General Disclaimer (learned from Dr. Melhorn)

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1 Non-injury-related related Psychological Issues as the Cause of Injury Claims Robert J. Barth, Ph.D. Chattanooga, TN and Birmingham, AL Contact Information: Robert J. Barth, Ph.D. Parkridge Hospital Plaza Two 2339 McCallie Ave. Chattanooga, TN / General Disclaimer (learned from Dr. Melhorn) All contents of this presentation remain the property of Dr. Barth, and cannot be used for any purpose in the absence of Dr. Barth s specific authorization. 1

2 Published version of this lecture: AMA s Guides Newsletter, November/December This talk is based on lectures and publications previously prepared for: American Medical Association American Academy of Orthopaedic Surgeons European Union of Medicine in Assurance and Social Security American Academy of Disability Evaluating Physicians North American Spine Society We are going to talk about several specific types of claims today Back Claims CRPS (rsd) claims Postconcussion Headache Posttraumatic Stress Disorder 2

3 Try to look past these specific types of claims, to see the over-riding riding principles, such as Pre-existing existing psychological factors predict who will file an occupational injury claim (regardless of whether there has been an injury). When we assume that injury is the cause of the claim, we are setting up the claimant for a lousy clinical outcome. A real-life life example of the problem: Molly and Cathy Real Life Example: Molly and Cathy Molly says that her back started hurting while she was at work. Therefore, her doctors declare that she has had a back injury. There is no evidence of injury, other than Molly s complaint of pain. Further, Molly s doctors say that she cannot work because of that injury. The only thing that indicated to her doctors that she could not work is Molly says she cannot work because of the pain. There are no other contra-indications for work. Molly stays out of work, and in Workers Compensation, for twelve years and counting 3

4 Real Life Example: Molly and Cathy Cathy Cathy says: she has not had a back injury, she does not have any back pain, she wants to return to work. Cathy and Molly s circumstances are otherwise identical (including their general medical status). How do we know this?... Real Life Example: Molly and Cathy Cathy and Molly are the same person (Dissociative Identity Disorder). Real Life Example: Molly and Cathy Clear cut example of a general medical injury and disability claim being completely dependent upon psychological factors, being endorsed by doctors as a general medical claim, and being accepted into the Workers Compensation disability system. 4

5 Molly and Cathy: How Common? Not Common Cathy and Molly are the same person (Dissociative Identity Disorder). Extremely Common Extremely Common Molly s doctors declare that she has had an injury, simply because Molly says she has had an injury. There is no evidence of injury other than her complaint of pain. Molly s doctors say that she cannot work, simply because Molly says that she cannot work. There is no other evidence of an inability to work. Molly receives years/decades of testing and treatment focused on a false assumption that she is injured, with no benefit. The true cause of her claim is ignored, and credible treatment options are avoided. Chronic pain complaints completely attributable to psychology, rather than injury or other general medical factors. Question #1 What is the typical cause of a low back pain occupational injury claim? Possible answer: Injury FALSE! 5

6 Injury is not the typical cause of a low back pain workers compensation claim No identifiable general medical mechanism in 85% of low back pain cases Deyo (2001). NEJM. AMA Guides 5 th Edition. AMA s Physician s Guide to Return to Work. Talmage and Melhorn, 2005 The nature of one s work does not change the risk of developing back pain. Bigos SJ, et al. A prospective study of work perceptions and psychological factors affecting the report of back injury. Spine, 1991, 16, 1-6. AMA s Physician s Guide to Return to Work. Talmage and Melhorn, 2005 Psychological factors predict who will file an occupational injury claim. The most predictive individual factors were (1) job task dissatisfaction and (2) distress as reported on Scale 3 of the Minnesota Multiphasic Personality Inventory (MMPI). Bigos, Battie, Spengler, et al. A longitudinal, prospective study of industrial back injury reporting. Clin Orthop Relat Res Jun;(279):

7 Psychological factors predict who will file an occupational injury claim. Scale 3 of the Minnesota Multiphasic Personality Inventory (MMPI)??? This scale was constructed using patients who exhibited some physical complaints for which no general medical explanation could be established. MMPI-2 Manual Psychological factors predict who will file an occupational injury claim. Scale 3 of the Minnesota Multiphasic Personality Inventory (MMPI)??? In other words, the extreme opposite of injury is the best predictor of a workers compensation claim being filed!!!! So, what are the risk factors for disabling chronic low back pain? 7

8 The nature of chronic pain. American Pain Society review: Sanders, S. H. (2000). Risk factors for chronic, disabling low back pain: an update for American Pain Society Bulletin, March/April. Scientifically established risk factors for chronic disabling low back pain Risk factors for disabling chronic low back pain Age Pre-existing existing somatization tendencies, Pre-existing existing depressive tendencies, Low activity levels, Job dissatisfaction, Blue collar employment, History of childhood abuse, History of substance abuse, Claims context of presentation, Unemployment. Dr. Alf Nachemson His book reviewed by Dr. Andersson, in the NEJM, as by far the best book ever written on the subject. 8

9 Back AND Neck Pain Textbook review: Nachemson AL, Jonsson E. Neck and Back Pain.. Philadelphia, Pa: Lippincott, Williams, and Wilkins; There is strong evidence that psychosocial variables generally have more impact than biomedical or biomechanical factors. (continued) Back AND Neck Pain psychosocial variables generally have more impact: passive attitude; a tendency to think catastrophically about the pain complaints; depression; anxiety; any other form of emotional distress; a history of sexual and/or physical abuse; a perception of poor health in general. Chronic disabling back pain medical-legal legal claims The primary importance of personality disorders 9

10 Personality Disorders Definition (DSM-IV IV-TR): A personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations ti of the individual s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment. Prevalence of Personality Disorders General population 10% - 13% Hales, R. E., Yudofsky, S. C., (2002). The American Psychiatric Publishing Textbook of Clinical Psychiatry, Fourth Edition. American Psychiatric Publishing. chronic pain patients 31% - 64% Gatchel and Weisberg (2000). Personality Characteristics of Patients With Pain. American Psychological Association. chronic disabling neck and back pain patients in workers comp 70% Dersh J, et al. Prevalence of psychiatric disorders in patients with chronic disabling occupational spinal disorders. Spine May 1;31(10): The primary importance of personality disorders 1. General medical investigation of low back pain claims will produce significant findings 10-15% 15% of the time (at the most), but 2. Investigating for a personality disorder will produce significant results 70% of the time for medical-legal legal claims of chronic low back or neck pain 10

11 The primary importance of personality disorders 1. General medical investigation of low back pain claims will produce significant findings 10-15% 15% of the time (at the most), but 2. Investigating for a personality disorder will produce significant results 70% of the time for medical-legal legal claims of chronic low back pain Rhetorical question: Why are we always doing MRIs and other general medical investigations, while we almost never respond to back claims by evaluating for personality disorders? Mental illnesses that are commonly associated with complaints of pain: Mental illnesses commonly associated with complaints of pain: Somatoform Disorders Mood Disorders Anxiety Disorders Personality Disorders Psychotic Disorders Factitious Disorders Substance-Related Disorders 11

12 Pain is typical for mental illness Psychiatric patients: 87% had complaints of pain 58% reported pain duration > 2 years Hales, R. E., Yudofsky, S. C., (2002). The American Psychiatric Publishing Textbook of Clinical Psychiatry, Fourth Edition. American Psychiatric Publishing. Bottom line in regard to medical-legal legal claims of back injury They usually aren t really injuries They usually aren t really injuries Hadler NM, Tait RC, Chibnall JT. Back pain in the workplace. JAMA Apr 11;297(14): Back pain is not an injury The injury-model for back pain is doing more harm than good. 12

13 They usually aren t really injuries Allan DB, Waddell G. An historical perspective on low back pain and disability. Acta Orthop Scand Suppl. 1989;234: A history lesson in how backache (something like a headache) transformed into the concept of back injury. Question #2 What are the risk factors for a complex regional pain syndrome type 1 (CRPS-1) scenario? (note: CRPS-1 is the modern concept that replaced the antiquated and misleading concept of reflex sympathetic ti dystrophy/rsd) Possible answer: Injury False! Risk factors for CRPS/rsd Can you rank these in order? Injury Mental illness Eligibility for compensation (e.g., occupational injury claim or other legal claim) And the answer is 1. Mental illness (predicts with over 90% accuracy) 2. Eligibility for compensation (70-80% correlation) What happened to injury? 13

14 Risk factors for CRPS/rsd Injury is not predictive of CRPS less than 1% correlation between injury and claims of CRPS outside of occupational injury systems, 35% of cases do not even attempt to claim a relationship to injury Definition of CRPS actually indicates a lack of injury-relatedness relatedness (rather clearly) Barth RJ and Haralson R. Differential Diagnosis for Complex Regional Pain Syndrome. The Guides Newsletter,, September/October American Medical Association. Question #3 What are the best predictors of response to surgery, spinal cord stimulation, and other medical interventions for pain? Predictors of benefitting from surgery, SCS, and other interventions for pain Possible answers: Physical examination findings MRI Myelogram Diskography Treating doctor s opinion False! False! False! False! False! 14

15 Psychological issues predict surgical, SCS, and other treatment outcomes... Elevated risk of surgical/treatment failure Occupational injury claim Medical-legal legal considerations Mental illness Depression Abnormal scores on psychological testing Less education Out of work > or equal to 6 months Long duration of pain complaints Multiple operations Previous unsuccessful surgery Elevated risk of surgical/treatment failure Lower activity level Lower job level Recurrent back pain High intensity of acute back pain Widowed or divorced Over 40 years of age Physically demanding occupation Catastrophic thoughts Somatoform tendencies Elevated stress levels Elevated risk of surgical/treatment failure Failure to benefit from more conservative care Elevated levels of pain-related behavior Social reinforcement for pain-related behavior Relief from domestic responsibilities subsequent to pain complaints Extensive time lying down because of pain complaints Pessimism Difficulty trusting doctors Assumptions that medical problems automatically involve weakness and inefficiency History of physical or sexual abuse, childhood abandonment, or neglect 15

16 Question #4 What is the cause of postconcussion syndrome? Question #4 What is the cause of postconcussion syndrome? Possible answer: Concussion / Brain injury False! PCS is demonstrated by people who never had a brain injury. And Prolonged postconcussion syndrome is not demonstrated any more frequently among people who have had a brain injury, compared to people who have not. Brain injury is not the cause of postconcussion syndrome So what are the risk factors for a prolonged postconcussion syndrome? 1. Legal claim (e.g. occupational injury claim, personal injury claim, etc.) 2. Pre-existing existing psychopathology Carroll LJ, Cassidy JD. PROGNOSIS FOR MILD TRAUMATIC BRAIN INJURY: RESULTS OF THE WHO COLLABORATING CENTRE TASK FORCE ON MILD TRAUMATIC BRAIN INJURY. J Rehabil Med 2004; Suppl. 43:

17 Question #5 What is the typical cause of persistent posttraumatic headaches? Cause of persistent posttraumatic headache Possible answer: Head injury False! Barth, RJ Obstacles to Claiming Permanence and Injury-Relatedness for Posttraumatic Headache. Guides Newsletter May/June 2009 American Medical Association Head injury is not the cause of persistent headaches Outside of those who have a legal claim, persistent headaches occur at the same rates for people who have and have not had head trauma When the possibility of non-injury injury-related related causes was actually investigated, medication was identified as the cause of the persistent posttraumatic headaches in the vast majority of the cases. Other than claims context, and medication, the most common cause of persistent headache complaints is emotional disturbance (e.g., pathological manifestations of depression and anxiety). 17

18 Question #6 What is the cause of posttraumatic stress disorder? Note: This discussion is limited to civilian PTSD claims, and does not address military combat PTSD claims Cause of PTSD Possible answer: Injury and/or any other emotionally traumatic experience False! PTSD is demonstrated by people who have never had a significant injury or traumatic experience, and PTSD is not demonstrated any more frequently among people who have had an injury/trauma, compared to people who have not. Risk factors for PTSD In the short term: Pre-existing existing psychological disturbance Eligibility for benefits (~70% correlation) Traumatic experience (~10% correlation) In the long term: Eligibility for benefits Pre-existing existing psychological disturbance (the only predictive factor, according to studies that did not look at benefit eligibility) What happened to trauma? 18

19 Risk factors for PTSD In the long term: Traumatic experiences do not have any predictive value in regard to long- term claims of PTSD (zero correlation between trauma experience and symptoms in the long term) Barth, RJ. Mental Illness, in: Melhorn, JM, and Ackerman, WE. Guides to the Evaluation of Disease and Injury Causation American Medical Association. Question #7 When studied in a scientifically credible manner, what is the rate of malingering among claimants? Question #7 When studied in a scientifically credible manner, what is the rate of malingering among claimants? These data show base rates of malingering that approach or exceed 50%... Larrabee GJ. Assessment of Malingered Neuropsychological Deficits. Oxford,

20 What all of this means for medical- legal claims of all types If the psychological, non-injury-related, related, non-general medical issues are not addressed, we will very often be lacking the data that is necessary for Making sense of the case and claim Treatment planning You can initiate an investigation of the psychological factors that are playing a role in any given case, before sending the claimant to a psychologist. Investigating before sending to a psychologist A laboratory model Standardized assessment questionnaires in your office (or the office of any trustworthy local doctor). 20

21 Standardized questionnaires in your office. Avoid/delay referral to mental health clinicians Provides credible, objective information for further decision making Explain The pain complaints. The claims of disability. Predict Treatment outcomes Results of this effort: Better clinical services. Avoidance of harmful misdirected and excessive testing and treatment, and the associated costs. Standardized questionnaires in your office. Option #1 A Simple First Step MMPI-2 (Minnesota Multiphasic Personality Inventory, Second Edition) BHI-2 (Battery for Health Improvement 2nd Edition) Questions that can be OBJECTIVELY addressed by Option #1 Is the claimant is hiding psychopathology that could account for pain complaints, injury claim, disability claim, etc? Is the claimant s presentation consistent with mental illness being the cause of the pain complaints, injury claim, impairment, and disability? Is the claimant s presentation consistent with physical injury being the cause of the pain complaints, injury claim, impairment, and disability? 21

22 Questions that can be OBJECTIVELY addressed by Option #1 Is the claimant s presentation of pain consistent with malingering? g Is this claimant likely to benefit from the proposed surgery or other treatment? Questions that can be OBJECTIVELY addressed by Option #1 Is the claimant s presentation consistent with mental illness in general? Is the claimant s presentation of mental illness consistent with injury- related psychological disturbance? Is the claimant s presentation consistent with fabricated or exaggerated mental illness? Services facilitated by your office (or the office of any trustworthy local doctor). Option #2 More Extensive Testing Option #3 File review by a knowledgeable consultant 22

23 Take Home Simple Summary Take Home Summary Pre-existing existing psychological factors predict who will file a medical-legal legal claim (regardless of whether there has been an injury) Psychological factors predict who will file an medical-legal legal claim Therefore, when we assume that injury is the cause of the claim, we are setting up the claimant for a lousy clinical outcome Treatment will be misdirected mistakenly focused on an injury model, which is usually not the most important issue. Appropriate treatment options will be ignored: e.g., treatment which focuses on the true non-work- related causes of the claim The patient is mistakenly enrolled (trapped?) in a medical- legal context And a medical-legal legal context reliably leads to a worse clinical outcome 23

24 Case Study Case Study 60 year old female. History: Claiming disability from low back pain of 20 years duration. Six fusions. For the second time in four years, a pain specialist anesthesiologist is recommending spinal cord stimulation. (continued) Case Study Mood disorder? Treating doctor, citing his years of experience with the claimant, insists that her depression is nothing more than a normal reaction to her chronic pain and disability. Records (and eventually interview) reveal pre-pain pain Major Depressive Disorder, Recurrent (with multiple episodes prior to the pain complaints). Testing reveals depression elevations beyond the typical effects of pain complaints and physical injury (despite minimizing response pattern). Diagnostic work-up never before attempted in 35 years of Major Depressive Disorder, Recurrent, or in 16 years of pain complaints. (continued) 24

25 Case Study Anxiety disorder? Treating doctor, citing his years of experience with the claimant, insists that all of her psychological problems are normal reactions to her chronic pain and disability. Records (and eventually interview) reveal pre-pain pain Panic Disorder, and treatment for non-pain pain-related anxiety. Case Study Personality disorder? Treating doctor, citing his years of experience with the claimant, insists that all of her psychological problems are normal reactions to her chronic pain and disability. Testing reveals consistency with Dependent Personality Disorder and Obsessive Compulsive Personality Disorder (despite minimizing response patterns). (continued) Case Study Somatoform disorder? Consistency with Somatization Disorder (extremely wide variety of pain, stomach, sexual, and pseudo-neurological complaints; dating back to her 20 s). Doctors have previously specified somatoform issues for claimant s chest pain, sweating, dizziness, fainting, hot flashes, blood pressure problems, blood sugar problems, and gastro- intestinal problems. (continued) 25

26 Recommendations: Case Study Spinal cord stimulation is a bad idea for this claimant: unlikely to benefit her. inconsistent with her stated goals. risk of worsening mood and somatoform disorder presentations. (continued) Case Study Recommendations: Standard set of recommendations for chronic low back pain: preventing/avoiding dependence on medical treatment, emphasizing coping with symptoms rather than attempting to eliminate them, avoiding "as needed" medication regimens, avoiding long-term drug treatment, gradually increasing activities, exercise therapy that involves gradually increasing the intensity of the exercise at fixed periods independent of the presence of pain. Return to work Getting out of the workers compensation system (continued) Case Study Recommendations: Mental health care (to take place outside of an occupational injury system): Major Depressive Disorder, Recurrent; panic; additional anxiety problems; somatoform considerations; personality disorder considerations; (continued) 26

27 Case Study Recommendations: Mental health care (to take place outside of an occupational injury program): temporal correlations between life stress/concerns and her pain complaints; the consistency of her test results with individuals who attempt to control others by complaining of physical symptoms and who use their physical complaints as a means of gaining attention (especially in light of her report that her husband is otherwise a "workaholic"); the tendency for individuals who experienced childhood abuse to adopt self-defeating disability behaviors. maintaining/returning to work is reliably beneficial for a patient s health (both low back pain and mental health). Note: I have presented this in a manner that reveals it to be a complicated mess that will require extensive intervention to straighten out, but Through 20 years of medical care for low back pain, all treating doctors had perceived it to be an uncomplicated and typical case of low back pain. 27

All contents of this presentation remain the cannot be used for any purpose in the absence of Dr. Barth s specific authorization.

All contents of this presentation remain the cannot be used for any purpose in the absence of Dr. Barth s specific authorization. The nature of back pain Robert J. Barth, Ph.D. Chattanooga, TN and Birmingham, AL Parkridge Hospital Plaza Two, Suite 202 2339 McCallie Av. Chattanooga, TN 37404 423/624-20002000 rjbarth@barthneuroscience.org

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