Diagnostic Criteria for PIISD – Private Insurance Induced Stress Disorder

By Carol A. Paris, MD
Psychiatric Times, October 28, 2010

The essential feature of private insurance induced stress disorder (PIISD) is the development of characteristic symptoms following exposure to an insurance-induced traumatic stressor involving direct personal experience of an event or witnessing an event that threatens another person. Traumatic events include, but are not limited to, recission of health insurance after developing a costly illness, denial of health insurance due to a pre-existing condition such as being female and fertile or delay of needed treatment or medication due to requirements for pre-authorization. In the case of physicians, traumatic events include witnessing the deterioration of patients due to financial ruin resulting from uncovered costs of care. Similar to some forms of PTSD, this disorder is prone to be severe because the stressor is of human/corporate design. Note: this diagnosis is not currently reimbursed by health insurance carriers.

Diagnostic criteria for PIISD include a history of exposure to a traumatic insurance-induced event meeting the following criteria and symptoms:

Criterion A: The person has been exposed to a traumatic insurance-induced event in which both of the following have been present:

• The person has experienced a health insurance traumatic event, due either to lack of access to health insurance, or due to failure of their health insurance to meet their health care needs. (NOTE: in the case of physicians/providers, the trauma is based on the inability to  provide needed care to one’s patients, or doing so at one’s personal  expense, ie, free care and/or oppressive paperwork burdens).

• The person’s traumatic response involved intense fear, helplessness,  anger, and confusion and was caused by financial considerations that  seriously complicate their (or their patient’s) medical treatment and  recovery.

Criterion B: The traumatic event is persistently reexperienced in one  (or more) of the following ways:

• Feelings of anger, frustration, and shame at the thought of one’s inability to access (or provide) needed care.

• Feelings of alienation from and abandonment by one’s countrymen and elected officials, precipitated by exposure to any form of corporate-controlled news media coverage of the health care crisis.

• Feelings of inadequacy, as an individual, as a family member, or as  a physician/provider, due to the repeated inability to obtain needed  care for oneself, one’s family member, or one’s patient.

• Avoidance of seeking, or providing, needed care due to fear of  serious financial strain or even bankruptcy.

• Fear of an acute confusional state or other cognitive disorder  following attempts to understand one’s EOBs (explanation of benefits).

Criterion C: Persistent avoidance of stimuli associated with the  trauma and numbing of general responsiveness, as indicated by three or  more of the following:

• Efforts to avoid thoughts, feelings or conversations about anything  related to health insurance or healthcare.

• Efforts to avoid interactions with physicians, hospitals or health  care centers that arouse recollection of the trauma. In the case of  physicians, efforts to avoid patients who are experiencing health  insurance trauma.

• Markedly diminished interest or participation in significant  activities.

• Feelings of detachment or estrangement from others.

• Restricted range of affect (eg, unable to experience feelings of  wellbeing)

• Sense of foreshortened future (eg, does not expect to have a career,  marriage, children, or a normal life span). In the case of physicians,  does not expect to remain in practice, anticipates early retirement or  disability due to consequences of health insurance trauma.

Criterion D: Persistent symptoms of increased arousal, as indicated by  two or more of the following:

• Difficulty falling or staying asleep, due to intrusive thoughts about the health insurance trauma.

• Irritability or outbursts of anger. In the case of physicians, this  often results in sanctions, possible loss of hospital privileges, and  being labeled a “disruptive physician.” In the case of patients, it  often results in suspiciousness directed at one’s physician, often  being labeled a “difficult patient.”

• Difficulty concentrating, resulting in functional impairment and  further jeopardizing career, health, and sense of well being.

• Hypervigilance, (eg, won’t let children play on playground equipment  for fear of minor injury resulting in possible retraumatizing need to  interact with one’s health insurance company).

Criterion E: The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if:
With bankruptcy
With home foreclosure

Dr Paris is a member of the Maryland Chapter of Physicians for a  National Health Program and a board certified adult psychiatrist in  private practice in Leonardtown, Maryland.