Presenter: Dr Michael Epstein. Program

Transcription

1 The GEPIC -Is it a bird, is it a plane, is it Superman? It s the Introduction to the Guide for the Evaluation of Psychiatric Impairment for Clinicians Presenter: Dr Michael Epstein Program What are we trying to do? How do we do it? Why do we do it? How did we get to the GEPIC? How did I become involved? What are the alternatives to the GEPIC? Why is the GEPIC preferred What do we measure-what do we exclude? What does apportionment mean? Some examples. FAQs 1

2 A typical case history Joe, 40 year old welder-history of depression injured in a motor accident, burns, grafts, and multiple fractures Rehabilitation, returned to work in the office. 3 years later extensive scarring with skin grafts, pain, limited mobility, has psychological symptoms and many social problems Has psychological and physiotherapy treatment. After 3 years applies for an impairment benefit. Victorian Transport Accident Act SECT 47 Impairment benefit Impairment more than 10 %. the impairment benefit is the amount shown in the table where "D" is the person's degree of impairment expressed as a number. Impairment of 30% or more benefit and can make common law claim. Impairment 50% or more then benefit + loss of earnings until retirement. 30% = $ Degree of impairment Impairment benefit 10% or less 0 11% 19% $ ((D 10) $1000) 20% 49% $ ((D 20) $1500) 50% 59% $ ((D 50) $1750) 60% 79% $ ((D 60) $2000) 80% 89% $ ((D 80) $4000) 90% 99% $ ((D 90) $8000) 100% $

3 What is the process? physical and psychiatric impairment determined. Psychiatric impairment using GEPIC [ Whole Person Psychiatric Impairment: Has to be apportioned (more later) 1.Impairment unrelated to the accident? Joe has a history of depression. 2.Impairment secondary to physical injury? 3.Joe has burns, grafts and multiple fractures causing more depression 4.Impairment not secondary to physical injury, ( pure mental harm )? Final psychiatric impairment is the latter. Impairment vs. Disability Impairment: an impairment is any loss or abnormality of psychological, physiological, or anatomical structure or function WHO. Permanent impairment is impairment that has become static or well stabilised with or without medical treatment and is not likely to remit despite future medical treatment. Disability: a disability is any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being WHO. A concert pianist loses a little finger Impairment 1% but Disability 100% 3

4 What is psychiatric impairment? A psychiatric impairment is any loss of psychological or mental function. mental function impairment includes: Speech Perception Judgment Mood Thinking Intelligence Behaviour How does the psychiatrist assess impairment of mental function? Interview and review of documentation [ accident [ current condition and treatment Mental State Examination [ diagnosis(es) [ unrelated diagnoses [ stability and prognosis 4

5 What use is made of the MSE? correlate GEPIC descriptors to MSE use GEPIC method to find Whole Person Impairment (WPI) Subtract impairment unrelated to accident subtract impairment due to consequential mental harm Joe s Psychiatric Impairment Diagnoses PTSD Depression secondary to scarring, pain and physical limitations Major Depressive Disorder in remission Whole Person Impairment WPI = 30% WPI unrelated impairment (0%) WPI impairment secondary to physical injury(15 %) Final psychiatric impairment is in median Class 2 =15% i.e. 30%- (15%+0%) 5

6 Common Psychiatric Disorders: Motor Accidents Acute stress disorder (acute stress disorder and post-traumatic stress disorder may occur in the absence of physical injury) Post-traumatic stress disorder Generalised anxiety disorder Adjustment disorder with depressed mood (and/or anxiety) Panic disorder Agoraphobia Obsessive compulsive disorder Major depressive disorder Pain disorder Substance use disorder Persistent depressive disorder (DSM 5) Why do we assess psychiatric impairment? Statutory schemes as a: Threshold trigger Means for determining level of benefits A reliable means of measuring psychiatric percentage impairment is critical for users, tribunals and claimants. If there is no reliable method then psychiatric injury may be excluded from statutory schemes. This has happened in NZ and in SA for WorkCover lump sum benefits All jurisdictions treat mental injury adversely compared with physical injury:? due to prejudice and fears of cheating ( can t people make up symptoms and fool the assessor?) Potential cost blowouts 6

7 Reasons for Measurement of Psychiatric Impairment the Victorian Experience Gate-keepers Victorian Accident Compensation Act To determine serious injury To determine compensation for noneconomic loss Victorian Transport Accident Act To determine impairment benefits To allow for common law claims Threshold for personal injury claims re Victorian Wrongs Act (Civil iability legislation) Any sensible method of measuring psychiatric impairment Must Appear to measure impairment Be based on the MSE Be easily and rapidly administered Produce a percentage score Reliable; different examiners produce similar results Be resistant to cheating Equitable seems fair and not designed to force claimants below a threshold. Have broad acceptance as fair and reasonable Be defensible in court and tribunal settings Impairment: reduction or loss of a physical/mental function and is determined by clinicians Disability: reduction in ability arising from an impairment and is determined by the courts 7

8 Compensable Psychiatric Impairment There usually needs to be a diagnosable psychiatric disorder. The disorder must lead to impairment. There has to be a clearly established link between the accident and the psychiatric disorder. The psychiatric disorder is not secondary to physical injury, in South Australian terms consequential mental harm. Problems with measuring psychiatric impairment No gold standard Blurring of impairment and disability Relies on self-reporting Overlap between neurological injury and psychiatric injury Pain disorders AND- [ 8

9 Any guide is built on shifting sands: an inherent absurdity in collapsing complex behaviour into a single number Experience of AMA Guides The Victorian Accident Compensation Act 1985 used the American Medical Guides to the Evaluation of Permanent Impairment 2 nd Edition. Chapter 12 Mental and Behavioral Disorders Table 1 9

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11 Advantages of AMA 2 Measured impairment (mainly) Relied on mental state examination Easily administered, did not rely on a questionnaire Produced a percentage score Excitement reigned but! Disadvantages of AMA2 Ability is a measure of disability, Potential is crystal ball gazing No definitions of functions and no descriptors provided No method of combining scores Some classes too large e.g. Class % No reliability - scores ranged from 5%-60% for the same person This is where I came in! 11

12 How I see myself Michael Epstein How my friends see me 12

13 How did I get involved Psychiatrist in Hospitals Prisons Private practice Worked with children, adolescents, adults Interested in stress related conditions Began doing medico-legal work Interested in dancing - As they say in this field it takes two to tango! Co-authored book about stress breakdown Wrote A DIY Guide to PSYCHIATRIC ASSESSMENT Co-authored GEPIC Has trained more than 150 psychiatrists in its use Has website as resource for people who do this work. 13

14 The journey to the GEPIC 3 of us, Drs Nigel Strauss,George Mendelson and myself improved AMA 2 writing The User s Manual in Several editions Never formally recognised Often cross-examined on it! The User s Manual had: Definitions Descriptors Median method for combining scores The Result Reliability and consistency emerged Courts accepted psychiatric impairment assessments Still some concerns about reliability of low levels of impairments Peace returned, we all gave a collective sigh of relief. 14

15 AMA4 & AMA5 AMA 4 was first published in 1994 but did not appear on the horizon until 1997 when the Victorian Government legislated to replace AMA 2 with AMA4. AMA 5 was published in November

16 Table - Chapter 14 Mental and Behavioral Disorders AMA 4 &5 Area or aspect Of functioning Activities of daily living Social functioning Concentration Adaptation Class 1: No impairment No impairment is noted Class 2: Mild impairment Impairment levels are compatible with most useful functioning Class 3: Moderate impairment Impairment levels are compatible with some, but not all, useful functioning Class 4: Marked impairment Impairment levels significantly impede useful functioning Class 5: Extreme impairment Impairment levels preclude useful functioning Major problems 1 Measures disability not impairment 3 of the 4 functions are measures of disability, not impairment activities of daily living social functioning Adaptation Has no method for combining scores 16

17 Major problems 2 Astonishingly - No Percentages!!! The explanation was: 1. no precise measures of impairment in mental disorders. 2. percentages implies a certainty that does not exist 3. likely to be used inflexibly by adjudicators 4. No data exist that shows the reliability of the impairment percentages 5. It would be difficult for Guides users to defend their use in administrative hearings!! What were they thinking! So how does AMA5 rate as a rating guide Does it measure impairment: NO Easily and rapidly administered?- NO Obtains a percentage score? NO Reliable?- POSSIBE Cheating?-POSSIBE Accepted?- NO Equitable - NO 17

18 Result In the real world the AMA Guides chapter on mental and behavioural disorders was unusable. We all had to scramble to produce something workable. The alternative was that psychiatric injury would not be compensated, not a real world option. The Consequences Victoria excised Chapter 14, User s Manual updated leading to The Clinical Guidelines to the Rating of Psychiatric Impairment (1997) excising ability and potential and improving definitions and descriptors. We revised this to produce the Guide to the Evaluation of Psychiatric Impairment for Clinicians, the GEPIC (2006). anguage updated, more consistent, some descriptors added. 18

19 New South Wales and New Zealand New South Wales removed Chapter 14 Psychiatric Impairment Rating Scale developed based on Chapter 14 with added descriptors, percentages and the median method as used in Victoria. Subsequently adopted in WA, Tasmania and Queensland. New Zealand ACC User Handbook to AMA4 published July 2002 did likewise but with different descriptors and percentage ranges and no combining method. Other Guides The Comcare Guides took a different approach. eg A psychiatric impairment of 15% requires. Any one of the following accompanied by a need for some supervision and direction in Activities of Daily iving: reactions to stressors of daily living with minor loss of personal or social efficiency; lack of conscience directed behaviour without harm to community or self; minor distortions of thinking The Guides To The Assessment Of Rates Of Veterans Pensions, the GARP, - measures disability 19

20 Comparison of the GEPIC, PIRS and NZ ACC Guide PIRS Method Behavioural consequences of psychiatric disorder are assessed on six scales, each of which evaluates an area of functional impairment: 1. Self care and personal hygiene 2. Social and recreational activities 3. Travel 4. Social functioning (relationships) 5. Concentration 6. Employability Impairment in each area is rated using class descriptors. Classes range from 1 to 5, in accordance with severity. The median class is selected, each class number is then added. A conversion table combines these numbers to produce a WPI 20

21 The PIRS example of 1 function Table 11.1: Psychiatric impairment rating scale Self care and personal hygiene (my emphasis) Class 1 (0-3%) No deficit, or minor deficit attributable to the normal variation in the general population Class 2 (4-10%) Mild impairment: able to live independently; looks after self adequately, although may look unkempt occasionally; sometimes misses a meal or relies on take-away food. Class 3 (11-30%) 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. Class 4 (31-60%) impairment: Needs supervised residential care. If nsupervised, may accidentally or purposefully hurt self. Class 5 (61-100%) Totally impaired: Needs assistance with basic functions, such as feeding and toileting. Problems with PIRS Different versions motor accidents/workcover. Forced to measure disability rather than impairment. Other descriptors discouraged(no room for clinical judgment) Conversion table means a person who scores class 3 for all 6 functions (6x3=18) has an impairment of only 22%! Maximum 30% requires classes if in class 4, then a score of 18 becomes 34%. FURTHER PROBEMS The author established his own epirs website where you pay and can try different combinations to get the best score. 21

22 ets pause for breath Despite the best efforts of the authors of the AMA Guides we slowly and painfully cobbled together something from the wreckage, it was making sausages. But it worked Then the AMA Guides 6 th Edition appeared The American Medical Association Guides to the Evaluation of Permanent Impairment 6 th Edition 22

23 How did they do it? Widespread dissatisfaction with AMA 4 & AMA 5 lead to AMA 6 AMA 6 appears scientific. produces a percentage. Method The authors took 3 measures, BPRS, part of the PIRS and the GAF arbitrarily allotted percentages. Embarrassingly, one the Global Assessment of Functioning (GAF) in DSM IV has been discredited 23

24 Global Assessment of Function Scale (GAF) from DSM IV-TR AMA6 reasons for using the GAF in DSM IV TR: The GAF has inter-rater reliability Widely used in clinical practice and hundreds of research studies imitation combining functional and symptom severity into one scale. Remedied by also using the BPRS DSM 5 reasons for dropping the GAF Conceptual lack of clarity: symptoms, suicide risk and disability combined Questionable psychometrics in clinical practice Combining Method Each of the 3 measures has been arbitrarily allotted a percentage scale, The 3 are ranked, the middle number is the final percentage. So BPRS 30% PIRS 5% GAF 10% The Final Percentage is 10% 24

25 and by the way These diagnoses do not count in AMA 6! adjustment disorders somatoform disorders dissociative disorders personality disorders psychosexual disorders factitious disorders substance use disorders (affective or other mental disorders due to substance-abuse are not rated sleep disorders (covered in chapter 13) dementia and delirium (chapter 13) mental retardation psychiatric manifestations of traumatic brain injury (chapter 13) THE GUIDE TO THE EVAUATION OF PSYCHIATRIC IMPAIRMENT FOR CINICIANS (GEPIC) Prepared by M.W.N. Epstein, G. Mendelson, N.H.M. Strauss Revised December

26 Principles of Psychiatric Impairment Assessment 1. The mental state examination as used by consultant psychiatrists, is the prime method of evaluating psychiatric impairment. 2. Diagnosis among the factors to be considered. 3. Consider other factors - educational, financial, social and family situation. 4. Character and value system of the individual of considerable importance. 5. Motivation for improvement is a key factor in outcome. 6. Review all treatment and rehabilitation methods. 7. Final judgement when history of illness, treatment, rehabilitation and of current mental and physical status and behaviour considered. An example of one of the 6 factors Mood (descriptors only indicative) Mood - a pervasive lasting emotional state Affect is mood noted during the period of the mental state examination. Affect has a number features, including: Range: Variability of emotional expression over a period of time, i.e., if only one mood is expressed over a period of time, the affective range is restricted. Amplitude: Stability: Amount of energy expended in expressing a mood, i.e., a mild amplitude of anger is manifested by annoyance and irritability. Slow shifts of mood are normal. Rapid shifts (affective lability) may be pathological. Appropriateness: The fit (or congruency) between the affect and the situation. Quality of Affect: Suspicious, sad, happy, anxious, angry, apathetic. Relatedness: Ability to express warmth, to interact emotionally and to establish rapport. 26

27 Mood Class Impairment Description 1 0-5% Normal to Slight - relatively transient expressions of sadness, happiness, anxiety, anger and apathy; - normal variation of mood associated with upsetting life events % Mild - mild symptoms: some or all of the below mild depression; subjective distress leading to some mild interference with function; reduced interest in usual activities; some days off; reduced social activities; fleeting suicidal thoughts; some panic attacks; heightened mood; - may experience feelings of derealisation or depersonalisation. Mood (cont ) % Moderate Impairment - moderate symptoms: some or all of the below: frequent anxiety attacks with somatic concomitants; inappropriate self-blame and/or guilt; persistent suicidal ideation or suicide attempts; marked lability of affect; significant lethargy; social withdrawal leading to major problems in interpersonal relationships; anhedonia; appetite disturbance with significant weight change; psychomotor retardation/agitation; hypomania; severe depersonalisation % Moderately - cannot function in most areas constant agitation; - violent manic excitement; repeated suicide attempts; - remains in bed all day; extreme self neglect; extreme anger /hypersensitivity; - requires supervision to prevent injury to self or others. 5 Over 75% - severe depression, with regression requiring attention and assistance in all aspects of self care; - constantly suicidal; - manic excitement requiring restraint. 27

28 The GEPIC Table Class of Impairment Percentage of Impairment 0% to 5% 10% to 20% 25% to 50% 55% to 75% over 75% MENTA FUNCTION Intelligence (Capacity for understanding) Normal to Slight Mild Moderate Moderately Thinking (The ability to form or conceive in the mind) Normal to Slight Mild Moderate Moderately Perception (The brain's interpretation of internal and external stimuli) Normal to Slight Mild Moderate Moderately Judgement (Ability to assess a given situation and act appropriately) Normal to Slight Mild Moderate Moderately Mood (Emotional tone underlying all behaviours) Normal to Slight Mild Moderate Moderately Behaviour (Behaviour that is disruptive, distressing or aggressive) Normal to Slight Mild Moderate Moderately GEPIC severity ratings ow Range Mid Range High range Class 1 0-1% 2-3% 4-5% Class % 14-16% 18-20% Class % 35-40% 45-50% Class % 65-70% 70-75% Class % 85-90% % Each class is divided into levels of severity; Severity levels in classes below the median class are promoted to ow range in the median class. Severity levels in classes above the median class are promoted to High range in the median class. The median level of severity is then determined leading to selection of the appropriate percentage range in the median class. 28

29 The GEPIC Table with severity ratings Class of Impairment Percentage of Impairment 0-5% 10% to20% 25 to 50% 55% to 75% Over 75% MENTA FUNCTION Intelligence (Capacity for understanding) Thinking (The ability to form or conceive in the mind) Normal to Slight Normal to Slight RANGE RANGE RANGE RANGE RANGE M M M M M H Mild H Moderate H Moderately H H M M M M M H Mild Moderate Moderately H H H H Perception (The brain's interpretation of internal and external stimuli) Normal to Slight M Mild M Moderate M Moderately M M H H H H H Judgment (Ability to assess a given situation and act appropriately) Normal to Slight M M M M M H Mild Moderate Moderately H H H H Mood (Emotional tone underlying all behaviours) Behaviour (Behaviour that is disruptive, distressing or aggressive) Normal to Slight Normal to Slight M M M M M H Mild Moderate Moderately H H H H M Mild M Moderate M Moderately M M H H H H H RANGE = OW () MID (M) HIGH (H) Determining Whole Person Psychiatric Impairment 6 mental functions in 5 classes Each function is allotted a class consistent with the MSE. e.g MSE no perceptual problems yet Class 2 in GEPIC! Determine the median class; the median number is the middle number , the middle number is , the middle number is , the middle number is 2. The final percentage lies within the range of the median class. Class 2 is between 10-20%. Use severity ratings to locate impairment in class 29

30 GEPIC Update 150 psychiatrists trained in its use I have done at least impairment assessments using the GEPIC and its precursor More than impairment assessments done using GEPIC Advantages Emerges from the clinical interview so takes little time Different assessors get similar scores for the same person Widely accepted In Victoria GEPIC used for motor accident, WorkCover and Wrongs Act claims a major advantage. Disadvantages Class % too large ess precise at low levels of impairment. Adrian - Worked Example 1 Adrian - 47 year old married man with three children. no significant individual or family health problems. process worker in a food factory for 5 years. THE ACCIDENT Motor cycle accident on weekend. Fractured right femur, multiple abrasions SUBSEQUENT PROGRESS hospital for a week and had a surgical fracture repair. visited by his manager and workmates. Rehabilitation for 4 weeks and had further physiotherapy off work 8 weeks. returned to work on a graduated return to work program. saw GP medication for anxiety, sleep and depression saw psychologist and continued with physiotherapy resumed production work but could not cope and ceased work Struggling with pain and reduced mobility 30

31 CURRENT CONDITION pain constant and limited right leg mobility. jumpy and on edge. twice weekly nightmares and daily flashbacks about accident ruminates most days. mood fluctuates markedly like walking on egg shells confused and hesitant, thoughts about the accident are distracting. sex life ceased because of lack of libido and pain. irritable with his family. marriage in trouble His children avoid him tearful at times. ceased all his recreational activities and can t work isolated. uncomfortable in crowds and supermarkets. avoids leaving home prefers not to drive because it frightens him. sounds seem louder and lights brighter. gambling on the internet and losing significant amounts of money. Adrian - Diagnostic Formulation and MSE leading to GEPIC Impairment MENTA STATE EXAMINATION sad and tearful limp favouring his right leg co-operative good eye contact well orientated depressed and anxious. perception disturbed. Cognition normal. spoke slowly, rate and volume fluctuated. problems with memory and concentration. No formal thought disorder, delusions or hallucinations judgment poor behaviour significantly disturbed. DIAGNOSTIC FORMUATION 1. Permanent disability of right leg associated with chronic pain. 2. Post traumatic stress disorder 3. Chronic Adjustment Disorder with Depressed Mood 31

32 Adrian - GEPIC Assessment Using descriptors in GEPIC the classes selected are: Intelligence Class 1 nil Thinking Class 3 moderate. Manifestations of thought disorder, to the extent that most clinicians would consider psychiatric treatment indicated: problems with concentration due to Intrusive thoughts, marked disruption of the stream of thought due to significant memory problems were diminished concentration Perception Class 2: mild persistent heightened, dulled or blunted perceptions of the internal and external world, but with mild but notable interference with function Judgment Class 3 misjudging social, work and family situations repeatedly leading to some disruption in relationships, occupational settings, living circumstances and financial reliability, gambling Mood Class 3 marked lability of affect; significant lethargy; social withdrawal leading to major problems in interpersonal relationships; anhedonia Behaviour Class 3 persistent behaviour that has some adverse effect on relationships or employment Class of TABE 1: EVAUATION OF PSYCHIATRIC IMPAIRMENT Impairment Percentage of Impairment 0-5% 10% to20% 25 to 50% 55% to 75% Over 75% MENTA FUNCTION Intelligence (Capacity for understanding) Normal to Slight RANGE RANGE RANGE RANGE RANGE M M M M M Mild Moderate Moderately H H H H H Thinking (The ability to form or conceive in the mind) Normal to Slight M Mild M Moderate M Moderately M M H H H H H Perception (The brain's interpretation of internal and external stimuli) Normal to Slight M Mild M Moderate M Moderately M M H H H H H Judgment (Ability to assess a given situation and act appropriately) Normal to Slight M Mild M Moderate M Moderately M M H H H H H Mood (Emotional tone underlying all behaviours) Normal to Slight M Mild M Moderate M Moderately M M H H H H H Behaviour (Behaviour that is disruptive, distressing or aggressive) Normal to Slight M Mild M Moderate M Moderately M M H H H H H RANGE = OW () MID (M) HIGH (H) 32

33 Adrian - Whole Person Psychiatric Impairment (WPI) Classes Classes in order Median Class is Class 3 (25%-50%) His severity ratings are rounded up to Class 3 M M M M - in order - M M M M His median severity is M, therefore %. He is at the top of the range. He has a WPI of 40%. Apportionment has not yet been done Exceptions from the rule Median number may not be a whole number e.g , the median number is 1.5 In this situation the percentage is the bottom of the next highest class, here to class 2 and 10% percent. If Adrian had scored then his median score is 2.5. He is then automatically in Class 3 but at the lowest level i.e. 25%. His WPI is 25%. If series skewed, e.g , the median number is 1 but the impairment may be up to 10 percent. This rarely if ever occurs or are not skewed series 33

34 Overlap Between Psychiatric and Neurological Impairment Acquired brain injury: impairment involves two disciplines, neurology and psychiatry. Cognitive Dysfunction and Behavioural Disturbance can be measured using Chapter 4 AMA 5 and/or the GEPIC Strong likelihood of overlap. Behavioural disturbance best measured using Chapter 4 Behavioural disturbance may be a manifestation of physical injury and is consequential mental harm. It may be counted using the GEPIC if there is no TBI. Emotional or Behavioural Impairment Chapter 4 table 3 - AMA 4 & 5 Impairment Description Mild limitation of daily social and interpersonal functioning. Moderate limitation of some but not all social and interpersonal daily living functions. limitation impeding useful action in almost all social and interpersonal daily living functions. limitation of all daily functions requiring total dependence on another person. Percentage impairment of the whole person

35 Chronic Pain Disorder Pain after an injury usually diminishes with time Characteristics of Chronic Pain Disorder: initial injury was often trivial pain is spreading or has spread insufficient organic pathology associated with psychiatric symptoms increasing dysfunction focus of clinical attention Impairment due to pain cannot be directly assessed but concommitants of pain, e.g. depression can be measured Why did South Australia choose the GEPIC? The choice was between: The PIRS AMA 6 The GEPIC 35

36 How does PIRS rate as an impairment guide? Does it measure impairment: NO Easily and rapidly administered?- NO Obtains a percentage score? YES Reliable?- POSSIBE Cheating?-EASY Equitable - NO Defensible in court and tribunal settings- YES Controversial - YES Does it seem to do the job YES How does AMA6 rate as an impairment guide? measures impairment? ONY PARTIAY easily and rapidly administered? NO Can a percentage figure emerge? YES Reliable? NOT SURE Cheating?- POSSIBE Equitable? NO Defensible in court and tribunal settings- YES Does it seem to do the job YES Is it any good - NO 36

37 How does GEPIC rate as an impairment guide Does it measure impairment: YES Easily and rapidly administered?- YES Obtains a percentage score? YES Reliable?- POSSIBE Cheating?-UNIKEY Equitable YES Controversial - NO Defensible in court and tribunal settings- YES Does it seem to do the job YES Differentiating pure mental harm from consequential mental harm The equivalent terms in Victoria are impairment secondary or consequential to physical injury Annotations for Determining Non Secondary Psychiatric impairment: Dr Michael Epstein & Dr Nigel Strauss was developed to assist with this process. Categories 37

38 Category 1 Psychiatric Impairment from a psychiatric injury which is secondary to a physical injury does not count. Category 2 Psychiatric impairment from a psychiatric injury or disorder which has arisen from a previous nonsecondary psychiatric disorder or injury may not be secondary to physical injury. Category 3 Psychiatric impairment from a pain disorder is usually secondary to physical injury. Category 4 A psychiatric impairment from a delayed psychiatric disorder or injury arising from an accident may may not be secondary to physical injury. Category 5 Psychiatric impairment from a psychiatric injury or disorder arising directly from trauma, whether or not there is a physical injury is not secondary to physical injury.. Category 6 Category 7 Category 8 Category 9 Category 10 Psychiatric impairment from a psychiatric injury or disorder, which has arisen within twelve hours of an accident or acute injury, counts. Psychiatric impairment from a psychiatric injury or disorder arising directly from an acquired brain injury is secondary to physical injury. A psychiatric impairment from a psychiatric injury or disorder arising from work place response occasioned by a physical injury is unrelated to the accident. A psychiatric impairment from a psychiatric injury or disorder arising from a complication of treatment for a physical injury is secondary to physical injury A psychiatric impairment from an acute psychiatric injury or disorder which has arisen from an acute exacerbation of a previous physical injury may rarely count as not secondary to physical injury. 38

39 Adrian WPI and Impairment after apportionment Post traumatic stress disorder Major depressive disorder due to arm pain and dysfunction. WPI is in median class 3 at the mid range i.e %. His final impairment is 40%. The assessor has decided that half, 20% of the whole person impairment is consequential mental harm. The impairment due to pure mental harm is 20% Some common examples using Victorian nomenclature 1. Back injury in accident leading to depression secondary to physical injury does not count. 2. Car accident with multiple fractures and PTSD PTSD is not secondary to physical injury and therefore counts. Depression from physical injuries does not count. 3. Car accident as above but husband killed PTSD and that component of the depression from husband s death. Neither is secondary to physical injury and counts. 4. Witnesses son killed by truck Grief, PTSD, all not secondary to physical injury and counts. 5. Car accident Traumatic brain injury TBI marked changes in cognition and behaviour - some insight leading to depression some symptoms traumatisation: Ch 4 re TBI impairment, depression from TBI secondary to physical injury and does not count, symptoms of traumatisation not secondary to physical injury and counts. 39

40 Cardinal Rule The cardinal rule is that any psychiatric impairment secondary or consequential to physical injury from the accident does not count. Apportionment Apportionment and stability are only relevant in the context of impairment assessments. Apportionment refers to separating the impairment assessment into the following categories: 1.Psychiatric Impairment related to the injury: a. Psychiatric Impairment that is pure mental harm i.e. not secondary or consequential to physical injury. b. Impairment from consequential mental harm resulting from a physical injury. 2.Impairment unrelated to the injury. 40

41 Example of Apportionment Rick has OCD and still has treatment. He had a motor accident, almost killed fractures and soft tissue injuries. He has severe PTSD requiring treatment. He develops chronic pain and is depressed. WPI 35% OCD impairment (unrelated) 5% Depression from pain (consequential mental harm) 10% Final impairment is 35 (5+10) 20% His impairment due to pure mental harm is 20% Factors involved in apportionment Impairment is only that seen at the interview, not estimated present before the accident. Impairment separated into: Unrelated impairment Impairment not secondary to physical injury Impairment secondary to physical injury pure mental harm or consequential mental harm Problems with: Neurological/psychiatric overlap eg head injuries Pain Multiple injuries Current unrelated mental illness/exacerbation? 41

42 Impairment unrelated to the injury Impairment unrelated to the accident includes: Pre-existing impairment present at the time of the impairment assessment (e.g. a chronic schizophrenic disorder) Pre-existing impairment - no longer present at the time of the impairment assessment (e.g. a major depressive disorder that was successfully treated and for which there has been no ongoing treatment or symptoms) Pre-existing impairment present at the time of the impairment assessment exacerbated by the accident (e.g. a chronic anxiety disorder) Impairment arisen since the injury and unrelated to the injury (a non-injury related assault leading to the development of a post traumatic stress disorder) Injury from another motor accident. Stability Stability is defined as impairment that will not vary by more than 3% in the next 12 months (American Medical Association Guides to the Evaluation of Permanent Impairment). The issue of stability is very important. The claim can usually only be finalised when the claimant s condition is considered stable. If the injury is not considered to be stable the claimant is left in limbo. 42

43 Stability II The condition is usually stable if: The claimant s accident injury occurred some years previously. If the claimant has had a variety of treatment with no change in symptoms. If the above 2 conditions apply it is unlikely a pain management program will bring about significant change. Although psychiatric or psychological treatment may have been beneficial at some time it is now unlikely to bring about much change (but may prevent further deterioration). Denise Example 2 27 year old full time medical receptionist Defacto no children Enjoys running, cycling, water sports and skiing Motor Accident Commuting in small sedan, hit by truck behind, car pushed into car in front, that driver died. Cut out, conscious, car destroyed. Injuries Fractured pelvis, fractures 3-5, fractured left ribs with haemopneumothorax, fractured right (dominant) humerus. Degloving injury left lower leg. Treatment Hospitalised 3 weeks ORIF pelvis, humerus, fusion 3-5, chest tubes, skin grafts from left thigh. MRSA infection. 43

44 Rehabilitation 3 months inpatient, 1 year outpatient. Physiotherapy, OT, HT, Gym, psychologist. Graduated return to work 9 months after accident. 15 months post accident returns to driving, hours increase to 4 hours 5 days a week. Completes rehabilitation, continues gym program and psychological treatment every 2 weeks. Current Condition Physical Ugly scarring left lower leg Reduced function right arm Pain and stiffness in back Pain in pelvis, concern re children, dyspareunia. No chest pain, significant weight loss Mental Depressed, fatigued, irritable, anxious, anhedonia, frequent suicidal thoughts Memory and concentration problems markedly interfere with ADs Nightmares frequently, flashbacks twice weekly Avoidant, fearful passenger Frequent panic attacks Upset reminders of the accident, blames herself for driver s death Financial and work problems & relationship finished Social Not resumed any recreational activities Conceals scarring Unsociable, had conflict with staff and patients, fired Ceased housework because of pain and lack of motivation,. Current Treatment (4 years since accident) Attended a pain management program with limited success Sees her psychologist every 2 weeks Using medication for pain, anxiety, depression and sleep. Mental State Examination Short, unkempt, walks with a limp, wearing slacks, limited movement of right arm. Speaks slowly, speech fluctuates in range and rate according to level of distress. Thinking Moderate-severe problems with concentration due to intrusive thoughts and obsessional ruminations Mark disruption of the stream of thought due to significant memory problems and diminished concentration persistent delusional ideas with severe pathological guilt 44

45 Perception persistent heightened, dulled or blunted perceptions of the internal and external world, with mild but noticeable interference with function manifested by frequent flashbacks to the accident and by noise and light sensitivity Judgment Moderate-misjudging social, work and family situations repeatedly leading to some disruption relationships, occupational setting, living circumstances and financial reliability. Mood frequent anxiety attacks with somatic symptoms, inappropriate self-blame and/or guilt; persistent suicidal ideation; significant lethargy; social withdrawal leading to major problems in interpersonal relationships; anhedonia; appetite disturbance with significant weight loss. Behaviour Occasional aggressive, disruptive withdrawn behaviour requiring attention or treatment Denise Diagnosis & Impairment assessment Post traumatic Stress Disorder Panic disorder Major depressive Disorder ( partly contributed to by her physical injuries. What is her level of impairment? ook at each function of the GEPIC to determine the appropriate class for each function. Intelligence Class 1 M Thinking Class 3 M Perception Class 2 M Judgment Class 3 M Mood Class 3 M Behaviour Class 4 H 45

46 TABE 1: EVAUATION OF PSYCHIATRIC IMPAIRMENT Class of Impairment Percentage of Impairment 0-5% 10% to20% 25 to 50% 55% to 75% Over 75% MENTA FUNCTION Intelligence (Capacity for understanding) Normal to Slight RANGE RANGE RANGE RANGE RANGE M M M M M Mild Moderate Moderately H H H H H Thinking (The ability to form or conceive in the mind) Normal to Slight M Mild M Moderate M Moderately M M H H H H H Perception (The brain's interpretation of internal and external stimuli) Normal to Slight M Mild M Moderate M Moderately M M H H H H H Judgment (Ability to assess a given situation and act appropriately) Normal to Slight M Mild M Moderate M Moderately M M H H H H H Mood (Emotional tone underlying all behaviours) Normal to Slight M Mild M Moderate M Moderately M M H H H H H Behaviour (Behaviour that is disruptive, distressing or aggressive) Normal to Slight M Mild M Moderate M Moderately M M H H H H H RANGE = OW () MID (M) HIGH (H) Final psychiatric impairment after apportionment Classes in order Median Class 3.. Severity evels MMMH.. Median Severity M WPI 40.% What is her level of impairment due to consequential metal harm 20 % What is her level of impairment due to pure mental harm injury? % 46

47 Difficult cases I Joyce was involved in a transport accident and was uninjured. The other driver was a violent criminal who harass her and threatened her family. She became distraught and suicidal. She jumped from a bridge and has been left with paraplegia and a traumatic brain injury. What is her level of impairment, is it pure mental harm or consequential Difficult cases II Phil, a disability support pensioner with a chronic schizophrenic illness was involved in five separate transport accidents, two of which involved him as a passenger and three as a pedestrian. I was asked to determine his level of impairment related to each accident and then to determine the impairment not secondary to physical injury from each accident. 47

48 Difficult cases III Brian, an accountant, was a pedestrian hit by a car and amongst other injuries had a left below knee amputation. He returned to work two weeks later. He renamed his yacht Foot oose" he resumed riding his bicycle wearing his prosthetic leg he saw a psychologist once for, in his words, "a checkup" what is his level of impairment? Problems with use of the GEPIC a) Incorrect Use of the Guides a) Misunderstanding the median method b) Not choosing one class alone for each function eg Mood is class 2 & 3! a) The Mental State Examination does not correlate with the class chosen eg In MSE no perceptual problems, in GEPIC Perception Class 2! b) Overlap with Neurological Chapter in AMA5 c) Assessing Pain-related Impairment rather than comorbid abnormal mental functioning d) Apportioning impairment secondary to physical injury and impairment that is not secondary to physical injury 48

49 FAQs 1. Why are there gaps between the percentage levels? 2. What about people who don t speak English or who can t speak? 3. Do people need to have a psychiatric diagnosis to be assessed? 4. What is the situation with children? 5. Can people fool the assessor? 6. Why do the Guides use the median rather than average scores? 7. Why doesn t GEPIC use a list of typical symptoms eg. flashbacks 8. Why is it only used by psychiatrists 9. Is there much consistency between assesors? 10. How long does an impairment assesment take? Conclusions 1. Measurement of psychiatric impairment is an important part of all benefits schemes 2. Psychiatric illness can arise from a number of causes including work injury and motor accidents 3. The Guides for the Evaluation of Psychiatric Impairment for Clinicians and its precursor has been used extensively in Victoria since 1997 with ready acceptance. 4. The GEPIC is now required to assess psychiatric impairments for Motor Accident Claims in South Australia. 5. Training in the of the GEPIC will commence soon. 49