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Gregory T. Hale, Ph.D.

Psychologist

Indianapolis, Indiana

COSTS……………..

Legitimate and expected changes in the quality of life for injured workers are real

Loss of psychological benefits related to working and being productive is often overlooked and minimized

About 95% of WC claims involve a real accident at work

About 6-7 billion of the estimated 60 billion spent on WC claims is related to fraud

Actual cost of SSA disability fraud is unknown. Why?

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CONTEXT MATTERS

We are often examining and treating people in a context that is not neutral……people have expectations

Sometimes we evaluate because we want to know who we are dealing with (i.e., influence of preexisting psychological disorder)

When a substantial external incentive exists (PI claim, disability application, compensation seeking, evasion of criminal prosecution) then consideration of malingering must be acknowledged

Research findings – litigating patients v. controls – higher functioning and more satisfied with their lives pre-injury than the controls/also report lower functioning post-accident than controls

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CRITICAL ISSUES FOR EMPLOYERS,

CLAIMS EXAMINERS,

CASE MANAGERS,

AND LAWYERS

Diversity of human behavior

Tend to underestimate the influence of psychological factors

Fail to fully investigate pre-existing psychological conditions

Human behavior is complex, unpredictable, rigid

Many claimants are motivated by factors that are unidentified

All of us tend to personalize our stress – “what happened to me is different and worse than anything you have ever experienced.”

Weak relationship between distress and pathology

“Who is injured is often more important than the injury”

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SYM

PTO

MS

TIME

CONCUSSION

Force

Symptoms improve over time

24-48 hrs: headache, fatigue, cognitive px, balance px

What is the typical recovery time in healthy young adult with norisk factors for protracted recovery?

10 to 14 days

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Keep this in mind -- Harvard Medical School study

Depression and anxiety disorders

Substance abuse

Posttraumatic stress disorder

Adjustment disorders

Pain disorders

Rarely see more serious psychological disorders

BEHAVIORAL RISK FACTORS AFFECTING

DETERMINATION OF CAUSATION

Biological predispositions and early life experiences

The meaningfulness of social supports

The role of enduring personality traits

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WHAT DO WE KNOW ABOUT

WHAT DETERMINES COSTS IN A

MEDICAL CLAIM

Variables associated with high cost claimants:– Retained an attorney

– Required surgical intervention

– Had a diagnosable psychological disturbance

– Injured workers in litigation were more likely to exhibit psychological disturbance

High cost of litigation partially results from failure to identify and treat hidden psychological issues

Cases often produce long term disability with minimal evidence of disease

Loss of faith in medical system turns claimant to attorneys for help in receiving psychological and medical treatment

STANDARDS RELATED TO CAUSATION

Indiana and psychological injury claims

Variability between states – KY, IL

Causal Analysis needs to be objective

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CATEGORIZATION OF

PSYCHOLOGICAL CLAIMS IN WC

Physical disorders contributing to a psychological disorder

Psychophysiological reactions in which psychological factors or disorder contribute to a physical illness

Psychological disorders resulting from a mental injury

SO WHERE DO PSYCHOLOGISTS FIT IN A WC

CLAIM?

CLARIFICATION OF BEHAVIORAL ASPECTS OF

THE CASE

MEDICAL AND BEHAVIORAL

INTERVENTIONS CAN BE DESIGNED TO ADDRESS

PSYCHOLOGICAL FACTORS

DETERMINING WHICH ASPECTS OF THE

BEHAVIOR ARE WORK-RELATED OR PRE-

EXISTING

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Psychologists Psychiatrists Social Workers

Marriage and Family

Therapists

Mental Health Technicians

School Psychologists

Psychometrists Primary Care Physician

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COMPONENTS OF A

PSYCHOLOGICAL EVALUATION?

Interview (avoid only using self-report)

Psychological testing

Record review

Mental status observation

Comparison of data from multiple sources

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ADMINISTRATION AND

INTERPRETATION OF

PSYCHOLOGICAL TESTING

Utilize properly trained evaluators

Tests need to be administered in a professional manner

Issues of reliability and validity are extremely important in litigated cases

Use of multiple tests can enhance the strength of the testing data

Can help evaluate progress in treatment and impairment

Test battery:– Personality inventories

– Cognitive tests

– Symptom checklists

– Specialized inventories

Limitations of psychological tests

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QUESTIONS OF CAUSATION

Understanding base rate data for psychological disorders

Was there an accident or injury?

Did the injury arise out of and in the course of employment, personal injury, or ordinary life events?

Did the injury aggravate or accelerate the course and severity of the existing condition?

Is there a relationship between the understood pre-existing condition and the current symptoms?

APPROACHES TO THE

EXAMINATION

Malingering

Defensiveness

Irrelevant or Random Responding

Honest Responding

Hybrid Responding

Responses maybe adaptive to an adversarial evaluation and when the stakes for the claimant are high

Sometimes there is a hidden desired outcome

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DECEPTION AND

MALINGERING

Excessive symptom report

Overly favorable presentation in the context of significant symptom report

Reporting unusual combinations of symptoms or experiencing all symptoms

Invalid response patterns on psychometric testing

Profile not fitting normative groups

WHAT ARE THE NUMBERS? PROBABLE SYMPTOM

EXAGGERATION AND

MALINGERING

29% Personal Injury

30% SSA disability

8% Medical cases

However, recent research suggests………

>50% of SSA disability cases involve either malingering or probable malingering based on PVT data

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HOW DO I DETERMINE IF

SOMEONE “INTENDS” TO

DECEIVE?

Need multiple indicators of symptoms exaggeration or test underperformance

Absence of viable alternative explanations for atypical performance

It is the combined improbability of findings, in the context of external incentive, without any viable alternative explanation that establishes intent.

CLINICAL PICTURE OF MALINGERING

Eager to discuss and call attention to symptoms

Attributes symptoms unrelated to the accident to the litigation/claim

Overdramatically magnifies symptoms

Over endorses symptoms

Endorses rare symptoms

Endorses overly specific symptoms with unrealistic accuracy

Endorses bizarre or ridiculous symptoms

Symptoms and their course are inconsistent with recognizable mental disorder

Symptom report and functional limitations are inconsistent with claimant’s previous report and the observation of others

Symptoms worsen when observed

Focuses on the degree of impairment rather than the condition itself

Rarely mentions the ability to learn new skills or perform different or modified job

Scores above the cutoff for malingering on psychological and/or neuropsychological tests

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PROFILE OF THE

DISABILITY PRONE

PATIENT

Symptom magnification

Pain avoidance behavior

Psychological distress

Job dissatisfaction

Treatment dependency

Catastrophizing as a coping strategy

Pending litigation

IMPAIRMENT AND

DISABILITY

Relationship between physical impairments, pain, and disability is modest

Disability and impairment is affected by factors other than structural pathology

Physical pathology has a minor role in predicting disability

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