Psychiatric Annals

The Psychology of Disability

Edwin J Mikkelson, MD

Abstract

1. Mayo Clinic Department of Neurology. Clinical Examinations in Neurology, Third Edition. Philadelphia: W. B. Saunders Company. 1 971 .

2. Tarter, R. Templer, D., and Hardy, C. Reliability of the psychiatric diagnosis. Dis. Nerv. Syst. 36 (1975), 30-31.

3. Strauss, J. Diagnostic models and the nature of psychiatric disorder. Arch. Gen. Psychiatry 29 (1973), 445-449.

4. Etkin, W. (ed.). Social Behavior and Organization Among Vertebrates. Chicago: University of Chicago Press. 1964.

5. Kellett, J. Evolutionary theory for the dichotomy of the functional psychoses. Lancet 2 (1973) 860-863.

6. Tienari, P. Estimation of working ability in psychiatric diseases. Duodecim 91 (1975), 979-986

7. Serebriakova, Zh. Study of 1 .41 3 schizophrenic subjects according to indices of qualification and invalidity. Zh. Nevropatol. Psikhiatr. 75 (1975), 1396-1399.

8. Minakov. V F. Clinical and socioeconomic effectivity in schizophrenic subjects. Zh. Nevropatol. Psikhiatr. 75 (1975), 117-122.

9. Ivanys, E. The development of the rate of mental diseases connected with the incapability to work in Czech and Slovak Socialist Republic during the past 20 years (1953-1972). Bratisl. Lek. Listy 64 (1975), 41-51.

10. Igarnick. Z. Psychological basis of working recommendations to mental patients. Zh. Nevropatol. Psikhiatr. 74 (1974). 1859-1863.

11. Nussbaurn, K. Schneidmuhl, A., and Shaffer. J. Psychiatric assessment in the Social Security program of disability insurance. Am. J. Psychiatry 126 (1969), 897-899.

12. Nussbaurn, K. Psychiatric disability determination under Social Security in the United States. Psychiatr. Q. 48 (1974), 65-73.

13. Nussbaurn. K.. Shaffer. J. W., and Schneidmuhl, A. M. Psychological assessment in the Social Security program of disability insurance. Am. Psychol. 24 (1969). 869-872.

14. Overall. J. E.. Hollister. K., and Hollister, L. E. Computer procedures for psychiatric classification. J. A.M. A. 187 (1964), 583-588.

15. O'Connor. N., and Tizard. J. Predicting the occupational adequacy of certified mental defectives. Occup. Psychol. 25 (1 951 ). 205211.

16. Kushlick,A..BI unden, R. , and Cox, G . A method of rating behavior characteristics for use in large scale surveys of mental handicap. Psychol. Med. 3 (1973), 466-478.

17. Shaffer, J., Nussbaurn, K, and Lewis, S. Psychiatric assessment from documentary evidence. Compr. Psychiatry 12 (1971), 564-571.

18. Nussbaurn , K " Schneidmuh I, A. , and Shaffer , J . Psychiatric disability rating in transition. Compr. Psychiatry 10 (1969), 327-333

19. Griffiths. R., Hudgson, R . , and Hallam, R . Structured interview for the assessment of work-related attitudes in psychiatric patients: Preliminary findings. Psychol. Med. 4 (1974), 326-333.

20. Hewitt, M., and Lond, M. The unemployed disabled man. Lancet 2 (1949), 523-526.

21 . Kinsman. R.. et al. Patient variables supporting chronic illness. J. Nerv. Ment. Dis. 163 (1976), 159-165.

22. Paley, A. , and Paley E. A study to determine factors which have predictive and therapeutic relevance to the rehabilitation of patients after cardiac surgery. Report of Research Grant Project No. R.D.2168-M-66-67-68. National Jewish Hospital and Research Center, Denver, 1969.

23. Nussbaum.K. Correlation of some psychiatric problems encountered at induction centers and in army hospitals. Psychiatr. Q. 18 (1 944), 225-232.

24. Wilder, J. The case for a flexible long-term sheltered workshop for psychiatric patients. Hosp. Community Psychiatry 27 (1 976). 112-11 6.

25. Early. D. Sheltered groups in open industry. Lancet 2 (1975), 1370-1373.

26. Wing, J. Industrial therapy in psychiatry. Proc. R. Soc. Med. 63 (1970). 1329-1332.

27. Cole, N. J. Psychiatrists, employers, and information exchange. Arch. Gen. Psychiatry 25 (1971), 381-384.

28. Griffiths. R. Rehabilitation of chronic psychotic patients. Psychol. Med. 4 (1974), 316-325.

29. Berry, J.. and Shapiro, A. The psychiatric patient in the community. Proc R. Soc. Med. 68 (1975). 795-798.

30. Taylor, F. The general aptitude test battery…

They can define variables, state hypotheses, design experiments, manipulate data statistically, get publishable results -and miss the whole point of the thing.

Neville Sanford in The American Psychologist, 2965

But, oh, I backward cast me e'e on prospects drear;

An' forward tho' I canna see, I guess and fear.

Robert Burns

INTRODUCTION

The concept of disability has troubled psychiatrists and social agencies for some time. Recently attempts have been made to develop an objective measure to evaluate the individual's claim for psychiatric disability benefits. The purpose of this pilot study is to explore the dynamics of disability and determine what leads people to seek disability. The effect of receiving disability on the patient's adjustment to life and his attitude toward future work is also investigated. A review of the literature reveals that this aspect of disability has been largely ignored.

METHODS

The patients described represent 50 consecufive referrals for psychiatric disability evaluation from a semirural area encompassing three small communities, about seven miles from each other and located approximately 45 miles from a large urban center. The economy of the area is based primarily on agriculture and light industry; no single large company economically dominates the area. Most of the population are middle-class whites about equally divided between Catholics and Protestants.

One author (E .J .M.) saw each of the patients once (often without the benefit of any outside records), for an average time of 45 minutes to two hours; the number of patients seen on any given day ranged from two to 12, with an average of five to six per day. The areas covered in the interview included history of the present illness, past psychiatric and work history, daily activities, family history, and thorough mental status examination based on the Mayo Clinic model.1 Early childhood developmental history was not explored unless specifically indicated - e.g., by psychiatric treatment beginning during childhood.

Patients were told that all information went into the report and might actually be used against their claim by the board that made the determinations. This statement usually brought about the same seemingly paradoxical response seen in court-referred cases; i.e., instead of becoming guarded and secretive, patients respond to the examiner's frankness and honesty by becoming more open and revealing.

The author did not participate in the determination of whether or not the patient would receive disability. This had two consequences: (1) the reports could be objective, since there was no need to justify a decision one way or the other; (2) the author remained in a "blind rater" position as to exactly what criteria were utilized by the board in making its decision.

RESULTS

There are obvious problems in attempting to make a psychiatric diagnosis based on brief interview data and relatively scant medical records; nevertheless, we shall attempt to group the patients diagnostically in a systematic manner. We shall also describe a typical patient from each group in detail to add clarity to the picture of the type of patient under consideration; disagreement over psychiatric diagnoses mandates such an approach to minimize misunderstanding.2,3

Neurotic Depression (N = 13)

This group, comprising almost 25 per cent of the total population, was close in size to the schizophrenic group - an unexpected result. Subsumed under this heading are reactive depressions; more chronic types of depressions, called by some "chronic characterological depressions"; and prolonged grief reactions of nonpsychotic intensity.

Of this group, eight had completed high school and five had advanced training.

Three patients had depression secondary to physical illness. Though all three had good work histories before the onset of illness, none had been able to cope with the added physical stress. The organic impairment in each, however, was not great enough alone to cause the degree of impairment described; in one case, moreover, it was not clear whether the primary problem was medical or psychiatric.

All prolonged grief reactions in the group occurred in women, all of whom had formed passive relationships with protective, sheltering men; when these men died, the patients were unable to care for themselves.

It is interesting to note that another three patients had depressive reactions secondary to an incapacitating physical illness in the husbands; although it was financially necessary for these women to return to work, none could do so because of depressive symptoms. Another woman had an analogous reaction to her divorce.

Comment. Most in this group were women (12 out of 13) who had had reasonable premarital work histories but had married men who somehow fostered their passivity. None were able to cope with the loss of the husband's care-giving capacity through death, divorce, or illness. The single unmarried patient had cared for her mother for 10 years before the mother's death.

All felt inadequate (many using that very word) to return to work; all showed mild depression on mental status examination but not severe impairment. Many were hesitant to attempt calculations but were able to do them when encouraged and when asked easy questions at first. Four patients were receiving no psychiatric treatment; two were receiving amitriptyline; one, Imipramine; one, Triavil®; four, minor tranquilizers; and one, thioridazine. Only one was receiving psychotherapy, the treatment of choice for this condition.

Case. This group is exemplified by "Jane," presented in detail here.

Jane is a 62-year-old widow living alone. Though she owns a car, she is driven to the interview by a friend because she fears driving. Her husband had died approximately one year before the interview. She had earlier applied for medical disability, but the claim was disallowed; she was referred for psychiatric evaluation.

Her husband, her first and only love, had done all the housework (in addition to his regular job); in fact, his fatal heart attack struck while he was ironing. Eleven years earlier, need for more income had driven her to work on an assembly line. This provoked severe anxiety and nightmares about "being tied to the job, unable to leave." Eventually she quit, and her husband worked overtime to allow her to stay home, "puttering around the house." She visits his grave twice weekly and is experiencing a gradually resolving grief reaction.

She maintains that she cannot work because her "equilibrium" is awry; she would be nervous if she had to work, saying: "I'd rather get along with bread and water than go to work." She resists psychotherapy and medication. On examination she is sad; though reluctant to attempt calculations, she can do them adequately with reassurance. No evidence appears of psychosis or suicidal ideation.

Schizophrenia (N = 11)

This group constituted slightly greater than 20 per cent of the patients applying for disability. Five had completed high school, and two had training beyond that level. Seven were receiving phenothiazine medication, one in depot form; one patient adamantly refused to take medication. Ages ranged from 19 to 58. Only one male patient was currently married; two women had been married but had been divorced by their husbands after the onset of their illness; both of these women were living alone. Three patients were already receiving VA benefits, two rather substantial sums. All had successfully held jobs before their illness, the duration of employment varying from one to five years. However, none had been able to hold a job for a sustained period since their first psychotic break. All those who had attempted to work reported that it made their symptoms worse and led to their either quitting the job or suffering another decompensation. Three male patients had been assaultive to employers and supervisors. Two of the patients who were receiving large VA pensions said they did not need extra money but friends had encouraged them to apply. None of the patients had any plans to return to work in the future, usually because of fear that it would make their symptoms worse. Only three of the group showed marked pathology on mental status examination - i.e., loose associations, delusions, cognitive impairment, hallucination. The others all showed subtle impairment - i.e., bland affect, concrete proverb interpretations.

Case. "Bill" is a 28-year-old single man, shabbily dressed, who regards himself as an eccentric intellectual. After repeating a grade for the second time, he fled school. He actively and passively resisted mother's attempts to get him to work. Finally he joined the military under family pressure and shortly thereafter became psychotic; he was discharged after assaulting an officer. During six years of almost continuous VA hospitalization, he was referred to several work rehabilitation programs; all these referrals occasioned a psychotic episode or outburst of violence. Finally he was discharged on pension. He applies now for disability because he feels he needs more money to live on, but he cannot find work that he regards as intellectually stimulating. Though granthose and paranoid on examination, he was not floridly psychotic; his affect was bland, and he was able to do calculations without difficulty.

Recurrent Psychotic Depression (N = 4)

This group (about 10 per cent of the population) were in their early 50s, except for one aged 61; all were female, two were divorced, one was single, one was widowed. All had been hospitalized in the past for psychotic depression. Two had education beyond high school. Though showing no gross disturbance on mental status examination, all seemed somewhat depressed and had some difficulty with calculations. Only one had a good work history: an R.N. who quit work when married. One had been able to work in her husband's business because she could "work when she wanted to." Two received antidepressants; two, low-dose phenothiazines.

(One male patient in addition to the above had by history clear late-onset manicdepressive illness, with previous good work history; he was applying for disability benefits because of expiration of unemployment. He had difficulty with calculations and bland affect.)

Comment. This group of women were older, sicker, and poorer in work history than the neurotic depressive group and had experienced hospitalization.

Case. "Rose," a 52-year-old single woman, was the daughter of a well-to-do lawyer. She had attended private schools and an exclusive junior college. She had worked only in college, as a part-time waitress; she had never had a fulltime job. She helped her mother around the house and later nursed both parents until thendeaths. She "always had" a depressive outlook on life, but her first severe depression occurred at age 30, responding to six months of hospitalization and a course of electroconvulsive treatment. Four years ago, when she felt suicidal, she was successfully treated with three months of hospitalization and antidepressants. Recently her sister's business has done poorly, and she has told the patient she will no longer be able to supply the customary $25 weekly allowance. The patient feels she cannot go to work. Though mildly depressed, she shows no cognitive impairment. With the family money gone, she feels forced towards starting a small shop, but she fails to do so out of a mixture of disdain for work and a feeling of inadequacy.

Alcoholism (N = 5)

Ten per cent of the population studied had alcoholism as the major diagnosis. All but one were males. Three were divorced, one was a widow, and one was married. All but one had been hospitalized several times, either for detoxification or for psychosis associated with excessive drinking. Only one was a high-school graduate. Three of these patients had marked disturbance on mental status examination, one because he was inebriated at the time of the evaluation. The other two had a great deal of difficulty with simple calculations and showed manifest signs of anxiety and depression. Only one had a good working history. Two had criminal records, and one had received a dishonorable discharge from the military. All but one were receiving psychiatric treatment, one of these in a detoxification unit. Two were receiving minor tranquilizers and one a tricyclicphenothiazine combination.

Case "John," 42 years old, is now drying out in a state hospital. He had begun heavy drinking in the military but had been able to hold a fulltime job until six years ago; he then had a succession of brief jobs and several hospitalizations for detoxification. Previous attempts to go from hospital to work had failed as being "too stressful." He hoped to use disability income to stay in a halfway house to ease the transition back to work. He was cognitively intact to examination and without affective disturbance.

Borderline Personality Organization (N = 6)

Of this group, four were women; only one, male, was married. Three had high -school educations; one, a B. A. All had worked for periods ranging from two to six years. Two had histories of hospitalization; all complained of chronic pananxiety except one, who complained of chronic depression; all had histories of severely defective object relations. All had at least minor abnormalities on mental status examination; two had loose associations and one, concrete proverb interpretations. AU but two were receiving psychiatric treatment; two were receiving minor tranquilizers.

Case. "Helen" is a 55-year-old divorcée on general relief. After leaving school (10th grade) she would work for a few years, then quit, as a repeating pattern. After marriage she stopped working; after divorce she lived on ADC benefits until these expired; then she returned to work on an assembly line, staying on the job despite chronic high anxiety. On the way home one day, she was assaulted and her shoulder was broken. Thereafter, despite healing of the fracture, she remained seclusive and too anxious to apply for work. Despite a feeling of "distance" and some difficulty with calculations, she showed no formal thought disorder of psychosis on examination. She currently receives supportive psychotherapy and minor tranquilizers.

Mental Retardation (N = 4)

These patients were younger than the other groups. None had a high-school education. Two were divorced, and two had never married. Two young males still lived with their families. All had obvious difficulty with calculation and general knowledge aspects of the mental status examination. Two had IQ deficiency confirmed by formal psychologic testing. Two had suffered from major psychiatric illness, one from recurrent psychotic depressions and the other from a nonspecific psychotic episode one year ago; both were receiving psychotropic medication. One patient had nonpsychotic psychiatric difficulties significantly impairing his adjustment. The fourth patient seemed generally motivated to work and well adjusted to his limitations.

Case. "Tommy," age 18, lived with his mother, her boyfriend and three sibs. His abusive, alcoholic father was in jail at the time of the interview. His three happy years of slow but steady academic progress with a caring foster family were interrupted when his mother regained custody of him and moved him to another city. Since then (one year ago) he has suffered anxiety attacks in school and has attempted to run off to rejoin the foster family. Though apparently desiring work, he becomes extremely anxious when placed in a rehabilitation setting; this prevents his entering a sheltered workshop or low-level factory job for which his intellectual level would theoretically suit him.

Antisocial Personality (N = 3)

Three patients seemed to fit best into the diagnostic category of antisocial personality disorder. All were males, and two were in their 20s. The older man had a history consistent with antisocial personality when younger but now appeared to be "burned out" and somewhat depressed. He had been incapacitated and hospitalized on several occasions. He had also committed thefts but had been protected from prosecution by his influential father. Two of this group had a high-school education. The pattern of one patient was to work only long enough to draw unemployment benefits and then get himself fired. He was applying for disability because his benefits were about to run out. Two patients had been hospitalized in the past; one was currently in outpatient treatment, receiving lithium for unclear reasons. One patient who used amphetamines would convince physicians that he was an adult version of the hyperactive child in order to obtain prescriptions.

No one case sufficiently typifies this group to warrant detailed presentation.

Anxiety Neurosis (N - 2)

Both of the patients with this diagnosis were men, aged 49 and 62. Both had concomitant physical disease. One was married and one a widower. One had an engineering degree; the other had quit school during his junior year of high school. Both had good work histories and blamed their primary disability on their physical illness. Neither had any abnormality on mental status examination other than anxiety. One was receiving no psychiatric treatment, and the other was receiving individual psychotherapy and Valium.® Both viewed themselves as being unable to work because of their medical problems.

Hysterical Personality Disorder and "No Psychiatric Diagnosis"

There was only one patient in each of these groups.

An unclassified case lying outside the present study is presented for its interest and complexity.

"Jan," a 24-year-old transsexual not yet surgically reassigned, gave the classic childhood history of gender dysphoria and adolescent cross-dressing. Dressed as a female, he attempted work once but was fired when it was discovered he was male. Like many previous stresses back into childhood, this event occasioned a massive overdose. After this, he first applied for disability benefits. Adjudication of the claim was somewhat delayed; he took a near-fatal overdose, after which the claim was hastily decided in his favor. After that, he lived a leisurely, workless life.

On reporting for re-evaluation, he appeared as an attractive woman without evidence of cognitive deficit, thought disorder, or psychosis; he did display some tendency towards use of a host of defenses, especially projection. He implied that if his disability payments were not renewed, he would kill himself. He felt that all his problems were caused by society's failure to accept him and his condition. He hoped to obtain grant money for sex reassignment surgery, ignoring the interviewer's reminder that reputable centers required extended periods of functioning, including work, as a woman. He believed that once he had been operated on, all his problems would be solved and he could go to work.

DISCUSSION

The relationship of those who work to those who are unable or unwilling to work has varied from age to age and culture to culture. If, as Etkin has suggested,4 man's evolution from the primates involved a change from herbivorous colonies to hunting territorial packs, it is likely that in the earliest societies those unable to work either died or, at best, were allowed to live but not to breed.5 The development of extended-family agrarian societies led to more beneficent treatment of disabled persons, especially at times of plenty. Gradually, the Church began to share the responsibility of caring for these people along with the extended families. Eventually, industrialization brought an end to this system in Western cultures by decreasing the influence and power of the Church and breaking up the extended family into nuclear constellations.

The great worldwide depression of the 1930s and ideologic upheavals in various countries led to the State's playing an increasing role in determining who would be considered disabled and what assistance they would receive. Throughout history, the psychiatrically disabled have been at a disadvantage because there is often no tangible evidence of their disability.

REVIEW OF THE LITERATURE

Not surprisingly, a computer-assisted search of the literature in regard to disability determination revealed that relatively more research on this subject has been carried out in communist and socialist countries than in capitalist countries. The thrust of this literature is directed at determining how much disability a person is entitled to for a given illness6-7 and how people can most effectively be returned to work. For example, a study of 549 schizophrenic patients showed that prolonging the period of temporary disability could lead to an ultimate return to work for 90 per cent of those studied. The authors believe that this temporary extension is justified because it allows the patients to obtain "a higher economic effectivity."8 Another study attempted to investigate "the influence of the medical insurance legal norms, and . . . changes in the medical experts' procedures, on the development of incapacity to work due to mental disease."9 The conclusion was that neurotic patients seemed to be more sensitive to these parameters - i.e., rates would increase when the criteria were liberalized. Another approach has been to assess "the defect structure and compensatory capacities of patients" by psychologic testing so that they can be matched with jobs in which they are most likely to be successful.10 Thus the tone of these studies is not one of how people can be helped for their intrinsic needs but, rather, how they can be rendered more effective workers for the State - a pervasive difference.

Nussbaum et al. have extensively reviewed the history of disability insurance under the Social Security program in this country and have outlined the criteria as they now exist.11 The methods used in determining disability are largely an outgrowth of techniques first developed by the military to aid in screening procedures.12 In general, there has been an ongoing attempt to make the assessment procedure more standardized, objective, and, ultimately, computerized.13"15 In order to achieve this goal, there has been an effort to devise a form or "instrument," which has been named the "psychiatric disability inventory."1618

While this undoubtedly represents an advance in quantifying the assessment of mental status and present functioning, the results of the present study would challenge the adequacy of this approach for determining the more subjective components that contribute to a person's inability to work. For example, in a study of schizophrenic patients Griffiths suggested that one of the best indicators of whether or not a patient would be employed at follow-up was the degree of confidence he had in his ability to return to work at the time of the initial assessment.19 In a similar study, involving both medical and psychiatric disability cases, Hewitt found that "the most important single medical factor was a mental one, in the main that of personal attitude towards disability."20 The importance of attitude has also been implicated in a patient's response to physical illness. Kinsman et. al have studied the effect of patient attitudes on the course of chronic respiratory disease,21 and the Paleys found a relationship between factors such as optimism and recovery from cardiac surgery.22 This may be related to Nussbaum's early finding in the military that "few malingerers will prove to be of military value and may actually be harmful to morale."23 Thus he suggested that the patient's attitude be given higher priority than his functional capacity in regard to whether or not he should be inducted into the military. As only 12 per cent of the present sample showed marked impairment of mental status at the time of examination, it is apparent that there are other factors at work leading these people to seek disability benefits. The characteristic most widespread in this sample was a feeling of inadequacy, which cut across diagnostic lines. Indeed, the patient who showed the most interest in returning to work was one of the most handicapped, in terms of functional capacity.

The emphasis in the literature on disability determination on schizophrenic and mentally deficient populations also prevails in the literature on rehabilitation. There are several studies dealing with the effectiveness of sheltered workshops,24,25 industrial therapy, 2^27 and the general community vocational adjustment of these groups.28"31 The only other diagnostic group that appears to have received comparable attention is that of the posttraumatic neurosis, apparently because of the frequency of lawsuits and compensation claims arising out of these cases,32 coupled with the ever-present suspicion of secondary gain as a motive. Allodi has commented on the frequency of hysterical traits in these patients,33 and, in a large survey of 500 cases, Thompson reports an overwhelming preponderance of anxiety neurosis, followed by hysteria, phobic neurosis, mixed anxietyhysteria, obsessive-compulsive neurosis, and hypochondriasis.34 In over 20 per cent of the population, he diagnosed a superimposed neurotic depression. Hirschfeld and Behan point out that "peptic ulcers and other suggestions of depression appear in histories of accident victims, indicating that disability exists before the mishap. After the accident has occurred, this disability is linked with an apparent physical defect, and it becomes acceptable to both patient and society."35 Both Modlin36 and Miller37 have shown that the likelihood of improvement is doubtful until the claim is settled; it seems not to be important in whose favor it is settled, so long as the question is resolved.

Many of the patients in the present study seem to correspond more closely to the latter population than to the chronic schizophrenicmental defective population usually described in the literature on work disability. The comparison is also relevant because of the finding that patients often do not improve until the case is settled. Miller stated that when he undertook his study there had not been any previous follow-up studies despite the large number of cases litigated; now the findings have been replicated in non-Western cultures as well.38'39

In a large follow-up study of disability insurance claims, Denker found that "in the higher disability income brackets the duration of the claim is likely to be longer. . . . Furthermore, it would seem that the monthly disability check eliminates the incentive to get out and fight life's struggles, and, in addition, it acts as a constant reminder to the highly suggestible, mentally ill patient that he is disabled, and an invalid, and recognized as such by the outside world."40 He concluded that lump-sum payments were more efficacious. Similar conclusions were drawn by Jolly,41 who found with industrial hysterics that the percentage of cures was high when lump-sum settlement was speedily made but low when weekly compensation checks were substituted. Similarly, a cross-cultural study42 indicated that in Denmark, when compensation was paid in a lump sum at an early stage of incapacity, 93.6 per cent of the injured recovered; whereas in West Germany, where monthly pension checks were allotted, only 9.3 per cent recovered from the same disease.

There is another comparison that can be made between the neurotically depressed subsample of disability applicants and the patients described in the literature on posttraumatic neurosis. Historically, the former had a marginal but adequate adaptation to life until a stress or loss occurred, following which they were unable to return to work. In the large number of female subjects, this was usually the loss of a husband or another nurturing object on whom the subject had become dependent. One of the borderline patients actually developed this attitude following a physical assault. Quitkin et al. have observed that patients with previous evidence of affective illness can have an "atypical" relapse, presenting primarily as anhedonia, following stress.43 A follow-up study of 150 "moderately" depressed women treated with either amitriptyline or psychotherapy found that 70 per cent sought further psychiatric help in the year following the resolution of their acute symptoms.44 Studies of severe stress as encountered in war45,46 and acute physical trauma47 have suggested that the stress itself can lead to depressive symptoms. However, the one Vietnam veteran in this sample seemed to fit more closely the pattern described by Yager of violence and maladjustment, even preceding the war experience.48

Thus this large nonpsychotically depressed group of disability applicants can best be described as people who seemed to have made a marginal adaptation to life by forming a dependent relationship to a nurturing object but were then incapacitated by either the loss of this object or an acute life stress. There seems to be a lack of follow-up studies in regard to this nonpsychotic, nonretarded group. Unlike compensation, disability payment is periodically re-evaluated, and the case is, in a way, never settled. Does this keep the neurotic and personality-disordered claimants from ever improving? What becomes of patients who are denied disability benefits because their functional capacity is rated great enough for them to return to work but who lack the confidence even to apply for a job or become so nervous before the interview that they become physically ill?

These unanswered questions lead to others of great importance in the light of our findings. How can one adequately assess the motivational component? The concept of motivation has been somewhat overlooked as a result of the ascendance in recent years of biologic theories of psychiatric illness; recent pharmacologic studies of determinants of animal behavior suggest that this variable cannot be overlooked. In a series of elegant experiments, Joseph and Appel49,50 have indicated that

the ability of the relatively potent compounds to disrupt the frequency of ongoing behavior and the dependency of these drug-behavior interactions on underlying neuronal activity are critically determined by the degree of motivation of the animal.

Another important factor for many of the patients - especially the schizophrenic group - was the fear that returning to work would exacerbate their mental illness. Many of these patients had suffered their first psychotic decompensations in association with problems at work or problems finding work; moreover, many gave clear histories of exacerbations produced by attempts at working - data suggesting that their fears were far from groundless.

It is not unusual for a study like the present one to raise broader social questions. For some patients the prospect of returning to work may create as many problems as the prospect of receiving disability benefits, in part because the usual type of work for which these patients are trained is assembly-line factory labor. In a number of studies Herzberg has documented the demoralizing effect of this type of work.51 Miller has even linked the increase in delinquency in Britain to the effects of assembly-line work on parental attitudes;52 Mant has suggested that the emphasis on compliance with the boss at work leads to a "displacement" of social aggression into sporte, crime, and racial conflct.53 These suggestions are particularly interesting, since some of our patients had been fired for assaulting supervisors; several related their mental decompensations directly to job stresses. Coles's skillful interviews,54 on the other hand, have implied that for at least some patients this type of work can provide stability and meaning to life.

PROBLEMS FOR FUTURE INVESTIGATION

One is left with several perplexing questions. What constitutes disability? Should one consider only patients with a cognitive functional deficit, or should more subtle attitudinal variables be taken into account? The law as stated would seem to favor the former, yet its application appears capricious. Several patients evaluated by one of us (E. J. M.) were already receiving disability benefits when evaluated (and therefore are not included in this report); none of them had a manifest thought disorder of cognitive deficit. Yet in a New York study55 these criteria were strictly used, excluding large numbers of addicts and alcoholics from qualifying for benefits. One might feel intuitively that malingerers should be excluded; yet Bleuler has suggested that "those who simulate insanity with some cleverness are nearly all psychopaths and some are actually insane. Demonstration of simulation, therefore, does not at all prove that the patient is mentally sound and responsible for his actions."58 This view is corroborated by Eissler.57

The most problematic patients are those who are not retarded, schizophrenic, or personality-disordered; in this study these are the patients who adapted to life via a passivedependent relationship to husband or relative and who, following the loss of this nurturant person, were unable to become self-sustaining. This group raises the most difficult questions because they arouse the interviewer's sympathy through their distress, yet they probably represent the group that would most benefit from returning to work with proper supports and rehabilitation.

There would seem to be two possible approaches to this problem. One would be similar to the suggestion Szasz58 has made for solving the dilemma of the criminally insane. He has suggested that behavior A simply be followed by consequence B, with no attempt to make a judgment relative to responsibility; he persuasively argues that this would be fairer to both the patient and society. That society may be beginning to agree is reflected in the tendency for states to adopt fixed-term sentences instead of indeterminate sentences.59 This solution for disability would mean either doing away with the system altogether or granting benefits to everyone who applied. The latter alternative would amount to virtually a minimum-income policy for the country. Besides the obvious high cost of this approach, there would be the added problem that people who might gain more satisfaction from life if they were helped to return to work would never discover this fact.

We favor, instead, an investigative approach: undertaking large-scale epidemiologic and follow-up studies to determine which patients can reasonably be expected to return to work after what sorts of intervention.

It might be argued that this entire area is not properly the province of the psychiatrist, that such issues are best left to legislators and politicians. To this one might answer that man's work is intimately related to his mental health ("Lieben und Arbeit"). Moreover, one of the most successful treatment approaches in the history of American psychiatry - the moral treatment concept - had as a major tenet what could only be called work therapy.60·61 We would agree, however, that, rather than determining policy, the psychiatristmight best advise decision makers on the basis of as much relevant information as possible; these data would be available only from the studies suggested to determine the effects of psychiatric disability benefits on those to whom they are granted and those to whom they are denied.

SUMMARY

Although the literature on this subject focuses most often on patients with schizophrenia and retardation, our study indicates that less than half of the applicants suffered from these disorders. Patients sought disability for a variety of motives, most prominently (1) a feeling of inadequacy; (2) fear of exacerbation of illness as a result of returning to work; (3) entitlement; and (4) the feeling of being "finished," of lacking any motivation to work.

A remarkably small percentage of the patients had marked cognitive deficits; one implication of this finding is that current efforts to quantify disability assessment may be misguided and may exclude deserving patients rather than undeserving ones. Only long-term follow-up studies can offer answers to these dilemmas. It would seem reasonable, however, to give increased weight to more subjective variables than can be derived from objective, cognitive measures. On this basis, the first epigraph that heads this article may serve as warning to many of the authors reviewed; the second may capture better than any questionnaire the outlook of these patients.

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