The “Complete” IME
C. Donald Williams MD CGP
Integrating file review, literature
references, interview findings, the
MMPI-2, the SIRS, or what I have
learned from 31 years of mistakes
1
2
Why this presentation?
• Uneven quality of psychiatric IME’s “in the
field”
• Human cost—denial or delay of treatment
with damage to individuals and families
and broader cost to community
• Economic waste—unnecessary litigation
• Aim to set a new practice standard
3
Prerequisites for excellence
• Diligence
• Attention to detail
• Humaneness
• Moral clarity
• Ingenuity
–
From Commonwealth Club lecture by Atul Gawande, MD Professor of Surgery, Harvard
Medical School—transcript included with permission of Radio Australia
4
The “complete” IME…
• Detailed line by line record review of…
– All IME’s
– All medical treatment, PCE’s, legal records
– Surveillance videos—minute by minute
• Detailed interview—90-120 minutes
• Psychological testing
– MMPI-2
– SIRS, other self report tests e.g. BDI-II, PHQ-9
• Logical synthesis of all elements
• Some relevant literature references
5
Why “complete” IME’s are needed
• High stakes and/or
• Big file and/or
• Conflict of opinion with sides dug in
and/or
• Poorly written prior IME’s and/or
• When opinion will be challenged as a
matter of policy of other side
6
Clarity of contract with client
• Clear client expectations, i.e. no shaded
•
•
outcomes
Assignment letter with questions
Resources you need
–
–
–
–
Knowledge and experience
Time—nights and weekends
Staff to proofread
Commitment of your practice – not a “sideline”
• Time line for completion and delivery
7
Informed consent
• Explicit examinee notification
– Non-confidentiality
– Who gets a copy of the report
– No doctor patient relationship offered
– Describe length of evaluation
• Respectful of examinee
• Query re: understanding
8
Psychological testing
• Self report questionnaires such as BDI-II,
Zung, and PHQ-9 easily challenged in
litigation, but useful for treatment eval.
• Objective and validated instruments
stronger.
– MMPI-II
– SIRS (Structured Interview of Reported Symptoms)
– TOMM (Test of Malingered Memory-neuropsychology)
9
One of today’s goals:
develop surface familiarity
with MMPI-2 and SIRS-Not to teach their use
(also to recognize poor use of
MMPI)
10
For quick overview of
psychological testing, Google -‘Mmpi-2 profile psych 427’
[http://www.csun.edu/~gk45683/P427%20-%2014%20%20Structured%20Personality%20Tests%20-%20bw.pdf]
“Structured Personality Tests
Psych 427-Psychological Testing
Gary S. Katz Ph.D.”
11
MMPI-2
• Validity scales
• Clinical scales
• Supplementary scales
• All have raw scores which are converted
to statistically defined T scores—
– A T score of 90 has the same statistical
meaning from one scale to another
– Scores of >65 are interpretable
12
MMPI-2
• Validity scales -advantage over self report
inventories—what was the “response set of test
taker ?”
– VRIN-variable response inconsistency to paired items
– TRIN-measure of “fixed responding” to paired items
– F-“inFrequency scale” higher scores=symptom exaggeration in
normal population
– Fb-“inFrequency back scale” items 371-567 normals
– Fp-“inFrequency” scale for psychiatric inpatients
– FBS—primarily related to head injury >29 suggests non-credible
– L -higher scores=overly virtuous/naïve presentation-the “look
good” profile
– K -higher scores=unintentional underreporting
13
The numbers represent
Clinical scales
1—Hs (hypochondriasis)
2—D (Depression)
3—Hy (Hysteria)
4—Pd (Psychopathic
deviate)
5—Mf (Masculine/feminine)
• 6—Pa (paranoia)
• 7—Pt (psychasthenia
“anxiety with obsessive
compulsive features”)
• 8—Sc (schizophrenia)
• 9—Ma (mania)
• 10—Si (social
introversion)
14
Restructured Clinical Scales
• Developed to capture demoralization, identify
•
•
the “core components” of the clinical scales,
related to but distinct from the Clinical scales.
RCd, RC1 through RC9, each capturing the
essential component of each scale, without the
demoralization component.
Example—RC2lpe identifies depression
separately from demoralization; RC3som
measures somatization separate from
demoralization—will illustrate with clinical
example
15
PSY-5 Scales
• Personality psychopathology: were designed
•
•
•
to measure 5 broad personality traits, on the
more pathologic end of the dimension. There is
a great deal of evidence that these scales have
utility.
AGGR, PSYC, DISC, NEGE, INTR
Stable over 5 years
Do not directly correlate with specific Axis II
diagnoses
16
“The Welsh code is 3”24861’+-70/95: FL+-/K”
What does this mean?
(Hint: Look at numbers, punctuation marks,
letters, and underlines)
17
Welsh code profile T scores= punctuation
marks (numbers)
•
•
•
•
•
100 or more = **
90-99 = *
80-89 = “
70-79 = ‘
65-69 = +
•
•
•
•
•
•
60-64 = –
50-59 = /
40-49 = :
30-39 = #
29 or less—no T
scores below 30
_ joining Welsh symbols means
scores identical
(underlines)
18
To interpret an MMPI-2
• First establish validity by examining validity
•
•
•
•
scale pattern, then, if valid….
Code types are patterns of scale elevations that
have statistically demonstrated high correlations
with clinical findings— more reliable than
single scale interpretations
Then interpret profile according to T scores,
starting with highest
Examine RC scales (purer content than clinical)
Examine PSY-5 scales to assess stable traits
19
Validity and content scales same person 2008 & 2007 after one year of group and individual
psychotherapy—note reduction of FBS and major reductions in scales 1 and 3
20
Restructured clinical (RC) scales same person 2008 & 2007—following one year of group and
individual psychotherapy. Note reduction in lpe (depression) and som (somatization)
21
PSY-5 scales same person 2008 & 2007—Note relative stability of traits, although INTR is showing
improvement with group and individual psychotherapy which we would expect with personality
change.
22
Structured Interview of Reported
Symptoms
• Best validated measure of Malingering,
especially when combined with MMPI-2.
• Structured Interview of Reported Symptoms,
•
Richards R et al (1992) copyright PAR, Inc.
“Structured Interviews and Dissimulation,”
Rogers R, in Clinical Assessment of Malingering
and Deception, Rogers R Ed, 2nd Edition,
Guildford Press (1997) pp. 320-327.
23
24
25
26
27
Record review
• Have staff arrange file according to file
type (IME, Medical treatment records,
Physical therapy records, Vocational
records and Legal correspondence) and
date, oldest to newest
• List every file, with content summary
when germane to psychiatric opinion
28
Report templates
• Create your own, modify with experience
• Save time
• Prevents omission of important data
• Standardizes presentation format
29
“Surveillance”
uses and misuses
30
“Surveillance”
• “An addendum letter dated September 28,
2004 prepared by Michael B. M.D.
commented on surveillance videotapes.
Dr. B. stated that he did not
recognize the claimant. However, he
nevertheless concluded that he suspected
that she was not truthful in all aspects of
her physical examination. On this basis he
diagnosed probable malingering.”
31
Surveillance
documentation
• “Then Video Track 2 appears on the screen which is
visualized from 00:00 through 01:29 in which she
appears to be adjusting a garden hose and repositioning
a yard sprinkler. Nothing is visualized from 01:35 until
02:10 when she emerges from behind a building and
walks over in the direction of the utility building. She
wanders around, limping, and then disappears behind
the utility building at 02:39. Nothing is visualized
between 02:39 until 02:54 when there is a break in the
video sequence and she takes another drink from a
bottle. She disappears inside the utility building at
03:00. Nothing is visualized from 03:00 until 04:50.
That concludes Video Track 2.”
32
Sample surveillance
video
33
Surveillance commentary—
with literature citations for support
• “In addition, information obtained from video surveillance is inherently
•
•
subjective with no proven inter-rater reliability or statistical validation. This
particular sequence has particularly significant shortcomings. It is a heavily
edited, discontinuous, extremely small sample, and is of far less significance
than a comprehensively validated psychological test instrument that has
been administered to millions of people. Furthermore, there are no articles
in the Journal of Occupational and Environmental Medicine that address the
use of surveillance videos in malingering. In a search of PubMed (the
database of all scientific health literature maintained by the National Library
of Medicine and the National Institutes of Health there are only two articles,
neither related to the issues in this case.[1] Consequently, it is my opinion
that the surveillance videos are without substance. By contrast, the MMPI-2
and the SIRS have established validity and inter-rater reliability in the
detection of malingering and factitious disorders.”
[1] Westbrook LE et al. Nonepileptic seizures after head injury. Epilepsia.
1998 Sep;39(9):978-82.
PMID: 9738677 [PubMed - indexed for MEDLINE]
Kurlan R et al. Movement disorder in reflex sympathetic dystrophy: a case
proven to be psychogenic by surveillance video monitoring. Mov Disord.
1997 Mar;12(2):243-5. No abstract available
34
Integration of records, interview,
literature references, and testing
Clarity and completeness
35
Sample assignment question
response
•
•
“Your diagnosis for conditions causally related to this industrial
injury.”
Response: “The diagnoses Major Depressive Disorder, single
episode, moderate/severe and Pain Disorder associated with
psychological factors and a general medical condition are causally
related on a medically more probable than not basis to the industrial
injury. Although Mr. Hxxxx has had serious problems with adjustment on
account of his personality disorder throughout his entire life, he has not
experienced a Major depression prior to this industrial injury. His
personality disorder and its attendant rigidity rendered him significantly
more vulnerable to the development of a Major depression because he
has little adaptive capacity. There is a strong characterologic quality to
his depressive disorder, but he satisfies DSM IV criteria for the diagnosis
of MDD, and it is necessary to adhere strictly to diagnostic criteria in
order to maintain consistency. Whether or not a claimant has
personality traits that are irritating should not be allowed to
interfere with an objective rating and diagnostic process.”
36
Category ppd ratings discussion
• “Mr. Hxxxx presently reflects an impairment that most closely corresponds to a (high)
•
Category 4 level of mental health impairment, essentially just below the cutoff for a
Category 3 rating. I do not believe that he is fixed and stable, however, and this
estimate is my impression of his current impairment. With both orthopedic and
psychopharmacologic treatment (but not with psychotherapy) he could improve to a
Category 2 level, although the chance of this degree of improvement is probably
less than 30%; it is more likely that with effective orthopedic intervention and
antidepressant medication (prescribed by his regular physician) that he would plateau
at Category 3. His pre-existing level of mental health impairment most closely
corresponds to Category 2. Because the criteria as defined in WAC 296-20-340
utilize archaic language and because the rating scale has not been validated, and
because as a result consistency in mental health impairment ratings has been difficult
to achieve in the industrial insurance arena, I excerpted a table from a recent
article[1] that proposes a correspondence among two validated rating scales and the
WAC ratings. I boldfaced and underlined the criteria satisfied by Mr. Hxxxx under
each of the three rating scales.”
[1] Williams CD. “Psychiatric disability assessments.” Psychiatric Annals, 2006;36(11)
774-783
37
GAF 21-40
AMA Guide Class
4—Marked
Impairment
WAC 296-20-340
Some impairment in reality
testing or communication
(e.g., speech is at times
illogical, obscure, or
irrelevant) OR major
impairment in several
areas, such as work or
school, family relations,
judgment, thinking, or
mood (e.g., depressed
man avoids friends,
neglects family, and is
unable to work; child
frequently beats up younger
children, is defiant at home,
and is failing at school).
Behavior is considerably
influenced by delusions or
hallucinations OR serious
impairment in
communication or judgment
(e.g., sometimes
incoherent, acts grossly
inappropriately, suicidal
preoccupation) OR
inability to function in
almost all areas (e.g., stays
in bed all day; no job,
home, or friends).
Impairment levels
significantly impede
useful functioning
Very poor judgment, marked
apprehension with startle reactions,
foreboding leading to indecision,
fear of being alone and/or
insomnia; some psychomotor
retardation or suicidal
preoccupation; fear-motivated
behavior causing moderate
interference with daily life;
frequently recurrent and disruptive
organ dysfunction with pathology
of organ or tissues; obsessivecompulsive reactions causing
inability to work with others or
adapt; episodic losses of physical
function from hysterical or
conversion reactions lasting longer
than several weeks;
misperceptions including sense
of persecution or grandiosity
which may cause domineering,
irritable or suspicious behavior;
thought disturbance causing
memory loss that interferes with
work or recreation; periods of
confusion or vivid daydreams that
cause withdrawal or reverie;
deviations in social behavior
which cause concern to others;
lack of emotional control that is
a nuisance to family and
associates; moderate disturbance
from organic brain disease such as
to require a moderate amount of
supervision and direction of work
day activities.
38
Summary
•
•
•
•
•
•
Detailed and documented record review
Thorough interview
Appropriate psychological testing and analysis
Literature references to support conclusions
Carefully explained rationale for conclusions
Objectivity, detail, and careful reasoning without
prejudice
=
Superior IME
39
• Further Issues and Questions?
40