Assessment of Psychosocial Contributions to Disability
Disability has traditionally been defined in terms of a largely biomedical model, where an individual’s limitations were seen as being the product of objectively verifiable physical problems. More recently though, disability has been redefined in terms of functionality within a social context. Thus, disability is best understood as a biopsychosocial phenomenon that combines biological, psychological, and social elements. Biopsychosocial assessment has inherent difficulties. Patients may lack insight into their psychological status and thus be unable to answer certain questions. Further, even if patients do have adequate insight, they may be motivated somehow to bias their reports of information. One method to overcome these challenges is the use of standardized psychometric measures that include validity assessment. Disability has traditionally been defined in biomedical terms and closely associated with objective physical impairment (Pledger, Am Psychol 58:279–284, 2003). More recent conceptualizations though hold that a comprehensive evaluation of disability requires not only the assessment of objective physical impairment but also an assessment of the psychosocial context in which the disability occurs. This conceptualization changed due to findings such as Ormel’s global study of 26,000 patients in 14 countries, which examined the origins of disability. The study determined that psychological factors were more predictive of physical disability than was disease severity (Ormel et al., JAMA 272:1741–1748, 1994).
Even when medical disorders are not present, psychological disorders can be disabling. According to the World Health Organization, mental health disorders are the most disabling of all conditions, accounting for 31% of the world’s disability (Mnookin, World Bank Group, & World Health Organization, Out of the shadows: Making mental health a global development priority. Geneva: World Health Organization, 2016; World Health Organization, Global Health Estimates 2015: Disease burden by Cause, Age, Sex, by Country and by Region, 2000–2015. Retrieved from Geneva: http://www.who.int/healthinfo/global_burden_disease/estimates/en/index2.html, 2016). Among mental health disorders, depression is the most disabling single condition in the world, accounting for 7.5% of the world’s disability, while anxiety accounts for an additional 3.4% (World Health Organization, Global Health Estimates 2015: Disease burden by Cause, Age, Sex, by Country and by Region, 2000–2015. Retrieved from Geneva: http://www.who.int/healthinfo/global_burden_disease/estimates/en/index2.html, 2016).
Among SSDI recipients in the United States, more than half have a disability involving psychological or subjective symptoms (especially pain, as pain disorders are a psychological condition), with 33% of SSDI recipients in 2010 having psychological disorders (up from 22% in 1986) and 28% suffering from painful musculoskeletal disorders (Congressional Budget Office, Policy Options for the Social Security Disability Insurance Program. Retrieved from http://www.cbo.gov/sites/default/files/cbofiles/attachments/43421-DisabilityInsurance_screen.pdf, 2012). These patients tend to gain disability status earlier in life, and stay on SSDI longer, because psychological and musculoskeletal conditions are less likely to be fatal.
Some psychosocial risk factors for disability such as socioeconomic status are objective in nature. In contrast, other psychosocial risk factors, such as depression, are determined to a large extent by the report of subjective states. To assess these subjective states, standardized psychological tests can play a valuable role. The defining characteristics of standardized psychological tests are discussed, as are their uses. Commonly used psychological tests are reviewed. Practical questions are also addressed, such as when to administer psychological tests, what psychosocial risk factors need to be assessed, what tests to use, methods of quantifying the level of psychosocial risk, and the detection of faking.
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