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St. Louis Dispatch

A Bad Case of PIISD: Private Insurance Induced Stress Disorder

A psychiatrist diagnoses victims of health insurance

Kevin Horrigan

In July 2009, Carol A. Paris, a psychiatrist and an advocate for a single-payer national health care system, found herself on a speakers panel with Donna Smith of Aurora, Colo.

Smith and her husband, Larry, had been featured in the 2007 Michael Moore movie "Sicko." After Larry Smith was diagnosed with chronic coronary disease and Donna Smith contracted uterine cancer, they couldn't keep up with the costs of health insurance. They were forced to sell their home in South Dakota and move into the basement of a daughter's home in Colorado. Moore took them to Cuba for treatment.

"I heard her talk," Paris said, "and I thought, 'That's an amazing story.' I see patients every day being pushed around by the health insurance industry and that story just pissed me off."

The more she thought about it, the more she realized that people dealing with health insurers exhibit some of the same symptoms as patients with post-traumatic stress disorder.

Back at her office in Leonardtown, Md., she took down her copy of the DSM-IV, the Diagnostic and Statistical Manual published by the American Psychiatric Association. It is the standard reference for describing and classifying mental disorders. She looked up PTSD and used it as a template for PIISD.

"The essential feature (she wrote) of private insurance induced stress disorder (PIISD) is the development of characteristic symptoms following exposure to an insurance-induced traumatic stressor involving direct personal experience of an event or witnessing an event that threatens another person. Traumatic events include, but are not limited to, rescission "termination" of health insurance after developing a costly illness, denial of health insurance due to a pre-existing condition such as being female and fertile or delay of needed treatment or medication due to requirements for pre-authorization.

"The essential feature of 'private insurance induced stress disorder' (PIISD) is the development of characteristic symptoms following exposure to an insurance-induced traumatic stressor involving direct personal experience of an event or witnessing an event that threatens another person." -- Dr. Carol Paris

"In the case of physicians, traumatic events include witnessing the deterioration of patients due to financial ruin resulting from uncovered costs of care. Similar to some forms of PTSD, this disorder is prone to be severe because the stressor is of human/corporate design. Note: this diagnosis is not currently reimbursed by health insurance carriers."

It goes on from there, describing in precise clinical language the effects on both patients and doctors of dealing with health insurance companies. It is bitingly satirical and heartbreakingly true.

"It makes you crazy," Paris, 59, said. And remember, the woman is a board-certified psychiatrist.

She said, "Everybody is getting screwed by this system except medical insurers, the pharmaceutical industry and medical equipment providers."

So why joke about it?

"That's what I have to do to keep my perspective. Otherwise I'd get so upset and just become ineffective because I become so angry and demoralized. The vast majority of my colleagues are working harder and trying harder, at least the ones in primary care. The ones in higher-paid specialties, they think, 'Screw it. If I can't get any enjoyment about practicing ethically, I'll do what I can to retire as quickly as I can because this sucks.'"

Several times a year, Paris delivers her PIISD speech to groups around the country interested in a single-payer, Medicare-for-all national health care system. She was in St. Louis a couple of weeks ago.

"I'm like a magnet for people getting screwed by the health care system," she said when I called to follow up on her speech.

The people she talks to are satisfied with neither the current health care system nor the one created by President Barack Obama's Affordable Care Act, the latter because private insurers still will be involved.

Paris, for one, hopes the Supreme Court strikes down the ACA because it will hasten the day that things get so bad that a single-payer plan will be instituted.

I asked her to diagnose the opposition within the middle class to health care reform.

"Ignorance, fear and shame," she said. "If you're healthy and young and your employer pays for a good bit of your premium, you're insulated from it. If you're older and fall on hard times, you're convinced that there's something wrong with you. It must be because you just haven't worked hard enough.

"They're already in a fight-or-flight fear mentality, almost the Stockholm Syndrome (sympathizing with their captors). The industry can get people to advocate in their own worst interest by keeping them frightened and ashamed. They wind up advocating for a conservative base that is screwing them right and left."

Until 2002, Paris said, when she set up her private practice, she had been insulated from the problems. Now she employs two people full time just to keep up with insurance. The more time she spends with patients, the less health insurers will reimburse her.

"I just reached a certain point in my life that I can't pretend any more that things aren't wrong. I got arrested at one rally and discovered that I can keep my medical license after a misdemeanor arrest. So I got arrested again in 2010 outside the White House. The Secret Service interviewed me that time."

In her own case, when she realized her PIISD was getting out of hand, she sold her practice and made plans to move to Nashville, Tenn. She will be close to her daughter in the summer and fall. The rest of the year she's going to work in New Zealand. Kiwis may get mad, but they don't get PIISD.

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Kevin Horrigan is a columnist for the St. Louis Post-Dispatch. Readers may write to him at: St. Louis Post-Dispatch, 900 North Tucker Blvd., St. Louis, Mo. 63101, or email him at khorrigan [at]

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