The “snarled stumper” is a case of a logger who experienced a relatively mild knee injury while work.  He underwent a simple arthroscopy.  Postoperatively he experienced much more severe pain that pre-operatively.  Every intervention since that point has been ineffective.  Within eight months his quality of life has been completely destroyed.

I would like to make a couple of comments with regards to the “snarled stumper.”  I think this is the example of the case we see daily that frustrates us at every level.  It is probably a big factor why most of us are participating in the roundtable.

Dr. ____, I am interested in your Health and Behavior assessment tool.  My observation is that many injured worker’s are already under a lot of work and personal stress. Often an injury and dealing with workers comp system puts them over the edge. The treatment paradigm should be the same for all–early intervention, giving patients the tools to fend for themselves, creating as many system solutions as possible, and treating them with a lot of respect.

Dr. ____, thanks for your support.  Your commitment to tackling these patients’ situations head on is admirable and I am a witness to your tenacity.  It is incredibly rewarding to see your patients “wake up” and move forward.  It is unpredictable who that person might be.

The Noncompliant Patient

Dr. ____, I agree with your concept of “disengagement” and “stuck”.  The term I have used for a while is “entrenched”.  What I have learned the hard way is that the common denominator is anger.  The more I have tried to convince a given entrenched patient to not become angry the worse it gets.  I am in the middle of a disaster right now that has dramatically reinforced my perception.  I had submitted a paper to the roundtable a few months ago, “Ability and Motivation.”  If the patient is angry their motivation is destruction, including self-destruction.  Their ability to deal with the situation is limited, as they cannot see it clearly.  I have learned that I have to let go but still keep the door open.

Dr. Schubiner is a pain specialist in Detroit who was one of the keynote speakers at a course I put on last year, “A Course on Compassion-Empathy in the Face of Chronic Pain.”  He clearly defined the Mind Body Syndrome (MBS) for us and has really changed our community’s paradigm on how we approach these patients.  Inadvertently my approach also treats mind body syndrome with similar tools but in a different format.  I don’t think the exact approach matters as much as starting with the correct diagnosis. Currently medicine has taken a neurological disorder, Mind Body Syndrome, and treated it like a structural problem.  The real tragedy is that MBS is predictably treatable with full engagement from the patient.

My personal goal is that when the medical system is dealing with an entrenched patient that we quit doing procedures on them. All procedures-not just spine surgery.  I am developing a proposal I am presenting to my hospital to address this issue.  I am changing the term from “entrenched” to “noncompliant”.  I have historically felt that noncompliant was a derogatory term.  I now understand the depth of frustrations these patients experience.  Any human that is experiencing this degree of anger is not going to be rational and responsive.  I am continually challenged on how to break through this barrier.

This is just a first draft and if any of you could email me directly with your input I would really appreciate it.

I saw a 73 year-old woman who came to me for a second opinion.  She had undergone a spine surgical consultation and had been told that she needed to undergo an eight level fusion of her spine from the tenth thoracic vertebra to her pelvis.  She was understandably apprehensive.

She was moderately physically active but not in great physical shape.  Her career had been the National Guard and she had been able to retire early.  Golf was her passion.  Two years earlier she had developed pain down her right leg and weakness of the muscles that elevated her foot.  The term commonly used to describe this condition is “foot drop”.  A surgery was performed in the South between her lumbar 3-4 and 4-5 to take the pressure off of the nerves.  The surgery is called a laminectomy. Her leg pain quickly resolved.  The damage to the nerves in her foot was permanent and she wore a brace to keep her foot from flopping.  Usually foot drop does not resolve with any surgical procedure as the damage has occurred within the nerve.

Her symptoms were now just a persistent foot drop.  She had no back pain or leg pain.  Her spine was completely straight.  She was able to walk with the brace on her lower leg easily. I looked at her new MRI scan and it showed that the surgeon had successfully taken the pressure off of the nerves to her foot.  There was generalized arthritis but for those of you who are familiar with this web site, there is no correlation with spinal arthritis and back pain.  Besides she had NO back pain.

You must be asking yourself, “Why does she need another surgery?  As the nerve is permanently damaged surgery will not help that.”

Even if the prior surgeon had left some bone spurs behind more surgery would not improve the chances of the nerve regaining function.

So you are correct.  My recommendation was that no further surgery should be performed.

I am going to expand on this situation to explain the implications of going forward with a T10 to pelvis fusion:

• This is an operation that can take up to 10 hours to perform
• You are in the hospital for a week
• The fusion takes about four months to heal
• Your strength does not return for at least six months
• The complication rate is over 70% with a significant chance of major problems.  They include: infection, paralysis, hardware failure, blindness, screws damaging nerves, blood clots to the lungs with the potential for death, etc.
• The cost of this operation to society is over $100,000.
• With her spine fused from her lower thoracic spine to the pelvis she will lose much of her ability to twist (golf game) and it is more difficult to bend over to tie her shoes.  With a fusion you lose all flexibility in that area of the spine.
• There is a chance that a fusion of this magnitude will cause long-term back pain.

I could go on for a while about the downside of this operation.  I know a lot about it, as this is an operation that I frequently perform. There is hardly anything more satisfying than giving a person back the ability to be completely upright.  However over my 25-year career I have gone through every possible complication with my patients.  Eventually we usually end up with a good result but it always feels like we are waging a battle. Then there are some with residual problems.

I am very clear about the risks, not for medical legal reasons, but for them to understand the degree of commitment required to undergo it. The benefit has to be worth the risk.  The only reason I perform an operation like this is for tumor, infection, fracture, or if a patient is bent over and cannot stand up.

In this patient’s situation the risk is high and the benefit is zero.

The tools that are presented on this website treat the Mind Body Syndrome of which chronic pain is a common manifestation. I was not aware of the Mind Body Syndrome until Dr. Schubiner taught me about it last year. It is the reason that the pain really does disappear.  Whether you use my approach or Dr. Schubiner’s or both it does not matter.  The treatment paradigm is consistent and powerful. I think you will enjoy his post.

Can Tics be Contagious?

Dr. Howard Schubiner

Author of “Unlearn Your Pain”

The story from upstate New York doesn’t want to go away.  There have been at least three national TV spots in the last few weeks about the 12 high school students who have developed tics.  Neurologists consider tics and Tourette’s syndrome to be chronic neurologic disorders that are primarily inherited.  The treatment consists of medications to attempt to control the abnormal movements and it is not generally believed that individuals can have any control over their tics.

However, the mini-epidemic in LeRoy High School near Buffalo is believed by excellent neurologists to be caused by a conversion disorder, i.e. a physical symptom that is not a pathological or structural process, but is caused by stress and unresolved emotions.  In other words, this is a manifestation of Mind Body Syndrome (MBS) or a Psychophysiologic Disorder (PPD).  (I will use these terms interchangeably.)

When one looks at the history of mini-epidemics of PPD, evidence abounds that PPD is a contagious disorder.  There have been well-documented epidemics of repetitive stress injury, sick building syndrome, and psychogenic seizure-like activity (also known as pseudo-seizures).  There is an interesting research article from Germany that demonstrates that back pain appeared to be contagious after the fall of the Berlin Wall. So, it isn’t really surprising that almost any symptom can be caused by MBS.  Once a careful medical history, physical exam, and environmental evaluation rules out evidence for a pathological disorder, the diagnosis of MBS should be confirmed.

In the LeRoy High School situation, experts have done this and have concluded that the girls are suffering from PPD.  However, this apparently hasn’t gone over very well with the patients, their parents, or many members of the community.  Today’s report showed angry parents filling a meeting of the school board asking them to prove that their buildings are safe.  Of course, they have a clean bill of building health from the state of New York and the CDC.  Yet, a psychological explanation for physical symptoms doesn’t seem to ring true or satisfy most people.

Over the past few weeks, I have encountered several stories about tics and Tourette’s syndrome that suggest that it may not be as much of a neurological disease as we once thought.  Story #1: A friend told me about a young man who suffered with Tourette’s for his whole childhood and adolescence.  As an adult, he participated in an intensive psychological retreat during which he expressed and processed many emotional issues from his life.  The tics resolved.

Story #2: I met a psychologist who told me that he cured a teenager of Tourette’s “by accident.”  The young man was sitting in the psychologist’s office and while waiting, he was throwing some balls into a box over and over.  When the psychologist entered, the boy apologized for his behavior and stopped.  But the psychologist suggested that it was fine to throw these balls and encouraged him to continue to do so, which he did.  During the course of a single one hour session, the boy expressed many issues that were bothering him and threw the balls more forcefully.  Following the session, he seemed relieved.  The tics disappeared and never returned.

Story #3:  I was telling these stories to a friend.  He immediately began to tell me his story.  As a child, he was diagnosed with Tourette’s syndrome.  The tics were incredibly embarrassing and humiliating to him.  He hated them and vowed to stop them.  He decided to resist them and spent many nights in bed holding his body against the urge to “tic.”  After a few weeks of mental effort directed to stopping the tics, they went away and have not recurred.

I am not suggesting that all tics or all Tourette’s syndrome is caused by PPD, but it wouldn’t surprise me if many cases are.  It is interesting that over time, people with Tourette’s tend to grimace and even swear uncontrollably.  Grimacing and swearing, of course, are signs of anger.  Could it be that some people with Tourette’s syndrome have unresolved resentment, anger, or rage?  It would certainly be wonderful if there were a relatively simple solution to these horrible disorders.  We need to do some studies to determine if tics and Tourette’s may respond to our usual MBS approach and treatment.  If you know of people with these disorders who are interested, please have them contact me at hschubiner@gmail.com

It shouldn’t be too surprising that some neurological events are contagious.  Patterns of speech are clearly neurological events.  People who grow up in the south have different speech patterns and inflections than do those from the north.  Phrases such as “like” and “you know” have become ubiquitous in the speech patterns of teenagers (and adults) in recent years.  If these neurological events are contagious, why not tics?

To your health,

Howard Schubiner, MD

Original Paper

“The Seed of Our Undoing”

Video Insight: “White Bears”

White Bears

In 1987 Dr. Daniel Wegner, a Harvard psychologist published a paper, “The Paradoxical Effects of Thought Suppression.” The experiment is commonly referred to as “White Bears”.  He divided volunteers into two groups.  Both groups were instructed in documenting all their thoughts during a five-minute period.  The term used to describe this exercise is “stream of consciousness”. They practiced this several times.  A research assistant then walked in and gave them specific instructions regarding thoughts of a white bear.  Every time they had a “white bear thought” they were told to ring a bell or to verbalize it.  Two groups were created.

• One group was first told to not think about white bears for five minutes and then spend the next five minutes trying to think about white bears while engaging in the stream of consciousness exercises
• The other group was instructed initially think about white bears and then to not think about them during the second five minutes while also continuing the stream of consciousness exercises.

The results were as follows:

• In both groups the participants could diminish the frequency of white bear thoughts when asked to suppress the thought.  No one though could completely get rid of these thoughts.
• In the “expression” part of the experiment the number of white bear thoughts increased in both groups.
• In the group who was initially asked to suppress the white bear thoughts there was a dramatic increase in these thoughts during the expression phase compared to the group who was first asked to think about white bears.
• The term “rebound” effect was used to describe this large increase.  When asked not to think about something, “not thinking” becomes associated with many other cues.
  • The incidence of white bear thoughts actually increased over the five-minute span of expression.

Trying not to think about something will markedly increase the chances of you thinking about it.

I feel this experiment is key to the whole mental health aspect of chronic pain.  There is a lot of anxiety and extreme frustration that accompanies the experience and also a lot of terrible indescribable thoughts.  The thoughts are usually so disturbing that we feel we have to suppress them.  Well guess what?  You are not only fooling yourself you are giving them a lot of power.  Over time it eventually takes a tremendous amount of emotional and intellectual energy to keep these thoughts suppressed.  It is the energy you need to be creative to help you solve your problems.

ANTS

David Burns in his book, “Feeling Good” uses a term he calls ANTS, which stands for “automatic negative thoughts”.  These ANTS are a universal part of the human experience. Since I picked up his book in 1990 I have always wondered why we don’t have “APTS” or “automatic positive thoughts.”  WE DON’T SUPPRESS POSITVE THOUGHTS.

This is also a major reason I often cannot persuade my patients to begin writing these thoughts down on paper.  It is the necessary first step of the reprogramming process, which is to create an awareness of these ANTS. The thoughts that come out are often unspeakable.  My patient’s first response is, “This is not who I am.”  That is correct.  These thoughts are not who you are.  They are JUST neurological connections and actually the opposite of you who are.  Otherwise you would not be suppressing them. You are only giving them life by blocking them.

In the reprogramming process you are no longer editing and fixing.  You are connecting and letting go.  The resultant energy surge is remarkable.

One experiment that demonstrates the power of reprogramming is the famous one by Ivan Pavlov, a Russian researcher. Pavlov showed how the brain can be trained, through repetition, to cause certain reactions in certain circumstances. His results further support the theories behind the Mind Body Syndrome.

Pavlov set up a situation where every interaction a dog had with food would involve the sound of a bell. Eventually just the bell sound would cause the dog to salivate, even without food. The sound became its own pleasurable experience.

One of his lesser-known experiments is one where he associated a dog’s interaction with food with an electric shock.  With repetition, the dog would look foward to the shock.  ”Within a few weeks the dog would actually wag its tail excitedly, salivate, and turn toward the food dish in response to the electricity.  It was “paw dependent” in that if the same shock was applied to its other leg, the dog would react violently.”  (1)

It is well-documented that patients suffering from chronic pain experience a significant decrease in the actual size of their brain.  It is unclear exactly why this occurs but it is a consistent observation.  It makes sense to me that if much of  your brain is stuck in the repetitive thought patterns associated with pain that the parts of your brain that normally experience close friends, excellent wine, great food, new experiences, etc. are going to atrophy.  It has also been shown that the phenomonon is reversible—with active interventtions such as reprogramming. Chronic pain sucks the life right our of you—including brain cells.  Don’t let that process continue!

1. Brand, Paul. “Pain the Gift that Nobody Wants”. Harper Collins, 1993, p 206.

Crystal is a woman from the southern part of Washington who is 82 years old and lives on her own.  Her family lives in California.  She had severe spinal stenosis in her lumbar spine at multiple levels.  This is a condition where bone and ligaments grow around the spinal canal and cause a constriction of the nerves passing through.  It resembles the narrow part of an hourglass. As the nerve compression gets worse standing and walking become increasingly difficult.  The classic symptoms are numbness, weakness, fatigue, and pain in your legs whenever you are upright.  She could not walk for more than half of a block without having to sit down.  As she had been this way for several years she was becoming increasingly weaker.  She was very unhappy at the prospect of losing her independence in addition to experiencing a lot of discomfort.  Because of this her anxiety was through the roof.

I performed a laminectomy on her at L2-3, L3-4, and L4-5.  This procedure removes the narrowing and about 70% of the time patients are able to walk without pain.  It takes a while for the strength and endurance to return.  Most patients don’t engage in the rehab enough to experience the full benefit of the surgery.  As she was so frail my optimism for her was tempered.  I knew her leg pain would improve but probably not her strength.  She also just did not seem like the person who would engage in a full rehab program.  As I never give up I still talked to her about the DOCC project and gave her this web site.

The surgery went well and her legs felt better.  At our first phone appointment she began to ask a lot of questions about the web site and had begun the writing exercises.  She was slightly encouraged and I was pleasantly surprised.  It evolved into a somewhat extended conversation about the central nervous system and conditioning.  It is difficult to make the effort to exercise when you have a lot of anxiety.  To see a full recovery I want all of my patients in the gym working out with weights three to five hours per week.  She was interested in getting completely involved in the process.

At one month from surgery she was sleeping better and felt her anxiety was lessening.  She was out walking a little bit.  I encouraged her to join a gym.  I really did not expect her to do so.

I talked to her a few months ago and heard a different person on the phone.  Her voice was energized.  She had joined a gym and was working out four or five times a week.  She felt a dramatic increase in her strength and endurance.  Her anxiety was down by 80-90%.  She was going out with her friends and socializing.  She was ecstatic and I was shocked.

The tools on this website are self-directed.  My observation is that it is not “if” you get better it is “when.”  The consistent factor is a patient’s willingness to engage.   It is stories like hers that keep me moving forward with this project.

NH

It has become increasingly clear that if a given patient engages in the principles outlined in this book that they will experience a dramatic decrease in pain and improved quality of life.  The richness of their new life often exceeds anything they experienced before their nightmare of pain began.  It is not a matter of “if” they get better it is “when.”  There is not an exact roadmap and often other resources fit a given person’s needs better than what I have suggested.  The key is to first address the anxiety, then the anger, and continue to “shift” the nervous system into a more functional set of circuits.  The plan must be somewhat structured and consistent to be effective.

However, the absolute major block I enounter almost every day is anger.  I honestly do not know how to help a patient get past it.  When anyone is angry they become irrational. When you are chronically angry it is your baseline and you cannot even recognize that you are angry.  I personally had no clue that I had any anger issues until I was 50 years old.  In fact, one of first lines to my wife when I first met her was that I was a “good catch” because  I had dealt with all of my anger issues.  I am glad that neither of us had any idea that I had not even opened the door to my frustrations as we never would have made it.

The problem with anger is that you cannot listen and accurately assess a given situation.  The conversation I have with a patient who is “entrenched” goes like this:

“Doctor, you mean to tell me that there is nothing wrong with my back.  I have been in pain for several years and I know that this pain is not in my head. You must be missing something.”

I reply, “The pain you are experiencing is not imaginary pain nor is it psychological.  We know that if we did a functional MRI of your brain right now that the part of your brain that corresponds to your area of pain would light up brightly.  All that matters is what is happening in your brain.  We also know that the brain can fire spontaneously without an indentifiable source of the pain.  I don’t believe you have the pain I know you are experiencing the pain and are very frustrated about being trapped.”

I also explain to them that degenerated discs are normal as you age and that there is no correlation between a degenerated disc and back pain.  The surgical success of a fusion for LBP is less than 30% with a significant downside of a failed surgery.

They then say, “I don’t want surgery.  I just want to be fixed and get my life back.”

When I reply that we have had very consistent results following the steps outlined in this book they explode saying, “I don’t want to read a book or anything like this. Just do something to fix my back.”  They will then starting ranting and often yelling that no one will help them.  Occasionally the will walk out of the room.

This is a frequent scenario.  I would estimate that at least 50% of my patients fall somewhere in this part of the spectrum.  They are “entrenched.”  I realize that chronic pain causes anger. It is that same anger that is also a complete block to engagement in effective treatment.  Anger is destructive and it is multi-directional.  It is particlurlarly self-destructive.  You also have a strong sense of “being right” when you are angry and even a stronger sense of everyone else “being wrong.”

I honestly do not know what to do to break into this mind set.  I have tried everything from being confrontive to being incredibly patient.  Nothing has worked.  In fact I have found out that the longer I spend trying to convince someone to engage the more angry they become.  It appears that people that are angy don’t like to be convinced to give up their anger.  Maybe they just cannot hear me.

If you are angry or living in one of the above disguises of anger, be careful.  You are trapped.  You are truly stuck and no one can even throw you a lifeline.  What you cannot see is the havoc you are wreaking on those around you and onto yourself.  I am open for suggestions.

NH

I would like to clarify an issue.  Essentially every patient I see that has been off work more than three months has elevated anxiety as noted on my intake questionnaire or it will come out in conversation.  I am always directly addressing their anxiety.  If I had a choice every patient would have some access to education, support, and the tools to diminish their stress.  The system can do only so much to decrease their stress, as just the potential of loss of employment is a huge stressor in itself.  It has been mentioned that questionnaires are not adequate to assess anxiety.  From my perspective I am not sure what would be an alternative.  We are all well aware of the limited access to psychology and psychiatry.

Definition of Anxiety:

• Feeling of worry
• Something that worries somebody
• Strong wish to do something
• Extreme apprehension

I tried to look up anxiety on Google Scholar this morning.  I could not find a clear definition.  I finally just went to the dictionary and pulled off the above one.  I looked at the first part of the DSM manual  (the manual defines mental health disorders) and am now curious as to exactly what diagnosis I would make from my orthopedic perspective to enable mental health support to be provided to an injured worker.  More importantly what would a claims examiner use to “buy” a diagnosis?

In which Axis does the diagnosis of anxiety have to be to made? (there are five levels)  Anxiety is part of essentially every Axis I diagnosis.  What anxiety diagnosis has to be made to fulfill criteria?  (Axis I is the level that the major diagnoses are made such as depression, ADHD, anxiety disorders, addictions, etc.)

Axis IV is “Psychosocial and Environmental problems.  Here are a few of the Axis IV choices:

• Occupational problems
• Problems related to the social environment
• Problems with primary support group
• Educational problems
• Economic problems

An injured worker has most of these issues.

Every human being experiences anxiety. In turn it is increased by Axis IV issues. Does that not qualify for assistance?

If a person has a diagnosable pre-existing anxiety condition it is unlikely that it would have already been a diagnosis that an injured worker is carrying around.  If a mental health professional makes the diagnosis after the person has been in the worker’s comp system for awhile then it is impossible to really sort out what is going on.  The Axis IV issues become a major factor.

So when is worker’s comp supposed to provide mental health services?  If there happens to be a pre-existing condition then it is a major obstacle in return to function and it would make financial as well as humane sense to treat it.

If the anxiety, etc. is caused by the stress of the claim then worker’s comp should cover it, as the injury was the cause of the person’s emotional distress.

Axis III is the Axis where the general medical conditions are listed that can directly or indirectly affect an Axis I diagnosis.  If there is a direct cause and effect then the Axis III diagnosis is also listed in Axis I.  One can make a strong argument that there are multiple musculoskeletal diagnoses that cause a significant increase in anxiety and should be put under Axis I.  The DSM must take the adversity experienced by the injured worker into account and it likely does not.

I am going to purchase the DSM book today.  I would like to ask the roundtable to provide me with the criteria needed to obtain mental health support for an injured worker. At this moment, I have no idea.

NH

I am not sure how it has come across that I feel that a referral to a mental health professional should be avoided.  My position is the of opposite of that.  I feel that every injured worker should have access to some level of mental health support.   I work with a veteran pain psychologist who is wonderful.  90% of her practice is caring for my patients.  If she feels it is necessary she will refer a patient to one of several psychiatrists for medication management.

I am unclear from the psychiatrist’s viewpoint what constitutes a diagnosable psychiatric disorder.  On my intake questionnaire I have a simple 0 to 10 scale for anxiety, depression, and irritability.  Essentially every injured worker that has been out of work for more than six weeks is greater than a 6 out of 10 on at least two of these scales.  What would be my threshold for a formal referral, especially in light of the fact that my state will not pay for an evaluation in a timely manner?  What is even more worrisome to me is the patient who puts down a zero for all three.  They are just a time bomb.

In the disability literature there are hundreds of papers linking stress and disability but there is not a clear-cut definition what the referral trigger should be.  What is the definition of a “diagnosable” mental health disorder?  As there is not a concise definition then I am in a continual battle with worker’s comp to persuade them to “buy” a psychiatric diagnosis.  While the patient is waiting what are we to do?  Their stress level climbs even higher as they wait for an answer.

The other comments are all ones that reflect my position and add a few pertinent dimensions.  I am just advocating that all of us take off the labels and listen to each other as human beings at every level.

I saw a patient a few months ago who is a young mother.  I have known her for years.  She developed quite severe axial back pain.  We had a short but direct conversation about stress and pain.  She came in a couple weeks later with her back pain feeling moderately improved but seemed upset.  I had a little extra time to talk to her.  She started out by saying that she had separated from her husband and was having a hard time finding a job and a place to live. I knew that he had not been working and she was home with two young children.  It turns out that he had been regularly beating her.  It happened enough that her children felt afraid of her if she yelled at them, but the physical abuse that occurred in front of them seemed OK.  If you met her you would be more than upset.  She is one of the nicest people you could meet. Under no criteria would she have a diagnosable psychiatric condition.  She really did not know what direction to go.  Her mother was helping out the best she could.  I did email my pain psychologist and although she had no funds she was able to be helped out.   On top of that her husband has chronic pain from failed back surgery.

Every person from elementary school on should be taught stress management and mental health skills. I feel the one factor that determines one’s success in life is the ability to process and handle stress.  Basic tools would be helpful in dealing with these matters.

Every injured worker needs to have access to at least a group that teaches these type of skills as well as offering support.  Individual referrals can be figured out more easily in that setting.  Psychology and psychiatry resources should be readily available.  Losing a job in a capitalistic society is a disaster.  It is bad enough if you are single.  It is much worse if you are the breadwinner of a family. When would you not need some level of mental health support?  I am not even considering the added stress of dealing with worker’s comp.

A major concern and obstacle to accessing mental health support is our tendency to label people.  Injured workers quickly become labeled.  This is particularly true if they make the mistake of complaining too loudly or express their frustration.  They become “difficult” and “manipulative.”  If their stress becomes higher they may have more pain and ask for more meds.  Now they are “drug seekers.”   The list goes on.  If a patient is labeled as “anxious” or “depressed” they are often put on antidepressants and that problem is “addressed.”  If after a few months they are still depressed then they might be referred to a psychiatrist or psychologist.  Meanwhile months have passed and often their lives have unraveled.

The other comments by the group are also relevant.  The person’s whole life including their mental state must be acknowledged from the minute they are injured. Every person that comes in contact with them makes a difference.  Just the validation of their suffering is important.

I made a comment a few weeks ago to David Tauben who is the head of the University of Washington pain center, and David Elaimy, my surgical performance coach that they should put on a mini-seminar, “Enjoying the Management of Your Chronic Pain Patients.”  A major part of the enjoyment of being a physician is addressing the whole patient and making the correct diagnosis.  If I had just sent the young mother I mentioned above to physical therapy for neck pain it would not have been helpful.  Because of our methods she will be able to get her life back on track and have the tools to live a much more fulfulling life.  My whole staff is involved in the process and that is what makes my job so enjoyable.

NH

Maslow’s Miss

Abraham Maslow  (1908-1970) was a brilliant professor of psychology.  He founded a branch of psychology known as “Humanistic Psychology”, which focused more on function than on dysfunction.  He is best known for his conceptualization of “man’s hierarchy of needs.”  The pyramid is depicted above.  The idea being that it was necessary to meet most of one’s needs in the lower part of the hierarchy before progressing to the top.  Self-actualization is not commonly attained.

The physiological needs he listed are air, food, water, sleep, and sex. Looking at the bottom of the triangle it is essentially impossible to progress up the pyramid if you cannot obtain air, food, and water.  Sleep is also critical.  Sex is important for species survival but not as important for individual survival. Your Hand Over the Stove

What struck me as I looked at his hierarchy was where is the need to not be in pain? I believe it belongs on the bottom row.  Any time a basic human need is not met anxiety quickly results.  If it continues to be unmet then it is followed by anger and eventually rage.  Anxiety driven by anger disrupts your quality of life and compromises your ability to function.  How are you going to progress up this hierarchy when you are consumed by pain? He simply missed this one.

A.H. Maslow, A Theory of Human Motivation, Psychological Review 50(4) (1943):370-96.

NH