By Elisse A. Blinder, Ph.D., QME
and Michael C.C. Lilienfeld, Director of Forensic Services
Let's consider two sides of Personality Traits; but ... to apportion or not to apportion? ... that is the question.
The answer is ... it depends; and the reality is that each side may discover that the findings fall in their favor in this regard.
Personality Traits are enduring aspects of a person's character that form in childhood. Many traits are unconsciously driven by various internal, unknown motivations. They are fairly hard-wired so to speak, and typically difficult to change. Many traits have both positive and negative components to them.
There are several Personality Traits we commonly find in Workers' Compensation applicants. More rarely do we find a full-blown Personality Disorder, but that is a topic for another discourse.
Among the most frequently encountered traits are Dependent, Histrionic, and Obsessive-Compulsive. When we note the presence Personality Traits, but not a formal Personality Disorder, on Axis II, the claimant would be expected to have some, but not all, of the characteristics associated with the particular personality constellation, which thereby creates a personality "style" in any given individual.
For example, all of us (psychologists, psychiatrists, attorneys) reading this blog, inherently have some Obsessive-Compulsive Personality Traits. One cannot possibly get through graduate school without some of the more helpful aspects of the obsessive traits: a capacity for order, organization, punctuality, conscientiousness, and productivity, to name a few.
According to DSM-IV-TR, Dependent Personality Traits are manifest in a pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation. The individual may have difficulty making everyday decisions without an excessive amount of advice and reassurance from others and may need others to assume responsibility for most major areas in his or her life. The individual may have difficulty expressing disagreement with others because of fear of loss of support or approval. There may be difficulty initiating projects or doing things on one's own (because of a loss of self-confidence in judgment or abilities rather than a lack of motivation or energy.) The individual tends to go to excessive lengths to obtain nurturance and support from others, even to the point of volunteering to do things that are unpleasant. There may be a feeling of discomfort or helplessness when alone because of exaggerated fears of being unable to care for him or her self. There may be a tendency to urgently seek another relationship as a source of care and support when a close relationship ends. The individual may be unrealistically preoccupied with fears of being left to take care of him or her self.
So often in a mental/mental case, we encounter a claimant who tells us a "horror story," working under conditions that a more emotionally developed individual would not long tolerate. They may well have been afraid to speak up because of fears of loss of support or approval. The individual continues to endure an alleged hostile work environment or perceived mistreatment. They do not seek employment elsewhere. So often these individuals tell us about four or five other co-workers who left because they could not stand working with the "perpetrator." Those folks had the wherewithal to take care of themselves.
The result is an injury to the psyche of someone with Dependent Traits, whereas someone without such traits may simply have sought other employment. So are these traits causal factors? No, not in and of themselves. Are they apportionable in terms of Permanent Impairment? Maybe. Typically, we'd be in a better position to judge this after the claimant has undergone a course of treatment and we see if there is any progress. If there is some progress, then apportionment would be less likely warranted. But if there is little or no progress, then apportionment to the traits should be considered.
Histrionic Personality Traits are manifest by pervasive patterns of excessive emotionality and attention-seeking. Histrionic individuals are uncomfortable in situations in which they are not the center of attention. Interaction with others is often characterized by inappropriate sexually, seductive, or provocative behavior. Such individuals tend to display rapidly shifting and shallow expressions of emotions and consistently use physical appearance to draw attention to themselves. There may be a style of speech that is excessively impressionistic and lacking in detail. Histrionic individuals tend to show self-dramatization, theatricality, and exaggerated expression of emotions. They tend to be suggestible and easily influenced by others or circumstances. Often they consider relationships to be more intimate than they actually are. They tend to lack insight into their own behavior and often use repression or denial, as well as somatization, as coping mechanisms.
What we see most often in the Workers' Comp arena is Histrionic Traits fueling a process of somatization. Often, but not always, there is an elevation of Histrionic patterns on the MCMI-III. Similarly, often, but not always, we find a "Conversion V" on the MMPI-2, (Hs and HY scales above the first standard deviation, D in-between them and below those levels). Also, we may see an elevation on the RC1 scale. We often see exaggeration on the FBS scale. Histrionic Traits do not, as a rule, cause physical pain or mental disorders in and of themselves. However, quite frequently, we find Histrionic Traits in individuals who exaggerate their level of pain and make it hard for such an individual to imagine that they could engage in some type of meaningful work that would not increase their pain. A claimant with a mental/mental case may present with engaged Histrionic Traits; their experiences having caused such things as headaches, insomnia, gastrointestinal complaints, and the like. Often we see this in orthopedic sequelae cases as well, along with exaggerations of pain perception (the key word is "perception," these people are not consciously lying).
In some cases, it may be appropriate to apportion to Histrionic Traits, while in others it may not. We need to be mindful of several factors. Are the traits increasing the level of depression that we would otherwise see? If they are, then some minimal apportionment may be indicated. Why not greater levels of Apportionment? Because, absent the predominant mechanism of injury, the traits would not be negatively engaged. Why not less Apportionment? Because the traits do make treatment responsiveness more difficult, and do contribute to sustaining ongoing emotional distress. How much apportionment is appropriate is a clinical art.
Obsessive-Compulsive Personality Traits are manifest by a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, sometimes at the expense of flexibility, openness and efficiency. Such individuals may be preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost. Their perfectionism can interfere with task completion. They have a sense of duty and may be excessively devoted to work and productivity to the exclusion of leisure activities and friendships. They tend to be overly conscientious, scrupulous and inflexible about matters of morality, ethics or values. They are often reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things. They frequently show rigidity and stubbornness. Obsessive-Compulsive individuals, because they have a good work ethic, tend to be conscientious employees and to be over-identified with their career or professional life.
Thus, many obsessive traits have both positive and negative sides to them.
Most often we see obsessive traits in people who have been very dedicated workers. When O/C Traits turn against an injured worker, the negative turn generally may warrant apportionment, but it can be a challenge to sort out the sequelae of the actual injury from the aspects of the individual that are working against their own reconstitution. For instance, in an individual with perfectionism, we may see a bigger drop in self-esteem than in someone without this driving quality; thus, we find someone engaged in more self-criticism for the loss of their role identity. The injury in a person with this quality, therefore, is greater; not dissimilar to the way in which a 105-pound woman might be more injured by a ceiling tile falling on her shoulder than would be a 195-pound athletic man. Intuitively, no one would apportion the greater injury to the woman's physicality ... this is simply part-and-parcel of seeing each person as a unique individual. Sometimes though, the negative turn is so great as to entrench the claimant much more permanently in thinking that they are "damaged" and, therefore, unable to disengage from the sick role. Obviously in someone like this, there would be more permanent psychological or psychiatric impairment than in someone whose traits did not turn on them so dramatically. Thus, an argument for Apportionment of disability.
These are but a few examples of how the complexities and nuances of one's characterological make-up may have an impact on both injury and impairment. While the more extreme versions of personality pathology are evident for obvious apportionment, it is much more of a challenge for the forensic examiner to not only identify these Personality Traits, but also, to determine how and why they may or may not play a part in the medical-legal picture.