Oxford Handbook of Occupational Health (2 edn)
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Psychoses due to occupational exposures
Epidemiology
Organic psychosis due to occupational exposures is thankfully unusual, but its very rarity means that the diagnosis may be missed. Historically, exposures in certain industries put workers at risk of organic psychoses or psychiatric effects:
Mirror silvering (mercury)
Manganese mining
Cold vulcanization of rubber (CS2)
Manufacture of organoleads for leaded petrol.
Clinical features
Manganese madness
A syndrome of hallucinations, nervousness, insomnia, emotional lability, (especially inappropriate laughter), compulsive behavior, and altered libido.
Organolead
Insomnia, anxiety, emotional lability, delusions and mania. If exposure is severe, death due to encephalopathy may occur.
Methylmercury
Depression, emotional lability (including inappropriate laughter), and increased response to stimuli (erethism). Neurological deficits, including coarse tremor, dysarthria, ataxia, visual field losses, and peripheral neuropathy, may co-exist.
Carbon disulphide
Irritability, agitation, hallucinations, and bipolar illness.
Causal exposures/industries
Organolead (tetraethyl lead, triethyl lead)
Methylmercury
Manganese: chronic exposure in manganese mining
Aluminium?
Tin (triethyl tin, trimethyl tin)
Organic solvents: e.g. in glues, paints, degreasants
carbon disulphide (CS2)
styrene—boat building
lacquers, varnishes—furniture making
microelectronics industry.
Individual susceptibility
Manganese: adverse effects generally present in susceptible individuals after 6mths exposure. The young appear more susceptible.
Clinical assessment and diagnosis
A history of exposure to any of these agents should alert the treating doctor to the possibility of an organic cause for the patient’s illness. Manganese intoxication may present with both psychiatric symptoms and parkinsonian features (see 
p.
292, Parkinsonism).
Prognosis
The psychiatric effects of manganese may be reversible if identified early and exposure ceases.
Health surveillance
See p.
436, Organic lead for details of organic lead surveillance.
Medical management
Withdraw from exposure.
Compensation
CNS toxicity characterized by tremor and neuropsychiatric disease is prescribed (C5(a)) for Industrial Injuries Disablement Benefit in those who have been exposed to mercury for >10yrs.
Relevant legislation
Control of Lead at Work Regulations 2002 Approved Code of Practice.
Stress 1: recognition and assessment
Definition
The emotional and physiological state of disequilibrium that pertains when the perceived demands of life exceed one’s perceived ability to cope. It is:
Not a mental illness
Not listed in the International Classification of Diseases (ICD) or the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM IV)
Natural response to range of challenges or life events
Not necessarily harmful; can improve performance in some situations
In some individuals may be a risk factor for poor mental ill health.
Epidemiology
435,000 people in the UK reported work related stress, anxiety, or depression in 2006/7. See 
http://www.hse.gov.uk/statistics/overall/hssh0910.pdf
20% of the UK working population ‘very’ or ‘extremely’ stressed
More than 9.3 million working days are lost each year in the UK from work-related mental ill health or ‘stress’
Individual, local, organizational, and cultural factors affect the level of reported stress
The sharp rise in cases of reported stress contrasts with the relatively minor secular changes in prevalence of mental illness.
Individual symptoms
Reduced self-confidence
Feelings of tension and nervousness
Self-doubt
Indecisiveness
Increased irritability
Fluctuations of mood
Sleep difficulties
Poor concentration
‘Burn-out’
Behavioural changes
Increased irritability
Impulsive behaviour
Social withdrawal
Less able to relax at home
Working more than usual
Increased use of caffeine, cigarettes or alcohol, addictive drugs or other substances
Remember stress is not an illness and all these symptoms are non-specific
Adjustment disorders
Mainly anxiety ± depressive symptoms
Temporal association with an apparent stressor
Significant impairment of social and occupational functioning is required to establish the diagnosis
Causal exposures/industries
HSE describes a system to identify risk factors at work (see p.
134, Organizational psychosocial factors)
Demand
Change
Relationships
Control
Role
Support
Workers in several sectors report higher levels of stress, but that does not mean these sectors are more stressful:
Secondary school teachers
HCWs
Call centre operatives
Emergency service workers (police in particular).
Sector-specific guidance on risk management is available on the HSE website. http://www.hse.gov.uk/stress/information.htm
Individual susceptibility
Previous history of work-related stress
Co-existing non-work-related stress (e.g. domestic upheavals)
Previous history of mental health problems
High alcohol intake
Excessive personal expectations, Type A personality.
Diagnostic assessment
Exclusion of psychiatric disorder: e.g. major depressive illness, generalized anxiety disorder, obsessive–compulsive disorder (OCD)
Identification of potential occupational stressors: including interpersonal conflict, bullying, harassment, or grievances, by risk assessment
Identification of non-work stressors
Identify current coping strategies: are they helpful, can they be influenced by individual mentors or training?
‘Post-traumatic stress disorder’ has very specific diagnostic criteria and the term should not be used if these are not met.
Prognosis
In general, excellent
Early intervention critical to successful outcome (see p.
311, Stress 2: interventions/risk controls).
Time off work
Can be detrimental to recovery of the employee unless the condition interferes significantly with performance at work. As far as possible, with adequate support and adjustments, it is advisable to keep the employee at work
If time off work is needed, there should be clarity about reason for absence, return to work process, and how progress will be monitored.
Relevant legislation and guidance
Protection from Harassment Act 1997
Tackling stress: The Management Standards Approach (1997). http://www.hse.gov.uk/stress/standards/
Stress 2: interventions/risk controls
Primary (preventing stress in the workforce)
See p.
134, Organizational psychosocial factors, Risk controls.
Stressor identification and risk assessment
Attention to job design
Skills and leadership training at all levels in the organization
Flexible working as part of work–life balance programme.
Secondary (preventing recurrence or exacerbation in an individual with work-related stress)
Attentive and compassionate management
Cognitive behavioural therapy (CBT)
Change management
Assertiveness training
Time management
Interpersonal skills training.
Interventions for the individual with work-related stress
Psychological support through occupational health (OH) and employee support programme:
Confidential self-referral service available to all employees
Access to clinical psychology
Therapy techniques aimed at problem-solving
Highly focused individualized approach
Emphasis on therapeutic benefits of work.
Including round-table discussions
Involving employee, OH +/– treating psychologist, patient’s manager, and HR taking a shared problem-solving approach to deal with stress issues
Particularly useful if patient is off work and where interpersonal conflict has complicated the situation
Enabling early agreement on a graduated rehabilitation programme back to work, establishing job definition, hours and days of work, etc.
Educating managers on nature of stress-related difficulties and ensuring their commitment to the rehabilitation programme, including preparation of the rest of the team for the employee’s return from sickness absence.
Further information and guidance
Health and Safety Executive. (1999). Managing Stress at Work. HSE, Sudbury.
Health and Safety Executive. (2001). Tackling work-related stress: a manager’s guide to improving and maintaining employee health and wellbeing. HSE, Sudbury.
Health and Safety Executive. (2004). Stress Management Standards. HSE, Sudbury.
Calnan M, Wainwright D (2002) Work stress: the making of a modern
epidemic. Open University Press, London. Available at: http://www.hse.gov.uk/stress/index.htm
Post-traumatic stress disorder 1: diagnosis and risk factors
Effects of severe stress
Extremely disturbing events can have marked and sustained emotional effects. Warfare has provided most evidence and it has generated many diagnoses, including Da Costa’s syndrome, soldier’s heart, and shell shock. The Vietnam War led to post-traumatic stress disorder (PTSD) entering the Diagnostic and Statistical Manual of Mental Disorders (DSM III) (American Psychiatric Association, 1980). The current revision is the DSM-IV (1994 American Psychiatric Association, 1994). The nosology used most frequently in the UK is the ICD-10 (WHO, 1992).1
Epidemiology
Community samples: no community-based survey of PTSD has been conducted in the UK and most data derive from the USA. Note the obvious sociocultural differences, including availability of firearms.
lifetime prevalence for adult exposure to trauma 3.9–89.6%
lifetime PTSD prevalence rates 1.0–11.2%
risk of PTSD is greater for ♀ than ♂ (20.4% vs. 8.1%)
younger urban populations report higher incidence (up to 30.2% for ♀ and 13% for ♂)
Selected samples:
4% of UK Armed Forces deployed to Iraq and Afghanistan
20% of those who have experienced physical assault.
Diagnosis and assessment (ICD-10 criteria)
Stressor criterion: victim must have been exposed to a stressful event or situation (either short- or long-lasting) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone.
Symptoms:
repetitive, intrusive recollection or re-enactment in memories, daytime imagery or dreams
commonly fear and avoidance (i.e. reminders of the event)
usually hyperarousal, such as an exaggerated acoustic startle response and hypervigilance.
Do not use the term PTSD loosely.
Acute, chronic, and delayed PTSD
The ICD-10 is not very specific: The onset [of PTSD] follows the trauma with a latency, which may range from a few weeks to months (but rarely exceeds 6mths)
DSM-IV subclassification: 1–3mths (acute); >3mths (chronic), and onset after 6mths (delayed)
Delayed onset is uncommon; delayed reporting is more common.
Assessment
Victims may be reluctant to admit to symptoms for fear of being seen as weak (especially military and emergency service personnel)
Victims may find it too disturbing to talk about the event
Insensitive and premature assessment may lead to re-traumatization
Relatives’ observations can be helpful.
In addition to clinical interview and mental state examination, there are standardized psychiatric measures:
Clinician Administered Assessment Scale for PTSD (CAPS): highly structured interview gives a measure of lifetime and current PTSD severity and functional impairment. Regarded as the gold standard
Impact of Event Scale–Revised (IES–R): a 22-item self-report scale, which assesses frequency of the core symptoms; intrusive phenomena (e.g. flashbacks), avoidance, and hyperarousal (not diagnostic measure)
Davidson Trauma Scale (DTS): a 17-item self-report scale that provides a measure of the severity and frequency of each DSM-IV symptom.
Risk factors for PTSD
No single event will cause PTSD in all exposed individuals. Risk factors include the following:
Pre-trauma factors:
anxious personality
previous and/or familial psychiatric history
lower education and sociocultural status
genetic predisposition, ↑ concordance in monozygotes
female gender, except among the military
younger age, especially in males
Concurrent life stressors
Trauma and peritraumatic factors:
severity—generally, there is a dose–response curve
physical injury—the meaning of an injury is as important as its objective severity
(perceived) threat of serious injury or to life (of self and/or others)
dissociation—depersonalization, derealization
extended exposure, such as being taken hostage and being trapped
elevated autonomic arousal, especially heart rate.
Post-trauma factors:
adverse reactions of others: criticism, rejection, blame
2° life stressors
lack of support.
Occupations at risk
Sectors likely to expose employees to work-related trauma.
Military
Heavy industry
Emergency services
Offshore oil and gas industry
Construction
Sea fishing
Farming.
Post-traumatic stress disorder 2: management
The National Institute for Health and Clinical Excellence (NICE) has published guidelines on the management of PTSD.
Psychological first aid is a widely agreed paradigm for helping individuals and communities after major calamity, including:
attending to basic needs for food, safety, etc.
outreach and dissemination of information
strengthening community, social, and family structures
psycho-education—normal reactions and coping methods
triage—identify those requiring psychiatric care
Watchful waiting:. most individuals do not develop PTSD; thus do not subject all victims to psychiatric treatment or even counselling. Instead, monitor progress and provide treatment for those whose symptoms last ~1mth
Facilitate peer, family, and community support
Critical incident stress debriefing (CISD):
mandatory debriefs should not be conducted
single-session debriefs are neutral or occasionally harmful.
Formal treatments
PTSD mostly occurs in the context of comorbidity, especially depression, anxiety, and alcohol abuse. The NICE guidelines endorse the following treatments:
Psychological therapies should be tried first:
trauma-focused cognitive behavioural therapy (TFCBT)
eye movement desensitization and reprocessing (EMDR)
Pharmacotherapy:
paroxetine and mirtazapine for general use
amitriptyline hydrochloride and phenelzine for specialist use
Medication is appropriate if the patient has not responded to TFCBT or EMDR, or is unwilling and/or unable to undergo such psychotherapy
Patients should be advised of side effects and discontinuation/withdrawal symptoms (particularly paroxetine)
A hypnotic may be used in the short term for sleep problems
Antidepressants are preferred for chronic sleep difficulties to avoid dependence
Propranolol and hydrocortisone may have psychoprophylactic properties, but routine use cannot be justified.
Prognosis
Most spontaneous recovery is within the first few weeks
There may be a re-emergence of symptoms 12mths after the event—the anniversary reaction
If persistent or recurrent after 12mths, symptoms may run a lengthy chronic course.
PTSD and the law
Civil proceedings: concerns about feigning and exaggeration of PTSD symptoms are common, but evidence suggests that this is not a widespread problem. Symptoms tend not to remit after claim settlement
Criminal proceedings: PTSD can mitigate or explain the conduct of the accused. However, merely suffering from PTSD does not mean that there is any causal connection between the individual’s mental state and the alleged offence
False vs. genuine claimants: rigorous assessment is essential and should include:
clinical interview
standardized measures
GP and hospital records
information from others (e.g. spouse).
Distinguishing false from genuine symptoms
Genuine claimants display consistent accounts across different settings and at different times. Caution should be exercised when individuals do not describe their symptoms and experiences in spontaneous and lay terms. Pseudo-technical language may suggest coaching. In most genuine cases, descriptions of dramatic events are accompanied by appropriate emotional displays (e.g. distress, disgust, anxiety). Reporting of symptoms (e.g. hallucinations and delusions), rarely associated with PTSD, should raise suspicion, as should the reporting of unremitting symptoms: PTSD is a phasic condition with spells of remission and relapse. Genuine claimants do not tend to be uncooperative or suspicious of the examiner. Most genuine claimants minimize their suffering and distress, and do not blame all their difficulties on PTSD.
Further information
National Institute for Health and Clinical Excellence (2005). Post-traumatic stress disorder. the management of PTSD in
adults and children in primary and secondary care. Royal College of Psychiatrists, London/British Psychological Society, Leicester. Available at: http://www.nice.org.uk/CG26
