Table I: Adapted from: Quint M: New Ailments: Bane of
Insurers. The New York Times,
November 28, 1994. Page D1-2
The apparent costs of work-related injuries, defined as
injuries or illnesses that cause loss of time from work, have grown
tremendously. In 1992, there were 13.2
million non-fatal injuries and 862,200 illnesses in the American workforce. There were approximately 6500 job related
deaths due to injuries and 60,300 deaths due to disease. The estimated total direct and indirect
costs of these injuries and illnesses were $171 billion. (Leigh, et.al, 1997)
Depression is both an important cause and consequence of
disability, both as a primary disorder and in combination with other medical
illnesses. In both roles, it has
significant economic consequences. Judd, et al (1996) found an important significant association between
self-reported functional impairment and the presence of sub-syndromal depression
and major depression. Greenberg, et al
(1993) reported the total estimated workplace
costs of absenteeism and impaired working ability associated with depression to
be $24 billion per year.
The Experience of Disability
While many people are injured or become ill at work, only a
small proportion of those goes on to become permanently disabled. The meaning of a disability to an individual
can influence its severity and the individual’s adaptation to it. The meaning
of any given impairment to an individual, and the degree to which he views
himself as disabled depends on the interplay of a number of factors. The consequence is that individuals with
similar impairments may experience widely varying degrees of disability. For example, the meaning of a physical
injury that prevents standing for long periods is different for a surgeon than
it is for a psychiatrist.
Some impairments, such as colorblindness, constitute only
narrow functional restrictions, and little psychiatric morbidity results. Other impairments, such as complete
sightlessness result in greater limitations, although substantial community
support and having an identity within the community may lessen the impact.
The patient with a psychiatric disability suffers directly
from the symptoms associated with the psychiatric disorder, including
depression, anxiety, panic, and pain symptoms.
Indirect suffering, resulting from the damage to the patient’s self
esteem, may cause greater distress.
Persons judged disabled frequently voice statements like “I feel like I
am no good to anyone” and “I am a failure in life.” A sense of powerlessness and hopelessness form part of a vicious
circle with the preceding direct symptoms, causing the circle to become a
downward spiral. Avoidance of social interaction because of shame and
embarrassment frequently lead to panic and agoraphobia.
A thought experiment may aid the clinician in better
appreciating the consequences of physical and mental disabilities. Much has been written regarding the trauma
of corporate restructuring and the resulting layoffs that occurred throughout
the late ‘80’s and early ‘90’s. That
these processes have a major impact on affected individuals has been taken for
granted. Those affected receive some social understanding and support. By
contrast, the patient with a psychiatric impairment secondary to a job related
injury must contend not only with the impact of loss of employment, but also
with both mental and sometimes physical pain.
The sense of being “different”, coupled with the devaluation that
usually occurs within the community, adds to their narcissistic injury. Loss of the “breadwinner” role within the
family, or loss of a feeling of being able to “contribute” to the family’s financial
well being, as well as being a “drain” on familial financial and emotional
resources, contributes to lessened self esteem and depression.
The duration of disability influences the degree of
trauma. A rapid return to work results
in little emotional distress. Major
depression usually results from prolonged disability and unemployment.
Real economic hardship
is another consequence of disability.
All disabled people experience economic anxiety. For many families, loss of “everything I
worked for” including formal bankruptcy, is the outcome. In turn, a number of factors help determine
the meaning of the disability to the individual. These factors provide a context for the injury or illness, define
its consequences, and provide support for either recovery or chronicity. These factors are listed in Table II.
·
1.
Gender
2.
Age of onset
3.
Whether congenital or acquired
4.
Severity of disability
5.
Presence / absence of compensatory skills
6.
Single or multiple
disabilities?
7.
Presence of pre-existing
mental illness
8.
Effect on vital
functions, e.g. work, sex
9.
·Prognosis of recovery
10. ·Financial impact
11. ·Prior level of functioning
12. ·Family and social support
13. ·Pain distribution, quality, and intensity
14. ·Quality of medical/rehabilitative services
Table II: Factors affecting the meaning of disability to an individual
The most common psychiatric finding
after disabling injury is Mild to Severe Major Depression. Major depressive
symptoms typically develop within eight and fourteen months from the date of
the injury. Anxiety and pain disorders
typically appear after the depression is well established, and secondary
reactions to the loss come into play.
The relationship between psychiatric disorders, including depression,
and disability is well established. The
presence of psychiatric disorders has been shown to have a significant positive
correlation with disability ratings.
Walker, et al (1996) found that when
compared with other inflammatory bowel disease patients, those with psychiatric
disorders had a higher number of lifetime psychiatric diagnoses, higher
prevalence rates of sexual and physical trauma, and a higher number of
gastrointestinal and other medical symptoms.
Bruce, et al, (1994) found that the
presence of depressive symptoms in otherwise healthy elderly patients increased
the risks of physical disability.
Finally, Duckro, et al ,
(1995) showed a direct relationship between depression and perceived disability
associated with chronic headache.
Depression following injury can be a response
to multiple causes, including:
1.
Loss of role status, both in the family and in the community
2.
Loss of hope of recovery
3.
Activation of pre-existing low self esteem previously
compensated for through having a successful work role identity
4.
Loss of self-esteem based on the apparent disparity between
the damaged “real self” and the internalized pre-injury self-representation
5.
Chronic pain
·
Loss of work as a means of sublimating aggression
Shame, blame, depression and anger are near universal
reactions to the loss of the ability to work.
The risk of suicide should never be underestimated and should always be
assessed when treating the disabled worker.
It is higher in the presence of substance abuse, in single males without
a social support system, and for those with co-morbid psychiatric disorders
with psychotic and/or impulse disordered features. The loss of sublimatory outlets for aggression, typically work
and recreational activities ,contributes activities, contributes to morbidity,
as does sexual dysfunction which may result directly from depression, from
medication, or from co-existing injury.
Assessments of disability are requested under a variety of
circumstances. These include: fitness
for duty evaluations, workers’ compensation claims, personal injury claims,
Social Security Disability claims, private disability insurance claims, and
claims arising under statutes which prohibit discrimination against the
disabled.
Fitness for duty
It
may be necessary to determine whether a person who is impaired as a result of a
psychiatric disorder is capable of fulfilling the responsibilities of a
particular position. For example, a
nurse’s aide may develop a major depressive illness accompanied by markedly
increased irritability, crying spells, and impaired concentration and
memory. The evaluator may conclude that
until the major depressive episode has resolved that it would be unsafe for
this individual to be providing patient care, and judge them to be temporarily
disabled for that position.
Example: Sally, a 39-year-old divorced white female living with her
daughter and a boyfriend, worked as a paralegal. Two years previously she had
suffered a shoulder injury in another job, which led to two surgeries, with a
poor result. Her supervisor noted
deteriorating work performance, with mistakes in letter writing, and failure to
remember instructions regarding case management. She suggested Sally undergo a psychiatric evaluation for possible
depression. Sally agreed, and began
treatment. She was able to continue to
work for several months, but her short term memory and concentration became
sufficiently impaired to require that she be placed on medical leave. Sally communicated most of the findings
directly to the employer. The psychiatrist approved medical leave based on her
impaired functioning, and with Sally’s permission communicated this to her
employer.
Causality
Workers’ compensation programs require a determination whether a
psychiatric condition is causally related
to a workplace injury on “a more probable than not basis” to determine whether
treatment should be paid for by the workers’ compensation plan, and whether
compensatory “time-loss” income benefits are due the worker. In this type of
assessment causality is defined as
meaning that the diagnosed psychiatric condition(s) is (are) judged to be the
result of the workplace injury in question with a 51% or greater degree of
probability. The forensic psychiatrist will note that the level of required
certainty is less rigorous for workers’ compensation causality determinations
than for the determination of guilt in a criminal matter. Nevertheless, the
determination of causality regarding psychiatric conditions is often complex
and controversial. It is usually adversarial because of the economic
consequences to the contending parties. For example, consider a case in which a
maintenance supervisor with a 15-year work history and a history of severe
physical abuse and neglect by alcoholic stepfathers is injured. He becomes
depressed when the physical injury does not resolve quickly. Self-esteem plummets rapidly, shame and
embarrassment set in, and a panic disorder develops. Is the depression and panic disorder causally related greater
than 50% to the childhood abuse, or to the injury and the loss of the structure
and self esteem support that work provided?
When multiple factors are involved in causation, when they are
intangible and subject to debate, and major financial liability is involved,
disputes frequently arise which must be referred to a judicial process.
When a claim is being closed administratively, an opinion
regarding the degree of impairment attributable to the injury compared to
pre-existing conditions may also be required. These factors are taken into
account in arriving at the financial settlement, which may take the form of a
pension (in the case of total disability), a permanent partial disability
settlement, or no award.
Example:
Henry, a 38 year old divorced white
male grocery checker, developed a repetitive motion injury following 13 years
on the job. His productivity suffered,
and he was threatened with termination.
His chiropractor referred him for psychiatric evaluation and treatment
under a worker’s compensation claim.
Henry responded well to antidepressant medication and group therapy, and
his productivity reached a new high.
Treatment was terminated. Henry
relapsed, and a resumption of medication was recommended. The insurance company managing the claim
denied treatment, and requested an independent medical evaluation.
Causality and
amount of damages
Personal
injury claims require both a determination of causality and the degree of
impairment resulting from a named event to determine damages. A psychiatric assessment may be requested by
a defense attorney representing an insurance company, or by a plaintiff’s
attorney in a personal injury claim.
For example, someone hit by a car with a resulting head injury may be
unable to return to work because of psychiatric sequelae to the head
injury. Estimates of the extent of the
injury as well as the need for and future costs of care related to the injury
are requested. These must be supported
by reference to data gathered in the evaluation with a supporting rationale.
Example:
Bertha,
a 45-year-old mini-mart chain supervisor was driving from one site to another
when she was rear-ended by another driver.
Initially diagnosed only as having low back strain, she was treated
essentially as a malingerer by all but her family physician, who had known her
for 10 years. When she was referred for
psychiatric evaluation, she was diagnosed as having a Major Depressive Episode,
severe. There was a history of alcohol
abuse of several years’ duration subsequent to a divorce 15 years
previously. The patient was referred to
a specialist group in a major city, and three level disk injury was
diagnosed. Because it was so extensive,
it could not be treated surgically.
However, with antidepressant medication and group therapy, the patient’s
depression steadily improved. When her
complaints were determined to have a physical basis, she improved even
more. Litigation regarding her
automobile accident yielded only a minimal settlement related to her mental status,
because she had nearly recovered to her prior level of functioning; the damage
was temporary, and no long term need for treatment was projected.
Degree
of disability assessment without
consideration of causality
Social
Security Disability evaluations focus on the determination of degree of
impairment. Although diagnoses are
requested, the focus is on the degree to which the impairment(s) interfere with
the normal day to day functioning of the individual. A “Listing of Impairments” is published by the Social Security
Administration (SSA,) and defines the extent to which activities must be
limited by different disorders, such as affective disorders, mental
retardation, anxiety disorders, and personality disorders in order to satisfy
the threshold requirements to qualify for benefits. The responsibility of the evaluator is to provide specific
information as requested. The SSA
personnel assemble the information and render a decision. Their decisions are subject to a three-step
review and appeal process, ending with a live hearing before an administrative
law judge.
Example:
Hank, a 49 year old
divorced and homeless Viet Nam veteran presented with a history of alcohol
abuse in early complete remission and Post Traumatic Stress Disorder. He was receiving group therapy and
medication through a local Veteran’ Administration facility. His history revealed two tours of duty
where he was involved in heavy combat as a landing zone preparer. His drinking began in Viet Nam, and
continued after discharge. He had
continuous symptoms of PTSD, and was never able to sustain continuous
employment as a roofer because of initiating frequent fights and a general
inability to get along with co-workers because of his high level of irritability. The issue to be decided was whether the
alcohol dependence was the primary disorder that would disqualify Hank for
benefits, or whether it was secondary to his PTSD.
Degree of disability assessment and treatment recommendations without causality
Private
insurance companies which underwrite group or individual disability insurance
policies primarily rely upon the reports of treating clinicians when
determining disability claims. These reports are then reviewed by claims managers
and in-house medical reviewers. Based upon those reviews, the insurer may
request confirmation of the findings and a review of treatment provided. The
goal of the insurance company is to minimize disability claims that result from
substandard care, to insure that accurate diagnoses are made, and to determine
whether the terms of the policy’s coverage are being satisfied. For
example, some policies were written that allowed for full benefits if the
policyholder became unable to perform the tasks of his own occupation, where
other policies provide benefits only if the insured is unable to perform the
tasks associated with any job. The entity requesting the evaluation typically
provides a specific list of questions to be answered and requires a comprehensive
evaluation. The evaluator is instructed to release the information only to the
requesting entity, much as an evaluation requested by an attorney goes only to
the attorney.
Example:
Patricia,
a 53 year old former nursing supervisor had been receiving disability benefits
for 3 years following an unsuccessful recovery from an abdominal surgery that
resulted in many complications because of a retroperitoneal abscess that
escaped detection for several weeks.
Ultimately she was diagnosed as having restrictive lung disease. She was treated initially by her colleague
physicians in the clinic where she was employed. No one physician was in charge.
She attempted to return to work, but lacked the stamina to walk across
the parking lot, in part because of her lung disease. Her physician recommended that she “go on disability.” She and
her disabled spouse moved to another community, where she was treated by an
internist with antidepressant medication.
The insurance company asked the following questions:
1)
Based on her history, do you feel she meets the criteria for a Somatoform
Disorder as classified in DSM IV?
2) If
you do not feel the patient has a Somatoform Disorder, do you feel the patient
has any other psychiatric diagnoses?
3) Is
the patient impaired, and if so, what is the primary impairing condition?
4) Is
the patient receiving appropriate treatment?
If no, what would you recommend?
5)
Please complete a mental functional capacity evaluation in full.
She was found to have an anxiety disorder and mild
depression, but not a somatoform disorder.
She was impaired, but less so than the insurance company had surmised,
and was willing to attempt part time employment. An internist had reported dyspnea at rest, but the patient denied
this symptom, and did not display it during the interview. She performed poorly
on portions of the mental status examination dealing with memory and
concentration, and psychological testing was recommended to differentiate
anxiety and organicity as an etiology.
Medical treatment was found to be appropriate, but it was recommended
that a psychiatrist be assigned to the management of the psychotropic
medications, and that brief treatment focused on restoration of function be
instituted. She was not a candidate for insight therapy.
The Differing Roles of Clinician and Independent (Forensic)
Evaluator
There are two types of
evaluations to be considered, forensic
and clinical. (Schouten, 1993, 1998;
Strasburger, et. al., 1997) These two
types of evaluations have separate goals, and whenever possible should be
conducted by separate psychiatrists, although this may sometimes be difficult
to achieve in actual practice. A
clinical evaluation is undertaken to formulate an effective treatment plan, and
is properly undertaken by the treating psychiatrist. A forensic evaluation addresses the issues that must be
considered in order to render an opinion with regard to causality. Although there is overlap between the two
types of evaluations, there is a difference in emphasis, and indeed there are
core conflicts between the two roles.
Role Distinctions
Clinician--Duty to
determine the “truth”
Clinician--Duty
to patient to “cure”
Forensic--Does
not advocate for patient
Clinician--Patient
“advocate”
Forensic--Uses
collateral information to determine objective reality
Clinician--Psychological reality for patient is of
primary importance
Forensic--Provides
reports to third parties as essential role
Clinician--Reporting to
third parties may undermine therapy relationship
Forensic--Empathy
to examinee not material
Clinician--Empathy
for patient essential
Forensic--Evaluation
explicitly not confidential; report provided to third party
Clinician--Confidentiality
primary duty to patient to allow effective treatment
At the
heart of this conflict is the fundamental notion that the clinician and the
independent evaluator serve different masters.
The clinician has a fiduciary duty to act only in the best interest of
the patient. While “best interest” is
open to interpretation, many clinicians take the view that they are obligated
to be advocates for the patient’s preferences.
Thus, if the patient is distressed and unhappy at work, the clinician
should assist him in staying out of work until the causes of the distress have
been addressed and corrected. The
independent evaluator has an obligation to provide an objective, scientifically
based opinion.
Another major difference between the clinician and the
independent evaluator is the information used.
Under the traditional psychotherapeutic model, the treating clinician
attempts to see the world through the eyes of the patient; historical accuracy
is less important than individual perception.
As a result, the treating clinician may or may not review prior medical
records. In addition, the treating clinician
rarely looks to outside sources to corroborate the patient’s story. Even contact with family members may be
controversial. The independent
evaluator, in search of an objective, accurate assessment, must evaluate the
medical records as extensively and closely as possible. The independent evaluator will also evaluate
other sources of information, including court records, reports of private
investigators, and personnel records.
None of these materials serve any purpose in the treatment of the
patient, yet they can make a crucial difference in the assessment of
disability. Finally, the treating clinician who fills out forms or gives
testimony in a manner contrary to what the patient sees as being in his or her
interest, may find that the treatment relationship is destroyed.
It is prudent for clinicians to resist both the external pressures
emanating from the attorney or patient or both and the internal pressures from
the therapist’s felt allegiance to the patient. The legal process is directed toward the resolution of disputes;
psychotherapy pursues the medical goal of healing. Although these purposes need not always be antithetical and may
even be congruent, the processes themselves typically create an irreconcilable
role conflict. In essence, treatment in
psychotherapy is brought about through an empathic relationship that has no
place in, and is unlikely to survive the questioning and public reporting of a
forensic evaluation. (Strasburger, et al, 1997)
Institutional policies
often force treating psychiatrists to function in both roles in disability
determinations, as for example by requiring either concurrence or
non-concurrence with Independent Medical Evaluations (IMEs). Even court
testimony is frequently required in administrative law hearings when disputes
arise, and by law the testimony of the treating psychiatrist is given more
weight than that of the forensic evaluator, on the grounds that the treating
psychiatrist is more knowledgeable about the patient. When the treating psychiatrist must participate in the disability
evaluation process, the following principles should be kept in mind:
1.
Obtain and document
informed consent from the patient to disclose information provided during the
course of the treatment
2.
Have a clear
understanding of the job duties
3.
Be honest about the
limitations on the sources of information used
Example:
The following example illustrates fairly common difficulties
encountered when the treating clinician fulfills the role of independent
evaluator.
Ms. A is a 45 year old married mother of two who presented
to an emergency room with complaints of acute confusion and memory loss. She
was employed as a floor supervisor in a manufacturing company, Widget, Inc.,
where she had worked for the last 18 years.
The owners of Widget took good care of Ms. A, paying her even when she
was out of work for several months with Graves’ Disease. All was well at work
until new owners bought into the business and brought along new managers.
Several new production engineers, all college educated, came to Widget to
manage operations. One of them took
over a number of Ms. A’s duties. Ms. A,
who had only a high school diploma, felt inferior and began hating work. She began having trouble concentrating and
made a number of uncharacteristic calculation errors that caused significant
waste. Her boss, who had been a father
figure to her since she joined Widget, criticized her mercilessly over these
mistakes. The engineers began
double-checking her calculations and work.
Two months later, she presented to the emergency room.
Ms. A was referred for extensive neurological and
neuropsychiatric evaluations; no abnormalities were found. She continued to complain of severe memory
disturbance, including not recognizing her own home when she awakened in the
morning. She continued to drive,
against the instructions of her physicians, and had a number of serious near
misses and several minor accidents. Ms.
A was adamant that she was suffering from a major medical illness as the cause
of her memory problems. She was
originally sure that she had a brain tumor, but when that was ruled out, she
and her husband expressed their beliefs that this was all a side effect of her
radioactive iodine treatment some years before. They were both dismayed, and angry, when Ms. A was referred to a
psychiatrist, Dr. C, for further evaluation and treatment.
Ms. A presented to Dr. C with classic neurovegetative signs
and symptoms of depression, and possessed no insight into her situation. She acknowledged being depressed, but
attributed it to her memory problems and frustration at being out of work. Her anhedonia and other symptoms were
prominent, but she attributed them to her “thyroid problem.” She reluctantly agreed to take
antidepressant medication and begin psychotherapy. Dr. C had no reservations about signing the form necessary for
Ms. A to begin receiving short term disability benefits, which provided her
with 75% of her former income, tax-free.
Six months after beginning treatment with Dr. C, Ms. A
brought in a form for long-term disability.
Dr. C reviewed the form with her, asking specific questions about each
of the categories of activities and her limitations. Eligibility for disability payments was predicated upon her
inability to perform duties of her former position. Ms. A insisted that she could not possibly go back to work
because of all of her symptoms. She
asked Dr. C to indicate that she was suffering from a thyroid disorder and
became angry when Dr. C entered a diagnosis of Major Depression and Anxiety
Disorder NOS. Dr. C did sign the
disability form, however.
After one year of treatment, Ms. A’s mood and overall level
of function had improved significantly.
Dr. C had signed disability forms periodically at Ms. A’s request,
largely because Ms. A insisted that she could remember nothing about her old
job duties. She also maintained that
she would be a safety hazard at work due to her forgetfulness with everyday
activities and anxiety. When Dr. C
urged her to take a job with lower wages, Ms. A refused, saying that she wasn’t
going back to work until she could earn what she had previously. Ms. A’s depressive symptoms had resolved,
but her anxiety symptoms persisted.
These symptoms, which contained elements of Panic Disorder and Social
Phobia, were exacerbated under stressful conditions, such as work.
During the second year of treatment, Ms. A attempted to work
part-time at a job largely unrelated to her previous job. She obtained the job through a family
member, and she was paid “under the table” so there was no impact on her
disability payments. Ms. A periodically
reported errors that she made at work, some of which resulted in minor
injuries. Several months after she had
started this job Ms. A brought in another disability form for Dr. C to sign. This time, however, the form asked whether
Ms. A was substantially disabled from performing any work for which she was
reasonably suited. Dr. C reviewed the
form with Ms. A and indicated that while she was able to perform some work she
remained at risk of injury. Ms. A began
spreading out her therapy appointments, eventually to once a month. Eventually, she obtained a job similar to
what she had had at Widget.
The Role of the Treating Psychiatrist
The role of the treating psychiatrist is to do exactly that:
treat the patient. Dr. C’s challenge was to break the self-sustaining cycle of
Ms. A’s depression, anxiety, objective impairment, and perceived disability.
The difficulties of this task were compounded when the issue of long-term
disability was introduced. While Dr. C
explored each of the specific elements of the disability form with Ms. A, as
her treating psychiatrist he was limited to Ms. A as his primary source of
information. She made clear her view
that she was not fit to return to work, and she had no desire to do so. As her treating clinician, Dr. C felt that
Ms. A would be better served by returning to work as soon as possible. On the other hand, he knew that he could not
force her to return to work, and he was aware of her tendency to become
symptomatic under stress. As in the
majority of cases, the patient would be the final arbiter of whether or not she
could or would return to work. At most,
the clinician can treat the symptoms, support and encourage the patient, and
provide guidance.
An independent evaluator called in to assess Ms. A’s
disability would have approached the situation quite differently. The independent evaluator would have
reviewed all available medical records as well as collateral sources of
information. These collateral sources
could include conversations with co-workers and supervisors of Ms. A and
surveillance materials. In some cases,
surveillance materials gathered by insurance companies show the claimant
engaged in activities inconsistent with the claimed disability. Finally, the independent evaluator would
likely conduct a clinical evaluation involving several hours of clinical
interview as well as a full psychological testing battery. Thus, the independent evaluation uses
broader, more detailed, and more objective sources of information in
preparation of an assessment of disability.
Such information is simply not available to treating clinicians under normal
conditions. The independent evaluation
is not a panacea from the clinical standpoint, however. Independent examiners
may face subtle pressures to issue opinions deemed to be favorable to the
insurance company in an effort to secure repeat assignments, and may in their
own way be subject to bias. An
independent evaluation concluding that secondary primary gain is was the
primary motivation for disability might result in a premature termination of
benefits, a return to work, and subsequent further injury or illness. A comprehensive evaluation can help avoid
such a negative outcome, however.
Psychiatric Disability Evaluation Outline:
A. General considerations
1. Reasons
for a disability evaluation
a) Employer
request
b) Insurance
company request
(1) Private
disability coverage
(2) Second
opinions re: treatment
c) Physician
request for psychiatric assessment as adjunct to general medical care –
treatment rather than causality issues central
(e.g. orthopedist requests psychiatric consultation for depressed
patient)
2. Role
and boundary issues
a) Confidentiality
is waived
(1) This
is made explicit to the examinee, who is advised to whom the report will be
provided
(2) The
examinee is advised that examination does not constitute nor is a substitute
for medical treatment
b) Role
of the independent psychiatrist evaluator
(1) No
follow-up treatment responsibility
(2) Potential
adversarial relationship to patient
c) Role
of the treating psychiatrist
(1) Follow-up
reports are often required by statute or insurance carrier, so patient must be
informed
(2) Some
confidentiality limitations: make explicit to patient
(a) Information
usually confined to diagnoses, medications, and general impression regarding
progress in treatment or lack thereof.
(b) Advise
patient that second or independent opinions may be requested in ambiguous
situations.
3. Consequences
of psychiatric disability for the patient
a) Suffering
from a psychiatric condition: both psychiatric symptoms (e.g. depression,
anxiety, panic, pain symptoms, phobias, etc.) and damage to self concept
b) Work
life and love life similar/equivalent in importance for individual fulfillment
c) Consequences
of loss of work role
(1) Devaluation
within the family
(2) Loss
of community prestige
(3) Economic
loss, insecurity
(4) Loss
of sublimations for the expression of aggression
B. The
psychiatric evaluation procedure
1. History
a) Medical
and collateral record review
b) Reason
for the evaluation
c) Presenting
problem in patient’s own words
d) History
of the presenting problem
(1) New
or recurrent problem?
(2) Static
or changing?
(3) Impact
on home and work functioning?
2. Social
history
a) Family’s
socio-economic status
b) Role
of work in family life
3. Educational
history
a) Detail
elementary, middle, and high school
b) Strong
and weak subject areas
c) Relationship
with teachers
d) High
school drop outs at increased risk
4. Employment
history
a) Job
types
b) Performance
level
c) Length
of employment
d) Reasons
for prior changes in employment
e) Job
satisfaction at the time of injury
5. Current
income sources: impact of illness
a) Evaluate
for primary gain in maintaining disability if receiving benefits
b) If
no benefits, motivation to forgo treatment and return to work prematurely,
inviting further injury
6. Past
medical history
7. Current
medical problems and names of physicians
8. Medications
9. Substance
use/abuse history
10.
Legal
problems
11. Past
personal psychiatric history
a) Hospitalizations:
Complaint, dates, hospital, duration, outcome
b) Outpatient
history: Complaint, dates, treating professional, duration, outcome
12. Family
psychiatric history
a) Suicide
attempts
b) Depression
c) Anxiety
Disorder
d) Alcohol
and substance abuse
13. Developmental
history
a) Family
structure
(1) Parents
together or divorced; stepparents
(2) Nature
of patient-parent relationship
(3) Birth
order; relationships with siblings
(4) Neglect
or abuse history; duration and severity
b) Work
role models: Parent work history
c) Age
when patient began work: Premature responsibility increases disability risk
d) Illness
history in family or patient
e) Relationship
with authority figures
f) Peer
relationships: Best friend?
g) School
experiences
(1) Academic
performance level through grades
(2) Last
grade completed
(3) Strong
and week subject areas
h) Dating
experiences; marital history
14. The
“typical day”
a) Narrative
description of how the day is spent
b) Time
of arising; napping; time of retiring
c) Activities
of daily living: who performs, changes since illness onset
(1) Bill
paying
(2) Meal
preparation
(3) Laundry
(4)
Housecleaning
15. Mental
status examination
a) Appearance
and behavior
b) Mood
and affect
c) Speech
and thought content
d) Preoccupations,
suicidal or homicidal ideation
e) Cognitive
functioning: orientation, fund of knowledge, memory testing, abstract thinking,
judgment, insight
16. Psychological
testing
a) MMPI-2,
MCMI-3, Rorschach, TAT
b) When
should testing be requested?
(1) To
clarify ambiguous or complex diagnoses
(2) To
compare with previous test results
(3) To
assess for neuropsychological impairment
(4) To
help resolve diagnostic disagreements between clinicians
(5) To
assess for malingering
17. Summary
and discussion
a) Logically
synthesize all information obtained
(1) Present
explanation of symptom/illness development
(2) Developmental
psychodynamic factors which may be re-enacted
(3) Neurobiological
and genetic factors
(4) Environmental
factors
b) Temporal
relationship between events and illness; degree and duration of impairment; use
of appropriate rating systems
18. Multi-axial
DSM IV diagnoses
a) Current
standard for psychiatric diagnosis
b) Utilize
5 axis format for listing diagnoses, important psychosocial and environmental
problems, and GAF
(1) Valuable
as a means of measuring change over time between evaluations
(2)
Changes in degree of disability
Discussion:
The psychiatric disability evaluation is conducted in a
context that sets it apart from routine treatment evaluations. The evaluating
psychiatrist does not owe the same duty to the patient as a treating
psychiatrist. Different situations in
which a psychiatric evaluation might be requested were outlined earlier in the
chapter. It is important that
confidentiality limitations and roles be clearly explained to the patient
before undertaking the evaluation.
Without such information it is impossible for the patient to give informed
consent to the evaluation process. (Grant and Robbins, 1993)
When the evaluation is being conducted at the request of a
third party, the patient is told that there will be no follow-up treatment
relationship with the examining psychiatrist, who may find himself in an
adversarial role vis a vis the patient.
If the evaluation is for treatment purposes (as might be the case when a
treating physician refers the patient for evaluation), the patient and
psychiatrist may choose to enter into a treatment relationship. The patient should be allowed to choose from
other treatment providers as well, however. This is of particular importance in
disability treatment situations since there is often an adversarial quality to
the claims administration process, and for therapy to be effective the patient
must have trust and confidence in the treating psychiatrist. In workers’ compensation treatment settings,
regular reports to the administrative agency are required, and the patient
should be informed that the confidentiality is limited. Sensitive material not
necessary to the administration of the claim should be excluded from reports
that should primarily document diagnoses; treatment modalities employed, and
progress in treatment. It is a good practice
to advise the patient that the patient, the treating psychiatrist, or the
administrative entity, may request second or independent opinions.
After determining who is requesting the evaluation, the
clinician should perform a review of available records. Much of the evaluation process is identical
to a standard psychiatric evaluation.
Only aspects particular to a disability evaluation will be discussed in
this article.
Ask how the patient experienced the development of
impairment and resulting disability. Define whether it is a new or recurrent
problem, and whether it is static or changing. What is the impact on home and
work functioning? What are the economic
consequences of the disability?
The role of work in the family’s life is important as it
relates to the nature of the work ethic that has been formed. An early forced
entry into the labor market often results in an early burnout. Such individuals may have developmental
histories marked by deprivation, neglect, and abuse that exert a major influence
on their response to injury.
School adjustment and performance correlate positively with
recovery from injury and return to work.
High school dropouts fare poorly in comparison with college graduates.
Strong and weak academic subject areas should be defined.
Employment history includes jobs held and their sequence,
performance level, and satisfaction.
Gaps in employment may reflect commitment to work, level of job skills,
flexibility and adaptability. Reasons for changes in employment should be described,
and patterns identified.
Example:
Ted had worked as a forklift driver for a distributor for the last 17
years. His employer indicated that he
had been a good employee, and that the company would modify the forklift
controls so that he could operate it with his uninjured hand.
Example:
Henry provided a history of frequent job changes. Most of his jobs lasted for only a few months. He was vague about the reasons for job
changes. The typical gap in employment
was about 6 months, during which period he would collect unemployment.
The
economic consequences of disability are described in the evaluation; typically
they include loss of income, but occasionally may yield income close to that
earned while working, as in the case of Ms. A.
In a situation where the work was particularly high stress, this may be
experienced as a good trade, and constitutes primary gain. Secondary gain is unconscious in its
nature. It occurs when assuming the
sick role gratifies dependency needs unmet in earlier development. However, in lower socioeconomic class
families, the loss of role status both within the family and the community can
be extremely adverse to the individual, who is treated as a freeloader—someone
little better than a welfare cheat.
“I feel like I can’t be
around anybody—nobody wants to talk to me.
I avoid people; I don’t go out of my house. My father in law asked me when I was going to go back to work.”
Litigation, or retention of an
attorney, is frequently cited as contributing to chronic disability. This belief has not been borne out by
prospective studies, however. (Dworkin, et.al., 1985; Modlin, 1986 ) What
indisputably contributes to morbidity and chronicity is denial or delay of
appropriate treatment. Correctable
conditions worsen, with both physical and psychological negative consequences.
(Gallagher, 1996)
Since substance abuse correlates nearly
100% with negative treatment outcomes, it is particularly important to explore
this area thoroughly, both with the patient directly and by collateral record
review. A prior arrests history for
minor offenses, although not favorable, is less prognostically negative than
active substance abuse. When substance abuse is present, concurrent treatment
for this comorbid condition is a requirement. Regular compliance reports should
be requested from the facility providing such care. A dual diagnosis treatment orientation is essential, as
pharmacotherapy is usually required for such individuals.
The patient’s family psychiatric
history and past personal psychiatric history are explored in a standard
manner. Severe character pathology is significantly correlated with protracted
if not negative treatment outcomes.
Patients with bipolar disorders and histories of psychoses confront more
obstacles to recovery. Depressive disorders with psychotic features are more
common than generally appreciated. (Dubovsky and Thomas, 1992)
Example:
A
53-year-old nurse’s aid fell and injured her back and shoulder while
transferring a patient. She was tearful
and nearly mute when she first presented for treatment. After 9 months of aggressive pharmacotherapy
and psychotherapy she admitted that she was having command hallucinations that
were telling her to commit suicide.
She had been too embarrassed and ashamed to admit to these symptoms when
first evaluated. The addition of
antipsychotic medication produced some immediate improvement.
The patient’s developmental history
provides the major clues to character formation, and the ease or difficulty of
coping with later adversity can be predicted by these influences. Abused and neglected children are likely to
become maladjusted, brittle, and angry adults.
Depression, substance abuse, panic disorder, and pain disorders find
fertile ground in this population. Premature work responsibility interferes
with the developmental tasks of childhood, and the price is paid later. For women, an excessive caretaking
responsibility for younger siblings while still a small child themselves is as
destructive as being sent into the fields at 7 or 8, and contaminates and
shapes attitudes towards work in adult life.
Sexual or physical abuse trauma
resonates with difficult work situations encountered as an adult, and renders
appropriate responses to workplace conflict more difficult, as well as
complicating relationships with health care givers and other authority figures.
(Johnson, et al 1994) ,and
Indvik, J: The impact of unresolved trauma on career management. International
Journal of Career Management, 1994;6(2):12-18)
The details of family structure are set
forth, and standard psychiatric concepts are employed in their incorporation
into the final impression.
Example:
Peter
was 41 and married for 14 years when he slipped and injured his back after
working as a foreman in a manufacturing concern for 8 years. His only prior employment was in a similar
capacity, and was of 7 years duration.
When he failed to recover and return to work quickly as he had expected,
he began to become depressed and paranoid.
He blamed his former employer for spreading “rumors” about him within
the community, and began to drive by the plant with a gun. He actively
fantasized about “going in with the gun blazing” to exact revenge. He
experienced command hallucinations telling him to “get even.” Panic disorder symptoms developed. Inquiry regarding his developmental history
revealed 7 alcoholic physically abusive stepfathers, and a mother that ignored
him and his 5 siblings. He recalled
frequent beatings with wood two by fours.
He left home at 16 and joined the Navy.
He remembered always being angry during those years, although he earned
an honorable discharge and was never the subject of disciplinary
proceedings. He remembered making a
conscious decision at the time of his marriage to “set my anger aside and not
think of it.” He worked 12-18 hours a
day for his employers, burying himself in his work, and deriving a sense of
self worth from being productive. He
admitted to being distant from his family because of his long work hours. He complained of feeling “betrayed” by his
employer, even though there was no evidence to support that contention. Group therapy, individual therapy, and aggressive
pharmacotherapy produced gradual improvement over several years.
A specific description of a patient’s
“typical day” is valuable because it is specific, and represents actual
behavior on which to base clinical conclusions. Bill paying, meal preparation,
laundry, housecleaning, and social interaction patterns on a day to day basis
yield important clues as to the patient’s current level of functioning, as well
as regression that may have occurred. Sleep patterns, particularly including
naps, may indicate avoidance and withdrawal.
When questions arise regarding complex
or ambiguous diagnoses psychological testing should be considered. This is
often useful when organic brain impairment is suspected. It may also establish a baseline that will
permit comparison with later findings, when assessing response to
treatment. Diagnostic disagreements
between clinicians can sometimes be resolved by reference to such testing.
The summary and discussion should be a
biography from a psychiatric perspective—one that tells the story of the
individual from a work perspective, drawing upon their developmental history,
neurobiological and genetic factors, environmental factors, and current life
circumstances. The time sequence of
events often provides further insight into the patient’s condition. The function,
meaning, and role of the current disability should be explored. Treatment recommendations are based on
current psychiatric knowledge, taking all known factors into consideration.
DSM
IV diagnoses are to be included, as part of the standard format, but their
limitations should be borne in mind.
Treatment recommendations are based on
the integrated assessment of the patient, one that takes into account both Axis
I and Axis II conditions. Personality
trait disturbances or full disorders are present in a majority of affected
patient in some sub-populations, and require sophisticated clinical skills.
(Azima, 1993; Oldham, 1995) The
importance of chronic and acute pain on psychological functioning should not be
overlooked. One series of patients referred to a pain clinic found 67% of
chronic pain patients had undiagnosed medical conditions that were responsible
for some or all of their complaints. (Hendler and Kozikowski, 1993) Every effort should be made to assure that
these and other potentially undiagnosed medical conditions are receiving necessary
attention from appropriate specialists.
Effective treatment may include group,
individual, and marital psychotherapy, along with appropriate pharmacotherapy.
(Williams, 1997) The treatment plan
must take all conditions into account, and the clinician’s awareness of
comorbid disorders is critical to successful outcomes. (Oldham, et. al.,
1995) Patients with personality
disorders require particular skills, and the treatment of this group requires
substantially longer treatment than solitary Axis 1 disorders. A
bio-psychosocial treatment approach will yield the best results.
Malingering
Questions of disability provide fertile ground for concerns
that the claim of disability is the result of malingering. While many insurers and evaluators focus on
the detection of malingering, research data shows that the incidence of
malingering is less than anticipated. (Minnesota Department of Labor and
Industries, 1995) Nevertheless, the possibility of malingering should be
considered and evidence for its presence or absence noted in the record.
Neurological disabilities are subject
to malinger. False or exaggerated
claims of memory disturbance, or confusion, can be difficult to detect. The evaluator must be careful to distinguish
between those symptoms that are malingered and those arising from undetected
illness or psychiatric disorders such as depression, anxiety, and somatoform
disorders. Psychiatric disorders are
also the subject of malingering efforts, largely because so much of psychiatric
diagnosis is based on self reported symptoms.
It is sufficient to note that
malingering must be considered in every disability evaluation. The evaluator who does not address the
issue, as part of the evaluation is likely to find the evaluation challenged at
some point. The treating clinician can
aid his or her patient by making an objective determination as to whether or
not the patient’s claims are exaggerated.
Such a determination, with documentation, can ease the patient’s path to
deserved insurance coverage.
A detailed discussion of techniques for
the detection of malingering is outside the scope of this chapter. There are
several excellent texts on this subject ( Forensic Deception Analysis; Rogers:
Clinical Diagnosis of Malingering and Deception) The authors make extensive use
of psychological testing, conducted by qualified psychologists, to assist in
diagnosis, assessment of cognitive functioning, and evaluation of possible
malingering. The Minnesota Multiphasic
Personality Inventory Second Edition, the Rorschach Inkblot Test, and the
Structured Interview of Reported Symptoms are all useful in this regard.
Disabled
by Disease or by Lack of Motivation? The Secondary Gain Question
Disability evaluations often present difficult problems
reminiscent of the time honored question: “Which came first, the chicken or the
egg?” The following is a typical
example of situations in which these problems can arise.
Example:
Mr. B, a well-known attorney in his
community, was brought before the Board of Bar Overseers in his state on
charges that he had embezzled funds from his clients’ accounts. His license to practice was suspended
immediately. Mr. B was devastated by
these charges, developed symptoms of a limited depression, and filed a
disability claim on the basis that he was no longer able to practice law
because of his depression. His insurer
initially granted limited benefits, but then suspended benefits after Mr. B
lost his license, pending an independent evaluation. The insurer argued that Mr. B’s inability to practice was not the
result of depression, but the consequence of his having violated the Code of
Professional Responsibility. Any
depression he experienced, the insurer argued, was secondary to his own
misdeeds.
The challenge of these evaluations is
to focus on the individual’s ability to function in a certain job. Whether or not the individual being
evaluated is allowed by the relevant licensing authority to engage in the
previous occupation is largely irrelevant.
The authors have evaluated cases such as this involving lawyers,
physicians, and financial services professionals.
Even in the absence of a governmental
prohibition against working in a specific field, individuals may find the
desire to work waning as their industries undergo major change. This concern is
heightened when economic downturns or changes in certain industries make work
in those areas undesirable. Such
changes may lead to feelings of sadness and other symptoms suggestive of
depression. With a diagnosis of
depression from a supportive clinician, the individual may be successful in
obtaining disability benefits. Thus,
the evaluator is left with this question: Is the claimant disabled from working
because of depression, or is he depressed because he no longer likes the
job? As with the disbarred lawyer, the
question is whether the individual could perform the job if he chose to do so.
Disability and the Americans with
Disabilities Act
Individuals with disabilities are protected against
discrimination by the Americans with Disabilities Act and similar state
statutes. (Langer, 1996) Those same
individuals may require disability insurance benefits to cover living expenses
during periods when they cannot work.
Some individuals have filed suit alleging disability-based
discrimination by their employers, while at the same time filing claims for
disability benefits. The courts have
differed as to whether both claims can be made simultaneously. Some have rejected
such claims, cf. Cleveland v. Policy Management Systems Corp., 120 F.
3d 513, (5th Circuit 1997). Others, noting that claims for
disability benefits do not involve the question of reasonable accommodations,
allow both claims, C.f. Swanks v. Washington Metropolitan Transit Authority,
116 F. 3d 382 (D.C. Circuit, 1997) They noted that the heart of the
anti-discrimination claim is that an individual with a disability is able to
perform the essential functions of the job, with or without some accommodation,
but is being subjected to disparate treatment because of the disability. The disability insurance claim, however, is
based on the fact that the individual is disabled and unable to perform the
essential functions of the job. The two
claims, by the same individual during the same time period, are mutually
exclusive. One cannot claim that one is
entitled to benefits due to an inability to work and then claim that one is
able to work for the purpose of the discrimination claim.
Discrimination against those with
mental and physical disabilities is a real phenomenon. The bias may be overt or subtle, it may be
based on actual experience or, more commonly, on stereotypes. Clinicians treating those with mental and
physical disabilities can make a major contribution to getting their patients
back to work and helping them overcome the bias. They can do so by conducting objective evaluations of the
patient’s specific abilities to function in different settings, and by being
willing to cooperate with the employer’s request for information. Such cooperation and sharing of information
must only occur with the patient’s permission, of course. The treating clinician should be clear with
those requesting the information that the evaluation is not an independent evaluation,
and that it is based on more limited information.
While treating clinicians can serve as
the patient’s advocate in getting back to work, they can also put their patient
and the patient’s co-workers at risk.
It is essential that any clinician that opines that a patient is able to
return to work after a period of disability has a clear sense of the nature and
responsibilities of the job, as well as his clinical condition. (Maffeo, 1990) For example, one
treating social worker opined that his patient, a research chemist who
conducted high pressure liquid chromatography with hazardous materials, was no
longer disabled by her depression and was fit to return to work. Upon inquiry by an independent evaluator,
the social worker indicated that he had no idea of the duties and the potential
dangers. In a similar case, a treating
psychiatrist argued that his psychotic patient could return to her job in
government, in spite of her active paranoia and lack of compliance with
medication, because he felt that no one could force her to take the medication.
The evaluation and treatment of individuals with
work-related disabilities provide a number of challenges to those clinicians
that undertake these tasks. The
importance of work to individual and societal well-being, the moral valence we
attach to it, and the diverse motivations for entering and leaving the
workforce all combine to make this an emotionally charged area with many
clinical challenges. As in all clinical
matters, the clinician and patient are best served when the clinician is honest
with him or her self and the patient about the limitations on knowledge and
ability and the constraints these limits impose. Attention to detail, understanding of the task involved and the
techniques for completing it, and a willingness to resist the multiple elements
of bias in the disability process are likely to lead to a positive outcome.
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