Nowhere is the medicalization of our society more apparent than in the area of mental disorders. Some estimate that 20% of Americans now claim to suffer from some form of diagnosable psychiatric disorder. Dysfunction has become a growth industry, and in the 1990's young people are ten times as likely to be depressed as their parents and grandparents were at their age. The Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association (now in Volume IV) has expanded over the last thirty years and doubled the number of diagnoses available. It has been affected by changing social norms and attitudes, and political and economic trends. While it still may be a valuable tool for research and clinical use, it may not be as helpful in understanding stress claims. Its authors have recognized this limitation and specifically include a cautionary statement which in part says, the clinical and scientific considerations involved in categorization of these conditions as mental disorders may not be wholly relevant to legal judgements ...

Some of the problems with using the DSM in any litigation setting are: (1) many diagnoses are overlapping, including some mild disorders with more severe disorders; (2) the criteria for a disorder are often based on subjective complaints alone, which are easily influenced by the context in which they are presented, (3) ordinary human distress can easily find a diagnosis if needed; (4) identification of a disorder does not by itself establish specific impairment or disability. Advances in medicine in psychiatry over the last hundred years have helped to identify the biological and psychological origins of mental disorders and their specific characteristics. Modern psychiatric and psychological treatment has also been of significant benefit to countless numbers of sufferers. Where the DSM has provided a common language among professionals and guidelines for assessment of patients, it has served a valuable role. Clearly there are illnesses such as Schizophrenia and Bipolar disorder (formerly manic depressive illness) which have such unique and dramatic symptoms that are not easily confused with ordinary human suffering. But the subjective nature of many stress-related illnesses and the ease in which a disease label can be attached, offer the litigant a range of possibilities from the least severe to the most severe types of disorders which are often distinguished only by the intensity of suffering that the individual conveys.

Although hypothetically any of the diagnoses in DSM could be claimed to be caused or at least aggravated by industrial stress, the more common types are: Mood Disorders, Anxiety Disorders, Adjustment Disorders and Somatoform Disorders (physical symptoms that suggest a medical condition but are greatly affected if not caused by emotional factors). The most frequently seen symptoms are those that relate to depression or anxiety. Depression can be as simple as a state of sadness and discouragement, or as complicated as a marked disinterest in life with accompanying weight loss, insomnia, difficulty in concentration, lack of energy, suicidal ideation, and even psychotic thinking. Anxiety symptoms can range from nervousness to an intense state of fear, panic, and physiological arousal. Depending on the constellation of these symptoms and their professed intensity, they are categorized into specific diagnostic mental disorders. Some of the disorders have strong biological or physical cause and may be recurrent or chronic regardless of any environmental influence. Not only can they constitute a preexisting condition, but the symptoms of the disorder may actually lead to work performance problems and the stress complications which the disorder has then caused. In other cases, environmental or stress factors can trigger or aggravate the disorder.

When physical symptoms spring from emotional factors, there may or may not be subjective emotional symptoms. In other words, some patients claim that they are under no emotional distress even while dramatic physical symptoms without explanation have taken over their lives. Others patients, such as those with chronic pain, may have a great deal of depression or anxiety, but will invariably say it is due to the pain. Distinguishing whether the emotional reaction is secondary to the physical symptoms and only a complication, versus one in which the emotional symptoms have a primary role, is not easy and requires a very thorough psychological assessment. Many psychosocial variables have been implicated in these chronic physical conditions, and they represent a major industrial health problem. One of the best predictors for disability is pre-existing job dissatisfaction.

One of the most common anxiety disorders seen in litigation today is Post-Traumatic Stress Disorder. This is most likely due to the fact that it is one of the few diagnoses which actually implies trauma or causation within its very name. The original diagnosis evolved from more narrow concepts of shell shock or battle fatigue in which an out of the ordinary stress or stunned the individual into an altered state of awareness and reactivity, and caused 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 required by the diagnosis are frequently twisted and have practically become almost meaningless. The diagnosis of Post-Traumatic Stress Disorder has been a controversial one and remains vulnerable to severe criticism even today. There is no question that distressing symptoms following severe trauma occur, but how many people actually suffer lingering effects and what degree of impairment remains are debatable.

Frequently there is the stress that results from job dissatisfaction, uncertainty about employment, reaction to a reprimand or warning, and threatened or actual termination. This is sometimes diagnosed as Occupational Problem. While there may be a great deal of subjective distress, and vague symptoms of anxiety and depression, there may not be an otherwise properly diagnosable disorder. These personnel, administrative, and occupational problems often precede or are the backdrop of 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 out of the workplace. 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 also represent an active process that perpetuates its own difficulties.

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