I use DragonDictate for writing reports, this can that lead to amusing (even Freudian) errors. I thought you may enjoy these ones from 2013.
He became involved in an altercation with a friend who was eating his dog
He expects to work with the penises in fitting and turning
They were living on their father’s thumb
One brother is a cockroach mixer
She continued to feel miserable and depressed and spoke to her general practitioner and was referred to as a carcass.
Apart from her family she enjoyed running and walking in wet cement weekly.
Her medical practitioner suggested disgusting counseling.
He had an episode of laryngeal spasm and in September the gander lost his voice.
He wore brochures for 3-4 hours per day
He slept with his maternal grandmother in a field for three years
(heading) FANNY MEDICAL HISTORY !!!
He has flown a number of times over the year and has fractured his nose and damaged his left eye.
He and his coffin moved to a unit together.
She had a daughter and had a thyroidectomy which fixed the problem
He and other members of the Battery were fired to Vietnam
He developed a mild adjustment order with regard to the President as a result of his facial scarring
He has a loaded libido and has to be careful with position
His sister is a nurse who lives standing up
Her mother died suddenly of a miserable haemorrhage
He had several more fractures of both wrists on six or seven occasions as a result of his many flights
She was taken to the clinic and x rated.
She became very regressed and was incontinent of faeces and Europe
In November 2013 the Victorian Competition and Efficiency Commission published a draft report with recommendations following its inquiry into aspects of the Wrongs Act 1958. I have taken excerpts from this that are relevant to psychiatrists. See full report
The Commission report stated that to ‘address anomalies, inequities and inconsistencies in the limitations on damages for personal injury and death, that the Victorian Government amend the Wrongs Act 1958 (Vic) to:
Project summary
Individuals with traumatic brain injury experience an initial period of disorientation and inability to lay down new memories. This is known as post-traumatic amnesia (PTA). Patients are generally given very little therapy while in PTA to minimise the risk of agitation. No studies have evaluated the effectiveness of therapy to enhance independence in activities of daily living during PTA.
Funding: $410,000. Funded under the ‘Bench to Bedside’ priority of the Neurotrauma Research Program
Chief Investigator: Professor Jennie Ponsford, Monash University
Commencement date: January 2014.
Anticipated conclusion date: June 2017
Project Aim
To better understand the processes of assessing patients in Post Traumatic Amnesia (PTA) and to evaluate the effectiveness of therapy to enhance independence in activities of daily living provided during PTA.
Benefits of project
Current practice is to minimise therapy during PTA to avoid agitation. This project will explore whether additional therapy in this phase reduces PTA duration and the time to attain functional independence or whether current guidelines to avoid to non-essential therapy are appropriate.
Introducing daily living activities during PTA has the potential to reduce the length of stay in hospital and improve patient outcomes within three to five years.
Duration of PTA is the strongest injury-related measure of long-term functional outcome in survivors of TBI and long-term care costs. Given the importance of PTA as a prognostic indicator following TBI and current lack of understanding of PTA, in terms of both its processes and potential for benefit from therapy, the research will provide world-first invaluable evidence.
As you may remember I have already written about this Act. Despite numerous discussions, pressure from various groups and meetings with representatives of the Transport Accident Commission there were no changes to the bill.
On November 14 2013 the Victorian Government passed the Transport Accident Amendment Bill 2013. The relevant sections for psychiatrists are the following;
TRANSPORT ACCIDENT AMENDMENT ACT 2013
SECT 21
Amendments relating to reimbursement of medical reports
(1) After section 60(2E) of the Principal Act insert —
“(2F) For the purposes of subsection (2)(a), the Commission is not liable to pay as compensation the reasonable costs of medical services that are the provision of a document obtained for medico-legal purposes, or related to medico-legal purposes unless the document—
(a) is requested jointly by the Commission and the person who is injured; and
(b) is provided jointly to the Commission and the person who is injured; and
(c) is provided by a registered health practitioner within the meaning of the Health Practitioner Regulation National Law.
(2G) For the purposes of subsection (2F), a document obtained for medico-legal purposes includes a document obtained for any of the following purposes—
(a) for the purposes of determining the degree of impairment under section 46A, 47(7) or 47(7A);
(b) for the purposes of Part 6 or Division 1 of Part 10;
(c) responding to a decision of the Commission under Parts 3 and 4 or in contemplation of such a decision;
(d) for the purposes of an application under section 77 for a review of a decision, or in contemplation of such an application.
(2H) For the purposes of subsection (2F), a document is not obtained for medico-legal purposes if the document is obtained from a person’s treating medical practitioner.
Amendment of section 93 (common law damages claims for mental injury due to injury or death of tortfeasor)
After section 93(2) of the Principal Act insert —
“(2A) A person who is injured as a result of a transport accident may not recover damages from a person indemnified by the Commission under section 94(1) or from the Commission in respect of a vehicle to which section 96 applies if—
(a) the injury is nervous shock or other mental injury; and
(b) the person was not directly involved in the accident and did not witness the transport accident; and
(c) the mental injury or nervous shock was suffered as a result of the injury or death of another person who was directly involved in the transport accident; and
(d) the transport accident was caused—
(i) in the course of the other person referred to in paragraph (c) committing, or intending to commit suicide; or
(ii) solely or predominantly by the negligence of the other person referred to in paragraph (c).”.
SECT 27
Amendments relating to serious injury applications
After section 93(17) of the Principal Act insert —
“(17A) For the purposes of paragraph (c) of the definition of “serious injury”, a person has a severe long-term mental or severe long-term behavioural disturbance or disorder if that person, for a continuous period of at least 3 years—
(a) has a recognised mental illness or disorder (other than abnormal illness behaviour) as a result of a transport accident; and
(b) displays symptoms and consequent disability that have not responded, or have substantially failed to respond, to known effective clinical treatments provided by a registered mental health professional who is registered under the Health Practitioner Regulation National Law to practice (other than as a student); and
(c) has severely impaired function with symptoms causing clinically significant distress and severe impairment in relationships and social and vocational functioning.”.
Commentary
I have already commented on the concerns myself and others have had about these amendments. I have highlighted the major absurdity
a registered mental health professional who is registered under the Health Practitioner Regulation National Law to practice
There ain’t no such person! There is no category for ‘registered mental health professional’ in the Health Practitioner Regulation National Law and no-one can register in this category with AHPRA. We told them but they did not listen, or care.
The following has been “borrowed” from the Slater and Gordon website.
New Transport Accident Commission laws to restrict common law claims, particularly for severe psychiatric injuries
On November 14 the Victorian Government passed the Transport Accident Amendment Bill 2013. The legislation is the latest in a series of actions taken by the TAC over the last 2 years that make it harder for seriously injured Victorian’s to make a common law claim when they have been seriously injured.
The main changes to TAC compensation laws are as follows;
As soon as this legislation became public, organisations representing social workers, psychiatrists, psychologists, health and other allied health professionals, emergency services workers, community organisations and the Law Institute of Victoria wrote to the Government calling for consultations to address a range of concerns about the proposed changes. The Government decided to proceed with the Bill without addressing these concerns.
The Bill is unlikely to significantly affect you if your common law claim (serious injury application) was commenced before 16 October 2013. If you have any questions about these proposed changes and how it may impact on your case it is best to speak with one of our expert lawyers.
WorkCover Changes Queensland – as from October 2013 – Edited for Psychiatrists
These changes are effective from 15 October 2013 and arose from some of the recommendations of the Parliamentary Inquiry into Inquiry into the Operation of Queensland’s Workers’ Compensation Scheme:
The introduction of a threshold of greater than 5% degree of permanent impairment (DPI) to access common law damages. This applies to injuries from 15 October 2013. For injuries that occur over a period of time, the date of injury is considered to be the date of initial health practitioner consultation for the injury.
Prior to these legislative changes there was no threshold.
WorkCover Qld are working with the Office of Fair and Safe Work Queensland (OFSWQ) – the Regulator – to develop training for doctors on the new Guide and updating Notice of Assessment forms. The Regulator will publish the GEPI in the Queensland Government Gazette.
These changes are effective from 29 October 2013:
• Employment to be ‘the major significant contributing factor’ for psychological or psychiatric claims.
For physical injuries the definition remains unchanged stating ‘Employment to be ‘a major significant contributing factor’ for psychological or psychiatric claims’. Note the term ‘ the major significant contributing factor’, this is a much mpre stringemt test than a major significant contributing factor.
The committee recommendation was: The Committee recommends that the current definition of injury be retained in its current form with the exception of psychological injuries which are addressed separately in section 4.4.
• Employers can request a prospective worker to provide them with information about pre-existing injuries or medical conditions.
Disclosure of pre-existing conditions applies to ‘employment processes’ from 29 October 2013. An employer may ask a prospective worker in writing about pre-existing injuries or medical conditions. The request must be accompanied by specific information about the future duties and the implications if the worker fails to properly disclose their conditions. A worker may not be entitled to compensation or damages if they have knowingly made a false or misleading disclosure about an injury or condition and they suffer an aggravation of that injury or condition.
This provision is going to make it more difficult for people with any mental health problems to gain employment.
Bear in mind the reasons for these legislative changes:
The objectives of the Act are:
1. To implement the Queensland Government’s response to the Finance and Administration Parliamentary
Committee’s report on its inquiry into the operation of Queensland’s workers’ compensation scheme.
2. To make changes to the basis for assessment of impairment and to align the method between the statutory and common law provisions of the scheme.
Over the Last two weeks I have been trying to lobby the Victorian government to change their “Transport Accident Amendment Bill 2013” in particular because of the definition of serious mental illness, the other sticking points are only paying for reports jointly agreed to by the Transport Accident Commission and victims (read lawyers) and concerns about common law claims. I have done two media interviews, spoken to government and opposition members and a consortium of solicitors mainly focusing on the definition of mental illness in particular. There have been street demonstrations by emergency service workers and dispiriting parliamentary debate. The thing I found particularly annoying was that the definition is just dumb, it refers to “registered mental health professionals with AHPRA (I’m paraphrasing). There is no such group. We psychiatrists are not “registered mental health professionals” we are registered medical practitioners, similarly with psychologists! There is no mention of mental health nurses or of social workers.
The issue is really about the usual terror that all governments have about people with long-term mental health problems overwhelming the system. This of course has led to people with mental illness being excluded from lump-sum payments for WorkCover claims in South Australia and the significant restrictions on claiming benefit for mental injury in New Zealand (see relevant legislation).
The opposition are vehemently opposed to the legislation but I thought their attack was all over the place and they certainly did not seem to grasp the particular issues we have been talking to them about. It seemed more an opportunity for pointscoring and in particular catering to their union base rather than dealing with the substantive issues. I guess that’s politics.
As secretary of the College for 6 years I found that dealing with government was much easier if you acknowledge their good intentions, whether or not there were any and suggested areas of difficulty, offering solutions. This seemed far more effective in bringing about change than just heated rhetoric.
I will keep you informed about what transpires. In the meantime South Australia is proceeding with a no fault scheme for motor accidents including AMA 5 and, surprise, surprise, the GEPIC. We have been told the GEPIC was the only system they had seen that seemed to make sense. Unfortunately they have adopted the Injury Scale Values used in Queensland. What this means effectively is that government can arbitrarily decide what level of impairment relates to what ISV value and only people with an ISV value above a certain level receive payment.
TRANSPORT ACCIDENT FURTHER AMENDMENT BILL 2013
This Bill was introduced into the Victorian Legislative Assembly by the State Treasurer Michael O’Brien. I have edited the second reading speech to include only matters relevant to psychiatrists. The 4 major changes are:
1.Establishing clinical criteria for what constitutes a severe long-term mental or severe long-term behavioural disturbance or disorder for the purposes of serious injury.
2. No claim for damages for a person who did not witness or was directly involved in a transport accident involving injury or death as a result an intent to commit suicide or suicide or through negligence.
3. An increase in family counselling benefits from $5870 per claim to $15 000 per claim.
4. As from 1 July 2014 the TAC will only reimburse medico-legal report expenses if the medico-legal report is requested jointly by the TAC and the person who is injured.
The Second Reading Speech
This bill is the result of the government’s commitment to maintain the integrity and improve the operational efficiency of the Transport Accident Commission scheme to ensure it remains financially viable so that it can support injured Victorians well into the future.
The objectives of the bill are to clarify the Transport Accident Act 1986 (the act), increase some client benefits and address anomalies. Legislative amendments relating to the original intent of the act. As a community we know much more about mental illness than we did when the TAC scheme was established in 1986 . The government understands that recovering from a transport accident can be a very emotional and challenging time.
This bill introduces clauses that, for the first time, set out clinical criteria of what constitutes a severe long-term mental or severe long-term behavioural disturbance or disorder for the purposes of serious injury. This provision has been developed in consultation with the Department of Health, including the chief psychiatrist. The clinical criteria will encourage people who were directly exposed to a transport accident and who have suffered a recognised mental illness or disorder to seek treatment by a registered mental health professional, to improve their chances of getting their life back on track as soon as possible.
The bill will clarify that the injury or death of a person through suicide, an intention to commit suicide or predominately through their own negligence does not give rise to an action by another person for damages in respect of mental injury (including nervous shock) where the other person was not directly involved in or witnessed the transport accident.
Legislative amendments relating to increased client benefits. Currently under the act, family counselling benefits are capped at $5870 per claim. This bill will increases the cap on family counselling benefits to $15 000 per family claim. This will allow an immediate family member of a person who is killed or severely injured in a transport accident significantly improved access to mental health treatment to address their understandable grief. It is intended that this provision will apply to both new and existing claims.
Currently, the TAC funds the reasonable cost of medical reports obtained by or on behalf of a client, in relation to injuries sustained in a transport accident. On average, clients attend eight medical examinations over the course of their claim, of which, only two are commissioned by the TAC. The remaining examinations are commissioned by the client’s legal representative in support of legal claims. To address the need for a client to attend multiple examinations and to minimise the occurrence of a client attending duplicate examinations in relation to the same specialisation, this bill will enable the TAC to reimburse medico-legal report expenses if the medico-legal report is requested jointly by the TAC and the person who is injured. It is intended that this provision come into operation on 1 July 2014 to inform and assist medical practitioners of this new policy change.
Byron Rigby has written an interesting paper on the relationship between depression/pathos and pain. The studies of pain have exploded in recent years but, frankly, I am more confused than ever. Especially with regard to chronic pain and CPRS. I have included some excerpts from Byron’s paper.
Medical practitioners and healing professionals of all persuasions are endlessly called upon to treat pain, anxiety, depression, unhappiness, distress and suffering in all their combinations and kinds. Yet the subtle relationships between these experiences are seldom considered, and have only recently been subject to serious research.
In almost all languages, the words for physical pain and mental suffering are similar, or even the same. Our expressions of distress about them, including crying, tone of voice, withdrawal and mutual sympathy are also often nearly identical. The behavioural, social and pharmaceutical measures we adopt to ameliorate these experiences are also sometimes similar.
Language reflects connections between many experiential, cognitive and affective states that are increasingly being found to be neurologically grounded. We talk about someone or some event as a “headache”. A person or event that distresses us may be referred to as a “pain in the …. (neck, gut, etc)”. We routinely refer to “wounded pride”, “a broken heart,” “hurt feelings”, “painful memories”, etc. The wistful memory of past things is called “nostalgia” (“our pain”).
Words like “pathos” and “passion” have migrated across languages with meanings varying between emotional and physical pain. Languages are replete with synaesthetic references, the commonest of which deserve to be regarded as potential leads to neurological connections.
I have been doing this work for more years than I care to remember. Recently I discovered that I have written 23,000 reports since 1996. My mind boggled (I have used that term for years and never knew what it means. According to the Merriam Webster dictionary it means: to be surprised, confused, or alarmed (esp in the phrase the mind boggles) well that seems to express what I thought. But as someone said of Vivaldi ‘he didn’t write 600 concertos, he wrote one concerto 600 times’ was I merely repeating myelf ad infinitum! But I digress. Nevertheless, I am still confronted with challenges, not least dealing with some claimants. I thought you might be interested in hearing about two recent situations, one of which turned out badly. I have de identified these as much as possible, not least because of fears of retribution from one of the claimants!
The first involved George, a middle-aged man who I had seen two years previously. He claimed to be a hard-working man with a wife and three children who was a factory worker. He had been injured in a rear end collision in 2009 that seemed relatively minor ($700 damage to his car) but that had left him with a neck and back pain to such an extent that he had been unable to work. He had had a variety of treatment with no evidence of any marked improvement. Was asked directly as to whether or not he or any members of his family had made any WorkCover, transport accident or personal injury claims and had answered “no, no and no.”
I was asked to provide a supplementary report for George and sent a bundle of report, some going back to 1990. It turns out that this “hard-working man who had been in virtually continuous employment” had had a back injury at work in 1990, was off work for eight years during which time he received WorkCover payments and then a disability support pension. He had three previous transport accident claims. His wife was not working because of a work-related back injury and was receiving WorkCover payments. His two brothers similarly had work-related back problems and were receiving WorkCover payments.
On the face of it, to say the last, there was a disparity between the information he provided and the information in the documentation. How to proceed? Do I write a supplementary report based on this documentation or do I see him again?
When there is any question about credibility you have to see the claimant. People always get things wrong, it is fascinating to interview different members of a family about the same event because you find that they all have a different version of what happened, the Rashomon effect, a term that has been used by scholars, journalists and film critics to refer to contradictory interpretations of the same events by different persons, a problem that arises in the process of uncovering truth. It is named for Akira Kurosawa‘s film Rashomon, in which a crime witnessed by four individuals is described in four mutually contradictory ways. As a barrister friend of mine told me “you can never rely on eyewitnesses”.
I reckon that in 95% of my interviews people get facts wrong, sometimes important facts that have no bearing on their claim and at other times facts that may be relevant. On a number of occasions when I have re-interviewed somebody about some missing information their response has been “well I didn’t think it was relevant”. In many cases they are right and of course we are always dealing with people who are having their privacy invaded and know that they have no confidentiality.
I do a bit of a juggling act if I recognise that people are reluctant to give me some information. I will say something like “look, tell me in general terms what this is about. If I don’t think it’s relevant I won’t write it down, but if I do think it relevant I will use a form of words that you are comfortable with.” I saw Harry, a man in his early 30s from a strict religious background, for a transport accident on behalf of his solicitor who was also his father-in-law. Harry told me that he had used recreational drugs over the years but not recently. He suddenly realised what he had said and asked “will this go in the report?” I said that it would. He panicked because he realised his father-in-law, who was strictly opposed to drug use and very close to his wife would find out about this part of his life. I told him that I would ask him about it in more detail and that if I did not think it was relevant I would not only not put it in my report but I would not have it in my written notes. He told me about some relatively minor drug use between the ages of 18 and 23. I ostentatiously tore up the sheet of paper I had been writing on having first shown to him and ripped it into small pieces for effect and shoved it in the bin. He was reassured and the interview continued. By the way, there was no mention in any of the other documentation about his drug use. If it had been mentioned I would have been obliged to make some comment about it in my report.
On another occasion I struggled with the dilemma of whether or not to record in my report that Peter, a man in his early 40s, had a mother who had died of AIDS. His mother had been infected by her partner. This was information that was closely held within the family circle. This information was also not in any of the other documentation. His mother had died some 15 years previously. I did not consider his mother’s death was relevant to his work injury and its aftermath. I recorded only that his mother had died of an infection.
What have these stories to do with my dilemma with George? The point I’m making is that other reports can appeared damning but they can also be wrong. If you assume that the information in the report you receive are accurate think again. It is astonishing how many errors are in reports, some trivial but also some important. The more accurate your report is about the small details the more credible it is to do with the important issues and your opinion!
So, I saw George again. At this point it became an anticlimax. He could not disagree about the previous work injury, his family history of work injuries, he remained evasive about whether or not he was working at the time of the accident. I asked to see his CentreLink benefit card and found that he had been granted a disability support pension in 2004. He reluctantly admitted that he had not worked since then. I always ask to see the CentreLink card because the date will often tell you when the benefits started although the benefit may be a New Start Allowance initially and later becomes a disability support pension.
In my report I made it clear that because of concerns about credibility I was not able to form an opinion about whether or not he had a diagnosable psychiatric disorder. I did not say he was a liar, a malingerer, a psychopath or that there appeared to be a family culture of rorting the system. Avoid using any of those loaded terms. It’s quite sufficient to indicate that your opinion has to be based on the accuracy of the information that you have been provided and if that proves to be incorrect you cannot form an opinion.
The second situation was with Angelo, a man I saw for his solicitor who had a WorkCover claim as a result of a road rage incident in which he claimed he had been assaulted and had been left with mental and physical injuries. I had read the documentation with an increasing sense of gloom. He came from a grossly dysfunctional family with a violent alcoholic father and an emotionally absent mother. He had been in and out of prison serving at least 10 years in all. His work record was very patchy but he had become a union organiser. At the time of the alleged injury he was working as a van driver and had become involved in an argument about a vacant parking spot. There had been some pushing and shoving and he had tripped backwards over the curb landing heavily on his back. He was claiming post traumatic stress disorder and a back injury. One thing in his favour was that he was the custodial parent to his two children.
He arrived at the interview 25 minutes late. There was a minor breakdown in communications with my office manager and I did not realise he had arrived for another five minutes. Normally when people arrived at late I make another appointment but on this occasion, because of my own stuff up I reluctantly decided to see him.
He looked like Bruce Willis with the leather jacket, shaven head, designer stubble and wraparound mirrored sunglasses. I went through my usual spiel about confidentiality et cetera. He was the sort of man who tried to physically dominate and his body language reflected that. He sat tall with an expressionless face and spoke in a monotone. I realised there was trouble when I asked him about the ages of his children. The few people who have been truly obnoxious to interview always seem to cavil when requested to provide family information but we had negotiated his parents and siblings, and indeed his ex-wife, relatively comfortably. I had asked him the birthdate of his daughter. I always ask people for the birthdate of the children because it gives me some idea of their closeness to their children and their long-term memory but also it provides me with a chronological pointer. It means I can say something like “so how old was your son when you and your wife separated?”
He told me that his elder child, a son was born on 13 April 1998 and was 14 years old. Without thinking I said “no, he must be 15 years old because he was born in 1998 and it is now 2013.” He said with menace, “he’s 14!!” I was a bit slow off the mark and said well he must have been born in 1999! He was insistent that he was born in 1998. I then realised this was a big issue for him, I have no idea why. Maybe he thought I was saying he was dumb! I just don’t know. He had another son and I remember thinking “Will I or won’t I”. I decided to go for it. “So when was your younger son born?” He told me his younger son was born in February 2002 and that he was 10 years old. I can remember hesitating, do I leave this issue because it seemed so fraught for him or do I mildly challenge him. You must remember that by this stage I was feeling a little pissed off myself. I found this guy menacing with an undercurrent of deep hostility (that I knew was nothing to do with me). Considering that I was seeing him for his solicitor he seemed, at best, very unhappy about seeing me.
In the end my need for accuracy won out and I found myself saying “wellll, he must be 11!”
Bruce II exploded in rage. He abused me, swearing and telling me he was sick of all my f…ing questions. I told him to control his behaviour or he would have to leave. He chose to leave and slammed his way out of the office. He left a final legacy, he spat on the door leading to the lift.
I must admit I was not unhappy about him going. I anticipated a very long and difficult interview. I anticipated I would have to be asking him about his convictions, his record of aggressive behaviour and so forth.
The question was then what to do to clean up the mess and not just the spit? I telephoned his solicitor immediately and explained the situation. The response was apologetic. I then wrote a report indicating all the information with which I’d been provided and stating what had happened during the interview and made very sure that I did not use any psychiatric terms in describing his behaviour (see the consequences of not doing so). I wrote that I had not seen him long enough to form an opinion. I felt surprisingly calm. I was grateful that he had not smashed anything in the office or on his way out.
In retrospect I should have approached him with more care. I should have explained that because he was 25 minutes late it was unlikely that I would be able to complete the interview and would have to organise an additional time. I should also have spelled out in detail what I would be asking him during the course of the interview. All this is in the documentation sent to him by his solicitor that had been provided by me but who knows whether or not he read it. If I knew that I had given myself extra time I may have been less pressured and have resisted pushing him. If I had been more “with it” I would have picked up his irritability and confronted it directly. I would have said “you seem irritable, can you tell me what that’s about?” He may or may not have responded but at least I would have had more control of the situation-I think.
It is a continuing struggle to make sure that people who experience a psychological injury are treated in a similar way to those who have a physical injury. The battle has already been lost in New Zealand to some extent. It was salutary reading the report of the Inquiry into the Operation of Queensland’s Workers’ Compensation Scheme published in May 2013. I have posted an edited version of this Report in “publications”. The Inquiry Report describes in some detail two particular issues, bullying and people making “stress claims” when they are faced with managerial action that they do not like. The paper is worth reading to see what the various participants have submitted. In particular there is a recommendation that the definition of psychological injuries be amended to include two types of psychological injuries identified as category A and B, the Committee is effectively recommending that criterion A for post traumatic stress disorder be category A and the rest be category B requiring a high level of proof for acceptance of such a claim! (see recommendation 11).
I have also extracted from this Report a table describing the Exclusionary Provisions for Psychological Injuries in the Commonwealth, States and Territories and New Zealand, WorkSafe Australia 2012
The recommendations are as follows:
Recommendation 10
The Committee recommends that psychological injuries be included under separate provisions within
the legislation.
Recommendation 11
The Committee recommends that the definition of psychological injuries be amended to include the
two types of psychological injury identified as category A and B above in section 4.5.
Section 4.5 The Committee considers that psychological injuries can be defined as two types:
A. Where a psychological injury is attested to by medical evidence and it results from an event
or series of events that deliver such significant trauma that it would reasonably be expected
it would impact adversely in the short, medium and long term on a significant proportion or
the majority of the population were they exposed to such significant events.
Examples of such events would include serious work related assault occasioning bodily harm
and in particular residual physical disability. Other events, that if supported by medical
evidence of ongoing psychological injury, may include people exposed to severe physical
threat such as hold-up, work place invasion such as robberies or where workers are exposed
to victims of road and rail incidents in the course of their employment.
B. All claims other than those identified above. This would include claims such as workplace
harassment and those types of claims where it is anticipated it would only produce a lasting
psychological injury to people whose pre-existing psyche is vulnerable. This type of claim is
more difficult to assess because the events around them are likely to be influenced by nonwork
psychological stresses, pre-existing psychological issues such as substance abuse, preexisting
depression, personality disorder, bipolar disorder etc.
The Committee considers that the level of proof required for acceptance of a claim under
the second type of claim should be quite high.
Recommendation 12
The Committee recommends that the current exclusions for reasonable management action be
removed and be replaced with specific exceptions for normal work place practices such as:
a) where action is taken to transfer, demote, discipline, redeploy, retrench or dismiss the worker
provided that action is taken in a reasonable way;
b) where a decision is made not to award or provide promotion, reclassification or transfer of, or
leave of absence or benefit in connection with, the worker’s employment provided the decision is
made in a reasonable way;
c) action by the Authority or an insurer in connection with the worker’s application for
compensation.
AND the definition be amended to be ‘the major significant contributing factor’ rather than the
current ‘a major significant contributing factor’ for Category B type psychological injury claims.
Recommendation 13
The Committee recommends that the Queensland Mental Health Commission be directed to
undertake a research study regarding the impact of the legislative changes if they are adopted and
that this study must directly inform the next review of the Workers’ Compensation Act.
Recommendation 14
The Committee recommends that the Attorney-General should initiate a review of the Work Health
and Safety Act 2011 with a view to considering whether recompense to victims of workplace bullying
could be made through mechanisms in that Act rather than through the Workers’ Compensation
Scheme.
Recommendation 23
The Committee recommends that a psychological specialty medical assessment tribunal be
included on the list of specialty medical assessment tribunals
An example of professional non-misconduct and vexatious litigation and misplaced indignation.
This is the case of: the Medical Board of Australia and McCarthy [2012] WASAT 210
In this case The Medical Board of Australia alleged that a consultant psychiatrist, Dr McCarthy, was guilty of gross carelessness by making three incorrect statements in a medical report.
The medical report was prepared at the request of the patient’s former employer for use in legal proceedings between it and the patient.
The Tribunal assessed the statements in their context, reviewed the relevant evidence in relation to each statement, and concluded that the Board’s allegations were not established. The application was dismissed.
A footnote stated “Practitioner’s application for costs will be heard in January 2013”. Dr McCarthy was represented by senior counsel. (Note that Dr McCarthy is identified although completely vindicated but the vexatious litigant retains his anonymity.)
The report refers to a Medical Board hearing regarding, what appears to be at face value, a frivolous complaint leading to a total waste of time and money.
Dr McCarthy, a psychiatrist wrote a report about a KR, a workers compensation claimant. The claimant objected to 3 phrases used in the report. The Medical Board then proceeded to a hearing alleging that the three phrases were false and that by making the statements Dr McCarthy was grossly careless. Two senior counsel were appointed and the matter was heard by a board including a judge.
It is particularly noteworthy that there was no complaint as to the ultimate diagnosis reached by Dr McCarthy.
It is difficult to conceive of any reason for proceeding with this by the complainant other than causing trouble for Dr McCarthy. It is difficult to understand why the Medical Board would go to such lengths to pursue it. There must be some sort of circuit breaker to head off these type of complaints.
The judge reprimanded Dr McCarthy for his indignant letter to the Board when he was informed of the complaints. He described KR’s complaint as “vexatious, malicious, inappropriate and incorrect“. He wrote “This man is currently behaving as he behaved on a number of fronts for many years and I don’t imagine any response would reassure him.”
It is difficult not to agree with Dr McCarthy no matter how inappropriate his language.
Furthermore the response of the judge may strike you as sanctimonious:
No matter how unjustified a complaint might be thought to be, members of the public are entitled to bring theirgrievances to the appropriate authority, and to have them investigated. They are entitled to be treated with respect.
When claimants make totally unfounded and ultimately damaging allegations regarding one’s professional competence out of what appears to be a sense of spite? One may give the appearance of respect but I would imagine most of us would feel anger and contempt although it was not wise to not denigrate the claimant no matter what the provocation.
One wonders what the emotional and physical toll was on Dr McCarthy. I wrote a paper about this some years ago. The paper was entitled “It’s not Fair!“and was about morbidity amongst healthcare providers following complaints.
The only satisfaction is that the good guy one, but at what a cost.
The Judgment (edited).
Dr Peter McCarthy is a consultant psychiatrist with many years experience. In 2006, he undertook a medical review of KR. The review was undertaken on instructions from KR’s former employer, Australia Post, for the purpose of workers compensation proceedings brought by KR against Australia Post in the Administrative Appeals Tribunal.
Dr McCarthy reviewed KR on 22 September 2006. He subsequently provided a report, dated 14 December 2006, to Australia Post. The Medical Board of Australia (Board) contends that three statements contained in that report were false, and that by making those statements, Dr McCarthy was grossly careless. The alleged inaccuracies are said to be grossly careless because of the significance of the statements to KR’s claim, and to his entitlement to receive workers compensation payments.
Two broad questions arise in relation to each of the allegedly incorrect statements.
1.The first question is whether the statement is inconsistent with what KR told Dr McCarthy during the consultation on 22 September 2006.
2.In that event, the question then arises as to whether the making of the incorrect statement amounts to gross carelessness for the purposes of s 13(1)(c) of the Medical Act 1894 (WA) (which was the applicable disciplinary provision applying to medical practitioners at the relevant time).
Dr McCarthy’s report was 10 pages in length. The first seven pages, in which all three of the allegedly incorrect statements are found, recited the history obtained by Dr McCarthy and concluded with his opinion. The balance of the report was given over to answering specific questions which had been asked of Dr McCarthy by Australia Post. In these proceedings, there is no complaint as to the ultimate diagnosis reached by Dr McCarthy.
The first ‘incorrect’ statement
Dr Mc Carthy wrote ‘[KR] admitted that his depression settled somewhat in 1998.’
The first thing that can be said about the first allegedly incorrect statement is that it comprises merely the first clause in a much longer sentence. The full sentence reads as follows:
[KR] admitted that his depression settled somewhat in 1998, but maintained that he continued to have fluctuating symptoms of anxiety and depression for the 6 years of his business, although it appeared his mood disorder was
not sufficient to motivate him to continue specialist treatment.
Two paragraphs earlier in the report, the following is said:
In 1998 he bought a bob cat and a truck and began working on his own business in April 1998 at house sites. He continued seeing Dr Fred Ng, Psychiatrist, who in his letter of 5 January 1998 reported that [KR] was making good progress on his anti-depressant medication Zoloft (sertraline) at the high but manageable dose of 225 mgs per day. Dr Fred Ng described his Major Depressive disorder as being in remission, i.e. having settled in January, although in his letter of 17 February 1998 he indicated that [KR] had become demoralised again due to a lack of work. [KR] had ceased seeing his Clinical Psychologist Graham Guest and thus the sychiatrist Dr Fred Ng indicated he adopted a more psychotherapeutic role in [KR’s] management, while [KR] remained on his anti-depressant medication. In June 1998 [KR’s] depression was in remission, and had remained in remission. It appears the opportunity to purchase his own bob cat and truck and to start his own business, had led to a settling of his psychiatric symptoms. His psychiatrist noted that [KR’s] morale and self-confidence, and his traumas from his difficulties at Australia Post ‘certainly continued to recede into the background’. He remained on his anti-depressant medication, his depression remained in remission, and he ceased seeing his psychiatrist sometime in 1998.
KR was cross-examined about his condition in 1998. When pressed, he reluctantly accepted that he had experienced some improvement as a result of his medication in 1998. He said that if his condition was 50% in 1997, it would have been 60% in 1998, and that he was ‘managing things better with the help of the drugs’.
As his report noted, Dr McCarthy had been sent a substantial number of earlier medical reports, including the reports of Dr Frederick Ng, KR’s treating psychiatrist. In cross-examination, KR ultimately accepted that, if the statement had said that ‘his depression settled somewhat in 1998 as a result of taking Zoloft’, then he would agree with that statement.
That concession is sufficient to dispose of the first complaint.
The effect of the statement is a proposition which KR accepts as accurate.
The Board also noted Dr Ng’s report of 8 April 1998 stated ‘I do believe that the major depression remains in remission due to the Zoloft’. Two months later, on 5 June 1998, Dr Ng reported a significant improvement in KR’s psychological state which he said ‘comes about as a result of feeling back in control of his destiny, and of being able to perhaps earn a living on his own accord’. He described KR’s depression as ‘remaining in remission’. Later that month, on 22 June 1998, Dr Ng described the depressive order as ‘currently in remission’ and said that he had responded exceedingly well to treatment so that his major depression ‘is now clearly in remission, and he is asymptomatic’. He described the prognosis as good.
Thus, the comment ‘his depression settled somewhat in 1998’ appears almost an understatement when measured against the contents of Dr Ng’s reports, which Dr McCarthy had before him and read prior to seeing KR.
The grounds for complaint seems to be that KR ‘did not admit or say that his depression settled somewhat in 1998‘ rather than the rather compelling support for Dr McCarthy’s statement from Dr Ng.
This invites consideration of what KR said at the consultation in September 2006. Dr McCarthy’s notes of the consultation show that events during 1997 and 1998 were discussed. We did not find KR’s evidence particularly reliable.His reluctance to accept the proposition, strongly supported by Dr Ng’s contemporaneous reports, that his symptoms had improved significantly in 1998 showed a tendency to recollect events in a way that supported his complaint against Dr McCarthy.
The second statement
Dr McCarthy wrote ‘He was somewhat vague whether he remained on medication, this was written in reference to the years between 1998 and 2004. The grounds of complaint was that [KR] told [Dr McCarthy) words to the effect that:
(i) between April [1998] and February 2004, he had worked as a self employed Bobcat driver;
(ii) whilst working [as] a self employed Bobcat driver, he had made approximately twelve applications for employment and four applications for income protection and workers cover and he had stopped taking Zoloft every time he completed an Application because he thought that each Application was more likely to succeed if he could manage without taking Zoloft;
(iv) he had resumed taking Zoloft within approximately three days of completing each Application;
(v) he had consulted with Dr Ng in October 2003 after which time, his prescription of Zoloft was increased to 275 mg daily;
(vi) with the exception of the periods of time when he stopped taking Zoloft, he had regularly taken Zoloft between 1998 and 2004 in varying doses of between 225 mg and 275 mg daily; and
(vii) he had remained depressed between 1998 and 2004.
In his written statement of evidence, KR said that he used words to the effect of those set out above. When questioned, KR he agreed that the reason he stopped taking Zoloft when he completed an application for employment or income protection insurance was that he wanted to be able deny that he was currently taking any medication. He said that the statement in his written evidence that he did that ‘every time’ he completed an application was a mistake, and that he only did that sometimes and had done so on the advice of a doctor although he knew that it was misleading. He said sometimes he would forget to take his medication, and sometimes he would go off it because he could not be bothered. He acknowledged that he told Dr McCarthy that there were times when he went off his medication.
Having heard KR’s evidence as to the frequency and duration of his periods off medication for various reasons, we have no clear picture of the extent to which he took himself off medication during that period. We thought Dr McCarthy’s comment that KR was ‘somewhat vague’ was correct.
KR might have been reluctant to discuss his behaviour that he knew was misleading. He was uncomfortable discussing that aspect of his evidence under questioning from counsel. We understand that Dr McCarthy’s comment expressed a conclusion and were not the actual words used.
The third statement
Dr McCarthy wrote ‘He has now ceased his Zoloft (sertraline) although it is not clear when and his current medication is …’. KR gave evidence that he said the words to the effect alleged by the Board. Dr McCarthy had no independent recollection of the discussion and relied on his notes to support the statement made in his report. Dr McCarthy was cross-examined and accepted the possibility that he may have misheard KR, although only on the basis that ‘anything is possible’.
Counsel for both parties accepted, and we agree, that the task for the Tribunal is not simply a question of deciding whose evidence is to be preferred. Both accepted that the Tribunal should be guided by the observations of Miller J in Hewett v Medical Board of Western Australia [2004] WASCA 170 at [119] – [121] where his Honour said:
It may be tempting in disciplinary proceedings for a tribunal to look to see who is telling the truth and who is lying, but there is a danger in following this path. It overlooks the fact that the ultimate question for a tribunal in these circumstances is whether the tribunal of fact is persuaded on the balance of probability that the allegations contained within the Notice of Inquiry have been made out.
In Briginshaw v Briginshaw (supra), Dixon J (at 362 – 363) formulated the appropriate reasoning processes that are required of a tribunal of fact sitting as the Board was in this case. His Honour said:
‘… Reasonable satisfaction is not a state of mind that is attained or established independently of the nature and consequence of the fact or facts to be proved. The seriousness of an allegation made, the inherent unlikelihood of an occurrence of the given description, or the gravity of the consequences flowing from a particular finding are considerations which must affect the answer to the question whether the issue has been proved to the reasonable satisfaction of the tribunal.
In such matters ‘reasonable satisfaction’ should not be produced by inexact proofs, indefinite testimony, or indirect inferences. Everyone must feel that, when, for instance, the issue is on which of two dates an admitted occurrence took place, a satisfactory conclusion may be reached on materials of the kind that would not satisfy any sound and prudent judgment if the question was whether some act had been done involving grave moral delinquency … It is often said that such an issue as fraud must be proved ‘clearly’, ‘unequivocally’, ‘strictly’ or ‘with certainty’ … This does not mean that some standard of persuasion is fixed intermediate between the satisfaction beyond reasonable doubt required upon a criminal inquest and the reasonable satisfaction which in a civil case may, not must, be based on a preponderance of probability.
It means that the nature of the issue necessarily affects the process by which reasonable satisfaction is attained. When, in a civil proceeding, a question arises whether a crime has been committed, the standard of persuasion is, according to the better opinion, the same as upon other civil issues … but, consistently with this opinion, weight is given to the presumption of innocence and exactness of proof is expected.’
This well-known and oft-cited passage stresses the need for the Board in this case to have approached its task by considering carefully as the primary issue whether it was satisfied to the requisite standard that the complaints had been made out. There is a danger that in looking first to see who was telling the truth and who was lying, the Board may have obscured what was the essence of its inquiry.
In this case, quite properly, neither counsel suggested that any of the witnesses were ‘telling lies’. The question remains, however, whether the Tribunal is satisfied to the requisite standard that the complaints are made out.
We are satisfied that KR did somehow convey to Dr McCarthy that, at the time of the consultation, he was not taking Zoloft.
As we have already noted, we have concerns as to the reliability of the evidence of both KR and JR (his wife) so that its weight is reduced to the extent that we are unable to be satisfied to the requisite standard that the report was false. It follows that the third complaint is not made out.
Dr McCarthy’s response to the Medical Board
When KR’s complaints were first referred to Dr McCarthy, he responded by letter to the Board. In that letter he described KR’s complaints as ‘vexatious, malicious, inappropriate and incorrect’. He said ‘This man is currently behaving as he behaved on a number of fronts for many years and I don’t imagine any response would reassure him’.
Dr McCarthy was cross-examined on those statements and it was put to him that they demonstrated an antipathy to KR which could only have emerged from his consultation with KR in September 2006, and provided a context against which the allegedly incorrect statements had been made Dr McCarthy denied that proposition.
We do not consider that those statements in Dr McCarthy’s letter of response to the Board, unfortunate as they are, should lead us to the inference suggested by counsel for the Board. The comments can more easily be construed as demonstrating a sense of indignation on Dr McCarthy’s part at the making of a complaint to his professional regulatory authority. Having said that, we would observe that the statements made by Dr McCarthy in his response were particularly unfortunate and ill-advised. No matter how unjustified a complaint might be thought to be, members of the public are entitled to bring their grievances to the appropriate authority, and to have them investigated. They are entitled to be treated with respect. Inflammatory responses respect neither the complainant nor the process. It is especially surprising to see comments of that nature made by a psychiatrist, albeit not the treating psychiatrist, in relation to a patient who has been treated over an extensive period for significant depression.
Conclusion
For the above reasons we find that the complaints of gross carelessness are not made out and the application should be dismissed. At the close of the hearing, counsel for Dr McCarthy foreshadowed an application for costs. The matter will be listed for directions on the question of costs.
Orders
1. The application is dismissed
2. The question of costs is listed for directions at 10 am on
13 November 2012.
I certify that this and the preceding [40] paragraphs comprise the reasons
for decision of the State Administrative Tribunal.
___________________________________
JUSTICE J A C, PRESIDENT
I have heard, unofficially, that Victoria is planning to switch to AMA 5. As far as forensic psychiatrists in Victoria are concerned, in the short term it will probably make little difference as the GEPIC is likely to stay with the exception that those who are qualified to do assessments using AMA 4 chapter 4 The Nervous System will need retraining in the chapter on neurology in AMA 5. This is now chapter 13 and is entitled The Central and Peripheral Nervous System. I have summarised the sections relevant to us in AMA 4, AMA 5 and AMA 6, see link.
As in AMA 4, the most severe cerebral impairment is identified and this impairment rating becomes the impairment rating for brain dysfunction.
Table 4.2 ‘Mental Status Impairments’ is now table 13.6 and is linked to table 13.5 headed ‘Clinical Dementia Rating’. The percentages within each class remain the same but there are some minor changes in the wording. Table 4.3, ‘Emotional or Behavioural Impairments’is now table 13.8 ‘Criteria for Rating Impairment Due to Emotional or Behavioural Disorders’. The wording is identical.
This is probably part of a move to rationalise the various systems of impairment assessment used in the different states, Commonwealth and territories. The organisation involved is the ‘Heads of Workers Compensation Authorities, Australia and New Zealand’ http://www.hwca.org.au/members.php#. The charter of this organisation is to promote and implement best practice in workers compensation arrangements in Australia and New Zealand in the use of policy and legislative matters, regulation and scheme administration. There may also be a link to a part of the National Disability Insurance Scheme that you may not be aware of, the National Injury Insurance Scheme. I will post more information about this as it comes to hand but, to give you some idea of what this is about I quote from the Canberra Times 28 August 2012 and the Productivity Commission report 2011. The Canberra Times article stated: With the National Disability Insurance Scheme receiving much public attention, it is easy to forget the Productivity Commission’s other recommendation to establish a National Injury Insurance Scheme. The NIIS is the forgotten little brother of the bigger, brighter and more popular NDIS, but that is no reason to ignore it…. The NIIS will provide no fault insurance coverage frustration to acquire a disability from catastrophic injury and require lifetime care and support. At an estimated cost of about 1.8 billion every year. The $22 billion a year NDIS, on the other hand, would cover people born with a disability such as autism, cerebral palsy all down syndrome or acquire a disability such as macular degeneration or hearing loss. Unlike the NDIS, which would be a national scheme funded through core government revenue, the NIIS, as proposed by the commission, would be a federal scheme funded through insurance premiums, surcharges, levies and increased municipal rates-and would exclude experience at risk rating to help prevent injury. The NIIS is more like a proper insurance scheme compared to the NDIS, which is essentially an entitlement scheme. The report from the Productivity Commission (2011) states:A sample of my collection of “great horrible comments”
A 43-year-old man saw a counsellor with his wife following the death of his seven-year-old daughter who was run over in front of him. They saw the counsellor two weeks after the accident. The counsellor said “good, let’s see what we can do to get early closure!”
A woman whose 12-year-old daughter was killed in a transport accident was told by her mother “good, now you know she won’t be raped when she gets older!”.
A middle-aged woman complaining about her marriage to her mother was told by her mother “I remember you complaining about the same things before you got married. I remember, even then, thinking “who are you to be so choosy.”
A middle-aged man who’s wife had died two weeks previously after 12 months of horrendous treatment for breast cancer was asked by some friends “why don’t come back dancing, you’ll feel much better.”
Two adolescent children of a woman were killed in an accident involving four other teenage deaths in a country town. The driver was convicted of careless driving. The woman was approached by a stranger in a supermarket who said “you’ll be pleased now that you have closure.”
I would be interested to hear any examples you may have.
Do’s
1. Do read the referral letter and accompanying documentation before you see the claimant.
2. Do get a consent form signed (see one in Resources).
3. Do a mental status examination
4. Do complete the report as soon as possible.
5. Do come to an opinion.
Don’ts
1. Don’t tolerate rudeness.
2. Don’t readjust your schedule for a court appearance until you are guaranteed payment.
3. Don’t look at surveillance material in the absence of the claimant.
4. Don’t tell the claimant your opinion.
5. Don’t write what you think the referral party wants to hear.
More information about differential payments between states for the same services.
This table provides information about payments by states for psychiatric treatment funded by workers compensation schemes. I wrote a previous blog about the different rates of payment for reports by psychiatrists. ‘Australian fee schedules for independent psychiatric assessment’ It is surprising how Victoria lags behind the other states but on the other hand some of the other states are having cost blowouts with their schemes and one can expect little interest in any movement on fees.
| C
M B S |
A
M A |
Cons. Psychiatrist | Vic | NSW | SA | QLD | WA | NT | TAS | ACT | Com
Care |
| 320 | 65 | <15 min | $71.13 | $81 | $75.20 | $81 | $75.40 | $81 | $81 | $81 | $81 |
| 322 | 75 | 15-30min | $142.22 | $162 | $151.70 | $162 | $150.50 | $162 | $162 | $162 | $162 |
| 324 | 85 | 30-45min | $205.99 | $235 | $224.30 | $245 | $225.40 | $235 | $235 | $235 | $235 |
I have just read the most sensible article on DSM 5 that I have yet seen. I have posted a link to the article in ‘Publications’. This is from the May 2013 issue of The Monthly and is written by Professor Nick Haslam, professor of psychology at the University of Melbourne. I was particularly struck by his response to the naysayers. He writes “many of these revisions have drawn criticism, but the fiercest challenges have addressed the new ways in which DSM 5 might pathologise normal behaviour. This charge has been led by a psychiatrist, Alan Frances, primary architect of DSM IV. His new book, Saving Normal, was published a week before DSM 5. He is an incisive psychiatric critic of the new diagnostic regime. Many psychologists have also engaged seriously with DSM 5 despite deep concerns over diagnostic inflation and the neglect of social and cultural influences…. Other critics have been entirely dismissive. The British Psychological Society’s response to DSM 5 rejects the very idea of diagnosis. Clients should be assessed for specific problems, not assigned to categories, The Socirty objects to “the medicalisation of… natural and normal responses… which do not reflect illnesses so much is normal individual variation” – appointed repeats, mantra like, 37 times, even though DSM 5 never employs the concept of “illness”.
He takes to task other critics for attributing to DSM 5 opinion is that it has not expressed.
He makes the point that “it’s not obvious why people feel the need to save normality from psychiatry more than from dermatology. It is also not clear why entirely different principle should apply when we think about physical illnesses and mental disorders: the idea that one is objective and real and the other subjective and arbitrary smacks of an old-fashioned dualism. Rheumatology, for example, like psychiatry, recognises more than 200 distinct conditions, this classification is in a state of flux. Two rheumatology researchers could have been writing about psychiatry when they recently observed that for most conditions “we do not understand their (causation), and there are no “gold standard”, unequivocal clinical and laboratory features to distinguish one disease from another or even from normality.”
He goes on to say “if DSM 5 adds to the ways in which personhood can be stripped and identity tainted, than it deserves all of its criticisms. Understood correctly, however, psychiatric diagnosis does nothing of the sort. Disorder does not define one’s identity or essence: diagnosing a person is not like identifying species. The disorder is not even an alien “thing” that a person has, like an illness. It is merely a set of very human characteristics that bring suffering and impairment. Normality is not defined by what DSM 5 leaves out.”
I urge you to read the article.
The highlights for me were Michael Linden’s talk on embitterement, Kimberly Dean’s talk on violence and mental illness, the discussions about developing a curriculum with regard to forensic psychiatry, especially in the civil area, and of course my talk on “bizarro world II“, nobody asked me what was bizarro world I, I had a ready reply – DSM5.
I was especially interested in Michael’s talk because he spoke about a group of people who seem to have been ignored both by DSM in its various iterations and by ICD 10 and 11. That is people who seem to have been coping well and for a variety of reasons experience a breakdown in their capacity for coping that may never significantly improve and who not do well with the usual treatments including psychotherapy, CBT, and medication. Michael had done impressive research and had focused on an aspect that I have seen as insignificant but I now recognise the importance of embitterment. I spoke to Michael about a book I wrote in 1989 called “Falling Apart, Living with Stress Breakdown” (7,257,841 on the list of Amazon bestsellers). Much of my clinical work has been with people in this group.
Kimberly Dean’s lecture was a delight. It was a deeply academic talk exploring large data sets and examining how different ways of looking at these datasets can produce totally different results. For example one study showed that when the confounding influence of alcohol were removed there is no difference in the level of violence between the general population and those with mental illness. Some years later exactly the same data was reanalysed with the opposite outcome!
It made me conscious, yet again, how seduced we are by numbers.
The other piece of research she spoke about was seeing what happened if intensive interventions were done with people with psychosis who were at risk of violence. The surprising thing was that it made no difference long-term. Perhaps that is a good thing for mental health services.
It was particularly interesting to have a frank and full discussion with the subcommittee developing criteria for forensic trainees. I thought they had done an impressive job, despite my previous quibbles and handled the adverse comments about the lack of any civil training effectively. In essence, the complaints were that there was insufficient emphasis on doing civil forensic work and that most of the people doing civil forensic work did not necessarily come from the criminal forensic stream and there was no training envisaged for them. These matters are being considered.
Apart from that the weather was great, the food, though expensive, was good and I spent a week travelling to a small aboriginal community at Kalkaringi, 750 km south-west of Darwin, that was a real eye-opener. A terrific indigenous community but plagued by the usual problems, lack of employment, lack of school attendance and lack of purposefulness.
DSM 5 was published in May 2013. We all need to be aware of those areas that have been changed and those that remain the same as in DSM IV TR. There is a detailed analysis of DSM5 on the website. But also see Nick Haslam’s article).
The general changes are that the multi axial system has been dropped, I believe this is a recognition that it was not useful and that it was rarely used in clinical practice although the concept it conveyed of looking at the mental disorder, personality issues, other medical issues, psychosocial issues remains a part of most clinicians’ diagnostic formulation.
The Global Assessment of Function scale has been dropped. It is interesting that the authors of AMA 6 chose to include the GAF and now that it has been removed it has even less credibility as does chapter 14 in AMA 6.
The chapter on Schizophrenia Spectrum and Other Psychotic Disorders has some minor changes with the addition that at least one of the Criterion A symptoms must be delusions, hallucinations, or disorganised speech. That DSM IV TR subtypes were eliminated. There have been changes to the conceptualisation of Bipolar 1 Disorder and Bipolar 2 Disorder as they now include both changes in mood and changes in activity or energy. The major change with regard to depressive disorders, apart from some new minor diagnoses, is the name change from dysthymia to persistent depressive disorder. There have been changes in relating bereavement and major depressive episodes.
Anxiety disorders include significant changes including separate chapters for Obsessive-Compulsive and Related Disorders and Trauma and Stressor Related Disorders. Panic disorder and agoraphobia are now regarded as discrete entities and if they occur together both diagnoses need to be made.
A number of comparatively rare new disorders have been encompassed under the concept of Obsessive-Compulsive and Related Disorders. The specifier has been modified to allow for a range between those who have good insight and those who have no insight into their behaviour.
Trauma and Stressor Related Disorders including Acute Stress Disorder and Post Traumatic Stress Disorder has had significant changes, the Criterion A requirement involving a person’s response to the trauma has been eliminated and the notion of repeated or extreme exposure to trauma such as that expressed by first responders is acknowledged. The only other major change has been to recognise negative mood and irritable behaviour and angry outbursts. Adjustment disorders have been appropriately bought into the category of stress-related disorders. The authors of DSM 5 claim that these disorders have been “reconceptualised as a mixed array of stress-response syndromes that occur after exposure to a distressing event rather than as a residual category for individuals who exhibit clinically significant distress but whose symptoms do not met the criteria for or more discrete disorder (in other words a wastebasket diagnosis). However the diagnostic criteria are identical so no real change there.
The authors have recognised that although the concept of Pain Disorder as in DSM IV TR was conceptually neat it was not based on any scientific evidence. The authors state that pain is almost always associated with psychological factors and recognise that some individuals with chronic pain have somatic symptom disorder, with predominant pain. For others an appropriate diagnosis may be psychological factors affecting other medical conditions or an adjustment disorder.
I was impressed with the DSM 5 and thought that a lot of the criticism was a great deal of nonsense. Critics appear to have picked on rare diagnoses to beat the authors with implying they are trying to medicalise normal behaviour. As a consultant psychiatrist the changes relevant to my areas seem sensible and understandable.
I was hot tubbing again on Friday. I think this is my fifth time in the hot tub. The first, a total fiasco, was at the Administrative Appeals Tribunal. There were four psychiatrists who turned up, one by telephone from another state. We were told that we would each give evidence and we would then have an opportunity to cross-examine each other. The first psychiatrist, a distinguished professor requested leave as he had more important things to do and was allowed to leave. The next, a psychiatrist from the country then gave evidence and again requested leave on the basis that she had a clinic to manage in her country town and she was also allowed to leave. Neither could be cross-examined. I was then called up and protested against the lack of opportunity to deal with the evidence of the first to psychiatrists. I gave my evidence and was then vigourously cross-examined by the interstate psychiatrist. I again protested against what seemed to me manifest unfairness in being the only one cross-examined as the interstate psychiatrist then gave his evidence but then had to go elsewhere. The chair seem to acknowledge this but nevertheless the farce continued. I was left feeling very disillusioned. The second time involved another AAT hearing. This time the other psychiatrist was a young, very knowledgeable and skilled witness who was impressive. We had an interesting dialogue discussing the issues we agreed with and the issues where we differed. It was a very satisfying experience. The tribunal seem to appreciate it. The third was a teleconference with a Sydney psychiatrist, thought to be something of a gun for hire who wanted to debate the issues over the phone. I decided to take charge of the dialogue and made it clear that we were not there to debate anything. We were try to sort out those areas where we agreed and those where we disagreed. The matter was dispatched within about half an hour, I thought quite satisfactorily. Subsequently I wrote a letter, sending a draft to the other psychiatrist who agreed with it and we jointly signed the draft and it was dispatched to the judge.
On this occasion I was given a subpoena to appear in the Sydney Supreme Court. I had a brief discussion with the barrister who gave me some gratuitous advice. He urged me not to fold under pressure, thanks a lot for that advice, I’ve been a witness before. This was a very large courtroom with a very long witness table that comfortably accommodated the three of us. Two of us had seen the claimant for his solicitor and the other had seen the claimant on two occasions for the defendant. The judge started off by asking each of us to give our opinion about the diagnosis and the reasons for that opinion. I was surprised that the psychiatrist who appeared on behalf of the defendant made it clear at the start that all forensic psychiatrist were basically guns for hire and I thought his evidence went downhill from there. All of us know each other so at the morning tea break we shared a cup of coffee and later shared lunch. Matters heated up in the afternoon when all of us were cross-examined, not least by the judge. All of us had made mistakes in our reports that were brought out during the course of the day. One of us took his mistakes on the chin and did not attempt to dissemble or argue. I thought that went well. The other did the reverse and got deeper and deeper into doodoo. He was also challenged because he had seen this man on two occasions with a 13 year interval and said he was unchanged but despite that had changed his diagnosis. He found it very difficult to deal with the challenge that evoked. I was pleased that we were able to remain friendly and there were no personalities bought into our confrontations with each other. I was left feeling satisfied that all of us had had an adequate opportunity to express our thoughts and opinions and to deal with challenges that arose face-to-face rather than in the usual vacuum one experiences as a solitary witness. The experience confirms to me that to be a good witness one has to have a number of qualities including a comprehensive, well argued report and opinion, a readiness to deal with whatever facts are presented, or assumptions. A willingness to actively defend your opinion without being an advocate for the claimant or the defendant and a professional attitude towards the inevitable disputes that occur. As always there were things for me to learn.
The South Australian government has changed the motor accidents scheme that was compulsory third party and is now more a no fault scheme. As part of the changes there will be payment of impairment benefits. It has been decided to use the GEPIC rather than the PIRS! Concern was expressed that the PIRS was simplistic, not focused on symptoms of impaired mental health and was inequitable. A training program will be developed. I have provided a link to the ISCRR, I have mentioned this organisation in a previous post. This organisation is a combined initiative of the Victorian TAC and WorkSafe and is funded to do research and accident and work issues. In this issue there is an article about workplace prevention of mental health problems. It is worth a read.