After the attack

Risk & Insurance, Feb, 2002 by Peter Rousmaniere, Jennifer Dr. Christian

The terrorist attack and anthrax-related deaths may create thousands of cases of posttraumatic stress disorder, along with many other types of mental stress cases. How many of these will translate into workers' comp claims or other employee absences is a question now haunting employers and insurers.

Posttraumatic stress disorder (PTSD) is real. Commonly associated with soldiers, it is an unfortunate, serious, and sometimes predictable consequence of people being in a traumatic situation that overwhelms all their usual coping mechanisms. Within the British Army it was called "old sergeant's disease," in the American Civil War people called it "irritable heart," and in World War II it was referred to as "battle fatigue."

Today, the formal definition of the American Psychiatric Association describes it as a disorder resulting from past exposure to traumatic experience, normally a major, unexpected, and fearful event. PTSD is not just an extravagant way to describe normal emotional responses to tragedy. Most Americans had symptoms of stress, anxiety, and trouble sleeping and concentrating in the period immediately following September 11, with 44 percent reporting substantial stress, according to a RAND survey conducted the weekend following the attack. Many still remained upset in early October, with nearly a quarter reporting they were very worried or had difficulty sleeping, according to a Pew Research Center survey.

The September terrorist attack and anthrax-related deaths may create thousands of cases of posttraumatic stress disorder. But there also is a significant risk that PTSD will be over-diagnosed in the aftermath of September 11 as it can be difficult to differentiate it from other, less severe psychological reactions.

Rather than an immediate response to a horrible event, (grief, shock, rage, etc.), PTSD is a late response--by definition it develops at least a month after the stressor event. The sufferer usually has a kind of bottled-up or stalled-out initial emotional response, and the stress disorder is the result of that abnormal reaction--and may have unfortunate effects for a lifetime.

Many state statutes or case laws exclude purely mental injury claims (so-called "mental-mental" claims) from workers' compensation, and most group health plans limit mental health services. Ed Welch, a former director of the workers' compensation bureau in Michigan who now directs educational programs from Michigan State University, asserts that the main reasons for such prohibitions in workers' compensation are an underlying prejudice against mental claims and a long-standing belief that it is especially difficult to pinpoint the cause of mental disabilities.

How Many Cases?

One of the most pressing questions for the workers' compensation industry is predicting the number of mental claims that will be connected with the events of September 11. Walter Penk, a Boston-area psychologist who has studied PTSD for decades for the Veterans Administration, told us that human-caused threats to one's sense of safety seem to cause relatively more cases of PTSD. Hypothesizing about a work force within 1,000 feet of the World Trade Center at the time of the attack, Dr. Peak said it would not be unreasonable for 20 percent to develop PTSD, "particularly if they were close enough to have been evacuated under threat to their lives and were eyewitnesses to death."

Drawing from the research community's findings in recent decades, he noted that "the risks of developing PTSD rise with age, but decline with higher educational level and higher quality of social supports to buffer threats and anxieties. The knowledge of being covered financially for health care is another form of support and comfort that tends to assuage symptoms. Those who are able to resume their work routines are those less likely to develop PTSD."

And there is the ill wind of earlier trauma. "I'd predict," he went on, "that half of the positive cases from the terrorist attack will have had prior exposure to trauma, such as violence and sexual abuse." Current events will awaken emotional reactions to memories of previous traumas--temporarily aggravating or permanently exacerbating underlying emotional problems in vulnerable employees.

How do mental stress cases develop in a community at large? We turned to Esther Giller, president of the Baltimore-based Sidran Traumatic Stress Foundation, which focuses on professional training and public awareness of PTSD.

She has studied reports by the University of Oklahoma College of Public Health, the Gallup Organization, and the local crisis counseling service. They found a 41 percent rate of mental conditions among people they called victims of the bombing in Oklahoma City. These were any occupant of a building or an outdoor area where physical injury may have occurred, office workers who were not present at the time, and immediate family members of all the direct victims. Rescuers had a 20 percent rate. These include firefighters, police, emergency service, physicians, nurses, and any civilians helping directly in the crisis period. Most of the conditions were PTSD, depression, and substance abuse.