Transcript Biopsychosocial Management of Disability

Elaine A. Tonel DO, MS
Center of Occupational and Environmental
Medicine, UCI
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60 y/o male Ironworker with a longstanding
history of chronic back pain due to a lifting
injury. He is recovering from a second back
surgery. He is dependent on long-acting and
short acting narcotics, anxiolytics-Xanax,
ativan. About a $2000 is spent a month on
medications. He is homebound and has not
worked for several years since the injury or
participates in any recreational activities.
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Can patients at risk for disability and delayed
recovery be identified early?
Are there risk factors that predict disability?
Are there interventions or treatments that
yield better outcomes for these patients?
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Musculoskeletal conditions are the most
expensive non-malignant health problems
affecting the working age population.
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Within 5 years, depression (and stress-related
conditions) will rank as the second leading
cause of disability in industrialized countries.
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Reduced activity in daily living
Engage in fewer social, occupational, and
recreational activities
Job loss
Dependence on narcotics, anxiolytics,
alcohol, recreation drugs
Mental illness
High medical utilization
Family Conflict
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Symptom-focused interventions do not
necessarily yield reductions in disability.
Research is accumulating that symptomfocused interventions are not sufficient to
achieve return to work.
In some cases symptom-focused
interventions have actually been shown to
increase as opposed to decrease disability.
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Excessive negative orientation towards one’s
symptoms and health status
Focus excessively on symptoms
Tendency to exaggerate the threat value of
symptoms
Helplessness-belief that one is powerless to
control or decrease one’s suffering
Poor recovery after surgery, higher levels of
pain, higher levels of anxiety, more severe
depression, likely to be referred to specialists
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Communication goals may be more important
determinants of disability than pain itself.
The interpersonal style of high
catastrophizers will interfere with the
development of a strong working relationship
with the provider. Difficult to connect with
Disclosure techniques important component
that targets catastrophic thinking.
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Disclosure Technique-opened ended
questions, empathetic reflection, prompting
Let them communicate their “illness/injury
story”
Avoid giving advice-unsolicited advice or
suggestions will be perceived as criticism
Education
Attention-demanding activity participation to
assist patients in disengaging from
catastrophic rumination.
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Fear is a common response to distressing
physical symptoms.
Fear is common response to distressing
psychological symptoms.
Fear promotes avoidance.
Fear promotes escape.
Fear amplifies experience of pain.
Fear leads to avoidance of physical activity of
reduced social involvement-disability.
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Longer periods of disability
Premature termination of physical therapy
Less benefit from physical therapy
Lower success of return to work trials.
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Techniques for treating phobias might assist
in the treatment of disability.
Exposure techniques can also be and
important tool for reducing disability
associated with fear.
Exposure techniques: movement/ exercise,
activity interventions, volunteer work,
modified RTW programs.
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Probability of negative anticipated
consequences must be minimized.
Do it until it hurts strategy will increase fear
of pain and lead to increased activity
avoidance.
Patient’s sense of control must be
maximized.
Predict exacerbations.
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Patient’s appraisal of level of disability
Beliefs are central determinants of behavior
and roadmaps of behavior.
Family background may be a source
Health professionals play a role
Strong beliefs impair the ability to think in
terms of degrees. Automatic reply to a
challenging activity is “ I can’t”.
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Longer periods of work disability
Difficult to engage in rehabilitation
Reduced motivation for rehabilitation
Negative expectancies for outcomes.
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Disability beliefs cannot be challenged
directly. Patients become strongly anchored
in their beliefs when they sense someone is
attempting to change their beliefs.
Identify life roles that have discontinued due
to pain and illness. Life roles are basis of
one’s identity.
Assist patients in resuming life role-relevant
activities-more pertinent and relevant
Goal setting, increasing life role activitiescreate reality that is incompatible with beliefs
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Exaggerated sense of loss and blame on
someone else.
Most resistant to change than any other painrelated psychosocial factor.
Targets-driver, doctor, employer, insurer
Goals-proving injustice to others, revenge
motives
Anger and depression is a vehicle for higher
level of pain experiences.
Invalidation increases motivation to provide
proof of injustice.
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Longer periods of work disability
Expressions of anger or hostility
Working Alliance challenges
Non-compliance
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Recognize the patient’s losses and suffering
Use language that is consistent “emotionally”
with the patient’s communication.
Don’t focus on the positive when they are
trying to communicate suffering.
Don’t disagree with their perception of
suffering and severity of disability.
Don’t use “yes” “but” language
Validate the emotional experience not the
sense of injustice.
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3 Problem Clusters
Functional Concerns
WorkPlace Concerns
Emotional Concerns
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Authorized a psychological assessment
High catastrophizer, increased levels of
depression and anxiety
Identified that had a history of alcohol abuse,
childhood physical abuse
Treated with cognitive behavioral therapy
Stopped narcotics, and anxiolytics.
Psychiatrist started SSRI.
Had sex with wife after 5 years, started to
travel, and spend time with his grandchildren