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News Gram™ May 2005

May 2005 ~ Volume 11, No. 10

Under the new law, the compensation schedule for stress claims is the highest of any category of disability in the system. All indications are that there will be many more such claims as the new provisions of the law apply to post-1-1-05 cases. As a result, it’s important to know something about psychiatric injuries that bear on the issue of figuring out how disabled a person really is.

The first feature of psychiatric diagnoses and their role in workers’ compensation claims is that these conditions are not supported by objective findings like blood tests, x-rays and EKGs. There are other sources of objective information other than these sorts of medical tests, however. For instance, the mental status examination (MSE) is an important element of the diagnostic process. When it is done properly, it goes a long way toward establishing a firm foundation for a psychiatric diagnosis. For instance, a patient who is depressed would likely reveal changes in her speech, facial expression, bodily movements, thinking and emotional responses. So characteristic are these alterations in behavior that one hardly needs a psychiatrist to identify the condition as one or another form of depression. Notice that they do not depend on the patient’s complaints or reports. Instead, they are observable components of the patient’s clinical presentation.

Secondly, while psychological tests can be treacherous instruments to employ in a psychiatric evaluation, they can contribute important information about the patient that would otherwise be difficult to obtain. The best tests to use in a comp setting are objective ones. In such a test, the answers are restricted to True, False, Other, and so on. They are not narrative in form. Thus, projective tests, like the inkblot (Rorschach) are usually not helpful in this setting. They are scored in different ways and the variety of scoring techniques introduces a degree of variability that is not helpful in a legal setting.

Thirdly, the issue of secondary gain is critical in workers’ compensation cases. Secondary gain is the reward one gets for being sick. Recall when you were a child and had a stomachache. You might have been put to bed, given your dinner and allowed to watch television without worrying about homework. It might be so nice to enjoy these benefits that you might have found yourself exaggerating the extent and intensity of the pain. The workers’ compensation setting provides a similar temptation, especially because the patient is inclined to exaggerate in order to obtain a financial gain. The feature of secondary gain suggests that patients might distort the findings on certain tests in anticipation of increasing the amount of their settlement. Therefore, it’s a good idea to use tests in which the physician must fill out the form rather than the patient. Even if the physician is biased in one or the other direction, he or she is still constrained by his professional obligation to tell the truth and provide frank information regarding the patient he is evaluating. We can reasonably assert that doctors tell the truth more often than patients in a medical-legal setting, which means that using tests in which the doctor fills out the form is more reliable than ones in which the patient does so.

Given these considerations, let’s consider what is needed in order for the physician to justify the presence in the patient of a compensable psychiatric condition. Most important in this context is an understanding of the difference between psychiatric and medical diagnoses and conditions. In medicine, a person may have a finding — let’s say, facial spots — usually called a sign. This sign may or may not point to an underlying medical problem. At best, a sign suggests the presence of a problem. Spots may indicate measles, primary dermatitis, infection or numerous other medical conditions. In order to establish the presence of a disease, it is necessary to identify other findings that also point to the disease. Some blood tests may be very helpful when it comes to a skin condition as can a biopsy of the skin lesion. In this way, through the identification of other signs and through the use of laboratory tests, a physician can determine just what pathological condition exists in his patient.

In psychiatry, things are very different. There are no laboratory tests to help confirm a diagnosis. There is nothing like an EKG to assist in narrowing the scope of possibilities. There is nothing to biopsy either. The reason is that, for psychiatrists, the behavior itself is the pathological entity. If someone stands in the middle of a crowded street and screams at the top of his lungs that he is Napoleon reincarnated, we might say he is suffering from a delusion — and psychiatrists regard a delusion as pathological. In medicine, a sign like spots is not necessarily pathological. It is just a pointer. The reason is that a medical diagnosis is based not on the sign but on the underlying diseased tissue. The difference between the two forms of diagnosis is critical to seeing what the problem with stress claims is in psychiatry.

The various objective measures in psychiatry are aimed at visible behavior. The analogous tests in medicine are aimed at identifying the pathological organ causing the sign pointing in its direction. Thus, medicine is grounded in deformations of anatomical structure that create disease states. The death of heart tissue — a myocardial infarction — is determined by looking at the heart or measuring the function of the heart as in an EKG. No such parallel exists in psychiatry. There is no anatomical alteration that the doctor has to identify.

In effect, we might say that the idea of psychiatric injury within the workers’ compensation system is, in reality, just a complicated way of describing pain and suffering. Fair enough. The medical representation of such troubling conditions may help in categorizing the problem the patient describes, but it is much harder to make sense of because it doesn’t really correspond to the medical concept of a disease. As a result, the evaluation of psychiatric disability is similarly different. Understanding the differences mentioned above is the key to navigating through the seeming muddle of psychiatric evaluations.

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