How Do Pre-existing Problems Block Recovery?

“Any time an injured worker is psychologically examined, there is always something found wrong with them psychologically. This makes me hesitant to order or recommend a psychological examination. I never know how much of this is pre-existing. Can you give me some general principles to understand all of this?”

Rather than avoid psychological examination, the earlier that exam is ordered, the sooner you understand the true needs and capacity of the patient.

Let me explain the epidemiology of psychological problems. There are two major studies, one in the 1980s and another one about 10 years later. When you look at all of the evidence, there is indication that less than a fifth of the population has one or more psychological problems that truly warrant treatment. There is also evidence that we may have expanded our definitions of disorders too far resulting in many people being diagnosed as having a problem when it is truly questionable that they need psychological care.

More importantly, it is now accepted that the existence of a psychological problem does not in and of itself constitute a disability. You can be anxious, depressed, and even addicted and capable of productive work. It may be advantageous to seek care for your problem, but it is inaccurate to believe that just the sheer existence of a problem indicates disability. Perhaps the best example is a simple virus (“a cold”) versus a bacterial infection. Most of us accept that we can, and we do work with a virus, and many of us work even with fairly severe bacterial infections while taking antibiotics. And there are those of us who work with broken limbs, strained necks and backs, and a host of other physical complaints.

Similarly, estimates run as high as 10% of the workforce has a mood disorder that warrants treatment. Likely, with depression, for example, the decreased concentration and problems with sleep, interfere with optimal work performance, but the individual is able to work. Also, you have to ask yourself if it is not likely better and therapeutic for a depressed patient to remain active, interacting, productive and not isolated from work while having their bleak mood and unpleasant thoughts. 

Thus, I ask you: “Is it healthy for a depressed person or an anxious person or a person who worries excessively about bodily functions (Somatoform Disorders) to remain out of the workforce?” I believe the preponderance of the data indicate that an individual removed from work is less likely to recover. 

Also there is a recent article about “pain centers” which indicates that those programs which truly return patients to work are those which incorporate vocational rehabilitation as part of pain treatment program. 

Thus, the goal of life and our society is to be productive and invested. There are disorders that make working, especially in some situations, difficult if not impossible. But in the best interests of the patient, working while they are being treated is far preferable to being treated rather than working.

Now let’s look at the second part of your question: What percent of these individuals with work injuries had problems prior to injury. I again return you to the epidemiological surveys of psychological disorder. What you find is that the lowest occurrence of disabling mental disorder occurs in the elderly. Some would argue that these people were innately healthier, and they aged appropriately because they were not prone to stress related illness and/or they do not lead lives in ways that increased stress.

However, the highest incidence of severe mental disorders occurs along family lines: the addictions, the psychotic disorders, and the more severe personality disorders. These individuals are reared in chaotic households, poorly taught to tolerate stress, have inadequate assistance making functional life decisions, are not adequately schooled, and they form dysfunctional relationships, have poor impulse control and often entanglements with law enforcement along with frequent job changes. 

These individuals also are most often transient workers, changing career direction frequently, working briefly, describe themselves as intolerant of the sameness of daily activities, abhorrent of working with concepts, facts, and abstractions and preferring work that distracts them; physically active work without specific life goals. 

These individuals work in high physical risk settings by choice, often forced to such jobs by their own poor tolerance for more occupationally structured work. That which drives them to the job is the same factors that become apparent when the high risk job results in injury. 

Their families are unlikely to have themselves sought or endorsed seeking psychological care. This longstanding need for care does not constitute a disability. But also, you must realize, psychological care requires a commitment, a capacity for self-examination and a level of motivation which is absent in the individual coming from this type of background. A diagnosed psychological disorder does not mean that the individual cannot work, nor does it mean that he/she can benefit from care.