I would like to clarify an issue.  Essentially every patient I see that has been off work more than three months has elevated anxiety as noted on my intake questionnaire or it will come out in conversation.  I am always directly addressing their anxiety.  If I had a choice every patient would have some access to education, support, and the tools to diminish their stress.  The system can do only so much to decrease their stress, as just the potential of loss of employment is a huge stressor in itself.  It has been mentioned that questionnaires are not adequate to assess anxiety.  From my perspective I am not sure what would be an alternative.  We are all well aware of the limited access to psychology and psychiatry.

Definition of Anxiety:

• Feeling of worry
• Something that worries somebody
• Strong wish to do something
• Extreme apprehension

I tried to look up anxiety on Google Scholar this morning.  I could not find a clear definition.  I finally just went to the dictionary and pulled off the above one.  I looked at the first part of the DSM manual  (the manual defines mental health disorders) and am now curious as to exactly what diagnosis I would make from my orthopedic perspective to enable mental health support to be provided to an injured worker.  More importantly what would a claims examiner use to “buy” a diagnosis?

In which Axis does the diagnosis of anxiety have to be to made? (there are five levels)  Anxiety is part of essentially every Axis I diagnosis.  What anxiety diagnosis has to be made to fulfill criteria?  (Axis I is the level that the major diagnoses are made such as depression, ADHD, anxiety disorders, addictions, etc.)

Axis IV is “Psychosocial and Environmental problems.  Here are a few of the Axis IV choices:

• Occupational problems
• Problems related to the social environment
• Problems with primary support group
• Educational problems
• Economic problems

An injured worker has most of these issues.

Every human being experiences anxiety. In turn it is increased by Axis IV issues. Does that not qualify for assistance?

If a person has a diagnosable pre-existing anxiety condition it is unlikely that it would have already been a diagnosis that an injured worker is carrying around.  If a mental health professional makes the diagnosis after the person has been in the worker’s comp system for awhile then it is impossible to really sort out what is going on.  The Axis IV issues become a major factor.

So when is worker’s comp supposed to provide mental health services?  If there happens to be a pre-existing condition then it is a major obstacle in return to function and it would make financial as well as humane sense to treat it.

If the anxiety, etc. is caused by the stress of the claim then worker’s comp should cover it, as the injury was the cause of the person’s emotional distress.

Axis III is the Axis where the general medical conditions are listed that can directly or indirectly affect an Axis I diagnosis.  If there is a direct cause and effect then the Axis III diagnosis is also listed in Axis I.  One can make a strong argument that there are multiple musculoskeletal diagnoses that cause a significant increase in anxiety and should be put under Axis I.  The DSM must take the adversity experienced by the injured worker into account and it likely does not.

I am going to purchase the DSM book today.  I would like to ask the roundtable to provide me with the criteria needed to obtain mental health support for an injured worker. At this moment, I have no idea.

NH