Although patients with even very severe mental disorders can often work in a limited capacity or in a sheltered setting, certain disorders clearly are more likely to result in work impairment. Psychotic conditions such as schizophrenia or severe bipolar disorder routinely lead to major impairment in social and occupational functioning. Similarly, certain chronic anxiety and depressive disorders that are unresponsive to treatment can be disabling, if not from all work, then perhaps for the type of work that the patient was for merly capable of doing. Posttraumatic stress disorder, which is the subject of much litigation involving disability claims, is known to produce chronic and long-lasting symptoms. It may be quite disabling for people who do certain types of work, particularly if the trauma occurred in a work-like setting. However, there are few objective data to support chronic total disability from post-traumatic stress disorder (Drukteinis 2002).
Somatoform disorders present a unique conundrum in disability claims, in that the impairment is purportedly due to physical symptoms but the underlying pathogenesis is substantially psychological. In some of these cases, such as chronic pain disorders, a peculiar disability issue has emerged. Although the disability is said to be caused by physical symptoms and is not, therefore, technically a mental health issue, a secondary psychological reaction is asserted as an independent impairment (Drukteinis 2000). So, for example, patients may claim disability due to back pain, but the medical evidence shows that a sedentary work capacity is still possible. Then, with what amounts to circular logic, patients say that it is their depression caused by an inability to work that makes them totally disabled. This scenario is often seen in situations where percentage ratings of permanent impairment are required as part of settlement negotiations.
Even more controversial are disability claims for addictive and personality disorders (Frisman and Rosenheck 2002). Should disability be granted for an individual's maladaptive behaviors, or are these conditions over which an individual has no control? Political, philosophical, public policy, and social science considerations have been involved in this controversy, with often contradictory research results. Practically, however, if a period of disability can be used to help with psychological growth and recovery even in these conditions, it may very well be justified. Permanent disability, on the other hand, should be more carefully examined.
In general, disability determinations should take into account the natural course of a mental disorder, the expected effects of adequate treatment, and a realistic prognosis. Work, by and large, is healthy and restorative for most people, even those with mental disorders, and should be encouraged. Disability, in contrast, can have an eroding effect on the individual. As a consequence, opinions about disability should be judiciously considered and sparingly made. It may be that Mr. G cannot practice as a trial attorney any longer because his age and increased vulnerability to depression make placing him in a high-stress work environment undesirable. However, Mr. G's years of practice as a trial attorney were a resource for not only financial reward but also replenishment of self-esteem. Where is he to find that now if he remains totally disabled? Can he find a new source for intellectual stimulation and challenge? Every type of work has its drawbacks, stresses, and negative aspects, but the net product of Mr. G's practice may have been more valuable to him than he realizes. From the standpoint of his own recovery from depression, it should not be taken away casually.
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