Neurosis in the workplace

Abstract

In the history of medicine new diseases have appeared recurrently , frequently in epidemic form. "New" medical and surgical treatments become fashionable and "Diagnosis" becomes a reinterpretation of ambiguous phenomena in accordance with prevailing concerns, often promoted by vested interests. Such an epidemic can be understood in its social context against its background of shared beliefs, social stresses and group demands. False rumours and other exacerbating factors can be identified and eliminated, and measures taken to control them. The management of such epidemics is a public health problem which demands community and institutional support as well as cooperation by the media. (Med J Aust 1986; 145: 323-327)

The "new" industrial epidemic,[1] a disorder of symptoms in the arms that is known in Australia as "RSI", repetition strain injury and "teno"[2],[3] has formerly been reported in both sporadic and epidemic forms as "occupation neurosis", and as its paradigms "writer's cramp" and "telegraphist's cramp"[4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28] It is categorised the International Classification of Diseases (ICD) at F48.8 within a subset of somatoform disorders within the range of mental and behavioural disorders. This functional disorder has long been recognized to signal conflict about endeavour and has been classed as a neurosis in neurological, psychiatric and occupational health textbooks since 1888.

A report on "RSI" in the Australian Public Service has shown a variable and rising "incidence" of the disorder and has identified over 4000 cases in that service alone.[29] The National Occupational Health and Safety Commission has compiled a set of recommendations on the prevention of what it perceives to be a physical injury[30] - an injury perhaps exacerbated by emotional stress. Both enquiries have proceeded on the basis of unevaluated medical information that has been interpreted by non-expert laymen who have represented various social interests, and both appear unaware of the dangers of lay interpretation of complex medical information.

An epidemic such as this can be explained by psychosocial phenomena which might be of two types: either they could be due to epidemic hysteria on the part of patients, or be the result of altered medical perception of endemic symptoms in the community.[31] The patients who are involved in litigation whom I have seen are derived from a large number of occupational categories, suggesting that both factors are operating with endemic symptoms giving rise to epidemic hysteria.

The functional symptom complex that is commonly known as "writer's cramp" or "craft palsy", together with its associated medical history, reported experience and observed behaviour, generally allows the diagnosis of one of the somatoform disorders to be made.[32] In these disorders, physical symptoms are entirely psychogenic and can occur in the absence of local pathology. The most common diagnosis made is of a conversion disorder (hysterical neurosis conversion type) which mimics, complicates or prolongs physical injury, and less frequently the Diagnostic and Statistical Manual (DSM) III diagnosis is of a psychogenic pain disorder or a somatization disorder. The somatic presentation of unrecognized depression or psychosis is common.

Conversion reactions, where physical injury is mimicked and complicated, tend to occur in this form in person with compulsive or dependent personalities. Passive-aggressive and paranoid traits, while also noted by others, might be an artefact of an unwanted psychiatric examination.

Pain and occupational impairment are experienced by the patient, but no pathological data have been offered to justify the current Australian nomenclature which incorporates a causal hypothesis.

Organic disorders have symptoms which allow them to be classified by site and pathology. Myofascial dysfunctions, crams, spasms and occupational myalgias are all task-related and, as do their counterparts in sport, proceed to a normal predictable recovery with rest or treatment. Neurosis endures beyond these time limits and has an entirely different natural history.

However, the symptoms that are caused by the task and the neurosis do not have a common cause. An hysterical neurosis is the physical manifestation of an emotional disturbance and is caused by ideas, beliefs and emotions. In those with RSI, such neurosis might be related to stress in the workplace or elsewhere; however, at present, task-relatedness is being induced artificially by the false belief that movements can be the cause of an "injury".

It follows that if no clear diagnostic distinction is being made between organic and functional disorders, and workplace pains are being conceptualized as the early stages of a preventable, progressive, work-caused, yet hypothetical "injury" - a term which implies physical or emotional trauma - then "diagnosis", investigation and management by physical therapy will raise alarm, increase the conviction that physical illness is present and contribute to stress and delay recovery. The very idea that one has been, and still can be, "injured" actually creates the neurosis, while accurate diagnosis provides reassurance.

The "injury" theory should rile feminists as it creates of "victim" of women (who are more commonly affected by RSI than are men). (The Oxford Dictionary defines a victim as "a person who is injured or maimed in order than an object may be attained or a passion gratified".) This "diagnosis" deems such a woman to have been damaged by unavoidable activity. She seeks to be called "injury" but deemed thus, she becomes encouraged in her dependency on those who benefit from the validation and promotion of her ill health. The perception of a woman as unable to accept that her disorder is caused or complicated by emotional factors exposes her to useless investigation and ineffective treatment in the guise of unwillingness to give offence.

Sufferers of psychogenic illness present differently from patients with organic impairment. Their symptoms, which suggest the involvement of both motor and sensory modalities, cannot be explained by any known pathophysiological mechanism. Their complacent acceptance of a level of disability ("la belle indifférence") which would be catastrophic if it were organic, reveals the new adjustment among the patient, the illness and the expectations of secondary gain from it. Paget wrote in 1867: "They say, 'I cannot'. It looks like 'I will not' but it is 'I cannot will'".[33] The functional disorder is one of the will or volition and one must in each case attempt to identify the ideas, needs and conflicts that act on the will to prevent the carrying out of the stated intention.

Rival truth claims

The possibility exists of conflict between rival coteries of experts.[34]

As long as theories continue to have immediate pragmatic applications, what rivalry may exist is fairly amenable to settlement by means of pragmatic testing. Rival definitions of reality are thus decided on in the sphere of rival social interests whose rivalry is in turn "translated" into theoretical terms.

The nature of neurosis

Originally, the term "neurosis" referred to any group of physical symptoms, without localizing signs, for which no pathophysiological mechanism could be found or postulated. As the ideas, memories, experience and behaviour that accompanied such disorders were recognized and acknowledged, the term became "psycho-neurosis" and took on its present meaning.

In conversion (an ideogenic and hence contagious product of a complex psychosocial system) "an individual achieves a primary gain by keeping an internal conflict or need out of awareness" the symptom has a symbolic value that is a representation and partial solution of underlying psychological conflict. The secondary gains are the advantages that are obtained from the neurosis.

Acute functional disorders are extremely common, yet medical examiners who see prolonged conversion reactions develop in the course of work might feel from their vantage point, that these are "diseases of occupation". On the contrary, they are subjective sensory and motor disturbances which manifest when a demand is made on an individual.

Gowers coined the term "occupational neurosis" and in 1988 described its paradigm, the then most common manifestation, (prolonged) "writer's cramp". He noted that it was a "disease easily imagined by those who have witnessed the disorder" and found his subjects to be of "distinctly 'nervous' temperament, irritable, sensitive and bearing overwork and anxiety badly". He remarked on "the number of sufferers enduring anxiety from family trouble, business worry or weighty responsibilities". He found that cramp occasionally followed a lowering of general tone, local disease or injury, and reported on his own difficulties in differentiating a genuine neurosis from a feigned one - a problem which confronts the medical examiner of today. He reported writer's cramps in typists and that it was already known in many different occupations that were characterized by neither rapid movements nor repetitive work.

Gowers recognized the pain to be referred to various parts of the wrist and arm, and described cramps, spasms, tremors, incoordination, paraesthesiae, fatigue, weakness, and spread of symptoms to the unused arm, a phenomenon that he and others have since attributed to a central origin.

Epidemiology

The first epidemics of writer's cramp were reported among male clerks of the British Civil Service in the 1830s and were attributed by the workforce to the introduction of the steel-nib. The medical profession was confused then (as it is now) as to whether the cause lay in tendons, muscles or peripheral nerves.

In 1971, a 14% prevalence of cramp symptoms was reported among Australian keyboard telegraphists and reanalysis showed that the rate varied between 25% in Sydney and 4% in Melbourne, a difference that was never explained satisfactorily. On the other hand, sporadic writer's cramp is thought to be rare, and affects 5.4 per 1000 office workers. The symptom was found to be virtually absent in those countries where compensation was not paid for it.

If one looks at upper limb "symptoms", studies have shown that 9% of the adult male population and 12% of the adult female population is experiencing some discomfort in the neck with or without associated arm pain and 35% of us can recall such an episode.[35]

Great Britain and Ireland Post Office Department Committee of 1911

In 1908 telegraphist's cramp was added to the schedule of diseases that was covered by the British Workman's Compensation Act of 1906 on the advice of a doctor who erroneously believed it to be muscular failure due to the rapid repetitive movements of telegraphy. Within four years, up to 60% of the workforce were reporting symptoms and 30% of the workforce had difficulties in manipulation, a situation which resembles that in the Australian Public Service today. Simultaneous prevalence studies on the European continent found only sporadic cases. In the United States, 4% to 10% of telegraphic staff members were at that time reporting "cramp symptoms"; "cramp" in the United States was known as "losing the grip" and was attributed to "predisposition".

A Committee was commissioned "to inquire into the prevalence and causes of the disease known as Telegraphists' Cramp and to report what means may be adopted for its prevention. The Committee investigated all the popular attributions of cramp; these included constitutional weakness, inaptitude for telegraphic work, the nature and amount of a telegraphist's work, the construction of Morse keys, the design of keyboards, inadequate working accommodation and the design of furniture. It examined all peripheral and central causal hypotheses, which were once again circulating, including "muscular failure"; however, during the course of the inquiry as the cases came under examination, the Postal Telegraphic Clerks' Association gave put his theory and proposed "stress" to be the cause. The Committee's conclusion was that cramp was a neurosis.

Seeking a non-medical covering term, the Committee introduced a new phrase into the English language when it reported:

[...] the "nervous breakdown" known as Telegraphists' Cramp is due to a combination of two factors, one a nervous instability on the part of the operator, and the other, repeated fatigue during the complicated movements required for sending messages."

As the telegraphing work was common to all telegraphic workers, yet not all persons developed cramp, the Committee, after extensive studies, concluded:

[...] the amount of fatigue required to cause cramp is governed solely by a personal factor and has no constant relation to the amount of work performed.

It further concluded:

If the conditions that lead to fatigue [...] can be remedied the personal factor alone remains as a cause of cramp; and this can only be eliminated by careful and judicious selection of staff.

The Committee recognized the importance of fear and rumours that were generated by the various attributions. The early identification of cramp-prone staff members was investigated and found to be unfeasible.

History of the concept of repetition strain injury

World-wide, the first referenced use of the term "repetition strain injury" was in a document of unknown authorship that was adopted by the National Health and Medical Research Council in 1982. It was subsequently reduced to the facile acronym RSI, and large extracts of medical publications have been replicated in The National Times, in government and union documents,[36][37] and in self-diagnosis guides. A massive mythology surrounds RSI and has a large input into the production of symptoms.

The term repetitive strain injury introduced a new name, which is simultaneously a "cause" and a "diagnosis", and is reputed to affect those whose work includes rapid repetitive movements, forceful movements and load bearing. An "incidence" is attributed to it on the basis of a new nomenclature for symptoms in the arms. Keyboard operators are asserted to have RSI which is caused by the "RS" of keyboard work. Movement at work is, by a linguistic trick, elevated to the status of the "cause" of an "injury".

Symptoms which spread to a second limb are attributed to compensatory "overuse" to protect the affected limb. The prediction of this has created invalidism by reducing the credulous to immobility. The belief that movement causes injury induces a fear of it, of tasks or equipment that involve it and generates symptoms on re-exposure.

The term occupational repetition strain injuries continues with a similar vicious circle of reasoning. The evidence of "injury" is also in the symptoms, which in turn are wholly attributed to the "injury". The patients who are seen are apparently workers, hence "occupational", "repetition" and "strain" are assumed, and escape from this circular reasoning is pre-empted for the reader by the authors' labelling as "incompetent personnel (medical and other)" those who fail to make this satisfying and comprehensive "diagnosis" - a diagnosis not to be found in any international classification of diseases. Several phenomena are given new names, and thereby new meanings and presumed causes: first, that conditions that are normally classified by their pathology are "manifestations of RSI"; secondly, that RSI "coexists" with other disorders; thirdly, that RSI is the cause of pain, weakness and fatigue of obscure origin that occurs in workers; and finally, that RSI is progressive.

The first idea confounds epidemiological study; it has been omitted from this paper. The second is synonymous with "conversion symptoms that complicate physical injury", or "functional overlay". The third is synonymous with "conversion symptoms, mimicking physical injury", or "functional disorder". The fourth has laid a foundation whereby each pain, ache, cramp and spasm that occurs in an occupational setting is interpreted as potentially the first symptom of RSI, which must be attended to early, medicalized and managed as an injury, or degeneration into "advanced RSI" and total invalidism is inevitable. It is this concept that has become widely disseminated by well-intentioned laymen and passes for the prevailing wisdom in the medical community.

Not due to inflammation

The contention that "keyboard work tends to predispose to tenosynovitis" is anecdotal,[38] not expert. Stenosing tenosynovitis is not a reported disorder of typists, yet occupational neurosis in the painful mode has, recurrently and erroneously, been attributed incorrectly to tenosynovitis. Occupational neurosis can be differentiated from tenosynovitis primarily by its excessive symptomatology in both motor and sensory history of failure to recover with the usual treatments for inflammation or injury.

Tenosynovitis was first proposed to be the cause of writer's cramp in 1840 by Strohemeyer whose unsuccessful surgical approach to cut tendons was dismissed quickly as being overzealous and naive, as it failed to relieve the occasional peripheral disturbance in coordination and to account for the clinical picture. Gowers reported the failure of immobilization, of separating tendons, of galvanic and faradic stimulation and of Indian hemp. Treatments that are based on a peripheral hypothesis remain unevaluated in the literature of RSI.

Negative results have been reported for the use of cortisone, ultrasonic therapy, cervical traction and manipulation, radiotherapy, vitamin B12, iodine, copper, local hydro-cortisone and most commonly-used psychotropic medications. This resistance to the usual treatments for inflammation or injury suggests another mechanism of symptom formation.

Causal hypotheses

The search for local pathology in occupational neurosis has yielded no results in 150 years; thus, treatable organic causes now appear improbable.

The earliest reports suggested muscular failure, peripheral nerve entrapment or disease, and central nervous system disorders, or combinations of all three.

Carpal tunnel syndrome is commonly suspected but is rarely a neurologically sound diagnosis - 37% of asymptomatic normal persons over 40 years of age show median nerve conduction defects.[39]

The suggestion of "disease of muscles" is not corroborated by the reliable relation of involved tissues to occupational tasks. Moreover, there is no known organic disorder where a group of muscles becomes dysfunctional and painful for one intentional activity but not for another.

"Musculotendinous injury" fails to account for multiple sensory symptoms or for weakness and fatigue, and "radicular irritation at the cervical spine" is a neurologically unsound diagnosis in most cases as it rests on signs that relate specific muscle weakness to discrete sensory deficits.

Identification of occupational neurosis

When one examines the symptoms of subjects with "cramp", it becomes apparent why classification has never been successful. Attempts to classify occupational neurosis have included "spasmodic and paralytic", "tremulous and neuralgic", "spasm manipulation difficulties and symptoms", "tremulous, spastic and ataxic", "painful and non-painful", and "simple, progressive and dystonic". The removal of circumstantial complexities leaves a phenomenon for which an organic mechanism cannot be postulated. The "yips"[40] in golfers and tennis "cramp" are sporting variants. The latter is not granted injury time at international matches. "Stages I to III of RSI" falsely implies that a local pathology can be deduced from the experience and behaviour of the sufferer.

Pain is not necessarily the early stage of cramp; rather, the expert evidence is to the contrary. The number of "diagnoses" that each case attracts confirms that every cramp is different and that all types merge with one another in the course of the affliction and are extremely sensitive to suggestion.

Contagion of belief and behaviour

Such an epidemic can be understood in the light of accepted theories of hysterical contagion.[41][42][43][44] An hysterical belief defined as "one which empowers and ambiguous element in the environment to threaten or destroy", is disseminated without appropriate verification.[45] A condition receives sympathetic attention with widespread publicity and there is not initial challenge to an incorrect attribution of cause. "Experts" emerge and encourage the adoption of the sick role which is made legitimate by the broad acknowledgment of the condition. The initial strain, which is either too closely identified with a valued aspect of people's lives to be admitted, or is too general and vague to be understood, is attributed to some factually incorrect powerful agent or force. Early reporting of now alarming symptoms reduces the pain threshold and influences others unconsciously to claim the same primary and secondary gains as those who were affected. The symptoms become epidemic when the situation is not properly controlled and the hysterical belief is allowed to prevail. The individual's acceptance of such a belief, which is arguably the causal factor in the development of the symptoms, is governed by the desire for the consequences of believing. The intensity of this desire is a function of the unconscious need to regress into illness and this need is governed by both personal and circumstantial vulnerability factors.

The texts which claim that epidemics of hysteria no longer occur on the scale of those in the 19th century may have to be rewritten in the light of the Australian experience of tens of thousands of cases of a predominantly manual astasia-abasia.

The 19th century European epidemics of invalidism with the causeless and unresponsive polymorphic symptomatology of neuroses, attracted the attention of Freud. His theory of the repression of unacceptable memories, ideas, needs and conflicts, which gain symbolic representation in symptoms, gave us the theoretical structure against which a psychogenic illness could be understood and treated, and ideogenic and iatrogenic illnesses avoided.

Post-Freudian views allow that the repressive forces of the society in question are internalized and block the expression of unacceptable sexuality, of anger, of wishes to be cared for, of fears for security, of wishes for self-fulfilment, and of other needs that are in conflict with the demands of the self or of the environment. So the powerless and dependent, and those who cannot otherwise express their righteous rage at their supervisors, employers and spouses, resort to the use of their exquisitely symbolic pain and incapacity as a mode of communication of their distress.[46]

Management according to the psychosocial model

A neurosis is a very common emotional disturbance, a way some persons deal with their thoughts and beliefs. It is not caused by steel-nibs, keyboards, movements, trauma or Agent Orange, but when these entities acquire a new meaning, becoming symbols of physical danger or economic insecurity, a vulnerable minority will react neurotically to them.

While British and American workers have become concerned about the effects of the visual display unit[47] and attribute to it birth defects and dermatitis, the keyboard is not considered pathogenic in those countries. The symbol and the symptom are socially determined.

Prevention

The "movement causing injury" concept is itself pathogenic and physical means of prevention based on it are inadequate. Only primary management can determine whether or not the shift to chronicity will occur. If doctors apply an "injury" model to functional symptoms, they enforce dependence and emphasize disability. The vulnerable patients will then emerge and their advance into chronic psychological and physical invalidism will become almost inevitable. Identification of vulnerability factors, and attendance to them, together with education about the experience of pain and its management would be more effective.

Group demands (presently concerning working conditions) must be attended to, but individual conflicts (so far subsumed in the perceived interests of the group) should be acknowledged and handled. These commonly concern family and maturational difficulties, wishes to have and care for children, anger at working conditions, at having to work longer or indeed at all, and frustration about a lack of fulfilment. Both personal and societal conflicts, especially those about work and technology, tend to be encouraged by those interests that benefit from their maintenance.

Management of the epidemic

Control of this epidemic will require a complete withdrawal of the injury theory and its mythology and terminology - all of which have contributed ot it. As such, it will require the abandonment of unproductive therapies in favour of methods of prevention that are directed at real aetiologies, and the recognition of the psychological vulnerability of those with prolonged illnesses.

As long as compensation is paid for functional symptoms as if they were the result of a hypothetical "injury", symptoms are rewarded and reinforced, and the epidemic will continue to spread. The financial and social implications of a cult of "the victim", of institutionalised and rewarded neurosis, will force the withdrawal of support for an idiosyncratic ideology and for nomenclature in conflict with prevailing international concepts. Support for the "injury" theory comes from the NSW Labor Council and from many trade unions who object to their members undergoing a psychiatric examination in the course of a compensation claim. Street protests have been organized in Queensland[48] and New South Wales[49] against the concepts that I have expressed in this paper. The National Occupational Health and Safety Commission has misquoted it as meaning "a conflict exists either at work or privately [...]" and reports that this theory has not been substantiated.

Conclusions

The "injury" concept is an example of a set of ideas which has arisen from a given set of material interests. Early intervention is based on the confused idea that the syndrome is both caused and preventable by physical means. This is not only inadequate but counterproductive. An epidemic of occupational illness has ensued.

This demonstrates how medical perception and common sense can be impaired by rumour and how, by generating a conflict about movement through a faulty conceptualization of a symptom, the medical profession can create an epidemic of psychogenic illness in a passive and dependent group.

What is convincing to one man may not be to another [...} Theories may again become convincing because they work - work, that is, in the sense of having become standard, taken for granted, knowledge in the society in question.

The understanding of the psychosocial causation of symptoms has prevailed in Europe and the English-speaking world for 100 years. Its temporary abandonment in Australia in favour of a medical model has set back the practice of holistic and preventive medicine.

The language that the syndrome has generated - "neurosis", "losing the grip", "nervous breakdown" - are graphic examples of how it has been considered at other times and in other places.

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