Winter 1997, Vol. 6, No. 2

Book review essay: The Diagnosis and Treatment of Occupational Disorders

By Len Sperry, M.D., Ph.D.

"Occupational disorders do not take lives, they merely ruin them. The victims of occupational disorders are rarely hospitalized or die by their own hand. Instead they are...constantly miserable and wishing they were dead. Every Monday morning, at work, they ache for Friday to come. Then every Friday nights, at home, they fear the coming of Monday morning. Their careers are either compromised or in a shambles, with some stuck in dead-end jobs, mired at the bottom of the corporate ladder, and others closer to the top...but tottering and about to fall off."

So begins Kantor's Occupational Disorders: A Treatment Guide for Therapists ( Praeger, 1997). Martin Kantor, M.D., is Clinical Assistant Professor of Psychiatry at the University of Medicine and Dentistry of New Jersey. His professional life has included both doing psychiatric evaluations and providing psychotherapy with individuals presenting with "occupational disorders." His purpose in writing this book is to emphasize how occupational disorders are essentially "9 to 5" manifestations of DSM-IV disorders. He contends that occupational disorders are often catch-all terms utilized by primary care physicians and psychotherapists. Unfortunately, this lack of precision leads to inadequate treatment in addition to misdiagnosis. For instance, a repetitive stress injury—such as carpal tunnel syndrome—may actually be a tendinitis (or its equivalent) or a conversion disorder, while "burnout" is often used loosely, when the actual diagnosis may really be reactive depression, posttraumatic stress disorder or an adjustment reaction. In addition to highlighting DSM-IV descriptions, Kantor describes the psychodynamics of a variety of occupational disorders. He believes that "most work disorders originate at least partly in the worker's early relationships. Often workers get sick because the boss reminds them of their hostile father, co-workers remind them of their competitive siblings, and underlings remind them of the new baby that displaced them from being their mother's favorite" (p. 5). Furthermore, Kantor contends that organizational factors also play a role in these disorders. He insists that much work stress originates in corporate structures and cultures which then create a hostile climate with which employees must contend. He criticizes popular writers who also make this attribution, but then blame corporations for victimizing workers. Taking a broader, more interactional perspective, Kantor contends that the effective clinician must consider both individual dynamics and corporate dynamics in assessing work stress.

The book is primarily written for occupational medicine physicians, primary care providers, psychotherapists, and front line managers who come in contact with workers whose workplace functioning is problematic. Such professionals need to be sufficiently capable of distinguishing between psychopathology and laziness and attitude problems.

Kantor reviews various dynamic, organizational, family, and work-site factors contributing to workplace dysfunction. He presents an incremental approach to developing correct diagnoses for both familiar and less familiar occupational disorders. He covers: The Endogenous Disorders; Somatoform Occupational Disorder; Depressive Occupational Disorder, Anxiety Occupational Disorder; Phobic Occupational Disorder; Obsessive-Compulsive Occupational Disorder; Sexual Occupational Disorder; Personality Disorder Occupational Disorder; Job Dissatisfaction; Non-DSM-IV Occupational Disorder; The Exogenous Disorders; An Overview of Treatment; Psychodynamic Therapy; Cognitive Therapy; Supportive Therapy; Steps in Treating the Occupational Disorders; and Dealing with Guilt and Low Self-Esteem.

While the book is subtitled: "A Treatment Guide for Therapists" there is very little specific information on treatment interventions and the treatment process, beyond establishing a diagnosis. In Part 3, entitled "Treatment," Kantor purports to provide a "Step-by-Step Guide to Treating Occupational Disorders." Of the five steps listed, step 5 is "Treating the Disorder." But only six pages of the 243 pages of text are devoted to treatment. Besides a few general guidelines, the reader will not come away from this book with specific treatment guidelines or specific treatment interventions. The author seems to subscribe to the internal medicine dictum: proper diagnosis dictates proper treatment, because making the correct diagnosis is 90 percent of the treatment. While this dictum may have some value for acute medical problems: i.e., the diagnostic entity: "cellulitis" should trigger the treatment entity: "amoxicillin." Unfortunately, this dictum has proved to be little more than a fiction with regard to the treatment of chronic medical diseases. In psychiatry, diagnosis is far from being 90 percent of the treatment. For example, even with an uncomplicated case of bipolar disorder, first-year psychiatry residents quickly learn that neither lithium carbonate or another anti-manic agent can guarantee total treatment efficacy or even 90 percent treatment success. Perhaps a more accurate subtitle would have been: "A Diagnostic Guide."

Aside from this major shortcoming, Kantor's book creditably reconstructs DSM-IV descriptions and criteria to work-related symptomatology. And this in itself is no small feat. DSM, even in its fourth edition, still seems to be phobic about the "work" dimension and overly enchanted with the "love"—significant other—dimension of the "love" plus "work" equals "mental health" equation. Accordingly, most Axis I and Axis II criteria are stated in "work neutral" language. Furthermore, there is only one V-Code involving work: "Occupational Problems"—V62.2, while there are five separate V-Codes for "Relational Problems." Some of Kantor's occupationally-focused descriptions of currently recognized disorders such somatoform disorders and depressive disorders are incredibly useful. Hopefully, these descriptions will positively impact the appropriate DSM-V committees which are now being formed. There are some important articulations of non-DSM occupational disorders which deserve to reach broad audiences, including DSM leadership, as well as the GAP Committee on Occupational Psychiatry and the APA Committee on Occupational Psychiatry.

I was particularly impressed with Kantor's brilliant articulation of the dynamics of the "hysterical personality disorder"—not to be confused with DSM's Histrionic Personality Disorder—in occupational settings (pp. 137-140). These articulations reflect the author's highly developed powers of clinical observation skills and formulation prowess.

For those occupational psychiatrists and clinicians searching for a guide to specific treatment interventions with some occupational disorders, I recommend Rodney Lowman's Counseling and Psychotherapy of Work Dysfunctions published by the American Psychological Association in 1993. I use the qualifier some because Lowman does not address Axis I type DSM disorders. Rather, he focuses on the kind of Non-DSM occupational disorders or dysfunction that Kantor describes in chapters 8-11, and in earlier chapters, when describing "exogenous" depression and anxiety. In addition to providing a clinically-relevant taxonomy for the diagnosis of these work-related dysfunctions, Lowman specifies and illustrates a number of clinically useful and valuable treatment strategies. Needless to say, I highly recommend Lowman's book. Unfortunately, I cannot recommend a single volume that describes both the diagnosis and treatment of occupational disorders—including DSM disorders—because there is no such book. In the meantime, occupational psychiatrists who are involved in disability evaluations will find some parts of Kantor's Occupational Disorders helpful, and other parts of this book extremely useful and valuable.

 
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