To the Editor: Psychological disorders linked with working conditions are internationally recognized as an emerging clinical entity.1–3 They have potentially serious consequences and may even be responsible for work-related suicide.4 Work-related stress is an impairment of mental, physical, or social functioning induced by either difficult working conditions or organizational and relational factors in the company. The clinical features of stress (including bullying at work) are heterogeneous but have in common their relationship with occupational factors. Occupational physicians are often on the front line in the diagnosis of these mental disorders and in the management of patients. To our knowledge, no documents are yet available to help practitioners to identify clinical syndromes of work-related stress and bullying and then optimize referral of patients to either medical (general practitioners and/or psychiatrists) or nonmedical specialists (psychologists, social workers, and lawyers). The purpose of this work was to review the key elements of a first consultation for a patient presenting with symptoms of work-related stress or bullying. The assessment includes several stages. The first part of the consultation focuses on the severity of symptoms and the identification of the clinical syndrome. Medical findings observed in cases of work-related stress and bullying are nonspecific. The disorder may correspond to a de novo diagnosis or the aggravation of a preexisting condition. Treatments prescribed and taken by the patient need to be noted down. Chronic delusional illnesses, depression, anxiety, adaptation, and personality disorders can be identified. Burnout is a suggestive syndrome.5 The physician should look for psychiatric comorbidities such as a personal or family psychiatric history and addictions and other risk factors for self- or heteroaggressive acts such as suicide attempts, self-inflicted injuries (eg, scarification), and so on. During the interview, it is also important to look for elements indicating a risk of suicidal or homicide attempts. The next one needs to evaluate the working and social environment, including the job history and chronology of events. The present episode must then be analyzed, into three phases: first the initial, so-called “serene,” phase, during which the patient does not report any particular difficulty; then the “problem” phase during which obstacles and conflicts gradually appear; and finally the third or “crisis” phase, for which the patient will generally see a doctor. Analysis of transitional elements (“what has changed?”) and elements of personal and collective resistance should be described in detail. Other work factors need to be listed (Table 1). Mechanisms and procedures of relay and support by occupational health and prevention teams or trade union representatives must be looked into. The patient's social and family environment may reveal the existence of protective or aggravating factors. A precarious social situation often forces patients to stay in the same job, which delays the diagnosis and limits the range of options offered. On the contrary, a protective family environment helps to maintain the patient in his job. Any legal action already undertaken by the patient is also useful to know for the practitioner.TABLE 1: Clinical Workup of a Patient Consulting for Work-Related Psychological Distress or BullyingTable 1 summarizes the different stages of the patients care. They may help general practitioners to distinguish between psychiatric cases requiring urgent management, a simple conflict situation with no psychological repercussions, and intermediate cases. It may be necessary to remove the patient from the working environment (sick leave) and try a medical treatment together with a workplace intervention. Reevaluation after appropriate medical attention is always useful. Occupational physicians are increasingly involved in dealing with complex situations of work-related stress or bullying and play a key role in their management after a first consultation to improve multidisciplinary work. Zakia Mediouni, MD Assistance Publique - Hôpitaux de Paris Occupational Health Department University Hospital of Paris West Suburb Poincaré site Garches, France Hélène Garrabé, MD Inspection Médicale Direccte Ile de France Fabienne Jaworski, MD Occupational Health Unit Thales Communication and Security, France Florence Danzin, MD Psychiatry Unit Charcot-St Cyr, France Pénélope Jauffret, MD APST BTP RP, France; Brigitte Clodoré, MD Mairie de Paris, France Alexis Descatha, MD, PhD Assistance Publique - Hôpitaux de Paris Occupational Health Department University Hospital of Paris West Suburb Poincaré site UVSQ Versailles University, Inserm UMRS 1018, France ([email protected]) ACKNOWLEDGMENTS The authors thank Dr Bértrand Bécour for reviewing this manuscript.
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