Mental and Behavioral Mental and Behavioral DisordersDisorders

Chapter 14Chapter 14

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Questions ?James B. Talmage MD,

Occupational Health Center,

315 N. Washington Ave, Suite 165

Cookeville, TN 38501

Phone 931-526-1604 (Fax 526-7378)

olddrt@frontiernet.net

olddrt@occhealth.md 2

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Jay Blaisdell asked for this”

Expert

Interest

Expert

Interest

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I preferto talk about Treatment

andhelpingpeople.

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/employer_resources/disabilityresources.aspx

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Even if the patient doesn’t want to return to work,it is usually in his/her best interestto do so.

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The Color: Purple

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6th 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

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6th Edition: Chapter 14

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Qualified Users p 348

PsychologistPsychologist Psychiatrist Psychiatrist Expertise in:Expertise in:

Psychiatric or psychological evaluation Psychiatric or psychological evaluation of patientsof patients

Diagnosis and treatment of mental and Diagnosis and treatment of mental and behavioral disordersbehavioral disorders

Utilization of the DSMUtilization of the DSM11

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.”

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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.

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DSM system p 349

Not used in rating, but explained

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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.

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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),

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Mood disordersMood 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 disordersAnxiety 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

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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

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“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.

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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 MedicalStates can make whatever rules it wants

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P 349Known by

every psychiatrist

and

every psychologist

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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

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Chapter 13CNS “Influence of

Behavior and Mood” is one of the 4 “Major” Categories of CNS impairment, P 326

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P 334

Errata

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Errata corrections to Table 14-3, page 350

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Table 14-3, p 350 (continued)

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Relevant Functional Impairment

Page 352

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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.

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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

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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

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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.

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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 person's complaints.

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Malingering

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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?

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MMI Diseases are chronic – relapsing …. Because the workplace may be a

significant stressor, the examiner should 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.

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PermanencePermanence

No way to establishNo way to establish, and Chapter 14 appears , and Chapter 14 appears to admit this simple fact (page 353; and the to admit this simple fact (page 353; and the 55thth Edition specified this fact), and then Edition specified this fact), and then moves forward with the creation of ratings moves forward with the creation of ratings anyway.anyway.

Only oneOnly one of the 7 case examples (14-5) even of the 7 case examples (14-5) even hint at how MMI was established (i.e., no hint at how MMI was established (i.e., no change in pre-existing mental illness and change in pre-existing mental illness and current malingering in the current malingering in the PASTPAST 12 months). 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.

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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

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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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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.

NOT Ratable, but the Real Problem

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Spine 2006;31:1156–1162

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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 work-related 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 Basis of Impairment Rating - 3 ScalesScales 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

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Final Answer: page 357

The Actual Rating

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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).

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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 61

Brief Psychiatric Rating Brief Psychiatric Rating ScaleScaleSum 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.

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Errata: Page 15

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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:

Psychological Social Occupational

PROBLEM: Should the score 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

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GAF = 51 – 70, Usually treated as outpatients66

GAF = 1-40 USUALLY HospitalizedGAF = 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)

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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)

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PIRS: pages 358-360

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PIRS: Table 14-11Self-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)

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Final Answer: page 357

The Actual Rating

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8080

The End

Thank You

The End

Thank You