Present: All the Justices
FAIRFAX COUNTY FIRE AND RESCUE
DEPARTMENT, ET AL.
v. Record No. 010791 OPINION BY JUSTICE CYNTHIA D. KINSER
March 1, 2002
RANDALL U. MOTTRAM
FROM THE COURT OF APPEALS OF VIRGINIA
In this workers’ compensation claim, the issue is
whether posttraumatic stress disorder (PTSD) is a disease
and, if so, whether it is an ordinary disease of life or an
occupational disease as defined in Code § 65.2-400.
Because we conclude that the evidence establishes that the
PTSD suffered by the employee in this case is an
occupational disease, we will affirm in part and reverse in
part the judgment of the Court of Appeals holding that PTSD
is an ordinary disease of life.
FACTS AND MATERIAL PROCEEDINGS
Randall U. Mottram had been employed by the Fairfax
County Fire and Rescue Department (the Department) and the
Fairfax County Board of Supervisors (collectively with the
Department, the Employer), for 19 years when he was
diagnosed with PTSD in 1996. During the first ten years of
his employment, he worked as a paramedic and then became a
paramedic supervisor with the rank of captain. In both of
those positions, Mottram responded to approximately ten
emergency calls per day. Not all of the calls to which he
responded as a paramedic involved severely injured people.
However, as a supervisor, he responded to the “big serious
calls with lots of people needing medical care.” Those
emergency calls included incidents such as airplane
crashes, amputations and decapitations, automobile
accidents with multiple victims, shootings, stabbings, and
house fires with fatalities of entire families.
Beginning in the early 1990’s, Mottram was assigned to
various administrative posts that did not require him to
respond to emergencies. However, every two months, Mottram
worked a 24-hour shift involving emergency response in
order to maintain his certification as a paramedic.
Mottram was working such a shift on March 10, 1996,
when he responded to a fire at a residence that resulted in
multiple burn injuries to several people and one fatality.
The fire was especially disturbing to Mottram because it
reminded him of a horrible house fire to which he had
responded fifteen to twenty years earlier in which six
members of a family, including children and grandparents,
had perished. While Mottram was treating a five-year-old
girl at the March 10 fire, the child inquired about her
stepmother. Mottram had just pronounced the stepmother
dead at the scene of the fire, and he was aware that the
2
child’s father was critically injured. In describing his
reaction to the child’s question, Mottram stated that he
“became removed from the scene. I was outside of myself.”
He said that he felt a “shroud of darkness” come over him
and that he had difficulty breathing.
Mottram first consulted Dr. Mary W. Lindahl, a
licensed clinical psychologist, on March 4, 1996, six days
prior to that March 10 emergency response call, because he
was concerned that he might be predisposed to suffering a
disabling injury. He reported experiencing intrusive
thoughts, overwhelming anxiety, and excessive sleeping.
Mottram saw Dr. Lindahl again on March 6 and 7. During
those visits, he stated that his symptoms persisted and
that he was considering taking leave from work because of
stress.
During another appointment three days after the
incident on March 10, Dr. Lindahl described Mottram as
“noticeably more distressed, and . . . becoming seriously
depressed.” Dr. Lindahl concluded that it “is difficult to
separate out the impact of the [March 10] call on Mr.
Mottram’s condition. . . . Clearly, he had some symptoms of
PTSD when he first came on [March 4]; however, his symptoms
worsened into a serious PTSD and major depression after the
[March 10] incident.” By December 1996, Mottram was
3
suicidal and had to be hospitalized for treatment, which
included electroconvulsive therapy. In a series of medical
status reports from March 1996 through June 1996, Dr.
Lindahl consistently described the March 10, 1996 episode
as the “critical incident.” However, she also separately
noted that Mottram “has chronic PTSD, so other work-related
incidents also contributed.”
Dr. Lindahl further stated that there is no evidence
that Mottram was exposed to critical incidents outside his
employment. Likewise, at a hearing on his workers’
compensation claim, Mottram testified that he had not been
exposed to medical emergencies or fires, nor had he
witnessed death or violent trauma, outside the
circumstances of his employment with the Department.
In 1998, Dr. Lindahl expressed the following opinion
regarding Mottram’s condition:
It is my opinion that Capt. Mottram is suffering from
an occupational disease which arises out of the course
of his employment in the Fairfax County Fire
Department. It is well-documented in the
psychological literature that emergency services
workers are at increased risk for Post-Traumatic
Stress Disorder, and there is some evidence indicating
that the longer the exposure, the more severe the
reaction. Mr. Mottram had a long career in the Fire
Department with exposure to many critical incidents.
As a result, he has developed Post-Traumatic Stress
Disorder that is chronic and cumulative.
4
The psychological literature to which Dr. Lindahl was
referring included an article discussing the neurobiology
of PTSD. Relying on that article, Dr. Lindahl stated that
Mottram’s exposure to critical incidents resulted in
“neurochemical alterations in multiple neurotransmitter
systems.” See Steven M. Southwick et al., Neurobiology of
Post-Traumatic Stress Disorder in PSYCHOTRAUMATOLOGY, KEY PAPERS
AND CORE CONCEPTS IN POST TRAUMATIC STRESS 49, 53 (George S.
Everly, Jr. & Jeffrey M. Lating eds., 1995).
Dr. Lindahl referred Mottram to Dr. Randolph A. Frank,
Jr., a psychiatrist who concurred in the diagnosis of PTSD.
Dr. Frank opined that Mottram’s PTSD was “incurred in the
line of duty as characterized by marked and intrusive
distressing recollections of events noted in a number of
calls that he was involved in, recurrent distressing
dreams, significant symptoms of increased arousal and
anxiety, sleep disturbance, severe difficulty
concentrating, and extreme hypervigilance.” 1
1
On brief, the Employer discusses a psychiatric
evaluation of Mottram conducted by Dr. Brian Schulman at
the request of the Department. Dr. Schulman diagnosed
Mottram as suffering from major depression that “was not
precipitated or accelerated by any condition emanating from
Mr. Mottram’s employment.” Despite noting symptoms of a
depressed affect, moderate degree of anxiety, and insomnia,
Dr. Schulman found no medical basis upon which to ascribe
those symptoms to PTSD.
5
In January 1997, Mottram filed a workers’ compensation
claim alleging that on March 10, 1996, he suffered an
injury by accident arising out of and in the course of his
employment, which resulted in temporary total disability
due to PTSD. In the alternative, Mottram claimed that he
was suffering from an occupational disease. At a hearing
before the Deputy Commissioner, Mottram elected to proceed
only on the theory of injury by accident and withdrew the
occupational disease claim.
The Workers’ Compensation Commission (the Commission)
denied Mottram’s claim, deciding that Mottram had not
proven a compensable injury by accident and that his
condition was not causally related to the incident on March
10, 1996. Mottram did not appeal that decision.
Mottram subsequently filed a second application,
claiming that his PTSD was an occupational disease arising
out of and in the course of his employment. The Commission
again denied the claim, finding that Mottram’s PTSD was not
compensable because it was a condition resulting from
cumulative or repetitive trauma, rather than a disease. In
distinguishing this Court’s decision in A New Leaf, Inc. v.
However, the validity of the diagnosis of Mottram’s
PTSD is not at issue in this appeal because the Employer
did not assign error to the finding that Mottram suffers
from PTSD. See Rule 5:17(c).
6
Webb, 257 Va. 190, 511 S.E.2d 102 (1999), the Commission
concluded that Mottram’s condition was “attributable to
exposure to one or more significant and distinct traumatic
events” rather than to a general exposure to such
incidents. 2
Mottram appealed the Commission’s denial of his
occupational disease claim to the Court of Appeals. That
court reversed, holding that Mottram’s condition is a
disease. Mottram v. Fairfax County Fire & Rescue, 35 Va.
App. 85, 96, 542 S.E.2d 811, 816 (2001). In reaching that
conclusion, the court recognized that PTSD may be
compensable as an injury by accident under certain
circumstances, but that, in other situations, it may be
appropriately classified as a disease. Id. at 93, 542
S.E.2d at 814. The Court of Appeals found that Mottram’s
condition was analogous to the employee’s allergic contact
dermatitis in A New Leaf because, “[j]ust as [that
employee’s] condition resulted from a bodily reaction to
irritating stimuli, Mottram’s condition resulted from
‘neurochemical alterations in multiple neurotransmitter
2
A Deputy Commissioner had found that the evidence was
“insufficient to establish that [Mottram’s] claim is
compensable as an ordinary disease of life.” Since the
Commission concluded that Mottram’s PTSD is not a disease,
7
systems.’ ” Id. at 95, 542 S.E.2d at 815. However, the
court concluded that, because “PTSD is a condition that may
develop from the general stresses of life and is not
necessarily tied to occupational stress,” it is an ordinary
disease of life within the meaning of Code § 65.2-401. Id.
at 96, 542 S.E.2d at 816. Thus, the court remanded
Mottram’s claim to the Commission for a determination as to
whether Mottram’s PTSD qualifies as a compensable ordinary
disease of life. Id.
The Employer appeals from that decision, asserting
that the Court of Appeals erred in finding that PTSD may be
a compensable ordinary disease of life. Mottram assigned
cross-error. He contends that the Court of Appeals erred
by concluding that PTSD is not an occupational disease.
ANALYSIS
The issue whether an employee “has suffered an
impairment that constitutes a compensable disease is a
mixed question of law and fact.” Stenrich Group v.
Jemmott, 251 Va. 186, 192, 467 S.E.2d 795, 798 (1996),
cited in A New Leaf, 257 Va. at 196, 511 S.E.2d at 104.
Hence, the Commission’s finding with regard to that mixed
question is not binding on appeal. Id. Instead, it is
it did not address whether it is an ordinary disease of
life or an occupational disease.
8
properly subject to review by this Court. Id.; Peanut City
Iron & Metal Co. v. Jenkins, 207 Va. 399, 403, 150 S.E.2d
120, 123 (1966).
As we have previously noted, the Employer does not
dispute that Mottram suffers from PTSD. 3 Thus, as in
Jemmott and A New Leaf, the factual part of the question is
not at issue in this case. The legal portion of the mixed
question, which the Employer does contest, is whether PTSD
is a compensable disease within the purview of the Virginia
Workers’ Compensation Act, specifically either Code § 65.2-
401 (establishing criteria for compensable ordinary disease
of life), or Code § 65.2-400 (defining occupational
disease). However, before deciding whether PTSD is
compensable under either of these statutory provisions, we
must first determine whether PTSD qualifies as a disease.
Merillat Indus. v. Parks, 246 Va. 429, 432, 436 S.E.2d 600,
601 (1993).
3
However, relying on the definition of PTSD in the
American Psychiatric Association: Diagnostic and
Statistical Manual of Mental Disorders (4th ed. 1994), the
Employer attempts to challenge the diagnosis of PTSD by
arguing that PTSD can only result from exposure to a single
traumatic stressor rather than exposure to separate and
distinct traumatic events. Since the factual finding that
Mottram suffers from PTSD is not the subject of an
assignment of error, see Rule 5:17(c), the question whether
PTSD can be caused by exposure to multiple traumatic
events, as opposed to a single such event, is not before
us.
9
With regard to that issue, the Employer argues that,
since Mottram’s PTSD resulted from exposure to multiple
shocking and frightening events, it is a repetitive trauma
injury rather than a disease and is, therefore, not
compensable under this Court’s decisions in such cases as
Merillat and Jemmott. The Employer points out that, when
the General Assembly amended Code § 65.2-400 to designate
hearing loss and carpal tunnel syndrome as ordinary
diseases of life, it did not include such disorders as
PTSD. Finally, the Employer argues that our decision in A
New Leaf is distinguishable because the employee there had
constant daily exposure to the allergens whereas Mottram’s
exposure was to separate and distinct traumatic events.
The Employer also notes that, for several years prior to
the incident on March 10, 1996, Mottram responded to
emergency calls only about six days a year.
Contrary to the Employer’s argument, we conclude that
our rationale in A New Leaf is controlling. There, the
evidence established that the employee’s contact dermatitis
was caused by her physical contact with chemicals contained
in certain flowers. 257 Va. at 197, 511 S.E.2d at 105.
The record also included an article introduced into
evidence that described contact dermatitis as a “ ‘reaction
of the body’s immune system to the substance to which that
10
person is sensitive.’ ” Id. (quoting Cindy Hoogasian,
Dermatitis Concerns Continue, FLORIST, March 1990, at 77).
Thus, we held that the employee’s exposure over time to a
causative agent in the flowers “triggered a dermatological
reaction, which is distinct from the wear and tear
resulting from a repetitive motion.” Id. at 198, 511
S.E.2d at 105.
In the present case, credible evidence establishes
that Mottram’s repeated exposure to traumatic stressors
caused reactions in his neurobiological systems, much like
the reaction of the employee’s immune system in A New Leaf.
Literature referred to by Dr. Lindahl and admitted into
evidence explains that, “[u]nder conditions of acute and
severe psychological trauma, the organism mobilizes
multiple neurobiological systems for the purpose of
survival.” Southwick at 63. However, these
neurobiological responses, although initially beneficial,
“may have long-term negative consequences that are related
to many of the chronic symptoms of PTSD.” Id. at 64. The
article also explains that individuals with “chronic PTSD
frequently exhibit increased anger, hostility, impulsivity,
and dysphoria[,]” and that such symptoms “may be related to
11
abnormalities in either norepinephrine, 5-HT, or both.” 4
Id. Thus, we conclude, as did the Court of Appeals, that
Mottram’s condition is a disease.
Since Mottram’s PTSD is a disease, the next inquiry is
whether it is a compensable condition. For it to be
compensable, Mottram must show either that PTSD is an
occupational disease under the provisions of Code § 65.2-
400 or that it is an ordinary disease of life that may be
4
The Columbia Encyclopedia defines norepinephrine as:
a neurotransmitter . . . that mediates chemical
communication in the sympathetic nervous system,
a branch of the autonomic nervous system. Like
other neurotransmitters, it is released at
synaptic nerve endings to transmit the signal
from a nerve cell to other cells. . . . The
sympathetic nervous system functions in response
to short-term stress; hence norepinephrine . . .
increase[s] the heart rate as well as blood
pressure. Other actions of norepinephrine
include increased glycogenolysis (the conversion
of glycogen to glucose) in the liver, increased
lipolysis (the conversion of fats to fatty acids
. . .) in adipose (fat) tissue, and relaxation of
bronchial smooth muscle to open up the air
passages to the lungs. All of these actions
represent a mobilization of the body’s resources
in order to meet the stressful challenge – such a
response is often termed the “flight or fight”
syndrome.
The Columbia Encyclopedia (6th ed. 2001), available at
http://www.bartleby.com/65/no/norepine.html.
5-HT (an acronym for 5-hydroxytryptamine, more
commonly known as serotonin) is also a neurotransmitter and
is a “potent vasoconstrictor.” Taber’s Cyclopedic Medical
Dictionary (18th ed. 1997).
12
treated as an occupational disease pursuant to Code § 65.2-
401. The term “occupational disease” is defined as “a
disease arising out of and in the course of employment, but
not an ordinary disease of life to which the general public
is exposed outside of the employment.” Code § 65.2-400(A).
The following six factors are necessary in order to
establish that a disease arose out of the employment:
1. A direct causal connection between the
conditions under which work is performed and the
occupational disease;
2. It can be seen to have followed as a natural
incident of the work as a result of the exposure
occasioned by the nature of the employment;
3. It can be fairly traced to the employment as
the proximate cause;
4. It is neither a disease to which an employee
may have had substantial exposure outside of the
employment, nor any condition of the neck, back or
spinal column;
5. It is incidental to the character of the
business and not independent of the relation of
employer and employee; and
6. It had its origin in a risk connected with the
employment and flowed from that source as a natural
consequence, though it need not have been foreseen or
expected before its contraction.
Code § 65.2-400(B). An ordinary disease of life may be
treated as an occupational disease if it is “established by
clear and convincing evidence” that it “arose out of and in
the course of employment . . . and did not result from
13
causes outside of the employment,” and that “[i]t follows
as an incident of occupational disease” or “[i]t is
characteristic of the employment and was caused by
conditions peculiar to such employment.” Code § 65.2-401.
With regard to whether Mottram’s PTSD is an
occupational disease or an ordinary disease of life, the
Employer argues that PTSD does not result solely from
occupational stresses. Instead, the Employer contends that
PTSD can be caused by exposure to traumatic events found in
everyday life, such as violent personal assaults, severe
automobile accidents, or being diagnosed with a life
threatening illness. However, the Employer acknowledges
that, of the six statutory factors required to establish an
occupational disease, only number four is at issue in this
appeal, whether PTSD is a disease to which Mottram may have
had substantial exposure outside of his employment. See
Code § 65.2-400(B).
We agree with the observation of the Court of Appeals
in Knott v. Blue Bell, Inc., 7 Va. App. 335, 338, 373
S.E.2d 481, 483 (1988), that “the question whether a
condition or disease is an ordinary disease of life [or an
occupational disease] is essentially a medical issue to be
decided by the trier of fact based on the evidence
presented.” Accord Marcus v. Arlington County Bd. of
14
Supervisors, 15 Va. App. 544, 550, 425 S.E.2d 525, 529
(1993). Contrary to the Employer’s argument, the focus is
not on the many causes of PTSD and whether some of them may
be found outside of an employment situation. Instead, the
focus must be on the nature of the employee’s occupation
and the relationship between that occupation and the
specific disease, as contrasted to diseases that are
readily found in other occupations or ordinary life. See 3
Arthur Larson, Larson’s Workers’ Compensation Law
§ 52.03[2] (2001). In this case, Dr. Frank emphasized that
Mottram’s PTSD was “intimately related to his service-
connected activities.” Moreover, there is no evidence that
Mottram was exposed to traumatic events outside his
employment. Thus, based on the record in this case, we
conclude, as a matter of law, that Mottram’s PTSD is an
occupational disease under Code § 65.2-400. See Mims v.
McCoy, 219 Va. 616, 618, 248 S.E.2d 817, 818 (1978)(where
the evidence was not in conflict, whether an individual was
a covered employee entitled to workers’ compensation
benefits was a question of law for the court).
In reaching this decision, we acknowledge, as did the
Court of Appeals, that PTSD may be compensable as an injury
by accident, depending on the circumstances under which the
condition developed. Mottram, 35 Va. App. at 93, 542
15
S.E.2d at 814. See also Burlington Mills Corp. v. Hagood,
177 Va. 204, 210-11, 13 S.E.2d 291, 293 (1941) (traumatic
neurosis caused by sudden shock or fright without any
physical impact may be compensable as an injury by
accident). We also recognize that PTSD is, in some
situations, an ordinary disease of life. See, e.g.,
Teasley v. Montgomery Ward & Co., 14 Va. App. 45, 49-50,
415 S.E.2d 596, 598-99 (1992) (employee’s PTSD was an
ordinary disease of life because employee had numerous
sources of stress outside of the employment that
contributed to his condition). However, we emphasize that
the credible evidence in this case establishes that
Mottram’s PTSD is an occupational disease. In other words,
each case turns upon its own facts.
CONCLUSION
For these reasons, we will affirm that part of the
Court of Appeals’ judgment finding that Mottram’s PTSD is a
disease, but will reverse that part of the judgment holding
that it is an ordinary disease of life. Finding that
Mottram’s PTSD is an occupational disease under Code
§ 65.2-400, we will enter judgment in favor of Mottram and
remand this case to the Court of Appeals, with the
direction that the case be remanded to the Commission for
16
the purpose of calculating the amount of Mottram’s workers’
compensation benefits.
Affirmed in part,
reversed in part,
and remanded.
17