PSYCHOLOGICAL EVALUATIONS
part 4 of 5

Most often, opinions regarding stress related illness and disability are made by a mental health provider who is currently treating the employee. This can be a doctor of psychiatry or psychology, social worker, or therapist. The employee usually gives a history of symptoms and circumstances surrounding those symptoms to the doctor, who typically makes a diagnosis and may advise the employee to not return to work for the time being. Later, this treating doctor may be called upon to provide a more extensive report regarding the employee's condition or to testify on behalf of the employee's claim. It is often asserted that the treating doctor is in the best position to give this opinion because he or she has intimate knowledge of the patient and has often been in contact with the patient over a period of time. A number of serious problems arise in this regard. First, the doctor may not be trained in the evaluation of these often quite complex cases. The initial opinion and recommendations may have been given after a brief interview where the history relied almost exclusively on the subjective reports of the employee. Rarely has the treating doctor reviewed in advance recorded information, other opinions, past medical records, or statements from collateral sources. Second, the treating doctor inherently accepts the patient's account and, in the absence of obvious manipulation, becomes allied to the patient's interest. It would be impossible for a treatment relationship to continue if the doctor did not believe the patient or, even worse, expressed an opinion contrary to the patient's position in the claim. Third, the treating doctor, at least in workers' compensation claims, may have adverse financial consequences by not supporting the claim since therapy bills can be dependent on such an opinion.

Independent assessment which includes a thorough understanding of the circumstances of employment, feedback from collateral sources, and a complete history of the employee both medical and psychological, is necessary. There is no way to adequately determine whether or not a mental condition is pre-existing or recent without such a thorough assessment. The claimant's account alone is unreliable because of the natural tendency to emphasize the factors in the claim itself and minimize other issues. Some emotional disorders occur as isolated episodes in time with no history of symptoms preceding. Others have a chronic or cyclical course which can be traced throughout the life of an individual. Still others are episodic, manifesting themselves only a few times throughout the person's life. A proper diagnosis, therefore, can only be made by a thorough understanding of the entire life history.

Certainly stress, especially where it is handled in maladaptive ways, can precipitate an emotional illness. The causes of any illness are usually more complex, involving a variety of biological, psychological, and social factors. However, inordinate stress can be a substantial factor in bringing about the illness. In determining the effect of stress in the work place on the employee, two crucial problems must be addressed. First, mental disorders, by their very nature, interfere with the person's social and occupational functioning. Even disorders that begin for totally unrelated reasons to work, eventually affect work. Poorer work performance can create a negative response from the employer or add a new burden from threat of job insecurity, through demotion or termination. So, just because there is work stress does not necessarily mean that it was the cause of the condition in the first place. Second, the presence of distress alone does not mean that a stress related illness exists which would create impairment or disability. A proper diagnosis is needed and the impairment must be consistent with the diagnosis. Unfortunately, while this distinction may appear to have merit, practically the threshold for psychiatric diagnoses is so low that it is never hard to make a diagnosis. It is a rare mental health provider who will not give a diagnosis to any person who walks through their door with a problem.

Although for the most part there are a limited number of diseases which afflict human beings, there have been ever growing numbers of diagnoses. Nowhere is this more apparent than in psychiatry and documented by the expansion of diagnostic categories over four volumes of the Diagnostic and Statistical Manual of Mental Disorders. It is possible today to find a diagnosis for any type of human distress or behavior. Likewise, when the epidemiology of various psychiatric diagnosis is explored as to the percentage of the population afflicted, no one can escape a diagnosis. Adding to that are the various faddish syndromes which are not diagnoses at all, but merely labels describing the interaction of individuals with each other or with their environment, e.g. battered wife syndrome, empty nest syndrome, sick building syndrome, etc. This shift to an illness rather than health orientation has many sociologic underpinnings, so that in the end the new diseases are pure value judgement: biology applied under the dictates of social interest. While this trend can be seen in all of medicine, psychiatric labeling is the most dangerous. In the past this has led to discrimination, confusing health with disease and disease with badness. In modern times it is leading from disease to privilege. In the work place this translates into the special status and damage remedies of many stress related illnesses.

Not only are there more diagnoses to choose from but many of the diagnoses themselves have vague and entirely subjective criteria that are easily met if a claimant is emphasizing distress. In illnesses such as schizophrenia there are such unique and dramatic symptoms (delusions, hallucinations, or disorganization) which are not easily confused with ordinary human suffering. But in depressive disorders the range of possibilities from the least severe to the most severe types are based to a great extent on the intensity of the suffering that the individual conveys. Many of the specific criteria of the most severe type, major depressive episode, are helpful clinically to identify biological illness processes. However, many of those same criteria can be met by any person who is conveying distress (depressed mood, diminished interests, poor sleep, tiredness, and difficulty with concentration). One of the more popular diagnoses today, post-traumatic stress disorder, has evolved from the more narrow concepts of shell shock or battle fatigue in which an out of the ordinary stressor stunned the individual into an altered state of awareness and reactivity and caused an intrusive and involuntary reliving of the traumatic event. This diagnosis has now been expanded to include just about any stressful situation and the claim often rests on no more than remembering the event with distress. The actual and detailed criteria contained in the official diagnosis are frequently twisted and have practically become almost meaningless. Lately, and without scientific basis, therapists having made the diagnosis of post-traumatic stress disorder, conclude that the profile is so typical of someone who has been traumatized that the inherence of an actual trauma is made in the evaluation. Psychological evaluations must therefore scrutinize the types of symptoms and disorders claimed, bearing in mind the subjective nature of many of these stress related illnesses and the ease in which a disease label can be attached.

Frequently distress is a result of an Occupational Problem that results from job dissatisfaction, uncertainty about employment, reaction to reprimand or warning, and threatened or actual termination. While much subjective distress can be conveyed, it does not necessarily result in a legitimately diagnosable disorder. These personnel, administrative, and occupational problems often precede or are the backdrop of workers compensation, discrimination, harassment, and other industrial stress claims. Psychological evaluations need to focus on personality characteristics of the employee as obtained from complete assessment of the individual through interviews and psychological testing, as well as from reports of behavior in and outside of the work place. Many personality disorders create an unusual sensitivity through suspiciousness of others, reading hidden meaning into remarks, unforgiveness of insults, impulsivity, mood instability, inappropriate intense anger, or fluctuating intense patterns of interpersonal relationships. These employees can create chronic problems in a work environment, and when their own behavior leads to untoward consequences, may initiate an industrial stress claim. It is important to note that these personality disorders are not just passive weaknesses on which the stress of employment has a greater effect, but represent an active process that perpetuates its own difficulties.

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