HEALTH STATUS AND PREDICAMENT IN COMPENSATION SEEKERS FOR RSI

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HEALTH STATUS AND PREDICAMENT IN COMPENSATION
SEEKERS FOR RSI

• Yolande Lucire PhD MB BS DPM FRANZCP
• Forensic Psychiatrist

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HEALTH STATUS AND PREDICAMENT IN LITIGANTS WITH
RSI

• 319 claimants litigating with arm symptoms were
  evaluated in a medico-legal assessment practice
  in the period between late 1984 and May 1991
  against the background of an epidemic of a new
  disorder, termed RSI.
• Files were placed in alphabetical order and 100
  were selected by random number screen.
• The information from an interview and review of
  the information about them was transferred to a
  data base created by the author on a Claris
  Filemaker program on a Macintosh computer.
• 100 case vignettes formed part of PhD.

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SAMPLE CHARACTERISTICS

• 319 claimants into into alphabetical order
• 100 selected by random number screen
• SEX
• 97 women and 3 men.
• AGE

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Age of onset
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Occupational category
41 were keyboard trades This reflected those
most heavily educated in prevention
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DURATION OF ABSENCE FROM WORK

• 82 persons were still absent from work and most
  still in receipt of workers' compensation.
• 86 had three months or more off work
• 75 had more than six months
• 55 had more than a year off work
• 5 had 5 years or more off work

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Time off work at time of interview
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Certification of incapacity to work of 100

• Up to five years later
• 81 Still off work
• 19 Back at work
• 22 had prior involvement in health based
  litigation compensation, disability policies

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WHERE WAS THE DIAGNOSIS OF RSI MADE?

• Not by family doctors
• Usually occupational health practices whose
  names gave notice of their political leanings
• Occasionally the doctors of their sick parents or
  sick children who incidentally learnt about the
  claimants symptoms.

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PRIOR LITIGATION OVER HEALTH

• 22 had prior involvement in health based
  litigation
• This figure is extremely high as a very small
  proportion of the population is ever so involved.
• Covers MVA, Workers Comp, AAT, disability policies

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SOMATIZATION INVOLVES A COMBINATION OF MOTOR AND
SENSORY SYMPTOMS

• Paraesthesiae, pain or strange sensations, hot
  cold formication, tingling
• in the back, neck, shoulder, arm or forearm on
  the dorsal, ventral , medial or lateral aspect of
  the arm
• Weakness through to paresis or paralysis
• Difficulties in manipulation,
• Crossover to the unused arm because I was
  protecting it.
• Came on suddenly, or slowly, at work, or at home,
  at night, anywhere, while hanging out washing or
  at the breakfast table.
• In summary mutimodal and mobile symptomatology
  inexplicable by any number of hyopthetical
  lesions

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PRESENTATION OF CASES

• Recited their symptoms as listed in guides to
  prevention of RSI put about both by government
  and unions.
• Gave their history in terms of their doctors'
  advice.
• Recited their union's goals to change working
  conditions as if they had joined a social
  movement.
• Symptoms and causal attribution theories were
  offered, as it were, in one breath, as a
  pre-wrapped package.

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DISEASE

• Three subjects had a physical disease
• gout
• frozen shoulder
• de Quervain's tenosynovitis

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The social predicament of the subject was
examined at

• At the time of the first report of arm symptoms
• At the time of her transition from 'person' to
  'claimant'
• At the time of inteview
• Inquiry focussed on events at work, at home and
  within the family.

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DISEASE AND FUNCTIONAL DISORDER

• Insufficient evidence to form a diagnosis (8)
• Disease, (N3) for those cases where there was
  local disease sufficient to account for all
  symptoms and for the extent of illness behaviour.
  
• Somatization total gt90

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WAYS OF SOMATIZING

• Occupational Tension Myalgia, (N6)
• Somatization complicating local problem
  Functional overlay (N 14)
• Somatization of anxiety or depression Functional
  disorder (N23)
• Somatization resolving a conflict or need (N31
• Somatization now, but the past was unable to be
  formulated
• Somatization with faking, perhaps malingering.
  (N6-7))

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Categories of somatizing

• Functional overlay N 14
• Functional disorder N23
• Hysteria or conflict neuroisis N31
• Unable to formulate N7
• Somatization with faking N 6

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MENTAL STATE

• Not interested in hearing of alternative views
  concerning their problems.
• Argued their entitlement from a position of
  doubt, creating a passable imitation of paranoid
  certainty.
• Belief, usually correct, that this examiner was
  not going to endorse their attribution theories
  in her report.
• Wanted to get those remedies which had been
  negotiated for them and these included long
  periods on compensable sick leave.
• Attributed bad faith to the examiner. Nine ( of
  319) complained of routine questions andbias to
  the HCCC, still causing me a lot of strife.
• High incidence of narcisistic, histrionic and
  parnoid attitudes/traits.

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PREDICAMENTS

• Predicaments have been defined as
• painful social situations or circumstances,
  complex, unstable, morally charged and varying in
  their import in time and place, readily
  discernible from a good history.
• Predicaments are rich in conflicts.
• To identify a predicament involved an
  examination, not only of the stress, conflict or
  life event but also of the various options
  available to that subject for coping with it.
• Predicaments were either understood intuitively
  and empathically or they are might not be
  understood at all.

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WHAT STRESSORS PREDISPOSE TO A PREDICAMENT?

• a) personal health impairment,
• b) forming new relationships,
• c) pregnancy,
• d) responding to the needs of children,
• e) relationship difficulties,
• f) serious illness in a close person,
• g) occupational problem,
• h) being engaged in other activities and,
• i) finding it senseless to work.

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INCIDENCE OF LIFE EVENTS

• a) personal health impairment,----------------33
• b) forming new relationship--------------------13
• c) pregnancy, ------------------------------------
  ---11
• d) responding to the needs of children, ----17
• e) relationship difficulties, --------------------
  ---26
• f) serious illness in parent spouse orchild---24,
  
• g) occupational problem, ------------------------2
  1
• h) being engaged in other activities ---------12
• i) finding it senseless to work.-----------------1
  2
• J)other-------------------------------------------
  -----3

Totla this to over 100
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THE DISTRIBUTION OF THE STRESSORS AND CONFLICTS

• 21 were experiencing three
• 30 were experiencing two
• 36 revealed only one event 93
• 2 difficulties that were not easily coded 95
• No reasons uncovered in two subjects 97
• 3 had physical disorder only 100.

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33/100 PERSONS REVEALED HEALTH PROBLEMS AND
DISORDERS OTHER THAN RSI

• Gynaecological problems were the most common
  women went off work to have hysterectomies,
  miscarriages, or surgery to enable pregnancy.
• Trauma-induced disorders following motor
  accidents and falls.
• These were followed by psychological problems,
  depression, psychosis, anorexia nervosa,
  addiction and a previously recognised tendency
  towards recurrent somatization,
• Various arthritic and metabolic illnesses,
• Serious cardiovascular disorders needing surgery.
  

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9 OUT OF 33 WITH COMORBID PRPBLEMS HAD SURGERY ON
COMPO FOR RSI

• 6 for gynaecological, miscarriage, to enable
  pregnancy or hysterectomy
• 1 laparoscopy for investigation as well a some of
  above
• 1 for bunions as well a some of above
• 1 for urinary incontinence
• 1aortic graft (her angina had been diagnosed RSI)

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MATCHES

• 13 were Forming new relationships
• In each case this involved a change of residence
  
• 7 had married within weeks of going off with RSI,
  
• 3 became engaged with intent to marry while in
  receipt of compensation payments and
• 2 had just married and moved house not long
  before making their claims.
• 1 had formed a relationship in another town, too
  far away to commute daily and had moved there
  before claiming compensation.
• 9 got married within weeks (either way)of going
  off work with RSI.

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HATCHES

• 11 Pregnancies
• The time frame used here encompassed the
  duration of the pregnancy and the three months
  after the birth of her child was counted as
  possibly pregnancy-related
• .
• Many were not reported and I learnt on second
  interview or file review

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RELATIONSHIP DIFFICULTIES

• The sample contained 72 married persons and
• six in de facto relationships
• 11 of the 72 married women were in the process
  of breaking up when the subject left work with
  RSI and had already separated by the time that I
  saw them.
• 2 of the married couples had separated
  temporarily and had reconciled.
• 4 more persons reported being desperately unhappy
  in their marriages.
• Three of the 6 de facto couples were in the
  process of breaking up.
• The other relationship problems also involved
  significant others, an only son, two lovers and a
  fiancé.

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SERIOUS ILLNESS AND DEATH

• Serious illness in parent, spouse or child 24
  persons
• 22 close persons close to the subjects, spouses,
  parents or children children had developed life
  threatening illnesses
• 4 spouses had become disabled for work on account
  of illness or accident..
• 12 claimants parents had developed cancer,
  dementia or terminal illnesses.
• 7 had lost one parent and 2 had already lost both
  parents from these diseases by the time of their
  interview.

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INCIDENCE OF LIFE EVENTS cf CENSUS
Life event
Number in100
Census rate
More than census
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LOSSES AS PRECIPITANTS OF SOMATIZATION

• If one looked at the information from another
  angle, it seemed that about 70 of the 100 were
  dealing with losses, some were dealing with up to
  four losses at once.

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LOSSES INCLUDED

• loss (actual or threatened) of a relationship
  with a significant other (26)
• loss of working capacity of a spouse accompanied
  by the loss of economic power (8)
• impending loss of parent, child or spouse by life
  threatening illness or death (24)
• loss health through causes unrelated to RSI
• Impending loss of employment through imminent
  retrenchment ( more than 10).
• losses which were more abstract
• lost faith in their religion,
• lost ideals,
• lost idealised beliefs about people close to
  them.

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Conflicting obligations

• Looking at the data yet another way, it seemed
  that about 60 of the claimants could not have
  continued to work and attended to their domestic
  obligations.
• Some had become full time students
• Some had relocated miles away from their
  workplaces.
• Most were fully engaged in caring for sick or
  disabled spouses, caring for sick and well
  children without the assistance of former helpers
  in a situation where child care would have been
  uneconomic.

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Some conclusions

• The individuals predicament provided the motive
• (unconscious) for entering the sick role
• Reasons or rationalisations came from the past
  and were learnt behaviours.
• Those with the strongest feelings of entitlement
  and the highest level of political motivation
  needed less cogent personal motives to enter the
  sick/claimant role and to develop and maintain
  symptoms.
• Feelings of entitlement related closely to
  political agenda and political agenda has always
  been an element of female hysteria.

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MORE OBSERVATIONS

• Somatization in its epidemic form is functional
  rather than dysfunctional for the women
  concerned.
• If it is allowed to pass the acute phase and
  become chronic, it becomes disabling.
• 16of public sevants who went off with RSI did
  not return to work but went on to compensable
  retirement.

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Why do women suffer more?

• Women have more domestic obligations.
• Women are over represented as women have more
  conflicts between occupational and domestic
  obligations

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RATIONAL CHOICE THEORY

• Rational choice theory (RCT), invites us to
  understand individual actors (which in specified
  circumstances may be collectives of one sort or
  another)
• as acting, or more likely interacting, in a
  manner such that they can be
• deemed to be doing the best they can for
  themselves, given their resources, and
  circumstances, as they see them.

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Rational choice theory

• RCT explains what people do (actions)
• in order to get what they want (desires),
• in terms of what they believe to be the case
  (beliefs).
• It examines how they explain why they did
  whatever they have done (reasons and conscious
  motives) and
• how they hide from themselves and others the fact
  that what they want is not acceptable and cannot
  be openly acknowledged (unconscious motivation).
• RCT takes into account how people prioritise all
  that they want (ranking of desires into a
  hierarchy).
• This all takes place in a situation where some
  behaviours are permissible and some not (social
  norms)
• and people know what is considered good and what
  they can get away with (social values).