example) is not empowered by the employer/insurer to look for these conditions.

All assume that the patient sees one group of physicians for his/her injury and another for routine ongoing health care. Most often, this could not be further from the truth.

As these underlying and co-existing health problems increase, the patient’s ability to recover from injury decreases. Eventually the boundaries between injury and unrelated health problems begin to blur. Is the patient short of breath because of chronic pain, obesity or chronic obstructive pulmonary disease from smoking?

Although not typically part of a psychological exam, I always inquire into how recent was this weight gain (or loss), what other (unrelated to injury) symptoms the patient is having and, most of all, do they have access to routine health care. Unless I ask these questions, those data rarely emerge in the patient’s chart.

D^{r. Adams replies:}

Frankly, it does not. It sounds like an aggrieved employee.  Nightmares, as a symptom, are not sufficient criteria for the diagnosis of PTSD.  You can find the complete criteria on my website. 

What this sounds like, although I would need to see the patient, is someone who is very angry at her employer. Perhaps she feels that the robbery was an inside job. Perhaps she feels her employer did not provide sufficient security.  She may blame the employer for how the robbery was handled and blame the police for not appearing more invested in apprehending the perpetrators.

Symptoms can be a very effective means of controlling other people. As soon as someone wants you to accept more responsibility, you present symptoms that make doing so quite impossible. You go from an employee who had no control in a robbery to one who now has total control over employer, coworkers, health care, insurer, family and even law enforcement.  No one can do enough for you.  This makes you very powerful where once you felt powerless.

What you need to determine is the extent to which anger is a key factor in explaining this patient's response to the event.

I have spoken before about "primary gain."  We become focused upon secondary gain (financial benefits, attention, affection, time off from work), but it is always important to consider whether the physical and emotional complaints are being used as though they are tools to solve complex problems.

D^{r. Adams replies:}

These can be summed in what I personally call the ICE acronym: 

Intellectual:  What is the functional (useful in a practical sense) intelligence level of the patient?  Does he have sufficient capacity to understand the procedure and its role in the course of care?  This may include the patient's interest not only in exploring materials provided by his physician but also the intellectual curiosity to seek other sources of information which may include those found in magazines, the internet and scientific publications.  Thus, part of the intellectual capacity concerns itself with the patient's motivation to learn as much as possible about the procedure.

Cognitive: With all information that is, or can be made, available, how much does the patient retain about the way the procedure is performed, the level of improvement anticipated, the degree of risk involved, the adverse side effects experienced by some patients and the applicability of the procedure in cases such as their own. Do they truly understand and accept the limits of improvement?

Emotional:  By far the most complex is determining how honest the patient is being about their subjective complaints of pain, their goals for the procedure, and their willingness to take a commanding role in their own future.  Prior to the procedure, how depressed has this patient been and what has been the role of depression in the experience of pain and disability.  Is this patient anxious, fearful of the future, feeling hopeless or perceiving themselves as helpless?   

It is not possible to move forward with precision without knowing these factors and how they have directed and will direct the patient.