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QME Personality Disorders and Apportionment

by Robert J. Gatchel, Ph.D., ABPP, William W. Deardorff, Ph.D, ABPP.


3 Credit Hours - $119
Last revised: 12/18/2014

Course content © Copyright 2014 - 2017 by Robert J. Gatchel, Ph.D., ABPP, William W. Deardorff, Ph.D, ABPP. All rights reserved.



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COURSE OUTLINE

 

Introduction and Course Overview

Learning Objectives

Personality Characteristics and Pain

MMPI “Pain Profile” Studies

The Conversion V Profile Type

The Neurotic Triad Profile Type

The Disability Profile Type

Other MMPI Profile or Cluster Types

Conclusions

Personality Disorders: The DSM-IV

The Diathesis-Stress Model of Psychopathology

Personality Assessment Instruments and Methods

Evaluating Personality to Help with Chronic Pain Treatment

The Stepwise Approach to Assessment

Pain Management Intervention Strategies

Apportionment to a Personality Disorder

Summary and Conclusions

References

 

INTRODUCTION AND COURSE OVERVIEW

 

Historically, going back to the ancient Greeks, Aristotle and Plato viewed pain as being “outside” the five basic senses (sight, hearing, smell, taste and touch), and more among the emotions, specifically a “quality or passion of the soul.”  Thus, this “state of feeling” was viewed as setting pain apart from the limitations of a pure sensory state, and extended it also to other areas of “mental life.”  This perspective pre-dated the subsequent and prevalent biomedical models of pain that viewed it as a pure sensory or mechanistic phenomenon.  It has not been until recently that we have discarded this outdated, dualistic biomedical view of pain as either a mental or physical event.  With the introduction of the biopsychosocial model of pain during the last decade, pain (especially when it becomes chronic in nature) is viewed as a complex interaction among physical, psychological and social factors (Gatchel et al., 2007).  Therefore, psychosocial factors (including personality characteristics) play an important role in the reception, reaction and coping with pain.  How to evaluate these personality characteristics and integrate them into a treatment program will be the focus of the present course.

 

LEARNING OBJECTIVES

 

List three MMPI profile types that have been related to patients with chronic pain

 

Describe the DSM-IV personality cluster types especially related to chronic pain patients

 

Explain the prevalence of DSM-IV personality disorders in a chronic pain population

 

Discuss the evidence for or against the concept of a “pain prone personality” type

 

Describe apportionment to a personality disorder

 

 

PERSONALITY CHARACTERISTICS AND PAIN

 

With the introduction and acceptance of the gate-control theory of pain (Melzack and Wall, 1965), came the realization that many diverse factors are involved in pain perception.  This theory’s major contribution was the introduction to the scientific community of the importance of central nervous system and psychosocial variables in the pain-perception process.  Indeed, it highlighted the potentially significant role of psychosocial factors in the perception of pain (Melzack, 1993).  Subsequently, the biopsychosocial model of pain was introduced which further emphasized the fact that pain is a complex, subjective phenomenon that consists of a host of factors, each of which can contribute to the interpretation of nociception as pain.  Pain is experienced uniquely by each individual, and the complexity of pain is especially evident when it persists over time as a range of psychological, social and economic factors can interact with physical pathology to modulate a patient’s report of pain and subsequent disability (Turk et al., 2002). 

 

Obviously, this biopsychosocial perspective of pain highlights the potentially significant role of psychosocial factors (including personality) in the pain-perception process. There is now a great amount of clinical research indicating the important role of personality in pain perception which can, in turn, have important clinical implications for treatment approaches.  Without a firm grasp of psychosocial/personality characteristics of patients, it becomes difficult to precisely “tailor” treatment programs to the specific characteristics of a pain patient.  In fact, the most treatment- and cost-effective pain management programs embrace an interdisciplinary approach, in which the unique interactions among biological, psychological and social factors of each individual patient is taken into account before specifically tailoring a treatment program to deal with these unique interactions.  The older, and ineffective perception that a single treatment program can be applied across all pain patients (i.e., “the one shoe fits all sizes” perception) is no longer accepted as valid.  Rather, tailoring the “shoe size” or treatment program to each specific foot or patient is the most useful and valid approach to take.  The major assessment techniques used to measure personality characteristics will be reviewed next.

 

MMPI “PAIN PROFILE” STUDIES

 

As a result of the acceptance of the importance of psychosocial factors in pain, a copious amount of clinical research was then stimulated in an attempt to isolate the specific psychological characteristics of patients with chronic pain.  One of the major assessment instruments used in this search was the Minnesota Multiphasic Personality Inventory (MMPI). The major scales of the MMPI are presented in Table 1. The early MMPI work attempted to differentiate functional from organic pain.  For example, one of the earliest studies was conducted by Hanvik (1951) in the evaluation of patients who were then considered to have either chronic pain with an organic cause, or to have a functional pain disorder without a clear-cut organic cause.  This study was based upon the earlier mentioned traditional biomedical reductionist view of pain that assumed that every “real” report of pain originated from a specific physical organic cause.  If such a physical cause could not be found, then pain was viewed as functional, or merely the result primarily of psychosocial factors which made it less “real” in nature.  Fortunately, even though this organic-functional distinction has been replaced with a more comprehensive biopsychosocial model, Hanvik’s (1951) early investigation provided the basis for numerous subsequent studies assessing the psychological profiles of patients with chronic pain, while primarily utilizing the MMPI in such investigations. 

 

It should also be mentioned that, even though Hanvik isolated 25 items on the MMPI to differentiate the organic versus functional pain groups, subsequent investigations were unable to replicate his initial results or any of the conclusions that he proposed.  Subsequently, the utility and validity of drawing a distinction between functional versus organic features of chronic pain have been challenged and has fallen into disrepute.  Rather, with the biopsychosocial perspective of chronic pain, it is now appropriately viewed as a complex interactive system which cannot be divided into distinct psychological or physical components alone.  It should also be noted that, although there have been additional efforts to try to identify various “pain prone personality” types with the use of the MMPI, such studies have been strongly criticized and this notion is no longer accepted as valid.  All of these studies, however, do not dispute the notion that the MMPI can be a useful method of assessing personality in pain patients.  However, it should be viewed as only one of a possible battery of tests to better understand the psychosocial functioning of an individual.  Indeed, as will be discussed next, there appears to be different MMPI profile types that are useful in better understanding the characteristics and coping abilities of chronic pain patients.

 

 

Table 1. MMPI-2 Scale Names and Descriptions

 

 

Scale

 

 

Abbreviation

 

Original Name

 

Description

 

 

L

 

Lie

 

This is rough indication of attempting to present oneself in a positive light and denying any faults.

 

 

F

 

Infrequency

 

This scale can show individuals that are attempting to exaggerate psychological symptoms and present themselves as more disturbed than they actually are. 

  

 

K

 

Defensiveness

 

The K scale is a more subtle measure of an attempt to present oneself positively. 

 

1

 

Hs

 

Hypochondriasis

 

A wide variety of vague and nonspecific complaints about bodily functioning are assessed. All the items on this scale deal with somatic concerns or with general physical competence.

 

 

2

 

D

 

Depression

 

Various symptoms of depression are assessed including poor morale, lack of hope in the future, and a general dissatisfaction with one's own life situation.

 

 

3

 

Hy

 

Hysteria

 

Items are of two general types: (1) reflecting specific somatic complaints and (2) showing that the client considers himself or herself well socialized and adjusted. Such people generally maintain a facade of superior adjustment and only when they are under stress does their proneness to develop conversion-type symptoms appear.

 

 

4

 

Pd

 

Psychopathic

Deviate

 

 

This scale is a general measure of rebelliousness including problems with authority, impulsiveness, troubled relationships, underachievement, and behaving outside social norms. 

 

 

5

 

Mf

 

Masculinity-

Femininity

 

 

High scores indicate that the individual is endorsing characteristics opposite of the gender stereotype (e.g. a male scoring high on Mf is endorsing stereotypical female traits and a lack of stereotypical masculine features).

 

 

6

 

Pa

 

Paranoia

 

This scale measures paranoid symptoms such as ideas of reference, feelings of persecution, grandiose self-concepts, suspiciousness, excessive sensitivity, and rigid opinions and attitudes.

 

 

7

 

Pt

 

Psychasthenia

 

This scale measures symptoms such as obsessive-compulsiveness, anxiety, excessive doubt, anger, and unreasonable fears.

 

 

8

 

Sc

 

Schizophrenia

 

This scale was originally developed to identify patients diagnosed as schizophrenic. Items assess a wide variety of content areas, including bizarre thought processes, peculiar perceptions, social alienation, poor familial relationships, difficulties in concentration and impulse control, lack of deep interests, disturbing questions of self-worth and self-identity, and sexual difficulties.

 

 

9

 

Ma

 

Hypomania

 

This scale assesses such things as elevated mood, accelerated speech and motor activity, irritability, flight of ideas, and brief periods of depression.

 

 

0

 

Si

 

Social

Introversion

 

This scale assesses a person's tendency to withdraw from social contacts and responsibilities. The items on this scale are of two general types: (1) deals with social participation and (2) general neurotic maladjustment and self-depreciation.

 

 

As noted above, the MMPI was one of the most widely used psychosocial measures of chronic pain.  However, with the subsequent introduction of the MMPI-2 and other tests designed specifically for populations with chronic pain, the utility of the MMPI has decreased over the years.  However, the extensive past research that used the original MMPI still provides valuable information into the various correlates of chronic pain and the personalities of individuals with chronic pain syndromes.  There have been two traditional MMPI profile types (the “Conversion V” and the “Neurotic Triad”), as well as a newer type (the “Disability Profile”) that have been found to be useful in better understanding the personality characteristics of chronic pain patients.

 conversionv

Figure 1: The Conversion V Profile

 

The “Conversion V” Profile Type

 

The Conversion V profile (Figure 1) represents a configuration of Scales 1 (Hypochondriasis) and 3 (Hysteria) that are significantly higher than that for Scale 2 (Depression).  This profile is produced when an individual endorses somatic symptoms, while also denying social anxiety and depressive symptoms.  Such individuals often react to stress with the development of physical symptoms, and also have limited insight into their feelings.  They also tend to be sociable, conforming, and passive-dependent.  The incidence of this Conversion V profile for a general medical patient population is roughly 5-15%, but is 35-60% for patients with chronic pain.  Although the individual with a Conversion V profile can share some of the symptoms of a person with the Neurotic Triad profile (to be discussed next), the Conversion V patient is more likely to report less psychosocial distress than is the Neurotic Triad profile patient.  This is most likely due to the fact that Conversion V profile individuals may be able to more effectively distract themselves from painful and distressing emotions by focusing on their physical symptoms.

 neurotictriad

Figure 2: The Neurotic Triad Profile

 

The “Neurotic Triad” Profile

 

Some chronic pain patients often have high scores on all three of the first clinical scales (Hypochondriasis, Depression and Hysteria).  This profile type (The Neurotic Triad: Figure 2) is frequently seen in individuals with the following characteristics:  somatic complaints; the presence of secondary gain (i.e., some financial or interpersonal gain for being “sick or in pain”); depressive feelings; and difficulty with sleep.  Moreover, such individuals are often hypothesized to have conflicted feelings about dependency, and they may also keep other people “at a distance” or interact with others in unpleasant or demanding ways.

 disabilityprofile

Figure 3: The Disability Profile

 

The “Disability” Profile

 

The Disability Profile (Figure 3), recently introduced by Gatchel, Mayer and Eddington (2006) for musculoskeletal pain patients, is comparable to what is called the “Floating Profile” in the psychiatric literature. This Floating Profile is defined as elevations of 4 or more of the clinical scales (T scores above 65). Overall, this profile has been associated with personality disorders (in particular, borderline personality disorder). Individuals with this particular profile do not have one particular defense mechanism to call upon in order to effectively cope with stressors in their lives and, therefore, often experience severe emotional distress.

 

Other MMPI Profile or “Cluster” Types

 

There have been numerous other profiles or cluster types developed in an attempt to classify chronic pain patients. The cluster groups were developed using a statistical technique called Hierarchical Clustering Analysis, which involves differentiation of subjects according to major clusters or patterns of MMPI profiles. One such cluster solution found in 10 separate studies used the P-A-I-N in order to describe the different typologies or clusters (Robinson, 2000). The Type P cluster consisted of elevations on most of the clinical scales, and it appears to be reflective of the most disturbed profile. It was associated with difficulty in the realms of psychosocial, educational, and vocational functioning. The Type A cluster was similar to the early discussed Conversion V profile. The Type I cluster appears to be a hypochondriacal profile associated with physical impairment of patients who had multiple medical procedures and multiple hospitalizations. Finally, the Type N cluster patients were characterized as relatively normal.

 

Conclusions

 

Because of the importance of psychosocial factors in chronic pain, it is not surprising that there would be MMPI profile and cluster types associated with how patients react to their pain or how patients may be predisposed to reacting to pain in particularly unique ways. There is no doubt that the first three clinical scales of the MMPI reviewed above have significant relevance to pain patients. Although these various profiles or clusters do not differentiate between the now outdated notion of functional versus organic pain patients, they can be used to indicate that physical symptoms may be used by certain patients to distract from painful emotions or to produce distressful affect. To date, though, none of these profiles or clusters have been found to support the presence of a single “pain prone personality type” or have they been able to predict treatment outcome effects. Again, though, it should be emphasized that these profile or cluster types should be used as only one piece of data in isolating psychosocial characteristics of patients with pain.

 

PERSONALITY DISORDERS: THE DSM-IV

 

In an attempt to increase the reliability of psychiatric diagnoses, the American Medical Association published a series of manuals that delineated specific criteria that had to be met before an individual could be given a particular diagnosis. As should be known, the DSM-IV (American Psychiatric Association, 2000) allows for diagnoses on five different axes, each corresponding to a different class of disorder. An Axis I diagnosis classifies major clinical disorders such as anxiety, depression, schizophrenia, etc. Axis II diagnoses consist of personality disorders, which will be the topic of the present discussion. In the DSM-IV, these personality disorders are included in Table 2.

 

 

Table 2. Major Personality Disorders

 

 

Overview

 

The DSM-IV lists ten personality disorders, grouped into three clusters (A, B, C) and these are coded on Axis II. The DSM also contains a category for behavioral patterns that do not match these ten disorders, but nevertheless exhibit characteristics of a personality disorder (Personality disorder not otherwise specified).

 

 

Cluster A (odd or eccentric disorders)

 

Paranoid personality disorder: characterized by a pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent.   

 

Schizoid personality disorder: characterized by a pervasive detachment from social relationships and restricted range of expression of emotions in interpersonal settings.  (lack of interest in social relationships, seeing no point in sharing time with others, misanthropy, introspection)

 

Schizotypal personality disorder: characterized by a pattern of social and interpersonal deficits along with cognitive or perceptual distortions and eccentricities of behavior.

 

 

Cluster B (dramatic, emotional or erratic disorders)

 

Antisocial personality disorder: a pervasive disregard for and violation of the rights of others.

 

Borderline personality disorder: a pervasive pattern of instability in relationships, self-image, affect, identity and behavior.

 

Histrionic personality disorder: a pervasive pattern of excessive emotionality and attention-seeking behavior.

 

Narcissistic personality disorder: a pervasive pattern of grandiosity, need for admiration, and a lack of empathy.

 

 

Cluster C (anxious or fearful disorders)

 

Avoidant personality disorder: a pervasive pattern on social inhibition, avoidance of social interaction, feelings of inadequacy, and extreme sensitivity to negative evaluation.

 

Dependent personality disorder: a pervasive pattern of needing to be taken care of by others that leads to submissive and clinging behavior and fears of separation.   

 

Obsessive-compulsive personality disorder: characterized by a preoccupation with orderliness, rigid conformity to rules, and moral codes at the expense of flexibility, openness and flexibility.  

 

 

Although Axis II personality disorders may or may not be directly psychologically-troubling for any particular individual, they may contribute to deficits in interpersonal functioning, reality testing, coping, etc. Finally, there are also Axis III (which allows for the diagnosis of a physical disorder such as diabetes, heart conditions, etc), Axis IV which is used to denote a person’s psychosocial stressors, and Axis V which involves rating a patient’s overall level of functioning in the past year on a scale from 0 to 100. By using this classification system, it is believed that many of the difficulties in obtaining consistent and reliable diagnoses can be eliminated. The resultant diagnoses can then be used for more effective treatment planning, and can also be duplicated across clinicians who make these diagnoses. It should also be noted that, in order to make this an even more reliable system, a Structured Clinical Interview for DSM diagnosis (SCID) has been developed, which requires clinicians to use the same sequence of questioning and the rating of symptoms verbalized by patients. This SCID approach has been found to be associated with a high degree of inter-rater reliability across clinicians (Spitzer et al., 1988). The SCID I is used to evaluate Axis I disorders, while the SCID II is used to classify Axis II personality disorders.

 

In light of the earlier reviewed MMPI findings with chronic pain patients, it is not surprising that there has been a greater prevalence of Axis II disorders found for chronic pain patients, relative to the general population. It should also be noted that the DSM-IV includes a method to “cluster” these various Axis II personality disorders into three major personality clusters. Cluster A includes the social personality disorders, consisting of the paranoid, schizoid, and schizotypal personality disorders. Individuals with these cluster disorders often appear odd or eccentric. Cluster B consists of the “flamboyant” personality disorders, including the borderline, histrionic and narcissistic personality disorders. Individuals with these often appear dramatic, overly emotional or erratic. Finally, the Cluster C consists of the anxious personality disorders, including the avoidant, dependent, obsessive-compulsive, and passive-aggressive personality disorders. Individuals with these disorders often appear anxious or fearful.

 

Of course, these clusters are important to know because they will have potentially significant implications for treatment recommendations and tailoring of the treatment program for patients. For example, elevations in depression and anxiety are usually found in chronic pain patients, but can be effectively treated through the psychosocial component of a pain management program with the use of methods such as cognitive behavior therapy, as well as psychopharmacological approaches. In contrast, the treatment of severely personality-disturbed pain patients is more troublesome because of the various types that are often recalcitrant to any type of traditional therapeutic intervention. Cluster B personality type individuals are especially troublesome because of the more “traumatic” nature of their ingrained characterological attributes, such as being inflexible, erratic, being oblivious to their own problems, and lacking empathy for others.

 

There have been numerous studies demonstrating the high prevalence of Axis II personality disorders in chronic pain patients.  Reich, Tupin, & Abramowitz (1983) completed one of the earliest investigations of personality disorders in a chronic pain population.  The researchers completed a semi-structured diagnostic interview of 43 individuals experiencing chronic pain.  The interviews were based on the DSM-III criteria for personality disorders.  The results indicated that 20 of the 43 patients (47%) met the criteria for Axis II disorders.  The most frequent personality disorders were histrionic and dependent.

 

Fishbain et al. (1986) completed an extensive study of 283 chronic pain patients that presented for treatment at a comprehensive pain program.  The investigators used a two hour semi-structured interview to determine the presence of a personality disorder based on DSM-III.  This was only the second study to use operational criteria for reaching diagnostic decisions. Results found that the chronic pain patients demonstrated a higher incidence of personality disorders (59%) than that found by Reich et al. (1983).  The diagnoses most commonly found were dependent (17%), passive-aggressive (15%), histrionic (12%), and compulsive (7%).

 

Large (1986) completed a study similar to Fishbain et al. (1986).  The researchers interviewed 50 patients presenting to a chronic pain program in New Zealand.  Of the 50 patients, 20 (40%) met the criteria for a personality disorder with the following breakdown:  mixed personality disorder (22%), dependent (10%), histrionic (6%).   

 

Reich and Thompson (1987) completed a similar study using a semi-structured interview to identifying personality disorder clusters.  In this study, the authors compared three groups: (a) patients with chronic pain, (b) psychiatric patients applying for disability benefits, and (c) psychiatric patient undergoing mental competency hearings.  Results indicated 37% of patients with chronic pain met the diagnostic criteria for a personality disorder versus 12% of patients undergoing mental competency hearings.

 

Polatin et al. (1993) completed one of the most methodologically sound studies of this type.  The investigators completed structured diagnostic interviews (SCID-II) of 200 patients presenting for chronic pain treatment.   The authors found that 51% of patients met the criteria for one personality disorder and 30% met the criteria for more than one personality disorder.  The most common diagnoses were: paranoid (33%), borderline (15%), avoidant (14%), and passive-aggressive (12%).

 

Weisberg et al. (1996) also evaluated patients participating in a chronic pain treatment program. In this study, 55 patients were evaluated using a number of measures including retrospective data, family and self-report information, testing, interviews, etc. The researchers found a 31% rate of personality disorders, slightly less than what had been reported previously.  The personality diagnosis frequencies were as follows: Not Otherwise Specified (27%), borderline (13%), dependent (11%).

 

In another study, Gatchel et al. (1996) also used the SCID-II to diagnose personality disorders in acute and chronic pain patients with temporomandibular disorders.  The results indicated a higher prevalence of personality disorders in the chronic versus the acute pain patient groups.  The most common diagnoses in the chronic pain group were paranoid (18%), obsessive-compulsive (10%), and borderline (10%).

 

In a more focused study, Sansone et al. (2001) explored the prevalence of borderline personality disorders in a small sample (N=17) of primary care patients with chronic pain.  The participants completed two self-report measures: Personality Diagnostic Questionnaire-Revised (PDQ-R) and the Self-Harm Inventory (SHI).  They also completed a semi-structured interview (Diagnostic Interview for Borderlines; DIB).  According the different measures, 47% (PDQ-R), 29% (SHI), and 47% (DIB) scored positively.  In addition, 25% of the group scored positively on two of the measures and 18% on three of the measures. Although this study suffered from methodological problems (very small sample size) the results are consistent with previous studies especially if one interprets the result relative to those that scored positively on all three measures.

 

This literature clearly indicates that, among some patients, there is an association between chronic pain and personality disorders. However, the studies do not consistently identify a specific personality disorder that is most likely to be found in a chronic pain patient population.  These mixed findings are likely due to multiple factors including demographic differences among samples, the methods used to make the personality diagnosis, the lack of specificity in the measures used, varying types of pain syndromes across the studies, and variations in how patients were recruited.  As discussed by Fishbain (1997), there is also significant overlap (co-morbidity) among the personality disorders making it difficult to determine a primary personality diagnosis. Until diagnostic criteria are better defined, and measures better validated, we might only hope to identify the presence of some type of personality disorder features in patients with chronic pain (e.g. Mixed, or Not Otherwise Specified).  

 

Even though there is much to be learned about the relationship between personality disorders and chronic pain, such studies clearly indicate that the effective evaluation and treatment of chronic pain patients needs to include an understanding of personality disorders in order to be therapeutically effective. Thus, of course, there is a real advantage of the accurate diagnosis of personality disorders. However, for ethical purposes, it is quite important to accurately diagnose such individuals and not just haphazardly “stick a label” on a patient. A reliable personality diagnosis serves many clinically beneficial functions as in Table 3 delineated below:

 

 

Table 3. Importance of Personality Diagnosis in Treatment

 

 

The treatment program can be better tailored to fit the individual’s unique personality characteristics, without disturbing the concurrent treatment of other patients in a group setting.  This will help to optimize the likelihood of a successful outcome. Because compliance with treatment is usually somewhat low in patients with personality disorders, tailoring the treatment to help maximize compliance to the treatment regimen will help improve therapeutic outcomes.

 

In cases in which a severe personality disorder is diagnosed, the treatment team will get a “heads up” in what to expect and be able to appropriately modify their initial reactions to the patients accordingly.

 

With an assessment of both premorbid and current personality disorders, changes that are attributed to the onset of pain may be accurately determined, and treatment can therefore be aimed at returning the individual to his or her previous style of functioning.

 

 

 

With the above points in mind, it should also be recognized that pain management programs are not developed to “change” the personality of an individual, but merely to help “manage” personality styles more effectively and to make the personality functioning of an individual more adaptive to the environment (through techniques such as learning new coping skills, more appropriate interpersonal interactions, better methods of dealing with stress, etc). It is very important to not “label” a person with a particular personality disorder that may remain in a patient’s chart and then subsequently “follow” that patient in the future. Loosely using labels that may follow a patient the rest of his or her life is an ethical consideration that needs to be very carefully considered. In my own practice, rather than using a personality disorder label, I merely use some of the personality characteristics that may be either adaptive or maladaptive and that our treatment program successfully addressed.

 

THE DIATHESIS–STRESS MODEL OF PSYCHOPATHOLOGY

 

In a conceptual model of how acute pain develops into chronic pain, Gatchel (2005) characterized this progression according to a three-stage model. In Stage 1 of this model (referred to as the acute phase), normal emotional reactions, such as fear, anxiety and worry develop subsequent to the patient’s perception of pain. This is viewed as a natural emotional reaction that often serves as a protective function by prompting the individual to heed the pain signal and, if necessary, to seek medical attention for it. However if the perception of pain exists beyond a two-to-four month period (which is usually considered a normal healing time for most pain syndromes), the pain begins to develop into a more chronic condition, leading to Stage 2 of the model.

 

During Stage 2 of this process, psychosocial and behavioral problems are often exacerbated or heightened. Anger, emotional distress, and depression are typical symptoms of patients in Stage 2. Frequently, the extent of these symptoms usually depends on the individual’s pre-existing personality and psychosocial structure, in addition to socioeconomic and environmental conditions. For example, depressive symptoms are greatly exacerbated during this Stage for an individual with a premorbid depressive personality who is seriously affected economically by the loss of a job due to pain and disability. Similarly, an individual who had premorbid hypochondriacal characteristics and who receives a great deal of secondary gain (e.g., sympathy from others) for remaining disabled will most likely display a great deal of pain and distress.

 

The model itself proposes a diathesis-stress perspective, in which the stress of coping with pain can lead to the exacerbation of the individual’s underlying psychosocial characteristics. The model does not propose that there is a pre-existing pain-prone personality but, rather, patients bring with them certain predisposing personality and psychological characteristics (i.e., they have a diathesis) that is exacerbated by the stress of attempting to cope with the now chronic nature of the pain. Indeed, the relationship between stress and the exacerbation of mental health problems has been well documented in the scientific and clinical literature. This is not to say that predisposing factors make chronic pain a “psychogenic disorder” in that it is all in the “person’s head.” Again, the chronic problem represents a complex interaction between physical factors and psychosocioeconomic variables.

 

 

Table 4. Three Stage Diathesis-Stress Model (Gatchel, 2005)

 

 

Stage 1

 

This is characterized by normal emotional reactions including such things as fear, anxiety and worry that develop subsequent to the patient’s perception of pain.

 

 

Stage 2

 

In this phase, psychosocial and behavioral problems are often exacerbated or heightened. Anger, emotional distress, and depression are typical symptoms of patients in the transition from the Acute phase to Acceptance of the Sick Role.

 

 

Stage 3

 

The progression to complex interactions of physical, psychological and social processes consolidates leading to abnormal illness behavior.  This is the chronic phase of the model in which there is an acceptance of the sick role.

 

 

Finally, the progression to complex interactions of physical, psychological and social processes characterizes Stage 3, which represents the chronic phase of the model. As the result of the chronic nature of the pain experienced, and the stress that it creates, patients’ lives begin to revolve around the pain and behaviors that maintain it. The patient begins to adopt a “sick role,” in which any excuse from social and occupational responsibilities become routine. As a consequence, the patient now becomes accustomed to the avoidance of responsibility, and other reinforcers maintain such maladaptive behavior.

 

With the above diathesis-stress model in mind, clinicians should be aware that the personality characteristics being displayed by a particular pain patient may be an exacerbation or amplification of their “normal” personality if the pain has become chronic in nature. That is to say, before the onset of chronic pain, the personality style of a particular individual may not have been maladaptive or interfering with his or her activities of daily living. However, after the exacerbation, many of the characteristics of that individual’s personality may be more prominently displayed (e.g., the inability to deal with stressors that normally would not have been problematic to deal with before the chronic pain). It will then be important for the clinician to help the patient to develop better coping skills to deal with this now higher than usual level of stress. It should be kept in mind that some of the basic characteristics of individuals with personality disorders include those listed in Table 5.

 

 

Table 5.  Features of Patients with Personality Disorders

 

 

they usually have poor coping strategies and are not flexible in changing them

 

these coping styles result in them being extremely vulnerable under conditions of stress

 

their style of perceiving and reacting to significant challenges is maladaptive, which then tends to perpetuate or intensify preexisting difficulties.

 

 

Thus, the presence of a personality disorder or cluster, in general, and not necessarily a specific type of personality disorder, may significantly impair coping abilities and could be related to problems with chronic pain and disability. One key hallmark of individuals with personality disorders is a failure of, or inadequate, coping skills. Indeed, the DSM-IV explicitly defines personality disorders in terms of traits or styles that are “inflexible and maladaptive and cause either significant functional impairment or subjective distress” (APA, 1994). Again, this has major clinical implications for how to best manage chronic pain patients.

 

PERSONALITY ASSESSMENT INSTRUMENTS AND METHODS

 

We have already discussed two major approaches to the assessment of personality disorders –the MMPI and Axis II diagnoses of the DSM-IV. However, it should be kept in mind that, for approaches such as these (which are categorical in nature; i.e., either the disorder is present or not present), they are susceptible to many of the limitations associated with a categorical system in terms of not taking into account overlap between diagnoses. In fact, many investigators frequently cite multiple personality diagnoses for the same patient when assessment is based upon a structured, categorical approach.

 

Various studies have revealed that, on average, 85% of patients diagnosed with a personality disorder receive multiple Axis II diagnoses, with the average degree of overlap between any two specific pairs of personality disorders being 10% (ranging from 0% to 45%; Gatchel and Weisberg, 2000). Thus, such data raise questions about the distinct boundaries assumed to exist between specific Axis II diagnostic categories. This is one reason why many clinicians use a cluster approach when utilizing the DSM-IV. Likewise, it suggests that, for finer grade distinctions of personality disorders, it is helpful to use other assessment instruments and approaches to supplement one another in coming up with a more confident understanding of personality characteristics of a particular individual. Fortunately, there are several other instruments that have been developed to assess personality disorders. Some of these are listed in Table 6 and have been reviewed by Gatchel and Weisberg (2000).

 

 

Table 6: Assessment Instruments for Personality Features

 

 

     Personality Assessment Schedule

     Personality Interview Questionnaire

     Millon Clinical Multi-axial Inventory (MCMI-III)

     Schedule for Non-Adaptive and Adaptive Personality (SNAP)

     NEO Big 5 Factor Personality Inventory

     Multidimensional Pain Inventory (MPI)

 

 

EVALUATING PERSONALITY TO HELP WITH

CHRONIC PAIN TREATMENT

 

There can be no doubt that based on their individual experiences, people develop unique ways of interpreting information and coping with stress. These patterns, in turn, affect pain perceptions and responses to the presence of pain, and, if they are maladaptive, then one would expect more difficulty in coping. As discussed earlier, individuals with a personality disorder in general would be expected to display an inability to cope with a major stressor such as chronic pain. Likewise, we earlier discussed the fact that individuals with personality disorders often have maladaptive coping skills. As such, one would expect independent evaluation of coping skills to further document these deficits in individuals with personality disorders. Indeed, there is growing demonstration of a relationship between ineffective pain-coping strategies and chronic pain (Gatchel et al., 2007; Gatchel, 2005). In fact, one instrument that directly addresses the issue of personality and coping is the Multidimensional Pain Inventory (MPI), also previously known as the West Haven-Yale Multidimensional Pain Inventory (Kerns et al., 1985). This instrument was developed to measure three psychosocial dimensions of pain: patients’ self-reported pain and the effects of pain; responses of significant others to the communications of pain patients; and level of daily living activities. Turk and Rudy (1988) subsequently developed a classification system using the MPI which categorized patients according to three subgroups that predict response to treatment: dysfunctional, interpersonally distressed, and adaptive copers.  Brief descriptions of these groups can be found in Table 7.

 

 

Table 7.  Characteristics of MPI Cluster Groups

 

 

Dysfunctional

 

The dysfunctional profile patients have a tendency to perceive the severity of their pain to be high, and to report that the pain interferes with much of their life. They also report a high degree of emotional distress because of their pain.

 

 

Interpersonally Distressed

 

The interpersonally distressed patients are similar to the dysfunctional patients, but they also perceive that their “significant others” are not very understanding of their conditions. They perceive that they have no good social support to help them with their pain problems.

 

 

 

Adaptive Coper

 

The adaptive coper patients report a high level of social support and relatively low levels of pain or perceived interference with their lives. They usually respond well to pain management programs.

 

 

According to their system, the dysfunctional subgroup patients were hypothesized not to respond as well to intervention as would patients in the other two subgroups. There have been a number of studies supporting this hypothesis, as well as other findings related to the MPI profiles. Some of these findings, as reviewed by Gatchel (2005), include the following:

 

Chronic pain patients who were classified as dysfunctional reported more pain-specific fear and avoidance than did patients in the other two subgroups. Such characteristics, in turn, are related to poor coping abilities and treatment outcomes in these dysfunctional chronic pain patients.

 

Pain patients with dysfunctional and interpersonally distressed profiles display more indications of acute and chronic personality differences relative to adaptive coper profile patients.

 

Patients with an adaptive coper profile demonstrate greater positive treatment outcomes when administered a pain management program.

 

There has been a great deal of other clinical research demonstrating the utility of the MPI with various chronic pain conditions, including low back pain, headache, and temporomandibular jaw pain. Needless to say, the assessment of such MPI profiles provides a great help in tailoring the needs for treatment strategies to account for the different personality and coping characteristics of patients. For example, patients with an interpersonally distressed profile may need additional clinical attention addressing interpersonal skills to perform effectively in a group-oriented treatment program. Pain patients with a dysfunctional coping profile may require more intensive clinical management.  In contrast, patients coming in with an adaptive coping style may be less emotionally distressed, already have some requisite coping skills, and require less intensive treatment. Thus, some specific treatment modalities are more likely to be needed than others for each profile type. 

 

An important issue to consider is whether there are certain biopsychosocial profiles that are more or less responsive to different treatment modalities.  For example, variables that are likely predictors of pain-related disability outcomes, such as catastrophizing, fear of movement/activity, poor coping skills, emotional distress, and their interactions with environmental factors (such as work place satisfaction, and health care system variables) need to be more closely evaluated whenever possible.  How do we go about doing this?  This will be discussed next.

 

The Stepwise Approach to Assessment

 

In previous publications, Gatchel has provided an example of a stepwise approach to the assessment of a patient who was referred to treatment for low back pain (Gatchel, 2001; 2005).  Of course, for the evaluation of a pain patient, it is incumbent to have a comprehensive physical examination conducted by a physician.  For a patient with low back pain, this examination could consist of assessment and documentation about the following:  range-of-motion; straight-leg raising; documentation of areas of tenderness; neurological signs; gait and posture evaluation; and Waddell non-organic signs.  This initial physical examination will provide valuable information concerning possible functional deficits and anatomical/neurological problems.  If needed, additional diagnostics can then be ordered.  Also, signs of potential neuromuscular inhibition and motivational problems will usually become apparent during this physical evaluation, which can then be further validated with information garnered from the psychosocial assessment data.  Once it is decided that this low back pain patient can be safely functionally tested, a more comprehensive functional capacity evaluation should be requested in order to obtain the baseline data needed to individually tailor a physical rehabilitation program for that patient.

 

In terms of the ideal approach to the assessment of possible psychosocial problems and issues, one then must decide which psychosocial and/or personality assessment tools should be used.  In doing so, one should be aware of the issue presented in Table 8.

 

 

Table 8.  Choosing Assessment Tools

 

 

No single psychosocial device can be used reliably in all personality assessments.

 

One cannot assume that one instrument can be used as a sole method for descriptive purposes.  Such data should be viewed as just one source of information to be considered, along with other forms of data.

 

One must also know about a patient’s history of social relationships, the presence or absence of social support networks, degree of life satisfaction and success, the history of coping with stressors, and so on, in order to make a probability statement concerning the prediction of some behavior such as response to pain (e.g., a person with a history of coping well with stressors has an 80% probability of not displaying a great deal of pain behaviors).  It is extremely rare that a totally accurate prediction of some behavior based on a single psychosocial or personality assessment instrument can be made.

 

Multiple sources of data should be used to provide a comprehensive evaluation of a patient’s biopsychosocial functioning.

 

 

With the above in mind, the following is a chart (Figure 4) of the stepwise process initially described by Gatchel (2001, 2005) for the low back pain patient. 

 

stepwisefigure

Figure 4: Stepwise Approach to Assessment

 

As can be seen, after the comprehensive physical examination, there is an initial screening process to “flag” obvious psychosocial distress which can be performed efficiently by utilizing tests such as the Beck Depression Inventory (which captures symptoms of depression), the SF-36 (which captures the overall physical and mental health functioning), and then a more specific low back pain type of instrument, such as the Pain Disability Questionnaire or the Oswestry Questionnaire.  After this initial psychosocial screening, if there are elevations in the measures, then the patient can be directly sent for rehabilitation treatment. If there are elevations, then a more comprehensive psychological interview can be conducted, as well as the administration of additional tests such as the MMPI-2 and/or the SCID for DSM-IV.  If there are no elevations or “red flags” on these psychosocial screening measures, then the patient can be referred to a comprehensive pain rehabilitation program.  In both cases, when the patient is entered into a treatment program, then the comprehensive physical examination, along with the comprehensive psychosocial evaluation (what we call the biopsychosocial evaluation), can be used to prescribe the specific treatment program for each individual.  Moreover, the MPI is also administered at this point in time in order to evaluate the patient’s overall coping style.  With this information on hand, the treatment staff can usually be prepared to deal with any unusual behaviors or barriers to recovery.

 

Pain Management Intervention Strategies

 

In the past, for many pain management programs, there was an unfortunate “disconnect” between the assessment that was administered to patients and the subsequent treatment program administered to those patients.  This was due to the fact that there was a tendency to apply a “one shoe size fits all” treatment strategy philosophy.  The more recent interdisciplinary pain management programs emphasize the need to carefully utilize the comprehensive assessment data in order to tailor a specific treatment program for each individual.  This has been emphasized throughout this present Course.  Because of this need, interdisciplinary pain management programs have been developed, and have been unequivocally demonstrated to be treatment – and cost-effective (See Gatchel and Okifuji, 2006, for a review of the literature supporting this conclusion).

 

At the outset, distinctions among primary, secondary and tertiary pain management care need to be highlighted because they suggest that the type of interdisciplinary pain management required for each is substantially different. For example, primary care is usually applied to acute cases of pain of limited severity. Basic symptom-control methods are used in relieving pain during the normal early healing period. Most often, only some basic psychological reassurance that the acute pain episode is temporary, and will soon be resolved, is quite effective at this stage of care.

 

Secondary care represents “reactivation” treatment that is administered to patients who do not improve simply through the normal healing process of primary care. It is administered during the transition from acute (primary) care to the patient’s eventual return to work or normal activities of daily living. This treatment has been designed to promote a return to productivity before advanced physical deconditioning and significant psychosocial barriers to recovery occur. At this phase, more active psychosocial intervention may need to be administered to patients who do not appear to be progressing. It is at this stage that an initial brief biopsychosocial evaluation can be administered to “flag” whether potential psychosocial issues or personality characteristics are present that may interfere with normal recovery. The earlier discussed initial screening process to “flag” obvious psychosocial distress factors can be administered at this point in time to hopefully capture such psychosocial/personality barriers to recovery, as well as any lingering physical functioning problems.

 

Finally, tertiary care requires a more comprehensive and intensive treatment approach. It is intended for patients suffering the effects of both physical deconditioning and chronic pain and disability. Basically, it differs from secondary care in regard to the intensity of the rehabilitation services required, including psychosocial and pain management. As reviewed by Gatchel (2005), the critical elements of interdisciplinary care can be found in Table 9.

 

 

Table 9.  Critical Elements of Interdisciplinary Care

 

 

In order to deal with any physical deconditioning problems, formal and repeated quantification of physical deficits are performed in order to help guide, individualize, and monitor the physical training progress of patients.

 

Psychosocial and socioeconomic assessments are conducted, again to guide, individualize and monitor pain and disability behavior-oriented interventions and outcomes.

 

A multi-model disability management program is utilized, which involves a wide array of cognitive-behavioral approaches, such as relaxation training, stress management, biofeedback, coping skills, etc.

 

Psychopharmacological interventions are available if detoxification and psychosocial management (of anxiety, depression, etc.) is needed.

 

An interdisciplinary, medically-directed team approach with formal staffing is conducted on a weekly basis, along with frequent team conferences in a low staff-to-patient ratio.

 

There is also an ongoing outcome assessment of physical and psychosocial variables at pretreatment, post treatment, and follow up periods, utilizing standardized objectives criteria.

 

 

As stated above, such an interdisciplinary biopsychosocial assessment-treatment program has been shown to be extremely effective in successfully managing chronic pain patients, relative to less intensive, single-modality treatment programs of the past.

 

APPORTIONMENT

 

With the passage of SB899, previous apportionment provisions under the Labor Code (§ 4750 and 4750.5) were repealed. Apportionment issues are now mandated entirely with Labor Code Sections 4663 and 4664. Under Labor code 4663, apportionment of permanent disability (PD) shall be based on causation (§4663a).  Further, apportionment determinations must include what approximate percentage of the PD was caused by the direct result of injury arising out of and occurring in the course of employment and what approximate percentage of the PD was caused by other factors both before and subsequent to the industrial injury, including prior industrial injuries.    Under Labor Code 4664, the employer shall only be liable for the percentage of permanent disability directly caused by the injury arising out of and occurring in the course of employment (§ 4664a).  All factors of apportionment must be considered using a causative analysis.  One method is (discussed in the ACOEM) is the six-step process for evaluating “work relatedness” as used in the example evaluation.  Apportionment to non-industrial factors must be considered.  In apportioning to causation and not disability, the issue of apportionment to pre-injury psychiatric symptoms and concurrent/subsequent psychiatric issues is carefully assessed. 

 

As we have seen, the prevalence of personality disorders among patients with chronic pain is very significant and far higher than that seen in the general population.  We have also seen that no one personality diagnosis has been established as consistently occurring more frequent in patients with chronic pain.  So far, the most consistent finding is that there are either multiple diagnoses present or a mix of features that defies classification.  Thus, the category of Not Otherwise Specified is often most appropriate.

 

The research has clearly established an association between personality disorders and chronic pain.  However, as we all remember from introductory statistics, correlation is not causation.  Simply because a person has a personality disorder (non-industrial) that does not necessarily mean that the injured worker’s psychiatric injury was caused in part by that disorder.  This is a challenging clinical issue for which there is no clear guidance in the research literature.  The search for a consistent “pain prone personality” pattern has not been successful.  There is no clear set of personality features that “causes” a patient to develop chronic pain (or predicts its occurrence).  However, as every experienced clinician can attest, there are personality features that make it more likely for one patient to become a chronic pain case and another not.  These clinical findings (or anecdotal evidence) are, in fact, supported in the early identification literature. This research has established that there are psychosocial variables that predict which patients will move from an acute to chronic pain state (“chronification”), even when these variables are assessed as early as 2-4 weeks after the initial injury (See Gatchel, Polatin & Mayer, 1995; Linton, 2005).  The fact that these predictive psychosocial variables exist suggests that some may be personality-disorder related.  Of course, this may not always be the case since many of these psychosocial variables are situation based such as work stress, work dissatisfaction, situational depression, etc.  The question may be: How do pre-existing personality disorders interact uniquely with other situational variables to cause the development of a chronic pain syndrome in one worker; whereas, in another worker experiencing the same situational variables and having no personality disorder does not develop chronic pain?

 

The following is an example of a case in which it was felt that the evidence strongly supported apportionment to non-industrial factors relative to a derivative psychiatric injury associated with chronic pain.  As will be seen, objective evidence included the history, medical records and psychological testing.  Although the MCMI-III was given, the patient did not complete it in a manner that allowed scoring.  Even so, the MCMI-III results would likely have provided even more objective evidence of the personality disorder.  Since this was a very lengthy report, those parts not relevant to the issues at hand have been deleted (all identifying information in this case has been changed significantly).  

 

 Psychiatric Qualified Medical Evaluation

 

Permanent and Stationary Evaluation

 

Patient Name:

Joan Smith

Date of Evaluation:

 

Claims Examiner:

 

Date of Injury:

 

Employer:

 

Claim#:

 

 

Procedures Used:             Comprehensive Clinical Interview

                                       Psychological and Pain Assessments of:

                                            Pain and Functional Ratings

                                            Patient Pain Drawing

                                            MMPI-2

                                            MCMI-III (not completed)

                                            Pain Patient Questionnaire

                                            Multi Dimensional Pain Inventory

                                            Modified Somatic Perceptions Questionnaire

                                            Beck Depression Inventory-2

                                        Review of Available Medical Records

 

Brief Background:

 

The applicant began working for ABC Construction in approximately April of 2003.  Ms. Smith alleges industrial injuries to her back, gastrointestinal, stress/anxiety, bilateral hands, wrists, and shoulders, occurring in a cumulative trauma fashion.  She alleges that the back injury was exacerbated by falling out of her chair on 6/3/2004.  She alleges the neck, shoulder, and upper extremity injuries occurred due to repetitive motion.  Lastly, she alleges that the stress and anxiety, along with the concomitant gastrointestinal problems, were due to how she was being treated by her immediate supervisors.  Ms. Smith has been declared permanent and stationary from an orthopedic standpoint. 

 

Identifying Information:

 

This is a 52-year-old female, who alleges multiple industrial injuries during the course of her employment with ABC Construction.  Ms. Smith alleges that these injuries primarily occurred in a cumulative trauma fashion culminating with a date of injury on June 3, 2004. 

 

Current Symptoms and Level of Function:

 

The following are Ms. Smith’s current symptom complaints and her reported level of function:

 

Psychological:

 

In an effort to understand the applicant’s symptoms of “stress and anxiety” she was questioned carefully about the type of psychological problems and symptoms she was experiencing.  She summarized her situation as being “physically and emotionally exhausted.” However, she consistently related this to her daughter’s current situation and reporting “I can’t help her.”  As will be discussed in greater detail subsequently, her daughter’s significant other recently died unexpectedly leaving her as a single mother with two young children.  Ms. Smith attempts to help take care of her grandchildren and was quite tearful when discussing this specific situation.  When asked about her primary areas of stress, she stated “the primary thing is that I can’t help my daughter or grandkids.”  Upon further questioning, she did report some distress related to her chronic pain “mostly in my lower back.” 

 

Physical:

 

The applicant currently complains of “a lot of pain.”  Initially, she was referring to almost total body pain.  Again, on more detailed questioning, she stated “it is mostly in my lower back.” She also reported numbness in the right leg.  She reported neck pain, bilateral shoulder pain (right greater than left), and upper extremity pain. 

 

Reported Level of Function:

 

Similar to what she reported previously, she does engage in ADL’s each day including “house cleaning.”  She stated she is currently “renting a couch” from a friend.  She reported that she is “up frequently during the night” and “I don’t sleep well.”  She will often sleep until 11:00 a.m.  She will then shower, dress, and engage in household ADLS.  She also currently spends a great deal of time caring for her two grandchildren due to the situation described previously. 

 

History as Presented by the Applicant (summarized):

 

Relative to the alleged injury to her lower back, the applicant stated this occurred with a very specific injury on 6/3/2004.  She stated that her work had become “busier and busier” in her position as a dispatch supervisor.  Ms. Smith “had to raise the chair all the way up” due to her short stature and she would generally “sit on the edge of the chair” while working.  She reported that on several occasions the chair would “fly out from under me” without warning.  Upon further questioning, the applicant stated she would essentially fall off of the front edge of the chair causing it to move backwards.  Even though she stated this occurred on several occasions, she reported that she never fell to the floor as a result of this occurrence.  After the incident on that day, she reported that her upper and lower back “started to hurt.”  She reported that although these pains had occurred in the past, she would generally go home, sleep, and “they would go away.”  She stated that “this time the pain didn’t go away.”  Ms. Smith reported that she went to the emergency room on 6/3/2004.  She stated she was given some type of injection at that time and released. 

 

Ms. Smith reported that the pain “went away” for approximately one week after the injection and then “returned.”  At that time, she consulted an attorney relative to her alleged work injury.  She stated her attorney referred her to Dr. Doolittle.  Ms. Smith reported that Dr. Doolittle ordered MRI studies and found “massive tears in both shoulders.”  The applicant reported she is “not sure” what was found in the lower back.  She stated that “I am supposed to have surgery on my shoulder.”  In addition, she stated that carpal tunnel syndrome was diagnosed in the wrists, bilaterally.  She stated that during this time, she was experiencing low back pain, mid back pain, neck pain, shoulder pain, as well as pain and “swelling” in both hands.  She reported that her treatment for these conditions thus far has included only medications. 

 

Relative to the alleged psychological injury, the applicant was again quite vague in attempting to answer concrete and detailed questions about the mechanism of the alleged psychological injury.  The applicant stated “I had stress, but not work stress.”  During that time, she stated “they were threatening me” referring to supervisors at the company.  She stated they would do things like “give a bonus and then take it away” and then “they started to monitor everything.”  She reported they had been running the business for about ten years and “it was growing.”  She was also reportedly told that “if you write up your dispatchers, you will get benefits.”  The applicant was evidently in a position to “write up” other dispatchers since she was a supervisor.  In response to this alleged directive, the applicant stated “I won’t hurt other people for my gain.”  Ms. Smith reported that the “stress” at work had been going on for approximately one or two months prior to the date of injury on 6/3/2004. 

 

Again, the applicant was a very poor historian for interim events.  The applicant’s primary treating physician was Dr. Doolittle.  As of March 2005, she carried physical diagnoses of bilateral carpal tunnel syndrome and bilateral rotator cuff tears.  She began medical pain management with Algology Pain Management in May of 2005.  Medical records indicate the applicant did follow-up with Drs. Doolittle and Algology on a regular basis.  She reported that on 3/31/2006, she underwent right carpal tunnel release and right shoulder open rotator cuff repair.  The applicant reported a difficult recovery from these surgeries and stated “they did not work.”

 

Early in 2006, diagnostic studies began to focus on the left shoulder.  On 10/25/2007, the applicant underwent left shoulder arthroscopy with arthroscopic subacromial decompression, mini open repair, and left rotator cuff.  Again, during the course of the clinical interview, the applicant reported that this surgery provided no benefit and “did not work.” 

 

In early 2008, the treatment began focusing on the lower back.  This included diagnostic studies (e.g. imaging and electrodiagnostic).  Medication management was also being provided including a regimen of Vicodin ES, Compazine, Soma, Lyrica, Prevacid, and Zoloft.  The applicant underwent an L4-5 epidural on 9/25/2008.  

 

Medical records indicate the applicant underwent the orthopedic AME in March of 2009.  The applicant was found to be permanent and stationary with no industrial injury to the lumbar or cervical spine.  The applicant continued to follow-up with her treating doctors.

 

Work History:

 

The applicant reported she was working for ABC Construction when the alleged industrial injuries occurred.  She stated her position was as a dispatch supervisor and that she began working there in approximately April of 2003.  She reported that her job duties included dispatching security officers as well as supervising other dispatchers.  Although she was somewhat unclear on this issue, she has evidently not worked since 6/3/2004. 

 

Ms. Smith was somewhat vague regarding her work history.  She stated that just prior to working for ABC, she “took a couple of years off” to help her husband and stepson.  Evidently, her husband was attempting to work, but was prohibited from driving due to legal problems. 

 

According to medical records, the applicant  worked for XYZ business as a secretary and leaving the job due to “stress.”  She also reported working as a bar tender and leaving that job due to “stress.”  This is consistent with what she reported to me during the clinical interview.  Prior to working as a bartender, she worked for another company from 1995 to 1997 and was “fired.”  She worked for LMNOP Bureau from 1994 until 1998 and “quit.”  She worked for the Los Angeles Tax office from 1990 to 1992 and left due to “stress.”

 

Other Medical Problems:

 

The applicant’s various other medical problems have been presented previously in the review of medical records section.  These are numerous and chronic, and will not be reiterated here.  The applicant did report that she recently had a pap smear come back positive.  She also had a test for the cancer virus, which came back positive.  She stated “that’s on my mind.”  

 

History of Work Injuries:

 

The applicant denied any history of work injuries aside from possibly the stress problems while working at XYZ.  Again, she stated that she did not file any type of workers’ compensation claim at that time. 

 

Educational History:

 

Ms. Smith stated that she dropped out of the tenth grade and then attended some classes at a community college.  She ultimately obtained her GED. 

 

Legal History:

 

The applicant did report an arrest in 2000 stating “I was busted for possession of methamphetamine.”  Ultimately, she stated that the charges were reduced to a misdemeanor after she completed probation.  After the arrest, the applicant was sentenced to some type of rehabilitation program.  She stated that the result of the methamphetamine use was “when my kids grew up, I freaked out and didn’t know who I was.”  She was married at the time and stated she began using substances due to this psychological stress.  During this discussion, she reiterated several times that “drugs have never been a problem for me.” 

 

Interviewer Observations and Mental Status Examination:

 

Deleted except for the following:

 

Suicidal ideation, plan, previous attempts: Ms. Smith currently denies suicidal ideation.  She did report a suicide attempt in 2000 when she “took a bottle of Xanax.”  She reported doing this after being arrested for methamphetamine possession.  Ms. Smith again reported that she did not seek treatment and “slept it off.”

 

On this evaluation occasion, the applicant also reported a suicide attempt in the 1970’s after her young nephew was killed and she “broke up with her husband.”  She stated she had lost 40 pounds in one month.  She did not discuss the specifics of the suicide gesture or attempt. 

 

Psychosocial Situation as Reported by the Applicant:

 

She was brought to California since “bad things were happening to me” as perpetuated by her mother and stepfather.  The applicant reported that her mother had left the family and remarried.  The applicant’s mother died at the age of 44-years-old when Ms. Smith was 17-years-old.  Her mother died of pancreatic cancer.  Her father died at the age of 82-years-old.  Ms. Smith has two sisters and one brother. 

 

Ms. Smith presents with a somewhat complicated psychosocial history relative to her immediate family.  She stated her first marriage was from approximately 1971 until the late 1970’s or early 1980’s.  She has a 36-year-old son from that marriage.  Her first husband was killed in a motorcycle accident in 1982 after they “split up.” 

 

Ms. Smith’s second marriage was from approximately 1976 until 1982.  She has two children from that marriage: a 28-year-old son and a 30-year-old daughter.  Her 30-year-old daughter, Julie, recently lost her 52-year-old husband due to a sudden heart attack.  She is left with a 5-year-old son and a 1-year-old daughter.   These are the grandchildren that Ms. Smith will often babysit.  There are significant stressors related to Julie’s situation currently.  Julie and her children have been forced out of the home and do not have a permanent residence.  In addition, Julie has had her own problems with substance abuse and chemical dependency.  Ms. Smith reported that at some point “Amber gave someone a ride who left speed in the car.”  Julie was evidently arrested and “she is still a felon.”  In addition, on the alleged one occasion that Ms. Smith has recently used methamphetamines, this was done with Julie to help with “energy.”  Ms. Smith also discussed that Julie may be using substances currently to deal with her own “stress.”  Ms. Smith reported that her ex-husband (Julie’s father) is not helping with the current situation.  He is on disability. 

 

Ms. Smith married her current husband in 1997.  Her current husband has multiple problems including a history of substance abuse and chemical dependency, as well as a CVA.  Ms. Smith reports that “he is sober and better now.”  The couple separated in 2005, but are on friendly terms.  As discussed previously, the applicant is in a sexual relationship with a long time friend. 

 

Psychiatric Treatment History:

 

Ms. Smith reported she began psychological and/or psychiatric treatment in 1976 after her nephew was shot and killed.  She reported she started on “nerve pills” at that time.  She began in psychological treatment with Ben Hur in the early 1980’s and first started seeing him while she was covered by Medi-Cal.  She stated she continues to see him on an infrequent basis currently.  The applicant denied any history of inpatient psychiatric hospitalization. 

 

The applicant reported she has been on a number of antidepressants over the years including Prozac “for a long time,” Zoloft (“for years”), and, most recently, Cymbalta.  She has been in some type of psychotherapy for at least the past 25 years.   

 

Substance Use:

 

The applicant reported that she rarely consumes. Ms. Smith reported she smokes .5 pack of cigarettes per day.  She currently denies use of any illicit or recreational drugs.  When asked specifically about a substance abuse or chemical dependency history, she denied any problems.  She basically states that “I grew up in the sixties.”  She states that she occasionally uses substances, but for each report of an instance of use, it is generally described as “one time,” and there is some justification. 

 

Comment:    The medical records clearly substantiate a long history of chemical dependency and substance abuse issues.  This includes poly-substance abuse of hallucinogens (mushrooms), methamphetamine, benzodiazepines, and marijuana.  On each occasion when the applicant has been discovered, she has had some justification for the use. 

 

Medications:

 

The applicant reported that her current medications include Xanax (1 mg, 1-3 per day, over the past 30 years), Norco (q.i.d.), Prevacid, Donnatal, and Dramamine.  She stated that she is also on something for hypertension. 

 

Psychological and Pain Assessments:

 

The patient was administered the assessment instruments as listed previously.  The following results were obtained:

 

Pain and Functional Ratings:

On the Pain Patient Questionnaire, the applicant currently rates her pain (0-100) at a 99, at its highest intensity, a 75 at its usual intensity, and a 70 at its lowest intensity.  Her pain rating during the clinical interview was at an 80 out of 100. 

 

These pain ratings can be compared to what was previously obtained on 2/16/2005.  At that time, she rated her pain at a 100 at its highest intensity, a 97 at its usual intensity, and a 60 at its lowest intensity.  She stated her pain at the time of the clinical interview at that time was a 100 out of 100. 

 

Currently, the applicant states that the pain interferes with work, family chores, and recreational activities 100% of the time, while it interferes with sexual functioning 80% of the time.  She states she is in pain 99% of the time.  Her pain is exacerbated by standing, lifting, and moving.  It is reduced by lying down. 

 

Pain Drawing:

On the Pain Drawing, the applicant showed pain in multiple body regions including the posterior cervical region, the shoulders and upper extremities, bilaterally, as well as the low back with radiation to the lateral aspect of the right buttock and down the right lower extremity to the foot. 

 

MMPI-2:

In this case, we have two MMPI-2 tests available for comparison.  The first is from 2-20-2005 and the second is current.  The difference will be discussed subsequently. Only the current MMPI-2 will be fully interpreted.

 

 

personality_mmpi_1

MMPI-2 Testing Date One

 

 

personality_mmpi_2

MMPI-2 Testing Date Two (Four Years Later)

 

 

Analysis of the consistency of item endorsements was evaluated using the accepted standards (Greene, 1991; Pope, Butcher, and Seelan, 2000, 2006; Graham, 1990; and others).  There were no item omissions, which is within acceptable limits.  In addition, the VRIN (T=46) and the TRIN (T=58F) were within normal limits.  This suggests that Ms. Smith answered the questions in a consistent manner. 

 

Validity of the profile was assessed using accepted standards (see Greene, 1991; Deardorff, 2000; Keller & Butcher, 1991; and Pope et al., 2000, 2006; MMPI Manual, 2001).  As can be seen, F, Fb, Fp, K, and S were all within normal limits.  Although the applicant did show a significant elevation on the FBS Scale, I do not use that for interpreting Validity since is it not yet universally accepted.  The applicant did show an elevation on L (T=71).  Elevations in this range on the L Scale can be due to a number of factors including a normal person who is very self-controlled and lacks insight into her own behavior, persons with religious and moralistic training, occupations that deny even the most common human faults, unsophisticated persons who are trying to create an unusually favorable impression of themselves, clients whose dynamics revolve around denial, and/or naïve self views.  Overall, in this case, the L Scale can be construed as a measure of psychological sophistication with high scores indicating a lack of sophistication (see Greene, 1991, page 107).  This will be taken into account in terms of interpretation of the Clinical Profile.

 

The clinical Profile can be interpreted from two different perspectives:  (1) Personality and psychopathology features and (2) Relative to the chronic pain.  As can be seen, Ms. Smith produced a very clear 1-3/3-1 Profile.  Scale 2 must also be taken into account in terms of its own elevation and the relative differences between Scales 1-3, and Scale 2. 

 

Personality features. The most commonly accepted interpretive method for the MMPI is to utilize 2-point code types.  This profile is clearly a 1-3/3-1 code type.  In patients with similar profiles, some tension may be reported, but severe anxiety and depression are usually absent, as are clearly psychotic symptoms.  This is certainly consistent with the subclinical elevation on Scale 2.  Rather than being grossly incapacitated in functioning, these patients generally function, but at a reduced level of efficiency.  The Somatic Complaints represented by the elevations on 1-3 include such things as headaches, chest pain, back pain, and numbness or tremors of the extremities.  Eating problems are common.  Other physical complaints often include weakness, fatigue, dizziness, and sleep disturbance.  The physical symptoms increase in times of stress and there is a clear secondary gain associated with the symptoms.  Patients with this profile present themselves as normal, responsible, and without fault.  They like excessive use of denial, projection, and rationalization, and they blame others for their difficulties.  They prefer medical explanations for their symptoms and often lack insight into psychological factors underlying their symptoms.  These patients tend to be rather immature, egocentric, and selfish.  They are generally insecure and have a strong need for attention, affection, and sympathy.  They are very dependent, but they are uncomfortable with the dependency and experience conflict because of it.  Although they are outgoing and socially extroverted (notice the very low elevation on Scale 0), their social relationships tend to be shallow and superficial.  They will often lack genuine emotional involvement with other people.  Patients with this profile harbor resentment and hostility towards other people, particularly those who are perceived as not fulfilling their needs for attention.  These patients need to convince other people that they are logical and reasonable, and they are conventional and conforming in their attitudes and values.  Because of the unwillingness to acknowledge psychological factors underlying their physical symptoms, these persons are difficult to motivate in traditional psychotherapy.  They are reluctant to discuss psychological factors that might relate to somatic symptoms.  It is occasionally possible for these patients to discuss problems, as long as no direct link to somatic symptoms is suggested. 

 

Chronic pain interpretation. This profile might also be interpreted relative to chronic pain issues.  According to Fordyce, patients with similar profiles present with a wide variety of vague and diffuse somatic complaints.  In these cases, there is often a very low correlation between subjective and objective findingsThese patients show pain behaviors and somatic complaints far beyond what would be expected due to nociceptive input and objective findings.  These patients show a high readiness to admit pain behaviors, but very little emotional distress associated with their reports of pain and other symptoms.  These patients will often use complaints of pain to extricate themselves from stressful situations.  The extreme elevations on Scales 1 and 3, in conjunction with the non-clinical elevation on Scale 2 (depression) suggest that this applicant is not uncomfortable in the sick role and may find aspects of it reinforcing.  As such, the applicant is showing a high readiness to admit pain behaviors, along with multiple somatic complaints, in conjunction with minimal distress regarding these symptoms.  Given the findings on the Validity Scales, it is not believed that this is due to conscious malingering (however, partial malingering was determined at the time of my evaluation five years ago).  Rather, this profile represents someone who unconsciously uses somatic symptoms to achieve specific psychological goals. 

 

Lastly, this profile suggests a very high level of symptom amplification.  These findings must be taken into account relative to any type of physical or psychiatric/psychological evaluation.  In addition, the MMPI-2 is one of the most objective measures of the various aspects of depression.  As can be seen, Scale 2 (T=62) is subclinical, and suggests that the applicant is not suffering from any type of depressive disorder.  Analysis of other MMPI-2 Scales that assess depression (DEP, T=55; as well as four of the five Harris-Lingoes Subscales for Depression) were all subclinical.  The only elevation was found on Physical Malfunctioning (D3; T=85), and this was due to endorsement of physical symptoms.  Therefore, although the applicant may report various symptoms of depression (subjective data), validated objective data such as the MMPI-2 suggests a lack of depressive symptoms. 

 

I think these MMPI-2 findings are also very important relative to the lack of elevation on Scale 7 (Pt, a measure of anxiety type symptoms).  As can be seen, on Scale 7, she achieved a T-score of 59, which is subclinical.  In addition, Content Scales measuring Anxiety were not particularly elevated including ANX (T=64),  A (T=44), and the Fears Subscales (both T less than 50).  Although the applicant provides a self report of symptoms consistent with generalized anxiety and panic episodes, this is not substantiated on objective testing.  Again, one must keep in mind, that these Clinical Scale results are part of a valid profile. The self-report of generalized anxiety and panic attacks is likely worse than what is actually occurring and is used to obtain the benzodiazepines (Xanax).  

 

As can be seen, the profile configuration is similar to what was found before aside from a significant increase in Scale 1 and 3.  As will be discussed, I believe this represents development of the chronic pain syndrome over time.

 

MCMI-III:

Although the applicant was administered the MCMI-III in an effort to tease out personality features that may be important for apportionment issues, she failed to complete this test to the point that it could be scored.  When apportioning due to causation, long-standing personality features that interact with an industrial injury can be important to assess especially when there is a complicated history of psychological issues. 

 

Multi-Dimensional Pain Inventory:

The MPI scores for the two test periods are as follows:

                                                 

 

MPI Results

 

 

 

Current   

 

 

2-2005

 

Scale 1 Pain Severity    

58

65

Scale 2 Interference     

41

33

Scale 3 Life Control

40

55

Scale 4 Affective Distress

60

42

Scale 5 Support

55

32

Scale 6 Punishing Responses

39

50

Scale 7 Solicitous Responses

56

34

Scale 8 Distracting Responses

68

48

Scale 9 Household Chores

68

48

Scale 9 Household Chores

59

65

Scale 10 Outdoor Work

47

51

Scale 11 Activities Away From Home

54

37

Scale 12 Social Activities

66

50

Scale 13 General Activity Level

59

53 

 

The applicant was re-administered the Multi-Dimensional Pain Inventory.  Previously, Cluster Classification was not possible and was coded as “anomalous.”  At that time, her pattern of scores did not make sense relative to established theories of chronic pain.  On this occasion, Cluster Classification was possible and she was placed in the “Dysfunctional” Cluster Classification Group.  As can be seen, she scored above average for Pain Severity and Affective Distress.  Interestingly, she scored above average for almost all of the Activity Categories including Household Chores, Activities Away From Home, Social Activities, and General Activity Level.  This does suggest that the applicant is trying to stay busy and active, regardless of her reports of chronic pain and disability. 

 

We can also make comparisons with her previous findings, from five years ago.  As can be seen, her Pain Severity rating has actually improved even though her reported Interference With Functioning has increased.  Her reported sense of Life Control has decreased.  Her reported Affective Distress on the MPI has increased.  In the face of these inconsistent findings, her Activity Scales have generally increased since her previous assessment, especially for Activities Away From Home, Social Activities, and General Activity Level.  Some of these inconsistencies may be due to the fact that the initial MPI results were determined to be “anomalous” and the patterns did not really make sense.  The current assessment is more consistent with the other data that is available for review.  It should be noted that the MMPI Scale II measure is much more sophisticated relative to assessing all dimensions of depression versus the Affective Distress Scale on the MPI. 

 

Beck Depression Inventory-2:

On the BDI, the applicant scored a 16, which is in the mild depression range of self-rated depression.  This compares with her previous BDI-2 findings as obtained by Dr. Douyon on 3/12/2010 of 19.  This is also in the range of mild depression. 

 

Analysis of individual items on the BDI-2 include a 3-I feel like I am being punished; and a 3 on changes in sleep pattern-I wake up 1-2 hours early and can’t get back to sleep.  These high scoring items must be taken into account relative to the applicant’s complaint of chronic pain and the adversarial nature of the workers’ compensation system.  Chronic pain patients will often artificially elevate BDI-2 scores due to endorsement of physical symptoms unrelated to actual depression as well as an endorsement of items related to being in the workers’ compensation system (e.g. I feel like I am being punished, “by the insurance carrier”).  Taking into account the results of the MMPI-2, even the BDI-2 score of 16 is likely higher than what the applicant is actually experiencing in terms of any depression. 

 

Epworth Sleepiness Scale:

On the Epworth Sleepiness Scale, the applicant scored a 4, which is in the normal range.  This suggests that she is not experiencing any type of sleepiness or anergia during the day.  It is also suggestive of restorative sleep.  These results are exactly the same as obtained on 4/2/2009.  Scores on the Epworth Sleepiness Scale between 0 and 10 are considered in the normal range. 

 

Again, these objective measures of subjective symptoms are somewhat discrepant.  During the course of the clinical interview, the applicant reports sleep disruption and lack of energy during the day.  She also reported this to other evaluators.  Even so, standardized objective measures such as the Epworth indicates she is likely obtaining restorative sleep and not experiencing any significant sleepiness or anergia during the day.  This amplification of symptoms on subjective self-report is also consistent with the MMPI-2 Profile.  Therefore, one must be careful to develop opinions based only on objective data.  In addition, any subjective self-report data provided by the applicant must take into account the high degree of likely symptom amplification.  Again, based on the Validity Scales of the MMPI-2, I do not believe that this is occurring due to conscious malingering.  Rather, it is more likely due to a personality style and various factors that are reinforcing pain behaviors and disability.

 

DSM-IV Diagnoses:  

 

DSM-IV Diagnosis

 

 

Axis I: 

 

Depressive Disorder with Anxiety and Depressed Mood, Resolved (309.28; Industrial). 

 

Pain Disorder Associated With Psychological Factors and A General Medical Condition (307.89; Industrial). 

 

Hallucinogen Abuse (305.30; Non-industrial). 

    

Cannabis Abuse (305.20; Non-Industrial). 

 

Anxiolytic Dependence with Physiological Dependence (304.10; Non-Industrial). 

 

Bereavement (V62.82; Non-Industrial, resolving).

 

 

Axis II:

 

Personality Disorder Not Otherwise Specified (Borderline, Dependent, Antisocial Features; specifics undetermined)

 

 

Axis III:

 

Per Medical Specialists.

 

 

Axis IV

 

Living situation, financial distress, daughter’s living situation, recent death of son-in-law, and recent “scare” relative to positive cancer screening tests (unresolved at this point). 

 

 

Axis V:

 

GAF current and past year: ___

 

         

Diagnostic Reasoning:

 

Deleted

 

Causation: Relationship of Work Exposure to Psychiatric Injury:

 

First part deleted

 

Evidence of Disease:  As discussed previously, the applicant now shows a chronic pain syndrome which has developed over the past five years since my previous assessment.  I believe she also suffered from some type of Adjustment Disorder that exacerbated her depression and anxiety beyond what has occurred throughout her life due to the personality disorder features.  This exacerbation in the depression and anxiety due to industrial factors has now resolved.  As such, she has residual aspects of the chronic pain syndrome. 

 

Epidemiology:  The epidemiological analysis helps to determine whether the presenting psychiatric symptoms could be work related or related to non-industrial factors.  As discussed in my previous evaluation, the psychological testing continues to suggest that Ms. Smith is showing symptom amplification including the psychological symptoms and complaints of pain.  However, I have now concluded that the partial malingering has developed into a chronic pain syndrome.  Other factors influencing the chronic pain syndrome include the intervening surgeries and other “system” pressures that I have outlined previously. 

 

Evidence of exposure:  The conclusion that Ms. Smith is now suffering from a chronic pain syndrome is supported by the evidenced based analysis of exposure.  In terms of development of a chronic pain syndrome, a relatively mild and innocuous work injury simply sets the “wheels in motion.”  The industrial aspect of the work injury then develops over time as discussed previously. 

 

Consideration of Other Relevant Factors.  Other relevant factors such as work history, medical history, pain and psychological testing results, and non-industrial explanations for the presenting symptoms have been considered relevant to the AOE/COE determination.  There continue to be multiple non-industrial stressors that are both occurring currently as well as on a chronic basis.  These will be discussed under a subsequent section, apportionment.  Previously, in 2005, I determined that all of the non-industrial factors provided a much stronger etiologic explanation for her psychiatric symptoms at that time than any alleged industrial injury.  However, I believe a chronic pain syndrome has developed in the interim and that a percentage of her current psychiatric symptoms is due to these industrially related factors. 

 

Validity of Testimony and Credibility.  As discussed in my previous report, I had significant concerns relative to the applicant’s credibility in responding to various components of the evaluation.  In fact, these concerns prompted the diagnosis of partial malingering (malingering in DSM-IV).  At that time, the testing battery suggested the applicant was showing pain behaviors and other symptoms far beyond what would be expected due to objective findings (symptom amplification).  The applicant continues to show these findings on the MMPI-2.  Previously, there were concerns relative to Ms. Smith’s credibility related to her report during the clinical interview.  At that time, in response to a variety of questions, she was either vague, gave incorrect information, or left out fairly significant information that was later discovered in the medical records. 

 

On this occasion, the applicant was more open in providing information and was more consistent in her report of the history and her current status.  In addition, the MMPI-2 Validity Scales were essentially within normal limits and reasonable credibility was established.  Also, the applicant certainly did not appear to artificially elevate very face valid instruments such as the Epworth Sleepiness Scale and the Beck Depression Inventory-2.  Both of these instruments are extremely face valid and easy to “fake” if an individual desires to do so.  Ms. Smith clearly did not attempt to manipulate these very face valid instruments and, hence, this provides evidence for increased credibility relative to the previous evaluation. 

 

Final AOE/COE Conclusions:

 

At the time of my previous evaluation, there was no evidence to support the finding of an industrial psychiatric injury.  However, in the interim, she has developed a chronic pain syndrome due to factors discussed throughout this report.

 

Preexisting Psychiatric Entities:

 

A variety of preexisting psychiatric problems were identified and many of these are ongoing.  These include such things as the long-standing personality features, the history of poly-substance abuse, the history of psychiatric treatment for a variety of reasons (dating back at least 30 years), the history of alleged generalized anxiety and panic attacks (dating back at least 30 years), among other things previously discussed. 

 

Periods of Temporary Disability:

 

Deleted

 

Permanent and Stationary:

 

Deleted first part

 

Although the applicant continues to be symptomatic, with her symptoms waxing and waning depending on environmental circumstances, she is considered permanent and stationary taking into account the above definition.

 

Apportionment:

 

Apportionment is extremely difficult in this case given the applicant’s extensive psychiatric treatment history, her inconsistent occupational history, the personality disorder features discussed previously, and current non-industrial psychosocial stressors.  Objective data include the psychological testing battery from five years ago relative to what we have currently.  In addition, we can evaluate the various non-industrial stressors that have been occurring in the life of this applicant, both previously and presently.  The most straightforward method for attempting to ascertain how these industrial and non-industrial factors might be impacting her current symptoms is to develop a table of these causative factors.  As can be seen in the following:

 

 

 

Analysis of Apportionment Issues

 

 

Industrial

 

 

Non-Industrial

 

Multiple “failed” surgeries from a clinical standpoint and by patient report.

 

Orthopedic injuries as accepted and outlined by the orthopedic AME.

 

Chronic pain syndrome/disability syndrome

 

 

 

 

 

 

 

 

 

 

Personality disorder features

 

Longstanding psychotherapy for characterologic issues (25 years plus)

 

Longstanding history of problems at various jobs (stress, quit, fired) suggesting personality  factors

 

History (and current?) poly-substance abuse

 

Benzodiazepine dependence (longstanding)

 

Bereavement and guilt – “I can’t help my daughter and grandchildren”

 

History of treatment for depression and anxiety, including psychotropics

 

Worry and positive CA screening tests.

 

 

Industrial – 75%

 

 

Non-industrial – 25%

 

I do not believe it is possible for anyone to validly tease out the relative contribution of the various non-industrial factors to her permanent psychiatric disability.  Rather, these will be grouped as a cumulative percentage.  Based upon all of the non-industrial factors available for review, it is determined that 35% of her permanent psychiatric disability is due to non-industrial factors and 65% is due to industrial factors, primarily development of the chronic pain syndrome. 

 

Treatment Analysis and Future Needs:

 

Deleted

 

Vocational Rehabilitation:

 

Deleted

 

Report Summary

 

1.   Psychiatric Diagnoses.  The claimant demonstrated multiple diagnoses on both an industrial and non-industrial basis.  On an industrial basis she demonstrated Depressive Disorder with Anxiety and Depressed Mood, Resolved (309.28; Industrial) and Pain Disorder Associated with Psychological Factors and A General Medical Condition (307.89; Industrial).  On a non-industrial basis she demonstrated: Hallucinogen Abuse (305.30; Non-industrial), Cannabis Abuse (305.20; Non-Industrial), Anxiolytic Dependence with Physiological Dependence (304.10; Non-Industrial), Bereavement (V62.82; Non-Industrial, resolving), as well as Axis II Personality Features. These findings are based upon all data available including the objective psychological testing, which is important in this case.

 

2.   Industrial Injury (AOE).  There is no evidence that there was a primary psychiatric injury as a result of the claimant’s employment.  However, here is now evidence of a derivative psychiatric injury in response to the chronic pain (system induced disability syndrome).  At the time of my previous evaluation, there was no evidence to support the finding of an industrial psychiatric injury.  However, in the interim, she has developed a chronic pain syndrome due to factors discussed throughout this report.

 

3.   Periods of TTD.  There has been no disability on a psychiatric basis.

 

4.   Current Disability Status and Permanent and stationary.  The claimant is permanent and stationary from a psychiatric perspective as of the date of this evaluation.

 

5.   Permanent psychiatric disability.  As discussed in the Schedule For Rating of Permanent Disabilities (SRPD) under the new law, permanent psychiatric disability is based on the GAF rating.  The applicant received a GAF of ____, which translates WPI of ___.

 

6.   Apportionment.  The patient had significant non-industrial psychiatric entities prior to the work related injury, since the work injury, and currently.  Therefore, apportionment is indicated as follows: Non-Industrial – 25%; Industrial – 75%.

 

Thank you for the opportunity to evaluate this woman. I reserve the right to change my opinion if and when other data become available such as more detailed medical records, etc.  This evaluation has been completed consistent with the Practice Guidelines and recent changes in the Labor Code (per SB899).

 

 

SUMMARY AND CONCLUSIONS

 

In this Course, a brief overview was provided concerning how the outdated dualistic biomedical approach to the assessment and treatment of pain has been replaced during the past decade by a more effective biopsychosocial model of chronic pain. In this model, along with basic physical variables, psychosocial factors (including personality characteristics) play an important role in the reception, reaction and coping with chronic pain. Evaluation of these psychosocial-personality characteristics, and how to integrate them into a treatment program, was presented.

 

The early and most widely used assessment method for evaluating personality characteristics of pain patients has been the MMPI. The early work in this area attempted to differentiate functional from organic pain. However, much of the early clinical research demonstrated that there was no utility or validity of drawing a distinction between functional versus organic features of chronic pain. Rather, with the biopsychosocial perspective of pain, it is now appropriately viewed as a complex interactive system which cannot be divided into distinct psychosocial or physical components alone. It was also emphasized that, although there have been additional efforts to try to identify various “pain prone personality” types with the use of the MMPI, such studies have been strongly criticized, and this notion is no longer accepted as valid. In all of these clinical studies, though, there is no dispute about the notion that the MMPI can be useful for assessing personality in pain patients. However, MMPI results should be viewed as only one of a potential battery of tests to better understand the psychosocial functioning of an individual with pain.

 

Using the MMPI, three major profile types have been identified as useful in better understanding the personality characteristics of chronic pain patients: the Conversion V Profile type, the Neurotic Triad Profile type, and the Disability Profile type. In addition, a number of other profiles or cluster types have been developed in an attempt to classify chronic pain patients. For instance, in 10 separate studies the P-A-I-N grouping has been found useful to describe the different typology or clusters. Although such a clustering has been found to be useful, it should again be emphasized that these profiles or cluster types should be used as only one piece of data in isolating psychosocial and personality characteristics of patients with pain.

 

In an attempt to increase the reliability of psychiatric diagnoses, the American Psychiatric Association published the DSM-IV which allows for diagnoses on five different axes, each corresponding to a different class of disorder. For our purposes, Axis II diagnoses consist of personality disorders which included the following: paranoid personality disorder; schizoid personality disorder; schizotypal personality disorder; antisocial personality disorder; borderline personality disorder; histrionic personality disorder; narcissistic personality disorder; avoidant personality disorder; dependent personality disorder; obsessive-compulsive personality disorder; and personality disorder “not otherwise specified”. Furthermore, the structured clinical interview for DSM diagnoses (SCID) has been developed, which requires clinicians to use the same sequence of questioning in the rating of symptoms verbalized by patients. This SCID approach has been found to be associated with a high degree of inter-rater reliability across clinicians. The SCID I is used to evaluate Axis I disorders, while the SCID II is used to classify Axis II personality disorders. As discussed, in light of the earlier reviewed MMPI findings, it is not surprising that there has been a greater prevalence of Axis II disorders found for chronic pain patients, relative to the general population. Finally, the DSM-IV includes a method to “cluster” these various Axis II personality disorders into three major personality clusters: Cluster A, Cluster B and Cluster C. Of these three clusters, Cluster B personality type individuals are especially troublesome because of the more “dramatic” nature of the ingrained characterological attributes, such as being inflexible, erratic, being oblivious to their own problems, and lacking of empathy for others.

 

An understanding of psychosocial and personality disorders in patients with pain is extremely important in order to become aware of developing a therapeutically effective pain management program. This will allow the better “tailoring” of the treatment program to fit the individual’s unique personality characteristics, and thus helping to optimize the likelihood of a successful outcome. A diathesis-stress model of psychopathology was introduced to highlight how psychosocial and personality disorder problems may arise as patients’ progress from acute to chronic pain stages. With this diathesis-stress model in mind, clinicians need to become aware of the fact that the personality characteristics being displayed by a particular pain patient may be an exacerbation or amplification of their “normal” personality if the pain has become chronic and stressful in nature. That is to say, before the onset of chronic pain, the personality style of the particular individual may not have been maladaptive or interfering with his/her activities of daily living. However, after the exacerbation, many of the characteristics of that individual’s personality may become more prominently displayed, resulting in the inability to deal with the stressors that normally would not have been problematic to deal with before the onset of chronic pain. A number of additional personality assessment instruments/methods were introduced, as well as how practitioners can evaluate personality in order to help manage patients with chronic pain using a “stepwise approach” to assessment. Finally, the close connection between the assessment process and the treatment tailoring process was emphasized in discussing primary care, secondary care and tertiary care approaches using an interdisciplinary biopsychosocial model for patient management.

 

Lastly, the complex issue of apportionment was discussed relative to the non-industrial contribution of a personality disorder to the emergence and maintenance of a chronic pain syndrome.

 

REFERENCES

 

American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington: APA.

 

American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders, 4th Ed, Text Revision. Washington, DC: American Psychiatric Association.

 

Gatchel RJ. (2001). A Compendium of Outcome Instruments for Assessment and Research of Spinal Disorders. LaGrange, IL: North American Spine Society.

 

Gatchel RJ. (2005). Clinical Essentials of Pain Management. Washington, DC: American Psychological Association.

 

Gatchel RJ, Mayer TG, Eddington A. (2006). The MMPI "Disability Profile": The least known, most useful screen for psychopathology in chronic occupational spinal disorders. Spine, 31, 2973-2978.

 

Gatchel RJ, Okifuji A. (2006).  Evidence-based scientific data documenting the treatment- and cost-effectiveness of comprehensive pain programs for chronic nonmalignant pain. Journal of Pain, 7(11), 779-793.

 

Gatchel, RJ, Polatin, PB, Mayer, TG. (1995). The dominant role of psychosocial risk factors in the development of chronic low-back pain disability.  Spine, 20, 2702-2709.

 

Gatchel RJ, Peng Y, Peters ML, Fuchs PN, Turk DC. (2007). The Biopsychosocial Approach to Chronic Pain: Scientific Advances and Future Directions.  Psychological Bulletin, 133, 581-624.

 

Gatchel RJ, Weisberg IN. (2000).  Personality Characteristics of Patients with Pain. Washington, DC: American Psychological Association Press.

 

Hanvik LJ. (1951). MMPI profiles in patients with low back pain. J. Consult. Psychology, 15, 350-353.

 

Kerns RD, Turk DC, Rudy TE. (1985). The West Haven-Yale Multidimensional Pain Inventory. Pain23, 345-356.

 

Linton, SJ. (2005). Understanding pain for better clinical practice: A psychological perspective.  New York: Elsevier

 

Melzack R, Wall PD. (1965).  Pain mechanisms: A new theory. Science, 50, 971-979.

 

Melzack R. (1993).  Pain: Past, present and future. Can. J. Exp. Psychology, 47(4), 615-629.

 

Polatin PS, Kinney RK, Gatchel RJ, Lillo E, Mayer TG. (1993). Psychiatric illness and chronic low-back pain. The mind and the spine--Which goes first? Spine, 18(1), 66-71.

 

Robinson RC. (2000). Psychometric testing: The early years of the MMPI. In Gatchel and Weisberg (eds). Personality Characteristics of Chronic Pain Patients. Washington, DC: American Psychological Association.

 

Spitzer RL, Williams JB, Gibbon M, First MB. (1988). Structured Clinical Interview for DSM-Ill-R. New York, NY: New York State Psychiatric Institute.

 

Turk DC, Monarch ES. (2002). Biopsychosocial approaches on chronic pain (pp. 3-29). In: RJ Gatchel and DC Turk (eds). Psychological approaches to pain management: A practitioner's handbook. New York: Guilford Press.

 

Turk D, Rudy T. (1988). Toward an empirically derived taxonomy of chronic pain patients: Integration of psychological assessment data. J. Consult. Clinical Psychology, 56:233-238.

 

 

 



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