Post-Traumatic Stress Disorder (PTSD)

In prior posts, we’ve examined how the demands of practicing render physicians and dentists uniquely susceptible to anxiety and depression.  In this post, we are going to examine Post-Traumatic Stress Disorder (PTSD), another serious condition that often affects doctors—particularly doctors who work in high stress environments and who are repeatedly exposed to trauma on a daily basis.

What is PTSD?

PTSD is a mental health disorder caused by exposure to a shocking or dangerous event.  Although most people who experience a traumatic event experience an immediate emotional response when they are experiencing the event, those who develop PTSD continue to experience the symptoms of exposure to trauma after the event, and feel stressed or panicked even when there is no danger.  While some of the symptoms are similar to other anxiety disorders, PTSD is categorized as a particular type of anxiety that is caused by a specific external catalyst.  The onset of PTSD can occur within months after a traumatic event; however, in some cases symptoms may not appear until years later.

Prevalence

PTSD is associated with those who have been exposed to a traumatic event, such as combat, violence, serious accidents, or natural disasters.   Approximately seven to eight percent of the U.S. population will have PTSD at some point in their lives, with about eight million adults suffering from PTSD in any given year.[1]

PTSD can be caused by one event, or by prolonged exposure to trauma over time.  This exposure can be experienced directly, and through indirect exposure (i.e. witnessing the event).[2]

Many physicians, depending on their specialty, interact on a daily basis with traumatic situations from early on in their careers, and sometimes encounter events where patients die or are seriously harmed in a way that is very distressing to a practitioner.  Significantly, research has shown that 13 percent of medical residents meet the diagnostic criteria for PTSD.[3]  Emergency physicians, physicians practicing in remote or under-served areas, and physicians in training (i.e. residents) are particularly prone to developing PTSD.[4]

The prevalence of PTSD is also substantially elevated in individuals who are also suffering from chronic pain.  While only 3.5% of the general population has a current PTSD diagnosis, one study found that 35% of a sample of chronic pain patients had PTSD.  Another study of patients with chronic back pain showed that 51% experienced significant PTSD symptoms.  In instances where the chronic pain is caused by the traumatic event (e.g. someone involved in a motorcycle accident or someone injured during the course of a violent crime), the pain can serve as a reminder of the event and worsen the PTSD.[5]

Symptoms

Physicians who suffer from PTSD may lose this ability to confidently react, which can impair their ability to safely practice.  Untreated, PTSD can also lead to a marked decline in quality of life, and potentially other mental health disorders or medical issues.  Some common symptoms of PTSD include:

Re-experiencing symptoms:

  • Flashbacks
  • Nightmares
  • Frightening thoughts
  • Physical reactions or emotional distress after exposure to reminders
  • Intrusive thoughts

Avoidance symptoms:

  • Staying away from places, events, or objects that are reminders to the traumatic experience
  • Avoiding thoughts or feelings related to the traumatic event

Arousal and reactivity symptoms:

  • Being easily startled
  • Feeling tense and “on edge”
  • Having difficulty sleeping
  • Being irritable or aggressive
  • Heightened startle reaction

Cognition and mood symptoms:

  • Trouble remembering key events of the traumatic event
  • Negative thoughts about the world, and oneself
  • Distorted feelings of guilt or blame
  • Loss of interest in previously enjoyed activities
  • Negative affect

Diagnosis

PTSD is typically diagnosed by a clinical psychiatrist or psychologist.  A diagnosis is made when an individual meets the criteria for exposure, and has at least one re-experiencing symptom, one avoidance symptom, two arousal and reactivity symptoms, and two cognition and mood symptoms.

Treatments

Some of treatments that are used, either alone or in conjunction, to treat PTSD include;

  • Cognitive Behavioral Therapy
  • Eye Movement Desensitization and Reprocessing (EMDR)
  • Prolonged Exposure Therapy
  • Antidepressants
  • Anti-anxiety medication
  • Medication for insomnia

The intensity and duration of PTSD symptoms vary.  Individuals who recognize any of the above-referenced symptoms in themselves should talk to a treatment provider right away.

These posts are for informative purposes only and should not be used as a substitute for consultation with and diagnosis by a medical professional. If you are experiencing any of the symptoms described above and have yet to consult with a doctor, do not use this resource to self-diagnose. Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.

References:

Medscape, http://emedicine.medscape.com
National Institute of Mental Health, https://www.nimh.nih.gov
WebMD, http://www/webmd.com/
[1] U.S. Department of Veterans Affairs, PTSD: National Center for PTSD, How Common Is PTSD?, https://www.ptsd.va.gov/public/ptsd-overview/basics/how-common-is-ptsd.asp
[2] U.S. Department of Veterans Affairs, PTSD: National Center for PTSD, PTSD and DSM-5, https://www.ptsd.va.gov/professional/PTSD-overview/dsm5_criteria_ptsd.asp
[3] Myers, Michael, MD, PTSD in Physicians, Psych Congress Network, Sept. 16, 2015, https://www.psychcongress.com/blog/ptsd-physicians
[4] Lazarus, A., Traumatized by practice: PTSD in physicians, J Med. Pract. Manage., 2014 Sept-Oct; 30(2): 131-4.
[5] DeCarvalho, Lorie T., PhD, U.S. Department of Veterans Affairs, PTSD: National Center for PTSD, The Experience of Chronic Pain and PTSD: A Guide for Health Care Providers,  https://www.ptsd.va.gov/professional/co-occurring/chronic-pain-ptsd-providers.asp

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Dealing with the Demands of Dentistry: It’s Ok to Ask for Help

Dentistry is not an easy profession.  The clinical aspects of dentistry are physically and emotionally demanding.  Performing repetitive procedures and holding static postures for prolonged periods of time can leave dentists feeling mentally drained, sore and fatigued.  And given the frequent exposure to patient anxiety and the need for precision when performing dental procedures, it is not uncommon for dentists themselves to develop anxiety about causing pain to patients or making a mistake when performing a procedure.

The other aspects of dentistry are no less challenging.  Many dentists work long hours, which makes balancing work, family, and other responsibilities difficult.  Other stressors include difficult and uncooperative patients, dissatisfied patients, finances, business problems, collecting payments, paperwork/bureaucracy, time pressure, cancellations, no-shows—the list goes on and on.  And that is not even taking into consideration major stressors, such as staff issues, board complaints, audits, and malpractice lawsuits.

When presented with these difficulties, dentists can become anxious and depressed.  Some even seek out mood altering drugs and/or begin to abuse alcohol, in an effort to alleviate the stress.

Thankfully, there are resources available where dentists can turn to for help.  Most dental associations have a subcommittee or group designed to provide confidential help to dentists struggling with emotional, mental and/or substance abuse issues.

For example, the Arizona Dental Association (AzDA) has a group called the Dentists Concerned for Dentist Committee (DCD).  The DCD is a group of fellow dentists who work with other dentists to help them with substance abuse problems, with an emphasis on “cure and return to practice.”  When the DCD is contacted, everything remains strictly confidential, and the State Board is not notified.  As explained by the DCD, “[t]here should be no grief or shame in seeking help.”  Accordingly, DCD records are “sealed and cannot be accessed by anyone.”

If you are a dentist in Arizona struggling with substance abuse, or you know a dentist who is, consider contacting the AzDA so that a referral can be made to the DCD.  You can find the contact information for the AzDA here.

If you live outside Arizona, consider contacting your local dental association to see if it has a similar program.

Remember, it’s ok to ask for help.

References:

“When Life Feels Just Too Hard,” INSCRIPTIONS, Vol. 30, No. 8 (August 2016) at p. 24.

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Case Study: Mental Health Disability Claims – Part 1

In a previous post, we have discussed how ERISA claims are different from other disability claims. We have also looked at an ERISA case involving “abuse of discretion” review. However, there is another type of review under ERISA—“de novo” review. Unlike abuse of discretion review, under de novo review, the court assesses the merits of the disability claim without affording any deference to the insurer’s decision. Whether your claim is governed by abuse of discretion review or de novo review will depend on the terms of your plan. An experienced disability attorney can look at your disability insurance policy and let you know which standard will apply.

In this post, we will be looking at two things. First, we will be looking at a case where the court reversed the denial of disability benefits under de novo review. Second, we will be looking at some of the issues that commonly arise in mental health disability claims. In Part 1, we will be looking at the initial determination made by the court regarding whether the claimant was entitled to disability benefits. In Part 2, we will be looking at how the court determined the amount of disability benefits the claimant was entitled to.

In Doe v. Unum Life Insurance Company of America[1], the claimant was a trial attorney with a specialty in bankruptcy law. After several stressful events, including his wife being diagnosed with cancer, claimant started experiencing debilitating psychological symptoms. The claimant was ultimately diagnosed with anxiety, major depression, obsessive compulsive disorder (OCD), attention deficit hyperactive disorder (ADHD), obsessive compulsive personality disorder (OCPD), and Asperberger’s syndrome. He filed for long term disability benefits, but the insurer, Unum, denied his claim. The court reversed Unum’s claim denial under de novo review, for the following reasons:

  • First, the court found the opinions and medical records of the claimant’s treatment providers to be “reliable and probative.” Id. More specifically, the court determined that claimant’s conditions fell within the expertise of the treating psychiatrist and that the psychiatrist’s conclusions were corroborated by neuropsychological testing.
  • Second, the court determined that the opinions provided by Unum’s file reviewers were not credible or reliable. The court noted that while Unum’s in-house consultants claimed that the neuropsychological testing did not provide sufficient evidence of disability, the single outside independent reviewer hired by Unum concluded the opposite and determined that there was no evidence of malingering and that the tests were valid.
  • Finally, the court rejected Unum’s argument that claimant’s psychiatrist should have provided more than a treatment summary. The court determined that this was “a problem of Unum’s own making,” because the evidence showed that Unum expressly stated in written correspondence that it was willing to accept a summary of care letter in lieu of the claimant’s original medical records.

Stay tuned for Part 2, where we will look at how much benefits the claimant actually ended up receiving.

[1] No. 12-CV-9327 LAK, 2015 WL 4139694, at *1 (S.D.N.Y. July 9, 2015).

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Are Insurance Companies Discriminating Against Mental Health Claims?

In previous posts, we have noted that disability policies often limit the disability benefits available for claimants who suffer from mental health disorders. For example, many policies limit recovery under a mental health disability claim to a 2 or 3 year period. In contrast, most disability insurance policies provide benefits for physical disability claims to age 65, and some policies even provide lifetime benefits for physical disability claims.

Recently, Representative Ruth Balser has introduced a bill in the Massachusetts state house that would prohibit insurance companies from treating behavioral health claims differently from physical impairment claims. According to Representative Balser, offering shorter benefit periods to claimants with mental health disorders is discrimination.

Supporters of the bill contend that the way that disability insurers currently handle mental health is based on stigmas and ignores available treatments options.  Supporters of the bill also argue that the bill will reduce government costs because individuals with mental health issues will no longer need to rely on Social Security or government welfare programs.

The insurance industry’s response is that requiring insurance companies to provide more coverage will cost businesses money because it will limit available options when buying insurance and force them to buy coverage that they do not want. The insurance companies also argue that the bill will actually result more people relying on government programs because they will not be able to afford the increased levels of coverage.

At the moment, the bill is still being considered in committee, so it has not yet become law. However, if the bill is ultimately passed, it could significantly alter the way insurance companies treat mental health disability claims, particularly if other states pass similar laws.

For more information, see http://www.milforddailynews.com/article/20151016/NEWS/151017038.

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