07: Psychological Factors and Workforce Health

In the practice of occupational medicine, the patient population consists of workers, and a key measurable outcome is their restoration to full function after an illness or injury. The bureaucratically driven practice of medicine today relies heavily on providers’ ability to explain the causes of injury and the influences on patients’ outcomes as either physiological or psychological. However, scientific evidence endorses cause-and-effect relationships among biology, psychology, and sociology. Much has been written about this “biopsychosocial model” of understanding these interactions. However, the biopsychosocialeconomic (BPSE) model broadens the scope further by taking into account the complex, variable interaction of

• biological factors (pathophysiologic, genetic, biochemical, physical, structural)
• psychological factors (mood, emotion, personality, behavior)
• social factors (personal and work relationships, religion, work culture)
• economic factors (income, future earnings, savings, bills, debt)

Application of the BPSE model assists providers in guiding the injured worker through the path to functional recovery.

For purposes of simplicity, in this chapter, the word “injury” is used to encompass both conditions. The term “provider” encompasses physicians, nurse practitioners, physician assistants, chiropractors, psychologists, and other health care providers in a treating role.

Injuries that disrupt individuals’ ability to work often become defining points, turning people’s lives upside down. They have to deal with pain, impairments, and dependency on others. They may be upset at someone or themselves for the circumstances that caused the injury. These stressors are exacerbated by the complicated workers’ compensation and disability benefits systems patients are forced to deal with. They worry about how they will support themselves and their families. Their absence from the workplace and alterations in their normal routines can significantly affect their relationships.

Moreover, the decision makers affecting a worker’s fate (employers, insurers, and medical providers) are frequently disconnected from one another and provide inadequate communication to the injured worker, causing delays in treatment and recovery, and increasing the individual’s stress.

No two people are the same. An identical injury, identical diagnosis, and identical treatment can have drastically different outcomes in various people’s lives; outcomes cannot be predicted by biological explanations alone. Treatment plans that focus only on physical impairment may not result in a successful return to full function. Application of the BPSE model demands a multidisciplinary treatment program that results in improved functional restoration.

Stress in the Workplace

“Feeling stressed,” or “stressed out” are common expressions of anxiousness. Stress subjectively describes an undesirable emotional tension or an uncomfortable state of mind resulting from an individual’s interpretation of circumstances. These terms are frequently used synonymously with nervousness or anxiety. Stress can arise from any situation or thought that induces feelings of frustration, anger, nervousness, or anxiousness. However, stressful circumstances are subjective, because what may be stressful to one individual could be enjoyable to another.

At its most basic level, occupational stress is associated with job requirements that do not align with the worker’s capabilities, resources, or needs. But, it also results from much more, including an unpleasant work culture, role conflicts, unrealistic expectations, excessive or insufficient responsibilities, job insecurity, interpersonal conflicts, inadequate social support, physical stressors, hazardous conditions, and highly automated work processes. Shift work is a significant risk factor for occupational stress-induced psychological conditions as well as non-psychological medical conditions.

Stress is a serious occupational health problem commonly resulting in decreased function and productivity. Low-grade stress can subtly affect a person’s mood and efficiency. It also causes physical and psychological injury and promotes disease. Stress alters the serum levels of multiple hormones including glucocorticoids, catecholamines, growth hormone, and prolactin. Principal effects result from a neurohormonal reaction initiating in the hypothalamus and resulting in adrenal glands releasing epinephrine and cortisol. Epinephrine’s effects include elevated blood pressure and heart rate, pupil dilation, and elevated blood glucose. Cortisol, the principal stress hormone, suppresses the immune system, bone formation, digestive system, and reproductive system, and increases glucogenesis. And yet, the process is not entirely understood: double-blind, placebo-controlled studies have not demonstrated that the direct administration of glucocorticoids affects mood, emotional arousal, or anxiety levels.^[i],[ii]

When physical exertion is needed, the effects of these hormones can be beneficial, sharpening the senses, elevating the heart rate, deepening respiration, and tensing muscles. The benefits of occupational stress can be seen on the first day at a new job or when one is working under a deadline. Appropriate mild neurohormonal effects increase energy and heighten concentration. However, after crossing a threshold, they induce myriad undesirable effects, including :

• nervousness
• irritability
• poor concentration
• depression
• fatigue
• fear
• upset stomach or nausea
• dizziness
• confusion
• heightened or lowered alertness
• sweating
• thirst
• headaches
• visual difficulties
• jaw clenching
• nonspecific aches and pains
• feeling overwhelmed and potentially panicked

Behavioral expressions may include :

• anger or short temper
• withdrawal
• outbursts
• excessive alcohol and/or drug consumption
• insomnia
• pacing
• sexual dysfunction

Long-term low-grade activation of the stress-neurohormonal response system leads to overexposure of these hormones and stimulatory responses. This increases the risk of a number of chronic health conditions, including those listed above as well as hypertension, weakened immune system, autoimmune disease exacerbations, digestive problems, stomach ulcers, obesity, cardiovascular disease, chronic pain, and suicide.^[iii]

Stressful working conditions can interfere with safe work practices and result in increased occupational injuries. They also prolong injury recovery and functional restoration. The International Labor Organization, in its Encyclopedia of Occupational Health and Safety, reports that job stress has become a leading source of worker disability in North America and Europe. Several studies, including those by the National Institute for Occupational Safety and Health (NIOSH) have found strong associations between job stress and delayed functional restoration. Studies have also demonstrated that injuries and work disability are related to psychosocial job factors, frequency of job problems, job dissatisfaction, negative human interactions, organizational deficiencies, patient and clinician expectations, and other factors.^[iv],[v]

Occupational stress plays a major role in adjustment disorder, major depressive disorder, and generalized anxiety disorder. Situations of extreme stress can result from workplace violence and can cause occupational PTSD.

Psychosocial Effects on Recovery

The tremendous inconsistency among injury outcomes under very similar, or even identical, circumstances owes to the complicated variability among individuals, physically, psychologically, socially, and economically—in other words, the components of the BPSE model. Biological factors alone poorly predict the outcome of occupational injury. For example, the average time for an otherwise healthy worker to physically heal from uncomplicated low back pain ranges from a couple days to a few weeks, and return to work can range from zero days to several months, years, or even permanent disability.

In addition to treating the biological injury, the provider using the BPSE model addresses the psychological, social, and economic factors affecting the patient. The first steps include holding a patient-provider discussion of these issues, educating the worker about the approach, and setting appropriate expectations. This process may include referrals to other specialists and close follow up.

Providers play a crucial role in their patients’ functional recovery. Providers who understand the complex intersection of biological and nonbiological factors and spend the time required to construct a comprehensive treatment plan with their patients see improved outcomes of functional restoration.

Reducing Workers’ Stressors Outside of the Workplace

Sometimes, occupational stressors are inevitable, and de-stressing is up to the worker. The provider should educate and support his or her patients about making lifestyle modifications—a process that takes time. Treating stress starts with diet, exercise, and sleep. The healthy diet emphasizes whole vegetables, fruits, complex whole grains, and lean meats and limiting fast or processed foods, alcohol, and overeating. Good sleep cannot be emphasized enough: providers can teach their patients good sleep hygiene, educating them about restorative sleep and explaining that sleep affects their mental and spiritual well-being. Aerobic exercise such as jogging or bicycling, yoga; deep breathing; meditation; and massage all reduce stress. Providers can inspire patients to engage in relaxing hobbies such as music and reading, and remind them of the benefits of healthy intimate relationships, emphasizing in-person versus internet contact. In addition, cultivating a good sense of humor, participating in community volunteer activities, decreasing commitments, and, if possible, working from home all decrease stress.

Reducing Stressors in the Workplace

Declining productivity of an individual or organization should prompt a search for stressors. Providers can impact populations when exerting influence at the organizational level. In the best case, they develop relationships of trust with industry leaders and convince them that organizational success results from improving the healthy work environment. Providers should educate the decision makers that there are proven associations between occupational stress and injuries, work absence, and hence, productivity losses. However, as discussed, work absence due to delayed functional recovery is the result of multifactorial elements and can be difficult to control. Regardless, efforts to mitigate workplace stress that reduce “presenteeism” (being present but not fully functional) result in increased productivity.