JAMES LEHRMAN,
          VS.                                                 File No. 
          MIDWEST SERVICE COMPANY,                            A R B I T R 
         A T I O N
               Employer,                                         D E C I 
         S I O N
               Insurance Carrier,
                              STATEMENT OF THE CASE
              This is a proceeding in arbitration brought by James 
         Lehrman, claimant, against Midwest Service Company, employer, and 
         American Mutual Insurance Co., insurance carrier, to recover 
         benefits under the Iowa Workers' Compensation Act as a result of 
         an injury sustained on July 23, 1984.  This matter came on for 
         hearing before the undersigned deputy industrial commissioner 
         July 1, 1988 and was considered fully submitted at the close of 
         the hearing.  The record in this case consists of the testimony 
         of claimant, Linda Lehrman, his wife, Phyllis Sylvia Smith., 
         Deborah Hanson, Vikki Maseun, and Cecelia Blaskovich; joint 
         exhibits 1 through 32, inclusive; and claimant's exhibits 33, 34 
         and 35.
              In addition, claimant filed an application to amend the 
         hearing assignment order and in support thereof called as 
         witnesses claimant and Sylvia Smith.  The application was denied 
         as the hearing assignment order was not issued by the undersigned 
         and therefore is not subject to modification by her.  See 
         Clousing v. Rosenboom Machine & Tool (Appeal Decision filed May 
         15, 1989).  However, claimant was permitted to make a record on 
         the issue in the event of an appeal.
              Pursuant to the prehearing report and order submitted and
         Page 2
         approved July 1, 1988 the following issues are presented for 
              1. Claimant's entitlement to healing period benefits for 
         the periods from December 18, 1985 to September 14, 1986, and 
         June 1, 1987 to June 22, 1987.
              2. The extent of claimant's entitlement to permanent 
         partial disability benefits; and
              3. Claimant's entitlement to certain medical benefits under 
         Iowa Code section 85.27.
                                 FACTS PRESENTED
              On July 24, 1984, claimant was injured in a collision with 
         another semi which resulted in the demise of the other driver.  
         Upon hospital admission, W. P. Isgreen, M.D., consulting 
         neurologist, noted his impression as: "Multiple trauma center 
         with fractured odontoid and pedicles of C2 with evidence of very 
         discrete intracerebral hemorrhage on the right and with left leg 
         paresis and hyperreflexia."  (Joint Exhibit 11) Claimant, who had 
         no independent recollection of the accident, underwent a fusion 
         on July 25, 1984 at Cl-C2.  Mrs. Lehrman recalled claimant was 
         completely bedridden for approximately ten days and hospitalized 
         for approximately one month.
              Mrs. Lehrman testified that in approximately October 1984 
         claimant began having violent temper outbursts that he "could not 
         control," a behavior pattern he had not shown prior to his 
         injury.  Mrs. Lehrman described the problems claimant had 
         sleeping, with headaches, and reliving the accident.  Mrs. 
         Lehrman explained that when they began to discuss claimant's 
         return-to-work, claimant began to think of different careers and 
         eventually decided to try to return to school and began an 
         electronics course at Western Iowa Technical College in September 
         1985.  Mrs. Lehrman testified claimant was a very good student 
         who got A's and B's and described claimant as a "compulsive 
         perfectionist" who was "diligent" in his home studies and 
         extended a special effort with his school work.
              Mrs. Lehrman recalled that in December 1985, claimant 
         developed a "very bad headache, "broke down," and was 
         hospitalized after which he began receiving regular psychological 
         counseling.  Mrs. Lehrman stated that after claimant was 
         discharged, he was better for awhile but then "school was too 
         much" and he began talking about quitting.  Mrs. Lehrman 
         testified she "pushed" at claimant to stay in school but he 
         eventually left in April 1986.  Mrs. Lehrman stated claimant 
         continued with his counseling sessions but "lost his temper in a 
         significant way
         Page 3
         about once per month" during which he was unreasonable and, at 
         times, violent.
              Mrs. Lehrman recalled an incident on May 5, 1987 which 
         involved an argument between claimant and their daughter.  
         Claimant "walked out" on the family at approximately 11:00 p.m. 
         and they received a call from the police department at 
         approximately 3:30 a.m. reporting that the police were holding 
         claimant who, although he could recall who he was, could not 
         recall why he left home.  Mrs. Lehrman also recalled another 
         incident later that same month when claimant, who would not go to 
         a family picnic, left a note for the family that it was the "last 
         time you'll ever see me."  Mrs. Lehrman stated she "signed a 
         warrant with the sheriff," learned claimant had "wiped out the 
         checking account," she called all of claimant's health care 
         providers and that when claimant was eventually found, he could 
         not recall where he had been but asked to be taken "where [he] 
         could get help."  Claimant was subsequently admitted to Marian 
         Health Center.
              During the summer of 1987, claimant was studying for the 
         insurance exam to become a licensed agent.  Although he 
         eventually passed the exam, Mrs. Lehrman stated claimant "has 
         done nothing" with it because of a lack of enthusiasm and a fear 
         of rejection.  In September 1987, the Lehrmans moved to LeMars 
         and claimant began employment at the A.S.C.S. in October of 1987 
         as a temporary worker measuring farm fields.  Claimant liked the 
         work and hoped it would become permanent but he was laid off from 
         the job in May 1988.  Mrs. Lehrman stated that since claimant 
         lost his employment he has applied at numerous places but has not 
         had any offers of employment from any of them.  Mrs. Lehrman 
         recited current incidents of troublesome behavior on claimant's 
         part and expressed her opinion that claimant needs to continue 
         his psychological counseling sessions.
              On cross-examination, Mrs. Lehrman acknowledged that before 
         the family moved to LeMars, they lived next door to claimant's 
         father and that this caused "a lot of stress, particularly during 
         the last four years they were there."   Mrs. Lehrman stated that 
         after claimant's accident the relationship between the two 
         families deteriorated and that there were "too.many problems."  
         Mrs. Lehrman denied, however, that these problems were the "main 
         stress" in claimant's life.
              Claimant testified that prior to 1984 he garnered most of 
         his income either as a truck driver or as a laborer and that he 
         particularly liked the "freedom of driving trucks."  Claimant 
         stated that with the weakness he has on his left side both he and 
         his physician felt it better he not return to truck driving.  
         Claimant explained that he left the electronics course work as he 
         felt he was not able to mentally handle the work; that he found
         Page 4
         it "demoralizing to keep house, cook and babysit"; and that he 
         lost interest in insurance work while he was employed with 
         A.S.C.S., but that since his layoff from the employment he has a 
         renewed interest in it.  Claimant opined, however, that he 
         "probably would not be successful at it" and if he wasn't, it 
         would bother him.  Claimant described his health prior to the 
         accident as "very good" with no limitations.
              Sylvia Smith, who described herself as a psychotherapist at 
         Great Plains Mental Health Clinic doing family, individual, group 
         and marital counseling and therapy, testified that her first 
         contact with claimant came on May 30, 1987 after claimant 
         experienced an episode of psychogenic amnesia when he left home 
         and appeared in Spirit Lake now knowing who he was or where he 
         had been.  Ms. Smith reported, however, that claimant had been 
         receiving individual therapy from Howard H. Marty, Ed.D., a 
         licensed psychologist, beginning December 19, 1985 when claimant 
         was admitted to the hospital because of great distress and that 
         claimant was being treated on a diagnosis of reactive psychosis 
         (298.80) which affects his "entire life and all those around 
         him," a condition which "waxes and wanes."  Ms. Smith described 
         claimant as having difficulty feeling confident to return to 
         school or the job market, an inability to maintain eye contact, 
         an inability to assert himself with his family, having confusion 
         and a confusion of thinking, and having difficulty relating to 
         people due to a lack of confidence and an emotional instability 
         to maintain relationships.  Ms. Smith stated that claimant reacts 
         to stress by withdrawing and running, that he does irrational 
         things and then "truly cannot recall" what he has done.  Ms. 
         Smith stated that claimant had no problems prior to his injury, 
         that she meets with him weekly to discuss his plans for the 
         future, both vocationally and socially, and.that it is intended 
         that the sessions will continue as they are necessary to treat 
         claimant's condition.
              On cross-examination, Ms. Smith acknowledged claimant had a 
         long-standing conflict with his father causing "stress" but 
         asserted that the conflicts have escalated since claimant's 
         accident as claimant,. as a result of the accident and his 
         illness, cannot "deal with his stressors."  Ms. Smith stated that 
         claimant cannot handle the "normal breadwinner kind of thing" 
         that he was capable of handling prior to the accident.
              Deborah Hanson, who identified herself as a vocational 
         rehabilitation counselor for the state of Iowa, testified that 
         she first met with claimant in the summer or fall of 1985 to 
         review claimant's options and to assist him in determining his 
         vocational alternatives and that she last saw him during the 
         summer of 1986.  Ms. Hanson recalled that she counseled claimant 
         once he enrolled in school and that academically he did very well 
         but that he was preoccupied with perfection and putting "a lot of
         Page 5
         extra pressure on himself."  Ms. Hanson found that the 
         "enrollment was taking too much out of him," that it became 
         detrimental to his well-being and that she was supportive of his 
         decision to leave.
              Ms. Hanson testified she reviewed claimant's physical and 
         mental records and opined that claimant's barriers to return him 
         to competitive employment included his cervical impairments, his 
         left side weakness, "soft tissue and brain swelling" and although 
         claimant is bright and intelligent, the patterns he has developed 
         concerning his emotional stability also present a barrier.  Ms. 
         Hanson stated that while claimant may have acquired his insurance 
         license, she would question his ability to actually sell 
         insurance because of the pressure of "commission only sales."  
         Ms. Hanson testified that employers would be hesitant to hire 
         claimant knowing of his emotional problems and his fear of 
         dealing with stress.
              Vikki Masuen, who identified herself as claimant's 
         sister-in-law, testified she is the head of the price support 
         unit for the Plymouth County A.S.C.S., and that the A.S.C.S. 
         hired claimant on a temporary full-time basis to perform 
         measurements to insure farmers were in compliance with what was 
         being reported.  Ms. Masuen stated that most of these 
         measurements were done in the office from photographs, although 
         claimant would "sometimes" go out into the field.  Ms. Masuen 
         testified claimant lost his employment on May 30, 1988 due to a 
         reduction in force when budgetary restraint caused a lack of 
         funds and that there is no assurance the A.S.C.S. will be able to 
         hire any temporary employees in the future.  Ms. Masuen stated 
         that she "could tell" claimant was having problems on certain 
         days when he became "moody," "quiet," and "wanted to be left 
         alone."  Ms. Masuen opined that claimant had no psychological 
         problems prior to his accident.
              Cecelia Blaskovich, owner of Medisult, Ltd., testified she 
         met with claimant on the request of defendant insurance carrier 
         to review claimant's medical treatment, manage the care and 
         assist claimant in finding employment or fulfilling a vocational 
         rehabilitation plan.  Ms. Blaskovich found claimant to have 
         marketable transferable skills and that based on information she 
         "fed into the computer," claimant would be capable of such 
         employment as hotel management, retail sales, housekeeper, 
         registered nurse, meat packer, air traffic controller, payroll 
         clerk, insurance claims adjuster, and heavy equipment operator.  
         Ms. Blaskovich stated she fully considered claimant's mental and 
         emotional problems in coming up with this list of jobs for 
              Howard H. Marty, Ed.D., counseling psychologist on the 
         staff of Plains Area Mental Health Center, testified he began 
         Page 6
         claimant after claimant's December 19, 1985 hospitalization.  Dr. 
         Marty explained his initial diagnosis was brief reactive 
         psychosis, but that within a short time it changed to adjustment 
         disorder with depressed mood because:
              A. First of all, the first diagnosis of brief reactive 
              psychosis with an emphasis on the brief -- it does not last 
              long.  I think I can accurately say that several of these 
              other occasions when Jim has had his distressful times, that 
              initial diagnosis would, again, have been applied during 
              those distressful times.
                 So it isn't so much an upgrading or downgrading as it is 
              a change.  The -- the brief reactive psychosis is over, and 
              now we need a diagnosis to fit what is going on when the 
              psychosis is over.  So we -- we used that at that time -- 
              and I'm not sure that's what they're still using.  I would 
              guess they may be using something else by now, but we used 
              adjustment disorder with depressed mood.
              Q. All right.  I see that there's an implication in this 
              diagnosis that this patient was suffering from depression; 
              is that right?
              A. Yes. Yes.
              Q. And that depression was, in fact, a cause of the 
              diagnosis which is brief reactive psychosis.  Is that a fair 
              statement, just a more severe type of depression?
              A. Well, if it had only been the depression, we probably 
              would have used a depressive diagnosis.  But there was more 
              to it than the depression, you know, with the -- being out 
              of touch with reality, not remembering, and all these kinds 
              of things that were going on with Jim at that time
              Q. Okay.
              A. -- that caused us to use the brief reactive psychosis 
              diagnosis rather than just a depressive diagnosis.
         (Marty Deposition, Joint Exhibit 27, pages 27-28)
              Dr. Marty described the treatment plan which was developed 
         to reduce claimant's anxiety, to increase his self-esteem, to 
         help him relate more comfortably to a career change and to 
         increase his assertiveness to enable claimant to relate to his
         Page 7
         father in a.more adult manner.  Dr. Marty opined that:
              In my mind, there is no doubt but what was going on in Mr. 
              Lehrman at the time of this hospitalization in 1985 was 
              related to the accident that took place in July of 1984.
                 Now, like I said earlier, I did not know Jim before this 
              time.  But from what I know and what I experienced and what 
              I took as a history and what was going on in his life then, 
              there is no doubt in my mind but what there's a relationship 
              between these two.
         (Marty Dep., Jt. Ex. 27, p. 11)
              Dr. Marty testified:
              Q. Based on what you knew of Mr. Lehrman from your -your 
              treatment and your evaluations of him, what do you think is 
              the likelihood that he would be able to complete some sort 
              of educational training program successfully?
              MR. DECK:  I object to that.  There is no foundation.  It's 
              calling for speculation on the part of this witness.
              MS. HIGGS:  Go ahead and answer, Doctor.
              THE WITNESS:  Well, I think it will depend a lot on what the 
              field is.  He has -- With the depression he has had and has 
              battled with during the time I worked with him, I would 
              think academic schooling would be -would be difficult for 
              him.  If it were more a vocational training or that type of 
              work in some field that he had a more intense interest in, I 
              think it would be very likely he could be successful.
         (Marty Dep., Jt. Ex. 27, pp. 15-16)
              Asked his opinion on claimant's ability to "go out and find 
         a job, present himself to perspective employer s to seek work," 
         Dr. Marty responded:
              Well, with his -- with his personality profile, with his 
              rather passive personality traits, he has some difficulty in 
              asserting himself and presenting himself in a dynamic way in 
              applying for jobs.  So he's -- To that extent he is somewhat 
              limited, plus he has the physical limitations from the 
              accident, however severe those might be, plus he's had the 
              depressive features
         Page 8
              that I have seen off and on in him, especially when I was 
              working with him, which made it difficult for him to go out 
              at that time.  Now, what's happening since then, I don't 
         (Marty Dep., Jt. Ex. 27, pp. 17-18)
              Dr. Marty "speculated" that claimant's impairment as the 
         result of his psychological injury would be 20 percent of the 
         body as a whole.
              When asked whether claimant's family problems was the main 
         stress in claimant's life, Dr. Marty stated he:
              would have a hard time saying that's the main stressor in 
              his life.  I've worked with a lot of people who have 
              difficulty getting along with their parents.  That doesn't 
              mean that's the main stressor in their life.  May be a big 
              factor, but it doesn't mean it's the main thing.
         (Marty Dep., Jt. Ex. 27, pp. 36-37)
              Dr. Marty testified:
              Q. Doctor, could any of the family stresses that we've 
              talked about and that Mr. Deck has questioned you about be 
              related to the fact that Mr. Lehrman was injured in the 
              truck accident?
              A. I think so.  I think very much so, yeah.  His being out 
              of work, not being the income producer for the family, all 
              the time that it took for healing and all, and his wife kind 
              of took over things during this time of his incapacitation, 
              I think it could be very much a factor.
         (Marty Dep., Jt. Ex. 27, p. 43)
              Gerald A. Brooks, M.D., Director of Inpatient Psychiatric 
         Services at Marian Health Center, testified that he admitted 
         claimant to the hospital on June 1, 1987 and explained:
              Mr. Lehrman had been hospitalized in LeMars and was referred 
              here by -- I don't recall if it was Dr. Powell or Sylvia 
              Smith.  Probably both.  Would you like the details of --
              Q. Yes, please.
         Page 9
              A.-- the admission there? He had left a suicide note in his 
              home in LeMars- He had then disappeared, showed up the next 
              day in the emergency room, apparently had overdosed.  He was 
              amnestic for the event.  And this -this amnesia had occurred 
              a few weeks prior to that, and he had had several -- in the 
              past couple of years, he had had several episodes of which 
              were diagnosed as as [sic] depression or psychotic episodes 
              and so he was referred here for evaluation.  At the time he 
              was referred, they felt that he might be suicidal.
         (Brooks Dep., Jt. Ex. 28, pp. 3-4)
              Dr. Brooks arrived at a primary diagnosis of psychogenic 
         amnesia on the basis that:
              I think it was a -- there were myriad factors here.  I think 
              that Jim is a person that has had psychological problems for 
              a long time.  And I think the accident was    Well, let me 
              back up a little bit.  I think he had    as all of us have 
              some psychological problems and we make peace with them one 
              way or another, and I think Jim had.  And then when this 
              accident occurred, it caused a -- an exacerbation of all 
              problems and it created new ones and it really -- and then 
              led to a deterioration of his psychiatric condition.
                 Details, for one thing, his job.  He -- Jim is a person 
              of very -- of low self-esteem, very insecure, doesn't feel 
              as good as other people.  And he had managed some kind of -- 
              of equity with other people in his job.  He felt as good as 
              anyone else.  He did a good job, and he -- and then later he 
              lost that, it put him into a position of having to deal more 
              directly with some other psychological problems that held 
              carried for a long time.
         (Brooks Dep., Jt. Ex. 28, pp. 9-10)
              Dr. Brooks testified:
              Q. Do you have an opinion within a reasonable degree of 
              psychiatric certainty as to whether or not his 
              hospitalization in June of 1987 was caused in part by the 
              trauma and the sequel of problems that cascaded, if you 
              will, on his life after July of 1984?
              A. Yes, I do.
         Page 10
              Q. What is that opinion?
              A. Well, I think that the accident was a contributor.  I 
              really can't quantitate that, but I do feel it was a 
         (Brooks Dep., Jt. Ex. 28, p. 11)
              On cross-examination, Dr. Brooks reported that while 
         hospitalized, Dr. Schmitz, a licensed psychologist, administered 
         the Bender Gestalt, house-tree person  drawing, the Minnesota 
         Multiphasic Personality Inventory, and the Rorschach test.  Dr. 
         Brooks testified:
              Q. Okay.  Is it true, then, that you would agree with Dr. 
              Schmitz that this patient was suffering from manifestations 
              of depression and anxiety?
              A.  Yes.
              Q. And that those -- that depression and anxiety was of 
              long-standing and chronic nature.
              A. Yes.
              Q. Would you agree with Dr. Schmitz that the depression and 
              anxiety preceded the auto accident in July of 1984?
              A. Yes.
              Q. In all likelihood it did; is that correct?
              A.  Yes.
              Q. Okay.  In other words, the periods of depression and 
              anxiety that this patient was experiencing were deep-seated 
              emotional problems with regard to this patient's 
              personality; is that a fair statement?
              A. Yeah. I'm not sure what you mean by deep-seated, but I 
              think generally I could probably say yes.  They were of long 
              duration, anyway.
              Q. Okay. And I guess when I say deep-seated, I just mean 
              long-standing and chronic in nature.
              A.  Yes.
         Page 11
              Q. And are you able to tell the commissioner with any 
              certainty as to how these -- this personality disorder or 
              these emotional problems developed in this patient?
              A. Well, I see two - two things going on here.  I see that 
              Mr. Lehrman's having emotional problems from a dysfunctional 
              Q. Meaning what?
              A. Meaning that his father was verbally abusive, according 
              to him -- and this was corroborated by the family members -- 
              was very abusive, unaffectionate, very critical; very 
              condemning person; and that he grew up, then, with feelings 
              of lower self-esteem and insecure.  And he didn't go on to 
              college.  I think he just felt inadequate, generally.  Quit 
              after a year, got a job as a trucker, and I think in that 
              way had made peace with a lot of his troubles until the 
              accident, which I think caused an exacerbation of a lot of 
              troubles and I think some new ones.
         (Brooks Dep., Jt. Ex. 28, pp. 22-24)
              The medical records of W. P. Isgreen, M.D., neurologist, 
         summarized claimant's immediate care following the accident as:
                 Patient was admitted to the hospital on 7-23-84 and 
              transferred to Rehab. on 8-1-84.
                 This was the first neurological admission to MHC for this 
              37-year-old man.  He had been involved in a truck accident 
              the day of admission and was sent here because of concern 
              about his neck.
                 When he arrived, screening x-rays showed odontoid process 
              fracture extending through both the right and left pedicle 
              of C-1.  CT scan showed right vertex hemorrhagic lacune.  
              His state at that time was a little bit difficult to 
              determine, except that the left leg was terribly weak.  This 
              had been collapsed under the man in the cab and there was 
              some concern that this was ischemic neuropraxis.
                 The man was stabilized and Dr  Kleider of Neurosurgery 
              dealt with the odontoid fracture with surgical intervention 
              48 hrs. after admission, on the 25th.  He was then fit with 
              four poster collar.
         Page 12
                 Examination at a more leisurely time later showed 
              extremely hyperactive reflexes in the left leg with crossed 
              adductors bilaterally, but being elicited more strongly by 
              right-sided stimulation.  My concern was cervical contusion 
              at the time of his odontoid fracture, although there were no 
              sensory problems to go along with that.  Sensory evoked 
              response was abnormal with no response on the left leg, and 
              markedly delayed responses on the right leg, both of which 
              suggested cord involvement.  Nerve conductions in the left 
              leg were normal and the EMG itself revealed no denervation.  
              Changes were a little bit too fast for lower motor neuron 
              lesions and it was suspected, however, that the problem may 
              have been upper motor in origin.
                 In any event, there was nothing further surgically to 
              fix.  The odontoid fracture was stable.  He began 
              physiotherapy and rehabilitation with emphasis on the left 
                 The acute need having passed, the man was passed to 
              rehab. for further treatment.
                 Condition on transfer is vastly improved.
         (Jt. Ex. 11)
              On December 21, 1984, Dr. Isgreen reported that claimant 
         was getting psychologically dependent on his cervical collar and 
         that claimant's "psychological state is really the problem at the 
         moment."  Dr. Isgreen opined that he was not "so sure that it is 
         wise for him (claimant) to think about getting back into 
              Following his final evaluation of claimant on October 30 
         1985, Dr. Isgreen opined:
              The man really shows difficulties in three spheres:
                 The first is that of psychological impairment, and one 
              can see that in the man's concentration, his mood, his 
              outbursts of temper, and his sexual dysfunction.
                 The second sphere is that of the cervical cord and given 
              the indication one can see with ocular motility, he had at 
              least contusion in the high posterior cervical area with a 
              so-called contusion cervicalis, and that has resulted in the 
              left side of his body not feeling as does the right with 
              weakness, maladroitness, and the somatosensory syndrome that 
              we have dealt with over the months.
         Page 13
                 The third problem is that of cervical mobility.
                 If one goes after the various parameters, then I think a 
              number of 18 to 20 per cent permanent-partial impairment is 
              not either overly generous not parsimonious. certainly at 
              this point I think the man has reached maximum medical 
              recovery, though I expect effectively, the left sided 
              symptoms to improve, as they certainly have in the past.
                 The cervical mobility, however, while it only adds up to 
              less than five per cent by calculating the numbers, 
              effectively, the impairment is much greater, and the man 
              truly has changed the whole angle of his carriage because of 
              the cervical problem.
                 The emotional sphere is a more difficult thing on which 
              to get a handle.  That, one almost does by the change in the 
              pocket and how much is due to premorbid problem and how much 
              is due to the accident, I can't say.  All one knows is that 
              he has problems now that he didn't have before.  I am not 
              talking so much about his ability to concentrate or his 
              memorizing problems.  It's more of a tone feeling that I get 
              from him.
         (Jt. Ex. 11)
                           APPLICABLE LAW AND ANALYSIS
              An employee is entitled to compensation for any and all 
         personal injuries which arise out of and in the course of the 
         employment.  Section 85.3(l).
              The parties do not dispute that on July 23, 1984 claimant 
         sustained an injury which arose out of and in the course of his 
         employment or that the injury is the cause of both temporary and 
         permanent disability.  The essential issue presented for 
         resolution was the extent of claimant's entitlement to those 
         benefits.  However, before that issue can be discussed, it is 
         first necessary to determine whether the medical treatment 
         claimant has received for his psychological problems came about 
         as a result of the work injury of July 23, 1984.
              The claimant has the burden of proving by a preponderance 
         of the evidence that the injury of July 23, 1984 is casually 
         related to the disability on which he now bases his claim.  
         Bodish v. Fischer, Inc., 257 Iowa 516, 133 N.W.2d 867 (1965).  
         Lindahl v. L. 0. Boggs, 236 Iowa 296, 18 N.W.2d 607 (1945).  A 
         possibility is insufficient; a probability is necessary.  Burt v. 
         John Deere Waterloo Tractor Works, 247 Iowa 691, 73 N.W.2d 732 
         (1955).  The
         Page 14
         question of casual connection is essentially within the domain of 
         expert testimony.  Bradshaw v. Iowa Methodist Hospital, 251 Iowa 
         375, 101 N.W.2d 167 (1960).
              However, expert medical evidence must be considered with 
         all other evidence introduced bearing on the casual connection.  
         Burt, 247 Iowa 691, 73 N.W.2d 732.  The opinion of experts need 
         not be couched in definite, positive or unequivocal language.  
         Sondag v. Ferris Hardware, 220 N.W.2d 903 (Iowa 1974).  However, 
         the expert opinion may be accepted or rejected, in whole or in 
         part, by the trier of fact.  Id. at 907.  Further, the weight to 
         be given to such an opinion is for the finder of fact, and that 
         may be affected by the completeness of the premise given the 
         expert and other surrounding circumstances.  Bodish, 257 Iowa 
         516, 133 N.W.2d 867.  See also Musselman v. Central Telephone Co.
         , 261 Iowa 352, 154 N.W.2d 128 (1967).
              Iowa Code section 85.27 provides:
                 The employer, for all injuries compensable under this 
              chapter or chapter 85A, shall furnish reasonable surgical, 
              medical, dental, osteopathic, chiropractic, podiatric, 
              physical rehabilitation, nursing, ambulance and hospital 
              services and supplies therefor and shall allow reasonably 
              necessary transportation expenses incurred for such 
              It would appear that defendants dispute the question of 
         casual connection on the basis that claimant, at the same time as 
         well as prior and subsequent to the injury, was also experiencing 
         family problems which were a source of stress in his life.  
         Defendants would assert that it was this family conflict which 
         acted as the precipitator or "main stressor" in bringing about 
         the need for claimant's psychological counseling.
              It cannot be the subject of much dissention that claimant 
         was not living in a vacuum, absenting him totally from everyday 
         experiences of dealing with family, neighbors and non-employment 
         life and that as a consequence thereof, those things would not 
         play a part in his emotional stability.  Clearly, claimant is not 
         a one dimensional being and this deputy could not be so naive as 
         to think that factors outside the employment life would not play 
         a part in one's mental health and well-being.  Likewise, however, 
         one cannot be so foolish as to believe that a loss of livelihood 
         by an injury as serious as that sustained by claimant would not 
         result in some emotional upheaval.  This must be particularly 
         true where the accident in which claimant was involved resulted 
         in the death of the other truck driver.
         Page 15
              The Iowa Supreme Court in Blacksmith v. All-American, Inc., 
         290 N.W.2d 348 (Iowa 1980) stated at 354:
              A cause is proximate if it is a substantial factor in 
              bringing about the result.  See Holmes v. Bruce Motor 
              Freight, Inc., 215 N.W.2d 296, 297 (Iowa 1974).  It only 
              needs to be one cause; it does not have to be the only 
              cause.  See Langford v. Keller Excavating & Grading, Inc., 
              191 N.W.2d at 670.
              No reasonable person could deny that claimant's work injury 
         was a cause of his seeking an receiving the continuing 
         psychological counseling.  Nor could that reasonable person deny 
         that the work injury was not the only cause.  The question thus 
         becomes, as the court stated in Blacksmith, whether or not the 
         work injury was a substantial factor in bringing about the need 
         for treatment.
              Dr. Isgreen, claimant's treating neurologist, repeatedly 
         noted claimant's emotional problems in his progress notes and of 
         them stated: "The emotional sphere is a more difficult thing on 
         which to get a handle.  That, one almost does by the change in 
         the pocket and how much is due to premorbid problem and how much 
         is due to the accident, I can't say."  (Jt. Ex. 11) Dr. Isgreen 
         notes, however, that claimant now has problems which he did not 
         have prior to the accident.
              Dr. Marty, who was claimant's treating psychologist for 
         some period of time, causally connects claimant's emotional 
         problems to the motor vehicle accident of July 23, 1984.  Dr. 
         Brooks, who saw claimant in his capacity as director of inpatient 
         psychiatric services, opined that claimant's work injury was a 
         contributor to his psychological problems while acknowledging 
         that claimant's depression and anxiety preceded the accident.  
         Sylvia Smith, who impressed this deputy as a witness by her 
         candor, demeanor and knowledge, opined that claimant's 
         personality imbalances are attributable to the motor vehicle 
              It is clear from the evidence that notwithstanding what 
         problems of a personal nature claimant may have had prior to his 
         injury, he was able to cope with those problems in a reasonable 
         and rational manner.  It is equally clear that subsequent to the 
         work injury, claimant has been unable to cope without the need 
         for treatment.  Claimant had no prior history of psychological or 
         psychiatric imbalance requiring treatment prior to the injury.  
         Claimant had no history of the psychogenic amnesia that he has 
         exhibited on a number of occasions since the injury.  No expert 
         has suggested that claimant is in any way malingering or 
         exaggerating his problems.  Claimant was sincere in his demeanor 
         while testifying.  Mrs. Lehrman, who has lived with claimant as 
         his wife for over sixteen years, stated that the couple had a 
         Page 16
         relationship with no psychological or psychiatric counseling 
         needed and that there was no threat of leaving, suicide, or child 
         abuse, verbal or physical, prior to claimant's injury.
              Consequently, it can only be concluded that the greater 
         weight of evidence, both medical and nonmedical, leads to the 
         conclusion that prior to the injury claimant was able to deal 
         with the stresses of life but that it became impossible to deal 
         with them after the injury and that therefore the injury was a 
         substantial factor in bringing about the need for 
         psychological/psychiatric treatment.  Accordingly, claimant's 
         treatment is found to be casually connected to the injury, the 
         injury is found to be a substantial factor in bringing about the 
         need for treatment, and defendants are liable for the expenses 
         incurred in that treatment, pursuant to Iowa Code section 85.27.
              Attention is thus turned to the extent of claimant's 
         stipulated permanent disability.  Dr. Isgreen has opined that 
         claimant's permanent partial impairment, as a result of the 
         cervical problems, is 18 to 20 percent of the body as a whole.  
         Dr. Marty, once pressed, speculated that claimant's psychological 
         problems resulted in a 20 percent permanent partial impairment to 
         the body as a whole.
              Functional impairment is an element to be considered in 
         determining industrial disability which is the reduction of 
         earning capacity, but consideration must also be given to the 
         injured employee's age, education, qualifications, experience and 
         inability to engage in employment for which he is fitted.  Olson 
         v. Goodyear Service Stores, 255 Iowa 1112, 125 N.W.2d 251 (1963). 
         Barton v. Nevada Poultry, 253 Iowa 285, 110 N.W.2d 660 (1961).
              A finding of impairment to the body as a whole found by a 
         medical evaluator does not equate to industrial disability.  This 
         is so as impairment and disability are not synonymous.  Degree of 
         industrial disability can in fact be much different than the 
         degree of impairment because in the first instance reference is 
         to loss of earning capacity and in the latter to anatomical or 
         functional abnormality or loss.  Although loss of function is to 
         be considered and disability can rarely be found without it, it 
         is not so that a degree of industrial disability is 
         proportionally related to a degree of impairment of bodily 
              Factors to be considered in determining industrial 
         disability include the employee's medical condition prior to the 
         injury, immediately after the injury, and presently; the situs of 
         the injury, its severity and the length of healing period; the 
         work experience of the employee prior to the injury, after the 
         injury and potential for rehabilitation; the employee's 
         qualifications intellectually, emotionally and physically; 
         earnings prior and subsequent to the injury; age; education; 
         Page 17
         functional impairment as a result of the injury; and inability 
         because of the injury to engage in employment for which the 
         employee is fitted.  Loss of earnings caused by a job transfer 
         for reasons related to the injury is also relevant.  These are 
         matters which the finder of fact considers collectively in 
         arriving at the determination of the degree of industrial 
              There are no weighting guidelines that indicate how each of 
         the factors are to be considered.  There are no guidelines which 
         give, for example, age a weighted value of ten percent of the 
         total value, education a value of fifteen percent of total, 
         motivation - five percent; work experience - thirty percent, etc.  
         Neither does a rating of functional impairment directly correlate 
         to a degree of industrial disability to the body as a whole.  In 
         other words, there are no formulae which can be applied and then 
         added up to determine the degree of industrial disability.  It 
         therefore becomes necessary for the deputy to draw upon prior 
         experience, general and specialized knowledge to make the finding 
         with regard to degree of industrial disability.  See Peterson 
         v.Truck Haven Cafe, Inc., (Appeal Decision, February 28, 1985); 
         Christensen v. Hagen, Inc., (Appeal Decision, March 26, 1985).
              Claimant was 41 years old at the time of hearing and a high 
         school graduate.  During high school, claimant was an honor 
         student and demonstrated his intellectual prowess in testing 
         subsequent to his injury and in his performance while enrolled at 
         Western Iowa Technical College in the electronics repair program 
         where he received A's and B's before having to abandon the 
         program due to his psychological problems.  Claimant 
         independently secured his license to sell insurance but has been 
         unable to turn this success into a career success.
              Claimant appears to have had a scant medical history prior 
         to this injury but his health, both mentally and physically, has 
         been devastated since July 23, 1984.  Claimant continues to have 
         left-sided weakness and a cervical impairment which precludes him 
         from truck driving and lifting.  Claimant also suffers from 
         intrinsic asthma which, although not caused by his work injury, 
         would further limit employment possibilities.
              Despite the best efforts by rehabilitation professionals, 
         both through the State of Iowa Department of Vocational 
         Rehabilitation and the private services of Medisult, Ltd., 
         claimant has no identifiable transferable job skills.  Claimant 
         has been unable to formulate a realistic plan for his vocational 
         future.  Any plan which claimant has formulated has not been 
         successfully carried out to its natural end.  Claimant has sent 
         and circulated his job resume, has had personal interviews, and 
         applied for jobs but has been unsuccessful in securing any 
         employment outside of the temporary work with A.S.C.S. at the
         Page 18
         behest of his sister-in-law.  The record does not show that 
         claimant developed any transferable skills from this position.
              The undersigned was not moved by the testimony of 
         defendants' expert, Cecelia Blaskovich.  Indeed, her testimony 
         somewhat bordered on the ridiculous.  To think that claimant, who 
         sustained injuries in an accident that necessitated a month-long 
         hospital stay, who has had at least two psychiatric 
         hospitalizations, who has had psychogenic amnesia, who continues 
         to receive regular counseling for stress and emotional disorders, 
         and who was unable to complete an electronics repair course at a 
         community college could succeed at, or even entertain the idea of 
         becoming an air traffic controller defies logic.  Or, to think 
         that he could train successfully as a registered nurse causes one 
         to question this individual's thinking.  This is particularly 
         true where Ms. Blaskovich worked with claimant over a number of 
         years and could never successfully place claimant in any 
         employment setting let alone in a professional setting.  The 
         Medisult report of May 21, 1986 indicated claimant could return 
         to work in a non-threatening, low stress job.  The undersigned 
         cannot conclude that many of the positions which Ms. Blaskovich 
         testified claimant would be capable of performing, would qualify 
         as non-threatening low stress jobs.  Ms. Blaskovich's testimony 
         is given little weight.
              Although claimant is obviously bright and intelligent as 
         well as motivated to secure employment, he also has barriers to 
         securing employment that may not be overcome.  Deborah Hanson 
         admitted employers are hesitant to hire individuals knowing of 
         emotional problems.  Claimant, who not only needs and has ongoing 
         psychological treatment, has had two psychiatric hospitalizations 
         and last had suicidal ideations when he was laid off from 
         employment due to budgetary limitations at A.S.C.S. This is 
         significant in light of the fact that claimant's loss of 
         employment was totally beyond his control and that this has been 
         the only employment claimant has been able to secure since his 
              Claimant's ability to enter a vocation by successfully 
         completing school is clearly questionable.  Claimant could not 
         complete the Western Iowa Technical College program.  Despite 
         securing his insurance license and his interest in real estate, 
         claimant has never sold a policy of insurance and his personality 
         traits make it unlikely that he would ever be able to.sustain an 
         employment effort in either of these areas.  While Dr. Marty 
         testified claimant might be successful in a less academic 
         environment, claimant's cervical impairment would begin to play a 
         part there.  The undersigned believes it would also be 
         questionable that claimant could succeed even in this 
         Page 19
              In Diederich v. Tri-City R. Co., 219 Iowa 587, 258 N.W. 899 
         (1935) the court, addressing the issue of the meaning of 
         disability stated:
                 What is "permanent total disability"?  Does this clause 
              refer to "functional disability" or to "industrial 
                 For clearness we shall use the term "industrial 
              disability" as referring to disability from carrying on a 
              gainful occupation--inability to earn wages.  By "functional 
              disability" we shall refer to the disability to perform one 
              or more of the physical movements which a normal human being 
              can perform.
                 It is obvious that "disability" here used cannot refer to 
              mere "functional disability",...
                 It is...plain that the legislature intended the term 
              "disability" to mean "industrial disability" or loss of 
              earning capacity and not a mere "functional disability" to 
              be computed in terms of percentages of the total physical 
              and mental ability of a normal man.
              ... [T]he Compensation law was passed for the purpose of 
              compensating the working man when injured.  The loss which 
              this claimant suffered due to the injury which he received 
              while in the employ of the company is the inability to carry 
              on the work he was doing prior to the time of the injury, or 
              any work which he could perform.  This man at fifty-nine 
              years of age, after thirty years as a street car motorman, 
              with little education, cannot find or hold a position that 
              would not require some manual labor, and, of course, due to 
              the condition of his back, he cannot perform such work.  To 
              say that he might become a stenographer or a lawyer or a 
              clerk or a bookkeeper is to suppose the impossible, for a 
              fifty-nine-year old man, with no education, is not capable 
              of securing or filling any such position.  His disability 
              may be only a twenty-five or thirty per cent disability 
              compared with the one hundred per cent perfect man, but, 
              from the standpoint of his ability to go back to work to 
              earn a living for himself and his family, his disability is 
              a total disability, for he is not able to again operate the 
              street car and perform the work which the company demanded 
              of him prior to the time of the accident.
         Page 20
              A finding that there is some work that claimant could do 
         within the physical and educational limitations he has does not 
         foreclose the finding of permanent total disability.  See Eastman 
         v. Westway Trading Corporation, II Iowa Industrial Commissioner 
         Reports 134 (Appeal Decision 1982); and Chamberlin v. Ralston 
         Purina, Appeal Decision filed October 29, 1987.
              Although claimant has had some employment since his injury, 
         the undersigned does not believe that the employment with 
         A.S.C.S. is representative of employment regularly available in 
         the labor market.  Considering then all of the elements of 
         industrial disability, claimant has established that he is 
         permanently and totally disabled from employment during the time 
         of his disability.  See Iowa Code section 85.34(3). Benefits 
         shall commence July 23, 1984.
              Accordingly, the issue of healing period benefits need not 
         be addressed.
                                 FINDINGS OF FACT
              Wherefore, based on all of the evidence presented, the 
         following findings of fact are made.
              1. Claimant sustained an injury which arose out of and in 
         the course of his employment on July 23, 1984, when he was 
         injured in a collision with another semi which resulted in the 
         demise of the other driver.
              2. The parties have stipulated and agreed that claimant's 
         injury is the cause of both temporary and permanent disability.
              3. Since his injury, claimant has had episodes of 
         psychogenic amnesia, suicidal ideations, psychiatric 
         hospitalizations, and patterns of behavior disorder which have 
         required treatment and which claimant did not demonstrate prior 
         to his injury.
              4. Claimant has an ongoing need for psychological 
              5. Although claimant has sources of stress involving his 
         non-employment life, claimant's injury of July 23, 1984 
         constituted a substantial factor in bringing about the need for 
         psychological and psychiatric counseling.
              6. Claimant is 41 years old and graduated from high school 
         as an honor student.
         Page 21
              7. Claimant was enrolled in an electronics repair class and 
         was receiving A's and B's in that program until his psychological 
         problems forced him to withdraw from this course of study.
              8. Claimant successfully studied and secured his insurance 
         license and has demonstrated his desire to sell insurance and 
         real estate.
              9. Claimant's personality disorders make it unlikely that 
         he would be successful in his sales position.
              10. Since his injury, claimant has been unable to secure 
         employment despite his best efforts as well as the best efforts 
         of rehabilitation professionals outside of temporary employment 
         with the Plymouth County A.S.C.S. which was secured at the behest 
         of his sister-in-law, who is head of the price support unit.
              11. Claimant has an 18 to 20 percent permanent partial 
         impairment of the body as a whole due to cervical problems which 
         include a permanent impairment of cervical mobility and a 
         weakness on the left side which may or may not improve.
              12. Claimant has a 20 percent permanent partial impairment 
         of the body as a whole due to his psychological/psychiatric 
              13. Claimant is precluded, as a result of the injury of 
         July 23, 1984, from engaging in employment for which he is fitted 
         by education and experience.
              14. Claimant's psychological impairment makes it unlikely, 
         at this time, that he would be successful in retraining efforts.
              15. Claimant is permanently and totally disabled from 
         employment during the period of his disability.
                                CONCLUSIONS OF LAW
              Therefore, based on the principles of law previously 
         stated, the following conclusions of law are made.
              1. Claimant has established that the medical treatment 
         which he sought and continues to receive as a result of his 
         psychological/psychiatric problems are casually connected to the 
         injury of July 23, 1984.
              2. Claimant has established that he is permanently and 
         totally disabled from employment for the period of his 
         Page 22
              THEREFORE, it is ordered:
              Defendants shall pay unto claimant weekly compensation at 
         the rate of one hundred ninety-seven and 70/100 dollars ($197.70) 
         per week, payable commencing July 23, 1984 and continuing 
         thereafter for so long as the claimant remains permanently and 
         totally disabled.
              Defendants shall pay all disputed medical expenses and 
         shall continue to provide claimant with the needed psychological 
         counseling as provided by the Plains Area Mental Health Clinic.
              Benefits that have accrued shall be paid in a lump sum 
         together with statutory interest thereon, pursuant to Iowa Code 
         section 85.30.
              Costs of this action are assessed against defendants, 
         pursuant to Division of Industrial Services Rule 343-4.33.
              Defendants shall file claim activity reports as requested 
         by the agency, pursuant to Division of Industrial Services Rule 
              Signed and filed this 30th day of January, 1990.
                                               DEBORAH A. DUBIK
                                               DEPUTY INDUSTRIAL 
         Copies to:
         Mr Charles T Patterson
         Attorney at Law
         P 0 Box 3086
         Sioux City IA 51102
         Mr Paul W Deck, Jr
         635 Frances Bldg
         Sioux City IA 51101