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Chronic Pain and Anxiety Disorders

Chronic pain by itself is often debilitating, and the struggle to obtain a correct diagnosis, effective pain management, and ongoing treatment can be stressful and overwhelming.  As we discussed in a previous post, depression often co-occurs with chronic pain, and can further complicate treatment.  The same is true of anxiety disorders.

Chronic Pain Disorders Associated with the Co-Occurrence of Anxiety

Like depression, anxiety is more likely to co-occur with certain conditions, such as:

It is no secret that physicians and dentists have stressful and demanding careers.  One Cardiff University study showed that of 2,000 British doctors, at various stages of their careers, 60% had experienced mental illness.[1]  Often practitioners ignore or fight through both chronic pain and anxiety and show up to work, to the point of endangering themselves or others before acknowledging their disability or seeking adequate treatment.

While anxiety alone can result in an inability to practice, either indefinitely or in the short-term, it is also quite common in those suffering from chronic pain to experience an anxiety disorder.  Anxiety disorders are also the most common type of psychiatric disorders in the United States, with 19 million adults affected.[2]

Chronic Pain and Anxiety—Worse Together

Facing a long-term or permanent disability can be anxiety provoking for a physician, who must (1) face giving up a career he or she invested so much time and financial resources to establish; (2) seek a correct diagnosis, course of treatment, and adequate pain management; and (3) often struggle with adapting to the loss of a previously enjoyed quality of life.  Conversely, chronic pain is also common in people with anxiety disorders,[3]  with up to 70% of people with certain medical conditions (including hypertension, diabetes, and arthritis) had an anxiety disorder first.[4]

Regardless of whether anxiety or chronic pain came first, individuals suffering from anxiety can experience pain that is particularly intense and hard to treat.[5]  In a 2013 study, 45% of 250 patients who had moderate to severe chronic joint or back pain screened positive for at least one of the common anxiety disorders (generalized anxiety, social anxiety, PTSD, OCD).  Further, those that had an anxiety disorder reported significantly worse pain and health-related quality of life than their counterparts without anxiety.[6]

Symptoms of Anxiety[7]

There are several anxiety disorders and, while the below list is by no means exhaustive, sufferers of anxiety often exhibit the following symptoms:

Generalized Anxiety Disorder

  • Difficulty controlling worry
  • Restlessness, feeling wound-up or on edge, irritability, muscle tension
  • Being easily fatigued and problems with sleep
  • Difficulty concentrating or having their minds go blank

Panic Disorder

  • Sudden and repeated attacks of intense fear
  • Feelings of being out of control during a panic attack
  • Intense worries about when the next attack will happen
  • Avoidance of places where panic attacks have occurred in the past

Social Anxiety Disorder

  • Feeling highly anxious about being around other people (including having a hard time talking to them, blushing, sweating, trembling, or feeling sick to your stomach)
  • Feeling self-conscious in front of others and worried about feeling humiliated, embarrassed or rejected, or fearful of offending others
  • Worrying before an event and/or avoiding places where there are other people
  • Having a hard time making and keeping friends

Post-Traumatic Stress Disorder

  • Flashbacks, bad dreams, difficulty sleeping, frightening thoughts, angry outbursts
  • Avoiding places, events, objects, thoughts, or feelings that are reminders of the traumatic experience and trouble remembering key features of the traumatic event
  • Being easily startled and feeling tense or “on edge”
  • Negative feelings about oneself or the world, and distorted feelings like guilt or blame
  • Loss of interest in enjoyable activities

Obsessive Compulsive Disorder

  • Fear of germs or contamination
  • Unwanted or forbidden thoughts, including aggressive thoughts towards others or self
  • Having things symmetrical or in perfect order; excessive clearing and/or hand washing; ordering and arranging things in a precise way; repeatedly checking on things; compulsive counting

Treatments for Anxiety

Some of the treatments that have been successful in addressing anxiety in those with chronic pain include:

  • Cognitive-behavioral therapy (CBT)
  • Psychodynamic therapy (talk therapy)
  • Support groups
  • Relaxation or meditation training
  • Alternative treatments, such as acupuncture and hypnosis
  • Exercise
  • Medication

Chronic pain sufferers who recognize any of the above-referenced symptoms in themselves should talk to their doctor to address these serious issues.

[1] Michael Brooks, Why doctors’ mental health should be a concern for us all, NewStatesmen, April 11, 2016, http://www.newstatesman.com/politics/health/2016/04/why-doctors-mental-health-should-be-concern-us-all

[2] What are Anxiety Disorders?, Global Medical Education, https://www.gmeded.com/gme-info-graphics/what-are-anxiety-disorders

[3] Chronic Pain, Anxiety and Depression Association of America, April, 2016, https://www.adaa.org/understanding-anxiety/related-illnesses/other-related-conditions/chronic-pain

[4] Global Medical Education, Supra.

[5] Celeste Robb-Nicholson, M.D., The pain-anxiety-depression connection, Harvard Health Publications, http://www.health.harvard.edu/healthbeat/the-pain-anxiety-depression-connection

[6] Health Behavior News Service, part of the Center for Advancing Health, Chronic pain sufferers likely to have anxiety, ScienceDaily, May 8, 2013, https://www.sciencedaily.com/releases/2013/05/130508213112.htm

[7] Definitions according to National Institute of Mental Health: https://www.nimh.nih.gov/index.shtml

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Chronic Pain and Depression

Chronic pain is often difficult to diagnose and treat.  Consequently, those who suffer from chronic pain typically must also deal with a significant amount of stress, due to repeated failed treatments, numerous medical appointments, interruption of work and enjoyable activities, and the inability of their friends or family to understand their physical limitations.  This can, in turn, cause or worsen depression.  When depression occurs alongside chronic pain, it can make dealing with and treating the pain even harder.

Chronic Pain Disorders Associated with the Co-Occurrence of Depression

While mental health conditions, including depression, can often be disabling in and of themselves, they are unfortunately also quite common in those suffering from chronic pain.  Depression is more likely to co-occur with certain conditions, such as:

  • Back Pain
  • Neck Pain
  • Joint Pain
  • Arthritis
  • Migraines
  • Fibromyalgia

Studies show that rates of depression are high in residents and medical students (15%-30%) than rates in the general population, and the risk of depression continues throughout a physician’s career.[1]  According to a British study, 60% of dentists reported being anxious, tense, or depressed.

Dentists, doctors, and other medical professionals place extreme amounts of pressure on themselves because the stakes of their professions are so high.  In addition to perfectionism and self-criticism, other predictors of depression in doctors include:  lack of sleep, stressful interactions with patients and staff, dealing with death, constant responsibility, loneliness, and making mistakes.[2]

Often practitioners work through both chronic pain and psychiatric disorders for some time before acknowledging their disability or seeking adequate treatment.  In the case of depression, this can be due in part to the social stigma that surrounds it.  For all of these reasons, depression may go undiagnosed or seem less of an immediate concern to those suffering from chronic pain.  However, if you are experiencing symptoms of depression and chronic pain, studies show that it is important to treat both, because chronic pain can become much more difficulty to treat if the depression is allowed to progress unchecked.

Chronic Pain and Depression—Worse Together

Facing a long-term or permanent disability can trigger depression—this is especially understandable for doctors or dentists who have put years into medical school and establishing their careers, only to become disabled and have to step away from a profession that has become a significant part of their identity. Depression can also precede chronic pain.  For example, several studies have examined the link between depression before the onset of back-pain.[3]

Regardless of which came first, together they are formidable to treat.  Major depression is thought to be four times greater in people with chronic back pain than those in the general population, and studies show that individuals suffering from both chronic back pain and depression experienced a greater degree of impairment than those with either depression or back pain alone.[4]

Treatments for Depression

Focusing solely on pain management can prevent both the patient’s and treating physician’s ability to recognize that a psychiatric disorder is also present.  Yet, even with correct diagnoses, both issues can be difficult to treat together.[5]  For instance, those who suffer from both chronic pain and mental illnesses can have a lower pain threshold as well as increased sensitivity to medication side-effects.[6]  Some treatments that have proved successful in addressing depression in those with chronic pain include:

  • Cognitive-behavioral therapy (CBT)
  • Psychodynamic therapy (talk therapy)
  • Relaxation or meditation training
  • Acupuncture
  • Hypnosis
  • Exercise
  • Medication

Symptoms of Depression

  • Little interest or pleasure in doing things
  • Feeling down, depressed, or hopeless
  • Trouble falling asleep or sleeping too much
  • Feeling tired or having little energy
  • Poor appetite or overeating
  • Trouble concentrating
  • Feeling bad about yourself, or that you are a failure or have let yourself or others down
  • Thoughts that you would be better off dead, or hurting yourself in some way

Chronic pain sufferers who recognize any of the above-referenced symptoms in themselves should talk to their doctor to address these serious issues.

_________________________________________________________________________

[1] Robert P. Bright, MD, Depression and suicide among physicians, Current Psychiatry, April 10, 2011.

[2] Id.

[3] William W. Deardorff, PHD, ABPP, Depression Can Lead to Chronic Back Pain, Spine-health.com, Oct. 15, 2004, http://www.spine-health.com/conditions/depression/depression-can-lead-chronic-back-pain.

[4] William W. Deardorff, PhD, ABPP, Depression and Chronic Back Pain, Spine-health.com, Oct. 15, 2004, http://www.spine-health.com/conditions/depression/depression-and-chronic-back-pain.

[5] Celeste Robb-Nicholson, M.D., The pain-anxiety-depression connection, Harvard Health Publications, http://www.health.harvard.edu/healthbeat/the-pain-anxiety-depression-connection.

[6] Anxiety and Depression Association of America, Chronic Pain,  https://www.adaa.org/understanding-anxiety/related-illnesses/other-related-conditions/chronic-pain.

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fMRI Brain Scanning: The Future of Proving Pain?

Many disability claimants suffering from chronic, intense pain are surprised and disheartened when their reported pain levels are received with skepticism by their insurance company.  Since pain is a subjective feeling, treating doctors typically ask patients to self-report their pain on a scale of 0-10, so that they can diagnose and treat the pain.  Unfortunately, most insurance companies are unwilling to accept self-reported pain levels and will often try to downplay the severity of the claimant’s pain, citing a lack of objective evidence.

Recently, researchers have developed a technology called functional MRI scans, or fMRIs, for short, which may provide a new way to objectively verify the existence of pain.  In this post, we will examine this technology and discuss how it might be used in the context of disability claims.

I.  What is an fMRI?

fMRI scanning is a noninvasive technique used by doctors to map and measure brain activity.  More specifically, fMRIs are used to measure and observe increases in MR signal caused by neural activity in the brain.  The fMRI data is then analyzed to determine which parts of the brain were active during the scan.  The data is then compared to known neurological signatures, or “biomarkers,” to determine if there are any correlations between the neural activity in the brain and the symptoms reported by the patient (such as chronic pain).

II. The Use of fMRI Scans to Prove Pain

Recently, a number of companies and researchers are focusing on using fMRI scans to produce objective evidence of pain.  For instance, Dr. Joy Hirsch, a professor at the Yale School of Medicine, claims to have developed a test that is capable of distinguishing real, chronic pain from imagined pain.

fMRI scans are also now being used to support the cases of claimants in disability cases. For example, a woman in New York recently used an fMRI scan to convince her insurer, after two years of litigation, that her disability claim never should have been denied.  An fMRI scan was also recently used in the case of Carl Koch, a truck driver from Arizona who suffered severe burns when the hose of his tanker broke loose and sprayed him with molten tar.  Mr. Koch visited Dr. Hirsch, who used functional brain mapping to conclude that Mr. Koch’s pain was real.  When the judge ruled that Dr. Hirsch’s testimony would be admissible at trial, the case settled for $800,000 – an amount ten times higher than the company’s original offer.

III. What the Skeptics Say

The use of fMRI scans to prove pain remains controversial. Some critics argue that the techniques being used in litigation have little support in existing publications.  Others, such as Tor Wager, a professor of psychology and neuroscience at UC Boulder, contend that the sample size in available studies is too small.  Proponents of fMRI refute both of these claims, arguing that a number of credible studies support the validity of their methods.

IV. The Future of fMRI Scans in Disability Cases

It’s easy to see how fMRI scans could prove useful in a disability claim.  For example, many dentists suffer from musculoskeletal disorders, particularly in their spines, that cause chronic, debilitating pain.  However, as noted above, these types of claims can be particularly difficult, because many insurance companies refuse to accept a claimant’s self-reported pain levels and limitations.  Co-workers, family, and friends can provide statements describing how the dentist’s pain is affecting his performance at work and his quality of life, but once again, insurance companies will typically similarly claim that such statements are “objectively verifiable” evidence of the pain.  Sometimes a cervical or lumbar MRI can identify potential causes for the pain, and/or a functional capacity exam (FCE) can help document the limitations the pain is causing—but these types of reports are also commonly challenged by insurance companies intent on denying benefits.

In such a case, an fMRI scan illustrating the doctor’s pain might serve as an additional, objectively verifiable method of establishing the existence of chronic pain.  Whether or not insurance companies are willing to accept fMRIs as reliable evidence of pain remains to be seen, and will likely depend, in large part, on how willing courts are to accept fMRIs as admissible evidence of pain.  If, in the future, this technology continues to develop and become more precise, and courts and juries demonstrate a willingness to accept fMRIs as proof of pain, fMRIs may eventually be enough to convince insurance companies to accept legitimate disability claims without ever setting foot in a courtroom.

REFERENCES:

  1. UC San Diego Sch. of Med., What is fMRI?, available at http://fmri.ucsd.edu/Research/whatisfmri.html.
  1. Sushrut Jangi, Measuring Pain Using Functional MRI, The New England Journal of Medicine, available at http://blogs.nejm.org/now/index.php/9863/2013/04/10/.
  1. Steven Levy, Brain Imaging of Pain Brings Success to Disability Claim, EIN Presswire (June 29, 2016), available at http://www.einpresswire.com/article/333249721/brain-imaging-of-pain-brings-success-to-disability-claim.
  1. Kevin Davis, Personal Injury Lawyers Turn to Neuroscience to Back Claims of Chronic Pain, ABA Journal (Mar. 1, 2016), available at http://www.abajournal.com/magazine/article/personal_injury_lawyers_turn_to_neuroscience_to_back_claims_of_chronic_pain.
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Orthopedic Issues Series: Degenerative Disc Disease – Part 2

In Part 1 of this post, we discussed the anatomy of the spine and some of the causes of Degenerative Disc Disease (DDD).   In Part 2 of this post, we will be discussing some of the symptoms of DDD, and some of the methods used to treat DDD.

Symptoms

Not all people with intervertebral disc degeneration experience pain or other symptoms.  This is due to the fact that the degeneration of the discs, by itself, does not bring on the symptoms described in the first paragraph above.  However, as disc degeneration becomes more severe, it can lead to other conditions that bring on the symptoms people normally associate with DDD (e.g., pain, numbness and tingling, weakness, etc.).  Some of the conditions commonly associated with DDD are:

  • Spinal osteoarthritis:  Sometimes referred to as spondylosis, this condition occurs when the breakdown of the cartilage and intervertebral discs leads to increased contact and irritation of the vertebrae.  It may also lead to the formation of osteophytes (abnormal bone growths) on the vertebrae that can also put pressure on nerves and contribute to the pain and nerve-related issues described above.
  • Spinal stenosis:  This condition can occur when an individual develops spondylosis. The inflammation associated with spinal osteoarthritis may cause a narrowing of the spinal canal (the hollow space in the middle of the vertebrae through which the spinal cord travels) and put pressure on the spinal cord.  This pressure on the spinal cord can cause numbness, weakness, cramping, or general pain in the arms and legs.  In some cases it can also cause bowel and bladder dysfunction.
  • Foraminal stenosis:  This condition is the result of reduced space between the vertebrae, often brought on by the degeneration of the intervertebral discs.  The reduced space may lead to increased pressure on nerve roots emerging from the spinal cord, resulting in localized pain as well as numbness, tingling, and weakness in the extremities.

Treatment:

Because DDD can cause such a broad range of symptoms and subsequent conditions, the treatment options vary widely.  Depending on the circumstances, treatment can range from conservative options, such as physical therapy and anti-inflammatory medications, to surgical intervention, in the form of a discectomy, laminectomy, laminoplasty, or spinal fusion.

If you are experiencing any of these symptoms, the best course of action is to consult a physician.

For more information on how disability insurers evaluate claims based on Degenerative Disc Disease, see:

A Stiff Upper Lip Can Lead to Getting Stiffed by Your Insurer

Disability Insurance: Who Gets Denied?

Myelopathy: Part 1

Myelopathy: Part 2

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Orthopedic Issues Series: Degenerative Disc Disease – Part 1

This post is the first in a series we will be doing on common orthopedic issues.  In Part 1 of this post, we will discuss the anatomy of the spine and some of the causes of Degenerative Disc Disease (DDD), a common yet misunderstood spinal condition that affects a large portion of the population.   In Part 2 of this post, we will go over some of the symptoms of DDD and some of the methods for treating DDD.

Anatomy

There are thirty-three vertebrae in the vertebral column of the human spine, twenty-four of which articulate and move.  Between each of the vertebrae in the three articulating sections of the spine – the cervical, thoracic, and lumbar spine – there is an intervertebral disc.  Each disc, composed of soft jelly-like center (nucleus pulposus) surrounded by a capsule of connective tissue (annulus fibrosis), provides shock absorption and flexibility within the spine.  There is very little blood flow to this region of the body, and if discs are damaged or deteriorate they cannot regrow or heal themselves.

Causes

Degenerative Disc Disease (DDD) is the breakdown in the size and cushioning of the intervertebral discs, which can lead to chronic pain, weakness, numbness and tingling in extremities, and reduced flexibility in the spine. The name of the condition is actually somewhat of a misnomer – it is not actually a “disease”, but rather a condition that is characterized by the degeneration of the intervertebral discs over time. Because of this, the condition can be confusing to understand.

Reduction in the size and cushioning of your discs is part of the normal process of aging, and magnetic resonance imaging (MRI) studies have shown that almost everyone over the age of 60 has degeneration of their intervertebral discs to some degree.[1]  Not all people with disc degeneration have back pain or other symptoms – in fact, individuals with relatively mild disc degeneration may experience no symptoms whatsoever.

However, age is not the only factor in DDD.  Deterioration of the intervertebral discs can be accelerated and exacerbated by other factors.  The culprit in many severe cases of DDD is stress-related damage in the form of repetitive use, trauma, injury, poor posture, poor movement, and obesity.  Among these, one of the most common factors is repetitive use.

Medical professionals are particularly susceptible to developing DDD due to the static postures that some specialties require in clinical practice, most notably dentists.  For example, the repetitive, static posture of a dentist performing clinical procedures creates compressive forces on the cervical discs due to neck flexion and compressive forces on the lumbar discs due to axial loading (the weight of the body compressing the spine vertically).  When these compressive forces are applied for year after year on a daily basis, the result can be an accelerated deterioration of the intervertebral discs.

For more information on how disability insurers evaluate claims based on Degenerative Disc Disease, see:

A Stiff Upper Lip Can Lead to Getting Stiffed by Your Insurer

Disability Insurance: Who Gets Denied?

Myelopathy: Part 1

Myelopathy: Part 2

[1] http://www.arthritis.org/about-arthritis/types/degenerative-disc-disease/

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Long Term Disability by Diagnosis

In previous posts, we have been looking at the findings from the most recent study on long term disability claims conducted by the Council for Disability Awareness.  In this post we will be looking at the types of diagnoses associated with long term disability claims, and which types of claims are most common.

CDA Graph - Diagnosis

As you can see from the chart above, the most common type of both new and existing long term disability is musculoskeletal disorders—a category which includes neck and back pain caused by degenerative disc disease and similar spine and joint disorders.

This is particularly noteworthy because physicians and dentists, who often have to maintain uncomfortable static postures for several hours each day, are very susceptible to musculoskeletal disorders.  In addition, claims involving musculoskeletal disorders can be challenging, because oftentimes there is little objective evidence to verify the pain.  If you suffer from degenerative disc disease or a similar disorder, an experienced disability attorney can explain how to properly document your claim to the insurance company.

References:

http://www.disabilitycanhappen.org/research/CDA_LTD_Claims_Survey_2014.asp

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Myelopathy: Part 2

In Part 1 of this post, we listed some of the symptoms and potential causes of myelopathy.  In Part 2, we will discuss some of the methods used to treat myelopathy.

Methods of Treating Myelopathy

  • Avoidance of activities that cause pain;
  • Acupuncture;
  • Using a brace to immobilize the neck;
  • Physical therapy (primarily exercises to improve neck strength and flexibility);
  • Various medication (including nonsteroidal anti-inflammatory drugs (NSAID), oral corticosteroids, muscle relaxants, anti-seizure medications, antidepressants, and prescription pain relievers);
  • Epidural steroid injections (ESI);
  • Narcotics, if pain is very severe;
  • Surgical removal of bone spurs/herniated discs putting pressure on spinal cord;
  • Surgical removal of portions of vertebrae in spine (to give the spinal cord more room); and
  • Spinal fusion surgery.

Conclusion

Myelopathy can be severely debilitating, particularly for doctors and dentists. Obviously, any physician or dentist who is experiencing a loss of motor skills, numbness in hands and arms and/or high levels of chronic pain will not be able to effectively treat patients.

If you are experiencing any of these symptoms, you may want to ask your doctor to conduct tests to see if your spinal cord is being compressed. If you have myelopathy and the pain and numbness has progressed to the point where you can no longer treat patients effectively or safely, you should stop treating patients and consider filing a disability claim.

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Myelopathy: Part 1

In previous posts, we have discussed a number of disabling conditions, such as Parkinson’s disease, essential tremors, carpal tunnel syndrome, and fibromyalgia. In this post, we are going to talk about another serious condition that can severely limit a physician or dentist’s ability to practice—myelopathy. In Part 1, we will discuss some of the causes and symptoms of myelopathy. In Part 2, we will discuss some of the methods used to treat myelopathy.

What is Myelopathy?

Myelopathy is an overarching term used to describe any neurologic deficit caused by compression of the spinal cord.

The onset of myelopathy can be rapid or it can develop slowly over a period of months. In most cases, myelopathy is progressive; however, the timing and progression of symptoms varies significantly from person to person.

What Causes Myelopathy?

There are several potential causes of myelopathy, including:

  • Bone fractures or dislocations due to trauma/injury;
  • Inflammatory diseases/autoimmune disorders (e.g. rheumatoid arthritis);
  • Structural abnormalities (e.g. bone spurs, disc bulges, herniated discs, thickened ligaments);
  • Vascular problems;
  • Tumors;
  • Infections; and
  • Degenerative changes due to aging.

Symptoms of Myelopathy

The symptoms of myelopathy will vary from case to case, because the nature and severity of the symptoms will depend on which level of the spine is being compressed—i.e. cervical (neck), thoracic (middle), or lumbar (lower)—and the extent of the compression.

Some of the symptoms of myelopathy include:

  • Neck stiffness;
  • Deep aching pain in one or both sides of neck, and possibly arms and shoulders;
  • Grating or crackling sensation when moving neck;
  • Stabbing pain in arm, elbow, wrist or arms;
  • Dull ache/tingling/numbness/weakness in arms, hands, legs or feet;
  • Position sense loss (i.e. the inability to know where your arms are without looking at them);
  • Deterioration of fine motor skills (such as handwriting and the ability to button shirts);
  • Lack of coordination, imbalance, heavy feeling in the legs, and difficulty walking;
  • Clumsiness of hands and trouble grasping;
  • Intermittent shooting pains in arms and legs (especially when bending head forward);
  • Incontinence; and
  • Paralysis (in extreme cases).
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