Summer 2000, Vol. 8, No. 3.

Psychiatric Disability

Psychiatric disability in the workplace–
An approach to understanding

By C. Donald Williams, MD, CGP
Yakima, WA

Introduction

Disability within a psychiatric context, for the purpose of this essay, will be narrowly defined as the inability to perform one or more of an individual's usual life activities such that the individual can no longer function in the workplace. Effective treatment requires accurate diagnosis and assessment. We will focus on the evaluation of an individual's ability to work following injury or illness.

It is useful to make a distinction between disabilities and impairments. Impairments are the cognitive and affective abnormalities associated with psychiatric disorders. Disabilities are the restrictions that are imposed by impairments in function, including work and relationships.

While many people are injured or become ill at work, only a small proportion of those go on to become permanently disabled. The meaning of the disability to the individual can influence its severity and the individual's adaptation to it. 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.

The interplay of factors

Mild to Severe Major Depression is present in 90% or more of patients referred for psychiatric evaluation after a disabling injury. 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. Sensitivity to chronic pain is influenced both by genetics and by mood state. Anxiety disorders are believed in part to derive from the heightened noradrenergic arousal that results from severe chronic pain in susceptible individuals. Depression can result from a multiplicity of causes including:

• loss of role status, both in the family and in the community;
  
• loss of hope of recovery;
  
• activation of intrapsychic negative self-representations previously compensated for through having established a successful work role identity;
  
• loss of self-esteem based on the increasingly apparent disparity between the damaged real self and the internalized pre-injury self-representation;
  
• chronic pain.
  

The meaning of any given impairment to an individual, and the degree to which he views himself as disabled depends on the interplay of the factors outlined above. 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.

Direct suffering from symptoms associated with a psychiatric disorder include depression, anxiety, panic, and pain symptoms. Indirect suffering, resulting from the damage to the patient's self esteem may cause greater distress. A sense of powerlessness and hopelessness form part of a vicious circle with the preceding direct symptoms contributing to a downward spiral. Avoidance of social interaction because of shame and embarrassment frequently lead to panic and agoraphobia. Loss of a sense of efficacy is nearly universal in this population. Nearly all patients complain, "I can't do what I used to do".

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.

An approach to understanding this patient population

Psychiatrists may be asked to participate in the disability process in several ways, but within a framework of two very separate roles: treating clinician vs. independent evaluator. Regardless of the assigned or chosen role, it is necessary to perform a comprehensive evaluation. This is just as essential as a prelude to undertaking treatment as it is when conducting an independent evaluation. One should not rely on prior evaluations conducted by other clinicians as a sole guide to diagnosis and assessment. This may appear obvious, but sometimes under the pressure of time-limited treatment authorizations it may seem tempting or expedient to take a short cut and to launch directly into treatment, hoping to conduct the assessment "on the fly". This is not advisable. It is a useful discipline to dictate a formal evaluation with all of the usual elements whenever beginning treatment. This imposes a certain discipline--similar to pilots going through a check list before take off. Prior evaluations are valuable, but should be viewed as consultations or second opinions.

It is equally important that the psychiatrist avoid yielding to pressure to adopt the agenda of any of the involved parties, whether they are the employer, attorney, or agency that made the referral. As a treating psychiatrist the obligation is always to provide the best possible psychiatric care to the patient. As an evaluating psychiatrist it is essential to maintain accuracy, impartiality, and to avoid shading the material or the conclusions to suit the requesting entity. To do less is not only professionally improper, but it also renders the entire legal and adjudicative process less efficient.

Assessment in either capacity is a complex process, with multiple biopsychosocial issues playing important roles. It is useful to consider each of these realms specifically.

Biological issues

The genetic and constitutional factors that influence the expression of the development and course of psychopathology are familiar to each practicing clinician. It is beyond the scope of this article to specify them in detail, but a broad overview can be presented. Affective, anxiety, pain and personality disorders (or trait disturbances) are prominent and frequent findings in this population. Substance abuse disorders should always be considered, and whenever there is any question in the mind of the clinician, laboratory screening tests and collateral sources of information should be utilized. Schizophrenias and dementias are relatively rare. A history of closed head injury, sustained for example in a motor vehicle accident or an assault, is relatively more common. This requires neuropsychological evaluation and expertise with pharmacotherapy utilized for organically based mood and behavior disorders. Exposure to toxic substances in the workplace can be another important factor impinging on the clinical presentation of the patient. Examples of such exposure include industrial solvents used in painting and fiberglass fabrication, farm chemicals, and the petrochemical industry. Neuropsychological testing is valuable for confirmation of the nature and extent of the impairment. Clinically such patients often display unpredictable mood swings coupled with extreme impulsivity. This can be quite dangerous, as they may attempt suicide by violent means, or assault other acquaintances or family members. One should look for an absence of any similar behavior prior to the injury to increase the index of suspicion of traumatic or toxic injury. The presence of a prior pattern of such behavior usually suggests personality disorders, other psychotic pre-existing conditions, and/or substance abuse.

Developmental issues

It is important that a thorough developmental history be obtained. A history of neglect, abuse, and educational failure negatively impacts the prognosis and demands more sophisticated treatment. A clinical approach that is cognizant of the potential transference issues and deals therapeutically with them will be markedly more successful than a more superficial approach.

For example, many patients with a history of abuse or neglect will unconsciously place themselves in harms way in the workplace, or will exhibit an absence of prudent self care, in an unconscious effort to replicate their developmental trauma. Such patients often work in low status jobs with high physical demands, such as nursing assistants. They have one of the highest injury rates of any occupational classification. It is common to hear of assaults by patients occurring in understaffed situations, back injuries associated with patient transfers undertaken alone instead of with other staff assistance, working double shifts with injuries occurring during periods of extreme fatigue, etc.

Social issues

The loss of status both within the community and within the family system that accompanies workplace injury and job loss can be quite devastating. It is common to hear patients state that they feel "worthless", that their children no longer respect them, and that their spouses resent the loss of income and frequently blame the worker. Such patients, particularly in the blue collar and laborer classes, often are asked, "When are you going back to work?" in supermarkets, or are treated to comments like "it must be great to get a check from the state every month". As a practical matter many such people live paycheck to paycheck, and frequently suffer repossessions of automobiles, bankruptcies, and other financial hardships as the system processes their claim and payments are withheld or delayed.

Summary

A biopsychosocial approach to both the assessment and treatment of psychiatric disability helps the clinician to respect the complexity that is inherent. A disciplined approach to assessment, whether in a treating or evaluation role, yields a better appraisal of the individual's condition, prognosis, and treatment needs. All of the clinical skills acquired in psychiatric training and practice must be called upon to perform this task well, and the clinician must resist the pressures that outside entities bring to bear in an effort to suit their particular agendas.

Reference:

Schouten, R. and Williams, C.D., 'Psychiatric Assessment and Management of Chronic Disability Syndromes,' in Psychiatric Care of the Medical Patient, 2^nd Edition, Stoudemire, Fogel, and Greenberg Eds, Oxford University Press, 2000.

 
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