http://www.psychological.com/forums/blog.php en Thu, 17 May 2012 22:47:26 GMT vBulletin 60 http://www.psychological.com/forums/images/misc/rss.jpg http://www.psychological.com/forums/blog.php http://www.psychological.com/forums/entry.php?553-Illegal-Aliens-and-Work-Injury Thu, 17 May 2012 13:42:08 GMT From the standpoint of paying workers’ compensation, the illegal alien status of a worker may be irrelevant. However, it is very relevant to the course and effectiveness of care. Patients that are in this country illegally move between semi-skilled labor positions, often between States, and in... From the standpoint of paying workers’ compensation, the illegal alien status of a worker may be irrelevant. However, it is very relevant to the course and effectiveness of care.

Patients that are in this country illegally move between semi-skilled labor positions, often between States, and in their attempt to avoid detection and deportation, develop a pattern of stealth in their behavior and in their communication. They want to remain below the radar.

Their compromised English skills make them prey to a variety of people, even within the workers' compensation system, who misdirect them and benefit from their plight. Even well meaning interpreters complicate care in their assumption that they understand what the patient meant to say, rather than strictly translating what was actually stated.

They often live in overcrowded conditions, are dependent upon others for transportation due to lack of a driver’s license, and they may have undisclosed indebtedness to those who are assisting them in integrating into this society.

They have not sought care in the past due to the expense or sometimes due to the paper trail about them that this would create. Thus, they give histories that are fictitious, and as patients, they give inaccurate names, ages and other demographics. They fail to understand the relevance of questions regarding family health and may deny ongoing health problems of their own, including diabetes and hypertension.

They approach health care providers as they would approach law enforcement, most often with hesitation, distrust, evasiveness and dishonesty.

Quite often, they do not understand their diagnosis and treatment, including purpose of procedures, return appointments or even when/how to take their medications. Moreover, they sometimes understand just enough English to be very frightened by what they think they hear.

Then two things can occur:

They find that this regular workers’ compensation income is more stable than day labor
They are told they will get a windfall profit at the time of settlement
From the standpoint of the health care provider, they represent a complex challenge and are concurrently dependent, yet resistant to care. They have all the same problems as other injured workers, compounded by ever-present cultural issues. ]]> Dr. Adams http://www.psychological.com/forums/entry.php?553-Illegal-Aliens-and-Work-Injury http://www.psychological.com/forums/entry.php?552-Non-Compliance Wed, 16 May 2012 13:20:18 GMT Some call it resistance, noncompliance or just being inconsistent, but there are some injured workers who elect not to participate in their own rehabilitation process. They inconsistently show for physical therapy, take (or refuse to take) their medications in opposition to what they are instructed... Some call it resistance, noncompliance or just being inconsistent, but there are some injured workers who elect not to participate in their own rehabilitation process. They inconsistently show for physical therapy, take (or refuse to take) their medications in opposition to what they are instructed to do, and they defer control of the course of their care to non-medical people. They allow friends, family and various agents to dictate what they do, or fail to do, despite the irrational nature of such a decision. While these outside sources rarely have health care licenses or even training, advice places them in positions of control, and, therefore, advice is readily available.

It is usually of questionable utility and rarely given in all sincerity.

However, armed with the assurance that they need, deserve or otherwise must have some specific care, patients become fixated on obtaining it. Instead of fighting against their injury or symptoms, they become embroiled in fighting against the system, and the quest for a specific person or care becomes more important than the goal of recovery. When they finally achieve that particular referral or whatever it is they have been told they want, the quest is over. It is now time to focus on the work of recovery. Unfortunately, their quest has derailed them from that focus. They have lost sight of worthwhile goals of recovery and productivity. They have no internal incentive and find that they are no better off than they were before, but they are more fatigued and deconditioned and have less money than ever. And it is back to square one.

Participation in one's own rehabilitation requires that the patient commit to a single focus: There is some job, somewhere, that he/she should be able to perform, and the goal must be to recover sufficiently to function in that job. ]]> Dr. Adams http://www.psychological.com/forums/entry.php?552-Non-Compliance http://www.psychological.com/forums/entry.php?551-Brief-Overview-of-Psychodiagnosis Tue, 15 May 2012 13:00:25 GMT This is the briefest description of how to understand psychological disorders. These disorders are diagnosed in such a way as to reflect: * recent vs chronic, * developmental vs environmental stressors, and * severity of the presenting problem. This is the briefest description of how to understand psychological disorders.

These disorders are diagnosed in such a way as to reflect:

• recent vs chronic,
• developmental vs environmental stressors, and
• severity of the presenting problem.

1. Clinical disorders are the reasons for which we seek care. Examples with which you may be familiar are major depressive disorder, posttraumatic stress disorder, and pain disorder. These are called "Axis I" disorders.
2. Underlying a clinical disorder may be a developmental or personality disorder. Examples are learning disabilities and dependent or compulsive personality disorder. These disorders will influence how the clinical disorder presents differently in each person. These (Axis II) disorders are not typically the reason why a person seeks care (but may be ample reason why a family member wishes they would). Axis II or personality disorders vary in their presentation, but what they have in common is that all of them interfere with adaptive responses to the world.
3. Concurrently, many people have a physical condition, disease or disorder. These (Axis III) problems may be a herniated disc, a torn rotator cuff, diabetes, high blood pressure, cancer history and a host of other physical problems which impact the clinical disorder.
4. Additionally, quite often people have stressors in their lives such as finances, education, legal and support system problems in relationships. These stressors (Axis IV) may give rise to the clinical disorder, make the clinical disorder worse or be worsened by the clinical disorder.
5. Finally, there is (Axis V) the true degree of impairment that exists as a result of all of this. There are people with major depressive disorder, for example, who may be only minimally impaired. There may be a patient with posttraumatic stress disorder who is severely disabled.

The point is that the existence of one or more disorder does not immediately tell us the degree of impairment. It requires looking at all (axes) factors. For the purposes of pure disability, this determination is not difficult for the skilled clinician to make. The challenge is identifying those problems that have arisen solely or primarily from a physical injury. ]]> Dr. Adams http://www.psychological.com/forums/entry.php?551-Brief-Overview-of-Psychodiagnosis http://www.psychological.com/forums/entry.php?550-The-Faking-of-Physical-Complaints Mon, 14 May 2012 12:47:33 GMT It is true that those with anti-social personality disorder (Cf. "psychopathic") are not encumbered by moral values, guilt or remorse. However, while many of those who falsify their symptoms are "psychopathic," there are others that do so for a wide variety of reasons. It is quite often the desperate need to solve problems by using the injury as a tool to do so.

I recall a patient who was a young minister. He presented as a sincere and moral young man with strict family, moral and ethical values. He had sustained a shoulder injury while working construction and had mild but permanent limitations. He had injury-related pain with mild depression and anxiety.

But he also had a chaotic family situation in which his niece and nephew were being abused, his wife was unfaithful, and there had been severe financial problems for several years. My office referred him to those who could assist him with the problems not related to injury. Both he and his wife complied with these recommendations and reportedly were making excellent progress.

He responded well to treatment related to injury, and as a result, he had less limitations than were initially expected. He was well on his way to return to alternate duty work for the same employer.

Then, one day he arrived, was quite cagey and manipulative. He began to complain of remote, if not absurd, physical and emotional symptoms. He had begun to realize that he could use these contrived complaints and bundle them with the injury to see if he could land a larger settlement. Someone had told him that this was a means to solving his longstanding financial concerns.

This young man was not a "psychopath," but he did become corrupted by the fantasy of solving all problems in his life by the use of his injury as a tool. ]]> Dr. Adams http://www.psychological.com/forums/entry.php?550-The-Faking-of-Physical-Complaints http://www.psychological.com/forums/entry.php?549-Deception Mon, 07 May 2012 13:28:28 GMT If a patient is suspected to suffer from Factitious Disorder or Munchausen's Disorder, the hospital and office records would indicate that he has done this repeatedly (and likely successfully). Thus, you would know that he has obtained (or tried to obtain) unnecessary surgeries and other procedures with very little effort.

However, there are those who have a unique form of malingering in which they create symptoms and seek procedures including surgery because they are fearful that their current symptoms. Since, in the future, they may not have medical benefits, they seek the procedures now while they are insured.

They are, indeed, aware that their symptoms are either not as severe as they are alleging. Driven by fear, they consciously amplify those symptoms because they strongly believe that they are headed toward the need for the surgery at some future time in life.

They often have just enough medical information to falsify their complaints and enough information to frighten themselves regarding their future need for surgery.

Such patients can be confronted in a kind-firm manner such that "there are no indications that you will ever need the surgery you are seeking. Surgery when it is not clearly indicated is a far greater risk to you." But you then must help them deal with their fears of an uncertain future that they have created for themselves in fantasy.

Not all malingering has as its goal financial remuneration; sometimes the tangible goal being sought is largely one based upon fear. ]]> Dr. Adams http://www.psychological.com/forums/entry.php?549-Deception http://www.psychological.com/forums/entry.php?548-Frequency-of-Depression-and-Chronic-Back-Pain Thu, 03 May 2012 13:38:49 GMT Depression is the most common emotional response to chronic back pain and major (clinical) depression is the most concerning of this mood disorder. The symptoms of major depression occur daily for at least two weeks and include at least 5 symptoms: * A predominant mood that is depressed, sad,... Depression is the most common emotional response to chronic back pain and major (clinical) depression is the most concerning of this mood disorder. The symptoms of major depression occur daily for at least two weeks and include at least 5 symptoms:

• A predominant mood that is depressed, sad, blue, hopeless, low, or irritable, which may include periodic crying spells
• Poor appetite or significant weight loss or increased appetite or weight gain
• Sleep problem of either too much (hypersomnia) or too little (hyposomnia) sleep
• Feeling agitated (restless) or sluggish (low energy or fatigue)
• Loss of interest or pleasure in usual activities
• Decreased libido
• Feeling of worthlessness and/or guilt
• Problems with concentration, memory or decision-making
• Thoughts of death, suicide, or wishing to be dead
• Major depression is thought to be four times greater in people with chronic back pain than in the general population.

In research studies on depression in chronic low back pain, 32 to 82 percent of patients show some type of depression or depressive problem, with an average of 62.

In one study it was found that the rate of major depression increased in a linear fashion with greater pain severity, and it was also found that the combination of chronic back pain and depression was associated with greater disability than either depression or chronic back pain alone. ]]> Dr. Adams http://www.psychological.com/forums/entry.php?548-Frequency-of-Depression-and-Chronic-Back-Pain http://www.psychological.com/forums/entry.php?547-Back-Pain-and-the-Brain Mon, 30 Apr 2012 13:26:11 GMT A study indicates that chronic pain affects overall brain function, which may explain many of the common cognitive and behavioral problems seen in such patients. MRI studies at Northwestern University, in Chicago, Illinois, found that individuals with chronic back pain (CBP) also had changes in... A study indicates that chronic pain affects overall brain function, which may explain many of the common cognitive and behavioral problems seen in such patients.

MRI studies at Northwestern University, in Chicago, Illinois, found that individuals with chronic back pain (CBP) also had changes in the functional connectivity of their cortical regions — areas of the brain that are unrelated to pain — compared with healthy control subjects in the study.

"This is the first clue we have that conditions such as depression, anxiety, sleep disturbances, and decision-making difficulties, which affect the quality of life of chronic pain patients as much as the pain itself, may be directly related to altered brain function as a result of chronic pain," states principal investigator Dante Chialvo, Neurology & Neurosurgery.

According to Dr. Chialvo, at rest, the healthy brain is in a state of cooperative equilibrium, so that when one region is active, the others are less active or deactivated. These resting areas, known as the default mode network (DMN), usually "shut off" when a person pays attention or undertakes a task.

However, the regions of the DMN in chronic pain patients never "quiet down."

"Our paper shows pain not only hurts patients, but the unrelenting perception of pain also harms the brain. Using technology such as MRI, we can objectively quantify this effect," said Dr. Chialvo.

The MRI studies showed that although CBP subjects could complete a given task as well as healthy controls, it was at the expense "of using their brain differently from the pain-free group."

Furthermore, the study suggests that over time, chronic pain may lead to permanent reorganization of the brain. "We observed that the effect on the cortical regions was greater among individuals who had had chronic pain for a longer period of time."

If these findings are confirmed, he added, this may indicate a need for early, aggressive treatment of pain to mitigate discomfort and/or prevent associated conditions such as depression, sleep disturbances, and cognitive impairment.

Dr. Chialvo's next research steps will include investigating potential functional differences in cortical regions of the brains of men and women.

"It is well-known that chronic pain affects 3 times as many women as men, but no one has a clue why this is. We are going to look at resting-state levels initially in healthy females and males and ultimately in individuals with chronic pain to determine whether the default network is different between the sexes," he said.

The National Institutes of Health supported the study.

J Neurosci. 2008;28:1398-1403. ]]> Dr. Adams http://www.psychological.com/forums/entry.php?547-Back-Pain-and-the-Brain http://www.psychological.com/forums/entry.php?546-Pain-amp-Narcotics Wed, 25 Apr 2012 13:14:47 GMT From the 1980s to the mid 1990s, narcotic pain medication was chiefly used for malignant (cancer) pain. However, in the mid-90s a series of scientific articles recommended these agents for some patients in chronic benign (nonmalignant) pain. At the time, narcotic abuse was predicted to occur... From the 1980s to the mid 1990s, narcotic pain medication was chiefly used for malignant (cancer) pain. However, in the mid-90s a series of scientific articles recommended these agents for some patients in chronic benign (nonmalignant) pain.

At the time, narcotic abuse was predicted to occur in only 5% of these patients, and restricting access for those who would not abuse them was deemed cruel and unwise.

However, by 2002, prescribed narcotic abuse had increased by 71% and has now increased each quarter for the past 3 1/2 years.

Here are some of the more obvious signs of abuse:

· Patient caught selling prescribed narcotics

· Patient caught forging prescriptions

· Patient found to be stealing drugs

· Patient injecting oral medications

· Patient obtaining drugs from multiple providers

· Patient concurrently abusing alcohol and/or street drugs

· Patient increasing dosage levels even though warned not to do

· Patient reports "losing" medication

· Patient seeks medication from Emergency Rooms between appointments

· Patient displays personal deterioration seen in drug abuse cases

Here are factors that, when combined, are often associated with risk for narcotic pain medication abuse:

1. History of drug and/or alcohol abuse with consequent arrests for DUI or other crimes

2. Cigarette smoking

3. Under 25 years of age

4. Males

5. History of psychological care

6. Presence of anxiety and/or mood disorders

What to do? To detect the potential for a patient to abuse prescribed medication, too many clinicians use their "gut feeling" based upon experience. This fragile approach may fail to predict some cases and falsely identify others.

There are research-based screening tools that are excellent at revealing potential and ongoing medication abuse. But remember that just because a patient falls into a higher-risk category does not mean he cannot be medicated with narcotics. It simply means the prescribing clinician needs to notice when the patient deviates from the expected course of recovery. ]]> Dr. Adams http://www.psychological.com/forums/entry.php?546-Pain-amp-Narcotics http://www.psychological.com/forums/entry.php?545-Cigarettes-and-Pain Tue, 24 Apr 2012 15:01:26 GMT Actually, claims of partial pain relief through smoking have been around since the 1930’s; there are some compelling studies which support this claim (and not just about traditional cigarettes). According to a study by researchers at the University of California, San Diego (UCSD) Center for... Actually, claims of partial pain relief through smoking have been around since the 1930’s; there are some compelling studies which support this claim (and not just about traditional cigarettes).

According to a study by researchers at the University of California, San Diego (UCSD) Center for Medical Cannabis Research, marijuana in moderate amounts decreased neuropathic pain by as much as 34% in two subjects. Small amounts of cannabis had no effect on pain, and at high levels, pain actually increased.

In another study from San Francisco General Hospital, smoked marijuana was associated with ≥30% reduction of average daily neuropathic pain in 10 of 16 experienced marijuana users with neuropathy due to HIV, nucleosides, or both.

Recently, results of a new study suggest that people with chronic neuropathic pain are twice as likely to smoke cigarettes as those who have chronic nociceptive pain. Why is this? Research studies have found a link between nicotinic receptors and acetylcholine receptors in the spinal dorsal horn, which are actively involved in the perception of pain.

Nociceptive pain is the common discomfort experienced as a result of injury, such as a broken bone or appendicitis. The pain is a message sent from peripheral nerves to the spinal column and on to the brain, signaling injury. The pain is typically well localized, constant, and often with an aching or throbbing quality. Nociceptive pain typically responds to anti-inflammatory agents and opiates.
Neuropathic pain is associated with injury to a nerve or the central nervous system. Such injuries can give rise to paresthesias, such as numbness, tingling, or electrical sensations. Among the many causes of peripheral neuropathy, diabetes is the most common, but the condition can also be caused by chronic alcohol use, exposure to other toxins, vitamin deficiencies, nerve entrapment and sympathetically mediated pain. Neuropathic pain often responds poorly to anti-inflammatory agents and opiates.

The possible physiologic relation between nicotine and treatment of chronic neuropathic pain deserves further evaluation. But bear in mind that in the scientific community conducts this research with nicotinic drugs that are ingested or injected, not with inhaled nicotine. The adverse risks of smoking outweigh any potential benefits of pain relief. ]]> Dr. Adams http://www.psychological.com/forums/entry.php?545-Cigarettes-and-Pain http://www.psychological.com/forums/entry.php?544-The-Natural-Progression Mon, 23 Apr 2012 13:28:28 GMT 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... 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. ]]> Dr. Adams http://www.psychological.com/forums/entry.php?544-The-Natural-Progression http://www.psychological.com/forums/entry.php?543-Discussing-Pain-with-Others Thu, 19 Apr 2012 13:21:27 GMT 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. This is not a valid concept. A study... 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.

This is not a valid concept. A 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. ]]> Dr. Adams http://www.psychological.com/forums/entry.php?543-Discussing-Pain-with-Others http://www.psychological.com/forums/entry.php?542-Anger Wed, 18 Apr 2012 13:11:58 GMT 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... 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. ]]> Dr. Adams http://www.psychological.com/forums/entry.php?542-Anger http://www.psychological.com/forums/entry.php?541-Diagnostic-Testing Mon, 16 Apr 2012 13:26:07 GMT The Paper Trail"

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. ]]> Dr. Adams http://www.psychological.com/forums/entry.php?541-Diagnostic-Testing http://www.psychological.com/forums/entry.php?540-Aggravating-a-Condition Thu, 12 Apr 2012 13:38:47 GMT A patient whose complaints are minimized, whose care is delayed, and whose benefits are slow in coming, may develope a constellation of symptoms that at once appear to be anger and concurrently appear to be depression. Symptoms will tell (sleep, eating, cognitive, mood) whether a mood disorder is... A patient whose complaints are minimized, whose care is delayed, and whose benefits are slow in coming, may develope a constellation of symptoms that at once appear to be anger and concurrently appear to be depression. Symptoms will tell (sleep, eating, cognitive, mood) whether a mood disorder is the cause of the current behavior. But the patient may just as likely be inordinately angered at what has occurred.

The patient has has lived with appreciable pain which has been trivialized. S/he has been financially dependent upon a third party. He cannot readily select his own doctor. He likely cannot afford his own prescriptions. And he battles to convince others, that his pain is more than a strain. This reliance upon others is sometimes referred to as "hostile dependency." Interestingly, this is also seen 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. ]]> Dr. Adams http://www.psychological.com/forums/entry.php?540-Aggravating-a-Condition http://www.psychological.com/forums/entry.php?539-Exasperation-over-Exacerbation Tue, 10 Apr 2012 13:23:46 GMT Allow me to very briefly to break down the three types of depression that one is most likely to see following an injury: Adjustment Disorder with Depressed Mood – is a transient problem, lasting several months in which the individual has mild depressive symptoms associated with physical... Allow me to very briefly to break down the three types of depression that one is most likely to see following an injury:

Adjustment Disorder with Depressed Mood – is a transient problem, lasting several months in which the individual has mild depressive symptoms associated with physical discomfort and loss of productivity.

Dysthymic Disorder (a.k.a. “Dysthymia”) – was once called depressive neurosis. These are moderate symptoms that span two or more years, wax and wane, and arise from the conflicts that are created within and outside of an injury. Dysthymic Disorder can be exacerbated by injury but quite often there are other issues that are of equal or greater concern.

3. Major Depressive Disorder (or Major Depressive Episode) – may be a misnomer in that the term “major” tends to influence how many see this quite common mood disorder. There is a form of the disorder called “early onset” in which a patient may have a long history of depressive episodes, created by changes in brain chemistry and may be unrelated to external events.

Obviously, it is crucial that we know which form of depression we are witnessing. It would be inappropriate, expensive and quite counterproductive to treat a depressed patient as though the injury was the sole and enduring cause of the mood disorder.


The true purpose of including “exacerbation of pre-existing” depression among our concerns is that we must return the patient to baseline.
This is critically important because the “baseline” of patient’s with recurrent major depression and dysthymic disorder may not be the same high level of functioning that characterizes our own life.

In other words, treatment of that part of the depression that is injury related is only meant to return the patient to the point where he/she can then seek care (or return to care) for the other contributing factors that may have existed for many years before injury. ]]> Dr. Adams http://www.psychological.com/forums/entry.php?539-Exasperation-over-Exacerbation