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Mental and Behavioral Disorders

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Title: Mental & Behavioral Disorders Author: Elizabeth Genovese MD Last modified by: James Talmage Created Date: 1/26/2008 5:06:58 PM Document presentation format – PowerPoint PPT presentation

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Title: Mental and Behavioral Disorders


1
Mental and Behavioral Disorders
  • Chapter 14

2
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_at_frontiernet.net
  • olddrt_at_occhealth.md

2
3
Jay Blaisdell asked for this
Expert Interest
4
I prefer to talk about Treatment and helping pe
ople.
5
Partnership for Workplace Mental Health, a
Program of the American Psychiatric Foundation
  • Work is central to a persons 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_reso
urces/ disabilityresources.aspx
6
http//www.workplacementalhealth.org/employer_reso
urces/disabilityresources.aspx
7
Even if the patient doesnt want to return to
work, it is usually in his/her best interest to
do so.
7
8
The Color Purple
8
9
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

9
10
6th Edition Chapter 14
11
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

12
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
    patients legal claim.

13
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.

14
DSM system p 349 Not used in rating, but
explained
15
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.

16
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),

17
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

18
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

19
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

20
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.

21
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).

22
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.

23
Legal Trumps Medical States can make whatever
rules it wants
24
P 349
  • Known by every psychiatrist and every
    psychologist

25
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.

26
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.

27
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

28
Chapter 13 CNS
P 334
  • Influence of Behavior and Mood is one of the 4
    Major Categories of CNS impairment,
  • P 326

29
Errata
30
Errata corrections to Table 14-3, page 350
31
Table 14-3, p 350 (continued)
32
Relevant Functional Impairment
Page 352
33
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.

34
Screen for Substance Abuse
35
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?

36
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.

37
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.

38
Page 353
38
39
Worst Job in the World ?
40
Motivation The Art of Helping People Achieve
What They Want to Achieve, By Making Them Do
What They Dont Want to Do
  • Tom Landry, Coach, Dallas Cowboys

40
41
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.

42
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.

43
Malingering
44
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.

45
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?

46
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.

47
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).

48
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.

49
A Physicians 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 persons life besides
    work. page 309

50
Doing the Rating
  • Initial Mechanics

51
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

52
Considerations
NOT Ratable, but the Real Problem
  • 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.

53
Spine 20063111561162
54
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.

55
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.

56
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
57
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

58
Final Answer page 357 The Actual Rating
59
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).

60
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61
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

62
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.

63
Errata Page 15
64
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)?
65
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

66
GAF 51 70, Usually treated as outpatients
67
GAF 1-40 USUALLY Hospitalized GAF 41-50
Usually require intensive outpatient therapy and
monitoring To assess
safety issues and the need for hospitalization.
68
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)

69
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)

70
PIRS pages 358-360
71
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. Cant 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) 23 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.

72
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77
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)

78
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79
Final Answer page 357 The Actual Rating
80
The End Thank You
80
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