Psychiatric disability

Since psychiatric disability is often invisible and unquantifiable, considering oneself psychiatrically disabled can take on many meanings.  Certainly there are those who assess their limitations, whether imposed by thought disorder, anxiety, or mood extremes, and accurately gauge themselves disabled.  It is a strength to accept reality for what it is, to live one’s life accordingly, and to claim the assistance society offers.  However, self-labeled psychiatric disability is not always accurate.  Clinically depressed patients sometimes underestimate their abilities and call themselves disabled the same way they call themselves failures, or bad or stupid — as self-denigration.  Others who yearn for nurturing or attention use disability as way to obtain these from caregivers.  And there are those who feel entitled to special privileges and treatment, and make undue claims on others using disability as a tool.

When I see a clinically depressed patient who is temporarily unable to work, I fill out disability paperwork, usually the California SDI form.  Such forms always ask me to estimate when the patient will be able to resume working.  With proper treatment, most depressive episodes significantly improve in less than three months, so that is what I usually estimate.  I consider this a little on the generous side, as I want my patient to have the disability benefit he or she deserves.  However, unlike recovery from pneumonia or a broken leg, recovery from depression varies widely.  Some patients are back to baseline in less than a month, others take much longer than three.  I have long been fascinated by the dynamics of predicting recovery.  Depression, almost by definition, leads to pessimism.  For this reason, my three-month estimate often strikes the depressed patient as too soon — too soon to hope to be well, perhaps too soon for me to expect much improvement of them.  Yet part of helping someone overcome depression is to lend optimism and hope.  I’d rather err on the side of quick recovery than to pessimistically assume long-term disability.  Indeed, when I’ve sometimes overestimated the recovery time, and the patient feels well in three weeks instead of three months, I feel I’ve made the more serious error.

A small subset of patients I see are, for want of a better term, “professional patients.”  It is their identity to be ill and disabled.  It is their defining characteristic, the first way they introduce themselves.  Saying it this way risks “blaming the victim,” as these people did not choose to be sick.  They are not malingering (intentionally faking illness).  However, even unwanted illness can assume a purpose for itself.  Disability becomes a calling card to see a variety of doctors, to call the crisis line and talk, to try a shopping bag full of medications.  It becomes a ready answer to that very difficult question: Who am I?  Some patients remain psychiatrically disabled because it is a way to be in the world, the only way they find comfortable or familiar.  It can be challenging to explore the meaning of such disability in therapy.  Patients sometimes complain that I don’t “believe” them, that I should take their disability on face value.  I prefer to help them find more options in life, as sometimes disability itself is a state of mind.

From the psychiatric perspective, there is a fine line between assertiveness and undue personal entitlement.  On the one hand, it is healthy and strong to assert one’s needs, to make a place for oneself in the world.  On the other, diagnostic terms like “narcissism” apply to people who feel, without reason, they are so special they need not obey the same rules as everyone else.  As described in my last post, some claims to keep pets in “no pets” housing, or to bring them to work or shopping for “emotional support,” seem to cross over this line.  Since narcissism is ego-syntonic (not seen as a problem by the patient himself), it is frequently difficult to address in psychotherapy, or to interest the patient in therapy at all.

I have given three examples of dynamics that may prolong self-rated psychiatric disability: depressive pessimism, dependency and identity needs, and narcissism.  I could equally and conversely write about denial and counter-dependency as factors that might prevent a truly disabled person from acknowledging it.  However, the legal entitlements granted on the basis of disability make the former a more interesting social conundrum.  On the one hand, our sense of charity calls for helping the distressed and disadvantaged.  On the other, we recoil at self-declared victimization as a means to special treatment.  When disability is subjective and difficult to quantify, as it is in many psychiatric conditions, society does not know whether to embrace or reject it.  A culture of innate entitlement only makes this approach-avoidance conflict more acute.

3 comments to Psychiatric disability

  • Anonymous

    Thanks Dr Reidbord:

    An excellent post. My perspective is as an insurance broker specializing in disability insurance for physicians, but also as a bi polar patient and family member. Until a few years ago, the best disability policies made no distinction between mental/physical disabilities. However, in recent years this has changed and the best available new disability coverage for some physician specialties(ER, Anesthesia) reflect a two year maximum benefit period for any disability caused by or contributed to by contributed to by any condition named in the DSM or its successors. Other conditions would entitle the insured to benefits through age 65/67. While the stated intent of these clauses is to draw a compromise in the case of “hard to objectively document” disabilities, I suspect that the language may actually overreach and limit benefits for unexpected conditions such as MS, Cancer and cardiac bypass, which are frequently accompanied by DSM symptoms such as depression and anxiety.

    Thanks for pointing out some of the ambiguities in these matters.


  • Jane Barrett

    Wow. I have suffered in ways you couldn’t imagine due to losing 6 jobs in 2 years. No, you can’t see my disability but I know I can’t work a regular job surrounded by people who think I’m stupid. Bipolar II. Finally after another threat of being fired and treated very harshly by bosses and coworkers alike I said no more. I sought help being unsure why I can’t perform when I tried so damn hated..

    I sought neuropsych testing, therapy and case management.

    I can’t find a provider who will sign my California disability claim. Mental health practioners don’t even believe me or feel I should receive wage replacement for California’s SDI Short Term Disability. None. Stigma from my own mental health practioners. I know IIm disabled, does this make me a narcissist? My mother-law-law told me her mother had mental illness (it was a benign tumor) and she worked two jobs and whatever it took. This spoken by a tenured teacher who couldn’t get fired if she kicked her students (true story).

    It’s bad enough I suffer ignorance and “lazy” spoken in whispers about me or careless when I have children to support. Where is the dignity in malingering? Why would I?

    Shame on you.

    • If the shoe doesn’t fit, don’t wear it. In other words, if my 2009 blog post doesn’t apply to you, please don’t take it personally.

      On the other hand, if you can’t find a provider who will sign your disability claim, and even your own mother-in-law implies you are not disabled, it’s possible you aren’t. Disability is not established by self-report; that’s why the state needs a doctor to attest to it. Rather than “stigma” from your mental health practitioners, you are getting the opposite: repeated hints that you are stigmatizing yourself. I’m sorry you’re going through this, but I stand by my original post. Take care.

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