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The Dependency Curve – Guest Post from Dr. David B. Adams

This Week’s Topic: “It’s Curvilenear”

Question: “He clings to me, then resents me, then begs me and then rages against me.”

Dr. Adams replies: ”We enter life entirely dependent aside from vegetative functions. We cannot exist on our own, and this characterizes most living species.

We oft-times terminate our existence by returning to that same position, reliant upon others for the same functions that we had learned to perform independently so many decades ago. It is the curvilinear shape of dependence.

We learn to ambulate, communicate and negotiate our world in stages and steps that enable us to function as separate beings, and, in turn, we then rear our offspring to do the same. This is how society exists and advances.

There are obstacles and trauma that require us to briefly regress to deal with illness and injury, loss and disappointment, but in all cases we return to that path of autonomy.

We marry and become interdependent. We allow others to manage most of our lives and become passive-dependent. We become addicted and co-dependent. We resent those upon whom we must rely and become hostile-dependent.

An injury may require an acute period of return to dependency. We call upon emergency medical services, rely upon primary care, must defer to hospital policies, and for the most part we become conditioned, helpless to the point that we cannot even remove our own sutures (sidebar: Unless you are married to a nurse, but that’s likely off-topic).

Injury becomes a struggle between the inherent need to be independent and the concurrent and often pressing requirement that we temporarily accept our dependent role. This will include passively accepting our providers, their schedules, their treatment approach, as well as the consistency/inconsistency of receipt of benefits. Since this most often is in sharp contrast to how we existed only seconds prior to injury, this is arguably the greatest trauma of all.

For some patients, dependency is a characterological flaw. It is a personality defect awaiting expression. It may have presented multiple times during the patient’s history, times to which we are not privy. But the chronically emotionally dependent patient becomes a challenge in case management.

Those assisting the chronically dependent patient become the target of neediness, resentment and fear. The role must remain clinical and, to some degree, sterile in order to address objective damages. The dependency may be emotionally catastrophic for some patients, but it is not often addressed during the course of injury care.

It is essential to recognize that the dependency arising after injury is either something that the patient finds aversive or something to which the patient too readily acclimates.

An injury can be catastrophic to the point of complete and permanent inability to attend to the Activities of Daily Living. In all other instances, the goal from the outset must be a return to whatever level of independence can be achieved. Thus, the inpatient healthcare team includes discharge planning and goals in their initial assessment upon admission.

PTSD – Part One: Causation and Symptoms

_______________________________
Diagnostic Confusion

One would think from the number of PTSD diagnoses made by family physicians, orthopedists, and neurologists that this condition is rampant if not inevitable for any serious personal injury. It is not that simple.

Posttraumatic Stress Disorder as a diagnosis emerged after the Vietnam War. Prior to the then, “shell-shock” was the terminology used in the WWII and Korean wars. The Diagnostic and Statistical Manual (DSM III) classified the diagnosis as an anxiety disorder, and further refined diagnostic criteria in subsequent editions. The diagnosis as it exists in today’s DSM-5 utilizes the most specific criteria yet, re-categorizing PTSD as a stress (trauma) related disorder.

In most States, PTSD (or any other mental injury) is not compensable under workers’ compensation without a preceding physical injury. Nonetheless, some employers will authorize an evaluation for a significant emotional trauma like a robbery, even in the absence of tissue damage. Morally, it seems the right thing to do, and from a legal (perhaps jaded) perspective, an employer who offers treatment under workers compensation may be shielded from liability.

You may be bringing or defending a claim of Posttraumatic Stress Disorder. While diagnosing the disorder is a clinical process, as you weigh the evidence for likelihood of PTSD, here is some data that may guide your assessment.

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More Than One Form of PTSD

If a trauma occurred more than three days but less than four weeks ago, the diagnosis is Acute Stress Disorder.

This is not to be confused with Posttraumatic Stress Disorder – Acute, meaning the symptoms have been present between four weeks and three months.

Posttraumatic Stress Disorder – Chronic means the symptoms have been present longer than three months.
Posttraumatic Stress Disorder – Delayed Expression applies to symptoms that first arise > 6 months after the trauma.

Further refinement of the diagnosis depends upon severity and degree of impairment in functioning. Extreme symptoms may include depersonalization, or the feeling of being an outside observer of one’s body; derealization, or unreal and dreamlike surroundings; both are symptoms and forms of Dissociative Symptoms. Children under 18 are diagnosed by a different set of criteria and they are very sensitized to the traumas encountered by their parents.

_______________________________________________
Symptoms & Diagnosis

In personal injury claims, the diagnosis of PTSD is commonly associated with motor vehicle accidents, fires, airplane incidents, amputations, and assaults. Chronic back pain from an injury does not result in PTSD unless the injury itself was traumatic (such as falling from height or being struck by a car).

What are the criteria for a valid claim of Posttraumatic Stress Disorder, and why is the diagnosis so often misapplied by primary physicians when pain is the only complaint? Rather than dispute what PTSD is not, let us examine the eight criteria for a valid diagnosis of PTSD:

A. There must be a triggering event: exposure to actual or threatened death, serious injury, or sexual violence in one or more of the following ways:
i. Direct experience of the event
ii. Witnessing the event as it occurred to others
iii. Learning that the (accidental or violent) event happened to a close family member or friend
iv. Repeatedly experiencing personal (not via media) exposure to the trauma (such as 911 first responders)

B. A diagnosis of PTSD requires one or more of these symptoms be present following the event:
i. Recurrent intrusive memories that are involuntary
ii. Nightmares of the event –police officers may dream that their family is in great danger and they are powerless to save them.
iii. Flashbacks – the person feels or acts as though the event is happening again
iv. Extreme psychological distress at exposure to internal or external cues of the event (smells, sounds)
v. Extreme physical reactions to internal or external cues of the event (GI upset or vomiting, for instance)

C. The patient persistently avoids reminders of the event in one or more ways:
i. Avoids memories of the event in all forms
ii. Avoids external reminders of the event (people, places, objects, etc)

D. Changes in mood or cognition in one or more of the following ways:
i. Amnesia for important aspects of the event
ii. Pan-negative beliefs about self or the world
iii. Irrational self-blame
iv. Persistent negative emotions of fear, anger or shame
v. Withdrawal from activities
vi. Withdrawal and detachment from others
vii. Anhedonia or the inability to experience happiness or pleasure

E. One or more of the following behaviors are atypical in presence or severity prior to the event:
i. Extreme irritability or aggression
ii. Reckless or self-destructive behavior
iii. Extremely on guard for surroundings/safety
iv. Exaggerated startle response
v. Difficulty concentrating

F. The symptoms in Criteria B-E have lasted > 4 weeks

G. The symptoms are severe enough to impair functioning in social, occupational or other areas of functioning

H. The symptoms are not the result of medication or other medical conditions

Next time: Treatment and Planning

The Mental Health Divide, Part II

continued from October 24, 2013)

More about the five axes of the DSM-IV-TR:

• Axis I relates to Clinical Disorders, which include all forms of depression (severity and recurrence), anxiety and mood disorders, PTSD, schizophrenia and psychoses. Think of these as disorders that are acute or chronic, biologic or reactive, but generally responsive to psychotherapy alone or in combination with medication. • Axis II reflects Personality Disorders, or features and traits that are lifelong characteristics that often interfere with daily functioning, relationships, and adaptability. Depending upon the patient’s insight and motivation, these traits are addressed via a range of psychotherapeutic approaches, either alone or in combination. Examples include Dependent, Avoidant, Obsessive-Compulsive and Narcissistic Personality Disorders. The most commonly used diagnosis is 301.9 – Personality Disorder NOS with (fill in the blank) Features when more than one trait is problematic. An IQ that falls below a certain threshold is also listed under Axis II. • Axis III lists the physical conditions present in the individual, and these are particularly pertinent to patients with chronic pain, injury or serious illness. • Axis IV outlines the psychosocial factors such as family dynamics, housing, occupation and finance that are affecting, or affected by, the individual. • Axis V measures the Global Assessment of Functioning (GAF), a numerical scale that assesses an individual’s ability to function in all areas of life, based upon the combination of Axes I-IV.

The DSM-IV-TR vs the DSM-V

Since its inception in 1952 and throughout its revisions, the accuracy and validity of the Diagnostic Statistical Manual (DSM) for classification of psychological symptoms has been challenged. Dr. Allen J. Frances, Professor Emeritus at Duke University, chaired the DSM-IV-TR task force (year 2000 Text Revision) and publicly objects to the impending release of the DSM-V.

An active blogger for the Huffington Post, he urges clinicians to ignore it’s changes altogether, asserting that the new version is vaguer than ever and will lead to labeling healthy individuals with its lowered threshold for criteria. In one of his blogs he states that the DSM-V is “offering its untested new diagnoses that will mislabel millions of the worried well as mentally ill”.  Parents of autistic children have the opposite concern, that their child will no longer fit in that diagnostic category and be denied access to medication and therapy.

Frances states that the DSM-V offers no leeway in differentiating, for instance, alcohol addiction vs dependence vs social use. The manual’s authors counter that early recognition will result in early intervention, but many practicing clinicians fear that the endpoint will be over-diagnosis that misidentifies normal variations in behavior.

The National Institute of Mental Health (NIMH)

On July 3, 1946, President Harry Truman signed the National Mental Health Act, which called for the establishment of a National Institute of Mental Health (NIMH). The process of diagnosing without etiology is the fundamental distinction between the DSM’s function and the conceptual model now proposed by the National Institute of Mental Health.

NIMH rejects all DSM versions and is devoting its considerable financial and scientific resources to the premise that all psychological conditions are biologic or chemical in nature, originating in specific regions of the brain, and thus amenable to medical intervention.  The stakes are significant – for insurance reimbursement, financial grants for research, pharmaceutical financing, and one hopes, the well-being of patients. Citing the difficulty in properly diagnosing mental health disorders when forced to choose an ICD code, in 2008 NIMH implemented its Strategic Plan, a diagnostic process using Research Domain Criteria (RDoc).

This plan utilizes a matrix of Constructs (rows) that are grouped into five Domains of Functioning, and seven classes of Variables (columns) with an eighth column for paradigms. The goal is to classify mental disorders along a continuum of biologic and genetic markers, neurological circuitry and specific regions of the brain. The attempt is not to diagnose a mental disorder by looking at the overall patient presentation, but to find one symptom that is present across a variety of disorders, eventually pinpointing the physical location of the symptom. This intersection would identify the origins of disease, and science (psychopharmacology) would intervene to avert mental disorder. This theory ignores the empirical research on the greater efficacy of “talking therapies” either alone or in combination with psychopharmacology, and even NIMH agrees that this lengthy research offers no immediate relief to patients.

Opponents to RDoc fear that severe illness (schizophrenia, bipolar disorder) may go untreated if the affected individual does not express a specific gene. They question the validity of research that is conducted solely in laboratories and does not involve practitioners in the field. NIMH counters that RDoc is an open document for which they have sought input from the medical community.

The term “Ivory Tower” designates an environment or atmosphere where intellectuals engage in pursuits that are disconnected from the practical concerns of everyday life” . The last sentence in the first paragraph of Draft 3.1: June, 2011 states that one of RDoc’s goals is “…to facilitate commentary from scientists and other interested stakeholders…” Should there be concern that patients and practicing clinicians are not mentioned in this sentence?

The Mental Health Divide, Part One

The Mental Health Divide

-Alice M. Adams, RN
Atlanta, Georgia

 

(Disclosure: I have worked fulltime for 20 years and now part time in a clinical psychological practice. As a nurse and patient advocate interfacing with physicians, nurse case managers and attorneys, dealing with insurance reimbursement was once 5% of one day a week; now it is closer to 20% of every day. Personal experience flavors objectivity in all of us.)

 

During the past month, the news has made the public aware of what mental health professionals have long been aware: the diagnosis of mental disorders is inexact, and treatment often proceeds without a known etiology.  In the real world of patient care, clinicians measure success in terms of empirical progress; has my patient improved, plateaued, or worsened? The answer is derived by objective observation and the patient’s self-reporting. But even objective observation contains an element of subjectivity, accounting for the diagnostic variability among clinicians examining the same patient.

Insurance and Pharmaceutical Influences in Diagnosis

The International Classification of Diseases’ (ICD) diagnostic codes govern the reimbursement of all care. Insurance companies require ICD-9 (and 10) codes from the DSM-IV-TR before they will authorize the evaluation or treatment of any mental disorder.  Psychologists and psychiatrists must choose a code that most closely matches the symptoms. A depressive episode is coded and further refined by duration, intensity of symptoms, single episode vs recurrent, and weighed against alternative diagnoses. The accuracy of diagnosis is largely dependent upon honest and complete disclosure from the patient.

But diagnoses fall in and out of favor; in favor they are overly utilized and can result in excessive labeling. Such labels facilitate insurance reimbursement and garner the attention of pharmaceutical companies. Recall when Ritalin was the only drug for ADHD replete with side effects and adverse reactions. Pharmaceutical companies took notice and funded extensive studies and trials that resulted in more targeted drug regimens. More funding and medication options in turn resulted in more ADHD diagnoses. And so on.

The DSM-IV-TR vs the DSM-V

Since its inception in 1952 and throughout its revisions, the accuracy and validity of the Diagnostic Statistical Manual (DSM) for classification of psychological symptoms has been challenged. Dr. Allen J. Frances, Professor Emeritus at Duke University, chaired the DSM-IV-TR task force (year 2000 Text Revision) and publicly objects to the impending release of the DSM-V.

An active blogger for the Huffington Post, he urges clinicians to ignore it’s changes altogether, asserting that the new version is vaguer than ever and will lead to labeling healthy individuals with its lowered threshold for criteria. In one of his blogs he states that the DSM-V is “offering its untested new diagnoses that will mislabel millions of the worried well as mentally ill”.[1] Parents of autistic children have the opposite concern, that their child will no longer fit in that diagnostic category and be denied access to medication and therapy.

Frances states that the DSM-V offers no leeway in differentiating, for instance, alcohol addiction vs dependence vs social use. The manual’s authors counter that early recognition will result in early intervention, but many practicing clinicians fear that the endpoint will be over-diagnosis that that misidentifies normal variations in behavior.

The National Institute of Mental Health (NIMH)

On July 3, 1946, President Harry Truman signed the National Mental Health Act, which called for the establishment of a National Institute of Mental Health (NIMH). The process of diagnosing without etiology is the fundamental distinction between the DSM’s function and the conceptual model now proposed by the National Institute of Mental Health.

NIMH rejects all DSM versions and is devoting its considerable financial and scientific resources to the premise that all psychological conditions are biologic or chemical in nature, originating in specific regions of the brain, and thus amenable to medical intervention.  The stakes are significant – for insurance reimbursement, financial grants for research, pharmaceutical financing, and one hopes, the well-being of patients.

Citing the difficulty in properly diagnosing mental health disorders when forced to choose an ICD code, in 2008 NIMH implemented its Strategic Plan, a diagnostic process using Research Domain Criteria (RDoc).

This plan utilizes a matrix of Constructs (rows) that are grouped into five Domains of Functioning, and seven classes of Variables (columns) with an eighth column for paradigms. The goal is to classify mental disorders along a continuum of biologic and genetic markers, neurological circuitry and specific regions of the brain. The attempt is not to diagnose a mental disorder by looking at the overall patient presentation, but to find one symptom that is present across a variety of disorders, eventually pinpointing the physical location of the symptom. This intersection would identify the origins of disease, and science (psychopharmacology) would intervene to avert mental disorder. This theory ignores the empirical research on the greater efficacy of “talking therapies” either alone or in combination with psychopharmacology, and even NIMH agrees that this lengthy research offers no immediate relief to patients.

Opponents to RDoc fear that severe illness (schizophrenia, bipolar disorder) may go untreated if the affected individual does not express a specific gene. They question the validity of research that is conducted solely in laboratories and does not involve practitioners in the field. NIMH counters that RDoc is an open document for which they have sought input from the medical community.  To be continued…

Closed Head Injuries & Strokes: A Primer for the Legal Professional

Closed Head Injuries & Strokes: A Primer for the Legal Professional

Head injuries or brain damage can occur anywhere – in the workplace, in an MVA, in medical malpractice, toxic torts, a domestic fall, and environmental exposures.

Litigated head injuries often arise from two sources:

  1. Accidents
    1. blunt trauma (fall, violent blow or MVA)
    2. penetrating trauma (gunshot)
    3. Medical causation (stroke)
      1. ischemic (a clot blocking blood flow to a major artery)
      2. hemorrhagic (rupture of a major artery causes damage to the brain)
      3. TIA or Transient Ischemic Attack (symptoms resolve within 24 hrs)

    In all instances, brain injury is affected by blood: either blocked flow(ischemia) or bleeding that starves one area while adding pressure to another area, damaging tissue. The location of the injury is the most important determinant of the severity and likelihood of recovery.

    Key Concepts

    • Rate and degree of recovery after brain injury is quite variable
    • The most common form of traumatic brain injury is the subdural hematoma, with a mortality rate ranging from 50 – 90%. [1]A significant percentage of these deaths result from the pressure on the brain that develops in the days after injury. Treatment of the SDH depends upon the location and age of the lesion. Because bleeding is not static, “Early and sometimes repeated CT scanning may be required in cases of clinical or neurologic deterioration, especially in the first 72 hours after head injury, to detect delayed hematoma, hypoxic-ischemic lesions, or cerebral edema.”[2]
    • Approximately 20-30% of patients will recover full or partial brain function. However, post-operative seizures are relatively common in these patients.
    • Although recovery from TIA (transient ischemic attack) occurs within 24 hours, these patients are at a high risk of falls because they may regain mobility before being aware of their surroundings.
    • Strokes arising from blood clots usually require anticoagulation therapy to prevent further clotting, but improper medication management can result in a fatal hemorrhage
    • Because patients can “go bad” quickly, frequent monitoring of vital signs, ICP (intracranial pressure) measurements, lab values, pupil checks and level of awareness is crucial.
    • A critical part of assessment includes changes, even by one point, in the Glasgow Coma Scale

    The Glasgow Coma Scale[3] (GCS) numerically represents the level of consciousness and is based on a 15-point scale for estimating and categorizing the outcomes of brain injury. The patient who is unable to respond verbally or follow commands can nonetheless have a reflexive response to painful stimuli. Families do not appreciate this form of assessment, but the patient’s physical response tells a great deal about how the brain is processing this noxious stimulus. The following signs are associated with a poor prognosis:[4]

    • A Glasgow Coma Scale less than 8 in the field
    • A Glasgow Coma Scale less than 5 in the ER
    • Unequal/changing pupil size
    • Presence of alcohol at the time of injury (alcohol increases bleeding)
    • Motorcycle accident (direct head impact and no airbag)
    • Problems with ventilation, further depriving the brain of oxygen

    A patient with an acute brain injury is often placed into a medically induced coma to protect and allow the brain to rest by slowing metabolism. Mechanical ventilation controls oxygen and carbon dioxide levels that can aid in reduction of swelling, and sedation allows an override of the patient’s breathing, which is often labored and dysfunctional.[5]

    Pain should be managed effectively because it can lead to a rise in intracranial pressure. An intubated patient is treated with short acting sedation and analgesia until time for weaning.

    Establishing the presence of pain and suffering in the unconscious patient includes knowledge of impending disaster (even with death cases), knowing the difference between purposeful movements and reflex, and evaluation of post-injury residuals.

    In order to put post-injury impairment into perspective, it is important to know who the patient was prior to injury. This information is sought by defense counsel in the determination of financial responsibility, but is equally important to plaintiff’s counsel in supporting a reasonable demand.


    [1] US Dept of Health and Human Services, ACR Appropriateness Criteria® head trauma. Bibliographic Source(s)

    Davis PC, Brunberg JA, De La Paz RL, Dormont D, Jordan JE, Mukherji SK, Seidenwrum DJ, Turski PA, Wippold FJ II, Zimmerman RD, Sloan MA, Expert Panel on Neurologic Imaging. ACR Appropriateness Criteria® head trauma. [online publication]. Reston (VA): American College of Radiology (ACR); 2008. 13 p. [51 references]

    [3] Herr K, Coyne PJ, Key T, et al. Pain assessment in the nonverbal patient: position statement with clinical practice recommendations Pain Manage Nurs 2006; 7:44–52

    [4] Marion DW, Find all citations by this author (default).

    Carlier PM Department of Neurological Surgery, University of Pittsburgh School of Medicine, PA 15213. Find all citations in this journal (default).

    The Journal of Trauma[1994, 36(1):89-95]