Psychosis is a general term often used to describe a severe impairment in mental functioning. Usually, this impairment is so substantial that the individual is unable to carry on normal activities of daily living, including most work activities. More formally, Yodofsky, Hales and Fergusen (1991) define psychosis as:
“A major mental disorder of organic or emotional origin in which a person’s ability to think, respond emotionally, remember, communicate, interpret reality and behave appropriately is sufficiently impaired so as to interfere grossly with the capacity to meet the ordinary demands of life. [Symptoms are] often characterized by regressive behaviour, inappropriate mood, diminished impulse control and such abnormal mental context as delusions and hallucinations [p. 618].”
Psychotic disorders are comparatively rare in the general population. Their incidence in the workplace is even lower, probably due to the fact that many individuals who frequently become psychotic often have problems maintaining stable employment (Jorgensen 1987). Precisely how rare it is, is difficult to estimate. However, there are some suggestions that the prevalence within the general population of psychoses (e.g., schizophrenia) is less than 1% (Bentall 1990; Eysenck 1982). While psychosis is rare, individuals who are actively experiencing a psychotic state usually exhibit profound difficulties in functioning at work and in other aspects of their lives. Sometimes acutely psychotic individuals exhibit behaviours which are engaging, inspiring or even humorous. For example, some individuals who suffer from bipolar illness and are entering a manic phase exhibit high energy and grand ideas or plans. For the most part, however, psychosis is associated with behaviours which evoke reactions such as discomfort, anxiety, anger or fear in co-workers, supervisors and others.
This article will first provide an overview of the various neurological conditions and mental states in which psychosis can occur. Then, it will review workplace factors potentially associated with the occurrence of psychosis. Finally, it will summarize treatment approaches for managing both the psychotic worker and the work environment (i.e., medical management, return-to-work clearance procedures, workplace accommodations and workplace consultations with supervisors and co-workers).
Neurological Conditions and Mental Stateswithin which Psychosis Occurs
Psychosis can occur within a number of diagnostic categories identified in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) (American Psychiatric Association 1994). At this point, there is no commonly agreed upon definitive diagnostic set. The following are widely accepted as medical conditions within which psychoses arise.
Neurological and general medical conditions
Delusional symtomatology can be caused by a range of neurological disorders affecting the limbic system or basal ganglia, where cerebral cortical functioning remains intact. Partial complex seizure episodes are often preceded by olfactory hallucinations of peculiar smells. To an external observer, this seizure activity may appear to be simple staring or day-dreaming. Cerebral neoplasms, especially in temporal and occipital areas, can cause hallucinations. Also, delirium-causing diseases, such as Parkinson’s, Huntington’s, Alzheimer’s, and Pick’s, can result in altered states of consciousness. Several sexually transmitted diseases such as tertiary syphilis and AIDS can also produce psychosis. Lastly, deficiencies of certain nutrients, such as B-12, niacin, folic acid and thiamine, have the potential of causing neurological problems which can result in psychosis.
Psychotic symptoms such as hallucinations and delusions also occur among patients with various general medical conditions. These include several systemic diseases, such as hepatic encephalopathy, hypercalcaemia, diabetic ketoacidosis, and malfunction of endocrine glands (i.e., adrenal, thyroid, parathyroid and pituitary). Sensory and sleep deprivation have also been shown to cause psychosis.
Schizophrenia is probably the most widely known of the psychotic disorders. It is a progressively deteriorating condition which usually has an insidious onset. A number of specific subcategories have been identified including paranoid, disorganized, catatonic, undifferentiated and residual types. People who suffer from this disorder often have limited work histories and often do not remain in the workforce. Occupational impairment among schizophrenics is very common, and many schizophrenics lose their interest or will to work as the disease progresses. Unless a job is of very low complexity, it is usually very difficult for them to stay employed.
Schizophreniform disorder is similar to schizophrenia, but an episode of this disorder is of short duration, usually lasting less than six months. Generally, persons with this disorder have good premorbid social and occupational functioning. As the symptoms resolve, the person returns to baseline functioning. Consequently, the occupational impact of this disorder may be significantly less than in cases of schizophrenia.
Schizoaffective disorder also has a better prognosis than schizophrenia but a worse prognosis than affective disorders. Occupational impairment is quite common in this group. Psychosis is also sometimes observed in major affective disorders. With appropriate treatment, occupational functioning among workers suffering from major affective disorders is generally substantially better than for those with schizophrenia or schizoaffective disorders.
Severe stressors such as losing a loved one or losing one’s job can result in a brief reactive psychosis. This psychotic disorder is probably observed more frequently in the workplace than other types of psychotic disorder, especially with schizoid, schizotypal and borderline features.
Delusional disorders are probably relatively common in the workplace. There are several types. The erotomanic type typically believes that another person, usually of a higher social status, is in love with them. Sometimes, they harass the person who they believe is in love with them by attempting contact via telephone calls, letters or even stalking. Often, individuals with these disorders are employed in modest occupations, living isolated and withdrawn lives with limited social and sexual contact. The grandiose type usually exhibits delusions of inflated worth, power, knowledge or a special relationship with a deity or a famous person. The jealous type believes inaccurately that their sexual partner has been unfaithful. The persecutory type believes inaccurately that they (or someone to whom they are close) are being cheated, maligned, harassed or in other ways malevolently treated. These persons are often resentful and angry and may resort to violence against those they believe to be hurting them. They rarely want to seek help, as they do not think there is anything wrong with them. Somatic types develop delusions, contrary to all evidence, that they are afflicted with infections. They can also believe that a part of their body is disfigured, or worry about having a bad body odour. These workers with delusional beliefs can often create work-related difficulties.
Work-related chemical factors
Chemical factors such as mercury, carbon disulphide, toluene, arsenic and lead have been known to cause psychosis in blue-collar workers. For example, mercury has been found to be responsible for causing psychosis in workers in the hat industry, appropriately named the “Mad Hatter’s psychosis” (Kaplan and Sadock 1995). Stopford (personal communication, 6 November 1995) suggests that carbon disulphide was found to cause psychosis among workers in France in 1856. In the United States, in 1989, two brothers in Nevada purchased a carbon disulphide compound to kill gophers. Their physical contact with this chemical resulted in severe psychosis—one brother shooting a person and the other shooting himself due to severe confusion and psychotic depression. The incidence of suicide and homicide increases thirteenfold with exposure to carbon disulphide. Further, Stopford reports that exposure to toluene (used in making explosives and dyestuffs) is known to cause acute encephalopathy and psychosis. Symptoms can manifest also as memory loss, mood changes (e.g., dysphoria), deterioration in eye-hand coordination and speech impediments. Hence, some organic solvents, especially those found in the chemical industry, have a direct influence on the human central nervous system (CNS), causing biochemical changes and unpredictable behaviour (Levi, Frandenhaeuser and Gardell 1986). Special precautions, procedures and protocols have been established by the US Occupational Safety and Health Administration (OSHA), National Institute for Occupational Safety and Health (NIOSH) and the chemical industry to ensure minimum risk to employees working with toxic chemicals in their work environments.
A number of medications can cause delirium which in turn can result in psychosis. These include antihypertensives, anticholinergics (including a number of medications used to treat the common cold), antidepressants, anti-tuberculosis medicines, anti-Parkinson’s disease medicines, and ulcer medicines (such as cimetidine). Further, substance-induced psychosis can be caused by a number of licit and illicit drugs which are sometimes abused, such as alcohol, amphetamines, cocaine, PCP, anabolic steroids and marijuana. The delusions and hallucinations which result are usually temporary. Although the content may vary, persecutory delusions are quite common. In alcohol-related hallucinations a person may believe that he or she is hearing voices which are threatening, insulting, critical or condemning. Sometimes, these insulting voices speak in the third person. As with individuals exhibiting paranoid or persecutory delusions, these individuals should be carefully evaluated for dangerousness to self or others.
Post-partum psychosis is comparatively uncommon in the workplace, but is worth noting as some women are returning to work more quickly. It tends to occur in new mothers (or more rarely fathers), usually within two to four weeks after delivery.
In a number of cultures, psychosis may result from various commonly held beliefs. A number of culturally based psychotic reactions have been described, including episodes such as “koro” in South and East Asia, “qi-gong psychotic reaction” within Chinese populations, “piblokto” in Eskimo communities and “whitigo” among several American Indian groups (Kaplan and Sadock 1995). The relationship of these psychotic phenomena to various occupational variables does not appear to have been studied.
Workplace Factors Associated with the Occurrence of Psychosis
Although information and empirical research on work-related psychosis are extremely scarce, due in part to the low prevalence in the work setting, researchers have noted a relationship between psychosocial factors in the work environment and psychological distress (Neff 1968; Lazarus 1991; Sauter, Murphy and Hurrell 1992; Quick et al. 1992). Significant psychosocial stressors on the job, such as role ambiguity, role conflicts, discrimination, supervisor-supervisee conflicts, work overload and work setting have been found to be associated with greater susceptibility to stress-related illness, tardiness, absenteeism, poor performance, depression, anxiety and other psychological distress (Levi, Frandenhaeuser and Gardell 1986; Sutherland and Cooper 1988).
Stress appears to have a prominent role in the complex manifestations of various types of physiological and psychological disorders. In the workplace, Margolis and Kroes (1974) believe that occupational stress occurs when some factor or combination of factors at work interact with the worker to disrupt his or her psychological or physiological homeostasis. These factors can be external or internal. External factors are the various pressures or demands from the external environment which stem from a person’s occupation, as well as from marriage, family or friends, whereas internal factors are the pressures and demands a worker places upon him- or herself—for example, by being “ambitious, materialistic, competitive and aggressive” (Yates 1989). It is these internal and external factors, separately or in combination, which can result in occupational distress whereby the worker experiences significant psychological and physical health problems.
Researchers have speculated on whether severe or cumulative stress, known as “stress-induced arousal”, originating from the work environment, could induce work-related psychotic disorders (Bentall, Dohrenwend and Skodol 1990; Link, Dohrenwend and Skodol 1986). For example, there is evidence linking hallucinatory and delusional experiences to specific stressful events. Hallucinations have been associated with stress-induced arousal occurring as a result of mining accidents, hostage situations, chemical-factory explosions, wartime exposure, sustained military operations and loss of a spouse (Comer, Madow and Dixon 1967; Hobfoll 1988; Wells 1983).
DeWolf (1986) believes that either the exposure to or interaction of multiple stressful conditions over an extended period of time is a complex process whereby some workers experience psychological health-related problems. Brodsky (1984) found in her examination of 2,000 workers who were her patients over 18 years that: (1) the timing, frequency, intensity and duration of unpleasant work conditions were potentially harmful, and she believed that 8 to 10% of the workforce experienced disabling psychological, emotional and physical health-related problems; and (2) workers react to work-related stress in part as “a function of perceptions, personality, age, status, life stage, unrealized expectations, prior experiences, social support systems and their capacity to respond adequately or adapt.” In addition, psychological distress can potentially be exacerbated by the worker feeling a sense of uncontrollability (e.g., inability to make decisions) and unpredictability in the work environment (e.g., corporate downsizing and reorganizing) (Labig 1995; Link and Stueve 1994).
Specific examination of the work-related “antecedents” of workers experiencing psychosis has received limited attention. The few researchers who have empirically examined the relationship between psychosocial factors in the work environment and severe psychopathology have found a relationship between “noisome” work conditions (i.e., noise, hazardous conditions, heat, humidity, fumes and cold) and psychosis (Link, Dohrenwend and Skodol 1986; Muntaner et al. 1991). Link, Dohrenwend and Skodol (1986) were interested in understanding the types of jobs schizophrenics had when they experienced their first schizophrenic episode. First full-time occupations were examined for workers who experienced: (a) schizophrenic or schizophrenic-like episodes; (b) depression; and (c) no psychopathology. These researchers found that noisome work conditions existed among more blue-collar than white-collar professions. These researchers concluded that noisome work conditions were potentially significant risk factors in the manifestation of psychotic episodes (i.e., schizophrenia).
Muntaner et al. (1991) replicated the findings of Link, Dohrenwend and Skodol (1986) and examined in greater detail whether various occupational stressors contributed to increased risk of developing or experiencing psychoses. Three types of psychotic condition were examined using the criteria of DSM III—schizophrenia; schizophrenia criterion A (hallucinations and delusions); and schizophrenia criterion A with affective episode (psychotic-affective disorder). Participants in their retrospective study were from a larger Epidemiologic Catchment Area (ECA) study examining the incidence of psychiatric disorders across five sites (Connecticut, Maryland, North Carolina, Missouri and California). These researchers found that psychosocial work characteristics (i.e., high physical demands, lack of control over work and working conditions—noisome factors) placed participants at increased risk of psychotic occurrences.
As illustrations, in the Muntaner et al. (1991) study, people in construction trade occupations (i.e., carpenters, painters, roofers, electricians, plumbers) were 2.58 times more likely to experience delusions or hallucinations than people in managerial occupations. Workers in housekeeping, laundry, cleaning and servant-type occupations were 4.13 times more likely to become schizophrenic than workers in managerial occupations. Workers who identified themselves as writers, artists, entertainers and athletes were 3.32 times more likely to experience delusions or hallucinations in comparison to workers in executive, administrative and managerial occupations. Lastly, workers in occupations such as sales, mail and message delivery, teaching, library science and counselling were more at risk of psychotic, affective disorders. It is important to note that the associations between psychotic conditions and occupational variables were examined after alcohol and drug use was controlled for in their study.
A significant difference between blue-collar and white-collar professions is the types of psychological demand and psychosocial stress placed on the worker. This is illustrated in the findings of Muntaner et al. (1993). They found an association between a work environment’s cognitive complexity and psychotic forms of mental illness. The most frequent occupations held by schizophrenic patients during their last full-time job were characterized by their low level of complexity in dealing with people, information and objects (e.g., janitors, cleaners, gardeners, guards). A few researchers have examined some of the consequences of first episodic psychosis relative to employment, job performance and capacity to work (Jorgensen 1987; Massel et al. 1990; Beiser et al. 1994). For example, Beiser and co-workers examined occupational functioning after the first episode of psychosis. These researchers found 18 months after the first episode that the “psychosis compromise[d] occupational functioning”. In other words, there was a higher post-morbid decline among schizophrenic workers than among those suffering from affective disorders. Similarly, Massel et al. (1990) found that the work capacity of psychotics (e.g., people with schizophrenia, affective disorders with psychotic features or atypical psychotic disorders) was impaired in comparison to non-psychotics (e.g., people with affective disorders without psychotic features, anxiety disorders, personality disorders and substance abuse disorders). Psychotics in their study showed marked thought disturbance, hostility and suspiciousness which correlated with poor work performance.
In summary, our knowledge about the relationship between work-related factors and psychosis is in the embryonic stage. As Brodsky (1984) states, “the physical and chemical hazards of the workplace have received considerable attention, but the psychological stresses associated with work have not been as widely discussed, other than in relation to managerial responsibilities or to the coronary-prone behaviour pattern”. This means that research on the topic of work-related psychosis is vitally needed, especially since workers spend an average of 42 to 44% of their lives working (Hines, Durham and Geoghegan 1991; Lemen 1995) and work has been associated with psychological well-being (Warr 1978). We need to have a better understanding of what types of occupational stressor under what types of condition influence which types of psychological disorder. For example, research is needed to determine whether there are stages which workers move through based upon intensity, duration and frequency of psychosocial stress in the work environment, in conjunction with personal, social, cultural and political factors occurring in their daily lives. We are dealing with complex issues which will require in-depth inquiries and ingenious solutions.
Acute Management of the Psychotic Worker
Typically, the primary role of persons in the workplace is to respond to an acutely psychotic worker in a manner which facilitates the person being transported safely to an emergency room or psychiatric treatment facility. The process may be greatly facilitated if the organization has an active employee assistance programme and a critical incident response plan. Ideally, the organization will train key employees in advance for emergency crisis responses and will have a plan in place for coordinating as needed with local emergency response resources.
Treatment approaches for the psychotic worker will vary depending upon the specific type of underlying problem. In general, all psychotic disorders should be evaluated by a professional. Often, immediate hospitalization is warranted for the safety of the worker and the workplace. Thereafter, a thorough evaluation can be completed to establish a diagnosis and develop a treatment plan. The primary goal is to treat the underlying cause(s). However, even prior to conducting a comprehensive evaluation or initiating a comprehensive treatment plan, the physician responding to the emergency may need to focus initially on providing symptomatic relief. Providing a structured, low-stress environment is desirable. Neuroloptics may be used to help the patient calm down. Benzodiazepines may help reduce acute anxiety.
After managing the acute crisis, a comprehensive evaluation may include collecting a detailed history, psychological testing, a risk assessment to establish dangerousness to self or others and careful monitoring of response to treatment (including not only response to medications, but also to psychotherapeutic interventions). One of the more difficult problems with many patients who exhibit psychotic symptomatology is treatment compliance. Often these individuals tend not to believe that they have serious difficulties, or, even if they recognize the problem, they are sometimes inclined to decide unilaterally to discontinue treatment prematurely. In these instances, family members, co-workers, treating clinicians, occupational health personnel and employers are sometimes placed in awkward or difficult situations. Sometimes, for the safety of the employee and the workplace, it becomes necessary to mandate compliance with treatment as a condition for returning to the job.
Managing the Psychotic Worker and the Work Environment
Case exampleA skilled worker on the third shift at a chemical plant began to exhibit unusual behaviour as the company began to modify its production schedule. For several weeks, instead of leaving work after his shift ended, he began to stay for several hours discussing his concerns about increased job demands, quality control and changes in production procedures with his counterparts on the morning shift. He appeared quite distressed and behaved in a manner which was atypical for him. He had formerly been somewhat shy and distant, with an excellent job performance history. During this period of time, he became more verbal. He also approached individuals and stood close to them in a manner which several co-workers reported made them feel uncomfortable. While these co-workers later reported that they felt his behaviour was unusual, no one notified the employee assistance programme (EAP) or management of their concerns. Then, suddenly one evening, this employee was observed by his co-workers as he began to shout incoherently, walked over to a storage area for volatile chemicals, laid down on the ground and began to flick a cigarette lighter on and off. His co-workers and supervisor interfered and, after consultation with the EAP, he was taken by ambulance to a nearby hospital. The treating physician determined that he was acutely psychotic. After a brief treatment period he was successfully stabilized on medications.
After several weeks, his treating physician felt he was able to return to his job. He underwent a formal return-to-work evaluation with an independent clinician and was judged ready to return to work. While his company doctor and the treating physician determined that it was safe for him to return, his co-workers and supervisors expressed substantial concerns. Some employees noted that they might be harmed if this episode were repeated and the chemical storage areas ignited. The company took steps to increase security in safety sensitive areas. Another concern also surfaced. A number of workers stated that they believed this individual might bring a weapon to work and start shooting. None of the professionals involved in treating this worker or in evaluating him for return to work believed that there was a risk of violent behaviour. The company then elected to bring in mental health professionals (with the worker’s consent) to assure co-workers that the risk of violent behaviour was exceedingly low, to provide education on mental illnesses, and to identify proactive steps that co-workers could take to facilitate the return to work of a colleague who had undergone treatment. However, in this situation, even after this educational intervention, co-workers were unwilling to interact with this worker, further compounding the return-to-work process. While the legal rights of individuals suffering from mental disorders, including those associated with psychotic states, have been addressed by the Americans with Disabilities Act, practically speaking the organizational challenges to effectively managing occurrences of psychosis at work are often as great or greater than the medical treatment of psychotic workers.
Return to Work
The primary question to be addressed after a psychotic episode is whether the employee can safely return to his or her current job. Sometimes organizations permit this decision to be made by the treating clinicians. However, ideally, the organization should require their occupational medical system to conduct an independent fitness-for-duty evaluation (Himmerstein and Pransky 1988). In the fitness-for-duty evaluation process a number of key pieces of information should be reviewed, including the treating clinician’s evaluation, treatment and recommendations, as well as the worker’s prior job performance and the specific features of the job, including the required job tasks and the organizational environment.
If the occupational medical physician is not trained in psychiatric or psychological fitness-for-duty evaluation, then the evaluation should be performed by an independent mental health professional who is not the treating clinician. If some aspects of the job pose safety risks, then specific work restrictions should be developed. These restrictions may range from minor alterations in work activities or work schedule to more significant modifications such as alternate job placement (e.g., a light-duty assignment or a job transfer to an alternate position). In principle, these work restrictions are not different in kind from other restrictions commonly provided by occupational health physicians, such as specifying the amount of weight which a worker may be cleared to lift following a musculoskeletal injury.
As is evident in the case example above, the return to work often raises challenges not only for the affected worker, but also for co-workers, supervisors and the broader organization. While professionals are obligated to protect the confidentiality of the affected worker to the fullest extent permitted by law, if the worker is willing and competent to sign an appropriate release of information, then the occupational medical system can provide or coordinate consultation and educational interventions to facilitate the return-to-work process. Often, coordination between the occupational medical system, the employee assistance programme, supervisors, union representatives and co-workers is critical to a successful outcome.
The occupational health system should also periodically monitor the worker’s readjustment to the workplace in collaboration with the supervisor. In some instances, it may be necessary to monitor the worker’s compliance with a medication regimen recommended by the treating physician—for example, as a precondition for being permitted to engage in certain safety-sensitive job tasks. More importantly, the occupational medical system must consider not only what is best for the worker, but also what is safe for the workplace. The occupational medical system may also play a critical role in assisting the organization in complying with legal requirements such as the Americans with Disabilities Act as well as in interfacing with treatments provided under the organization’s health care plan and/or the workers’ compensation system.
At present, there is no literature on specific prevention or early intervention programmes for reducing the incidence of psychosis in the workforce. Employee assistance programmes may play a crucial role in the early identification and treatment of psychotic workers. Since stress may contribute to the incidence of psychotic episodes within working populations, various organizational interventions which identify and modify organizationally created stress may also be helpful. These general programmatic efforts may include job redesign, flexible scheduling, self-paced work, self-directed work teams and microbreaks, as well as specific programming to reduce the stressful impact of reorganization or downsizing.
While psychosis is a comparatively rare and multiply determined phenomenon, its occurrence within working populations raises substantial practical challenges for co-workers, union representatives, supervisors and occupational health professionals. Psychosis may occur as a direct consequence of a work-related toxic exposure. Work-related stress may also increase the incidence of psychosis among workers who suffer from (or are at risk of developing) mental disorders which place them at risk of psychosis. Additional research is needed to: (1) better understand the relationship between workplace factors and psychosis; and (2) develop more effective approaches for managing psychosis in the workplace and reduce its incidence.