by James O'Brien, M.D.
One of the most common conditions seen in Workers' Compensation stress claims is Post-Traumatic Stress Disorder. Post-Traumatic Stress Disorder (PTSD) is a psychological condition which occurs after an individual experiences an event outside the realm of normal human experience. According to DSM4, the official descriptive manual of mental disorders, such experiences may include serious threat to one's life or physical integrity; serious threat or harm to one's children, spouse, or other close relatives and friends; sudden destruction of one's home or community; seeing another person who has recently been or is being seriously injured or killed as the result of an accident or physical violence. The symptoms following exposure to a catastrophic event may include rumination, exaggerated startle response, difficulty in concentrating, memory impairment, guilt feelings, and sleep difficulties.
In Workers' Compensation, the most common PTSD claims involve victims of robbery, assault, and rape. Individual responses to the same traumatic event may vary, depending upon such factors as susceptibility based upon personality strength and past history of mental illness. Military psychiatry provided the basis for today's understanding of PTSD. In World War I, the term used to describe PTSD was "shell shock." There was considerable debate then whether or not the resultant symptoms were the result of physical factors, such as carbon monoxide gas exposure, or psychological factors, dubbed "hysteria" at the time. After World War II, psychiatrists conducted more detailed studies of combat veterans in Europe suffering from what was then called "combat fatigue." The first study of PTSD in civilian life was undertaken in the forties by Alexandria Adler, who examined the victims of the Cocoanut Grove fire disaster (a devastating incident in a crowded nightclub that resulted in many deaths). This report highlighted the fact that symptoms of depression and anxiety associated with traumatic exposure may be more permanent and persistent than originally thought. Studies of concentration camp survivors followed, and described the "psychic numbing" phenomenon (a disinterest and apathy toward events in the immediate environment), and pessimism. Because of the malnutrition to which this group was exposed, the condition was considered to have both physical and psychological underlying causes.
Today's diagnostic description of Post-Traumatic Stress Disorder is largely based upon experience and studies of Vietnam veterans. In 1979, the federal government established Operation Outreach to help Vietnam veterans handle readjustment and psychiatric problems. This also allowed clinicians the opportunity to develop models by which to distinguish genuine from malingered PTSD. In contrast to the stereotype of the crazed Ramboesque Vietvet, an individual with true PTSD was likely to feel intense guilt and downplay his experience, while the malingerer often dramatizes his combat record and blames others for his problems. The true PTSD victim is often a stoic often in denial who is quietly suffering. In true PTSD, the victim often downplays symptoms while the malingerer overplays and draws attention to them.
In the Workers' Compensation arena, there are many pitfalls to the proper assessment of PTSD. The principal problem is overdiagnosis. A common experience such as a conflict with a supervisor, business losses, or chronic illness cannot be the basis of a PTSD diagnosis, according to DSM-IV. Clinicians, especially overly zealous applicant appointed psychiatrists, are frequently overinclusive in the utilization of this term. I have actually read reports by psychiatrists that claim PTSD on the basis of witnessing a verbal argument between two coworkers. The proper DSM- IV term for most instances of an emotional reaction to an unpleasant change at work would be an "occupational problem" (which is not a mental disorder), or an "Adjustment Disorder," a condition that is time limited.
A less frequent problem but a management nightmare for the clinician occurs when the claimant was the victim of a severe trauma in the distant past, but adjusted well without any evidence of impairment or disability. He then raises the issue of the past trauma as the focus of a claim that is really being filed as a grievance over a more recent personnel action or an extraoccupational stress. These cases require an astute evaluator to distinguish "hot" vs. "stale" issues in the workplace.
The principal symptom in PTSD that leads to disability is phobic avoidance, which means being afraid of returning to the site of the trauma. Many PTSD victims of a robbery or an assault at night have difficulty working or going out at night (if the victim is able to go out at night, but unable to work at night, this should raise suspicion of exaggeration). Another common problem in genuine PTSD is that the victim may be loathe to return to a work site in a high crime area, a reaction that is understandable. In my experience, four conditions are necessary for the successful resolution of a Workers' Compensation claim for PTSD. These include (1) a motivated patient, (2) a motivated or at least facilitative employer who can accommodate reasonable recommended work restrictions (such as day duty only), (3) the relative absence of complicating preexistent psychological factors, such as drug abuse, alcoholism, job dissatisfaction or severe personality disorder, and (4) a therapist who will encourage the patient to reacclimate to the workplace and not allow the patient's condition to worsen by endlessly extending disability.
Richard Rodgers Ph.D.** has offered a clinical model for determining when clinicians should thoroughly investigate the possibility that an individual is malingering psychological symptoms after a traumatic incident. These include a poor work history; prior history of disabling injuries; discrepant capacity for work and recreation; unvarying, repetitive dreams (most actual dreams are symbolic, like being chased by a monster, not "being assaulted over and over"); antisocial personality traits; overidealized functioning before the trauma; evasiveness; and inconsistency in symptom presentation.
Most recent studies on Post-Traumatic Stress Disorder treatment focus upon early diagnosis and immediate and aggressive therapy. Critical incident debriefing for all victims is an important early intervention. Antidepressants may help in some individual cases, but in most instances, behavioral desensitization therapy on a short term basis while the applicant continues to work, at least on a restricted basis, seems most effective. A new treatment using behavioral technique and rapid eye-movement exercises called EMDR is widely researched and is showing promise.
Therapy provided six months after the event, especially in a medical- legal setting, is most often useless and counterproductive. It is important for the therapist to define specific goals and time limits for treatment to prevent secondary gain issues as well as assumption of a victim role that would derail any constructive attempts at rehabilitation. If a patient is not significantly improved within six months, it is usually appropriate to issue a permanent and stationary report with an outline of the resultant permanent disability and apportionment. The report should also include any information on missed appointments, noncompliance, or other evidence that the individual may be resisting rehabilitation attempts in a passive aggressive manner. The therapist should be sensitive to transference issues (feelings toward the therapist) created by the trauma itself. In the case of a rape of a female victim by a male assailant, it may be better in some cases to refer the patient to a female therapist if the victim is overwhelmed by fear of men.
Even under the best of conditions, treatment is often difficult. Being a Workers' Compensation claimant often creates its own stress. If a patient is the victim of multiple crimes in a site with lax security and the employer does not aggressively address employee safety problems, the resentment and feelings of abandonment by the employee can lead to irreconcilable hatred and dissolution of the employee-employer relationship. Nonindustrial issues inevitably arise during therapy and must be addressed as part of the industrial treatment.
Unfortunately, I expect to see more incidents of PTSD, given rising crime rates and the ineffectiveness of the judicial system in isolating dangerous felons. Los Angeles is the "bank robbery capital of the world." Employers are often reluctant to use aggressive measures to combat crime, given the potential for contributory negligence lawsuits in the event of a "shootout." Although PTSD is not a medical disease per se, the psychological effects of a traumatic incident may have a profound effect on the injured workers ability to adapt and continue at his position without impairment. Aggressive early intervention by a therapist experienced in medical-legal treatment is essential to assess the situation accurately and prevent chronic invalidism.
*Diagnostic and Statistical Manual of Mental Disorders-Revised, American Psychiatric Assn., 1995.
**Clinical Assessment of Malingering and Deception, Richard Rodgers Ph. D. Guilford Press 72 Spring Street, New York, NY 10012.