Post-traumatic stress disorder in workers' compensation

Post-traumatic stress disorder (PTSD) injuries in workers compensation (WC) have recently attracted the attention of legislators and other system stakeholders. With more focus on compensating those who suffer from PTSD due to a work-related event, it’s important to understand:

• Why PTSD injuries in WC may become more prevalent
• What is the definition of PTSD injuries
• Who is affected
• Where these injuries impact the WC system
• Their potential cost

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Why could PTSD injuries become more significant to WC?

While PTSD and other mental injuries are not common in WC, some experts believe the frequency may rise due to unreasonable workloads, long hours, and poor work-life balance. Several states are exploring expanding PTSD injury compensation, especially for first responders. These typically include firefighters, police officers, and emergency medical technicians, but could possibly expand to occupations such as correctional officers, emergency dispatch operators, and child protective services employees. Florida, for example, recently enacted Senate Bill 376, which provides workers’ compensation indemnity benefits to first responders suffering from PTSD under certain circumstances, and does not require a physical injury to have occurred.

Worker advocates and other groups have raised awareness of PTSD and emphasized the importance of reducing the stigma associated with mental injuries in WC that could increase the number of claims filed and deemed compensable. PTSD now has its own category in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, called “Trauma- and Stress-Related Disorders.” The previous edition classified PTSD as one type of anxiety disorder.

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What are PTSD injuries?

The National Institute of Mental Health defines PTSD as “a disorder that develops in some people who have experienced a shocking, scary, or dangerous event.” To be diagnosed with PTSD, an adult must have all of the following for at least one month:

• At least one reexperiencing symptom
• At least one avoidance symptom
• At least two arousal and reactivity symptoms
• At least two cognition and mood symptoms

As it relates to WC, PTSD injuries are a subset of mental injuries, broadly defined in the following three categories:

• Physical-mental — a physical injury that progresses to include a mental injury or disability
• Mental-physical — a mental condition that causes some physical injury or disability
• Mental-mental — a mental injury or disability that arises without a physical injury

Although PTSD injuries can arise in any of these three categories, to be considered work-related— and thus compensable under WC — a required degree of stress typically needs to be established, unless the state has established a presumption that PTSD is compensable.

Related: Post-Traumatic Stress Disorder – Suffering in silence

Who is at risk?

Any worker witnessing violence or a horrific accident while on the job might develop PTSD or other mental injuries. This may even apply to workers who witness stressful content over video or other media as part of their jobs.

First responders are particularly susceptible to mental injuries, and the incidence of PTSD is estimated to be significantly higher for first responders compared to the general population.

According to the U.S. Department of Veterans Affairs, about 55% of the general population will experience at least one traumatic event in their lives and, as a result, about 7%–8% of the population will have PTSD at some point in their lives. In comparison, the National Center for Biotechnical Information concluded that the prevalence of PTSD among emergency medical technicians (EMTs) is greater than 20%. Various sources have reported the prevalence of PTSD among firefighters to be in the 7%–37% range.

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Where and how do PTSD injuries impact the WC system?

All 50 states and the District of Columbia specifically address WC compensability for mental-mental and mental-physical injuries, either by statute, regulation, and/or case law. WC laws vary greatly across the country, with approximately half of the jurisdictions allowing compensation for mental-mental injuries or illnesses under limited circumstances. Compensable mental-mental injuries must typically be considered extraordinary and the predominant or substantially contributing cause. Other jurisdictions generally allow for compensability only for mental-physical injuries.

Potential cost

WC data on PTSD is not readily available. This is due to both the scarcity of PTSD data in general and the data reporting requirements for WC. In particular, first responders — who likely have a greater exposure to events leading to PTSD — are generally employees of state municipalities and political subdivisions. These employers are often self-insured and not required to report data to the National Council on Compensation Insurance (NCCI). Hence, reliable statistics on mental injury claims and costs are not readily available.

While it’s difficult to pinpoint the exact portion of system costs associated with PTSD, an individual PTSD claim has the potential to be very costly. For example, if a work-related mental injury renders a claimant unable to return to any employment, then the claimant may be eligible for lifetime indemnity benefits. On the medical side, there could be continual psychiatric visits and medications prescribed. There are also potential complications that could result in significant injuries, such as health issues directly related to PTSD, and the possibility that injured workers could harm themselves.

In addition to the potential costs associated with a single claim, catastrophic events such as terrorist attacks and mass shootings can affect many workers simultaneously, which could result in a large number of PTSD claims from a single event.

In summary, although PTSD is more common among first responders, it can affect employees in any industry or location. PTSD injuries can be devastating to injured workers and their families, and have the potential to be very costly for the WC system. PTSD and other mental injuries may become more significant in the future due to increasingly stressful work conditions, greater awareness of these injuries, and broadening WC eligibility requirements. Stakeholders should continue to raise awareness about the impact of PTSD on employees and the WC system.

Related: 10 more issues impacting workers’ compensation in 2018

This piece first ran on NCCI.com, website of the National Council on Compensation Insurance.