A worker is injured, anxious, and depressed. Is his or her emotional condition caused by the injury? Is the psychological condition – separate from any physical injury – causing any impairment? Is treatment needed and, if so, what kind? Can the worker return to full duty in the same environment the injury occurred? If not, why not?
These questions, and many others, are often faced by attorneys and insurance personnel in workplace injury cases involving claims of emotional distress. Such claims often prove both challenging and controversial, as the interplay of pre-existing conditions, injury, somatization, motivation, and intercurrent stressors can be difficult to unravel. In some areas of medicine, diagnostic tests can point convincingly to causation, such as in the case of a crush injury, fracture, or disc herniation. In contrast, psychiatry lacks even a definitive diagnostic test, much less one that provides objective indicators of etiology. The mental health examiner must weigh a host of potential contributing factors in arriving at opinion about causation. Then, it is on to impairment, where the line between capacity and motivation is blurred even more than in cases of physical injury. (WCxKit)
A full discussion on the nature and causes of psychiatric conditions in workers compensation far exceeds the current forum, as would a detailed description of the appropriate methods for evaluating and diagnosing these conditions.
The following 10 “red flags” are common problems seen in evaluations, not only from treating providers but from “expert” examiners as well, and are suggested as a quick reference guide:
- Insufficient time spentwith claimant: How long does it take to sort out the many factors needed to determine causation, impairment, and treatment needs? Anything under 1.5 to 2.0 hours is likely inadequate. After all, forensic experts in high profile criminal cases spend dozens, if not hundreds, of hours getting to know and understand the defendant. The stakes in WC cases, though different, are also high. The information needed to render a well-informed opinion cannot be obtained in 15 or 20 minutes.
- Insufficient record review:Have both medical and mental health records been reviewed? So often we see records from medical providers noting some symptoms of depression or anxiety, and causally (and often casually!) attributing the symptoms to the workplace injury or event. Mental health records also frequently include diagnoses and causal imputation. A good evaluation report must not only note these records but must evaluate their basis and value. Also, request for and review of records preceding the injury is critical.
- Failure to identify pre-injury, peri-injury, and post-injury stressors: It is critical that all other possible contributing stressors be detailed and accounted for. In Connecticut, where I practice, a psychiatric condition is only compensable under WC if it arises out of a physical injury. For example, if a worker loses a limb in a construction accident and develops depression secondary to the disabling injury, that clearly falls under the purview of the law. But often we see claims for emotional distress arising more out of the stressful workplace environment than in response to the actual injury. Not infrequently, a minor physical injury is incidental, and it is the stressful workplace event or context that is truly the substantial causal element. Other life stressors, including financial and social consequences of the workplace injury, must also be accounted for. Finally, prior life stressors or traumas (e.g., a prior history of abuse or injury) must be assessed, as these often represent a predisposing vulnerability factor and can be associated with both pre-existing symptoms and/or impairments.
- Lack of malingering assessment:There are several widely used and standardized assessment instruments for assessing symptoms exaggeration or malingering (they will not be listed here to protect the integrity of the tests). A thorough assessment of malingering integrates results of these measures with observation, consistency of records, assessment of motivational factors, and collateral information to make a determination about the validity of the claimant’s self-report. Any evaluation in a WC case that does not address this issue thoroughly should be cause for concern.
- Psychological testing:Has psychological testing been conducted? Is the rationale for the tests used provided? It is difficult to determine the appropriate use and interpretation of test results without direct consultation with a psychologist. For starters, however, it is important to note that results of many objective tests are only valid when viewed in aggregate: Individual responses to individual test questions are not valid for interpretation, and should never be reported as such.
- No family history:What is the claimant’s genetic and environmental vulnerability? Providers and examiners frequently omit such history in WC cases in an effort to protect the individual’s privacy. However, defensible assessment of causation cannot be done without knowledge of the family history.
- Mental status exam:This section appears in most psychiatric reports, with the intent of describing what is observed about the claimant on examination. What is his or her apparent emotional state? Is he forthcoming with information, or guarded and defensive? Importantly, do the observed emotional state and the reported symptoms and function match?
- Where is the beef?A description of symptoms supporting the diagnosis is critical, and these symptoms should accord with the criteria set forth in the DSM-IV-TR. Reports should also include a detailed description of day-to-day function. Can the claimant socialize, travel, engage in hobbies, or do housework?
- Differential diagnosis.Is it really post-traumatic stress disorder (PTSD)? The diagnosis of PTSD is the sin qua non of psychic injury arising out of workplace events. Why? Because it is the only psychiatric diagnosis that denotes causation. However, many workplace injuries and their circumstances do not truly meet what is referred to as Criterion A: that is, a stressor must involve not only “threat to the physical integrity of self or others,” but the individual’s emotional reaction at the time must include “intense fear, helplessness, or horror.” Caution is urged in accepting diagnoses of PTSD caused by routine events or injuries.
- Misguided Permanent Partial Disability (PPD) ratings: Mental health examiners rarely use the AMA Guides to the Evaluation of Permanent Impairment, instead relying on the traditional multiaxial diagnostic system per DSM. The only Axis that reflects impairment is Axis V, the Global Assessment of Functioning or GAF. However, the GAF scale reflects symptom severity and/or impairment, and in the case of desynchrony between the two the lower score is to be used. Thus, an individual who is functioning well despite severe symptoms may warrant a low GAF score that is not reflective of actual impairment in either social or occupational function. If asked specifically to use the Guides, mental health examiners must be aware that the Guides 6th edition has a new system that uses the median of three distinct measures to calculate a PPD rating. The process is not subjective yet is rarely used. In a recent WC evaluation, I reviewed a claimant’s file in which the treating provider had given a 40 percent PPD rating for mental health. In contrast, my evaluation following the AMA Guides formula yielded a 10 percent rating, of which I concluded about half was related to the workplace incident. Bottom line: impairment ratings are usually subjective and often unreliable. Beware of any GAF rating under 40, unless the person is gravely disabled and on the verge of hospitalization, this is likely to be an inflated rating of severity.(WCxKit)
These “red flags” provide a thumbnail checklist, but fall well short of the knowledge required to fully understand and evaluate reports and opinions in this field. Attorneys and insurance adjusters would benefit from additional education on the nature of mental illness and the challenges inherent in determining causation and impairment in these cases.
Author: Dr. Andrew Meisler is a clinical and forensic psychologist in practice in Hartford, CT, with faculty appointments at the UConn School of Medicine and the Yale University School of Medicine. He serves as independent examiner for attorneys and insurers, provides consultation to the office of the Attorney General in workers compensation claims, and has extensive deposition and trial experience in state and federal court as well as at the CHRO and Workers Compensation Commission. Contact at: firstname.lastname@example.org or phone (860) 236-8087, #108.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
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