Cushing's Syndrome in the workplace

Cushing's Syndrome in the workplace can become a burden and even a danger to all who interact with the patient. Typical behaviors are generally an attempt to hide or cover their shortcomings and may appear like early onset dementia. They may be very nice people at first glance, friendly, very talkative, and try to give the appearance of having empathy, but there is a disconnect where their words and their actions do not fall into alignment. Narcissistic defense mechanisms and even abuse are used to hide the fact that they are deteriorating mentally and emotionally. Accepting resposibility for mistakes and shortcomings rather than deflecting this responsibility to others is at most on the level of a token acceptance. Boundaries and agreements are pushed and overstepped leaving a wake of disharmony among their coworkers as they increasingly have difficulty in forming and maintaining real relationships. This pattern of behavior may also be seen outside the workplace in the form of difficulty maintaining a successful marriage, and in the event of divorce, it is likely to be a high conflict divorce and include behaviors that encourage their children if there are any, to alienate the non custodial parent, and other legal issues. 


Balancing what is right for the Cushing's Syndrome Patient and the organization that employs them can be a challenging task. A careful balance must be weighed with the protection of the rights of a patient under the Americans with Disabilities Act and the Equal Opportunity Commision on one side and the violations of substance abuse policies and professional misconduct that can arise as a result of the prescribed medication used to treat the patient on the other. To complicate things there are for the purposes of this discussion three basic forms of Cushing's Syndrome. Cushing's Syndrome resulting from Cushing's Disease is an endogenous (from within the body) form of Cushing's Syndrome where there is a serious health issue, but no external substances being used. It is not uncommon for patients to struggle with geting a formal diagnosis and surgical help for years, while suffering in the same way that patients with the other forms of Cushing's Syndrome do. Pseudo Cushing's which may result from long term alcoholism and other conditions is the second form of concern. The third form is exogenous Cushing's Syndrome (from outside the body) where a patient takes corticosteroids either as prescribed or to excess beyond what ought to be prescribed and meets the DSM V standard for Corticosteroid Induced Neurocognitive Disorder. 


Each of these looks the same and the behaviors are the same, but handling each of them appropriately may be different. The first challenge is to confirm that it actually is Cushing's Syndrome, and then ascertain which form is applicable for someone in the workplace is suspected of having Cushing's Syndrome.  Statistically, exogenous Cushing's Syndrome is a growing demographic over the last 70 years. If there is a clear striking appearance of the physical characteristics, and the behavioral characteristics with a known underlying autoimmune disorder and a known history of taking corticosteroids such as Prednisone, then it is highly likely that the patient is suffering from the Exogenous form. Pseudo Cushing's may not be as pronounced as exogenous Cushing's Syndrome because the hypercortisolism may not be as pronounced. It is likely that the patient will have run into prior issues with either significant medical issues or the drug and alcohol policy before being able to reach this physical level pseudo Cushing's and no longer be employed.  Endogenous Cushing's patients will likely have many health ailments that are symptoms that go unrecognized for years. These can include, but are certainly not limited to diabetes, osteoporosis and glaucoma. These conditions are typically not autoimmune in nature, and while the patient may have taken coricosteroids at some point, would not be on continous corticotherapy as the Exogenous Cushing's Syndrome patient would.


One of the questions involved in determining what to do about the situation is in evaluating whether the patient is a direct threat. The volatile emotional state that is a well known part of any form of hypercortisolism can bring this into question, as are questions regarding cognitive impairment and judgement. Another concern is that some statutes have mixed regard for prescribed versus non prescribed psychoactive substances rather than the psychoactive nature of those substances. There is also "29 CFR § 1630.9 (b) It is unlawful for a covered entity to deny employment opportunities to an otherwise qualified job applicant or employee with a disability based on the need of such covered entity to make reasonable accommodation to such individual's physical or mental impairments." that must be considered. However, and in relief of that, there is also "29 CFR § 1630.14 (c) Examination of employees. A covered entity may require a medical examination (and/or inquiry) of an employee that is job-related and consistent with business necessity. A covered entity may make inquiries into the ability of an employee to perform job-related functions." that allows employers the ability to require a factual examination of an employee for fitness of duty that may be trying to hide either a corticosteroid use disorder or a coricosteroid induced neurocognitive impairment. 


Each of these concerns, employees, and positions must be uniquely considered on a case by case basis, but there are some basic policies and procedures that might be helpful. The first is by making a reasonable accomodation for the employee. Perhaps a suggestion to see an endocrinologist regarding a possible diagnosis of Cushing's Disease may help that employee if they choose to take it, and it may even save their lives and lead to a resolution of thier disability. Alternately, and as a function of the physical effects of hypercortisolism on the brain, the employee may use every narcissitic defense technique available to them to minimize, deflect, deny, stonewall, lying and even flat out refual to avoid quantitative testing. This would likely be the case if an exogenous Cushing's Syndrome patient felt that they may become exposed in a way that could potentially jeopardize their employment. If this occurs, a proper fitness test would be to require a neurological evaluation for ICD 10 code F19.188 Corticosteroid Induced Neurocognitive Disorder which falls under substance use disorders in the gold standard DSM V. A negative result would eliminate the concern if properly tested, but may serve as a baseline for future testing as untreated Cushing's Syndrome will progressively harm all levels of function until death. The same can be done with a neutral ressult. A positive result would have to be considered in the context of what direct threat is posed, how does this relate to the employee's performance in that position, how might reasonable accomodations be made, what treatment programs are available, how does this result relate to the organization's drug and alcohol policy, how does this result relate to any other regulations for that position such as professional misconduct, how will the progression of the condition be dealt with?  


The drug policy that universally finds acceptable or allows a patient to be free of the consequences of a drug policy because they have a prescription for it, rather than the adverse side effects of that medication is a drug policy that is worthy of reconsideration because it has the possible effect of enabling a medically prescribed dependence, addiction or use disorder. Rather than a policy of this nature, a thoughtful consideration of the policy held for FAA pilots under  CFR Title 14  Chapter I  Subchapter D  Part 67  Subpart B  §67.107 (4) Substance dependence, except where there is established clinical evidence, satisfactory to the Federal Air Surgeon, of recovery, including sustained total abstinence from the substance(s) for not less than the preceding 2 years. As used in this section— ii) “Substance dependence” means a condition in which a person is dependent on a substance, other than tobacco or ordinary xanthine-containing (e.g., caffeine) beverages, as evidenced by— (D) Continued use despite damage to physical health or impairment of social, personal, or occupational functioning.


It is recognized that when a patient on long term prescribed corticotherapy has been taking corticosteroids such as Prednisone for 15 or more years, that the damage to the patient from the adverse side effects of the medication used to treat an underlying illness typically becomes greater than the damage from the original underlying illness. This puts exogenous Cushing's Syndrome squarely in violation of the policy of the Federal Air Surgeon. Currently approximately 1% of the U.S. population has an active prescription for Prednisone, the most popularly prescribed corticosteroid, but not the only one. Extrapolation of a large cohort study on the prevalance of factitious Cushing's Syndrome suggests that there are approximately 30,000 current cases of factitious Cushing's Syndrome. In this perspective, patients on long term corticotherapy with visibly obvious signs and behaviors of Cushing's Syndrome, particularly in excess of 15 years ought to be considered as patients who have the illness of addiction that are active in their addiction with respect to the drug and alcohol policy. To consider otherwise does a disservice to the people that these patients serve, their colleagues, the organization as a whole, any profession  that they belong to, and to the patient and their families as well.