Deal proactively with patients’ psych problems

Early treatment saves money down the road

Have you ever had an injured patient who just wouldn’t get better no matter how many treatments or modalities he received? You might think the patient is malingering — making up symptoms to stay out of work or to get more money from a settlement.

But the problem likely goes deeper than that, says Laurence Miller, PhD, director of psychological services at Heartland Pain and Rehabilitation in Lantana, FL. If you suspect that psychological issues may be interfering with a patient’s recovery, refer the patient for a psychological evaluation, he suggests. In fact, Miller, a clinical psychologist, recommends that case managers routinely refer all patients with a potential disability for psychological screening.

Not only will a routine psychological screening help you identify patients who might need more than physical treatment for their condition, it will help ease some patients’ resistance to receiving psychological services. "You can justify that it is part of the regime. That way, it’s not stigmatizing," he says. By the time you know the patient isn’t responding for treatment, the patient is already stigmatized, and it’s the worst time to send him for evaluation, he adds. "It will save money to aggressively treat the syndromes up front," says Miller. "The longer you wait, the more money you’ll spend."

If your program won’t allow routine psychological evaluations, make sure the patient gets a referral if you suspect any kind of psychological problem, he suggests. "It may be difficult to make the referral. You’ve got to justify it from the expenditure point of view, and most patients don’t want to be sent to a psychiatrist," he notes. "No matter how you explain it, all they hear is that you think they’re making up their symptoms."

Psychological treatment will not cure every patient, but you can make a dent if you do it early, Miller says. In other countries, where there are state-sponsored compensation systems that treat patients — and no lawyers get involved with their care — the return-to-work rates are much better than in the United States, he says. The best results are when treatment begins within six months post-injury, he adds. "Anxiety is situationally based. As time goes on, the disability becomes entrenched."

Make sure that at some point during treatment, someone sits down and explains as clearly as possible what is wrong with the patient and what can be done. "Patients need a reality check," suggests Miller. "In many cases, they are never given a clear message as to what is wrong with them."

Some patients do indeed malinger, but more fail to get better for reasons that don’t show physical symptoms, he says. "Malingering is not a diagnosis. When someone says a patient is malingering, they are calling them a liar and a thief and a perjurer. That is accusing them of consciously and knowingly making up symptoms to gain something, like money, or to avoid something, like a criminal conviction," Miller says.

Fabricating symptoms or making up a syndrome out of nothing is a pretty unusual occurrence, he says. For a patient to exaggerate his or her symptoms is more common. Physicians often don’t see the patient’s psychological problems, even when the symptoms are not consistent with the physiological injuries, Miller says. "Most orthopedists, neurologists, and even some psychologists and psychiatrists don’t have the knowledge of the full range of things that can affect rehab," says Miller.

The biggest dilemma that case managers and other clinicians face is that they often must decide between two possibilities: Either it’s a legitimate injury or disability, or the patient is making it up. "Those choices don’t give you much clinical wiggle room," he notes.

Legitimate disorders abound

There are a lot of legitimate disorders that may be confused with malingering, particularly in the rehabilitation setting, Miller says. For example, there may be symptoms that aren’t fully explainable or attributable to a patient’s medical condition or injury. The patient may unconsciously be blowing his symptoms out of proportion because of a somatoform disorder. "The underlying psychological reason is usually to fulfill another unfilled need," Miller says.

One common example is that the person feels he or she has not been treated fairly, and the employer or insurance company becomes the focus of those feelings. "When people talk about how unfairly they are treated, it’s easy to dismiss it as neurosis," says Miller. "But in many cases, the system does abuse and unfairly fail to treat patients."

Another example typically occurs among young blue-collar workers. Having been told all his life about the value of hard work, an employee subconsciously wishes he could slack off, so he exaggerates his disability because it allows him to work less. You may see a patient with an injury that seems minor in itself, but there was a prior head injury or other injury that could explain it. This is called misattribution. "It may be a cumulative effect so that the present injury, though minor in and of itself, is more severe than expected," says Miller.

Patients who suffer from hyponchondriasis are convinced that they have a serious illness or injury in spite of the medical evidence against it. Many of these patients are afraid to go back to work for fear that their illness or injury will return.