The psychiatric examination for workers' compensation purposes is a specialized subcategory of the more general clinical psychiatric examination. In addition to diagnostic assessment, the workers' compensation examination requires assessing the role of work in causing or contributing to psychiatric syndromes or conditions and associated disability. Moreover, the workers1 compensation examination emphasizes the determination of residual functional capacities. The psychiatric examination also has rather specific medicolegal implications adding both a challenge and a burden to the psychiatric examiner not present with the typical clinical examination. This article describes the content of the psychiatric examination in workers' compensation matters.
The workers' compensation examination takes place in the context of an adversary medicolegal system. The clinician who foils to understand the implications of this overriding social dynamic is unlikely to achieve valid results. The setting entails certain potential advantages as well as drawbacks in making an accurate diagnostic appraisal and measurement of disability. In most instances, the worker is not coming to the examination to ask for help ' or assistance. It is understood at the outset that a medicolegal examination is to be conducted. Moreover, ? most clinicians will carefully define , the nature and the purpose of the examination to the worker at the outset, expJaining that the examination is not confidential and that a written report will be sent to the requesting party or parties. This parameter of the examination has clear, albeit disparate and frequently different, implications for workers.
In some cases, the worker, as well as those supporting and opposing his or her application, may presume that the clinician is biased about the examination based on the referral source. This often leads to initial difficulty in establishing a working rapport because the clinician must attempt to undo and counteract both the "ally" and "adversary" expectations. It is often a good idea to "go with the resistance" in these situations and to understand that the observed behaviors might have a different meaning in the workers' compensation evaluation than they would in a more traditional clinical setting. One does well to reserve judgments on many factors, such as communications, resistance, hostility, suspiciousness, and guardedness, until most of the data are in and some decisions can be made about the power of external influences on the clinical presentation. This process is illustrated by the increasing number of workers who, on the advice of their attorneys, bring tape recorders to their examinations.
An assessment of how these issues influence self-disclosure during the amination is a critical and necessary measurement made by the clinician. Under certain circumstances, the lack of confidentiality and the nontraditional expectations produce a decrease of worker selfdisclosure, but this is by no means always the case. Generalizations about these matters are difficult at best and lead to false conclusions at worst.
While the potential complications of examining in the medicolegal setting are easily seen, potential advantages are generally overlooked. The worker is rarely in a condition of immediate psychosocial or psychiatric distress. In the absence of acute psychiatric decompensation, the examiner is frequently able to obtain a more comprehensive and longitudinal history of the worker's lifelong adjustment that is relatively free of the confounding factors induced by marked cognitive or affective dysfunction. Frequently, the worker will come with extensive medical, psychological, and employment records, which can serve to alert the clinician to critical areas of inquiry, as well as offer the benefit of previous expert observations.
Establishing a rapport with the worker is critical. Unlike the clinical setting where individuals usually regard themselves as going to a physician for help, immediately creating an implicit understanding of the relative role of both participants, the clinician in workers* compensation settings attempts to immediately create a framework that offers a substitute implicit structure to the examination. The clinician is advised to put the worker at ease immediately. In general, an informal, nonauthoritarian, and friendly demeanor produces immediate results. Seemingly innocuous comments inquiring about the mode and ease with which the individual arrived at the examination frequently allow the worker to feel more at ease and at the same time allow the clinician to begin to establish a database regarding cognitive function.
A word of caution is necessary here. A number of examinees have no idea what a psychological or psychiatric examination entails, having never been in one before, and may be either openly or subtly resistant to the entire examination process. If the worker makes certain requests or demands at the start of the examination, the astute clinician will "test the waters" and if sufficient resistance is sensed, the clinician will generally do well to comply with the worker's request or demand. For example, the claimant may insist on being accompanied into the examination by a significant other (frequently a spouse), or in rare instances, the spouse or significant other may insist on accompanying the claimant into the examination. In general, the examiner would do well to accept these demands, using the additional data provided by conjoint interviews, and strategically arrange a way to interview the claimant alone later during the examination process. Il may otherwise be impossible to secure the claimant's necessary participation in the examination.
While each examiner finds his or her own way of securing cooperation at the beginning of the examination, one useful method entails requesting the claimant to fill out preliminary data sheets. This provides structure, decreases initial anxiety, and also provides preliminary data about the claimant's alleged difficulties free of the confounding effects of interviewerinterviewee interactions. Most useful is a cover sheet that asks the claimant to spontaneously report present or current symptoms and problems, combined with a separate sheet divided into headings that allows an individual to describe his or her entire occupational history. The benefit to the worker is that he or she gets an indication of the subject matter and scope of die examination. This in turn tends to allay the anxiety that is often generated by the phrase "psychiatrist's appointment."
These techniques do not replace the data gathering aspect of the interview, and they should not be considered short cuts. They are techniques that speak to the nontraditional nature of the psychiatric examination in the workers' compensation setting.
THE PSYCHIATRIC EXAMINATION
The examination itself can be conveniently broken down into several different sections. The clinician must keep in mind at all times the necessity of covering a number of relevant topic areas during the course of the examination. In most instances, an initial open-ended interview style allows maximum latitude for claimants to describe their story in their own words, which is likely to lead to a more accurate diagnostic appraisal. Statements such as, "Tell me a bit about your job," or "I'd like to begin by having you tell me a bit about where you've worked," are generally sufficient. The examiner must not coach the claimant at this juncture but rather provide minimal structuring remarks consistent with obtaining a comprehensive history of the claimant's alleged work-related problems.
If the claimant's injuries are allegedly physical with a secondary mental component, then it is important to allow the claimant to describe his or her injuries, as well as the treatment and impact of that treatment. The manner and style of description, the particular words used in describing physical symptoms, and the claimant's remarks about efficacy of treatment are critically reviewed with a diagnostician's ear toward making preliminary hypotheses about functional and psychological contributions to somatic complaints.
This is particularly important in the workers' compensation area because of an inexact correspondence between the legal and psychological concepts governing the decisions that are made, and the unwary clinician can be confused and misled. It is critical to make sharp distinctions between the nature of the environment as perceived and described by the worker, and the nature of the worker's reaction to that environment. In the labor law area, the nature of the environment is typically of primary importance, ie, whether there were violations of rules and regulations, unfair practices, or discrimination. For the clinician, the first consideration is the nature of the worker's reactions to that environment - whether there are maladaptive responses and deterioration in work functions. Unfortunately, many believe that the absence of a psychopathological reaction will diminish the strength of allegations relative to the nature of the environment, and it is difficult for them to understand that an illegal environment does not necessarily need to be associated with a pathological reaction.
If the claimant makes no spontaneous comment about emotional reactions or symptoms, whether about physical injury, peer relations, supervisory relationships, the speed and pacing of the work, ease in which the work is done, or the nature of the work itself, this should be duly noted by the clinician and later described in the report. The physician then should make direct inquiry into the emotional arena. Again, every effort should be made to allow claimants to make spontaneous remarks reflecting their own perceptions and are relatively free of the examiner's influence.
At some point in obtaining the history of work-related difficulties, it is necessary to obtain specific information about the details of the claimant's job. This entails both the description of the work components and the claimant's attitude toward work. The relative ease or difficulty the claimant has in doing the work also should be noted. If the claimant describes difficulties in either peer or supervisory relationships, a detailed description of those difficulties should be obtained. Specific attention should be paid to the claimant's affect in describing such alleged difficulties. Obtaining the claimant's own theories or ideas about how such difficulties emerged is highly relevant.
Obtaining a clear, longitudinal history of the emergence of the claimant's emotional symptoms is important. Particular attention should be paid to the time frame of the emergence of the symptomsespecially the waxing and waning of the symptoms. A clear description of the claimant's present symptoms also must be obtained. The clinican needs to distinguish present symptoms and adjustment from symptoms and adjustment during earlier phases of the symptom complex. This may not seem like a particularly relevant concern to the clinician who treats patients daily and pays careful attention to day-to-day symptoms but it is surprising how frequently the medicolegal examiner creates ambiguity in examination reports by failing to distinguish present adaptation from adaptation at the beginning or emergence of symptom complexes.
In the medicolegal area, as opposed to the traditional treatment area, powerful secondary factors often operate to influence, not always within the worker's awareness, how symptom courses are reported. Understandably, workers often believe that to admit that previously doubling symptoms have reduced or remitted will weaken the legitimacy of their original claims, which were made when the symptoms were more acute.
A detailed description of the claimant's daily life is a necessary component of the medicolegal examination. Claimants who demonstrate relative candor in the examination will frequently provide detailed spontaneous descriptions of various aspects of daily activities. More guarded and resistant individuals, on the other hand, are less likely to provide such spontaneous descriptions, and careful attention must be paid during the remainder of the examination for opportunities to obtain more off-hand, but nonetheless extremely relevant, descriptions. For example, when asked directly about his day-to-day adjustment, one claimant explained that he did little besides sit in a chair and stare off into space for most of the day. However, in describing his parents, he remarked that they lived close by and that he had daily contact and visits with them.
Information should be obtained about general hygiene, attention to appearance, routine activity, daily responsibilities, and the nature of all contacts with other people. If television watching is the claimant's major daily activity, then soliciting information about the shows watched, the content of the shows, and the frequency of viewing provides useful information in indirectly assessing both cognitive and affective functioning. It is surprising how frequently clinicians can be misled by failing to obtain such information. For example, a recent case involved a woman with alleged head injuries who had undergone diree separate batteries of sophisticated neuropsychological tests and who was thought to have a significant organic mental impairment. Each battery of such tests allegedly demonstrated this impairment Unfortunately, no examiner had obtained relevant information about the claimant's daily life activities and adjustment. The claimant, a rather naive person, freely provided an extensive, detailed, and lengthy description of a myriad of rather complex daily life activities entailing family and motherly responsibilities as well as general management of the household and household finances. This information was in direct conflict with the conclusions drawn from psychological test instruments and led to an entirely different set of conclusions regarding mental impairment.
The clinician also would do well to set aside sufficient time for the examination. Generally, 2 to 3 hours are required for a comprehensive examination. In select instances, more time may be required. The clinician who sets aside insufficient time for an examination is bound to rush the claimant; hurrying the examination does neither the claimant nor the medicolegal system a service.
A word about "multiple" examinations also ts in order. Some clinicians have found that several brief examinations spaced over days or weeks can produce a more comprehensive assessment. Our own clinical experience suggests that little, if anything, is to be gained by this procedure. In fact, it can be cogently argued that an extended psychiatric examination occurring over the course of several hours, together with a battery of psychological tests which take an additional several hours and frequently result in a total of 5 to 7 hours spent in the office, provides far more useful information about residual functional capacities than individual 45minute sessions spaced out over tune. The lengthy examination also more closely approximates the work day, so that the effects on function of factors such as fatigue, low frustration tolerance, and basic attitudes can be more realistically assessed. At a practical level, the inconvenience created by repeated sessions, particularly when considerable distances are involved, often builds up a self-defeating negative set in claimants.
A complete developmental and family history is a necessary part of the examination. Careful attention must be paid to the quality of intimate life relationships beginning with the family of origin. The claimant's spontaneous descriptions of each family member, including siblings, is desirable. Attitudes and feelings toward significant parental figures should be obtained as well as the current quality of relationships with parents and siblings. A description of childhood friends and adolescent activities and behavior patterns also should be obtained. A detailed and longitudinal history of the quality of intimate attachments and relationships, with particular attention to the recent past, helps to establish the claimant's social capacities and interpersonal flexibility and is a good measure of coping resources.
Particular attention should be given to the history of marital relationships and the kind and quality of parenting capacities. Careful attention should be directed to the claimant's family obligations with an emphasis on the inherent stresses and conflicts involved in attempting to balance work roles and obligations with family roles and obligations.
Obtaining a clear understanding of the claimant's financial circumstances, even though people often hold financial issues as more "personal and private" than their intimate relationships, is crucial. Attention should be directed to current financial resources, past financial obligations, and difficulties, as well as to the possible financial rewards that may accompany disability claims. The clinician would do well to have an independent knowledge of vesting privileges, annuity benefits, and retirement packages in general in order to accurately understand the nature of the particular claimant's financial circumstances. If the claimant has a history of bankruptcy, a clear articulation of how that occurred and how it was responded to psychologically and practically is useful.
A popular misconception among the public and many clinicians is that workers on disability are being paid for not working and that they are naturally inclined to prolong the situation. This is a cynical and misguided view. The unfortunate reality is that for most workers, even those who derive certain nonfinancial secondary gain from their disability, being on disability represents a major financial reduction and hardship. In fact, it is important for the clinician to determine and separate out those emotional reactions of the worker that are in direct response to work conditions and experiences from those that are a product of the disability status itself. It is not uncommon to see workers who have lost their houses, cars, and most of their possessions as a result of the financial aftermath of an injury and who are "righteously" depressed.
An extensive occupational history is necessary. All too frequently medicolegal examinations pay only cursory attention to the claimant's previous occupational adjustment prior to the alleged industrial injuries. A skeletal occupational outline does not suffice for disability evaluations. This is particularly true in the California Workers' Compensation System where careful attention must be paid to issues of nonindustrial disability and preexisting disability. Unlike the Social Security system where the clinician's task is to assess whether the claimant is capable of work in any capacity, the California Workers' Compensation System requires quantitative measurements of degrees of disability and apportionment of disability to other feetors besides the specific job that may have produced disability. Each job that the claimant has held, including the length of service, the type of work, attitude, and adjustment to the job, and particular circumstances under which the job was left, are highly relevant in determining disability.
Changing motivations toward work are also relevant, particularly at different phases of the life cycle. The interactive and interpersonal requirements of various jobs also need some general quantification. Periods of unemployment or underemployment are noted, and explanations for such periods are sought. The meaning of work in maintaining self-worth both with present and previous employment is particularly germane.
The claimant's educational background and intellectual capacities form another critical subcategory of the evaluation. Intellectual capacity is measured both indirectly in the mental status examination and directly through various psychological test instruments that can be employed in a graded fashion depending on the clinical circumstance. Learning disabilities or marginal intellectual capacities must be clearly articulated, because failure to do so will surely confound measurement of psychiatric disability.
Included in the history of developmental experiences is an assessment of impulsi vi ty, aggressiveness, behavioral control, and the formation of attitudes and values in the context of the larger social fabric. Cultural norms in regard to various ethnic or racial groupings must be taken into account. This is a particularly sensitive area these days and the clinician needs to learn to deal effectively with socioculturel issues. Stereotyped, popular knowledge of cultural issues can lead the clinician to erroneous conclusions, invalidated reports, and professional embarrassment.
Direct questioning regarding sexual exploitation as a child or youth is frequently indicated.
A history of medical illness and surgical procedures is required. Likewise, a history of prior industrial claims and the disposition of those claims is needed. Careful attention should be paid to potential hypochondriacal, somatoform, and psychophysiological symptoms in eliciting the medical history. Specific attitudes toward illness in general and a family history of extended illness or disability can provide a crucial link in attempting to understand a disability claim.
A history of habit patterns should be obtained. Information about eating habits, a history of obesity, or anorexia frequently can be overlooked. We have seen a number of individuals with gastric stapling or bypass procedures who make no spontaneous articulations about weight problems over the years and for whom direct inquiry is required to obtain this history. A smoking history also should be obtained. One of the most relevant and perhaps most overlooked factors in a psychiatric examination is a clear longitudinal history of the claimant's use of alcohol. An indirect approach to information in this area is initially used followed by a series of highly specific and direct questions when indicated. The single most overlooked diagnosis in workers' compensation examinations is alcoholism. Hints about such difficulties ranging from work tardiness and absence to subtle indicators of unexplained gastric distress and chance findings of abnormalities in liver function tests or red blood cell indices should heighten the examiner's awareness of the possibility of alcohol abuse. Direct inquiry is also necessary regarding other psychoactive substances if no spontaneous information is obtained.
The worker's arrest record, both adult and juvenile, as well as his or her driving record is an often overlooked source of characterological information and information on effectiveness of adaptive strategies. Many times we have been led to a chronic alcohol abuse problem where the worker denied that alcohol had ever been a problem through DUI (driving under the influence) arrests.
A detailed description of any past history of psychiatric episodes and of prior counseling should be included in the evaluation. If no information is volunteered by the worker, then specific questioning should be directed toward these The nature of previous psychiatric episodes, their treatments, and their success are important jarts of the disability evaluation. For example, with family counseling the dentified patient may be a child but the claimant also may participate - notation of such counseling is releSimilarly, a history of unexplained falls or of emergency room visits for bruises and contusions can je subtle hints of possible substance abuse.
Many individuals fail to mention extensive histories of chiropractic treatment - a treatment which in our experience frequently is a form of supportive relationship but never dentified as such by either the claimant or the chiropractor. Useful nforniation about this relationship can usually be obtained by merely asking the claimant what kind of aerson the practitioner happens to >e. Not infrequently, the claimant responds with commentary about what a warm, helpful, caring individual the practitioner is. The importance of such commentary in determining dependency dynamics is relatively straightforward.
Claimants should be queried about the success of previous treatments, their perceptions of the sractitioners, and the effects of the alleged illness on their daily lives. A review of all available medical records, while not a direct component of the psychiatric examination, can se critical in establishing a history of somatoform disorders. Some individuals with long histories of somatoform syndromes, when asked directly and explicitly, deny any history of substantial medical contact. While the reasons for this denial are not always clear, the clinician who tails to use a medical history in a diagnostic appraisal frequently will misunderstand the necessity and importance of somatic symptoms in the claimant's overall adjustment.
For example, an individual with many job changes in a short time who has been repeatedly terminated or laid off from jobs and can provide little or no sufficient explanation for these changes is frequently a person with longstanding occupational impairment. Likewise, lengthy periods of unemployment when social, cultural, and practical circumstances provide no explanation are frequently indicators of psychiatric disability. Individuals whose careers appear to peak quite early in life and who then show either lateral or downward career accomplishments may well have psychiatric disability. Similarly, the individual with long-term, stable, and secure employment at the lower levels of the employment hierarchy whose intellectual capacities would have predicted much higher vocational accomplishments are frequently individuals with psychiatric disability.
The clinician should look for extreme shyness, early social withdrawal, self-identification as a loner, and subtle indicators of antisocial attitudes or behavior.
The mental status examination is both the most difficult and elegant aspect of the psychiatric examination. A complete description of the claimant's general behavior is required both during formal aspects of the examination and during the more informal portions. Diligent assessment of affect, cognition, and thought processes are a fulcrum portion of the evaluation. Rapport with the examiner and interpersonal skills are crucial. Careful consideration should be given toward the claimant's general posture during the examination, particularly regarding issues of candor, openness, and disclosure, or defensiveness, guardedness, and resistance. Sometimes, indirect indices of affect and cognitive functioning can be more useful than direct examination. For example, describing the individual who provides a lengthy, detailed, and highly self-confident description regarding exactly how the trip to the examiner's office was made can provide a powerful adjunct to the clinician's summary statement about a worker's unimpaired cognitive functioning, particularly when motivation to complete assigned cognitive tasks in the formal mental status examination was questionable.
The clinician needs to remember that the worker's evaluation will probably be read by nonpsychologically trained persons and therefore the sterile mental status examination couched in jargon will be of little value and may defeat the reader. The mental status examination should be a word picture that brings the worker alive to the reader and allows the reader to see and hear the worker through the clinician's senses.
THE ROLE OF PSYCHOLOGICAL TESTING
Psychological testing can provide a critical adjunct to the comprehensive psychiatric examination and medicolegal report, especially in the workers' compensation area where opinions are often contested and the examiner may be expected to substantiate his or her findings more rigorously than in clinical settings. Psychological tests can provide objective corroboration for data gained from the worker's selfreport, particularly when the worker is unable to adequately describe his or her subjective experience or when his or her credibility is in question. The availability of psychological test data can be helpful for the clinician to check against his or her own "experimenter bias" and to reduce the perception of bias that is sometimes held by the "side" that did not refer the worker to the examiner.
In cases where complaints are presented involving both physical and psychological symptoms, psychological tests can help in sorting out and defining the origins of symptoms. Finally, it is imperative that psychological tests be employed in cases where previous psychological testing was conducted. The opportunity that such a situation creates for measuring increments of change over time can be invaluable and frequently speaks directly to the kinds of issues that are most prominent in workers' compensation considerations.
Several cautions need to be raised regarding the use of psychological tests. The appropriate administration and interpretation of psychological tests is a complex activity requiring a great deal of preparation and practice. Not all psychologists have concentrated their training and practice in psychodiagnostic works, just as not all psychiatrists specialize in forensic and disability evaluations. Psychologists also should be aware that the translation of diagnostic experience from general clinical assessment to the workers' compensation area is not automatic and requires considerable adjustment and refinement of skills.
The choice of psychological tests, or more properly, the definition of what constitutes a psychological test is an important issue where many misunderstandings have developed. Clinicians would do well to understand the reliability and validity of each test instrument, as well as the instruments' limitations. There are no shortcuts to comprehensive mediocolegal evaluations. Clinicians, whether they be psychologists or psychiatrists, who rely heavily on subjective self-report instruments and symptom checklists in medicolegal evaluations undermine the credibility of the psychological enterprise as it pertains to industrial injuries. Self-report instruments have their uses in that they provide a structured opportunity for the worker to express his or her concerns, and they can provide the clinician with clues about areas that require further exploration during the interview, but they are not psychological tests and their data is not scientifically defensible.
Clinicians should be aware and expect that there will not always be an exact correspondence between the psychological test data and the impressions of the clinician. These occasions should not be used to indict either the test data or the clinician. It remains the clinician's responsibility to explain and integrate all of the data and in so doing, the explanation and integration of disparate data can provide an opportunity for an even richer and more comprehensive assessment.
After obtaining all of the relevant and germane medical history, completing the mental status examination, and obtaining the psychological test battery, the examiner integrates all of these into a diagnostic appraisal. At this point, it is useful to follow the general guidelines propounded in the DSM-IIl-R. Failure to use these categories can lead to both medical and legal disputes that are grounded more in a misuse of terms than in any substantive difference of opinion.
A word of caution is necessary, however. The DSM-HI-R and all psychiatric diagnostic guidelines have definite limitations. The DSM-III-R even provides a warning about the use of the diagnostic categories in medicolegal settings. For example, the concept of diagnosis, which refers to mental disorder, and the concept of disability, which refers to functional capacity, are not interchangeable and should not be confused. Needless quibbling about the nuances between a dysthymic disorder and a depression not otherwise specified, or the exact length of an adjustment disorder serve no useful purposes.
Further in this same vein, the clinician should be aware that an accurate description of personality adjustment is regularly overlooked in many medicolegal examinations. The reasons for this are many, not the least of which is the relative underemphasis on personality style and adaptation in psychiatric training programs in recent years. The understandable emphasis on diagnosis of reactive psychiatric illnesses, whether they be biochemical or environmentally induced, and the emphasis on rapid treatment intervention methods has had the unfortunate effect of diminishing the relevance of weighing more subtle, but established patterns of behavior and adaptation that are characteristic of the individual's life. This unfortunate circumstance leads to an underidentification of character structure and psych opathology in determining psychiatric disability.
CAUSATION AND DISABLITY
After the diagnostic appraisal comes a formulation with particular emphasis on the issue of causation. A discussion of disability then follows. While a detailed description of disability factors and the correlation between these factors and the clinical examination is beyond the scope of this article and is covered elsewhere in this journal, it should be clear that conclusions regarding psychiatric disability will be no more valid than the database on which they are founded. A permanent disability rating report that fails to provide the necessary behavioral and descriptive data on which conclusions are based is not only less than helpful to the legal system, but also serves to undermine the delicate social and political balance that recognizes and accepts the whole concept of psychiatric disability.
In the end, a well-reasoned and thoroughly documented medicolegal report can serve the worker well, regardless of which side has commissioned the report. The worker's condition can be clearly defined with realistic and reasonable remedies set forth so that the worker is supported and restored in keeping with both the spirit and the letter oi the workers' compensation legislation.