Treat the “Abyss”

There is an ongoing debate amongst physicians whether anxiety and anger should be addressed in the treatment of chronic pain.  It is the “common wisdom” in medicine that the reason patients on worker’s comp do not do well with medical interventions, especially surgery, is that they have too many “secondary gain” issues. These essentially amount to the workers prolonging their medical treatment in order to take more time off work, receive more benefits, etc.

The general solutions to the problem were to “get tougher,” limit the time off of work for a specific type of injury, decrease time loss benefits, etc.  The idea was to make it less attractive to be on disability.  I also bought into the same philosophy and took a very hard-nosed approach to my worker’s comp patients.  I felt that it was in their best interest.

About 20 years ago I had a vague awareness develop that I was dealing with patients who had been responsible and hard working, heads of families who were suddenly disabled.  It did not add up.  I realized that there was a lot of anger and frustration.  It seemed to be an issue in a patient’s ability to move through the system. I still did not quite know how powerful a force it was in destroying lives.  At the time I had not yet been fully introduced to my own anger issues fueled by uncontrollable anxiety.

In my own life, I hit an extreme burnout period from 1996 to 2003 where, within six months, I went from not having much fear about anything to experiencing crippling anxiety.  I stayed fully functional in my practice, but the personal price for doing so was devastating.  I also discovered that when I could no longer control my anxiety, my frustration levels reached levels that I had never experienced.

By 2004, I was fully back on track and have continued my journey out of a very dark place.   As a result of being able to look back on the experience, I was able to understand the role of anxiety fueled by anger in taking me down.

Two years ago, I realized that anxiety is a necessary part of life and becomes extreme when basic needs are not met.  Not being in pain is a basic need.  I began to carefully ask my patients about the “abyss.”

I defined the abyss as: (anxiety x anger) time. It is a very dark place. And there does not seem to be a way out.

No matter how “put together” a given patient appears, as soon as I begin to describe the “abyss,” their heads begin to involuntarily nod.  When I hit the part about being trapped by the various parts of the system, they can no longer contain themselves.  I think that many if not most would test out reasonably well on psychological testing and would not be considered to have any type of psychological diagnosis.  Being in the “abyss” just sucks the life right out of you.  I spent almost seven years in it.

Everyone in chronic pain has a lot of anxiety and frustration.  It is compounded by the system and few people really want to sit around all day and do nothing, although I do realize that 10-20% of people on disability are malingerers.

Everyone has pre-existing anxiety and frustration. Both are always exacerbated in the presence of chronic pain. Additionally, the worker’s comp system must take responsibility for its role in exacerbating these issues. There is no point in trying to give a person a psychiatric diagnosis to enable treatment.  Carrying that diagnosis can herald another set of long-term problems for the patient.

We need to quit debating the merits of treating or not treating the mental health aspect of chronic pain and just treat it.