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Follow the reasoning of Dr. Julie Armstrong, a clinical and forensic psychologist in Marina Del Ray, Calif. At 17 years old, with a fourth-grade education, Ana (not her real name) walked through mountains with her grandmother from Mexico to enter the United States illegally. She settled in Southern California where relationships with two different men ensued. One relationship involved the abusive father of her three children, and another with a man who was eventually sentenced to prison.

Ana, in her mid-40's, found work for the first time. She sewed automobile upholstery, working heavy fabrics on industrial machinery in a sweatshop. Nine years into her job, she filed a workers' compensation claim in 2009 for pain in her back, shoulder and psyche. Her treating physician, an orthopedic surgeon in the insurer's medical provider network, performed a triple cervical fusion and she returned to work.

She returned to full duty only to be laid off four days later, along with eight other workers. She filed a third claim for orthopedic and psyche injuries and, for the first time, hired an attorney. Her orthopedist then told her she needed rotator cuff surgery.

Armstrong, acting as a Qualified Medical Examiner, saw Ana to assess her psychological complaints and determine industrial causation (or not) and impairment.

Ana, 56, appeared depressed and lethargic. She complained of depression, insomnia social withdrawal, and weight gain. She had moderate chronic pain in her arms and hands.

After an interview, psychological tests found clinical elevations on the depressive, hypochondriac and histrionic scales. Armstrong's diagnosis? Adjustment Disorder with depression, the most common occupational psychological diagnosis today in California. Was this caused by work injury or personal life? Ana's history suggested her personal life as the primary cause. And being fired is not compensable.

But Ana's fortunes changed when Armstrong looked at all the medical records from the orthopedist, but found no reference at all to depression until the visit at which the orthopedist recommended rotator cuff surgery. The interview confirmed that Ana was clearly affected when she learned she had to have a second surgery, and began to fear she would never work again. This connected the data points for Armstrong. "She became depressed when she learned she had to have a second surgery," Armstrong said. "Her job was her only experience of independence; it provided gratification and a sense of productivity. She was deprived of her primary source of personal satisfaction ... ."

Armstrong recommended cognitive behavior therapy and pills for insomnia and depression, and saw Ana again in mid-August. Ana's symptoms had improved, but only somewhat. Working through the impairment formula, Armstrong gave Ana a Whole Person Impairment rating of 12 percent for the psyche injury. A separate orthopedic QME will assign Ana a physical impairment rating. Then Armstrong apportioned the causes. This injury changed Ana.

"I look at Ana's lifelong emotional difficulty," Armstrong said. "I look at the residual orthopedic impairment. I ask if she is able to go back to work."

Armstrong's final apportionment was 60 percent to industrial causes, 40 percent to nonindustrial causes. Would you have done otherwise?

PETER ROUSMANIERE is an expert on the workers' compensation industry. He can be reached at riskletters@lrp.com.

October 1, 2012

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