Transcript Mental & Behavioral Disorders - American Academy of Disability

Mental and Behavioral
Disorders
Chapter 14
1
Questions ?
James B. Talmage MD,
Occupational Health Center,
315 N. Washington Ave, Suite 165
Cookeville, TN 38501
Phone 931-526-1604 (Fax 526-7378)
[email protected]
[email protected]
22
Jay Blaisdell asked for this”
Expert
Interest
3
I prefer
to talk
about
Treatment
and
helping
people.
4
Partnership for Workplace Mental
Health, a Program of the American
Psychiatric Foundation
Work is central to a person’s identity and
social role. It provides income, but more
than that, it is often an important source of
self-esteem.
For many people, lack of work equates with
lack of meaning. Thus, loss of work
capacity is a life crisis, one that demands an
immediate and focused response.
http://www.workplacementalhealth.org/employer_resources/
disabilityresources.aspx
5
http://www.workplacementalhealth.org/emplo
yer_resources/disabilityresources.aspx
6
Even if the patient
doesn’t want to return to work,
it is usually in his/her best interest
to do so.
7
7
The Color: Purple
88
th
6
Edition: ICF Model
 “Historically, the numerical ratings applied for
organ system impairment and whole person
impairment throughout the Guides are based
largely on consensus and expert opinion.
Research has focused on reliability and
reproducibility of ratings17 and functional validity
of ratings15, 32,33. The evidence basis for
impairment percentages assignable to ICF
functional levels must await further
empirical testing19…”

6th Edition, page 9
99
6th Edition: Chapter 14
10
Qualified Users p 348
 Psychologist
 Psychiatrist
 Expertise in:
 Psychiatric or psychological evaluation
of patients
 Diagnosis and treatment of mental and
behavioral disorders
 Utilization of the DSM
11
Qualified Users
p 351
“Treating psychiatrists and
psychologists should avoid serving
as an expert witness or IME examiner
for legal purposes on behalf of their
own patients.”
“The dual role can be detrimental to the
therapeutic relationship, can be a considerable
source of examiner bias, and can compromise
the patient’s legal claim.”
12
AMERICAN ACADEMY OF PSYCHIATRY AND THE LAW
ETHICS GUIDELINES FOR THE PRACTICE OF FORENSIC PSYCHIATRY
Adopted May 2005
 IV. Honesty and Striving for Objectivity
Psychiatrists who take on a forensic role for patients
they are treating may adversely affect the
therapeutic relationship with them. Forensic
evaluations usually require interviewing corroborative
sources, exposing information to public scrutiny, or
subjecting evaluees and the treatment itself to potentially
damaging cross-examination. The forensic evaluation
and the credibility of the practitioner may also be
undermined by conflicts inherent in the differing clinical
and forensic roles. Treating psychiatrists should
therefore generally avoid acting as an expert witness
for their patients or performing evaluations of their
patients for legal purposes.
13
DSM system
p 349
Not used in rating, but explained
14
Diagnoses & Rating p 349
 It is not the purpose of this chapter to rate
impairment in all persons who may fit a DSM-IV
diagnosis. It is understood that many
conditions are common in the general
population, and whether or not they are
included in the DSM-IV, they do not require an
impairment rating (eg. brief adjustment
disorder, normal grief reactions). Patients with
severe mental illness may have a greater role
impairment than a patient with a severe physical
ailment.
15
IR Limited To * …
(p 349)
 Mood disorders, including major depressive
disorder and bipolar affective disorder.
 Anxiety disorders, including generalized anxiety
disorder. panic disorder, phobias, posttraumatic
stress disorder. and obsessive compulsive
disorder.
 Psychotic disorders, including schizophrenia.
* Because the Guides is generally used in medicolegal settings
(eg, Worker's Compensation),
16
Mood disorders
 Major Depressive Disorder
 Dysthymic Disorder
 Depressive Disorder Not Otherwise Specified
 Bipolar I Disorder
 Bipolar II Disorder
 Cyclothymic Disorder
 Bipolar Disorder Not Otherwise Specified
 Mood Disorder Due to a General Medical Condition
 Substance-Induced Mood Disorder
 Mood Disorder Not Otherwise Specified
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Anxiety disorders
 Panic Disorder without Agoraphobia
 Panic Disorder with Agoraphobia
 Agoraphobia Without History of Panic Disorder
 Specific Phobia
 Social Phobia
 Obsessive-Compulsive Disorder
 Posttraumatic Stress Disorder
 Acute Stress Disorder
 Generalized Anxiety Disorder
 Anxiety Disorder due to a General Medical Condition
 Substance-Induced Anxiety Disorder
 Anxiety Disorder Not Otherwise Specified
18
Psychotic disorders
 Schizophrenia
 Schizophreniform Disorder
 Schizoaffective Disorder
 Delusional Disorder
 Brief Psychotic Disorder
 Shared Psychotic Disorder
 Psychotic disorder due to a general medical
condition
 Substance-induced psychotic disorder
 Psychotic disorder not otherwise specified
19
“NOT Ratable” by Chapter 14
 Psychiatric reaction to pain: It is inherent in
the AMA Guides that the impairment rating for a
physical condition provides for the pain
associated with that impairment. The
psychological distress associated with a
physical impairment is similarly included
within the rating.
 Somatoform disorders.
 Dissociative disorders.
 Personality disorders.
20
NOT Ratable in Chapter
 Psychosexual disorders.

Errata adds “Sexual and Gender Identity”
 Factitious disorders.
 Substance use disorders: Affective or other
mental disorders … are not rated.
 Sleep disorder
 Dementia and delirium (covered in Chapter 13).
 Mental retardation.
 Psychiatric manifestations of traumatic brain
injury (covered in Chapter 13).
21
The rules for using this chapter
would include: p 349
• In the presence of a mental and behavioral disorder
without a physical impairment or pain impairment,
utilize the methodology outlined in this chapter;
• In the event of a mental and behavioral disorder that is
judged independently compensable by the jurisdiction
involved, the mental and behavioral disorder impairment
is combined with the physical impairment;
• Whenever it is specifically required by a
compensation system;
• In most cases of a mental and behavioral disorder
accompanying a physical impairment, the
psychological issues are encompassed within
the rating for the physical impairment, and the
mental and behavioral disorder chapter
should not be used.
22
Legal Trumps Medical
States can make whatever rules it wants
23
P 349
Known by
every
psychiatrist
and
every
psychologist
24
Use of Tests
 The use of well-standardized psychological tests, such
as the Wechsler Adult Intelligence Scale (WAIS) and the
Minnesota Multiphasic Personality Inventory-2 (MMPI-2),
may improve diagnostic accuracy and support the
existence of a mental disorder (Table ]4-3).
 The ability of neuropsychologists to detect "faking" on
neuropsychological test batteries remains controversial.
Suffice it to say that the tests are most useful in
assessing strengths and weaknesses in cognitive
functioning of impaired cooperative patients. rather than
as a barometer of who is "faking bad" and who is giving
their best effort…. It is standard practice that a
neuropsychological test battery should include
instruments that include 2 symptom validity tests.
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Review test results to ensure that …
 The testing was done by a trained examiner and not
merely cosigned by a supervising psychologist.
 Test findings are internally consistent.
 The tester documented which materials were reviewed,
and testing results were consistent with information in
the record.
 Patient baseline/premorbid level of function was
adequately explored and documented.
 Appropriate normative data are listed for each test.
 The testing performed contained 2 or more symptom
validity tests.
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Meaning of Abnormalities
Abnormalities on neuropsychological test
batteries are not pathognomonic of brain
damage. Factors that may have an impact
on test results include aging, education.
motivation, ethnicity, culture, prescribed
medications, substance abuse, pain,
peripheral nervous system pathology. and
psychiatric disorders
27
P 334
Chapter 13
CNS
“Influence of
Behavior and
Mood” is one
of the 4
“Major”
Categories of
CNS
impairment,

P 326
28
Errata
29
Errata corrections to Table 14-3, page 350
30
Table 14-3, p 350 (continued)
31
Relevant Functional Impairment
Page 352
32
14-4 Suggestions for M & BD IME
 Assess personality structure and health with special attention to





antisocial, borderline, histrionic, narcissistic, passive dependent, and
passive-aggressive features.
Evaluate principal defense mechanisms. A key example is
somatization, which is a low-level defense mechanism. Scrutinize
primary care and secondary medical records for the presence of
somatization as a primary defense mechanism.
Screen individuals for past and current substance abuse, which
can mimic symptoms of other psychiatric diagnoses.
Evaluate the legal history, especially in regard to prior lawsuits,
work-related injuries, bankruptcies, driving under the influence,
incarcerations, restraining orders, and court-ordered child support.
Obtain military history: overseas service, adjustment to service,
type of discharge, pay grade, military arrests, disability pension.
Note whether there is a pattern of over-endorsing symptoms
during the psychiatric interview.
33
Screen for Substance Abuse
Suggestions for M & BD IME
 Assess the patient's motivation vis-a-vis RTW. Does the disease process
diminish the patient's motivation, or does the illness role gratify unconscious
or conscious needs in the patient (eg, dependent needs inherent in the
underlying personality construct)? Is secondary gain present? Is some
combination of all these elements present?
 Determine if symptom exaggeration or malingering is present.
Malingering may be subtle, marked, or frank.
 Ask about the patient's attitude to the third-party payer (employer, insurance
company, etc). Does worker feel payer responded appropriately?
 Assess the influence of the litigation process on RTW (promoting RTW
vs illness behavior). Is there a history of failed attempts to RTW? Who
decided-physician, patient, or attorney-whether there would be a RTW?
 Determine whether adequate pharmacologic and biological treatment
has been provided. Assess whether enough medications have been tried,
at adequate dosage, and of adequate duration. Has the patient frequently
rejected medications because of side effects? Has the patient accepted and
complied with reasonable treatment?
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Motivation:
PAGES 352-353
 Motivation for improvement may be a key factor
in the severity and extent of an individual's ability
to lead a productive life despite a challenging
impairment. whether that impairment is physical
or mental. Some have described this as a
bridge between impairment and disability.
The examiner also needs to assess changes in
motivation over time and whether problems in
motivation are due to the illness or the primary
gain or secondary gains.
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Motivation & Malingering
 Motivation to report symptoms can be influenced by a host of
factors, …. These factors may change over time. Since psychiatry
continues to lack definitive testing to confirm most major illnesses,
careful consideration of any complaint lacking apparent basis is
warranted. Exclusion or inclusion of somatization disorder, factitious
disorder. and/or malingering must be done with care. Assessment of
motivation is often challenging and requires skill to avoid biased or
prejudiced conclusions.
 Nevertheless, motivation is a significant link between an impairment
and resulting disability. For some people, poor motivation can be a
major cause of poor functioning. Understanding an individual's
underlying character structure may be important in determining
whether he or she is motivated to benefit from rehabilitation.
Personality characteristics typically remain stable throughout the life
span. However, internal and external events and psychological
reactions can significantly influence the course of illness and
motivation.
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Page 353
38
Worst Job in the World ?
Motivation:
“The Art of
Helping People Achieve
What They Want to Achieve,
By Making Them Do
What They Don’t Want to Do”
Tom Landry, Coach, Dallas Cowboys
40
Motivation & Malingering
Malingerers may present with
complaints suggesting a mental and
behavioral disorder, a physical
disorder, or both. Examiners should always
be aware of this possibility when evaluating
impairments. The possibility of avoiding
responsibility and/or obtaining monetary awards
increases the likelihood of exaggeration and/or
malingering. Nonspecific symptoms, which are
difficult to verify, tend to be overrepresented,
including headache, low back pain, peripheral
neuralgia, and vertigo. Malingering occurs along
a spectrum-from embellishment to exaggeration
to outright fabrication.
41
Motivation & Malingering
Malingered psychiatric conditions may
be more common in medico-legal
settings commonly involving the
avoidance of unpleasant duty or
requirements, for example, incarceration, military
service, or when someone is seeking insurance or
entitlement benefits.
 Deception is usually suspected when the individual's
symptoms are vague, ill defined, overdramatized,
inconsistent, or not in conformity with signs and
symptoms known to occur. In this regard, the history,
mental status and physical examinations, records, and
other available collateral information may demonstrate
inconsistencies in the nature and intensity of the
42
person's complaints.
Malingering
43
Response to Treatment
? At MMI ??
 Assess history of the response to treatment & determine
whether there has been an adequate treatment course.
 Treatment sufficiently aggressive and of adequate
duration?
 Treatment resulted in improvement in patient function?
 Suitable number of treatment options been applied?




Medication compliance been assessed?
Has the patient been cooperative with treatment interventions?
Rejection of treatment options by the patient should not justify an
impairment rating.
In certain illnesses (eg, schizophrenia) the lack of insight may
interfere with treatment.
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Response to Treatment
 Response to treatment should be documented.
Treatment may result in only a partial remission. One
should attempt to evaluate whether residual problems
represent symptoms or medication side effects.
Limitations that remain after optimal treatment
represents the degree of impairment.
 Because medication side effects must be considered as
part of the impairment. optimal psychopharmacologic
management includes trials of medications, which both
minimize side effects and maximize efficacy.
 If present, have comorbid substance abuse and physical
disorders and their treatment that produce mental
symptoms been addressed in the treatment plan?
45
MMI
 Diseases are chronic – relapsing ….
the workplace may be a
significant stressor, the examiner should
 Because
look for evidence of repeated deterioration upon
the patient's return to his or her chosen
occupation. The individual's resilience in the
face of stress is a significant factor in whether
the individual can return to work and maintain
function there.
46
Permanence
 No way to establish, and Chapter 14 appears
to admit this simple fact (page 353; and the
5th Edition specified this fact), and then
moves forward with the creation of ratings
anyway.
 Only one of the 7 case examples (14-5) even
hint at how MMI was established (i.e., no
change in pre-existing mental illness and
current malingering in the PAST 12 months).
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Vocational Issues
 Vocational impairment may represent an important
portion of the overall impairment. One individual may
have a pronounced impairment in other areas but still
function successfully in the workplace. In another
individual, a circumscribed impairment may profoundly
impair the patient's ability to work. It
would be
unusual, however, to find an
impairment that affects work only.
 An employer's willingness to modify existing work
conditions and opportunities may be a central part of the
patient's successful return to work. And as is true with
many physical diagnoses, early return to the workplace
in some capacity facilitates a successful return to work. 48
A Physician’s Guide to Return
to Work – AMA Press
“True psychological
impairment is NEVER
confined exclusively to
the boundaries of work,
and it affects other areas
of a person’s life besides
work.” – page 309
Doing the Rating
Initial Mechanics
50
Steps in Rating (Short Version)
 Determine if situation qualifies for rating
 Determine if mental illness
 Assess credibility
 Make diagnosis
 Do rating
 Assess work-relatedness
 Adjust for pre-existing psych diagnoses
 Adjust rating
 Address vocational issues
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NOT Ratable, but the Real Problem
Considerations
 Psychiatric impairment should be rated based on Axis I
pathology only. Whether there is one or multiple Axis I
diagnoses, there is only one impairment rating.
 Underlying
personality vulnerabilities and borderline
intellectual function are preexisting conditions which are
not ratable. Personality disorders other than antisocial
personality disorder lack sufficient interrater reliability,
and the law does not recognize sociopathy as a
legitimate source of impairment. As the evaluator
assesses each of the 6 domains of functional impairment
(Table 145), it is important to consider what portion of
the impairment is due to the potentially unremitted illness
versus the portion driven by possible chronic preexisting
personality vulnerabilities and/or borderline intellectual
functioning.
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Spine 2006;31:1156–1162
53
Further Considerations
 Compromise of activity of daily living (ADL)
function due to financial constraints or lack of
transportation is not to be rated.
 Must assess not simply the # of activities
restricted but the overall degree of restriction or
combination of restrictions.
 There are limits on the evaluator's ability to
assess patient concentration in a one-time
interview. In the aggregate, an estimate of the
patient's ability to concentrate may rely more on
the collateral sources of information as well as
the employment history.
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Further Considerations
 A person who appears to concentrate
adequately during a mental status examination
or a psychological test may not do so in other
settings (eg. reading. watching movies).
 Limitations in the 6 domains listed in Table 14-5
due to physical impairments, should not be
included.

Eg. If patient cannot carry out ADLs due to spinal cord
injury, no IR from M & BD.
55
Further Considerations
 To measure the impairment caused by a work-related injury or
incident, the evaluator must determine whether a ratable
preexisting mental and behavioral impairment existed. If so,
by definition the current impairment is a sum of both the
preexisting impairment and the impairment resulting from the
work injury/incident. Calculate the current permanent
impairment using the methods described in Section ]4.6.
Calculate a second impairment rating based only on the
preexisting condition. The impairment rating due to the workrelated injury or incident will be the difference between the 2
scores.
 Impairment scores do not, in themselves, indicate whether a
patient can work or not. This is an independent assessment
that must be made during the evaluation. For example, a
patient with a 40% impairment may be 100% disabled from
employment.
Twice the WORK
56
Basis of Impairment Rating - 3 Scales
 Brief Psychiatric Rating Scale – p. 357 T 14.8
 Focuses solely on symptom severity. Measures major psychotic
and nonpsychotic symptoms in patients with major psychiatric
illnesses. The scale can be applied to adult inpatients and
outpatients, and has shown excellent reliability in clinical trials.
 Psychiatric Impairment Rating Scale
 Behavioral consequences of psychiatric disorders are assessed
on 6 scales, each of which evaluates an area of functional
impairment (Table 14-5). The PIRS is similar in construction to
the GAF but has been expanded to provide greater detail in
order to rate impairment.
 Global Assessment of Functioning Scale
 Constitutes Axis V of the DSM-IV and is a 100-point single-item
rating scale for evaluating overall symptoms. occupational
functioning, and social functioning
57
Final Answer: page 357
The Actual Rating
58
Brief Psychiatric Rating Scale

The ratings are not to be based on
“gut impression” (page 356).

The ratings are to be based on the
detailed appendix that is provided in
section 14.8, page 369-381 (and on an
additional reference mentioned at the
beginning of the section).
59
60
Brief Psychiatric Rating Scale
24 items: Anxiety, depression,
suicidality, guilt, hostility, elevated
mood, grandiosity, suspiciousness,
hallucinations, etc.
Each is rated on a seven point scale
of severity

Not present, very mild, moderate,
moderately severe, severe, extremely
severe
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Brief Psychiatric Rating Scale
Sum the 24 ratings.
Go to table 14-9, page 357.
Find the sum of the 24 ratings in the left
column
Find the corresponding “BPRS impairment
score” in the column on the right…
Write the “BPRS impairment score” in the
homemade version of the table that is
provided in section 14.6d, p. 357.
62
Errata: Page 15
63
Global Assessment of
Functioning
Luborsky first published using a 0-100
scale for functioning

Health-Sickness Rating Scale
 Psychiatry
1962; 7: 407-417
GAF was included in DSM-III
Now standard part of diagnostic procedure
Evaluates function: PROBLEM: Should the score
Psychological
 Social
 Occupational

depend on the worst of these
three, or the average of these
plus propensity to violence, as
Proposed by Kennedy (2003)?
Global Assessment of
Functioning Scale (GAF)
Axis V of the Multi-axial System
Should base it only on psychological,
social or occupational functioning – not
physical or environmental limitations.
10 intervals – 1-10 …..91-100
Basically reflects opinion of evaluator
(based on examination) regarding what
evaluee can or cannot perform
65
GAF = 51 – 70, Usually treated as outpatients
66
GAF = 1-40 USUALLY Hospitalized
GAF = 41-50 Usually require intensive outpatient therapy and monitoring
To assess safety issues and the need for hospitalization.
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Psychiatric Impairment
Rating Scale (PIRS)
Six items, divided into tables 14-11 through
14-16 (pages 358-360).
Each item is assigned a rating of 1-5 based
on the criteria in each table.
Write down the rating for each table.
Sort the six ratings from lowest to highest.
(example in Guides: 1 2 2 4 4 5)
68
Psychiatric Impairment
Rating Scale (PIRS)
 Sort the six ratings from lowest to highest.
(example in Guides: 1 2 2 4 4 5)
 Select the middle 2 and sum them 6
 Determine rating from Table 14-7 (360)
 Put information in “GAF impairment score” in your
homemade version of the table that is provided in
section 14.6d (357)
69
PIRS: pages 358-360
70
PIRS: Table 14-11
Self-Care, Personal Hygiene, and Activities of Daily Living
1 No deficit, or minor deficit attributable to the normal variation in the
general population.
2 Mild impairment. Able to live independently; looks after self
adequately, although may look unkempt occasionally; sometimes
misses a meal or relies on take-out food.
3 Moderate impairment. Can’t live independently without regular
support. Needs prompting to shower daily and wear clean clothes.
Does not prepare own meals, frequently misses meals. Family
member or community nurse visits (or should visit) 2–3 times per
week to ensure minimum level of hygiene and nutrition.
4 Severe impairment. Needs supervised residential care.
5 Totally impaired. Needs assistance with basic functions, such as
feeding and toileting.
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Psychiatric Impairment
Rating Scale (PIRS)
 Sort the six ratings from lowest to highest.
(example in Guides: 1 2 2 4 4 5)
 Select the middle 2 and sum them 6
 Determine rating from Table 14-7 (360)
 Put information in “GAF impairment score” in your
homemade version of the table that is provided in
section 14.6d (357)
77
78
Final Answer: page 357
The Actual Rating
79
The End
Thank You
80
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