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.
Travelling through Europe over the last month was physically exhausting but mentally refreshing. In particular I enjoyed the Hundertwasser Museum in Vienna, an extraordinary architect, well-known in New Zealand for designing the best public toilet I have ever seen. The other highlight was wonderful untouched art nouveau building in Prague called, boringly, the municipal house that has every art nouveau details you could imagine and is to die for. Fortunately it contains a beautiful cafe and restaurant and a large auditorium in which we listen to Mozart and Strauss.
Now back to work! One of the things that greeted me when I returned was a form describing requirements for psychiatric reports by Victorian WorkCover and the Transport Accident Commission for quality assurance purposes. I have enclosed a link to this form. When I first looked through this I could see no major problems but I had occasion to look at it recently and became much more concerned. Items 1-4 seem unexceptional. There appear to be no items 5, 6, 7, or 8.
Problems are with items 9 and 10.
Item 9, The summary formulation.
Item 9.4 “including evidence to support or change the plan, based on best practice ( what is best practice with regard to some of the conditions we see such as chronic pain syndrome, adjustment disorder, I could go on.); item 9.7 strategy to aid or improve safe return to work (in most claims for psychological injury there has usually been a breakdown in the relationship with the employer, how is this relevant in that context.
You are also assessed as to whether or not you have made a recommendation to provide the report to the treating health practitioner. I do not understand why that is relevant. If this is a question that has been specifically asked then you will respond to it but why should you otherwise?
(Ironically there is no question asked referring to the examiner’s views about other opinions, this is a usual part of what I do.)
Unless these questions are specifically asked they will not be answered but this summary formulation seems to indicate that they should always be answered whether or not they had been asked.
The other issue is with 10. RESPONSES TO SPECIFIC QUESTIONS. This states “To ensure the report is a stand alone document, each question should be retyped in full as detailed in the referral request, and comprehensively addressed”.
For years we have been asking the claims agents to send their questions in an electronic form so they do not need to be retyped, this is particularly so because each claims agent asks different questions. To retype all these questions is a waste of time, this now codifies that the claims agents do not need to go to the trouble of sending out these questions in an electronic format.
I am a member of the Victorian AMA VW A/TAC committee and we have been asking them for years to do this. We have also been asking that they cut back the number of questions. There were about 32 questions that were being asked. They agreed to this but what they have done is asked a question is with four parts to each question keeping the original 32.
I have discussed by concerns with the Victorian branch of the AMA and they will write a response along the lines I have suggested.
I was struck by the program for the upcoming May Congress of the College. There is a section run by the Faculty of forensic psychiatry that appears to be exclusively related to the psychiatry and psychology of offenders, there seems to be nothing for those of us who do civil assessments. There have been discussions about the curriculum for the faculty and it appears that civil assessment will be regarded as an optional extra. Presumably an optional extras for those who have done the offender based course but what about most of us who got into civil assessments midway through our career from doing clinical psychiatry and have no interest in doing offender based psychiatry. I have always felt that the Faculty of Forensic Psychiatry is a real hybrid with an unknown number doing the civil work who seem to be pretty much disregarded and the other section dealing with offender based psychiatry where there are academic chairs, academic journals and so forth with institutions and a range of options for trainees. The options for trainees in the civil area are a didactic course and some mentoring by those of us who do the work, hardly satisfactory. I had hoped that the Institute for Safety, Rehabilitation Research and Compensation (the ISRRC) funded by the Victorian WorkCover Authority and the Victorian Transport Accident Commission would have some focus on our area but my expectations have not been met.
A number of people have asked me to set up a question and answer forum to see if we can thrash out some of the more complicated issues. For example I have seen two claimant recently who are alleging that prescribed medication caused significant side-effects and damage, both claiming economic damage, one who alleges the medication made him a compulsive gambler and the other alleging that the medication made her a zombie and she had to sell her profitable business at a loss. Both did not manifest any significant psychiatric disorder when assessed. Do they have a claim? The man who was a compulsive gambler had been a compulsive gambler previously and despite knowing about this unusual side effect for at least 12 months continued taking the medication. A further problem arises when one considers the issue of not counting for secondary psychiatric impairment. Is a side-effect from a medication a physical injury or consequential upon a physical injury? If so, it does not count. Bullying, as we know, seems to have become today’s equivalent of RSI. Is it bullying when a manager tells a poorly performing worker “the time so trying is passed, it’s time to start performing!”
Like most things worth doing, assessing people and writing reports can never be perfect and I am always learning, not that I’m happy about it. I was in court last week about a matter to do with bullying. I had seen this person four times and written four reports. Generally when I write a review report, having seen someone previously, what I’m interested in is what has happened since I last saw them regarding symptoms, treatment, work, relationships and so forth and of course also taking account of extra reports provided and commenting on them. I had done just that and (always a mistake) was feeling a little smug. When I was being cross-examined I realised that my first report although very comprehensive had no real details about particular instances of bullying. As the barrister said “you’ve just made general comments about the bullying haven’t you doctor, we have no idea whether it was at the very mild or at the very severe end of the spectrum? I was kicking myself for not having closely re-read my first report when I saw her subsequently because it was clearly a glaring omission. After the necessary blow to my ego I then decided, as all I always do if I have not done well in court, to make sure that in future I read the initial report closely with regard to the incident or incidents to make sure it was clear in my mind because if it is not clear in my mind how can be clear in anybody else’s mind. Another day, another lesson.
Illustrating the chaos that has resulted from the inability of the authors of the AMA Guides 3-5 to provide a method of assessment. New Zealand has modified AMA 4 chapter 14 Mental and Behavioural to produce the ACC Handbook.See also Bizarro World II.
The Motor Accident Authority in New South Wales published the Psychiatric Impairment Rating Scale also modifying chapter 14 AMA4. It is salutary to compare the two versions.
NEW ZEALAND ACCIDENT COMPENSATION ACT
The ACC User Handbook to the AMA “Guides to the Evaluation of Permanent Impairment” 4th Edition –
Using the same table in chapter 14 AMA 4 the New Zealand version is compared with the PIRS
ACC Handbook PIRS
class 1- 0-9% 0-3%
class 2-10-35% 4-10%
class 3-36-60% 11-30%
class 4-61-79% 31-59%
class 5-80-100% >60%
In the NZ system the figures taken from the four categories are not added, averaged or combined. The figures are to assist the assessor, in conjunction with clinical judgement, to arrive at a whole-person impairment rating based on the claimant’s current level of functioning, and expressed as a single percentage.
The Guidelines state:
The final whole -person impairment rating is not expected to be:
The PIRS determines the number for each category (the four categories have been broken up into six categories). The middle number that is the median number is determined and that is the final class. The numbers for each category are then added together. The sum of those numbers is used with a table correlating the median class with the total number of producing the final percentage impairment. Ironically a claimant may score in class 2 for each category leading to a median class 2 and a sum of 12 but the final percentage impairment is 6%!
The following examples illustrate the differences
Concentration, Persistence, and Pace
NZ ACC Handbook Class 2 Mild – 10–35%
Independent, but in some areas functioning is not particularly effective.
Impairment levels compatible with some (but not all) useful functioning.
Examples: ̇Can undertake basic training. But may have difficulty concentrating on complicated instructions.
̇Can focus intellectually on demanding tasks, but possibly only for a limited time.
̇Usually employed, but may have erratic work history marked with periods of unemployment.
̇May need some assistance with such things as decision making and finances.
The PIRS
Concentration, Persistence and Pace
Class 2 – 4-10% Mild impairment: Can undertake a basic retraining course, or a standard course at a slower pace. Can focus on intellectually demanding tasks for periods of up to thirty minutes, e.g then feels fatigued or develops headache
These absurdities are what led to a total rewrite of the chapter . We were all hopeful but something meaningful would urge,alas our hopes were dashed . The American Medical Association Guide to the Evaluation of Permanent Impairment 6th edition chapter on Mental and Behavioural Impairment (AMA6) has ditched the previous non-method and has substituted a dog’s breakfast. The method developed involves use of the Global Assessment of Function scale in the DSM IV, the Brief Psychiatric Rating Scale BPRS and a modified version of the PIRS. One is expected to combine the results from these different methods producing a final number. The GAF is so vague as to be almost useless, the BPRS is used to assess whether treatment has made any change for people with serious mental illness with an initial measurement and then a later measurement. Although it has been validated and is reliable, not in this context. I have already commented on my concerns about the PIRS.
This process is very time-consuming and is not, to say the least, an advance.
One of the many pluses of being a psychiatrist that is rarely discussed is that we hear fascinating stories, stories that are moving, stories of bravery, of cowardice, of stupidity and of grandest of spirit. One of my peer review group members recently spoke movingly about a particular case he was involved in many years ago and it struck me that all of us have stories that have stayed with us. It may have been because the story was so unusual, the suffering so extreme, the bravery was so extraordinary or because we stuffed up. One stuff up occurred when I was a neurology registrar and saw a woman in her 60s who had developed some limb weakness that was finally diagnosed as one of those rare neurological disorders, the excitement being the diagnosis as no treatment is available. Anyway this woman, I’ll call her Jane was very distressed. The consultant asked me to speak to her. She told me a story of loveless marriage with a husband who had recently retired and was driving her mad with her only solace being golf three times a week. She had no insight at first but then realised she was terrified that her limb weakness would force her to have to stay home and spend time with the husband. She ventilated freely with many tears, I congratulated myself on a job well done….. We did a ward round the next day and the consultant asked Jane how she was feeling. She said, and I can remember it as if it was yesterday “I was fine until that young man came to talk to me and I’ve been feeling terrible ever since!” Well, I was enraged, here was I exercising my therapeutic acumen, teasing out a difficult situation, giving her insight and she was blaming me! It was not fair. My consultant was not happy and made his displeasure widely known. It was a good lesson in leaving well enough alone.
The second memorable case was also a woman, she was called Pip. Pip and her husband had a cottage in the country and went there frequently with their children. She was walking home at dusk with her daughter on a winding country road, a utility drove past with a piece of timber projecting forward at an angle that struck her on the right side of her head causing a significant skull fracture. I saw her two years later with regard to her claim. She had totally lost her memory for recent events. Every day she had to learn anew who she was, where she was, who her family were, how to do even the simplest of activities. At some level she was aware of what she was lost and was quite devastated. It was a very isolated lesion, she was cognitively intact with no real changes in personality and no problems with mobility.
The third memorable case was a 26 year old electrician called Harry who was married with two young children. During the course of his work he had suffered a devastating electrocution leading to the destruction of both arms. Of course he was not able to return to work as an electrician. I saw him with regard to his claim and was surprised to see that he had not, in fact refused, to see a psychiatrist or psychologist or counsellor. His explanation was memorable, he said, “I feel like I’m circling a black hole. I have to keep looking away from it because if I look into I’m a gonner. I know that if I see anybody they will make me look into it and I won’t survive. My only way of keeping going is to try and not think about it and just get on with things.
I know that you must have similar stories. I would love to hear them. I would love to hear what you learned from them.
This impossible dichotomy was brought into the Victorian legislation in 1996 and has since metastasised. The then Minister for WorkCover stated (Hansard Victorian Legislative Council Page 1245 – 10 December 1996)
In June 1996 the surplus of assets over liabilities stood at something like $55 million. During the course of 1995-96 it was evident that the cost pressures were growing, and during the five months to November that pressure has further accelerated. The increases in total weekly benefits, in lump sum payments and legal and medical costs can be attributed largely to the extraordinary growth in the number of claimants classified as seriously injured. During 1995-96 the numbers of serious injury classifications grew by a net 1200 from 2910 to 4109 — a 41 per cent increase.”
And that
the number of workers who have been classified as seriously injured through the compounding of psychological or psychiatric factors with a primary physical injury having risen from less than 1 in 8 some 2 years ago to 1 in 4, and the figure is still rising.
The minister went on to say
the reality is that certain lawyers and doctors are abusing the system by using the secondary psychological or psychiatric factors, such as depression, to achieve serious injury status for their clients. I can do no more than quote … comments …made by Mr Koutsoukis from Maurice Blackburn, who stated on radio during the past few days:
We previously got them over the serious injury line by saying … that person is depressed.
Although the whole notion appears unjust it has been incorporated into the Victorian legislation including the Accident Compensation Act, the Transport Accident Act and the Wrongs Act. It has also been incorporated into New South Wales legislation. The argument is that build within the AMA Impairment Guides with regard to physical injury is some component for pain and suffering and that to also include a percentage related to psychiatric impairment would be double dipping.
in consultation with WorkCover and TAC Nigel Strauss and I developed a document called “Annotations for determining non-secondary psychiatric impairment”. Even using that document there are two areas which I find particularly difficult to tease out. I can give you two examples.
Bill was a 50-year-old man who had a back injury at work in a foundry. No real surprises there. He had physiotherapy treatment I was sent back to work after six weeks with a modified duties certificate. The stated that he should not lift more than 5 kg and should avoid repetitive movements, twisting and bending and should be able to change positions as required. There was realistically no meaningful work for him to do. His employer and his fellow employees resented him being back at work because there was more pressure on his thigh workers and his employer felt he was paying him but he was not producing. After a while his fellow workers began criticising Bill for not getting better and their complaints became quite overt. Bill was dreading going to work especially because his employer had him sit in the lunchroom most of the day reading the paper. The relationship between Bill, his employer and his fellow workers broke down and he ceased work in a bad state. He has lost all trust in his employer and has refused to go back to work there. He has limited skills and fewer job opportunities. He has applied for a serious injury application. He still has some back pain but his major concern now arises from his depression coming from what happened after he returned to work. Unless he has made a separate claim any psychiatric impairment has to be secondary to physical injury. This always seems inequitable to me.
The second situation that I find very difficult is those people who have made a personal injury claim who, in Victoria, have to exceed a threshold of 10% psychiatric impairment not secondary to physical injury. For many their claim arises out of a physical injury that may have settled.
Stella, an operating theatre nurse, had been treated for two or three years with Zoloft for depression and had developed a severe widespread rash. She had been seen by dermatologists and it was some time before the relationship between her rash and the Zoloft was recognised. Her Zoloft was stopped and the rash disappeared but in the meantime she had endured a great deal of discomfort, time off work, irritability and her quality-of-life and diminished markedly affecting her relationship with her husband and her children and she had difficulty coping with her work as an operating theatre nurse. She made a personal injury claim against her psychiatrist. The problem was that the rash is now gone but she continues to be distressed and miserable because of what she experienced. To my mind, her psychological response is secondary to the toxic effects of the drug and therefore does not count with regard to psychiatric impairment. Is that fair? I don’t think so but I don’t know how else the matter can be dealt with. What are your thoughts?
I have reviewed the workers compensation fee schedules for all but the Northern Territory and Tasmania. The range of fees is vast and the services for which fees are provided differs markedly (for full information see ‘Australian fee schedules for independent psychiatric assessment’ on the website). In some states you receive an extra fee if the interview was done with an interpreter, in some states there is a specific fee for watching videos.
Two typical examples are the fee for an examination and report. This fee ranges between $871.96 and $2074.30, with an extra $212.60 if an interpreter is present. The reading and preparation time in one state is a total fee of $47.98 for reading more than 20 pages but in another state the rate is $482 per hour.
I have now reached the point where it is no longer economically viable for me to do WorkCover examinations in Victoria, especially when people do not turn up or appointments cancelled at short notice.
I estimate that the average claim involves me reading for at least an hour and usually two, the interview takes me more than an hour and the report preparation time is at least another hour. So, for a total of four hours I receive a fee of $871.96 plus $47.98 for an average rate of $230 an hour.In my experience the overheads of doing medicolegal work are higher than those required for usual clinical practice.
Compare that with the equivalent fee for an initial consultation of more than 45 minutes funded by Medicare. The MBS fee is $260.30!
Copies of “The Little Red Book of Advocacy” by Trevor Riley, mentioned by His Honour, Judge Parsons in the seminar, are still available from the Law Society of Northern Territory @ $22 (but only 2 pages specific to Expert Witness). Otherwise, well done on a great website and forum.
Dush Shan
Have you ever heard of the ISCRR, if not join the group. I have known about this group since its inception but keep forgetting the name. ISCRR stands for the Institute (there was a short break while I checked I had got the title right ) for Safety, Compensation and Recovery Research. I won’t bang on about this clunky title but for goodness sake. Even IRRSAC would be better (Insitute for Recovery Research, Safety and Compensation!
Anway this is a worthy veture, at last the workers’ compensation and transport accident authorities have put in some money to do some research on work and transport injury issues, OK some of the research is a blinding glimpe of the obvious but some seems useful.
On its homepage the ISCRR is described as the Institute for Safety, Compensation and Recovery Research (ISCRR) and is a joint initiative of WorkSafe Victoria (WorkSafe), the Transport Accident Commission (TAC) and Monash University. It was established in 2009 to facilitate research and best practice in injury prevention, rehabilitation and compensation. Funding and support is provided by the three partner organisations.
ISCRR has a collaborative research model. This relies on extensive and ongoing consultation and engagement with all stakeholders involved at every stage of a research endeavour: from setting the research agenda, through facilitating and conducting excellent research to translating the research findings into best practice in WorkSafe and TAC operations.
Go to their website at http://www.iscrr.com.au they produce a monthly update on the research they have been doing. I have posted one of their one page report summaries from the March update entitled EXPLORING PATIENT PERCEPTIONS OF BARRIERS AND FACILITATORS OF RECOVERY FOLLOWING TRAUMA.
It is worthwhile subscribing to their monthly update to see their range of research activities. You might even persuade them to get a name change!
The Comcare review released in February 2013 has important implications for psychiatrists (click here for the complete review) . There is understandable concern about the growth in claims for psychological injury. Between 2006–07 and 2009–10, psychological injury claims accounted for 10 % of all claims under the Comcare scheme. However, those claims represented 35 % of the total cost of claims. During 2010–11, psychological injury claims accounted for 12 % of all claims and 32 % of the total cost of claims. In 2010–11, the average duration of incapacity for injured employees with claims for psychological injuries was 12.3 months. By contrast, the duration for other types of injuries was as follows:
(a) falls, slips and trips: 4.1 months;
(b) body stressing: 3.6 months;
(c) vehicle incidents: 3.2 months;
(d) hitting / being hit by objects: 2.0 months; and
(e) other injuries and diseases: 4.2 month
The review recognises that psychological injuries can cover a range of conditions, including stress, adjustment disorder, anxiety, post-traumatic stress disorder and depreand that there can be difficulties diagnosing psychological injuries, over and above the difficulties of diagnosis involved with physical injuries; and the diagnosis often involves subjective as well as objective elements. Furthermore, multiple factors often contribute to the onset of psychological conditions (for example, underlying personality disorders, relationship problems and financial pressures, as well as work-related pressures) and it can be difficult to isolate the employment contribution to the injury.
The review makes the point that psychological injuries can also arise from an employee’s perception of and reaction to external events, which can be different to other employees’ perception of and reaction to the same events.
The reviewers also note that the rate of claims for psychological injuries for premium payers has increased by 30 % in the past three years and is four times higher than the incidence among licensees. This suggests that psychological injuries may be more of an issue in the public sector than the private sector.
The increased incidence of psychological injury claims has been attributed to a range of causes, including the increased pressures of work life, employment instability, increases in employee expectations and a more litigious society. It may be reasonable to suggest that a principal explanation for the increased incidence of psychological injury claims can be found in the increasing demands placed on employees through such mechanisms as efficiency dividends, constant performance evaluation and the restructuring of employment arrangements. A further explanation may be found in poor management practices, which might be said to reflect a low priority given to preventing or resolving workplace stress.
The reviewers point out that the various Australian workers compensation schemes use different guides to assess permanent impairment, the majority based on the fourth or fifth edition of the American Medical Association guides. The diversity in approach to assessment means that benefits can vary significantly from one scheme to another, and that there is little capacity for scheme administrators to learn from shared experience. Medical assessors also have difficulty in developing assessment skills that can be used across the schemes.
The threshold level for psychiatric injury ranges between 1% in Queensland,5% in the Northern Territory,10% in Comcare,15% inNew South Wales and in Western Australia and 30% in Victoria.There is no lump sum payment for Psychiatric injury in South Australia and the ACT. This is clearly inequitable but a reflection of the fear of governments that claims for psychological injury will overwhelm the system.
The review notes that permanent impairment claims in 2011-2012 totalled 250 of which 88 were for psychological injury.
The reviewers also discussed whether or not medical panels or tribunals would assist the process, because there are medical members of the AAT and because there is such a wide geographic range for ComCare claimants medical panels or tribunals would not be helpful. They included a table this table summarises what is done with regard to medical tribunals and panels and panels in the different states and territories.
Impairment Guide
The reviewer noted that the Strategic Issues Group on Workers’ Compensation (the SIG WC) has agreed to seek endorsement from Safe Work Australia members in March 2013 on a national permanent impairment assessment guide (the proposed National Guide) and a proposed permanent impairment assessor document. The proposed National Guide is based on AMA5, as amended by the New South Wales scheme. They recommend that the threshold be kept at 10% for both physical and psychological injuries and that the proposed National Guide be used.
My condern with regards to the prposed National Guide is that this will cement in place the PIRS as the only impairment method the determing psychological injury. I have written extensively about the PIRS elsewhere .
There does not seem to be any indication about whether or the issue of secondary and non-secondary psychiatric impairment is being considered.
I understand the reasons for the review and recognise the significant increase in psychological injury claims especially arising from “workplace bullying “. The concern is that if something is not done to rein in the costs then psychological injury will no longer be included in such schemes to the detriment of workers. My major concern is that people be claimants be treated equitably. My additional concern is the metastatic growth of the PIRS, an instrument that I regard as deeply flawed .
There was a Comcare review some years previously that led me to develop the RAPID MSE, This is a psychiatric impairment rating system dependent on the mental state examination that is not subject to gaming and measures impairment rather than disability . I encourage you to have a look at it.
The issue of confidentiality is problematic for civil forensic psychiatrists. Most of us err on the side of caution and have claimants sign a document acknowledging that the information they provide will be incorporated into a report. The information is otherwise kept confidential by me. I have no control over what happens to the report however.
We assume that because people arrive they have given implicit consent to release of information. I was involved in a recent matter before the Medical Board of Australia where the issue in question was that the “practitioner prepared and provided a report to try and company which included a possible diagnosis, without having met performed a clinical assessment of the complainant.”
in brief a complainant had arrived for a medicolegal assessment by a psychiatrist with regard to his workers compensation claim. He refused to sign the full disclosure document and was told the interview could not proceed. In the interim the psychiatrist overheard him dealing with office staff and thought he was aggressive and angry. Documentation provided to the psychiatrist indicated that he had been described as a difficult employee and “paranoid”. The psychiatrist wrote a briefing note to the insurance company stating why he had not been able to complete the examination. The psychiatrist went further. The psychiatrist wrote that he was concerned about the complainant’s behaviour and thought there was a “possibility that he does have a significant psychiatric illness” and “may have a paranoid disorder”. The psychiatrist urged the insurance company to warn future assessors that the complainant may be difficult and may make complaints about them although there was no indication of any physical threat.
This letter was used by the insurance company to deny the claim and, somewhat unwisely, the psychiatrist agreed to the release of this letter to support their decision. This led to the complainant making a complaint to the Medical Board of Australia.
Another experienced psychiatrist formed the view that he had breached confidentiality. My opinion was that behaviour had been observed in a public place ie the waiting room and that confidentiality did not apply. See definitions below.
Definitions of Medical Confidentiality
Psychiatry: The ethical principle that a physician may not reveal any information disclosed in the course of medical care.
McGraw-Hill Concise Dictionary of Modern Medicine. © 2002 by The McGraw-Hill Companies, Inc.
A substantive rule in bioethics saying that the information a patient reveals to a health care provider is private and has limits on how and when it can be disclosed to a third party; usually the provider must obtain permission from the patient to make such a disclosure.
Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. © 2003 by Saunders, an imprint of Elsevier, Inc. All rights reserved.
confidentiality /con·fi·den·ti·al·i·ty/ (kon″fĭ-den″she-al´ĭ-te) the principle in medical ethics that the information a patient reveals to a health care provider is private and has limits on how and when it can be disclosed to a third party.
Dorland’s Medical Dictionary for Health Consumers. © 2007 by Saunders, an imprint of Elsevier, Inc. All rights reserved.
The second issue was whether he was entitled to report on the behaviour he had observed and overheard. In my view he was. The third issue was whether this constituted a psychiatric report. In my view it did not. I understand a psychiatric report to be amassing considerable amount of data, doing a mental status examination and using that information to form an opinion. This did not appear to be the situation. I thought the critical matter was whether or not the psychiatrist had been fully frank in stating what informed his concerns. I believed he had done so.
This matter raises the further issue of the experience of many civil forensic psychiatrists that if claimants are not happy with the report they make a formal complaint about the psychiatrist.
I would be interested in your views on this matter. By the way the psychiatrist on the matter referred to above was found to have no charges to answer.
I have provided for your interest a link to a consent form to release claimant’ s information.
Timing in the Interview
One of the great benefits from being a member of the Medical Panels in Melbourne is that I get to work with other psychiatrists. All of them are experienced interviewers, they are all aware of the issues that need to be dealt with and the information that is required.
The differences are in the sequence of the interview. I have found this very informative. My usual style has been to establish the family network, find out any information about personal and family medical history, drug and alcohol use, accidents, psychiatric and/or psychological treatment both current and in the past and medication regime and other physical treatments. I then begin at the beginning and progressively move through family life, education, work history, marital history, recreational activity and drug and alcohol use prior to the injury or accident. I proceed to the injury/accident and what has happened since then leading to the current situation where I explore current symptoms and current treatment.
The problem with that approach has been that I sometimes find myself running out of time to comprehensively cover the current situation, which is ridiculous because that is often the focus of the interview.
I have noticed that other interviewers start with the injury and/or accident and work on from that to the current situation and then go back and look at those earlier matters. I have begun using that technique and I have found it very helpful.
Timing is critical in my interviews. If I don’t remain disciplined and on track then I run out of time to deal with essential matters. Part of the skill of the interview is to make sure that I have sufficient time to deal with the usual issues but also to deal with red herrings and other critical matters about which I had no knowledge before the interview.
The best interviewers, in my experience, seem to know intuitively when to move on to fresh areas and are able to work claimants like a sheepdog rounding up a flock of sheep. The worst interviewers seem to have no knowledge of time. I remember being in an interview which was about a man’s impairment assessment where the critical matter was his current symptomatology and level of function. To my astonishment the interviewer started to question him closely about the reasons for the breakdown of his first marriage some 30 years earlier! I was a little irritated.
The website is about to go live. It has been a much bigger project than I expected and the learning curve was almost vertical. I am still finding problems but they are being fixed, one by one.
I hope that you find the website interesting and that it meets your needs for information and provides a forum for your opinions. Membership will be limited to those professionals working in this field including psychiatrists, psychologists, lawyers and academics.
I have made some informed guesses about what you might need but if there is missing information let me know. If there are papers that you have written that you think might be interesting to others then send them to me. Please make comments about any matters that concern you. Feel free to criticise, warn, praise, excoriate and whatever. I hope this website becomes a meeting place for our shared ideas and experiences.
By the way, I understand it takes a little time before Google recognises this website so that at first you may have to use https://www.civilforensicpsychiatry.com.au.
update, civilforensicpsychiatry.com.au is now recognised by google.
Some days I finish work feeling like a wrung out dish rag, on other days, not that common, I feel exhilarated. The vast majority of claimants are cooperative, polite and have done some home work. There are a small group that can be particularly difficult. Many of these are people with whom I have great sympathy but their approach to the interview may be frustrating. Bear in mind that every plaintiff I see is meant to be given a list of the questions that I will be asking by their solicitor. (see for the list)
There are interviews that I find particularly taxing. These include interviews when I am seeing somebody who has done no preparation and is not able to provide even a reasonable history. There are other people who need to answer every question with a speech. Similarly there are those people who answer my question by answering another question I haven’t asked. There are also the people who are pissed off and are unwilling to divulge any information. Of particular difficulty are those, where for good reasons, there is concern about their credibility. These claimants are in a very small minority but nevertheless I sometimes feel the claimant and I are going through the motions.
Oh, of course there are those who right near the end of the interview (when I’m feeling done and ready for lunch) say something like “should I tell you about the sexual abuse when I was a child?” Or “did you want to hear about the accident that occurred a week ago?” and suchlike. Of course this is after I have asked all my usual questions about serious injuries, operations, accidents, WorkCover or accident claims, psychiatric or psychological treatment et cetera.. I can see lunch going out the window.
The other group that I dread seeing are those who have extremely complicated psychiatric histories often associated with drug and alcohol abuse and significant family problems. Even with the best will in the world these interviews can be extremely prolonged.
So what interviews leave me exhilarated? I see some people who have dealt with terrible injuries with extraordinary courage and resilience. I find them enormously impressive.
Are there any other types of claimants that you find particularly difficult?
A ream of paper weighs 2.5 kg, how do I know? Well, last week I weighed the paperwork of all the claimants I had seen that week. It came to 15 kg! Admittedly one of them was a desktop review and the paperwork for that weighed 7 kg alone, I was sent it the previous week but had no time to get to it until last week.. So I was sent 3000 pages (approximately) to wade through. On talking to my colleagues I realised we are all facing this avalanche of paper. The impression I get is that there is no culling process, rather a junior person is sent with a file and told to photocopy it and ‘send it off to Epstein’. Some of the paperwork includes hospital notes with handwriting that is frequently illegible and with acronyms that are unintelligible. With the tendency for health groups to be set up even the heading on the paper gives no indication as to where the person was at the time, in a hospital, a mental health clinic, or where?
I was able to decipher some of the acronyms using the Internet. I have similar problems with the acronyms used by other health professionals. It took me some time to work out what a SLAP lesion was. (It is something to do with a split in the labrum surrounding the shoulder joint.)
There are several points arising from this, one is I never get paid for the amount of time I spend reading this paperwork. The second is that a lot of the paperwork is quite useless, the third is that the only people who seem to write a reasonable history are the psychiatrists. It is amazing the number of reports I receive that are undated so I have no idea when the claimant saw that person. It is not uncommon to get an undated report from a psychologist that may mention the first interview date but gives no idea of the frequency of the treatment or if the claimant is still being treated, but there are three or four pages taken from the DSM IV giving the diagnosis!
I have adopted a few tactics to deal with this. I do not read handwritten notes because most of the them are illegible and an incredible waste of time. I charge for the number of pages I’ve been sent. I dispose of all the documentation provided immediately after the report has been released (it is physically impossible to keep this stuff) and I encourage people who send me work to be a little more selective.
I would be interested in your experiences in dealing with this avalanche.
Today I had the opportunity to use AMA 6. It took me between 15-20 minutes to do the impairment assessment using chapter 4. There are three measures. The Brief Psychiatric Rating Scale, the GAF and the PIRS. The BPRS, as you know is used mainly in inpatient facilities for people with serious mental illness to assess the response to treatment. In this case it is used as a one-off measure and many of the 26 items such as suspiciousness, hallucinations, unusual thought content, bizarre behaviour, self-neglect, disorientation, conceptual disorganisation, excitement, distractibility, mannerisms and posturing are not relevant to the type of disorders that we see. One is expected to score each of these 26 items between 1 to 7 and then add up all the numbers. Arbitrarily the summed score is related to an impairment score e.g. 41-45 equals 15%. The GAF as you know divides groups of symptoms into decades and again arbitrarily a percentage score has been attached to each decade, for example 31-40 equals 20%. Above 70 the impairment score is 0%. You then use the descriptors in the PIRS to get numbers for each function and add the two middle numbers. This sum is then used to determine the PIRS impairment score. So a sum of 5 equals 15%, a sum of 6 equals 20%, a sum of 8 equals 40% (this is different to the combining method used in the PIRS in Australia).
You are then expected to get the middle of these three scores. This is the final impairment rating. It is time consuming, without any validity and with no pretence at equity. I was so annoyed I sent an email to one of the Australian contributors to AMA 6 who assured me that because of its time-consuming assessment process it would never be used here more generally, although it is used in the Northern Territory motor accident system where the legislation requires use of the current edition of the AMA Guides.