Problems in the assessment of psychosomatic conditions in social security benefits and related commercial schemes

Journal of Psychosomatic Research, Vol. 39, No. 6, pp. 755 765, 1995 Copyright © 1995 Elsevier Science Ltd Printed in Great Britain. All rights reserved 0022 3999•95 $9.50 +.00

Pergamon 0022-3999(95)00037-2

PROBLEMS IN THE ASSESSMENT OF PSYCHOSOMATIC CONDITIONS IN SOCIAL SECURITY BENEFITS A N D RELATED COMMERCIAL SCHEMES* M A N S E L A Y L W A R D a n d J O H N J. L O C A S C I O Abstract--The medical community must recognize that support of claims for Incapacity Benefit and related commercial schemes places the patient in a small and special sub-population of clinical practice which may require specialist investigation, treatment, and documentation. Determination of functional capacity and of disability requires knowledge either not available or unfamiliar to most physicians with caring and therapeutic roles, especiallyof legal or contractual provisions and occupational data. However, it is not necessary for them to determine disability and they should not be asked to do so. The new, medical assessment procedures for Incapacity Benefit in the UK do not require this, and the largest provider of related commercial schemes (Long Term Disability; Permanent Health Insurance) has already eliminated this requirement from its application process. When such application is anticipated or requested, the medical record should be prepared and appropriate consultation obtained. Subjective issues should be identified and addressed. Comprehensive psychiatric evaluation, especiallyin subjectiveimpairment, is critical in chronic incapacity. The estimation of functional capacities in the absence of objective data is particularly troublesome, but, clinicians can provide the Disability Medical Analyst with appropriate medical documentation.

Keywords: Incapacity; Disability; Functionalcapacity; Somatization; Social Security Benefits;Permanent Health Insurance.

SOCIAL SECURITY AND INCAPACITY BENEFITS

Difficulties in the assessment of claims both for Social Security Benefits and related commercial schemes which rest primarily on subjective complaints pose a very c o n s i d e r a b l e challenge. Before discussing capacity assessment we first set the scene by describing those U K Social Security Benefits which require some form o f medical input. Whilst the specific points are applicable only to the British benefit system they illustrate general principles which are applicable to m a n y other countries. There are three principal types o f Social Security Benefits in the British system: a. C a t e g o r y Benefits I n d u s t r i a l Injuries Scheme (Industrial Accidents a n d Prescribed Diseases) Severe D i s a b l e m e n t A l l o w a n c e (SDA) Disability Living A l l o w a n c e ( D L A )

Address for correspondence: Dr Mansel Aylward, Principal Medical Advisor, Department of Social Security, Room 06/25 Adelphi, 1-11 John Adams Street, London WC2N 6HT, UK. Address for reprints: Dr John LoCascio, 2nd Vice President and Medical Director, Unum Limited, Milton Court, Dorking, Surrey RH4 3LZ, UK. * The views expressed in this paper are not necessarily those of the Department of Social Security. 755

756

M. AYLWARDand J. J. LOCASCIO Disability Working Allowance (DWA) Attendance Allowance (AA)

b. Insurance Benefits Incapacity Benefit (IB) replaces Sickness Benefit (SB) and Invalidity Benefit (IVB) from 13 April 1995 c. Means-tested Benefits Income Support

Category Benefits In those paid under the Industrial Injuries Scheme and Severe Disablement Allowance (SDA), the recognition and assessment of disablement rests upon a quantification of the effects of loss of faculty (loss of faculty is the loss of power or function of an organ of the body. It is not in itself a disability). In Disability Living Allowance (DLA) and Attendance Allowance (AA), which are concerned with care needed by the disabled person, eligibility criteria are based upon the needs for attention or supervision resulting from mental or physical disablement. They do not require a knowledge of the disabled person's capacity for remunerative work.

Insurance Benefits Separate provision in the form of insurance benefits exists within the British Social Security System to meet income-replacement needs of people who suffer loss of earnings or reduced earnings capacity arising from disablement. These incapacity benefits provide income replacement for chronically sick or disabled people who, because of their medical condition, could not be expected to work. Since April 1995, Incapacity Benefit has replaced Sickness Benefit and Invalidity Benefit and is based on two new tests of medical incapacity: an Own Occupation Test, and an 'All Work'

Test. For the vast majority of spells of sickness absence from work during the first 28 weeks of medical incapacity Statutory Sick Pay is received by most employees. The test here is whether the person is capable of following the usual occupation. In the majority of cases an 'All Work' Test is appfied after 28 weeks of medical incapacity. For the 'All Work' Test of medical incapacity a threshold for benefit has been set at a level where it would be unreasonable to expect someone to work because of the effects of their medical condition, and not the level at which work becomes impossible. It is an objective assessment of incapacity for work, assessing a person's medical condition against a common standard of the physical, sensory and mental capabilities required to work. In April 1992 Disability Working Allowance (DWA) was introduced alongside Disability Living Allowance (DLA) and Attendance Allowance (AA). This allowance differs from previous disability income-replacement benefits in that it is targeted at disabled people who wish to do some work and also receive benefit. It is designed to provide both long-term help for people who have a significant disability, and also short-term rehabilitative help for people recovering from an illness. Benefits under the Industrial Injuries Scheme may be payable to employees who become disabled either as a result of an accident arising out of, and in the course

Psychosomatics and functional assessment

757

of employment, or who develop a disease in their job which is on a list of Prescribed Industrial Diseases. Assessments of disablement for industrial injuries purposes are carried out by adjudicating medical authorities (AMAs). These are independent statutory authorities consisting of one or two doctors. The AMA has to decide what injuries resulted from the accident, and respond to three disablement questions: (i) Whether the accident has resulted in a relevant loss of faculty? (ii) At what degree is the extent of disablement resulting from a loss of faculty? (iii) What period is to be taken into account by the assessment. Assessment of disablement in Prescribed Diseases is made in the same way as for accident cases. However, before the AMA can assess disablement it must decide whether the diagnostic requirements for the Prescribed Disease are satisfied. In conclusion we can see that although medical assessment and examination will have a pivotal role in determining the degree of disablement in benefits paid under the Industrial Injuries Scheme and for SDA, and in resolving the question of capacity for work in Incapacity Benefit, the introduction of DLA, AA and DWA moved away from medical examination as a principal source of information towards a principle of self-assessment by the disabled people themselves and those caring for them.

Means-tested Benefit Income Support is the principal benefit under this heading; eligibility for which is not dependent on medical or disability issues.

THE GROWTH OF BENEFIT

Over the past decade, there has been a dramatic growth of claims on governmental and commercial programmes for the effects of disability or chronic illness. The new, more objective Medical Assessment for Incapacity Benefit [1] described above must be viewed against this background as must the similar schemes offered by insurers (Long Term Disability or LTD; Permanent Health Insurance or PHI). Statistics from the Department of Social Security of the United Kingdom dramatically illustrate the very substantial increases in the numbers of people receiving Invalidity Benefit (IVB) by diagnostic categories (Fig. 1). It is unlikely that the changes have been due to increases in the prevalence or severity or diminution of the effectiveness of treatment. It is more probable that: "Attitudes and behaviour in society are changing rapidly and for physicians working in industry and commerce the changes tend to be quicker and more radical than elsewhere. Ethics, as a code of conduct, must take account of these changing attitudes and also of legal standards" [2]. We believe that the increase in the number of people receiving Invalidity Benefit (IVB) is due to a major cultural shift in medical practice. 'Subjective' impairments

758

M. AYLWARD and J. J. LOCASCIO

700000

Male days of incapacity Analysed by cause for the years 1984 to 1993

600000 500000 400000 300000 200000 100000 0 1984/5 1985/6 1986/7 1987/8 1988/9 1989/90 1990/91 1991/92 1992/93 Year IOther

Ieirculatory

IMental~Nervous

IMusculoskeletal

~Respiratory

~lnjuries

~Totalcauses

Fig. 1

(i.e. those such as weakness, dizziness and poor concentration which even with best medical efforts cannot be objectively quantified), which in the past have been considered an insufficient basis for chronic, total incapacity, are now increasingly cited as the sole manifestation of a variety of conditions which feature prominently among claims for Incapacity Benefits and Long-term Disability. In the US these submissions have occurred with such frequency that they have come to the attention of the courts in the context of the uniform appeals process for Social Security Disability Insurance [3]. Recent years have seen a proliferation of non-specific syndromes and diagnoses defined in terms of symptoms rather than physical aetiology (e.g. chronic pain and fatigue syndromes). This proliferation of subjective claims has serious implications for the economic as well as the physical health of our society. Unfortunately an expanding and confusing terminology ('hypochondriasis', 'hysteria', 'functional overlay', 'somatization', 'malingering', 'illness behaviour', etc.) has impeded rational consideration. The establishment of a comprehensive and reasoned approach to judging the functional impact of 'subjective' impairment has become an issue of great importance. We now present such an approach and advocate its application in all clinical situations requiring physicians to estimate functional capacities.

A PROPOSED CLINICAL STANDARD The Americans with Disabilities Act is based upon the concept: diagnosis never equals disability. Legal controversies notwithstanding, this is a familiar medical principle. For example physicians routinely support patients with uncomplicated diabetes or controlled seizures in their application for employment. However, where

Psychosomaticsand functionalassessment

759

disablement occurs, it must be shown to be a result of the effect of the medical condition for the award of benefit to occur. We propose the following test: For long-term disability~incapacity benefit, the effects of the medical condition and its resultant disabilities must be of such a severity, so prolonged, and sufficiently resistant to therapy that no practical alternative exists. Application of this test depends upon a standard terminology for functional capacity assessment:

Functional Impairment Functional Limitation Functional Restriction Functional Capacity

The reduction of function in, or loss of, a body part or system. What a person cannot do because of illness or injury. What a person should not do because of risk (of recurrence, delayed healing, or injury to self or others). The ability (mental, physical or sensory) to perform a particular task or activity.

The demonstration of a reduced functional capacity is not equivalent to disability. The latter depends upon demonstration that: (a) (in the social context) a person is unable to perform a normal bodily or mental process as well as a person of the same age and sex who is in good health; or (b) (in the occupational context) a person is unable to perform a material and substantial duty of a contractually defined occupation. It is the role of the Disability Medical Analyst (DMA) to apply these principles and provide reasoned, authoritative opinions of functional capacity. As Fig. 2 illustrates, the actual determination of disability requires additional contractual and occupational data and is usually the responsibility of a non-medical adjudicator. Only under special circumstances, such as eligibility for Prescribed Diseases Under the Industrial Injuries Scheme, or application of Pre-existing Clauses in Commercial Schemes is diagnosis a primary focus. More usually, diagnosis is no more than an explanation of the basis of an impairment; impairment and resultant functional incapacity can be documented even in the absence of an established diagnosis. However, the absence of an accepted medical diagnosis implies a high degree of subjectivity. In such cases the application of the principles of functional analysis is particularly important.

PSYCHIATRIC CONDITIONS In the long-term, severe functional disability is invariably associated with psychological disturbances as primary and secondary ICD and DSM Axis 1 Diagnoses [4] must be identified. Even in the absence of diagnosable disorders, subjective impairment resulting in claims for Incapacity Benefit or Long-term Disability (PHI) requires rigorous psychiatric analysis.

760

M. AYLWARDand J. J. LOCASCIO

Functional Capacity Assessment Diagnosis Medical Model Impairment/Lossof Faculty

Restrictions and/or Limitations

}

Disability Model

Functional Capacity

Disability/Incapacity <

Occupationaland Legal Data Fig. 2

We believe that formal psychiatric evaluation should always be considered for the patient with a chronically disabling condition and especially so in cases where 'subjective' issues dominate the picture of incapacity, for four main reasons: (1) Acute psychiatric diagnoses are treatable and have occasionally been missed by the Primary Care Physician. (2) Adequate treatment of all conditions must be documented to fulfil the clinical standard. (3) Some syndrome diagnoses require the appropriate assessment of psychiatric aetiology and morbidity (e.g. Chronic Fatigue Syndrome [5-7]). (4) Even in the absence of overt psychopathology, disproportionate impairment requires the thorough evaluation of: Personality (Axis 2) Disorders and personality traits Symptom reporting behaviours symptom magnification somatization 'Secondary gain'

Psychosomaticsand functional assessment

761

Objective impairment, such as the loss of a limb, is easily conceptualized and accurately reported. Loss of strength of a muscle group may be more difficult to quantify, but in both the U K and the US, examination centres are increasingly available to address that goal. Subjective impairment, as in psychiatric disorder, is quite a different matter in that the examiner must rely on the patient's description of feelings, symptoms, and behaviours, and must in turn exercise judgement as to the severity of their functional consequences. The special status of psychiatric diagnosis derives from the availability of detailed, standardized diagnostic criteria and a large body of'experts' trained in the application of these criteria. The highly developed psychiatric diagnostic systems assist the DMA in determining the reasonableness of expert opinion and the likely impact of the reported impairment with minimal recourse to the cumbersome assessment tools required by other subjective claims. When 'subjective' impairment exists in pure form it is more likely to be recognized as such by the clinician. Some diagnoses are purely subjective by definition (e.g. The Centers for Disease Control of the US Government have issued criteria defining the Chronic Fatigue Syndrome [5-7]). However, subjective issues are more difficult to recognize and evaluate when objective findings support some degree of impairment, but the relationship to the severity of disablement in the particular case is unclear [8]. Such situations are common in both disability and clinical assessment. A familiar example is the case of a person with a sedentary job who recovered well from a laminectomy and remained asymptomatic for years, only to have back pain recur and produce significant disability. In the absence of detectable physical changes, this person will display disproportionate symptoms. If the expected degree of impairment would not prevent gainful employment but the reported impairment does, then clinicians, asked to support an application for Incapability Benefit or LTD, are faced with a difficult clinical problem. The difficulty clinicians encounter managing such situations has resulted in the establishment of multispecialty clinics for their evaluation. Although originally applied to chronic pain, the principles of analysis pioneered by these clinics can be applied in the course of functional analysis to any subjective impairment. This method is schematically depicted in Fig. 3. This process is consistent with the axiom 'diagnosis does not equal disability' in that it emphasizes that psychiatric assessment is a necessary component o f analysis even in the absence o f an Axis 1 or Axis 2 diagnosis. The importance of consistency and consensus

The principle of consistency utilized in psychometric testing can be applied to functional analysis. Impairment of any kind should have consistent effects regardless of the setting. For example, a person who is limited in the ability to make rapid finger movements should have similar difficulties across pertinent functional capacities such as the use of a keyboard and a piano. A person who is limited to sitting for short periods should have equal difficulty in the office and when driving a motor vehicle. Consistency of behaviour across functional capacities is a well established clinical principle [9] that can be applied to the functional analysis of behaviours resulting from either objective or subjective impairment.

M. AYLWARDand J. J. LOCASCIO

762

The Subject Claim

Diagnosis I or Impairment

I

Objective

I

Restrictions and Limitations

I

Subjective

I

1

Restrictions and Limitations

I

Functional Capacity Fig. 3

It is important to note that lack of consistency must be distinguished from repeated exacerbation and remission as typically occurs in chronic, recurrent conditions such as bronchial asthma and rheumatoid arthritis. In such conditions, exacerbation and remission of symptoms are almost invariably associated with corresponding variations in easily obtainable objective findings. The problem then becomes one of pattern recognition and detailed documentation. Consensus is a concept which, in the setting of functional analysis, implies agreed expert opinion. If the DMA is to feel confident that chronic and severe impairment is present despite the absence of objective findings, then it must be made evident that medical science has exhaustively explored all reasonable diagnostic and therapeutic avenues. This can only be demonstrated by multiple and complementary opinions. If we return to the example of recurrent back pain, then it is best to seek opinions from some combination of GP, neurologist, orthopedist, neurosurgeon, psychiatrist, rheumatologist and consultant in rehabilitation medicine (in the US: physical medicine and rehabilitation [PM&R] physician).

763

Psychosomatics and functional assessment

Multi Disciplinary Model Functional Syndrome eg chronic pain, fatigue

I Objective Data

Subjective Data

Psychiatric Data • • • •

S y m p t o m Reporting Behaviours S y m p t o m Magnification Somatization Secondary Gain

I v

Consultant

I Restrictions and Limitations

Functional Capacity Fig. 4

The presence of symptoms in excess of physical findings means that, part of the assessment of functional impairment must be based solely on those symptoms. Most physicians will protest that they are capable of accurately judging the reliability of reported symptoms. They are correct in the vast majority of cases. However, claims for Long Term Disability or Incapacity Benefit are not representative of the vast majority of cases seen in clinical practice, but are an extremely small atypical subpopulation. SYMPTOM REPORTING

Figure 4 illustrates the type of psychiatric input required from the psychiatric examiner and from standardized neuropsychiatric testing. It is the duty of the DMA to help the psychiatric examiner by indicating what is required:

764

M. AYLWARD and J. J. LOCASCIO

• distinguishing objective from subjective issues, • requesting analysis of symptom reporting behaviours even in the absence of Axis 1 or Axis 2 diagnoses, and • providing the best clinical data base possible within the limits of the particular benefit program. MALINGERING

Malingering represents a dilemma both for clinician and DMA because the definition of malingering requires the demonstration of intent to deceive. While it is widely acknowledged, malingering occurs in a small minority of patients and applicants for benefit, documentation of intent can rarely be provided by medical evidence. We submit that a clinician or DMA can offer a convincing argument that a particular patient is safely capable of more than the history would indicate. It can also be shown that such a patient is in all probability capable of patterns of activity based upon the behaviours and abilities typical of the clinical group to which the objective and subjective evidence assigns them. For example the vast majority of patients with laminectomies remain capable of sedentary to light work as defined in the Dictionary of Occupational Titles of the US Department of Labor. Having done this, however, the DMA or clinician can leave determination of intent to others better equipped to document such a judgement. CONCLUSION

Increasingly, physicians feel uncomfortable in determining incapacity and longterm disability [10]. We believe they should not be asked to do so. Such determinations require knowledge of legal and contractual provisions and occupational data. Thus for this reason the new Medical Test for Incapacity Benefit does not require the physician to so certify and the largest carrier of related commercial schemes in the UK has already eliminated this requirement from its application process. However, clinicians, including psychiatrists and psychologists can provide useful information about individual patients and can also clarify the underlying concepts about psychiatric disorder and psychological contributions to disability. In this age of tight budgets, many clinicians will strenuously object to the use of expensive resources to document disability. However, in contributing to assessing claims for long-term benefit the clinician will have helped the small sub-population whose normal life activities are devastated by medical impairment, and who require the support of the society to provide for basic necessities for the rest of their lives. How better could medical resources be expended? REFERENCES 1. DEPARTMENT OF SOCIAL SECURITY. The Medical Assessment for Incapacity Benefit. London: 1994. 2. COX RAF, EDWARDS FC, McCALLUM RI. Editors. Fitness for Work. Second Edn. Appendix 6, 1.1. Oxford: Oxford University Press, 1995. 3. F O S T E R v. H E C K L E R , 780 F.2d 1125 (4th Cir. 1986).

Psychosomatics and functional assessment

765

4. AMERICAN PSYCHIATRIC ASSOCIATION. Diagnostic and Statistical Manual of Mental Disorders, Four Edn, Washington, DC: American Psychiatric Association, 1994. 5. HOLMES GP, KAPLAN JE, et al. Chronic Fatigue Syndrome: a working case definition. Ann Intern Med 1988; 108: 387-389. 6. SCHEUDERBERG A, STRAUS SE, et al. Chronic Fatigue Syndrome Research: definition and medical outcome assessment. Ann Intern Med 1992; 117: 325-331. 7. F U K U D A K, STRAUSS SE, et al. The Chronic Fatigue Syndrome: a comprehensive approach to its definition and study. Ann Intern Med 1994; 121:953 959. 8. JENSEN MC, BRANT-ZAWADSKI MN, et al. Magnetic Resonance Imaging of the lumber spine in people without back pain. N Engl J Med. 1994; 331: 69-73. 9. WADDEL G, McCULLOCH JA, et al. Nonorganic physical signs in low-back pain. Spine 1980; 5(2): 117-118. 10. DEPARTMENT OF SOCIAL SECURITY. Research Report No. 18: GPs and IVB, Chapter 4. London, 1993.

SUGGESTED READINGS 1. AMERICAN MEDICAL ASSOCIATION. Guides to the Evaluation of Permanent Impairment, Fourth Edn. Chicago, 1994. 2. WORLD HEALTH ORGANIZATION. International Classification o f lmpairments, Disabilities, and Handicaps. Geneva: World Health Organization, 1993.