Introduction

C. Donald Williams, M.D., CGP

Educational Objective

The participant will acquire a new understanding of the factors that influence the course of workplace injuries and their outcome. Utilizing current concepts of psychological development as well as psychopharmacologic principles, group and individual therapy treatment guidelines based on Axis 1 and Axis 2 diagnoses will be presented.

Introduction

The purpose of this course is to provide a comprehensive introduction to the evaluation and treatment of injured workers.

With regard to evaluation, we have two goals. The first is to address the issues that must be considered in order to render an opinion with regard to causality. Secondly, we intend to highlight information necessary formulating an effective treatment plan. Although there is overlap between the two types of evaluations, there is a difference in emphasis.

Our second aim is to describe, with examples, an approach to the treatment of these patients that includes individual psychotherapy, group psychotherapy, and pharmacotherapy. We shall discuss the interplay of Axis 2 disorders with depression, anxiety, and pain, and discuss their implications with regard to prognosis and treatment. Our third aim shall be to provide you to with a brief overview of those systemic and organizational factors that promote health and prevent disability; those that promote recovery if an injury is sustained; and those which promote disability and retard recovery.¹

Background

Workplace injuries exact a huge economic burden in our society. In 1994 compensation costs, treatment costs, and other indirect costs amounted to $171 billion, including direct costs of $65 billion and indirect costs of $106 billion². Injuries cost $145 billion and illnesses $26 billion. Low back pain alone was calculated to cost $26.8 to $56 billion in medical care, compensation payments, and time lost from work. 90% of these costs are incurred by the 5% who become chronically disabled.³

A treatment model similar to that used for soldiers injured in wartime has been employed for the psychiatric treatment of injured workers. Wartime military practice emphasizes a highly structured, non-analytic approach with an emphasis on a rapid return to the combat military unit. In the case of injured workers, the emphasis has been shifted to focus on a rapid return to work. Underpinning this approach is wartime experience: soldiers with a post-traumatic stress disorder who were not returned to their units quickly tended to develop full-blown and disabling chronic conditions resistant to conventional therapeutic efforts, depriving combat military units of manpower.

Clinicians and organizations involved in the assessment and treatment of patients who experience workplace injuries frequently employ this military derived model. The stated goal is a rapid return to the workplace. Action-oriented medical interventions, physical therapy, accompanied by admonitions to "learn to live with the pain" are commonplace.

However, biases on the part of physicians may lead to incomplete evaluations, missed diagnoses, and treatment failures.^{4 5} The false belief that psychological problems and psychiatric disorders are the primary cause of chronic pain syndromes may cause doctors and claims administrators to label patients as neurotic or malingering. In fact, chronic pain more often precedes depression, and causes social and psychological problems.⁶ Another false belief is that receipt of compensation and retention of a lawyer reduces the likelihood of RTW.⁷ In fact, prospective studies fail to demonstrate any predictive power regarding future employment status. A third false belief is that receipt of compensation will prevent a return to work. Both prospective and retrospective studies contradict this assumption.^{8 9}

The interplay between pre-existing personality disorders and workplace injuries is complex. Disputes regarding whether the workplace injury or the preexisting personality disorder is responsible for maintaining ongoing disability are commonplace. One side asserts that the personality disorder sustains the disability, while the other maintains that "but for the injury" the worker would still be working. In one respect, both sides are correct. The process can be more accurately understood as one in which the fragile sublimatory outlets for aggression are disrupted by the injury, disrupting the fragile ecology of the individual, disturbing his relationships with family, friends, coworkers, and society.^{10 11}

Popular notions regarding the prevalence of fraud appear to be inaccurate as well.¹² Recent statistics published on the Internet by the responsible state agencies regarding fraudulent claims by workers reveal incidence rates that are remarkably low.¹³ For the two year period 1992-94, of 9000 completed investigations, there were less than 150 guilty findings, a rate of under two percent (of actual investigations, not of total claims). Investigation costs are not low however; using budget figures and case activity data compiled for eight states, each guilty finding cost $117,000.¹⁴

Figures between states show a wide variation, due to many factors, including experience, resource allocation, and other factors.

"Workers' compensation fraud is rare in Wisconsin. Of 73,678 work-related injuries reported in 1994, only 5 cases merited referral to district attorneys for prosecution for fraud. Those five cases totaled $44,674 in workers' comp payments. Wisconsin Workers' compensation paid $598 million in lost wages and medical costs in 1993, the most recent year available. Another indication that fraud is negligible is that workers' comp insurance is getting significantly less expensive for the second straight year."

The number of alleged cases of workers' compensation fraud reported to the Division is low in comparison to the number of reported injuries. The Division estimates that there were more than 220,000 compensable injuries in Wisconsin in 1995. About 73,000 of these injuries involved lost time. During that year, there were 143 allegations of fraud to the Division. In 1995, the Division recommended 22 cases for criminal prosecution for workers' compensation fraud under s. 102.125, Stats. Thus, well-founded allegations of criminal fraud brought to the Division are only a tiny fraction of total reported claims.

For Washington state the figures are larger, but still small as a percentage of the total: "The Attorney General's Office is charged with supporting the department in these pursuits. Criminal prosecution in some cases is also warranted, and sometimes-criminal charges are sought. County prosecutors in local jurisdictions handle these cases. Many times, though, local prosecutors decline to take such cases because of a backlog of other criminal cases deemed more important. A total of 73 fraud investigations were completed during fiscal year 1996, resulting in 60 administrative fraud orders. A total of $2,354,706.82 in repayments were ordered, including penalties." Employer fraud amounted to $3.7 million; Worker fraud equaled $2.3 million.¹⁵

In 1996 in Oregon, 213 investigations of abuse or fraud were closed. 31 percent were unfounded, 16 were issued a notification letter, 25 percent were retained for future pattern development, and 25 percent were given a letter of reprimand or warning.¹⁶

Both administrative and professional cultures interfere with effective evaluation and treatment. In the administrative realm unsophisticated or narrow conceptions regarding cost containment, cost shifting to the social security disability system or other public agencies, and a need to show cost cutting results for the immediate reporting period may lead to a denial or delay of treatment and diagnostic authorization. In the medical realm, psychiatric abnormalities that are the normal response to chronic pain may cause physician withdrawal and disinterest. A lack of familiarity with alternative treatment models with demonstrated efficacy might result in a failure to employ the most effective methods. Insurer behavior may also contribute to poor outcomes; necessary diagnostic studies are often delayed, or denied. Physicians may choose not to order needed studies because of the administrative conflict and inconvenience associated with such requests.

This comes at a price. Rehabilitation by comprehensive multidisciplinary teams yielded a RTW average of 54-85%, depending on patient selection, compared to less than 30% of chronic patients receiving conventional treatment.¹⁷ Referral delays for comprehensive treatment for Back Pain Patients have been shown to increase direct costs¹⁸ by $15,000 to $50,000.

We hope with this course to enable you to perform better psychiatric evaluations and to provide more effective treatment to workers' compensation patients. Complexity must be recognized. "The first step in making a diagnosis is to think of it. Discarding discordant data, trying too hard to make a favored diagnosis fit, and refusing to let go of the assigned diagnoses are all diagnostic traps in which even a seasoned clinician can tumble."¹⁹ Reading this elegant paper on "Clinical Problem Solving" by George E. Thibault, the reader's attention is captured by the drama and tension associated with a rapidly developing medical crisis. That it concludes with the death of the patient because of a failure in the diagnostic process lends urgency to the principles that it highlights.

Similar crises of conceptualization and problem solving exist in psychiatry, but they often elude notice. Why? Perhaps it is in part because the time scale by which we practice is elongated; rarely do we have a drama like Thibault's, with a failure to accurately appraise a clinical problem leading so quickly to a fatal outcome. Our failures occur in slow motion, and are more easily ignored. It is easier to ignore or overlook poor outcomes when they occur without fanfare. A fatalistic attitude that such outcomes are to be expected given such [a condition] or [that kind of patient] is easier to sustain. Such pseudoexplanations may prevent clinicians from subjecting the underlying assumptions on which they are based to appropriate critical scrutiny.

A sense of history is valuable. Before John Cade and Morgan Schou discovered the effectiveness of Lithium in the treatment of bipolar mood disorder, manic-depressives were generally considered untreatable. It was only in 1970 that the FDA approved lithium for the treatment of mania. Before the work of Mahler, Winnicott, Masterson, Kohut and others in the mid 1970's, patients with Borderline and narcissistic disorders were rarely treated effectively; they simply were not understood. It was not until 1980 that the persistence of ADD into adulthood was generally recognized, and that emphasis began to be placed on attentional deficits. Only in the last ten years has the importance of comorbid disorders and combination therapy been generally appreciated.²⁰ Ten years ago no effective treatment was available for Obsessive Compulsive Disorder.

In each of these examples, progress resulted from advances in neurobiology, a better understanding of psychological developmental issues, or both. Careful clinical observation, the systematic testing of hypotheses and the corroboration of findings by independent observers led to further conceptual refinements of theory and practice, and therefore to more effective treatment.

My thesis is that injured workers with their psychiatric problems are in the same boat that their OCD, Borderline, and ADHD predecessors were 5, 15, and 25 years ago; poorly understood by most clinicians today, they often receive little or no treatment or ineffective treatment when they are referred. Their treatment failures occur in slow time. There is a disconcertingly familiar (to psychiatry) tendency to speak and act disparagingly towards these patients. They are often evaluated and treated by psychiatrists who lack experience in approaching their complex problems with a biopsychosocial model. And with the decline in psychotherapy training in most current residency training programs, many new psychiatrists lack the knowledge and requisite experience dealing with transference and countertransference phenomena to function effectively with these challenging patients, either in an evaluation or in a treatment mode. In fact, it especially must be appreciated by clinicians that countertransference phenomena are powerful influences in the conduct of psychiatric evaluations.

Case examples will be utilized to illustrate the relevant principles. Although not a primary purpose of this course, some attention will be paid to practice management issues, communication with insurers, paperwork requirements, and courtroom testimony.

Theory

I propose a theoretical approach to treatment that encompasses an awareness of diagnostic, developmental and psychodynamic issues.

Patients with workplace injuries may develop psychiatric disorders as a result of the traumatic losses associated with injuries on the job.²¹ These conditions include Major Depressive Disorders, Panic Disorders with or without Agoraphobia, and Pain Disorders. Injuries and the losses that follow in their wake often bring pre-existing personality disorders to light or aggravate those already in evidence.

Group psychotherapy²² is a treatment model that offers a clinically specific and cost effective response to patients injured in the workplace. Depressed patients without comorbid diagnoses can often be treated successfully with group therapy alone in combination with pharmacotherapy. Candidates for individual therapy in combination with group therapy include depressed patients with comorbid diagnoses of Borderline Personality Disorder (or borderline traits), Panic Disorder with or without Agoraphobia, or a combination of these diagnoses. A solitary emphasis on the immediate return to work with suppression of all feelings of loss, anger, and grief regarding the trauma of the injury is more likely than not to yield poor clinical results. A bio-psycho-social approach should be utilized to take into account the particular circumstances and opportunities presented by patients with workplace injuries. Injured workers carry multiple psychiatric diagnoses as a rule, with depression present in nearly all patients and Axis II conditions present in three fourths of cases referred for treatment. Anxiety, Pain, and substance abuse disorders are other commonly encountered comorbid conditions requiring specific treatment.

The psychiatric clinician treating injured workers becomes aware of certain features common to such patients. Mild to Severe Major Depression is present in most, if not all of those referred for psychiatric evaluation. The injured worker in this referral population typically develops major depressive symptoms between eight and fourteen months after the date of the industrial injury. This depression results from a multiplicity of causes including:

1. loss of role status, both in the family and in the community;
2. loss of self-esteem based on the increasingly apparent disparity between the damaged real self and the internalized pre-injury self-representation. The worker who is already lacking in self-esteem, or who is functioning on a borderline level prior to the injury is particularly vulnerable to using and perceiving the injury as a means of justifying and externalizing responsibility for non-performance.
3. chronic pain;
4. loss of hope of recovery;
5. activation of intrapsychic negative self-representations previously compensated for through having established a successful work role identity.
6. An inability to re-establish their fragile early sublimations for the expression of aggression.

Panic and other anxiety disorders occur more frequently in injured workers describing abuse and neglect in their developmental histories. However, an intensification of symptoms often occurs in concert with the social withdrawal that frequently accompanies disabling injuries. Agoraphobic symptoms in particular have a tendency to become more prominent.

Pain disorders (when not the result of missed physical diagnoses) are almost invariably associated with depressive illness. Patients who have difficulty putting feelings into words complain more of pain. Patients who have a highly developed capacity to symbolize affects may experience pain in equal amounts, but they devote less attention to it and are less preoccupied with pain than their less-verbal counterparts.

Treatment Modalities

The nature and severity of the patient's psychiatric condition determine session frequency. Borderline patients with life threatening behavior may need to be seen on a daily basis as an alternative to inpatient hospitalization; this is cost effective and therapeutically advantageous because of its tendency to be less productive of regression. The group therapy sessions can be increased or decreased in frequency as the patient's condition dictates, from one to five times per week. Since the groups are comprised of different members there is less likelihood of regressive dependency developing. Continued functioning is required, with the patient being encouraged to talk through intense feelings rather than act them out.

Once or twice weekly individual therapy sessions may be necessary to enable some patients to tolerate the group work. This may arise when issues involving intense shame and embarrassment need to be partially detoxified in an individual setting prior to being dealt with in the group. For example, an initial revelation of compulsive self-mutilation is often possible only in an individual setting, because of the often-overwhelming affect accompanying the behavior and its meaning. It can likewise be destructive to healthy group functioning if the time and attention needs of one member are so great that they lead to that person's monopolizing the group's time for an extended period.

Substance abuse coexists frequently with affective, anxiety and personality disorders.²³ Vigorous multimodality treatment interventions may be required, including separate inpatient or outpatient substance abuse treatment and combination pharmacotherapy targeted to the coexisting Axis I diagnoses. These patients are demanding and difficult clinical challenges. Patient non-compliance is a major cause of poor treatment outcome, contributing to their poor prognosis. Private clinicians might consider referring these high-risk patients to institutional settings to diminish the likelihood of splitting treatment efforts.

Patients with solitary diagnoses of Major Depression, Pain Disorder, or these diagnoses in tandem can often be treated effectively with a combination of group therapy and pharmacotherapy, requiring little or no individual therapy. This decision should be made on a case-by-case basis.

The Psychiatric Workers' Compensation Evaluation
A. Introduction
1. Reasons for a disability evaluation
a) Employer request

(1) 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.

b) Insurance company request

1. Private disability coverage
   
2. Second opinions re: treatment

(a) 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 workers' 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.

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
8. Medications

a) Names of physicians

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

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
5. 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. Multiaxial 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
3. Measure of treatment effectiveness

19. Treatment considerations

a) Co-morbid conditions are common and require integrated treatment; e.g., Major Depression and Panic Disorder or Substance Abuse
b) Treatment modalities

1. Individual and group psychotherapy
2. Psychopharmacological treatment

A. Types of Evaluations

1. Basic Psychiatric Evaluation

a) 4-6 page report includes

1. Identifying data
2. Chief complaint
3. History
4. Past medical history
5. Mental status examination
6. Summary and discussion
7. DSM IV diagnosis

b) Time required: 1-2 hours
c) Purpose: to determine need for psychiatric treatment of client

2. Intermediate Psychiatric Evaluation

a) 6-9 page report includes all components of the basic evaluation
b) Additional content

1. Detailed review of psychiatric IMEs
2. Critique of their facts and rationale

c) Time required: 2-4 hours
d) Purpose: to determine causality in medium complexity case

3. Complex Psychiatric Evaluation

a) 10-14 page report includes all components of intermediate evaluation
b) Additional content

1. Thorough review of all medical documents
2. Temporal correlation of medical and psychiatric findings

c) Time required: 3-5 or more hours
d) Purpose:

1. Complex litigation, with depositions and testimony probable
2. Aids in organization of case at the outset and in strategic planning

Case Examples: Workers' Compensation Evaluation and Treatment

C. Donald Williams, M.D., CGP

Case #1

Ineffective initial treatment: Clear causal relationship between injury and psychiatric condition

Sara M. DOB 10-21-43 Date of Injury 3-27-94

Synopsis

Initial diagnosis	PTSD
Initial Treatment Modality	No meds; 1x/wk individual RX for 2 years
Outcome	No apparent progress
Subsequent Diagnosis	PTSD; Major Depressive Episode, Moderate
Second Treatment	Prozac 40 mg Group Rx 1-2x/week for 16 months
Outcome	Successful job placement; offered employment as teacher's aide

Detailed History

Sara M. was a 53-year-old divorced white female with four grown emancipated children who was employed as a residential mental health counselor when she was violently assaulted by a patient in March, 1994. She was trapped in a room by a chronically mentally ill patient who followed her in, and she was severely beaten about the head with a telephone handset and choked. The assault continued for 5-10 minutes, and was only interrupted by other group home residents, as she was the only staff on duty at the time.

The following account of the assault was provided in the initial psychiatric evaluation:

"While performing her usual duties, Ms. M. was approached by one of the patients who was requesting a bar of soap. Ms. M. noticed that there was something unusual in the patient's manner, speech, and his request. The assailant was yelling at her at the top of the stairs to get him some soap. Ms. M. went up to the second floor to show this individual where the soap would be found in the shower. The assailant began screaming at Ms. M, yelling at her to "get me a god damned bar of soap!" Ms. M. then attempted to get this individual down to the main floor. She was able to convince this individual to go down the stairs as long as she walked beside him. He refused to walk in front of her. The assailant's diagnosis is paranoid schizophrenic. Ms. M was able to get into an office on the first floor, attempting to call for assistance. Unfortunately, before she could reach the phone, the assailant followed her and grabbed her left shoulder. She told him to leave or she would call the police. At that point, the assailant hit her in the face with his fist. He hit her several times directly in the face. He then knocked her down behind the desk. Ms. M ended up hitting a chair with her head behind the desk. At that point, the assailant began kicking Ms. M and hitting her with his fist as well as with the phone on the head and hands. The beating lasted more than 15 minutes. Ms. M was screaming for help. She was trapped in the office and felt that there was no way out. She put her hands in front of her face to protect herself. At one point, the assailant tried to put the telephone cord around her neck. Ms. M remembers thinking at the time that this is what it is like to die. Initially she panicked but, after some time, she felt calm as if she was going to die. The next thing she knew, another client/patient came to her rescue. There was no other staff member on duty at the time of the assault.

By the time the other individual had reached Ms. M, she was covered with blood. The assailant had broken the phone on her head. She was able to use a cellular phone to call 911. Ms. M found herself having to reassure others that she would be okay. She eventually called her supervisor who came in to help out. The fire department arrived to take Ms. M to the hospital. During the assault, her dentures and glasses were broken. She states she was placed on a backboard and remembers fighting, and not wanting to leave. She believes she was in some form of shock.

Ms. M was taken to Y-Hospital. There she received stitches above her eye and in her head. She was released to go home with her brother.

The patient had worked at that facility for six years at the time of the incident.

Ms. M states that she was told by Mr. W, who is the associate director of the residential unit, that it was a quality assurance committee's decision that the assault was her fault and that he and Ms. C-M--, who is Ms. M's supervisor, agreed. She notes that she had to use sick leave instead of Department of Labor and Industries' time-loss and her vacation leave in order to cover her time off. She states that she has requested the quality assurance findings and the incident report, but these have not been sent to her since her request."

Sara M. stated that she had been receiving weekly psychotherapy from Dr. F. for about two years. She added, "I feel I'm two years behind in recovery. I feel like I should have been over this by now. I have my safe areas that I go to - my home, my business, and my customers who are very protective." Regarding her psychotherapy, she stated "I could not go there and talk to him about things that bother me. My hands hurt all the time. I became tearful and I cried. I would try to tell him my fears, but he would respond 'Every time somebody mentions work you talk about a pain.'" She stated that she began to feel more shame and an increased sense of uselessness. She stated that she felt guilty about bringing up some of her concerns.

When we review Dr. F's initial consultation, we find that he states: "Ms. M. has been seriously traumatized. The resulting diagnosis of Post Traumatic Stress Disorder is severe enough that this patient is having difficulty leaving her home without being overwrought with anxiety and fearful in the normal workplace." He recommended psychiatric treatment, and specifically recommended that psychotherapy be employed without the use of medication.

A neurology consultation conducted five months subsequent to the assault yielded diagnoses of

1. Post Concussion Syndrome;
2. Post Traumatic Stress Syndrome;
3. status post multiple soft tissue trauma.

1. Dementia due to head trauma, memory impairment, and disturbed executive functioning;
2. Anxiety Disorder, Not Otherwise Specified;
3. Post Traumatic Stress Disorder.

This evaluation was conducted seven months following the assault. Specific PTSD symptoms included startle reactions, nightmares, and a sense of doom and dread in unfamiliar situations.

A follow-up neurology evaluation conducted ten months subsequent to the assault revealed right carpal tunnel syndrome, continuing depression, and anti-inflammatory medication.

At the time of my consultation 23 months following the assault, Ms. M. reported that she was frightened of males of the ethnic group matching her assailant. She could not tolerate having people behind her - because she associated that with being attacked from behind in the episode in question. She carried a handgun. Startle reactions continued. She was unable to visualize any future for herself. She had amnesia for certain aspects of the event. Irritability, constant fatigue, daily crying spells, thoughts of death, and problems with concentration were all reported. Passive suicide attempts were likewise reported.

Ms. M. had worked six years at the mental health center at the time of her injury. She entered the work force approximately three years prior to that time, at the time of her divorce from her husband of 28 years.

The patient began group psychotherapy with associated pharmacotherapy, specifically Prozac, beginning at 10 mg. per day and stairstepping up to 40 mg. per day. Her group therapy sessions were scheduled for two times per week. She demonstrated enough improvement to allow for beginning vocational services following six months of treatment. Treatment was continued while she began an on-the-job training experience as a Teacher's Aide with behaviorally disturbed elementary school students. She had both an effective vocational counselor and a supportive supervising teacher. Playground duty was initially too threatening for her, but over a course of four months, she was gradually able to work up to managing both that and lunchroom duty on her own. She felt valued by her students. She stated that her therapy was helping her in that she felt she could talk about anything. Although she felt challenged to increase her level of functioning, she did not experience her treatment as confrontational in a demeaning sense, something certainly not intended by her prior psychiatrist.

Discussion

What can we learn from this case? The initial evaluation and accompanying diagnostic workup appear to have been of high quality. However, two years of treatment appeared to produce little concrete evidence of improvement, and ultimately resulted in the patient's refusing to return to the psychiatrist for treatment. Several areas deserve attention.

1. No medication was prescribed, in spite of abundant literature indicating the efficacy of SSRI's for depressive disorders accompanying post traumatic stress disorder. Her initial treating psychiatrist was a psychoanalyst-in-training. No adequate rationale was provided for omission of pharmacotherapy.
2. Perhaps her psychiatrist was influenced by the professional culture and bureaucratic pressures that so often surround the treatment of injured workers. For example, she stated "I could not go in there and talk to him about things that bother me. My hands hurt all the time, and I became tearful and I cried. I would try to tell him my fears, but he would respond 'Every time somebody mentions work you talk about a pain.'" This is not standard practice for non-Workers' Compensation patients, and it should not be practiced on Workers' Compensation patients either. When a patient describes fears, and clearly demonstrates this symptom complex our patient presents, the underlying disorder must be addressed. Her response to her psychiatrist's equating talk of work with pain, essentially stating that she was employing pain to avoid work, increased her shame and sense of uselessness. This is a fundamental conceptual error. She may have been "using" her pain, but it was to protect herself from her terror, not from work. Subsequent events have borne that out.
3. Although treatment is not complete, this example represents a comparatively easy treatment case. The patient is psychologically minded, motivated to work, and is able to understand the therapeutic aspects of work. She is not fully recovered. She continues to have flashbacks of her assault and she continues to experience anxiety. Compared to norms, she is irritable. However, she has improved to a degree that allows her to function in the workplace.

Treatment considerations: Initial treatment was unsuccessful because of a) the lack of pharmacotherapy b) the insistence by psychiatrist that she was intentionally maintaining her psychiatric symptoms.

Group therapy was useful because of opportunity to see others with similar problems that had progressed; because of the practice it afforded in symbolizing feelings; because of learning regarding the use of Prozac.

At the time of transfer, she was being pressured to move forward with a vocational plan. A vocational counselor was successful in arranging a placement as a teacher's aid in an elementary school, working in a behaviorally disturbed classroom. She was initially fearful of group situations, and phobic regarding playground duty, but with support was able to function effectively, earning praise from her teacher and principal.

Case #2
Interplay between injury and Axis 2: Complex Treatment

Synopsis

Initial diagnosis:	Major Depressive Episode, Single Episode, Severe
Initial Treatment Modality	Group Therapy and Medication
Subsequent Diagnoses	PTSD; Major Depressive Episode, Psychotic Features; Pain Disorder; Panic Disorder with Agoraphobia; Borderline Personality Disorder; Cannabis Abuse
Secondary Treatment modalities	Daily Combined Therapy, Pharmacotherapy
Outcome	Uncertain
Ralph P.	40-year-old married (18 years) white male
DOI	3-27-95

Detailed Symptoms/Complaints
The patient was referred for psychiatric treatment after having been evaluated at a Pain Clinic in Seattle. A Psychiatric IME was performed, which diagnosed "Mood Disorder" related to the industrial injury. Psychiatric treatment was recommended. No Axis 2 diagnosis was made. During the initial treatment visits, the patient displayed high levels of Irritability, daily crying spells, social withdrawal, and pain behavior and complaints. Pervasive suicidal and specific homicidal ideation directed towards former employer were described daily; nightmares 4 nights per week of hunting and being hunted included vivid murder and killing scenes, with blood, smells, texture, temperature; and the smells and sounds of burning flesh. The patient reported actual drive-by-stalking behavior at times.

Legal

No criminal history.

Military

Honorable discharge with no disciplinary problems in military. Employment history-two jobs only, each of 7-10 years duration.

Treatment

1-9-96-ongoing Group therapy 4X/week; Individual therapy 2x/week Aggressive combination pharmacotherapy (with 2nd opinion concurrence) Wellbutrin, Navane, Zoloft, Depakote.

Referral for Pain Clinic/Rehab at University Hospital; the patient cooperated with and completed evaluation, with the conclusion that patient was too disturbed to participate at this time (8/97). The diagnoses and the treatment plan were affirmed.

Outcome

Uncertain

Discussion

This patient presents very serious treatment challenges. His psychosis includes suicidal and homicidal command hallucinations. He has been hospitalized because of suicidal and homicidal impulses. He has undergone evaluations by three psychiatrists and two pain clinics. He represents a current threat both of harm to self and harm to others. He has made progress in treatment, as documented by independent professionals, but at a very slow rate. His prognosis is uncertain. He represents a particularly clear example of how a workplace injury can disrupt "the fragile sublimations for aggression" work represents for personality disordered patients. His depression, psychosis, panic disorder, and rage are all related to this loss.

Treatment Considerations
The treatment is intensive, and designed to approximate a day hospitalization program, but at less expense. An individual therapy component is necessary because of the borderline organization, and the need for more detailed handling of dyadic issues. Combination pharmacotherapy is required for symptom management. Because of the intensity of the patient's primitive rage and projective identification, it is difficult for the therapist to avoid acting out this anticipated rejection and condemnation and it is a struggle to maintain a clear therapeutic focus.²⁴ Group therapy helps to dilute the more difficult transference aspects, and also makes treatment more bearable for the psychiatrist and the patient. This type of patient also represents a narcissistic challenge to all physicians involved in providing care because of the slow response to treatment, and the devaluation of efforts made on his behalf. A psychologically mature treatment team is essential. The initial Pain Clinic evaluation was antitherapeutic because of their inability to thread their way through these transference/countertransference pitfalls. The second Pain Clinic evaluation, conducted in a University setting, succeeded in meeting these challenges. They were particularly effective in that they avoided falling in the trap of fostering splitting among the treating professionals. The patient completed the University evaluation with a sense of hope and without the sense of humiliation associated with his prior experience.

Case #3
Complex Possible Malingering Case: No Causal Relationship
A detailed example of a disability evaluation/consultation to a physician as an aid to assess appropriateness for surgery.

Synopsis

Initial diagnosis:	Bipolar Mood Disorder
Initial Treatment Modality	Pharmacotherapy and multiple psychiatric hospitalizations
Subsequent Diagnoses	Bipolar Mood Disorder; Cannabis and Alcohol Abuse; Personality Disorder with narcissistic and antisocial traits
Secondary Treatment modality	Pharmacotherapy only
Outcome	Not Working

R. -----MD
------------------
Seattle, WA 98122

Re: Mr. Z
Date of Evaluation: 7/9/97
D.O.B.: -/11/5-
L&I Claim #

Dear Dr.-------:

Thank you for referring Mr. Z for a psychiatric evaluation. I met with Mr. Z on July 9, 1997. I obtained history from both Mr. Z, his older brother, and from extensive medical records provided by his legal representative.

Identifying Data
Mr. Z is a 48-year-old divorced white male who lives by himself; he has been living on his own for the last 3 1/2 years. He has two grown sons, ages--and--. He is currently unemployed.

Chief Complaint

"Getting on with my life - to adjust.

Records Reviewed

1. A Psychiatric Evaluation dated 5/18/93 by M.D., was reviewed. Dr.-diagnosed Mr. Z has having a Major Depressive Episode in remission, and did not feel that he had a significant personality disorder. He noted that there had been a "pre-cursor to the subjective and severe depression felt immediately after the accident in 1992." He described this as related to conflict with his supervisor, and opined that the injury caused a worsening of his already depressed condition." At that time he was felt to be fixed and stable, and little residual leg pain was reported.
2. A Discharge Summary from the psychiatric unit of --- Hospital dated 1/15/9--1/21/9-- was reviewed. This discharge record reflects a diagnosis of Bi-Polar Disorder, Manic; Alcohol Dependence; Adjustment Disorder with mixed emotional features; and Narcissistic Personality Traits. The Admission Note describes the patient as being agitated, histrionic, and inappropriate in his behavior. Insomnia, combativeness, cheerfulness, and sadness along with racing thoughts and pressured speech were noted. Difficulty with thinking and concentration were reported. The patient was noted during his hospital stay to have racing thoughts and rapid speech. Motor hyperactivity and restlessness was present. Inappropriate "sexual acting out and comments" was noted. He was placed on Lithium. He demonstrated improvement with a medical regimen appropriate to the diagnosis of Bi-Polar Mood Disorder.
3. A Psychiatric Discharge Summary by Dr.--, dated 1/25/94 was reviewed. Again a diagnosis of Bi-Polar Disorder, Manic, with psychotic features was made along with Posttraumatic Stress Disorder. Combative Behavior, grandiosity, and grandiose delusions were in evidence (he believed he was Jesus Christ). His family, who is documented as having expressed great concern about him, accompanied the patient. In addition, the patient's attorney likewise felt that he was "not really dealing with reality and could represent a danger to himself or others." Dr.-stated "There is a long history of possible manic episodes with some episodes of alcohol in an attempt to calm him down. The patient was recently hospitalized with similar manic and grandiose episodes. After 23 years of marriage, his wife left him for a 24-year old male."
4. A Psychiatric Evaluation dated 6/23/95 by ---M.D. was reviewed. Dr. --, who previously evaluated the patient in 1993 recounted Mr. Z having filed a claim for job distress in May, 1990 which was rejected by the Department of Labor & Industries in December, 1990. The industrial injury of May 14, 1992 was again described, as were continuing problems with Mr. Z's manager. Dr.-also had available for review a Psychiatric Evaluation conducted by --, M.D., on May 22, 1990. Dr.-found no evidence of psychosis but did diagnose an Anxiety Disorder. Dr.-initially reiterated an Axis I diagnosis of Major Depressive Episode in partial remission, causally related to the covered injury. Dr.-amended his diagnosis after reviewing additional records to a Bi-Polar Affective Disorder by history, with a major depressive episode in partial remission, which was causally related to the covered injury. He also noted Alcohol Abuse by history and Mixed Personality Symptoms. At the time of this 6/23/95 evaluation, Dr.-noted a clinically significant depression. Major vegetative symptoms of depression were noted. Dr.-opined that Mr. Z had a pre-existing depression or mood disorder prior to the covered injury, but stated that in his opinion, the depression had been exacerbated considerably as a result of the covered injury of May 1992. He did state that he felt the industrially related psychiatric condition was fixed and stable.
5. A letter dated November 17, 1995 by--, M.D. was reviewed. In his letter Dr.-reiterates his opinion that Mr. Z had a Major Depressive Episode, Recurrent. He expressed the opinion that the claimant had a predisposition to a psychiatric disorder. He stated that the May 18, 1993 Psychiatric Evaluation revealed that the claimant's major depressive episode was in remission. Dr.-stated that the claimant's major depressive episode, resolved in 1993, recurred as a result of back pain in early 1994. He states "Due to the nature of Mr. Z's Bi-Polar Disorder he no doubt will have successive remissions and exacerbations due to a series of events, life stresses, seasonal changes, etc. The chronicity of his pain from the covered injury and its impact as a stressor relative to causing exacerbations of his mood disorder, in my opinion he meets criteria for mental impairment, permanent, under Category 2 of the WAC 296-20-340." Dr.-stated that the claimant was capable of working four hours per day based on his industrially related condition.
6. A Discharge Summary dated 12/14/95 was reviewed. The patient was described on admission as aggressive and threatening and uncooperative with racing thoughts. Speech was pressured and disorganized and loosening of associations and grandiosity were noted. The patient had to be placed in physical restraints. Non-compliance with medication was noted.
7. A Psychiatric Discharge Summary dated 3/8/96 by Dr.-was reviewed. He was admitted because his 90-day less restrictive alternative was revoked because of increased symptoms of depression and poor functioning. Severe depression with psychomotor retardation was noted. Some agitation was present. Dr.-noted that Mr. Z's behavior was far better during this hospital stay than it had been in prior stays, and also commented about how strong his familial support was. The discharge diagnoses were Bi-Polar Disorder, not depressed on Axis I and Antisocial Personality Disorder on Axis II.
8. A Psychiatric Evaluation dated 7/19/96 by --, M.D. was reviewed. This comprehensive nine-page evaluation resulted in an Axis I diagnosis of "Bi-Polar Disorder, unrelated to the industrial injury of 1992." On Axis II a Mixed Personality Disorder with antisocial and narcissistic features was noted, also unrelated. Dr. --, as have several of the psychiatrists, that Mr. Z was not a reliable historian. He felt that Mr. Z was either misleading him intentionally or that he was persistently inaccurate for other reasons. Dr.-felt that as of May 1993, the injury ceased to be a factor in Mr. Z's emotional condition.
9. Two Psychiatric Evaluations by --, M.D., were reviewed. The first was dated 8/25/92 and the second evaluation was dated 2/13/96. Dr.-revised his original diagnosis of Major Depressive Episode related to the industrial injury in the initial evaluation, to Bi-Polar Disorder with psychotic features and episodic Alcohol and Cannabis Abuse and Dependence in the subsequent evaluation. In addition, a Personality Disorder, NOS, with narcissistic and antisocial features were reported.
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