With what type of "injury" is the worker's compensation system dealing when it comes to stress claims? Skeptics might respond that almost any person can be found to be mentally ill at least part of the time. Indeed, one study estimates that 15-30% of the general population at any given time is suffering from mental or emotional disfunction.10 Furthermore, one person's normal way of coping with life might be some other person's mental disability. Yet, despite the indeterminate nature of the entire question, it is clear that an extremely wide variety of personality and behavioral changes can occur following mental trauma or stress.11 These include neurotic and psychotic reactions, personality disorders, psychophysiological disorders, substance-abuse disorders and disorders of impulse control, as well as antisocial behavior.
Just what are the sources and causes of these mental "injuries?" At the most basic level, the answer is "life." Every aspect of our environment, from our family relationships to our friendships to our jobs and outside pursuits influence our mental makeup. Everything from the physical conditions of life (where we live, where we work), to the emotional aspects of our relationships, to our personal conditions (pain and physical condition, body image, financial status) to our basic behavioral choices (use of drugs and alcohol, active versus relaxed lifestyles) constitute sources for our mental being, and thus our moments of stress and disturbance. In addition, predisposing factors such as heredity, age, and gender, must be considered. To isolate any one factor in this broad spectrum of influences would be foolish, just as it would be foolish to say that any one of these factors plays no role. Everything in life plays a role in one's mental state. This of course includes work.
As far as the work environment is concerned, numerous factors ranging from the witnessing of shocking, unexpected events to the experiencing of steady stress can influence the mental wellbeing of the individual. Dr. Paul Rosch,12 president of the American Institute of Stress, and Dr. Carroll M. Brodsky,13 a much-published expert in the field, identify the following as major sources of everyday stress in the workplace:
workplace changes, such as new physical settings, increased quotas, new work shifts, new supervisors
insufficient time to get the job done to one's personal satisfaction or the satisfaction of supervisors
lack of clear job description or clear direction
lots of responsibility with little authority
the absence of proper recognition or reward for good job performance
intolerance or aggressiveness by supervisors
the inability to effectively or safely voice complaints
prejudice, discrimination and direct harassment on the basis of race, sex, ethnicity or physical characteristics
dangerous or dirty work conditions, neglect or unpunished violations of safety standards by coworkers or superiors
non-acceptance or loss of acceptance by the work group
workplace organization which stifles expression of emotions or ego
This laundry list of typical workplace stressors is experienced by every working individual to one extent or another. According to Dr. Rosch, these stresses cost American industry $150 billion annually in terms of absenteeism, reduced productivity and direct medical expenses. Interestingly, National Council of Compensation Insurance studies in 1980 and 1982 discovered that 59% of stress claimants are under 40 years of age.14
Of course the response to workplace stress will be unique to every individual. Some individuals might experience highly unpleasant events in the workplace and react with confidence and strength. Other individuals might be deeply disturbed by events that the average person would find fairly innocuous. Why some individuals continue to exhibit productive, "normal" behavior in the face of stress while others exhibit reduced ability to function remains difficult to assess and impossible to predict.
The symptoms of any "mental disorder" are expressions of each person's attempt to maintain his or her emotional balance, something known as "psychological homeostasis," a term originally coined by the physiologist Walter Cannon to refer to the many factors which act upon the individual as he or she seeks to establish a state of mental equilibrium. "Homeostatic mechanisms are the shock absorbers with which the person/organism defends against stress. In the same context, trauma is an event or agent that disrupts homeostatic mechanisms."15
The term "stress" refers to the effects and responses produced in an individual when events or conditions interfere with that individual's normal functioning, necessitating an adjustment or coping behavior. Psychologically, the individual's defense against stress consists of coping mechanisms which develop in three stages: 1) alarm reaction (in which resistance to stress is low and adaptation has not yet been achieved), 2) stage of resistance (during which optimal adaptation is attained) and finally 3) stage of exhaustion or collapse, when adaptation is lost due to depletion of energy. Stressful situations are handled primarily by ego-mechanisms, which for the most part are conscious modes of thinking and problem solving. There are many ego-mechanisms, but the primary one is repression, which is used to push stress concerns into the subconscious.
Mental stress becomes problematic when this coping mechanism produces unproductive or destructive ("maladaptive") forms of behavior. Usually, when stressors impinge on the individual, he or she attempts to relieve the resulting stress through characteristic coping behaviors he or she has devised. Ideally, these behaviors produce an adjustment so that life can continue in a smooth and productive way. However, if these coping behaviors are maladaptive (such as psychophysiological disorders, personality disorders, paranoia, or schizophrenia), it becomes a mental disorder, which in some cases may produce disability or the need for medical treatment.
One very common coping behavior in response to stress is anxiety, which arises from repression of painful conflicts in the individual's past. It may give rise to generalized apprehension, tension, and unhealthy behavioral patterns (such as overeating, excessive drinking or smoking, and other neurotic behavior). All of life's events require mental adaptation and adjustment, and most of the time this process works with little or no discernible destructive behavioral effect. However, adaptation and adjustment may take a detrimental turn, whereby, instead of responding to stress in a positive way, the individual develops behavior patterns which diminish or undermine his or her mental wellbeing.
At this point we should note that the above-described pattern of stimulus (stressors) and adaptation/adjustment constitutes one of the areas of psychological study where the "chicken-and-egg" question is of necessity often asked. What is the real source of an individual's mental complaints? Why is there a maladaptive response? Is it because of preexisting forces which predispose the individual to such response? Or is the maladaptive response something that arises by happenstance, depending on contemporary circumstances? Or is it both? These questions become very important when the issue is the legal causation for a mental problem. If the chief or only cause of the maladaptive response or maladjustment is the preexisting condition, it would seem unfair to place "blame" on stress factors such as employment, whereas if the preexisting condition provides only the setting, requiring a negative stress stimulus to activate the mental problem, attribution of "blame" on employment (if that is the stress factor) is more appropriate.
This dilemma is illustrated by a study of the predisposing causes for depressive reactions to rape.16 Most of the women victims in this study experienced depression after their assault, but as a group these women were not significantly more depressed than a non-victim control group at the 4-month follow-up. The exception was a subgroup of victims for whom depression continued even at the 12-month follow-up. The strongest determinants of adjustment over the longer period were associated with the victims' prior level of functioning. Women who had already experienced psychological problems, such as depression, anxiety, obsessive-compulsive behavior and sexual experience recovered more slowly from the rape experience. Naturally, one must then ask, what is the actual causation for the long-term depression -- the rape, or the preexisting confluence of maladaptive coping behaviors? The same question must be asked when a claimant points to workplace events as the cause for his or her mental distress.
Dr. Daniel S. Harrop17 has suggested that psychological treaters should keep this issue of causation carefully in mind. If a patient comes in for consultation or treatment and complains of a traumatic event as the cause for his or her mental/behavioral imbalance, a diagnosis of cause-and-effect focused on that traumatic event makes initial sense. However, if that same individual continues to complain of such mental/behavioral imbalance after six months, the doctor should reconsider his or her diagnosis. Six months is almost always enough time for a person to adapt and find new balance after a traumatic event. If such balance has not been found, there are almost certainly pre-trauma factors which must be explored as the true source of the patient's continuing complaints.
This analysis provides important lessons for understanding the role of employment stress in mental claims. When difficulties in the performance of work (up to and including full disability) follow a traumatic event, logic dictates that the workplace event may have been the triggering cause (at least in terms of aggravation), but if the individual remains unable to work after a longer period of time, it becomes increasingly unlikely that the workplace traumatic event is the continuing reason for such inability to work. Although the claimant probably will have by then consciously or subconsciously determined to use the workplace event as the primary explanation for all of his or her problems, it becomes more and more likely with the passage of time that the actual explanation for his or her problems rests not with the workplace event, but instead solely with preexisting factors which the employee brought with him or her into the workplace.
For many, if not most mental disorders, the causes and origins (or "etiology") are either incompletely understood or essentially unknown. All possible factors, whether they be personal-psychological, social/cultural, or biological, must be examined. There are at least fifteen major groupings of psychiatric disorders affecting adults, as well as twelve different personality disorders. Dr. Harrop has for easy understanding broken "stress injuries" into five major groupings:18
Adjustment Disorder: Time limited disorder, with variable symptoms, over not more than a six month period. A specific event causes specific symptoms (anxiety, despondency) for a specific period of time. While equally common in men and women, women tend to seek treatment more frequently.
Generalized Anxiety Disorder: Excessive worry more days than not over six months and problems with functioning.
An Acute Stress Disorder occurs after a particular event that is personal and threatening and the person developed fear, helplessness or horror. [Note: Stress Disorders, when used psychiatrically, mean reactions to things outside the range of normal human experience.] The reaction is time-related to the event, there is a numbing or detachment present, and the person reexperiences the event through dreams and thoughts.
A Posttraumatic Stress Disorder is similar to above, but the feelings go on more than one month: detachment, avoidance, persistent anxiety. (Acute: 1-3 months; Chronic: greater than three months; Delayed Onset: onset of symptoms at least six months after the event).
Major Depression: Persistent melancholic mood for at least two weeks; sleep, appetite, concentration, daily functioning all disturbed. [Note: Depression, when used psychiatrically, does not mean "unhappiness" but refers to a specific syndrome.] May become Dysthymia: Depressed mood most of the day, more days than not, over 2 years.
Often exhibiting themselves during times of stress but not caused by stress are personality disorders (enduring patterns of behavior that deviate markedly from the expectations of one's culture). These are formed by early adulthood and are stable over time, causing impairment in different ways.
Certainly the most common mental disorder found in contemporary worker's compensation cases is "post traumatic stress disorder." In order to understand this disorder, it is helpful to turn to the American Psychiatric Association, which has developed a Diagnosis and Statistical Manual of Mental Disorders (which we will hereinafter refer to as DSM-III-R, the common reference),19 to provide the field with a common language with which to diagnose and treat psychological disorders. DSM-III-R provides a description of post traumatic stress disorder which, although already quite brief, may be summarized still further for our purposes as follows:
The essential feature is the development of characteristic symptoms following a psychologically traumatic event that is generally outside the range of usual human experience. The stressor producing this syndrome would evoke distress in most people and is beyond common experiences such as simple bereavement, chronic illness, business losses, or marital conflict. Characteristic symptoms include persistent re-experiencing of the event, such as intrusive recollections, dreams, flashbacks and intense distress at exposure to events that symbolize or resemble aspects of the traumatic event; persistent avoidance of stimuli associated with the trauma, including amnesia, diminished participation in significant activities, and personal estrangement; and persistent new symptoms of arousal, including inability to sleep, outbursts of anger, difficulty concentrating, hypervigilance, and physical manifestation of distress. Impairment may either be mild or affect nearly every aspect of life.
Post traumatic stress disorder is thus "based on a combination of external events and internal psychological responses to these events. It is the particular combination of the nature of the life event and the psychological responses that form the basis of this nosological category."20 The psychiatrically recognized etiology for this disorder coincides most handily with the usual concept of causation under the law. There is a specific event and a series of reactions to that event. There have been enough studies of individuals experiencing severe unusual traumatic events (such as threats to one's physical safety or the safety of close ones, sudden destruction of one's home or community, or seeing another person killed or badly injured as the result of an accident or physical violence) so that psychiatry has a much firmer understanding of the nature and progress of this disorder than of most others. Here, the law's need for "factual" causation appears most easily satisfied.
Things become much more difficult to grasp, psychiatrically and legally, as one moves away from post traumatic stress disorder toward more diffuse diagnoses. According to Dr. George Bussey, "adjustment disorder" is a psychiatric illness that also requires external stress, although not as severe as in the case of post traumatic stress disorder. When there is an adjustment disorder, there is a maladaptive reaction to an identifiable stress, usually impairing occupational functioning or normal social functioning. Here patterns are less readily identifiable, because reactions to lesser (and often recurring) stresses are much more variable. What is devastating to one person (due to that individual's preexisting personality) may be of little consequence to someone else.
As one moves toward more generalized forms of anxiety, there is even less unanimity of medical opinion regarding etiology. "[T]he common thread is that, short of an overwhelming stressor similar to that found in [post traumatic stress disorder], or a less severe but clinically significant stressor as seen in adjustment disorder, the primary etiology of the disorder lies in the personal sphere of the patient. . . . The normal stresses associated with work, play, and family are not deemed sufficient to create a disorder except in those with a preexisting, though possibly latent, psychological impairment."21 Here the necessary ties for legal causation have become quite tenuous.
Mention must also be made of a mental illness at the opposite end of the causation spectrum: schizophrenia. Here, the primary focus is on genetic, biological, and neurophysiological deficits inherent in the afflicted individual, as opposed to external pressures, such as stress. Few theorists speak of environmental stress in relation to schizophrenia, and when they do, they focus merely on "vulnerability." Dr. Bussey summarizes: "In other words, the individual is predisposed, long before exposure to any kind of work, not to be able to tolerate the routine stresses involved in many different aspects of life. Therefore, the decompensations in schizophrenic individuals who do enter the workforce are generally due to the nature of the disease and its negative impact on the person's ability to address the stresses of routine day-to-day living."22 The cause of mental illness and disability in this instance is "internal," not the result of "external" causes. Generally, then, the concept of workplace causation (including aggravation) has no appropriate place in the arena of schizophrenia.
The concept of workplace causation does play a proper legal role in the broad spectrum of disorders ranging from post traumatic stress to anxiety. Here, judicial factfinders must explore the complex inter-relationships between preexisting personal experiences and predispositions on the one hand, and external stimuli, such as work, on the other. This must be done in order to determine whether a sufficient factual causal link exists between a person's disabling mental complaints and his or her experiences at work so that the disability can be deemed compensable under the worker's compensation law.
10Note, "When Stress Becomes Distress: Mental Disabilities Under Workers' Compensation in Massachusetts," New England Law Review, Vol. 15, 1979-80, p. 287.
11A very helpful guide through the complex maze of mental responses and conditions is provided in the multi-volume Attorney's Textbook of Medicine, published by Matthew Bender. Much of the following discussion utilizes as a reference the excellent article by James Nininger and Lanny G. Foster, "Personality and Behavioral Changes Following Trauma," Chapter 101 (1986).
12"Legal Relief From Tension - Work-induced Stress Spurs Workers' Comp Claims," by Nancy Blodgett, American Bar Association Journal, Vol. 72, October 1, 1986.
13"A Psychiatrist's Reflections on the Workers' Compensation System," Behavioral Sciences & the Law, Vol. 8, Autumn 1990, pp. 331-348.
14Cited in Blodgett, see footnote 12.
15Nininger and Foster, p. 101-5, see footnote 11. The article provides an extensive analysis of how stress interferes with homeostasis and how the human mind responds. The following brief summary discussion is based upon this analysis.
16"Victims of Rape: Repeated Assessment of Depressive Symptoms," by B. M. Atkeson, et al., J. Cons. Clin. Psychol., Vol 50, pp. 96-102 (1982), cited in Nininger and Foster at pp. 101.9-10, see footnote 11.
17Presentation to the Twenty Second International Workers' Compensation College of the International Association of Industrial Accident Boards and Commissions, April 26, 1995.
18Direct quote from published notes, "Anxiety and Stress Disorders," see footnote 17.
19Many of the leading scholarly articles dealing with stress have focused their attention on DSM-III in its 3d edition, published in 1980, or DSM-III-R, the revised edition, published in 1987. In effect, DSM-III has become the official classification scheme.
203 Treatments of Psychiatric Disorders 2066 (Task Force Report of the American Psychiatric Association 1987), cited in "Mental 'Stress' Claims and Workers' Compensation: The Problems and Suggestions for Change", by George D. Bussey, Federation of Insurance & Corporate Counsel Quarterly, Vol. 43, Winter 1993, pp. 99-145. Dr. Bussey provides an excellent summary of the issues of causality as a medical-psychiatric response. The following discussion relies in particular on Dr. Bussey's analysis of current concepts in the etiology of psychiatric disorders.
21Bussey, pp. 126-127, see footnote 20.
22Bussey, p. 128, see footnote 20.