COURT OF APPEALS OF VIRGINIA
Present: Chief Judge Fitzpatrick, Judge Willis and
Senior Judge Overton
Argued at Alexandria, Virginia
RANDALL U. MOTTRAM
OPINION BY
v. Record No. 1472-00-4 JUDGE JERE M. H. WILLIS, JR.
MARCH 6, 2001
FAIRFAX COUNTY FIRE AND RESCUE AND
FAIRFAX COUNTY BOARD OF SUPERVISORS
FROM THE VIRGINIA WORKERS' COMPENSATION COMMISSION
Diane C.H. McNamara for appellant.
Ann Gouldin Killalea, Assistant County
Attorney (David P. Bobzien, County Attorney;
Robert Lyndon Howell, Deputy County Attorney,
on brief), for appellees.
Randall U. Mottram appeals the decision of the Workers'
Compensation Commission denying him benefits for post-traumatic
stress disorder (PTSD). The commission held that Mottram's PTSD
was not compensable because it was a condition resulting from
cumulative or repetitive trauma, as opposed to an occupational
disease. For the following reasons, we reverse and remand.
I. BACKGROUND
Mottram worked for the Fairfax County Fire & Rescue
Department for approximately nineteen years. He was a paramedic
during the first ten years and an EMS supervisor the remaining
time. His duties included responding to emergency calls and
rendering aid at the scenes of accidents and other emergencies.
On January 27, 1997, Mottram filed a workers' compensation
claim alleging that on March 10, 1996, he suffered an injury by
accident. The commission denied Mottram's injury by accident
claim, ruling that his condition, which was purely
psychological, was not causally related to a physical injury or
an obvious sudden shock or fright arising in the course of his
employment. Therefore, the commission held that Mottram's
condition was not compensable as an injury by accident. That
decision was not appealed and became final.
On February 12, 1998, after his injury by accident claim
was denied, Mottram filed a new claim seeking benefits for an
occupational disease. The transcript of the April 23, 1997
hearing on the injury by accident claim was made a part of the
record in the occupational disease case.
At the April 23, 1997 hearing, Mottram testified that on
March 10, 1996, he responded to a major fire. After dealing
with multiple burn injuries and a fatality, he was assigned to
evaluate victims who had escaped the fire. One of these
victims, a five-year-old child, asked about her stepmother.
Mottram was "taken back" because he had just pronounced the
woman dead. The question shocked him. He felt as though he had
just been "punched in the stomach." He testified that although
some of his previous experiences had been troublesome, he had
never before felt like that and nothing had so immobilized him.
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At the April 23, 1997 hearing, Mottram denied seeking
medical treatment for any disturbing event before the March 10,
1996 incident. After the March 10 incident, he sought
treatment. He denied feeling suicidal before that incident. He
acknowledged that some of the flashbacks that he experienced
after the March 10, 1996 fire reminded him of a fire fifteen to
twenty years before, which had involved six fatalities.
At the April 23, 1997 hearing, Mottram admitted thinking
before March 10, 1996 that he might be predisposed to PTSD.
However, he testified that after that incident, he was unhappy,
had lost interest in life, and had memory problems. At the
April 23, 1997 hearing, Mottram minimized the psychological
impact of shocking events that he had experienced prior to March
10, 1996. He testified to no previous traumatic event, other
than the fire that had occurred fifteen to twenty years before.
On July 14, 1998, at the hearing on his occupational
disease claim, Mottram testified that over the years he had
responded as a paramedic to approximately ten calls per day but
that not all were severe. He testified to responding to
multi-victim motor vehicle accidents, burns, multi-family house
fires with fatalities, and other events resulting in death and
serious injury. He described some of these calls as being
especially horrific because they involved shootings, stabbings,
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amputations and decapitations. He had not mentioned these in
the injury by accident case.
Mottram was evaluated by Dr. Mary W. Lindahl, a clinical
psychologist, on March 4, 1996, six days before the incident
that underlay his injury by accident claim. At that time, he
was concerned that he had PTSD. He described to Dr. Lindahl
symptoms of intrusive thoughts, overwhelming anxiety, excessive
sleeping, and thoughts of former emergencies he had attended.
He told Dr. Lindahl that he was considering taking a leave of
absence due to stress.
On April 13, 1996, Dr. Lindahl reported:
Mottram is at present in a severe
vegetative depression characterized by
severe anxiety, an overwhelming need for
sleep, nightmares, hopelessness about the
future, mental confusion, inability to
concentrate, loss of appetite, social
withdrawal, and suicidal ideation. . . .
Dr. Lindahl stated that Mottram's symptoms began after
responding to a fatal fire. However, as evidenced by Dr.
Lindahl's report of the March 4, 1996 interview, he had those
symptoms prior to the March 10 fire. 1 She opined that his PTSD
and depressive symptoms were directly related to his work in the
fire department.
1
In a May 4, 1996 report, Dr. Lindahl clarified that
Mottram had some symptoms of PTSD when she first saw him on
March 4, 1996. However, the symptoms worsened into serious PTSD
and major depression after the March 10, 1996 incident.
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Dr. Lindahl referred Mottram to Dr. Randolph A. Frank, Jr.,
a psychiatrist, who concurred in her diagnosis of PTSD. Dr.
Frank determined that Mottram had been depressed at least since
December 1995.
On June 4, 1996, at the request of the employer, Dr. Brian
Schulman, a psychiatrist, conducted an independent psychiatric
evaluation of Mottram. In his July 9, 1996 report, Dr. Schulman
concluded that Mottram suffered from major depression, with the
onset occurring during the fall of 1995. He opined that, "[t]o
a reasonable degree of medical certainty, this depression was
not precipitated or accelerated by any condition emanating from
Mr. Mottram's employment." Dr. Schulman further opined that
nothing outside the normal range of firefighting experiences
occurred on or about March 10, 1996 for which Mottram would not
have been adequately trained and prepared.
On August 14, 1996, Dr. Frank expressed his strong
disagreement with Dr. Schulman's conclusions. He stated that as
Mottram's treating physician, he felt that he knew him extremely
well. Dr. Frank also stated that he was well versed in the
diagnosis and treatment of PTSD, because he served as the
consultant for the Virginia State Police and had treated many
cases of PTSD in that capacity. He opined that:
Mottram suffers from PTSD which he
incurred in the line of duty as
characterized by marked and intrusive
distressing recollections of events noted in
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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.
He also displays some emotional detachment
and restricted range of affect that are also
consistent with the disorder. I do not feel
that this was related to a pre-existing
depression, but rather his symptoms
developed over the course of the last year
as he became exposed to a number of severely
distressing stimuli in his work as a
firefighter.
Dr. Lindahl also disagreed with Dr. Schulman. She stated
that she had extensive training and experience in the diagnosis
and treatment of PTSD. She stated that Mottram had answered
numerous calls that met the trauma elements in the PTSD
diagnostic criteria and that he was experiencing symptoms of
PTSD prior to March 10, 1996. Dr. Lindahl stated that the March
10 incident was traumatic to Mottram because it reminded him of
a similar fatal fire five years before.
In a January 1, 1998 report, Dr. Lindahl stated that PTSD
is a known risk of employment for emergency service workers and
that there was no evidence that Mottram was exposed to similar
conditions outside of his employment. In a March 9, 1998
report, she stated that Mottram's PTSD was related to his work
and that his development of depression was secondary to the
PTSD. On May 16, 1998, in response to a questionnaire from
Mottram's counsel, she explained the etiology of his PTSD as
follows:
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Mottram's PTSD was produced by exposure
to critical incidents. There is no physical
trauma involved. Rather, exposure to the
incident(s) result in neurochemical
alterations in multiple neurotransmitter
systems . . . . These changes appear to be
a result of the organism's adaptive survival
responses. These responses, initially
beneficial to the individual, also result in
long-term negative symptoms of PTSD.
The deputy commissioner denied Mottram's occupational
disease claim, finding that his PTSD resulted from cumulative or
repetitive trauma. On review, the full commission affirmed. In
so ruling, the full commission concluded as follows:
To treat PTSD, in the context of this
case, as a disease rather than a condition
resulting from cumulative trauma would be to
expand the definition of "disease" too
broadly . . . . In fact, both the criteria
for PTSD and its definition are more
consistent with an injury resulting from
cumulative trauma in this case. The
condition follows a traumatic and shocking
event, or events as is the case here. This
is more consistent with cumulative trauma
than the development of a disease.
II. PTSD UNDER THE ACT
Mottram contends the commission erred when it concluded
that his PTSD was a "cumulative trauma" condition. He argues
that PTSD is a disease and that he should be compensated for his
PTSD as an occupational disease.
The compensability of work-related mental disabilities has
been a controversial topic in workers' compensation law. As has
often been stated, the Workers' Compensation Act defines two
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compensable categories: injury by accident and occupational
disease. See Code § 65.2-101 (defining "injury"); Code 65.2-400
(defining "occupational disease"); see also Holly Farms v.
Yancey, 228 Va. 337, 340, 321 S.E.2d 298, 300 (1984) ("A
definition of either 'injury' or 'disease' that is so broad as
to encompass any bodily ailment of whatever origin is too broad
because it would make unnecessary and meaningless the two
categories specifically set forth in the Act."). The Supreme
Court has recognized that the term "disease" does not equate
with the term "injury." Stenrich Group v. Jemmott, 251 Va. 186,
193 n.1, 467 S.E.2d 795, 799 n.1 (1996). The term "injury" does
not include a disease in any form, as used in Code § 65.2-101,
but is "language of limitation." Id. "[W]hether a claimant
suffers from a disease within the contemplation of the Act is a
mixed question of law and fact, and whether a proper definition
has been used to test the authenticity of a doctor's opinion is
strictly a legal one." Id. at 198, 467 S.E.2d at 801.
"A disease is a condition which may arise from any number
of causes, including trauma, that impairs the function of the
body or any part thereof. . . . The distinction between injury
and disease lies in the 'obvious sudden mechanical or
structural' aspect of injury." Ogden Aviation Services v.
Saghy, 32 Va. App. 89, 97, 526 S.E.2d 756, 760 (2000) (citation
omitted). See also 1B Arthur Larson, The Law of Workers'
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Compensation § 41.31, at 7-491 to 7-492 (1991) (noting that the
traditional distinction between "occupational diseases" and
"accidental injuries" was "both the fact that [diseases] could
not honestly be said to be unexpected, since they were
recognized as inherent hazard[s] of continued exposure to
conditions of the particular employment, and the fact that
[diseases] were gradual rather than sudden in onset").
Considering these distinctions, we conclude that PTSD may
be compensable as an "injury by accident" or as an "occupational
disease," depending on how it develops. This conclusion is
buttressed by both the commission's decisions and our decisions,
which have treated PTSD both as an injury and as a disease.
A. PTSD AS AN INJURY
We have recognized that, under appropriate circumstances,
PTSD may be compensable as an injury by accident. See Hercules
v. Gunther, 13 Va. App. 357, 412 S.E.2d 185 (1991). In
Hercules, a power plant truck driver was delivering rocket
propellant to a building. As he walked toward the building, it
exploded. Although he sustained only minor physical injuries,
two of his friends, with whom he had just been talking, were
killed. Thereafter, he was diagnosed with PTSD. Affirming the
commission's award, we held that the driver's PTSD was
compensable as an injury by accident because it resulted from
"an obvious sudden shock or fright arising in the course of
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employment." Id. at 362-63, 412 S.E.2d at 188. See also
Burlington Mills Corp. v. Hagood, 177 Va. 204, 13 S.E.2d 291
(1941) (holding that a nervous condition resulting from a sudden
shock or fright without physical impact may be compensable).
B. PTSD AS A DISEASE
We have also had occasion to address PTSD as a disease.
See Teasley v. Mongomery Ward & Co., 14 Va. App. 45, 415 S.E.2d
596 (1992); Marcus v. Arlington County Bd. of Supervisors, 15
Va. App. 544, 425 S.E.2d 525 (1993).
In Teasley, the employee, following an ongoing series of
disagreements, had a confrontation with his supervisor over his
work assignments. He broke down emotionally and was diagnosed
with PTSD. He sought benefits, contending that his PTSD was an
occupational disease. The commission held that PTSD was "an
ordinary disease of life to which the general public is exposed
outside of employment." It denied the employee's claim because
he failed to prove entitlement to compensation under Code
§ 65.1-46.1 (now Code § 65.2-401). Holding that the evidence
supported those findings, we affirmed that decision. Teasley,
14 Va. App. at 49-50, 415 S.E.2d at 598-99.
In Marcus, an emergency communications technician
supervisor developed "traumatic stress reaction with physical
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manifestations." 2 Her duties as an emergency communications
technician supervisor included the dispatch of police, fire and
ambulance units and counseling subordinate personnel to help
them deal with the stress of their duties. Finding that
traumatic stress reaction "is the same kind of reaction that
occurs in a setting outside of the employment," the commission
held that Marcus' condition was an ordinary disease of life.
Affirming, we said:
Physical reactions to stress, such as those
experienced by Marcus, are suffered by much
of the population and are caused by a
variety of factors. Indeed, the commission
found that the symptoms Marcus experienced
were caused not only by her job, but also by
events outside of her employment -- events
to which the general public is exposed
outside of the employment -- . . . . We
find that this conclusion is supported by
credible evidence in the record and,
accordingly, we will not disturb the
commission's finding on appeal. See Knott
v. Blue Bell, Inc., 7 Va. App. 335, 338, 373
S.E.2d 481, 483 (1988) ("the question
whether a condition or disease is an
ordinary disease of life is essentially a
medical issue to be decided by the trier of
fact based on the evidence presented").
Marcus, 15 Va. App. at 550, 425 S.E.2d at 529.
2
Although Marcus experienced some emotional response to her
stress, her condition was primarily "mental-physical"; that is,
she suffered physical symptoms resulting from mental stress.
However, her condition, like Mottram's, derived from mental
stress. Therefore, we find her case instructive.
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III. MOTTRAM'S PTSD
The threshold question in this case is whether Mottram's
condition is an injury or a disease. If the former, his right
to compensation is barred by the commission's decision rejecting
his injury by accident claim. If his condition is a disease, it
remains to be determined whether it is an occupational disease
defined by Code § 65.2-400, or an ordinary disease of life. If
the latter, we must determine whether it is compensable under
Code § 65.2-401.
In A New Leaf, Inc. v. Webb, 257 Va. 190, 511 S.E.2d 102
(1999), the Supreme Court addressed the distinction between
injury and disease. Webb, a flower shop employee, suffered
allergic contact dermatitis resulting from physical contact with
chemicals in flowers. Her condition was described as a
"reaction of the body's immune system to the substance to which
that person is sensitive." Id. at 197, 511 S.E.2d at 105.
Distinguishing between the body's response to irritating stimuli
and physical impairment based on cumulative trauma resulting
from repetitive motion, the Court held that Webb's condition was
a disease. Id. at 197-98, 511 S.E.2d at 105.
Webb's condition was physical. Mottram's condition is
psychological. However, the two cases are analogous. Just as
Webb's condition resulted from a bodily reaction to irritating
stimuli, Mottram's condition resulted from "neurochemical
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alterations in multiple neurotransmitter systems . . . [being] a
result of [his body's] adaptive survival responses." Thus, we
hold that Mottram's condition is a disease.
Although, when based upon a single physical injury or
obvious sudden shock or fright, PTSD may be considered an injury
by accident, when it is suffered as a result of ongoing stress,
it qualifies as a disease. Therefore, having identified
Mottram's condition as resulting from multiple stressful events,
the commission erred in designating it an injury and in refusing
to consider it as a disease.
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 as
defined by Code § 65.2-401. 3 Therefore, the commission must
3
Code § 65.2-401 reads:
"Ordinary disease of life" coverage. -- An
ordinary disease of life to which the
general public is exposed outside of the
employment may be treated as an occupational
disease for purposes of this title if each
of the following elements is established by
clear and convincing evidence, (not a mere
probability):
1. That the disease exists and arose
out of and in the course of employment as
provided in § 65.2-400 with respect to
occupational diseases and did not result
from causes outside of the employment, and
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determine whether, under the circumstances of his case, that
condition is nonetheless compensable under the provisions of
Code § 65.2-401.
Reversed and remanded.
2. That one of the following exists:
a. It follows as an incident of
occupational disease as defined in this
title; or
b. It is an infectious or contagious
disease contracted in the course of one's
employment in a hospital or sanitarium or
laboratory or nursing home as defined in
§ 32.1-123, or while otherwise engaged in
the direct delivery of health care, or in
the course of employment as emergency rescue
personnel and those volunteer emergency
rescue personnel referred to in § 65.2-101;
or
c. It is characteristic of the
employment and was caused by conditions
peculiar to such employment.
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