Psychological and Behavioral Medicine
10
PSYCHOLOGICAL AND BEHAVIORAL MEDICINE
CONSULTATION AND EVALUATION
Patient’s Name: Ms. Smith
Patient DOB: 11/XX/56
Patient SSN:
Date of Initial Evaluation:
Date of Report:
Evaluator:
Presenting Problem/History:
Ms. Smith is a fifty-three year old Caucasian female who was originally seen in my office with complaints of chronic pain. She returned for testing on xx/xx/xx and completed the testing on xx/xx/xx. She returned for an assessment results conference on xx/xx/xx and the evaluation was completed on that day. She reports her pain is secondary to an on the job accident which took place on 01/24/07. At the time of her injury Ms. Smith was employed at the Post Office working in mail processing.
On the day of the initial interview she reported her neck and right and left shoulder pain as 9/10, range 8/10 to 10/10 on a Visual Analogue Scale (VAS). She reported her mid and lower back pain as 9/10, range 8/10 to 10/10 on a VAS. She reported her right and left hip and pelvic pain as 9/10, range 8/10 to 10/10 on a VAS. She reported her right and left leg pain as 8/10, range 8/10 to 10/10 on a VAS. She reported her right and left wrist and right and left hand pain as 9/10, range 8/10 to 10/10on a VAS.
Referral Question:
Ms. Smith was referred by her attorney, for a Psychological/Behavioral Medicine Evaluation to determine the psychological impact of her injuries.
Evaluation Procedures:
I interviewed Ms. Smith once and administered a battery of Psychological/Behavioral Medicine tests as described below. Additionally, I was supplied with and reviewed the following medical records:
Regional Medical Center, DOS: 03/13/06 to 10/17/08
Internal Medicine, DOS: 01/23/06 to 12/11/07
Orthopaedic, DOS: 03/06/07
Neurology & Spine, DOS: 05/17/07 to 11/20/09
Occupational Health, DOS: 01/28/08 to 10/21/08
Medical Plaza Family Medicine, DOS: 03/26/08 to 10/30/09
Orthopaedic Associates, DOS: 04/20/09
Rehabilitation Medicine, DOS: 10/12/09 to 01/17/10
Physical Residual Functional Capacity Assessment: J.L., MD DOS: 12/15/08,
S.E., MD DOS: 04/01/08
J.T.B., Ph.D., DOS: 06/10/08
Mental Residual Functional Capacity Assessment, E.W. MD, DOS: 06/23/08
Psychiatric Review Technique, E.W. MD, DOS: 06/23/08,
J.V., Ph.D., DOS: 12/03/08
Medical History:
The following are Ms. Smith’s current medications:
Wellbutrin XL, 150mg, 1 per day
Ryzolt, 200mg, 1 per day
Neurontin, 800mg
Effexor XR, 225mg
Lasix, 20mg
Urecholine, 25mg
Ambien, 10mg
Hydrochlorothiazide, 25mg
Estradiol. .5mg
Ibuprofen
Tylenol
Percocet, not currently taking
B12 Liproshots
Estrogen lotion
Ms. Smith’s medical history includes hypertension and arthritis. Her prior surgeries include an appendectomy, a caesarian, and a hysterectomy.
Ms. Smith’s medical history as relates to her on the job accident on 1/24/07:
While at work on Wednesday, 01/24/07, Ms. Smith felt a severe pain in her lower back and pressure running down both her legs after performing a bending and twisting motion. She reported this to her supervisor and there seemed to be some confusion as to the source of this pain because Ms. Smith was being treated for kidney stones at that time. Ms. Smith continued her shift and returned to work the next day. She reports that she had filled out the incident forms. The first physician that she saw as relates to the accident was Dr. A on February 19, 2007, who ordered a MRI and x-rays which were performed on that day. Dr. A referred Ms. Smith to Dr. E, orthopaedic surgeon. Dr. E indicated the MRI of 02/19/07 showed very minimal degenerative changes at L4-L5 of no clinical significance. Dr. E recommended conservative treatment. Ms. Smith continued conservative treatment with Dr. A and was then referred to Dr. N, neurosurgeon. His response to the MRI was similar to that of Dr. E, in that he recommended conservative treatment consisting of physical therapy, medication and a TENS unit. He also recommended an epidural steroid injection, but unfortunately, Ms. Smith had an allergic reaction to this. There was little response to this treatment and Dr. N requested a functional capacity exam, which was performed on 9/05/07. Unfortunately, Ms. Smith was unable to complete all of the testing and the reports states that she worked into her pain barriers, but her significantly high heart rate, which was above the usual safe working levels hindered the testing. Dr. J at McLeod Occupational Health then treated her. Conservative treatment was continued. Ms. Smith was again referred to Dr. N, who repeated the MRI in October of 2009. This MRI revealed “mild lower lumbar spondylosis with a slight left lateral recess narrowing at L4-L5, but there was no significant disk herniation or canal stenosis.” Dr. N recommended electrodiagnostic studies of the lower extremities, which were performed by Dr. L on 10/06/09. These further studies indicate that Ms. Smith was suffering with right S1 radiculopothy with lumbar spondylosis, lumbar degenerative disk disease, cervical degenerative disk disease, right carpal tunnel.
This ended a period of more than two years of frustration for Ms. Smith before an organic finding to explain her complaints was found. There were no indications that surgery was an option, therefore conservative treatment was continued. Ms. Smith continues this conservative treatment, but with very limited effectiveness.
Family/Social History:
Ms. Smith is a native of Florence County, South Carolina. She grew up in a two parent home, with one sister and four brothers. She left home at the age of nineteen when she was married. She has been married three times and is currently divorced and living alone. She has two daughters with which she has frequent contact.
It appears that her support network consists of primarily of her two daughters.
Ms. Smith reports twelve years of formal education with additional training in typing and computer skills. Prior to employment at the Post Office, Ms. Smith reports working at General Electric for approximately fifteen years as a lead person and dark room operator. At the time of her injury, Ms. Smith had been working at the Post Office for sixteen years as a non-courier
Behavioral Functioning:
Ms. Smith reports constant burning pain in her neck, right and left shoulder, back, pelvic area, right and left leg, right and left arms including her wrists and hands. She describes her back pain as a stabbing, throbbing, burning, tingling pain. She reports stabbing pains that radiate down her neck into her collarbone and into both shoulders. She reports that her right leg frequently goes numb and her left leg, arms and hands occasionally go numb and that the tingling sensation is very uncomfortable. She reports that at times her hands and fingers are so tender she cannot even wear a ring.
She uses the following affective words to describe her pain as exhausting, tiring, nagging, miserable and unbearable. She indicates her pain levels are increased by changes in the weather, especially the days before it rains. She also reports that standing and walking longer than fifteen minutes increases her pain levels. She reports that when standing she feels the pain radiate back and forth across her back. She reports activities that require repetitive arm movements, for example sweeping and dusting, aggravate and increase her pain. Her pain interferes with her sleep. She reports that the maximum amount of continuous sleep she gets is three to four hours, with the use of a sleep aid, less without. She also reports episodes of excessive sleep associated with both sleep medication and her other medication, even then upon awakening not feeling rested, but groggy.
She reports that she uses compression stockings to help alleviate the pain from muscle contractions cramping. She discontinued using a heating pad for relief when she was burnt and scarred by one. She attempts to find a comfortable position in order to rest, but finds it very difficult.
She describes her typical day as primarily a fruitless attempt to find relief from her pain by attempting to find a comfortable position. She stays home, only leaving when absolutely necessary and then usually with one of her daughters. She attempts light house work, cooking, cleaning, washing clothes, dusting, stating “but, I pay for it.” She is assisted with her activities of daily living by her daughter(s) almost everyday, but finds it hard to ask for this help.
She reports that she used to be a happy, interactive person who enjoyed her life, her work, as well as entertaining friends and family. In addition to not being able to work, she reports her pain has interfered with her enjoyment of life, mood, relations with others, her ability to concentrate and her overall general activities.
Psychological and Emotional State:
The patient completed the following battery of psychological instruments with the assistance of myself and staff, in addition to being interviewed using the Mini International Neuropsychological Interview (MINI).
Minnesota Multiphasic Personality Inventory - Two (MMPI-2)
West Haven/Yale Multidimensional Pain Inventory (WHYMPI)
Pain Interference and Impairment Index
Projective Drawings
Coping Strategies Questionnaire
Amen Clinic Anxiety and Depression Type Questionnaire
Patient Information Summary
Ms. Smith began the testing process on xx/xx/xx. Her behavior throughout the testing process was cooperative. After one hour of testing she requested a break to take a “pain pill,” Neurontin and Tylenol. She returned on xx/xx/xx to complete the testing.
Results of the interviews, combined with the test results, indicate an individual who, although being treated with psychotropic medication, is experiencing psychological maladjustment for greater than two years.
Minnesota Multiphasic Personality Inventory - Two (MMPI-2):
The MMPI-2 is a 567 item, true/false self-report measure designed to aid in the assessment of a wide range of clinical conditions. The MMPI-2 normative samples consist of 1,138 males and1,462 females from diverse geographic regions and communities across the United States. Individuals between the ages of 18 and 80 were recruited for inclusion in the samples.
Ms. Smith’s responses to the traditional MMPI-2 validity scales are within the range that supports the interpretability of her clinical profile. Her MMPI-2 clinical scale scores are likely to be a good estimate of her current personality functioning. The patient’s item response pattern suggests that she may have answered items in the latter part of the MMPI-2 in an exaggerated or random manner, possible invalidating that portion of the test.
Ms. Smith’s MMPI-2 clinical profile is that of someone who is overwhelmed by anxiety, tension, and depression. These individuals feel hopeless and alone, inadequate, and insecure, and believe that life is hopeless and that nothing is working out right. They have difficulty concentrating and making decisions.
Individuals with this profile typically live a disorganized and pervasively unhappy existence. They may have episodes of more intense and disturbed behavior resulting from an elevated stress level. They tend to overreact to even minor stress, and may show rapid behavioral deterioration. They also tend to blame themselves for their problems. They tend to view the world in a highly negative manner and usually develop a worst-case scenario to explain events affecting them. They tend to worry to excess and interpret even neutral events as problematic. Their self-critical nature prevents them from viewing relationships in a positive manner. They also show a meager capacity to experience pleasure in life and are pessimistic.
Problematic personal relationships are also characteristic of such individuals. They are behaviorally withdrawn. They may relate to others ambivalently, never fully trusting or loving anyone. Many individuals with this profile never establish lasting, intimate relationships. Their shyness is probably symptomatic of a broader pattern of social withdrawal.
Pain patients with this MMPI-2 profile are usually characterized by symptom exaggeration and a lack of effectively functioning defenses. They tend to show chronic psychological problems such as being tense and anxious, feeling more intense pain than other patients, and having reduced cognitive functioning. Among pain patients, this group tends to have the most negative outcome from traditional medical treatment because of their related psychological and life problems.
West Haven/Yale Multidimensional Pain Inventory (WHYMPI):
The West Haven-Yale Multidimensional Pain Inventory was normed on a large heterogeneous group of chronic pain patients. Compared with this group of chronic pain patients, Ms. Smith’s scale scores on the primary MPI scales can be described as the following: Pain Severity and Interference scales were significantly above average; Affective Distress and Distracting Responses scales were somewhat above average; Support, Punishing Responses, Solicitous Responses, and General Activity scales were average; Life Control scale was somewhat below average.
The two composite scales can be describes as follows: the Dysfunctional Composite Scale score was significantly above average and the Interpersonal Distress Composite Scale score was somewhat below average.
Ms. Smith’s overall profile classification is Dysfunctional, which indicates, that when compared to other chronic pain patients, she is experiencing more interference in her life due to the pain and experiencing less of a feeling of control over her life. She has reacted with affective distress.
Pain Interference and Impairment Index:
The Pain Interference and Impairment Index is a thirty-six-item self-report questionnaire. Test results indicate Ms. Smith is experiencing problems with activities of daily living such as bathing, dressing, eating, writing, using the toilet independently, walking, riding in a car, driving, and sleep.
She also has a great deal of difficulty with movements, especially standing, sitting, carrying things, lifting things, and pushing and pulling things and grasping things with her hands. Additionally, she has trouble bending, reaching for things, stooping and squatting, and twisting.
She also indicates her pain prevents her from working at her previous job, having desired sexual activity, obtaining restful sleep, enjoying past social and athletic activities, participating in hobbies she used to enjoy, exercise and going out socially.
Overall, the Pain Interference Intensity would fall within the marked (75% to 100%) category. The Pain Interference Frequency would fall within the marked (75% to 100%) category.
Projective Drawings:
The House-Tree-Person test (HTP) is a projective test designed to measure aspects of a person's personality. The test can also be used to assess brain damage and general mental functioning. The test is a diagnostic tool for clinical psychologists, educators, and employers. The subject receives instructions to draw a house, a tree, and the figure of a person.