Welcome to the first addition of the Stress Management Institute Newsletter!

Please note that our San Francisco office has moved to a new location:

5 Third Street, Suite 412, San Francisco, CA, 94103.

Tel. 415-543-3283 Fax. 415-543-3741 Toll-free. 1-888-847-4837

Our Sacramento office location remains the same at 2801 K Street, Suite 410, Sacramento, CA 95816.

Toll-free 1-888-847-4837 Fax 415-543-3741

Please use our San Francisco office address for ALL correspondence. Please update your records accordingly.

Now, ON TO THE NEWS!

This newsletter will offer information related to the behavioral-medicine world in general, with some emphasis on Workers' Compensation related issues. I will address different issues across the spectrum of behavioral-medicine psychology, including Sports Psychology. Any reader should feel free to forward this newsletter to any of their friends and/or patients. This is an open forum where I will share information that is relevant to the broad field of healing.

As California State SB 899 legislation altered the landscape of industrial medical-legal issues, it's clear that the injured worker has had more difficulty obtaining services that previously were readily allowed. ACOEM Guidelines have been used as the archetypal structure for determining services.

Putting aside political issues as a background for using ACOEM Guidelines, there has been a real shift and some serious consideration of what makes sense in terms of the intent and spirit of Workers' Compensation law whose original mission was to return the injured worker to preinjury status, or as close to that status as possible. It's not new news in the world of behavioral medicine that palliative care doesn't cure very much beyond the placebo affect, and that the apparent benefits are short-lived. For example, the ideal purpose of physical therapy is to train the person to practice what they learn for maximum ergonomic, structural and personal comfort, and beyond some training and re-learning, years of physical therapy do not go beyond this mission.

For decades psychologists have been doing research on presurgical psychological assessment, in an attempt to predict who might benefit by invasive procedures designed to alleviate pain. ACOEM Guidelines recommend the use of presurgical psychological assessment, and there is some serious research that has done well in predicting surgical and possibly social-psychological disasters. As clinicians we also know that historical issues that remain unresolved and that have suffering at the essence of the condition typically predict failure with surgeries or invasive procedures designed to alleviate pain. For example, over a decade ago a study was published using the results of surveys at the Spine Care Center in San Francisco which demonstrated that 75% of the patients with failed spinal surgeries had a history of some form of abuse, especially sexual and physical abuse. Clinicians have known that whether the perception of abuse was based upon physical, sexual, or emotional factors, chronic suffering can have its manifestation in Somatization Disorders, Conversion Disorders, Somatoform Disorders and Pain Disorders. Sometimes the subjective experience of elaborated pain is in fact what we call a "depressive equivalent." The patient may not describe himself/herself as subjectively "depressed" or dysphoric, but they behave as if they are suffering. These individuals have difficulty in various forms of interpersonal relationships because the suffering is manifested as extreme helplessness, victimization and dependency. These underlying attitudes typically compromise functional relationships.

In the world of presurgical psychological assessment, the clinician uses an extensive clinical history and psychometric testing to offer some probabilities of outcome with surgery, whether spinal surgery or implantation surgery, where the goal is pain relief.

Clinical research has identified some of the following as MAJOR PREDICTORS OF POOR OUTCOMES:

CONSISTENCY OF SUBJECTIVE AND OBJECTIVE FACTORS: when a patient's "objective" presentation in mental status and clinical examination is inconsistent with subjective complaints, these patients are often driven to seek treatment through other issues than the relief of pain.

EXAGGERATION: when a clinician identifies the patient as suffering from "symptom magnification", "supratentorial" driven symptoms, "histrionic" presentation of subjective complaints and/or outright factitious or malingering presentation, the patient usually does not do well with surgery.

HISTORY OF COMPLIANCE: when a clinician identifies the patient as being noncompliant with recommended procedures, the patient usually does poorly with surgery. Lack of compliance can be from motivational issues, psychiatric phenomena and more essentially may be related to a self-defeating individual. The patient that has any behavioral history of being self-defeating, typically does poorly with surgery. Psychodynamically these individuals are more comfortable with suffering than they are with well-being.

HISTORY OF LITIGATION: litigation oftentimes has a powerful effect in creating motivation to remain in the sick role, and even with the best of surgical procedures, the so-called "outcome" involving subjective complaints are rather dismal.

OCCUPATIONAL GOALS: typically without occupational goals, the patient doesn't do well.

PERSONAL GOALS: when the patient only identifies that "I want to feel better" as the primary basis for surgery without linking feeling better to increased activities of daily living, returning to the workplace, improved personal social relationships, they don't get better.

HISTORY OF ABUSE: unresolved historical suffering based upon a history of subjective perception of abuse interferes with the person being comfortable with well-being and with physical comfort. The lack of resolution of psychological suffering precludes well-being in the body.

HISTORY OF EMOTIONAL ABANDONMENT (developmental versus contemporary): when a person has unresolved feelings about having been emotionally abandoned, they typically show signs of suffering interpersonally, and quite commonly the subjective expression of pain behavior elicits social rewards and TLC that's not otherwise forthcoming.

HISTORY OF SOMATIZATION: a long-standing history of somatization typically is associated with poor outcomes. This is because somatization is actually a functional psychological defense that serves purposes to the person's identity. The issue of somatization is a complicated psychodynamic process, and usually shows signs of evolution prior to the person turning 30. Oftentimes how a person's illness in childhood was handled by the family can predict the potential for somatization, and sometimes the person showed signs of somatic responses to stressful situations as a vehicle to solve a problem. Somatization can actually be a distraction defense from decompensation in the severely disturbed individual. Albeit rare, if that's the case, you don't want to take away the physical complaints because the person will actually decompensate into a psychotic process.

HISTORY OF REGRESSIVE COPING: patients with significant histories of ongoing regressive coping strategies in the face of current knowledge and advice from physicians (tobacco dependency, caffeine dependency, street drug abuse, prescribe medication abuse) do not have a viable sense of self-esteem. These individuals typically will undo the best of surgeries and fail.

HISTORY OF FAMILIAL DISABILITY IDENTIFICATION: when part of a patient's identity is linked to a family history of disability, the identity often prevails and leads to poor outcomes with surgery.

LIFE CHANGE INDEX: when a person has gone through tumultuous times within the previous 12 to 18 months without much resolution, these patients are more at risk for health problems and poor outcomes with surgeries.

INTERNAL SOURCES EXTERNAL LOCUS OF CONTROL: when a patient feels he/she does not have much control in his/her life, the person does poorly with surgery. Associated with the perception of having little control are feelings of helplessness, victimization and having been dealt a "raw deal" from life.

These individuals sometimes show a "honeymoon of pain relief" following surgery, but typically between the third month and seven month they regress to presurgery levels of pain. I have observed this process hundreds of times in working with surgical patients in the last 30 years.

PSYCHOMETRIC TESTING RESULTS: The Minnesota Multiphasic Personality Inventory (MMPI) has been used for decades as a screening tool in medical centers. When the MMPI Presurgical Risk scales that have been used in research predict negative outcome, the index is correct 95% of the time. Unfortunately there are times when we may have 10 to 15% false positives and false negatives. Sometimes the patient looks as if they will benefit from surgery based on psychometric testing, but there are clinical indicators to predict otherwise that the testing doesn't pick up. The MMPI is a very powerful tool in presurgical screening as it can tease out factors of somatization, impact of depression, regressive coping styles, hypochondriacal presentation and conversion proneness.

The above list is not exhaustive of phenomena that may predict poor outcomes, but constitutes the most powerful predictors for poor outcomes, or the alternative, good outcomes.

I have worked with many surgeons in the last three decades, and interestingly most of them tell me that when the psychometric testing indicates "borderline" or poor candidacy for surgery, the patient usually doesn't do well. That's consistent with the literature that predicts correctly about 95% of the time of poor candidates.

It's also been my clinical experience, that when the MMPI indicates good candidacy, but that there are a couple of clinical indices to suggest questioning pursuing surgery, these patients can be treated before surgery. After surgery it's usually too late.

In comparing patients for surgery, there is ample literature to indicate that when patients are trained in various forms of relaxation including hypnosis, that they often do much better. I will address the issue of surgery preparation in a later issue. For the moment, anyone who would like some information regarding the impact of stress on functioning, please go to our web site, www.aboutstress.com. The site is primarily informational. We offer a Presurgical audio program on CD that's been tested with over 300 patients having various medical problems ranging from brain tumors to cardiac problems to degenerative disc disease, et cetera.

In later issues, I will discuss some of these issues in more detail. Please feel free to share information with your friends and colleagues, and feel free to raise questions that I might answer in future newsletters.

Remember: Do one good deed each day and the world can be a better place.

Best wishes,

Martin Shaffer Ph.D.

AME, QME, Sports Psychologist