State News : Alabama

PTSD is one of the most frequently asserted mental health conditions we see in the workers’ compensation system. And while there’s no question that true PTSD can sometimes be debilitating, the reality is that the diagnosis is often over-applied in claims, not because of fraud, but because treating providers want to advocate for their patients.

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The problem is that “advocacy” often replaces science. Providers frequently overlook one of the most basic requirements of the DSM-5-TR: for PTSD to be validly diagnosed, symptoms must last at least one month after the traumatic event. When this threshold is ignored, ordinary stress reactions get mislabeled as psychiatric conditions, and those labels inevitably find their way into the claim file.

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This isn’t just an academic issue. Over-diagnosis creates inflated claims exposure, unnecessary treatment, and leverage for plaintiffs’ attorneys who argue for higher settlement values. The DSM itself cautions against over-pathologizing, but when practitioners skip the diagnostic framework, employers end up paying for conditions that don’t actually exist under the medical criteria.

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A few key points for employers and carriers to remember:

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• Most psychological impairments don’t stand alone. In workers’ comp, psychological symptoms are generally considered part of the impairment rating for the physical injury. A back injury that causes depression, for example, is still rated as a back injury with no separate psychological impairment.

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• Alabama law sets a clear boundary. We are a “physical/mental” state. That means an employee must first prove a physical injury before a psychological claim is even compensable. There is no such thing here as a stand-alone impairment for a mental condition. Which means there should never be a stand along psychological impairment.

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• Over-diagnosis drives claim costs. Misapplied PTSD labels can lead to unnecessary psychiatric treatment, inflated reserves, and higher settlements. Being aware of the DSM’s duration requirement (and making sure your IME physicians and defense experts highlight it) is one of the simplest ways to push back.

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Bottom line: PTSD is real but in the comp system, it’s often misdiagnosed, and that mistake costs money. Employers and carriers should stay alert to whether diagnostic criteria are being followed and push back whenever providers are stretching science into advocacy.

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About the Author:

This article was prepared by Mike Fish, an attorney with Fish Nelson & Holden, LLC, a law firm dedicated to representing self-insured employers, insurance carriers and funds, and third-party administrators in all matters related to workers’ compensation. Fish Nelson & Holden is a member of the National Workers’ Compensation Defense Network. If you have any questions about this article or Alabama workers’ compensation in general, please contact Fish by e-mailing him at mfish@fishnelson.com or by calling him directly at 205-332-1448.