Dr. David B. Adams – Psychological Blog

Psychology of Illness, Pain, Anxiety and Depression

Differential Diagnosis

differential diagnosisA consistent and recurrent, if not recently increasing, when a patient is referred to my practice for pain and depression, s/he has a more pressing agenda: “problems with the workers’ compensation system.”

One could reasonably argue that depression is attributable to, or exacerbate by, hurdles encountered in the “system” However, we tend to distinguish between depression that arising from combating pain and that which arises from combating other individuals.

This is a difficult differential diagnosis. A patient whose complaints are minimized, whose care is delayed, and whose benefits are slow in coming, may develop a constellation of symptoms that at once appear to be anger and concurrently appear to be depression.

While the vegetative symptoms (sleep, eating, cognitive, mood) will tell whether a mood disorder exists, the cause of the depression may extend far beyond “I hurt, and there is nothing I can do about it.” It may also be associated with “I hurt, and no one wants to do anything about it.”

The patient may have lived with appreciable pain which has been trivialized. S/he has become financially dependent upon a third party. The patient cannot freely a private physician. The patient is unlikely to be able to afford medications and finds that third parties question the need for such prescriptions. The patient may have battled to convince others, that the pain is arising from more than a strain.

This reliance upon others is sometimes referred to as “hostile dependency.” Interestingly, this is also seen in teenagers who seek to, but cannot really afford to, be independent. They become angry at the rules and regulations imposed by those in control.

So let us assume that the patient is quite angry. Anger will resemble depression in several important ways: In both depression and anger, the individual is sullen, often withdrawn and brooding, restless and agitated, and likely no one who wants to listen to what seems like endless complaining. The patient feels helpless, powerless and has ceased to be hopeful that things will change in the short run.  What is the differential diagnosis?

The problem with misidentifying an angry person as depressed is that the treatment for clinical depression is not benign. The drugs used to treat depression can interact with other drugs, can lead to symptoms (side effects) of their own, and are not inexpensive. More importantly, antidepressants are not a solution to anger. Medication does not prevent the patient from feeling victimized by the system.

Whether it is the authorized treating physician, the adjustor or the nurse case manager, someone needs to spend some time differentiating (and helping the patient separate) between anger and depression. If the patient is both angry and depressed, then both may need to be addressed as part of injury management. This is the psychological aspect of differential diagnosis.


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