The Worker's Comp Patient....

[Psychobabbling]

I have patient who is relatively new to me, involved in a worker's comp case, who has proven rather difficult to treat. I won't go into a ton of details, but here's some highlights:

1) Had been seeing her PMD for about 4 months. PMD punted her to our clinic for a "higher level of care"

2) Initial interview took way too much time, they spent 30 minutes talking about their worker's comp case, making sure to specify when their symptoms started EXACTLY and how it correlated perfectly with work related issues

3) A little impressionistic; Somatizes in the room (oh my god I'm getting a headache, etc)

4) Feels like they self-sabotage their treatment; Example: I've been getting so nauseous, I know it was from drug x (stops drug x). Then a doctor put me and drug y but it did nothing. OK - so you want to try drug z? "sure" - month later. "so i stopped drug z, it made me nauseous" - but you've been nauseous on drug x, after drug x, before drug y, with drug y, etc etc. "yes, but it's definitely drug z" - OK - why didn't you call me before you stopped it "well because I had this appointment" - OK - but you called me that day to see when your appointment was...."yes but...."

5) Responds to any kind of confronting (and I mean as empathic as I can come across for some of the things they says. Not an exact quote but like "Drug Z caused me vomit 10 times a day but I've gained 10 pounds because of all the food I've been eating") - by crying, devaluing, etc

Being a resident on this case has proven problematic as well. I have been told, in essence, to censor my documentation, write excuses from working, etc. None of which sits well with me.

Does anyone have any recommendations for patient's with ongoing worker's comp claims, this sort of self-defeating approach to treatment (malingering? factitious?), and ways to navigate dealing with an attending/supervisor when your views on the case are drastically different?

Much appreciated, as always

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[novopsych]

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[smalltownpsych]

It can be difficult, if not impossible to help someone who does not want to get better. Patients with this type of presentation can be very frustrating. Motivational Interviewing techniques can be helpful as that keeps focus on where patient is at with their desire to change. The supervisor stuff should be talked through to arrive at a good treatment plan that you are both on board with.

 

[birchswing]

I'm not a doctor (that's a disclaimer).

I'm not familiar with how worker's comp works, but does the person have to keep coming to see you to get it? If not, then the initial appt where the patient made sure to connect an incident to the symptoms would make sense from a factitious point of view--but why would the patient keep coming back—especially if the only treatment he/she's getting is nausea-inducing drugs?

From my lay point of view as a patient and without you having described many symptoms or your diagnosis, this sounds like it could be a condition that is not meant to be treated with medication. I know the personality type you're describing. They usually have a fractured childhood in some way. I know it's a bit cliche, but your description of devaluing and crying almost sounds like an invitation for someone to say borderline.

I don't know why the borderline diagnosis is so taboo. The people I know who have been diagnosed with it have been grateful for it and have done better and gained insight instead of chasing non-solutions, which is the alternative to diagnosing it.

I'm also not sure why you say the patient is self-defeating. That implies an awareness that your patient doesn't seem to have.

As far as being told to contain (in the psychological sense) the patient for the time being (write out the excuse notes, etc.), I would recommend a viewing of Lars and the Real Girl. It's been mis-categorized as a comedy. I think it's a great film about the power of containment.

 

[OldPsychDoc]

There's frequently a secondary gain, as mentioned above, in maintaining the sick role--maybe it's being able to stay away from a job or boss they don't like, or just the ability to be paid to stay home and watch daytime TV. What has helped me is when I can make clear that my role is to treat the impairment and return the patient to baseline as well as possible, and if at all possible, refer the disability determination to a different physician.

 

[vistaril]

agree with OPD....you've got to separate yourself from the whole issue of disability. Make it clear to the patient that you are not there to
determine whether or not they get disability. When I get patients like this, I just listen to them, nod with empathy, and then just treat them with the understanding that you probably won't be able to help them much. Also, keep the do no harm principle in play too.......if the patient isn't going to benefit much from whatever you do, may as well concentrate on treatments that offer little risk of harm at least.

 

[jettavr6]

Generally, the drugs that cause them the least side effects are xanax, klonopin, soma and adderall. Percocet, although a major cause of nausea in most, tends to alleviate nausea in the work comp population. The klonopin / soma mixture is the only treatment which helps for PTSD. The adderall counters the side effect of fatigue.

I wish what I wrote above was a joke. Sadly, I've had more than a few patients that fit that exact profile. What do I do in those circumstances? I refuse to prescribe anything which I feel will propagate the problem or continue their learned helplessness, malingering, etc. At almost every appointment with the few workers compensation patients that I have, I keep emphasizing what type of work they "can" do and that we are going to get them back to that lien of work ASAP. Some get pissed off and leave, while others actually understand, and get with the plan.

Any attending that tells you that you must write a work excuse when there is reasonable evidence to suggest that this is improper should be reported. It is considered healthcare/insurance fraud.

 

[Psychobabbling]

Thanks for the replies.

The motivational interviewing techniques is interesting, I'll try to employ more of an emphasis on that.

I didn't mean to suggest she was borderline, but it is something I've considered (that and HPD). She typically engages in somatization, regression quite a bit, so I lean a little more to the histrionic side. They usually ramp up my "counter transference" (buzz word at my clinic, lol) the most (I reference that because people cite it all the time, largely out of context, which always makes me laugh).

OPD - I guess I find it hard to "treat the impairment" with this lady. She overly endorses ALL depressive/anxiety symptoms, and my impression of her is that she may actually meet criteria for something, but her tendency to be somewhat dramatic/impressionistic/somatic really clouds what the hell I'm supposed to be doing. My real impression is of a primitive woman who has difficulty expressing herself, so she over endorses symptoms as a means to secure attention from others (a little more on the borderline side but I don't really have a good sense of her developmental history from an object relations perspective either)

That being said, I feel at least justifiable starting on SSRI - just not with the "you have to diagnose as Adjustment Disorder," (as that seems to be conflicting by nature). I emphasized with her that her issues at work seemed to be causing her to feel this way, that I would like to continue to work with her to better understand what her baseline is, and that the primary treatment that I would recommend would be therapy to work with breathing techniques/grounding techniques/development of coping skills...at least to start. That gets agreed upon...and then she sabotages her treatment (or not?). She told me she stopped Paxil prior to this worker's comp psychiatric evaluation, but, tells her counselor that this doc told her to stop and ask for prozac, so she did....If you don't want to follow my recommendations, you don't want to go to partial or day program for a higher level of care (so anxious and depressed, I was going to check myself into the hospital)....then what am I possibly doing besides kicking my feet in mud?

I totally get the struggles of depression, anxiety, personality struggles, psychosis (not from a "I've experienced all of these") but having treated a number of people throughout my training and seeing a variety of interpersonal issues, to say the least, I can certainly empathize with patients. However, we're all adults. If you don't follow recommendations, don't consult with me, listen to various other doctors you run into, etc etc Then...that's okay with me. I'll gladly help refer to someone else, I'll gladly see you until you get your appointment, and I'd be glad to actually work with you to help you to the best of my ability. In the end, I don't think anyone can help someone who doesn't actually want to be helped. If a primary drops a patient with diabetes because they refuse to be compliant with treatment - that's their right. They recommend metformin and an insulin regimen. Patient refuses. That's okay - he's a referral, I wish you the best of luck. This almost fantasy of rescuing people and what not, I'm not really about that.

That's probably me sounding "harsh" and being a "bad resident," but those are my beliefs. I am 100% open to new ways of thinking, conceptualizing patients differently, trying different approaches, etc. I really am. I've had patients where I see them a second or third time and say "hmm, my initial impression was a little off. It seems to be more so x/y/z. We've been able to establish a better alliance. We both know now what the issues are and are working towards treating them and monitoring for improvements." Usually that happens when personality props its ugly head - and I'm aware of those issues I have with certain PDs - and make more a concerted effort to make sure I'm not missing something on an evaluation for treatment when I recognize such.

I don't know. I feel like I'm going crazy sometimes. Every psychiatrist has a different approach to treatment that works for them. It's certainly valuable to take information from sources that varies your own style, but it's nice to run by someone with a similar style to your own certain cases, because I think that can be really valuable in terms of if you "missed" something or could think of a presentation a different way...

I'm rambling, end of post.

 

[tr]

ITA with the advice to implement motivational interviewing. MI not only helps manage the patient's feelings, it helps *you* manage your countertransference. Instead of engaging in a struggle with the patient, you just roll with it and take opportunities to develop discrepancy. "Oh, you stopped your medication? It sounds like these side effects are very distressing for you. On the one hand you have this horrible nausea, and on the other this depression and anxiety. It's a real dilemma. Maybe it's worth more to you to avoid the nausea and just live with the anxiety and depression. What do you think?"

OR
"I know it's really hard for you to live with these symptoms, and on the other hand now your income actually depends on them, and it might be sort of hard to picture how your life would be without them. What do you think?"

This kind of response puts the conflict out for the patient to really look at and deal with, and prevents you from being in the position of arguing with the patient, which is frustrating for you and tends to cause them to dig in their heels.

 

[birchswing]

ITA with the advice to implement motivational interviewing. MI not only helps manage the patient's feelings, it helps *you* manage your countertransference. Instead of engaging in a struggle with the patient, you just roll with it and take opportunities to develop discrepancy. "Oh, you stopped your medication? It sounds like these side effects are very distressing for you. On the one hand you have this horrible nausea, and on the other this depression and anxiety. It's a real dilemma. Maybe it's worth more to you to avoid the nausea and just live with the anxiety and depression. What do you think?"

OR
"I know it's really hard for you to live with these symptoms, and on the other hand now your income actually depends on them, and it might be sort of hard to picture how your life would be without them. What do you think?"

This kind of response puts the conflict out for the patient to really look at and deal with, and prevents you from being in the position of arguing with the patient, which is frustrating for you and tends to cause them to dig in their heels.

I know I'm not a doctor, but either motivational interviewing is not what I thought it is or it's not what you think it is.

What you described sounds like patronizing, passive-aggressive behavior. And I think most patients would see it as such.

I agree with you though that a technique is needed where the doctor is not arguing with the patient (as the OP said he confronted the patient for saying that each drug made him/her nauseous and confronted him/her about not signaling a med change during a phone call).

To those two points, I will say two things: I have never had a psychiatrist who could be bothered to know if I stopped a med due to side effects before an appointment. Even if I called and talked to a secretary, the secretary would tell me I'd have to make an appointment to discuss this with the doctor and that if I were having an issue that needed attention to go to an ER. That's the standard response these days. I don't think it's a particularly good approach. How are you supposed to try a new drug and titrate it when you have to wait three months to get back in and have no communication in the mean time? And whatever appointment would be available would obviously be past my already scheduled appointment. Maybe the OP is different but his/her patient could be used to the system I know in which there is no patient-doctor communication outside of appointments. The way the OP described it, it did sound a bit as if he/she was antagonizing the patient a bit on that point of why-didn't-you-call-me. I'm in agreement with you there. That isn't helpful.

As for the nausea on three different drugs—let's say we're talking about three SSRIs—of course a person is going to have nausea starting an SSRI. Blaming the patient is ridiculous. We have no reason to know whether the OP educated the patient on the nausea that starting whatever drug it was could cause. We're not working with enough information to make a statement on that. So instead we're throwing out bombs like: Maybe you'd rather be anxious and depressed the rest of your life? When it's equally possible that the patient has an ulcer (SSRIs can cause increased irritation of ulcers) or that the drugs being used have the inherent side effect of causing nausea upon starting them but that the patient hasn't been educated. If you have a doctor who thinks nausea from an SSRI is a rare response and stops that SSRI to throw out another one and then is baffled that the patient has continuing nausea, well, you've got a problem. That's a hump the patient has got to get over. And the psychiatrist has to know there's a hump and provide hope about getting over that hump.

Again, this is assuming we're talking about SSRIs, but we have no idea. I'm not against motivational interviewing; it's just that what you posted sounds like it would increase antagonism. And in addition, we don't even have any real information on the patient. We're hearing one side, with most information redacted.

 

[tr]

I know I'm not a doctor, but either motivational interviewing is not what I thought it is or it's not what you think it is.

My feeling on this is that you can't argue with success. Call it what you like, I use these techniques regularly and have seen amazing results with them. Patients with inveterate social anxiety who turn around and engage in the very social activity they were saying they could never possibly face, after a short 5-10 min conversation. Patients who were totally opposed to necessary medical treatment who become very agreeable and cooperative after a talk of twenty or thirty minutes. The results are not to be believed.

That said, I'm happy to hear your alternative suggestions for phraseology. Keep in mind that it's actually quite hard to represent a fluid conversation with a few, one-sided sentences. Obviously what I posted above is not what I would say word-for-word, but a very brief synopsis of the most critical points of a typical conversation. You would need to set this up with a lot of empathetic reflection and follow the patient's lead (which I had to impute from the information in the original post, of course it's a best guess as to what the patient would have actually said). However it's not realistic to represent that in this format. I'd refer you to Miller and Rollnick (Motivational Interviewing: Preparing People for Change) for a more extended treatment.

What you described sounds like patronizing, passive-aggressive behavior. And I think most patients would see it as such.

So if it's done in a patronizing way, it won't work. It's key to this that you actually have to bring yourself to see the patient's side of the argument, even though the patient's priorities don't match yours and his decisions are not the ones you would make. The interviewer needs to recognize explicitly the priority structure that the patient is working with. E.g., for a drug addict, the acute need for a high really does outweigh the cost of the havoc he is wreaking on his life - or at least it does in the moment, and his behavior is following that priority structure. Explicitly stating that this is what he is doing, and recognizing the power of the need for the drug, can be revelatory, and paradoxically also opens the door for him to think about whether that is really the priority structure that he wants to live under.

So instead we're throwing out bombs like: Maybe you'd rather be anxious and depressed the rest of your life?

I'd note that "maybe you'd rather live with the anxiety and depression than the nausea" is quite different than "maybe you'd rather be anxious and depressed the rest of your life." The former is an evenhanded recognition of the patient's priority structure. The latter is challenging and argumentative.

 

[Armadillos]

When it's equally possible that the patient has an ulcer (SSRIs can cause increased irritation of ulcers) .

Probably not equally likely.

Also IMO all psychotherapy/motivational interviewing is inherently patronizing, a patient has some sort of belief or behavior and we are manipulating them to change it. In the case of motivational interviewing it works better the less the patient realizes they are being manipulated and instead believe the change was their own idea. Thats pretty patronizing, but who cares?

 

[Ceke2002]

I know I'm not a doctor, but either motivational interviewing is not what I thought it is or it's not what you think it is.

What you described sounds like patronizing, passive-aggressive behavior. And I think most patients would see it as such.

I agree with you though that a technique is needed where the doctor is not arguing with the patient (as the OP said he confronted the patient for saying that each drug made him/her nauseous and confronted him/her about not signaling a med change during a phone call).

To those two points, I will say two things: I have never had a psychiatrist who could be bothered to know if I stopped a med due to side effects before an appointment. Even if I called and talked to a secretary, the secretary would tell me I'd have to make an appointment to discuss this with the doctor and that if I were having an issue that needed attention to go to an ER. That's the standard response these days. I don't think it's a particularly good approach. How are you supposed to try a new drug and titrate it when you have to wait three months to get back in and have no communication in the mean time? And whatever appointment would be available would obviously be past my already scheduled appointment. Maybe the OP is different but his/her patient could be used to the system I know in which there is no patient-doctor communication outside of appointments. The way the OP described it, it did sound a bit as if he/she was antagonizing the patient a bit on that point of why-didn't-you-call-me. I'm in agreement with you there. That isn't helpful.

As for the nausea on three different drugs—let's say we're talking about three SSRIs—of course a person is going to have nausea starting an SSRI. Blaming the patient is ridiculous. We have no reason to know whether the OP educated the patient on the nausea that starting whatever drug it was could cause. We're not working with enough information to make a statement on that. So instead we're throwing out bombs like: Maybe you'd rather be anxious and depressed the rest of your life? When it's equally possible that the patient has an ulcer (SSRIs can cause increased irritation of ulcers) or that the drugs being used have the inherent side effect of causing nausea upon starting them but that the patient hasn't been educated. If you have a doctor who thinks nausea from an SSRI is a rare response and stops that SSRI to throw out another one and then is baffled that the patient has continuing nausea, well, you've got a problem. That's a hump the patient has got to get over. And the psychiatrist has to know there's a hump and provide hope about getting over that hump.

Again, this is assuming we're talking about SSRIs, but we have no idea. I'm not against motivational interviewing; it's just that what you posted sounds like it would increase antagonism. And in addition, we don't even have any real information on the patient. We're hearing one side, with most information redacted.

Wow, that's kind of a surprise to me with how your medication is managed. If that's the general case for most patients in the US I could understand why someone would stop and start or change meds without necessarily letting their Doctor know or discussing any adverse side effects beforehand. Having said that though it does ping my 'what else is going on here' button when someone is apparently deciding to not take their medication based on a side effect as innocuous as nausea. I mean back at the start of the year, until I was re-medicated at least, I would have gladly chosen feeling queasy over basically wanting to string myself up on a daily basis. Sure I still got side effects when I was started back on a (new) antidepressant, and some of those were kind of annoying (really could have done without the dosage based akathisia) but there are side effects and then there are *side effects*. I could understand this patients apparent reluctance for medication, or her jumping on and off it at the first sign of any issues whatsoever, if she actually had a history of bad reactions to medication, but that doesn't seem to be the case here. Which automatically makes me wonder if she's re-enacting maladjusted interpersonal relationship type behaviour via her refusal or acceptance of medication/treatment. I say that because I know I did the exact same thing when my PD symptoms were at their height. It just so happens in my case I actually do have very bad reactions to some medications (resulting in at least a couple of trips to the Emergency Dept.), but I still milked that for all it was worth - alternatively placing myself in the role of victim, and assigning the various therapists I was seeing at the time the role of 'saviour', or swapping the roles around and playing caregiver to the therapist with a bunch of unconscious but well placed reassurances. All of which basically amounted to me getting stuck in old, negative patterns of relating and did exactly zip to advance my progress in therapy, until I learnt to change the way I related in therapy at least. It sounds to me like the OPs patient is going to be stuck in her same old negative holding pattern as well, unless she also learns a better way of relating that doesn't involve using her medication as a prop for her to play out her other issues around.

 

[smalltownpsych]

In motivational interviewing, the patient is the one coming up with the alternatives. I merely reflect those back. "So what you are saying is that you could either take the pill and feel nauseous or not and feel anxious". Then I would ask if there are other alternatives and maybe even suggest a few. This interchange is actually probably ahead of where the patient in the example is at in their stage of change. Also, since I am not a prescriber, you would think that I wouldn't have to worry about that as much, although you would be surprised how much these patients want me to align with their false hope that the right pill will fix them.

 

[Ceke2002]

Just some quick notes of possible advice from a patient's point of view:

• Definitely agree with Motivational Interviewing. Others have already posted good comments on that so no need to add more.
• Be consistent in your responses to her. If she does have a PD of some sort she will pick up on any inconsistencies and most likely interpret them as some sort of relational instability and act out accordingly. No matter how many buttons she presses, no matter what she says or does, she should know she is going to illicit the same response from you at all times.
• Plenty of positive reinforcement for willingness to change, more co-operation in treatment, etc etc, also a good idea - you want to empathise with the ambiguous/unwilling parts whilst giving an extra boost to those parts that are perhaps at least showing signs of moving more towards the contemplation or preparation stage(s).
• If she is using her medication experiences to re-enact negative patterns of relating, probably without even realising she's doing it, don't allow yourself to get pulled into whatever state of play and individual role assignment she might be setting up. You are her therapist, not her saviour, not her rescuer, not someone for her to play off any of her own rescue or care giving scenarios on, and so forth. Of course I'm not saying be a complete robot and never allow yourself any room to respond to her as an individual, just try to keep in mind what your primary role in this actually is, not what she might like it to be. You want to forge a therapeutic bond, it's a bit hard to do that if she's assigning false roles and ideas (or ideals) to you and you're not staying on top of that.

 

[smalltownpsych]

Just some quick notes of possible advice from a patient's point of view:

• If she is using her medication experiences to re-enact negative patterns of relating, probably without even realising she's doing it, don't allow yourself to get pulled into whatever state of play and individual role assignment she might be setting up. You are her therapist, not her saviour, not her rescuer, not someone for her to play off any of her own rescue or care giving scenarios on, and so forth. Of course I'm not saying be a complete robot and never allow yourself any room to respond to her as an individual, just try to keep in mind what your primary role in this actually is, not what she might like it to be. You want to forge a therapeutic bond, it's a bit hard to do that if she's assigning false roles and ideas (or ideals) to you and you're not staying on top of that.

Good psychodynamic principle! This is something that many clinicians forget about and thus get sucked right in to the enactment. Kernberg would say that you need to interpret the interpersonal hostility. To wit, this patient is angry because the people who are supposed to help her are not giving her what she needs and it feels just like mom and dad all over again. Bringing that out into the open can be an effective intervention. However, in my experience this is more effective with Borderline Personality types of presentation than this more dependent style.

 

[Psychobabbling]

Hello hello - read through most of the responses (skimmed some of the more long winded ones)

Just a quick update - MAN, those benzos sure do treat a bunch of things! I had no idea they improved symptoms of anxiety and depression! Magic!

(decided to just have her go back and try the benzo since SSRIs were difficult to tolerate..) More later

 

[birchswing]

Hello hello - read through most of the responses (skimmed some of the more long winded ones)

Just a quick update - MAN, those benzos sure do treat a bunch of things! I had no idea they improved symptoms of anxiety and depression! Magic!

(decided to just have her go back and try the benzo since SSRIs were difficult to tolerate..) More later

SSRIs are difficult to tolerate and Paxil is one hell of a something to get off of.

If this person isn't already benzo tolerant, might I suggest starting with a less addictive med such as Lyrica?

It's considered first-line treatment in Europe for anxiety. It has similar anxiolytic effects to benzodiazepines with a lower risk of physical tolerance.

EDIT: Forgot to add my usual disclaimer that I'm not a doctor.

 

[Ceke2002]

SSRIs are difficult to tolerate and Paxil is one hell of a something to get off of.

If this person isn't already benzo tolerant, might I suggest starting with a less addictive med such as Lyrica?

It's considered first-line treatment in Europe for anxiety. It has similar anxiolytic effects to benzodiazepines with a lower risk of physical tolerance.

EDIT: Forgot to add my usual disclaimer that I'm not a doctor.

Psst, I think they were being sarcastic