Psychiatric Annals

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The Injured Worker and Disability Evaluation 

Psychiatric Disorders and Work Function

Allen J Enelow, MD

Abstract

Psychiatrists and to a lesser extent many clinical psychologists have tended to resist efforts to quantify psychiatric symptoms and their effects on the ability of an individual to function socially. Efforts to develop rating scales for evaluating overall functioning and degrees of psychiatric impairment have been made for many years. Scales to measure interpeTSonal interactions and global impairment assessments have been used in psychiatric research with increasing frequency in the last 30 years. However, this has not filtered into the everyday practice of psychiatric clinicians to any large extent. Similarly, psychiatrists and psychologists practicing in the workers' compensation arena have brought this resistance to quantification with them to their more recent entrance into the field of assessment.

Beginning in 1945, following the powerful impetus given to the use of psychotherapy by the experiences of World War II veterans with combat neuroses (now termed posttraumatic stress disorder), there was a significant loss of interest in the skills of assessment and diagnosis as psychiatrists became intensely interested in psychotherapy. Most psychiatrists and many, if not most, clinical psychologists, paid little attention to diagnosis in their training as well as in their practices. Some authorities went so far as to declare diagnosis irrelevant. The assessment of disability was rarely, if ever, included in psychiatric training. Fortunately, this is being remedied with a marked increase in training in diagnosis over the past 7 or 8 years.

The emergence of the purely psychiatric workers' compensation claim as a significant percentage of all such claims (together with other economic considerations) brought large numbers of psychiatrists and psychologists into medicolegal practice. Because of their concentration on therapy, many were poorly prepared for this significant shift in emphasis from treatment to assessment.

Their resistance to quantification was reinforced by the ambiguity of the old California rating system. In it, there was a condition referred to as neurosis, but nowhere was there a definition of that term. Further, neurosis was to be rated in terms of six categories: minimal, very slight, slight, moderate, severe, and profound. These were not only not defined, but also no criteria were given for assigning them. Thus, the examining clinician could pronounce a category such as moderate neurosis with no fear of being challenged by data. Another clinician could pronounce the neurosis of the same applicant as very slight with equal conviction. Because each knew the percentage of disability associated with each term, they were in essence arguing over whether to give the applicant a 50% disability or a 10% disability with no way of determining whether either figure had validity on any basis.

In an effort to reduce the inconsistency and scatter in the evaluations of the extent of permanent disability as made by different examiners, the California Division of Industrial Accidents Medical and Chiropractic Advisory Committee formed a Subcommittee on Permanent Psychiatric Disability. That subcommittee was given the charge of developing guidelines for the evaluation of permanent pardal disability in order to create legally useful definitions of psychiatric injuries and their impact. Further, it was agreed that many reports contained less than an adequate amount of data to support the legal conclusions in those reports. The subcommittee was comprised of psychiatrists, clinical psychologists, a retired workers' compensation judge, a medical sociologist whose research had been in the area of quantifying .human interactions, and a vocational rehabilitation specialist.

The objective of this subcommittee was to increase the consistency in evaluating the extent of permanent disability. The committee developed a format for psychiatric disability evaluation reports to be used by psychiatrists and psychologists, as well as a format for reporting psychological test data.

A…

Psychiatrists and to a lesser extent many clinical psychologists have tended to resist efforts to quantify psychiatric symptoms and their effects on the ability of an individual to function socially. Efforts to develop rating scales for evaluating overall functioning and degrees of psychiatric impairment have been made for many years. Scales to measure interpeTSonal interactions and global impairment assessments have been used in psychiatric research with increasing frequency in the last 30 years. However, this has not filtered into the everyday practice of psychiatric clinicians to any large extent. Similarly, psychiatrists and psychologists practicing in the workers' compensation arena have brought this resistance to quantification with them to their more recent entrance into the field of assessment.

Beginning in 1945, following the powerful impetus given to the use of psychotherapy by the experiences of World War II veterans with combat neuroses (now termed posttraumatic stress disorder), there was a significant loss of interest in the skills of assessment and diagnosis as psychiatrists became intensely interested in psychotherapy. Most psychiatrists and many, if not most, clinical psychologists, paid little attention to diagnosis in their training as well as in their practices. Some authorities went so far as to declare diagnosis irrelevant. The assessment of disability was rarely, if ever, included in psychiatric training. Fortunately, this is being remedied with a marked increase in training in diagnosis over the past 7 or 8 years.

The emergence of the purely psychiatric workers' compensation claim as a significant percentage of all such claims (together with other economic considerations) brought large numbers of psychiatrists and psychologists into medicolegal practice. Because of their concentration on therapy, many were poorly prepared for this significant shift in emphasis from treatment to assessment.

Their resistance to quantification was reinforced by the ambiguity of the old California rating system. In it, there was a condition referred to as neurosis, but nowhere was there a definition of that term. Further, neurosis was to be rated in terms of six categories: minimal, very slight, slight, moderate, severe, and profound. These were not only not defined, but also no criteria were given for assigning them. Thus, the examining clinician could pronounce a category such as moderate neurosis with no fear of being challenged by data. Another clinician could pronounce the neurosis of the same applicant as very slight with equal conviction. Because each knew the percentage of disability associated with each term, they were in essence arguing over whether to give the applicant a 50% disability or a 10% disability with no way of determining whether either figure had validity on any basis.

In an effort to reduce the inconsistency and scatter in the evaluations of the extent of permanent disability as made by different examiners, the California Division of Industrial Accidents Medical and Chiropractic Advisory Committee formed a Subcommittee on Permanent Psychiatric Disability. That subcommittee was given the charge of developing guidelines for the evaluation of permanent pardal disability in order to create legally useful definitions of psychiatric injuries and their impact. Further, it was agreed that many reports contained less than an adequate amount of data to support the legal conclusions in those reports. The subcommittee was comprised of psychiatrists, clinical psychologists, a retired workers' compensation judge, a medical sociologist whose research had been in the area of quantifying .human interactions, and a vocational rehabilitation specialist.

The objective of this subcommittee was to increase the consistency in evaluating the extent of permanent disability. The committee developed a format for psychiatric disability evaluation reports to be used by psychiatrists and psychologists, as well as a format for reporting psychological test data.

A second, and most important, task undertaken by the subcommittee was the development of a list of work functions that could be assessed clinically and through psychological testing. These were derived from the criteria used by the Social Security Administration but were considerably refined and reduced in aumher according to their direct impact on the ability of a given worker with a psychiatric impairment to function in the labor market. These will be described later in this article.

These new protocols represent a major change in philosophy. The term neurosis has been discarded. The subcommittee is now examining eight psychological and social functions that are relevant to the applicant's ability to function in the open labor market. Definitions have been provided for each function and for the five levels of disability that can be assigned to each.

Another requirement of the new protocols is the use of DSM-III-R diagnoses. The DSM-IH-R, as did the DSM-III before it, has specific criteria for each diagnosis. Certain symptoms and certain periods of time or duration of existence of these symptoms are specified in DSM-III-R criteria. Further, the DSM-III-R uses a multiaxial system with three useful axes. For the purpose of disability evaluations, the subcommittee eliminated axes IV and V, considering them to be speculative rather than empirically-derived.

IMPAIRMENT AND DISABLITY

Rationalizations are common when psychiatrists take a stand on the issue of quantifying impairment. References to the subtleties in interpersonal interactions and to the flavor or complexities of human behavior and psychological symptoms are frequently found in the statements of psychiatrists who resist efforts to reduce the ambiguity characteristic of impairment ratings. As a consequence, there is considerable confusion about the difference between symptoms and disability. For instance, depression can be disabling or it can be subjective dysphoria without creating actual disability. Depression itself is not disabling, it is the manifestations of depression, such as psychomotor retardation, impaired concentration, and feelings of apathy, that produce impairment.

The symptoms that are temporarily somewhat disabling, such as the depression caused by being out of work or anxiety caused by uncertainty regarding the future course of treatment in an orthopedic surgical condition, are not to be coafused with permanent disability. A permanent disability is one that can be predicted to be present from that time forward. Commonly, depression associated with being out of work or fear of the future will disappear soon after the individual has returned to the workplace and is once again gainfully employed.

Examiners have displayed much confusion with regard to their use of the term disability as applied to the symptoms that may be found in a given applicant Not all examiners have been clear about the important difference. The result has been a lack of consistency in the evaluation of the extent of permanent disability, which is all the more troublesome in workers' compensation because of the necessity to arrive at conclusions about degrees of partial disability.

Eight work functions were determined to be significantly specific yet appropriately inclusive to be able to cover the psychological functions of any worker from one doing unskilled labor to one performing supervisory or decision-making job functions. All were chosen as being amenable to rating partial levels of impairment.

The eight work functions are:

* the ability to comprehend and follow instructions,

* the ability to perform simple and repetitive tasks,

* the ability to maintain a work pace appropriate to a given work load,

* the ability to perform complex or varied tasks,

* the ability to relate to other people beyond giving and receiving instructions,

* the ability to influence people,

* the ability to make generalizations, evaluations, or decisions without immediate supervision, and

* the ability to accept and cany out responsibility for direction, control, and planning.

LEVELS OF IMPAIRMENT

The following were taken as levels of impairment of each function with definitions that were considered sufficiently broad to allow flexibility yet specific enough to be useful in determining the level of impairment.

Minimal - an impairment that is producing discomfort only and does not limit function, such as subjective dysphoria, or mild anxiety.

Very slight - an impairment that is not obvious and might escape the notice of the average individual, including the clinician, but that is detectable with diagnostic measures, such as careful mental status examination or psychological testing. Psychological tests can be employed appropriately in assessing each function.

Slight - an impairment that is noticeable, limits a given function, but does not preclude it. An example of slight disability would be psychomotor retardation that creates slowed thinking, which reduces comprehension as measured in the appropriate subtest of the WVIS-R (to be specified elsewhere) or in the responses to complex questions asked by a psychiatric examiner in the course of a mental status evaluation. The function is measurably limited, yet not precluded.

Moderate - an impairment that markedly limits the function so that cognitive test scores or the ability to respond to the examiner and to carry out simple tasks involved hi being examined are clearly severely restricted.

Severe - the particular function being tested, such as comprehension, is nonfunctional. A severe impairment precludes a given function.

A note of explanation about the use of psychological testing in assessing disability levels is in order at this point. Such functions as comprehension, attention, memory, slowing or psychomotor retardation, the ability to handle complex tasks, and the ability to use higher order reasoning as in decision-making cannot be measured with sufficient accuracy or specificity by mental status examination alone. Cognitive psychological testing, such as the WAIS-R, provides a fer more reliable and valid empirical test of these functions. Therefore, while the degrees of impairment that are relatively more severe can be easily assessed through mental status examination, the more subtle degrees of impairment are best assessed through the use of cognitive testing. The WMS-R, the Trail-making tests, and in some cases the Wechsler Memory Scale can be very useful.

THE WORK FACTORS

The following descriptions of the work factors are listed in the order of their importance in terms of limiting the ability of the disabled worker to compete in the open labor market. The first three work factors - comprehension, simple repetitive task performance, and the ability to maintain a work pace appropriate to a given work load - are the controlling factors. They are far more important than the remaining five functions, and this is reflected in the structure of the new disability formula.

Work factor 1

The most basic psychological function in any work situation is the ability to comprehend and follow instructions. It is obvious that if an individual is so impaired that he or she is unable to comprehend and follow instructions, that individual would not be employable. However, there are degrees of impairment of comprehension.

In studying comprehension, the examiner is requested to consider the following aspects:

* the ability to maintain attention and concentration for necessary periods,

* the ability to apply common sense understanding to carry out instruction whether given in written, oral, or diagrammatic form, and

* the ability to adapt to situations requiring the precise attainment of set limits, tolerances, or standards.

When measuring comprehension, cognitive psychological testing (eg, the full WAIS-R) is a far more sensitive instrument than the mental status examination, particularly in the areas of minimal, very slight, and slight impairment.

Work Factor 2

The second work function is defined as the ability to perform simple and repetitive tasks. This includes the ability to ask simple questions or to request assistance when needed. Performing simple and repetitive tasks involves routine, concrete, organized activities that can be done either through mental status testing or, perhaps more empirically and measurably, with cognitive testing. The ability to remember locations and work procedures is an essential part of this work function. The ability to make decisions based on simple sensory data, a psychological function that is easily tested, is still another aspect of performing simple and repetitive tasks.

Work Factor 3

The third work function, the ability to maintain a work pace appropriate to a given work load, is a most important one. Clearly, psychomotor slowing as in depression or repeated errors caused by anxiety will reduce the ability to keep up with the work pace and is almost always unacceptable to an employer. Assessing the ability to maintain an appropriate work pace involves assessing the ability of the impaired person to perform activities on schedule, to maintain regular attendance, and to be punctual. There may be specific limiting factors in this function, such as those produced by phobias.

For example, an individual may be able to perform activities on schedule, maintain regular attendance, and be punctual, as long as he or she works on the ground floor. A phobia for working above the ground floor or taking an elevator may cause an impairment that becomes specific to a given situation, which of course, must be specified in a psychiatric report. However, this cannot be described in that fashion in the final discussion of work functions or in completing a work function impairment form. A recent directive from the California Disability Evaluation Bureau stated that evaluating physicians may not qualify in any manner the description of an impairment rating for a given function. A qualified description will be treated as "not ratable." Further, if all eight functions are not rated, the entire assessment of disability level will be rejected. The examiner is requested to take special circumstances under consideration and give his or her best judgment, ie, minimal to slight.

In other words, given the fact that a given symptom occurs only under special circumstances, the examiner must give a rating that describes the variation without qualifying statements. As an example, the individual who cannot work above the ground floor or take an elevator might be rated as minimal to moderate. This would imply that under certain circumstances it can be minimal while under other circumstances the disability can markedly limit the function. The California Disability Evaluation Bureau rater will then arrive at a figure that averages the extremes.

A second function in maintaining an appropriate work pace is the ability to complete a normal workday or week, performing at a consistent pace without excessive rest periods. This is often a problem for individuals suffering from chronic pain.

The above three work functions are the most important. Most of the disability rating will come from these three factors. Further, they are universal in the sense that there are probably few if any jobs that do not require some level of ability in these three work functions. The next five work functions to be described are of less importance, some of them of minimal importance in terms of the total job market, as will be discussed below.

Work Factor 4

The fourth work factor, the ability to perform complex or varied tasks, is a function that involves higher level intellectual functioning that can be impaired by a variety of psychiatric symptoms. Included under this heading is the ability to synthesize, coordinate and analyze data, as well as the ability to perform jobs requiring the precise attainment of established limits, tolerances, or standards. Again, as with the first three work factors, cognitive testing (eg, the WUS-R) is extremely useful in assessing the impairment in this work function. In addition, the ability to respond appropriately to the tasks given by the examiner in a typical mental status examination will give a somewhat rougher estimate of the ability Co perform complex and varied tasks.

The remaining four work factors are more related to the interpersonal and personality trait aspects of a psychiatric assessment than to cognitive assessment. The personality traits of a given patient are usually assessed in two ways. The first of these is the psychiatric examination itself. How does the individual relate to the examiner? How does the individual relate to other personnel in the office, provided, of course, | that there is the opportunity to make such observations? What does the history of the applicant tell the examiner about his or her experiences with other individuals during social development and in his or her previous work history? The data provided by the Minnesota MuItiphasic Personality Inventory (MMPI) can provide additional insights into the work factors 5 through 8. This may be particularly important given the feet that the examiner has one or, at most, two opportunities to examine an applicant hi l]/2 to 3 hours, the usual limits of duration of such an examination. It may not be possible to get a thorough and complete picture of many of the personality traits of the individual in that period of time. The MMPI and, to a lesser extent, some other psychological tests can provide a depth of information that is usually only obtainable through prolonged exposure to the applicant.

Work Factor 5

The fifth work factor, the ability to relate to other people beyond giving and receiving instructions, is usually best assessed in the examination of the interaction between the worker and the examining psychiatrist as well as the worker's account of his or her experiences with coworkers or peers. To be able to relate to other people comfortably, one must be able to get along with coworkers or peers without exhibiting behavioral extremes. It also includes the ability to perform work activities requiring negotiating, instructing, supervising, persuading, or speaking with others.

Here again, the mental status examination, the account of the worker's experiences with other workers, supervisors, and supervisees, and the management of such tasks as are given with self-administered tests will help in the assessment of this work factor. In addition, the MMPI or a projective personality test, such as the Rorschach test scored by the Exner System, may provide additional data. A third and most important aspect of relating to others is the ability to respond appropriately to criticism from a supervisor. This too can be assessed both clinically and through personality testing, such as the MMPI.

Some confusion may arise in attempting to differentiate between the fifth work factor, the ability to relate to other people beyond giving and receiving instructions and work factor 6, the ability to influence people. The ability to relate to Other people beyond giving and receiving instructions refers to the ability to get along with coworkers or peers without exhibiting behavior extremes. It encompasses the social behavior of the worker in relation to other workers. The ability to influence people is a function of convincing, redirecting, or "selling." Thus, a supervisor, an outside sales person, a teacher, or social worker would have to have some level of ability to influence other people effectively. These two factors are related but are distinctly different from each other.

Work Factor 6

The ability to influence people effectively and consistently includes the ability to convince or redirect others. Again, one must assess the behavior of the worker with the examiner and perhaps with office staff if there is an opportunity to make observations. Accounts of others who work with the patient, when available, may be helpful in evaluating the worker's ability to convince or redirect others. Personality testing also may be helpful. To be able to effectively influence people on a consistent basis also requires the understanding of the meaning of words and the ability to communicate effectively. Here, the observation of the worker's communications with the examiner and the cognitive testing afforded by the WAIS-R can be extremely helpful. A third factor in this work function is the ability to interact appropriately with the examiner, which can be observed during the interview.

Work Factor 7

The seventh factor - the ability to make generalizations, evaluations, or decisions without immediate supervision - is a function of higher order reasoning. Careful observation during the interview will be most helpful in this particular assessment. Cognitive testing and especially the WVIS-R also can be useful. This work function requires the ability to recognize potential hazards and observe appropriate precautions, to understand and remember detailed instructions, to make independent decisions or judgments, and to set realistic goals.

Work Factor 8

The eighth work function is the ability to accept and carry out responsibility for direction, control, and planning. This is a higher order of decision-making and supervisory work function and does not apply to all jobs. However, for teachers, administrative assistants, social workers, and supervisors, this function is important It requires the ability to set realistic goals or make plans independently of others. This may be both a personality function and a cognitive function and reflects such qualities as judgment, insight, and the ability to function autonomously. Mental status examination, the individual's past history, and personality assessment are all helpful in arriving at a conclusion about the level of disability in this area. This function also requires the ability to negotiate, to instruct or to supervise people, and to respond appropriately to changes. While this function can be assessed clinically by a careful examiner, personality testing is often very helpful in arriving at a valid assessment.

A question arises about the sixth, seventh, and eighth work factors, which apply to a rather small percentage of the labor force. The eighth work function particularly involves the smallest number of actual occupations. This factor still must be evaluated for a worker who is not in a job affected by that factor, as must all other iactors. For example, if an individual never had to direct, control, or plan a job, it is unlikely that he or she ever had the ability to perform those tasks as he or she would most probably have risen to that level during his or her work history, with the exception of those who have just entered the work force. However, the law clearly states that each applicant must be assessed in terms of his or her ability to compete in the entire labor market. Thus, it becomes important to determine whether the individual ever had the ability in question, such as to direct, control, or plan a job. There are many clues to this. If, in fact, an individual has been in the work force for more than a few years and has never held such a job, that individual has probably never had that ability. A thorough work history will usually answer questions about such abilities that are limited to a small number of occupations.

THE PSYCHIATRIC EXAMINATION

The assessment of disability in terms of psychological functions relating to the ability to obtain and hold a job is a detailed, comprehensive, and often time-consuming examination procedure. Unfortunately, this can lead to abuses of the system. Unnecessary psychological testing can be done, and rather large amounts are sometimes charged for self-administered testing that can be computer scored and interpreted for a fraction of the amount charged by the examiner. One should question an extremely extensive battery of tests. Tests of little usefulness are those that are little more than inquiries to be Glied out by the applicant as to how he or she feels or ask similar questions that could easily be directly asked of the applicant.

To briefly summarize, a minimal psychological test battery consisting of the WUS-R with 1 1 subtests, the MMPI, and Trails A and B would be a basic battery sufficient to answer the questions required of the examiner with regard to impairment of work functions. A few other tests can be of additional usefulness in selected cases.

Of great importance is the psychiatric interview itself. Both the content of the interview and the process between the interviewer and the worker are evaluated. The manner in which the worker describes his or her present symptoms, the credibility of his or her account, including estimates of the degree of exaggeration or understatement, and the manner in which the worker relates to the examiner in describing his or her symptoms and complaints are all important sources of data.

Careful attention must be given to the history of the present illness or injury and its treatment. Attitudes such as distrust, openness, candor, defensiveness, and the ability to make realistic assessments of one's own shortcomings are all factors that should be carefully assessed and recorded together with the facts provided by die worker. For this purpose, an open-ended style of interviewing is most appropriate. Least useful is the checklist type of self-administered history questionnaire used by many occupational medical clinics. The content of the worker's story can be obtained through a carefully designed questionnaire, but the interpersonal process that is omitted results in the loss of a most important source of data.

Following the open-ended phase of the diagnostic interview, much information must be obtained through a more structured type of interviewing that includes the occupational history, the past mental health and medical history, the family history, the developmental history, and the social history. These aspects of the history help to clarify the questions of causation. A careful psychiatric history will contain information about past episodes of psychiatric illness, periods of psychotherapy, and a medical history that will give some data about the frequency of illnesses and medical care, Somatoform disorders often are characterized by a history of many episodes of illness or medical care often for problems that are difficult to diagnose, are considered to be functional, or cover a multitude of body systems.

Sometimes the examiner will find a history of repeated surgical interventions, often for conditions in which the diagnosis is unclear. Similarly, the family history and developmental history may give evidence of psychiatric problems that were never brought to the attention of physicians or mental health clinicians. These may include periods of severe depression during adolescence, periods of extreme social withdrawal, or the inability to establish close or intimate relationships with others. A history of marked social withdrawal in eariy adolescence followed by the development of psychiatric symptoms in later adolescence is often a cardinal diagnostic sign of a psychotic condition that is nonindustrial.

In assessing the work factors Chat relate to interpersonal behavior, the occupational history can provide very useful information when a sequential description of the occupations engaged in by the worker is obtained along with an assessment of career mobility and a discussion of difficulties and accomplishments in each occupational setting. When a given individual has had many jobs over a relatively short period of time, has been terminated or laid off repeatedly, and has little or no explanation for this, this is presumptive evidence of preexisting occupational impairment. A careful inquiry by the examiner is necessary to further elaborate on this presumption. If the career direction has been lateral or downward throughout the individual's career, this is a sign of preexisting disability. Long periods of unemployment are suggestive of psychiatric disability.

In the structured part of the interview, an open-ended approach should be used, but specific data points must be inquired about directly in order to obtain information concerning: the presence or absence of psychiatric problems with a genetic causative factor; developmental disorders; the ability to handle stresses and normal developmental crises; the worker's educational and legal histories; previous problems, such as substance abuse and difficulty getting along with others; and the ability to have successful marital and family relations.

In addition to the mental status examination, psychological testing offers an important additional source of empirical data, particularly useful assessing those work functions that depend on cognitive functioning but also helpful in assessing personality. Cognitive tests and timed tests, such as the WVIS-R and Trails A and B in addition to the MMPI, are probably sufficient to provide all of the data needed for these assessments. A number of other self-administered tests may give information about the individual's complaints and perception of his or her problems but they are not reliable diagnostic indicators and often do little more than confirm a high complaint level, somatic preoccupation, or an attempt to convince the examiner that disability exists. Because of the prevalence of secondary gain factors in workers' compensation, empirical data from testing add to the validity and reliability of assessments.

OTHER CONSIDERATIONS

A word about secondary gain factors is in order here. What is referred to as secondary gain by psychiatrists is the part of the reward for illness that is not so clear to the applicant. For example, when someone is disabled, that individual is exempted from responsibility and the necessity to expose him- or herself to the stress of work. This exemption from responsibility also is often recognized by family members. In fact, an over-solicitous family can reinforce these secondary gain considerations and produce a state of psychological invalidism in the injured worker, especially if other family members assume the burden of economic support of the family.

Other types of secondary gain include the attention or care given the individual by health workers and family members. In addition, those individuals with a dependent personality disorder will find gratification of their dependent needs from invalidism secondary to disability, which can complicate or prolong recovery, and which often results in a permanent disability that is largely the product of the preexisting personality disorder.

In rating au of the work functions, it is important for the clinician to specify the conditions under which these functions are impaired when the impairment is not consistently present. This particularly applies to phobias, to impairments in relation to particular individuals with whom a worker has had painful or threatening relationships, and to specific stresses with which an individual has demonstrated an inability to cope. A statement of disability that such and such a condition occurs whenever the individual is under stress is a useless one - the term stress is too difficult to define. In addition, it is doubtful that there is any circumstance that is free from stress. However, when a specific work function is impaired under conditions of a specific type of stress, that should be included in the description of the impairment of that function. This is primarily for the guidance of the rehabilitation counselor. Again, the reader is reminded that while it is necessary to specify what type of stress is likely to produce a given impairment, such qualifications cannot be placed in the final rating of impairment level of each disability factor in the summary section, as well as in a work function impairment form.

SUMMARY

This article has described guidelines that were established in California to increase the specificity and replicabtlity of disability assessments. These guidelines include an outline for describing all of the data necessary for arriving at conclusions about impairment of work functions as well as eight work factors or functions to consider when assessing disability. These work factors were modified from Social Security disability guidelines to fit the issue of partial disability. Specific component factors for each of these work functions have been identified. It is hoped that this will provide a more quantitative, replicarle, and equitable system for assessing permanent psychiatric disability. If the guidelines outlined in this article are applied in good conscience by the medicolegal community, data will be generated that will make it possible to further modify these work functions. In the meantime, the eight work factors described here appear to be the best available for objectively assessing and quantifying permanent psychiatric disability.

If the factors of impairment are not applied in good conscience by an evaluating physician, the claim examiner should refer that report to his or her own consultant for a rebuttal. A biased evaluation of the factors of impairment sometimes can be detected. For example, if the supporting data as required by a work function impairment form consist only of subjective symptoms or repetitions of the applicants' complaints, the impairment rating for that factor has not been properly justified. In other words, supporting an assessment of slowing (work factor 3) with the statement that depression is causing an inability to keep up with the work pace is an example of using a symptom as though it justified a level of impairment. Instead, there should be evidence of slowing from findings from the mental status examination, the behavior of the applicant, and (the strongest evidence) definite signs of slowing from scores on those subtests of the WUS-R or the Trail Making Test that are timed.

Another clue to a faulty evaluation is a disparity between the level of impairment and the current level of function of the applicant. For example, to state that there is a severe disability of comprehension should immediately flag a biased and exaggerated level of impairment. The term severe means that a given function is precluded. If such a factor as comprehension was precluded by the impairment, the individual would not have been able to answer the examiner's questions. Similarly, the applicant's description of a typical day, which is required by the protocols, should give some clues as to whether the individual can understand instructions, perform simple or repetitive tasks, and maintain some degree of appropriate work pace. A woman who is carrying out all of the duties of raising children, preparing meals, and cleaning the house is probably not very impaired except perhaps in the area of desire to return to work. A correct and careful evaluation will provide data from psychological testing, actual observations of behavior, and actual descriptions of current level of functioning that support or disprove the alleged level of impairment.

In summary, the psychiatric protocols and disability rating changes represent a radical change in philosophy of rating disability under California Workers' Compensation regulations. Subjective ratings are now to be largely supplanted by ratings that must be tied to the worker's actual behavior, medical history, and examination findings. No longer can certain magic words be uttered, such as "moderate neurosis," without further effort to validate such a statement on the basis of data. Hopefully, pages and pages of boiler plate material from word processors and long descriptions of alleged complaints with little or no empirical or objective data will disappear. Instead, detailed histories will cover every aspect of the individual's past and present adjustment and descriptions of data will support statements about actual impairments in those psychological functions that are essential to obtain and retain a job.

BIBLIOGRAPHY

Enelow AJ, Herrara A, Adler LM, et al. The Evaluation of Permanent Psychiatric Disability: A Report to the Medical Advisory Committee of the California Division of Industrial Acadents. San Francisco, Calif; State of California Department of Industrial Relations, Division of Industrial Accidents - Workers' Compensation Appeals Board; 1987.

10.3928/0048-5713-19910101-08

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