This document provides an overview of understanding psychological injuries in the workplace. It defines psychological injury as a diagnosable mental illness that can disrupt ability to work. Common causes of workplace psychological injuries include heavy workloads, shift work, and poor management styles. Psychological injuries are diagnosed using systems like DSM-5 and ICD-10 and common conditions include adjustment disorder, depression, anxiety, and PTSD. Substance use can also impact mental health. Managing psychological injuries requires collaboration between the worker, employer, treating practitioner, and case manager to support treatment and return to work.

1. Understanding
Psychological Injuries:
A Basic Framework
Dr James Hundertmark
MBBS, FRANZCP

2. Workplace psychological injuries
(refer to section 1 of the workbook)
Definition of psychological injury:
“A psychological injury or mental illness is a diagnosable
illness that affects a person’s thinking, emotional state and
behaviour. It can disrupt their ability to work and carry out
other daily activities, and to engage in satisfying personal
relationships.” (Quoted from “Managing Psychological Injuries: A
guide for rehabilitation and return to work coordinators” WorkCoverSA)
A workplace psychological injury is a mental illness
associated with work factors.

3. Workplace psychological injuries
As per the Workers Rehabilitation and Compensation Act,
Section 30A:
“Psychiatric disabilities
A disability consisting of an illness or disorder of the mind is compensable if and only if –
(a) the employment was a substantial cause of the disability; and
(b) the disability did not arise wholly or predominantly from –
(i) reasonable action taken in a reasonable manner by the employer to
transfer, demote, discipline, counsel, retrench or dismiss the worker; or
(ii) a decision of the employer, based on reasonable grounds, not to
award or provide a promotion, transfer, or benefit in connection with
the worker’s employment; or
(iii) reasonable administrative action taken in a reasonable manner by the
employer in connection with the worker’s employment; or
(iv) reasonable action taken in a reasonable manner under this Act affecting the
worker.”

4. Overview of the session
• Common causes of psychological injuries
• Some statistics
• Diagnosis and the DSM
• Common psychological conditions
• Substances
• Psychosocial flags
• Working with key stakeholders

5. What is a psychiatrist?
• A psychiatrist is a qualified medical doctor who has obtained
additional qualifications to become a specialist in the
diagnosis, treatment and prevention of mental illness and
emotional problems.
• Psychiatrists are trained to recognise and treat the effects of
emotional disturbances as well as the effects of physical
conditions on the mind.
• Train first as a doctor, which takes 6 years of university study,
work in a general hospital for 2 years, interview by panel for
training program, post-graduate training takes a minimum of 5
years during which doctors work in hospitals, consultation-
liaison, the community, child and elderly settings with regular
examinations

6. Tracey EMIN – your artistic diversion
• Born July 3, 1963, one of the leading figures of the
Young British Artists movement in the 1990s
• graduated in fine arts from the Maidstone College of Art
in 1986
• first solo exhibition at White Cube Gallery in London in
1993, 'My Major Retrospective’
• on the short list for the Turner Prize in 1999
• represented Britain at the 52nd Venice Biennial in 2007
• 2007 made a Royal Academician and awarded an
Honorary Doctorate from the Royal College of Art,
London

7. Common causes
(refer to section 1 of the workbook)
• Usually caused in one of two ways:
1. Specific major traumatic event/critical incident
(i.e. hold up)
2. Gradual onset - developed over long period in response
to a series of work-related events or factors
• May be secondary to a workplace physical injury
• Psychological injures which occur from gradual onset
may be more complex and difficult to determine

8. Common causes
Workplace contributing factors can include:
• Heavy workloads and fast paced work
• Physical or psychological monotonous repetitive work
• Environmental issues
• Shift work
• Climate and culture
• Management styles
• Interpersonal relationships
• Work roles
• Organisational changes

9. Why some people and not others?

10. Diagnosing a psychological injury
(refer to section 2 of the workbook)
• Diagnosis is the term used to describe the ‘symptom
complex’ presented by a patient
• Arriving at a diagnosis can be difficult – why?
• For most psychiatrists the clinical interview is the main
system of examination and diagnosis
• Two diagnostic systems:
– International Classification of Diseases (ICD) (ICD-10
current version 2010)
– Diagnosis and Statistical Manual of Mental Disorders
(DSM) (DSM-5 current version 2013)

11. DSM
• Established in the 1950s
• Various versions over the years
• Some disorders have come and gone from one edition to
the next, e.g. homosexuality
• Most recent version released in May 2013 – DSM-5
• Some concern about medicalisation of emotions
• Case managers may request the practitioner provide a
diagnosis using DSM-5 or any other version/tool.

12. “Everyone I have ever slept with”

13. Common psychological conditions
(refer to section 3 of the workbook)
1. Adjustment disorder
2. Depressive disorder
3. Anxiety disorder
4. Post Traumatic Stress Disorder (PTSD)

14. 1. Adjustment disorder
• An excessive or unusual reaction to “stress” or challenge
in a person’s life (work life, relationships, conflict
situations, assault or accident of any kind)
• Experience feelings of depression and/or anxiety
• Social withdrawal/isolation
• Disturbance of emotions
• Various adjustment disorders
• Adj dis with depressed mood
• Adj dis with anxiety
• Adj dis with disturbance of conduct

15. 1. Adjustment disorder
• To qualify for an adjustment disorder the persons
reaction must be:
• “Marked distress that is in excess of what would be
expected from exposure to the stressor” or
• “Significant impairment in social or occupational
functioning”
• That is, an expected or normal reaction to a stressful
work place situation is not an adjustment disorder

16. 1. Adjustment disorder
Treatment:
• Medication – SSRIs, SNRIs
• Medication side effects
• Duration of medication use
• Psychological therapy
• Group therapy

17. 1. Adjustment disorder
Prognosis
• Usually develops within 3 months of onset
• Usually lasts no longer than 3 to 6 months
• May persist in some cases

18. Tracey EMIN - Biography
• Grew up in Margate, difficult childhood
• parents of British Romani and Turkish Cypriot descent
• father owned Hotel International in Margate but the
business failed and the family suffered financially
• dropped out of school at thirteen, raped at that age
• squatted in London, provided a strong inspiration for
much of her later work
• studied art in Essex and London, deciding to destroy all
her work after a traumatic abortion in 1989
• began working only several years later, reworking her
past with letters and mementos from her youth

19. 2. Depressive disorder
• A clinical condition characterised by a low mood over a
period of time (2 weeks in DSM for MDE)
• Very common disorders, 4%M, 7%F in one year
• Accompanied by other symptoms:
insomnia, change in appetite and weight, loss of energy,
poor motivation, concentration and memory
• May involve thoughts of self harm or suicidal ideation

20. 2. Depressive disorder
Treatment
• Psychotherapy treatment
• Supportive Psychotherapy
• Cognitive Therapy
• Insight Orientated Psychotherapy
• Medication – TCA, MAOI, SSRI,
SNRI, Nassa, Melatonin acting,
Augmentation strategies
• Duration – maintenance
• Physical Therapies – ECT, TMS

21. 2. Depressive disorder
Prognosis
• About 66% of sufferers will respond to the first
antidepressants they use
• The combination of supportive psychotherapy, illness
education and medication can lead to recovery over a 6
month period

22. 3. Anxiety disorder
• A condition which is dominated by the symptom of
anxiety - anxiety is a normal emotion
• Very common disorders, 7%M, 12%F
• Anxiety is an emotion/feeling experienced as a
psychological or physical symptom of tension or
impending doom
• A result of sympathetic autonomic nervous system
activity (flight or fight)
• Shortness of breath, racing heart, tight chest, shortness
of breath, sweating, nausea
• Variety of disorders e.g. Panic, GAD, OCD, PTSD, SAD

23. 3. Anxiety disorder
Treatment
• Medication – Benzodiazepines: diazepam, temazepam,
alprazolam; Imidazopyridines: Stilnox, Imovane;
Antidepressants e.g. TCA, SSRI
• Medication side effects
• Duration of medication use
• Psychological therapy
• Behaviour/Exposure Therapy
Available behaviours/Avoidances
• Cognitive Therapy

24. 3. Anxiety disorder
Prognosis
Overall prognosis is good
• Prognosis can be affected by severity of symptoms,
coping style and general circumstances
• Anxiety disorders often resolve with treatment over a 6
month period

25. “My Bed”

26. 4. Post Traumatic Stress Disorder (PTSD)
Develops in some people following exposure to an that
involved (DSM “Criterion A” ) actual or threatened death or
serious injury event (military combat, sexual assault,
serious fires etc )
1. Repeated thoughts, dreams, nightmares or flashbacks
related to the original trauma
2. Avoidance of things linked to the trauma
3. Increased arousal symptoms such as hyperviligance and
exaggerated startle response
Is classified on the DSM as a anxiety disorder
• Over-diagnosed by clinicians especially in compensation
settings
• At risk of substance abuse

27. 4. Post Traumatic Stress Disorder (PTSD)
Treatment
• No universally successful treatment paradigm
• Examples of commonly used techniques include talking
through the trauma, medications, exposure therapy for
avoidances and EMDR

28. 4. Post Traumatic Stress Disorder (PTSD)
Prognosis
• True PTSD can resolve with effective treatment over the
course of 1 to 2 years. A minority of cases go on to be
chronic

29. 4. Post Traumatic Stress Disorder (PTSD)
Useful questions to ask:
• Was the original trauma sufficient for the diagnosis?
• What is the evidence that the trauma caused death,
serious injury and definite concern of these?
• Where all three symptoms groups clearly present?
• Has the worker seen a treater who has the skills to treat?

30. Stay in touch with the case
• When managing a psychological injury case, it is
important to stay in regular contact with the treating
medical practitioner and keep up to date with current
medical management and progress
• You can refer to a psychiatrist for treatment or an
independent medical opinion (IME)
• If seeking an IME, prepare questions in a way that will
provide you with the best possible information

31. Preparing for an IME
(refer to section 3 of the workbook for more information)
• In the referral letter, provide a half page summary case
overview, brief history, medical status, occupation and
purpose of the IME
• List and provide copies of all relevant reading material
• Provide all pre-reading material at least 7 DAYS PRIOR
to the appointment
• Include employer input where relevant
• Consider the need for an interpreter
• Design targeted, relevant and specific questions
• Limit the number of questions (8-12 maximum)

32. Example questions - IME
(refer to the workbook for all example questions)
Example questions are divided into key categories:
• Diagnosis
• Causation
• Treatment
• Capacity
• Prognosis

33. Example questions - IME
Diagnosis (example):
• What is your diagnosis, namely is the worker suffering
from or has the worker suffered from an injury in the
nature of a psychiatric illness? Please elaborate on how
you arrived at this diagnosis.
Causation (example):
• Is the worker’s employment a substantial case of their
injury/illness?
Treatment
• Does the worker require further treatment for the injury
and if so, please outline the nature and extent of such
treatment?

34. Example questions - IME
Capacity (example):
• What is the worker’s functional capacity for undertaking
their pre-injury employment? Please provide details of
these capabilities and any modifications that will assist
them to remain or return to work?
Prognosis (example):
• Has the worker’s condition followed the expected period
of recovery? If not, please advise why not?

36. Substances – Drugs & Alcohol
(refer to section 4 of the workbook)
Alcohol
• A psychoactive substance and consumption can lead to
feelings of relaxation and euphoria
Drugs
• Any chemical taken which affects the way the body
works, some examples include:
– Nicotine
– Cannabis
– Opioids
– Amphetamines
– Medications

37. Substances – Drugs & Alcohol
Cannabis plant
• smoked and produces euphoria, perceptual changes,
decreased anxiety, slower reaction time
Opioids
• Opium comes from the plant ‘papaver somniferum’
• Opioids include heroin, morphine, oxycodone, codeine
• Side effects include dry mouth, nausea, constipation,
confusion, depression
• Strong dependence caused with major withdrawal

38. Substances – Drugs & Alcohol
Amphetamines
• Psychostimulant drugs (naturally occurring & synthetic)
• Naturally occuring: nicotine, adrenaline, caffeine
• Synthetic: methamphetamine, pseudoephedrine,
Ecstacy, Crack, Meth
• Produces euphoria, reduced appetite, increased energy
• Highly addictive
Cocaine
• White powder extract often snorted or injected
• Produces euphoric effects

39. Why do we use illicit substances?
• Alcohol and other illicit drugs are often used
to try and “treat” a co-morbid psychiatric
condition
• Anxiety (incl PTSD) or depression often go
hand in hand with an alcohol problem, the
user feels the drug removes their
unpleasant emotion, eventually two
problems may result
• Some drugs attach to the receptors for
powerful brain chemicals like opiates,
GABA, serotonin and dopamine

40. Substance use - referrals
• Drug and Alcohol Services South Australia (DASSA) is a
Statewide Health Service and which addresses alcohol,
tobacco, pharmaceutical and illicit drug issues across the
state
• Alcohol and other withdrawal services now at Glenside
• Metropolitan Community Services (9 sites)
• Drugs of Dependence Unit
• Drug and Alcohol Research Unit
• Driver Assessment Unit
• Clean Needle Program

42. Psychosocial flags
(refer to section 5 of the workbook)
• Developed initially to help in understanding psychosocial
influences in musculoskeletal injuries
• Can help identify obstacles to recovery & RTW
• Yellow flags
• Blue flags
• Back flags
• Red flags
• How can they assist in psychological injury
management?

43. Managing psychological injuries
(refer to section 6 of the workbook)
• Returning to work is healthy
• The longer the time away from work the lower the
chance of successful rehabilitation
• Returning to activities of daily living is healthy
• Key stakeholders should work in collaboration
• Key stakeholders:
– Worker
– Employer/RRTWC
– Treating medical practitioner
– Case manager
– Rehabilitation provider (where applicable)

44. Managing psychological injuries
Working with the worker
• Establish a rapport and build trust as early as possible
• Maintain regular communication
• Keep up to date with progress and treatment
• Discuss concerns regarding return to work
• Encourage ideas about ways to work through issues
• Encourage frequent contact with the employer and the
worker’s colleagues
• Be supportive
• Set time lines for steps in rehabilitation and recovery

45. Managing psychological injuries
Working with the employer
• Establish a relationship as early as possible
• Work together to mitigate workplace stressors
• Encourage the employer to increase workplace supports
• Maintain regular communication
• Encourage regular contact between the employer and
the worker

46. Managing psychological injuries
Working with the treating medical practitioner
• Establish rapport as early as possible
• Arrange a case conference to discuss the best way
forward
• Request an update on treatment and progress
• Keep requesting information on available work options
and part time or restricted work options
• Push to get some work capacity even if very small

47. Good practice case management tips
• Early contact with the employer and worker
• Early and prompt determinations
• Ensure treatment plans are in place
• Follow up with providers on treatment goals and
progress
• Complete structured case management reviews at
regular intervals (i.e. 2, 6, 10, 13, 26 and 52 weeks)
• Utilise the expertise of team leaders, team managers,
IMAs or technical/legal advisors
• Include the worker in identifying barriers to recovery and
return to work and how to overcome these

48. More information
• Beyond Blue www.beyondblue.org.au
• The Black Dog Institute www.blackdoginstitute.org.au
• National Institute of Mental Health (NIMH)
www.nimh.nih.gov
• Mental Health First Aid www.mhfa.com.au
• The Mental Health Coordinating Council
www.mhcc.org.au
• SANE Australia www.sane.org
• The Centre for Mental Health Research
http://bluepages.anu.edu.au

49. Questions