Journal of the Royal Society of Medicine Volume 84 March 1991
Accident
proneness
H 0 Engel FFOM
and illness
proneness: a
163
review
46 Chandos Road, London N2 9AP
Keywords: accident proneness; heartsink patients; disability
Summary Accident proneness may be an episodic or a lifelong disability. It is suggested that many of the chronically accident prone individuals are the same as those prone to recurrent organic illnesses, that is they suffer from a congenital 'diathesis'. Definition A section of the population provides a disproportionate number of patients who are frequent attenders or absentees from work, who are liable to injury, illness or misfortune, who cause damage to themselves, to property and machinery all around them. Marsh and Candle1 stated that 13% of patients create half the workload in general practice and Wamosher2 found that 15% of patients generated nearly 50% of doctor contacts. Those who attend surgeries, casualty departments or occupational health departments very frequently are well-termed 'heartsink' patients by O'Dowd3. As long ago as 1919 Greenwood and Woods4 showed that 10% of workers incurred 56% of the accidents in a munitions factory.
History Accident proneness has been described in industry for 100 years5-8 and is usually considered a psychological condition of accident repeaters9"10, either lifelong or episodic, at times of stress. The Index Medicus has carried a section on accident proneness since 1976, but the references are almost all to traffic accidents", alcohol abuse, premenstrual tension and disturbed children. While working for 27 years in an engineering factory one could not fail to notice that patients who had repeated absences for work accidents also had frequent sickness absences. All absences over 3 days were tabulated and most of these patients were interviewed and as necessary examined by the occupational physician regarding fitness for their job. Absences were classified 'W' for works accidents and occupational diseases (mainly dermatitis) and 'S' for sickness and accidents at home or in traffic. Recurrent absences due to 'W' and 'S' often went in parallel. Some authorities believe that repeated accidents may be largely due to failure to eliminate or improve adverse working conditions such as poor design, layout or maintenance5"12"13, rather than to personal factors, but this does not explain recurrent accidents which are evidently not due to ergonomic deficiencies.
Aetiology There are undoubtedly individuals of both sexes and all races who are less well endowed in their health and dexterity than average. This is evidently due to a congenital predisposition. Some children from an
early age are clumsier than their peers, more vulnerable to injury at games and later in life at work and more prone to infections or allergies. Episodic accident proneness may be due to temporary stress14 and is reflected in more frequent attendances or absences from school or work than average. It occurs during periods of domestic preoccupation, with loss of sleep, legal or financial problems, unemployment, premenstrual tension, advancing age'5 or addiction all predisposing to accidents at work, at sport or on the roads - or, it is suggested, to illness. Accident proneness is also seen in hyperactive or aggressive children, those with behaviour problems, truancy, divorced parents and later in frequent changes ofjobs, in unemployment or drug dependance. Connolly16 found that injuries were often preceded by adverse 'life events' in the 6 previous months. But the lifelong accident prone is liable to misfortune at any age and this vulnerability appears often to be familial. It is not confined to underprivileged poorer social classes, where one might expect more -accidents or illness due to poor hygiene, nutrition and overcrowding and poor supervision. Rich families also have their lame duck who gets all the injuries, infections or allergies.
Symptomatology While all toddlers fall about or burn themselves, they soon learn by painful experience to avoid falls and fire. The adolescent in manual trades is two or three times more liable to work accidents in his first year, until he becomes trained, more dexterous and secure in his group and with his supervisor. He is also more liable to traffic accidents - hence insurance companies load the premium of the under 25s very heavily. But accident prone subjects continue with accidents or health problems without very obvious cause. Every country recognizes them, they are the cartoon character 'Mister Magoo' in the USA, the hero of the television series 'Some mothers do 'ave 'em' in UK, the Schlemihl in Germany, the Cuffy in the West Indies. Diagnosis Records of attendances and absences will readily reveal the heartsink patients with their thick folders and files and the patient becomes well known to the surgery and hospital receptionist, the casualty sister and the doctor. Differential diagnosis Three varieties of heartsink patients constitute the hard core of frequent attenders and absentees: (1) The psychoneurotic has psychological symptoms such as tiredness, malaise and dizziness, without clinical signs, abnormal tests or injuries.
0141-0768/91/
030163-02/$02.00/0 © 1991 The Royal Society of Medicine
164
Journal of the Royal Society of Medicine Volume 84 March 1991
Table 1. Heartsink patients: classification
Objective organic PsychoOrganic abnormal signs logical symptoms symptoms or injury Psychoneurosis Somatization disorder Munchausen Accident/illness prone
++ 0
+ ++
0 0
+ 0
++ ++
0 ++
+, sometimes present; + +,
alwpys present; 0, absent
(2) The somatization disorder17-'9 consists of organic symptoms without organic cause, due to an unacknowledged underlying neurosis. Patients with Munchausen's syndrome may be included as a rare subdivision, who appear to have an underlying masochism. (3) The accident and illness prone has organic symptoms due to organic causes or injury (see Table 1). Differentiation is also needed from single disease causes such as fragilitas osseum and postmenopausal osteoporosis as a cause of fractures. In women battering by husband or 'friend' has to be considered.
Prevention Anyone known to be accident prone has to be professionally advised on job selection, to avoid unsuitable employment where he or she may be at risk of repeated injury. Careers advisors and disablement registration officers can help in finding safe employment. There should be no need to discover from frequent accidents that a person should not drive a heavy goods vehicle or handle machinery which requires dexterity and skill. Treatment Patience and tolerance are required and a careful and full examination. As in somatization once the diagnosis is made unnecessary tests and investigations should be avoided. Thus when the same woman is seen at the casualty department on Saturdays having been beaten up by her drunken husband there may be something in her makeup to facilitate these 'accidents'. If the causes are, social, emotional or addiction these may be difficult to change. The doctor may suggest suitable social services in support for problem families, especially in cases of battering or incest. For the emotionally disturbed or addicted, psychiatric advice, counselling, group therapy or support organizations may be available.
Prognosis But frequently the recurrent injured and sick have no obvious remediable precipitating causes. They are
the physically disadvantaged and vulnerable, who will always be with us, like the poor. Perhaps someone has already coined a suitable syndrome like 'RSI' for muscle strain or 'ME' for fatigue and muscle aches. Meanwhile 'congenital diathesis' may make a convenient label. This should be useful to administrators now that GP remuneration depends more on services provided than on list size. Anyone with a high score for attendances and home visits would justify extra remuneration, and medical insurance companies might load their premiums for accident and illness repetiteurs with this handy diagnosis, which does not imply that the subject is labelled neurotic. Cassius says it all with perfect brevity: 'The fault dear Brutus is not in our stars, but in ourselves, that we are underlings'. References 1 Marsh G, Kaim Caudle P. Team care in general practice. London: Croom Helm, 1974 2 Wamosher Z. The returning patient. A survey of patients with high attendance rates. J R Coll Gen Pract 1966;11:166-73 3 O'Dowd T. Five years of heartsink. BMJ 1988;27:528 4 Greenwood M, Woods HM. The incidence of industrial accidents upon individuals with special reference to multiple accidents. Industrial Fatigue Board. Report No 4. London: HMSO, 1919 5 Farmer E, Chambers EG. A study of accident proneness among motor drivers. Industrial Fatigue Board. Report No 84. London: HMSO, 1939 6 Webb WB. The illusive phenomenon in accident proneness. Public Health Rep 1955;70:951-6 7 Haddon W, Suchman EA, Klein D. Accident research: methods and approaches. London: Harper & Row, 1964 8 Henker FO. Accident proneness and how to prevent it. Clin Orthop 1987;222:30-4 9 Kune JB. Accident liability. Br J Ind Med 1985; 42:334-40
10 Schulzinger MS. The accident syndrome. Springfield, il: C Thomas, 1956 11 Rawson AJ. Accident proneness. Psychol Med 1944; 6:88-94 12 Cazamian P. In: Parmeggiani L, ed. Encyclopaedia of occupational health and safety, 3rd edn. Geneva: International Labour Office, 1983:20-1 13 Adelstein AM. Accident proneness: a criticism based upon an analysis ofshunter's accidents. JR Statist Soc
1952;115:354-400 14 Rahe RH. Life change events and illnesses reports. Ann Clin Res 1972;4:250-65 15 Morse JM, Tylko SJ, Dixon HA. Ch.practeristics of the
fall-prone patient. Gerontologist 1987;27:516-22 16 Connolly J. Accident proneness. Br J Hosp Med 1981;26:473-81 17 Lipowski ZJ. Somatization: The concept and its clinical application. Am J Psychol 1988;145:1358-68 18 Quill TE. Somatic disorder, one of Medicine's blind spots. JAMA 1985;254:3075-9 19 Bass C, Murphy M. The chronic somatiser- and thegovernment white paper. J R Soc Med 1990;83:203-5 (Accepted 28 September 1990)
Accident
proneness
H 0 Engel FFOM
and illness
proneness: a
163
review
46 Chandos Road, London N2 9AP
Keywords: accident proneness; heartsink patients; disability
Summary Accident proneness may be an episodic or a lifelong disability. It is suggested that many of the chronically accident prone individuals are the same as those prone to recurrent organic illnesses, that is they suffer from a congenital 'diathesis'. Definition A section of the population provides a disproportionate number of patients who are frequent attenders or absentees from work, who are liable to injury, illness or misfortune, who cause damage to themselves, to property and machinery all around them. Marsh and Candle1 stated that 13% of patients create half the workload in general practice and Wamosher2 found that 15% of patients generated nearly 50% of doctor contacts. Those who attend surgeries, casualty departments or occupational health departments very frequently are well-termed 'heartsink' patients by O'Dowd3. As long ago as 1919 Greenwood and Woods4 showed that 10% of workers incurred 56% of the accidents in a munitions factory.
History Accident proneness has been described in industry for 100 years5-8 and is usually considered a psychological condition of accident repeaters9"10, either lifelong or episodic, at times of stress. The Index Medicus has carried a section on accident proneness since 1976, but the references are almost all to traffic accidents", alcohol abuse, premenstrual tension and disturbed children. While working for 27 years in an engineering factory one could not fail to notice that patients who had repeated absences for work accidents also had frequent sickness absences. All absences over 3 days were tabulated and most of these patients were interviewed and as necessary examined by the occupational physician regarding fitness for their job. Absences were classified 'W' for works accidents and occupational diseases (mainly dermatitis) and 'S' for sickness and accidents at home or in traffic. Recurrent absences due to 'W' and 'S' often went in parallel. Some authorities believe that repeated accidents may be largely due to failure to eliminate or improve adverse working conditions such as poor design, layout or maintenance5"12"13, rather than to personal factors, but this does not explain recurrent accidents which are evidently not due to ergonomic deficiencies.
Aetiology There are undoubtedly individuals of both sexes and all races who are less well endowed in their health and dexterity than average. This is evidently due to a congenital predisposition. Some children from an
early age are clumsier than their peers, more vulnerable to injury at games and later in life at work and more prone to infections or allergies. Episodic accident proneness may be due to temporary stress14 and is reflected in more frequent attendances or absences from school or work than average. It occurs during periods of domestic preoccupation, with loss of sleep, legal or financial problems, unemployment, premenstrual tension, advancing age'5 or addiction all predisposing to accidents at work, at sport or on the roads - or, it is suggested, to illness. Accident proneness is also seen in hyperactive or aggressive children, those with behaviour problems, truancy, divorced parents and later in frequent changes ofjobs, in unemployment or drug dependance. Connolly16 found that injuries were often preceded by adverse 'life events' in the 6 previous months. But the lifelong accident prone is liable to misfortune at any age and this vulnerability appears often to be familial. It is not confined to underprivileged poorer social classes, where one might expect more -accidents or illness due to poor hygiene, nutrition and overcrowding and poor supervision. Rich families also have their lame duck who gets all the injuries, infections or allergies.
Symptomatology While all toddlers fall about or burn themselves, they soon learn by painful experience to avoid falls and fire. The adolescent in manual trades is two or three times more liable to work accidents in his first year, until he becomes trained, more dexterous and secure in his group and with his supervisor. He is also more liable to traffic accidents - hence insurance companies load the premium of the under 25s very heavily. But accident prone subjects continue with accidents or health problems without very obvious cause. Every country recognizes them, they are the cartoon character 'Mister Magoo' in the USA, the hero of the television series 'Some mothers do 'ave 'em' in UK, the Schlemihl in Germany, the Cuffy in the West Indies. Diagnosis Records of attendances and absences will readily reveal the heartsink patients with their thick folders and files and the patient becomes well known to the surgery and hospital receptionist, the casualty sister and the doctor. Differential diagnosis Three varieties of heartsink patients constitute the hard core of frequent attenders and absentees: (1) The psychoneurotic has psychological symptoms such as tiredness, malaise and dizziness, without clinical signs, abnormal tests or injuries.
0141-0768/91/
030163-02/$02.00/0 © 1991 The Royal Society of Medicine
164
Journal of the Royal Society of Medicine Volume 84 March 1991
Table 1. Heartsink patients: classification
Objective organic PsychoOrganic abnormal signs logical symptoms symptoms or injury Psychoneurosis Somatization disorder Munchausen Accident/illness prone
++ 0
+ ++
0 0
+ 0
++ ++
0 ++
+, sometimes present; + +,
alwpys present; 0, absent
(2) The somatization disorder17-'9 consists of organic symptoms without organic cause, due to an unacknowledged underlying neurosis. Patients with Munchausen's syndrome may be included as a rare subdivision, who appear to have an underlying masochism. (3) The accident and illness prone has organic symptoms due to organic causes or injury (see Table 1). Differentiation is also needed from single disease causes such as fragilitas osseum and postmenopausal osteoporosis as a cause of fractures. In women battering by husband or 'friend' has to be considered.
Prevention Anyone known to be accident prone has to be professionally advised on job selection, to avoid unsuitable employment where he or she may be at risk of repeated injury. Careers advisors and disablement registration officers can help in finding safe employment. There should be no need to discover from frequent accidents that a person should not drive a heavy goods vehicle or handle machinery which requires dexterity and skill. Treatment Patience and tolerance are required and a careful and full examination. As in somatization once the diagnosis is made unnecessary tests and investigations should be avoided. Thus when the same woman is seen at the casualty department on Saturdays having been beaten up by her drunken husband there may be something in her makeup to facilitate these 'accidents'. If the causes are, social, emotional or addiction these may be difficult to change. The doctor may suggest suitable social services in support for problem families, especially in cases of battering or incest. For the emotionally disturbed or addicted, psychiatric advice, counselling, group therapy or support organizations may be available.
Prognosis But frequently the recurrent injured and sick have no obvious remediable precipitating causes. They are
the physically disadvantaged and vulnerable, who will always be with us, like the poor. Perhaps someone has already coined a suitable syndrome like 'RSI' for muscle strain or 'ME' for fatigue and muscle aches. Meanwhile 'congenital diathesis' may make a convenient label. This should be useful to administrators now that GP remuneration depends more on services provided than on list size. Anyone with a high score for attendances and home visits would justify extra remuneration, and medical insurance companies might load their premiums for accident and illness repetiteurs with this handy diagnosis, which does not imply that the subject is labelled neurotic. Cassius says it all with perfect brevity: 'The fault dear Brutus is not in our stars, but in ourselves, that we are underlings'. References 1 Marsh G, Kaim Caudle P. Team care in general practice. London: Croom Helm, 1974 2 Wamosher Z. The returning patient. A survey of patients with high attendance rates. J R Coll Gen Pract 1966;11:166-73 3 O'Dowd T. Five years of heartsink. BMJ 1988;27:528 4 Greenwood M, Woods HM. The incidence of industrial accidents upon individuals with special reference to multiple accidents. Industrial Fatigue Board. Report No 4. London: HMSO, 1919 5 Farmer E, Chambers EG. A study of accident proneness among motor drivers. Industrial Fatigue Board. Report No 84. London: HMSO, 1939 6 Webb WB. The illusive phenomenon in accident proneness. Public Health Rep 1955;70:951-6 7 Haddon W, Suchman EA, Klein D. Accident research: methods and approaches. London: Harper & Row, 1964 8 Henker FO. Accident proneness and how to prevent it. Clin Orthop 1987;222:30-4 9 Kune JB. Accident liability. Br J Ind Med 1985; 42:334-40
10 Schulzinger MS. The accident syndrome. Springfield, il: C Thomas, 1956 11 Rawson AJ. Accident proneness. Psychol Med 1944; 6:88-94 12 Cazamian P. In: Parmeggiani L, ed. Encyclopaedia of occupational health and safety, 3rd edn. Geneva: International Labour Office, 1983:20-1 13 Adelstein AM. Accident proneness: a criticism based upon an analysis ofshunter's accidents. JR Statist Soc
1952;115:354-400 14 Rahe RH. Life change events and illnesses reports. Ann Clin Res 1972;4:250-65 15 Morse JM, Tylko SJ, Dixon HA. Ch.practeristics of the
fall-prone patient. Gerontologist 1987;27:516-22 16 Connolly J. Accident proneness. Br J Hosp Med 1981;26:473-81 17 Lipowski ZJ. Somatization: The concept and its clinical application. Am J Psychol 1988;145:1358-68 18 Quill TE. Somatic disorder, one of Medicine's blind spots. JAMA 1985;254:3075-9 19 Bass C, Murphy M. The chronic somatiser- and thegovernment white paper. J R Soc Med 1990;83:203-5 (Accepted 28 September 1990)
