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The “Complete” IMEThe “Complete” IMEC. Donald WilliamsC. Donald Williams MD CGPMD CGP

Integrating file review, literature Integrating file review, literature references, interview findings, the references, interview findings, the MMPI-2, the SIRS, or what I have MMPI-2, the SIRS, or what I have

learned from 31 years of mistakeslearned from 31 years of mistakes

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Why this presentation?Why this presentation?

• Uneven quality of psychiatric IME’s “in Uneven quality of psychiatric IME’s “in the field”the field”

• Human cost—denial or delay of Human cost—denial or delay of treatment with damage to individuals treatment with damage to individuals and families and broader cost to and families and broader cost to communitycommunity

• Economic waste—unnecessary litigation Economic waste—unnecessary litigation

• Aim to set a new practice standardAim to set a new practice standard

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Prerequisites for excellencePrerequisites for excellence

• DiligenceDiligence

• Attention to detailAttention to detail

• HumanenessHumaneness

• Moral clarityMoral clarity

• IngenuityIngenuity

– From Commonwealth Club lecture by From Commonwealth Club lecture by Atul Gawande, MDAtul Gawande, MD Professor of Surgery, Professor of Surgery, Harvard Medical School—transcript included with permission of Harvard Medical School—transcript included with permission of Radio AustraliaRadio Australia

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The “complete” IME…The “complete” IME…

• Detailed line by line record review of…Detailed line by line record review of…– All IME’sAll IME’s– All medical treatment, PCE’s, legal recordsAll medical treatment, PCE’s, legal records– Surveillance videos—minute by minuteSurveillance videos—minute by minute

• Detailed interview—90-120 minutesDetailed interview—90-120 minutes• Psychological testing Psychological testing

– MMPI-2 MMPI-2 – SIRS, other self report tests e.g. BDI-II, PHQ-9SIRS, other self report tests e.g. BDI-II, PHQ-9

• Logical synthesis of all elementsLogical synthesis of all elements• Some relevant literature referencesSome relevant literature references

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Why “complete” IME’s are Why “complete” IME’s are neededneeded

• High stakes High stakes and/orand/or

• Big file Big file and/orand/or

• Conflict of opinion with sides dug in Conflict of opinion with sides dug in and/orand/or

• Poorly written prior IME’s Poorly written prior IME’s and/orand/or

• When opinion will be challenged as a When opinion will be challenged as a matter of policy of other sidematter of policy of other side

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Clarity of contract with Clarity of contract with clientclient• Clear client expectations, i.e. no shaded Clear client expectations, i.e. no shaded

outcomesoutcomes• Assignment letter with questionsAssignment letter with questions• Resources you needResources you need

– Knowledge and experienceKnowledge and experience– TimeTime—nights and weekends—nights and weekends– Staff to proofreadStaff to proofread– CommitmentCommitment of your practice – not a of your practice – not a

“sideline”“sideline”

• Time line for completion and deliveryTime line for completion and delivery

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Informed consentInformed consent

• Explicit examinee notificationExplicit examinee notification– Non-confidentialityNon-confidentiality– Who gets a copy of the reportWho gets a copy of the report– No doctor patient relationship offeredNo doctor patient relationship offered– Describe length of evaluationDescribe length of evaluation

• Respectful of examineeRespectful of examinee

• Query re: understandingQuery re: understanding

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Psychological testingPsychological testing

• Self report questionnaires such as BDI-Self report questionnaires such as BDI-II, Zung, and PHQ-9 easily challenged in II, Zung, and PHQ-9 easily challenged in litigation, but useful for treatment eval.litigation, but useful for treatment eval.

• Objective and validated instruments Objective and validated instruments stronger. stronger. – MMPI-IIMMPI-II– SIRS SIRS (Structured Interview of Reported Symptoms)(Structured Interview of Reported Symptoms)

– TOMM TOMM (Test of Malingered Memory-(Test of Malingered Memory-neuropsychology)neuropsychology)

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One of today’s goals:One of today’s goals:develop surface familiaritydevelop surface familiarity

with MMPI-2 and SIRS--with MMPI-2 and SIRS--NotNot to teach their use to teach their use

(also to recognize poor use of (also to recognize poor use of MMPI)MMPI)

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For quick overview of For quick overview of psychological testing, psychological testing, GoogleGoogle

----

‘‘Mmpi-2 profile psych 427’Mmpi-2 profile psych 427’

[http://www.csun.edu/~gk45683/P427%20-%2014%20-%20Structured[http://www.csun.edu/~gk45683/P427%20-%2014%20-%20Structured%20Personality%20Tests%20-%20bw.pdf]%20Personality%20Tests%20-%20bw.pdf]

““Structured Personality TestsStructured Personality TestsPsych 427-Psychological TestingPsych 427-Psychological Testing

Gary S. Katz Ph.D.”Gary S. Katz Ph.D.”

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MMPI-2MMPI-2

• ValidityValidity scales scales

• ClinicalClinical scales scales

• SupplementarySupplementary scales scales

• All have All have raw scoresraw scores which are converted which are converted to statistically defined to statistically defined T T scores—scores—– A A T scoreT score of 90 has the same statistical of 90 has the same statistical

meaning from one scale to anothermeaning from one scale to another– Scores of Scores of >65 >65 are interpretableare interpretable

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MMPI-2MMPI-2• Validity scalesValidity scales -advantage over self report -advantage over self report

inventories—what was the “response set of test inventories—what was the “response set of test taker ?”taker ?”– VRIN-VRIN-variable response inconsistency to paired itemsvariable response inconsistency to paired items– TRINTRIN-measure of “fixed responding” to paired items-measure of “fixed responding” to paired items– FF-“in-“inFFrequency scale” higher scores=symptom exaggeration in requency scale” higher scores=symptom exaggeration in

normal normal populationpopulation– FbFb-“in-“inFFrequency requency backback scale” items 371-567 scale” items 371-567 normalsnormals– FpFp-“in-“inFFrequency” scale for psychiatric inpatientsrequency” scale for psychiatric inpatients– FBSFBS—primarily related to head injury >29 suggests non-credible—primarily related to head injury >29 suggests non-credible– LL -higher scores=overly virtuous/naïve presentation-the “look -higher scores=overly virtuous/naïve presentation-the “look

good” profile good” profile – K K -higher scores=unintentional underreporting-higher scores=unintentional underreporting

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The The numbersnumbers represent represent Clinical scalesClinical scales

1—Hs 1—Hs (hypochondriasis)(hypochondriasis)

2—D 2—D (Depression)(Depression)

3—Hy 3—Hy (Hysteria)(Hysteria)

4—Pd 4—Pd (Psychopathic (Psychopathic deviate)deviate)

5—Mf 5—Mf (Masculine/feminine)(Masculine/feminine)

• 6—Pa 6—Pa (paranoia)(paranoia)

• 7—Pt 7—Pt (psychasthenia (psychasthenia ““anxiety with obsessiveanxiety with obsessive compulsive features”compulsive features”))

• 8—Sc 8—Sc (schizophrenia)(schizophrenia)

• 9—Ma 9—Ma (mania)(mania)

• 10—Si 10—Si (social (social introversion)introversion)

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Restructured Clinical ScalesRestructured Clinical Scales

• Developed to capture demoralization, Developed to capture demoralization, identify the “core components” of the identify the “core components” of the clinical scales, related to but distinct from clinical scales, related to but distinct from the Clinical scales. the Clinical scales.

• RCd, RC1 through RC9, each capturing the RCd, RC1 through RC9, each capturing the essential component of each scale, without essential component of each scale, without the demoralization component.the demoralization component.

• Example—RC2Example—RC2lpelpe identifies depression identifies depression separately from demoralization; RC3som separately from demoralization; RC3som measures somatization separate from measures somatization separate from demoralization—will illustrate with clinical demoralization—will illustrate with clinical exampleexample

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PSY-5 ScalesPSY-5 Scales

• Personality psychopathologyPersonality psychopathology: were : were designed to measure 5 broad personality designed to measure 5 broad personality traits, on the more pathologic end of the traits, on the more pathologic end of the dimension. There is a great deal of dimension. There is a great deal of evidence that these scales have utility.evidence that these scales have utility.

• AGGR, PSYC, DISC, NEGE, INTRAGGR, PSYC, DISC, NEGE, INTR• Stable over 5 yearsStable over 5 years• Do not directly correlate with specific Axis Do not directly correlate with specific Axis

II diagnosesII diagnoses

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““The The Welsh codeWelsh code is 3”2 is 3”248614861’+-7’+-70/90/95: 5: FL+-/K”FL+-/K”

What does this mean?What does this mean?

(Hint: Look at (Hint: Look at numbers, punctuation numbers, punctuation marks, letters, marks, letters, andand underlinesunderlines))

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Welsh code profile Welsh code profile T scores= T scores=

punctuation marks punctuation marks ((numbersnumbers))

• 100 or more = 100 or more = ****

• 90-99 = 90-99 = **

• 80-89 = 80-89 = ““

• 70-79 = 70-79 = ‘‘

• 65-69 = 65-69 = ++

• 60-64 = 60-64 = ––

• 50-59 = 50-59 = //

• 40-49 = 40-49 = ::

• 30-39 = 30-39 = ##

• 29 or less—no T 29 or less—no T scores below 30scores below 30

• __ joining Welsh symbols joining Welsh symbols means scores identicalmeans scores identical

((underlines)underlines)

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To interpret an MMPI-2To interpret an MMPI-2

• First establish First establish validityvalidity by examining by examining validity scale pattern, then, if valid….validity scale pattern, then, if valid….

• Code typesCode types are patterns of scale elevations are patterns of scale elevations that have statistically demonstrated high that have statistically demonstrated high correlations with clinical findings— correlations with clinical findings— more more reliablereliable than single scale interpretations than single scale interpretations

• Then interpret profile according to Then interpret profile according to T T scoresscores, starting with highest, starting with highest

• Examine RC scales (purer content than Examine RC scales (purer content than clinical)clinical)

• Examine PSY-5 scales to assess stable traitsExamine PSY-5 scales to assess stable traits

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Validity and content scales same person 2008 & 2007 after one year of group and Validity and content scales same person 2008 & 2007 after one year of group and individual psychotherapy—note reduction of FBS and major reductions in scales 1 and 3individual psychotherapy—note reduction of FBS and major reductions in scales 1 and 3

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Restructured clinical (RC) scales same person 2008 & 2007—following one year of group Restructured clinical (RC) scales same person 2008 & 2007—following one year of group and individual psychotherapy. Note reduction in and individual psychotherapy. Note reduction in lpelpe (depression) and (depression) and somsom (somatization)(somatization)

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PSY-5 scales same person 2008 & 2007—Note relative stability of PSY-5 scales same person 2008 & 2007—Note relative stability of traitstraits, although , although INTR INTR is showing improvement with group and individual psychotherapy which we would expect is showing improvement with group and individual psychotherapy which we would expect with personality change.with personality change.

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SStructured tructured IInterview of nterview of RReported eported SSymptomsymptoms

• Best validated measure of Malingering, Best validated measure of Malingering, especially when combined with MMPI-2.especially when combined with MMPI-2.

• SStructured tructured IInterview of nterview of RReported eported SSymptomsymptoms, , Richards R et al (1992) copyright PAR, Inc.Richards R et al (1992) copyright PAR, Inc.

• ““Structured Interviews and Dissimulation,” Structured Interviews and Dissimulation,” Rogers R, in Rogers R, in Clinical Assessment of Clinical Assessment of Malingering and DeceptionMalingering and Deception, Rogers R Ed, 2nd , Rogers R Ed, 2nd Edition, Guildford Press (1997) pp. 320-327.Edition, Guildford Press (1997) pp. 320-327.

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Record reviewRecord review

• Have staff arrange file according to Have staff arrange file according to file type (file type (IME, Medical treatment IME, Medical treatment records, Physical therapy records, records, Physical therapy records, Vocational recordsVocational records andand Legal Legal correspondencecorrespondence) and date, oldest to ) and date, oldest to newestnewest

• List every file, with content summary List every file, with content summary when germane to psychiatric opinionwhen germane to psychiatric opinion

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Report templatesReport templates

• Create your own, modify with Create your own, modify with experienceexperience

• Save timeSave time

• Prevents omission of important dataPrevents omission of important data

• Standardizes presentation formatStandardizes presentation format

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““Surveillance”Surveillance”

uses and misusesuses and misuses

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““Surveillance” Surveillance”

• ““AnAn addendum letter dated September 28, addendum letter dated September 28, 2004 prepared by Michael B. M.D. 2004 prepared by Michael B. M.D. commented on surveillance videotapes. commented on surveillance videotapes. Dr. B. stated that he did not Dr. B. stated that he did not recognize the claimantrecognize the claimant. However, he . However, he nevertheless concluded that he suspected nevertheless concluded that he suspected that she was not truthful in all aspects of that she was not truthful in all aspects of her physical examination. On this basis her physical examination. On this basis he diagnosed probable malingering.”he diagnosed probable malingering.”

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SurveillanceSurveillancedocumentation documentation • ““Then Then Video Track 2Video Track 2 appears on the screen which appears on the screen which

is visualized from 00:00 through 01:29 in which is visualized from 00:00 through 01:29 in which she appears to be adjusting a garden hose and she appears to be adjusting a garden hose and repositioning a yard sprinkler. Nothing is repositioning a yard sprinkler. Nothing is visualized from 01:35 until 02:10 when she visualized from 01:35 until 02:10 when she emerges from behind a building and walks over in emerges from behind a building and walks over in the direction of the utility building. She wanders the direction of the utility building. She wanders around, limping, and then disappears behind the around, limping, and then disappears behind the utility building at 02:39. Nothing is visualized utility building at 02:39. Nothing is visualized between 02:39 until 02:54 when there is a break in between 02:39 until 02:54 when there is a break in the video sequence and she takes another drink the video sequence and she takes another drink from a bottle. She disappears inside the utility from a bottle. She disappears inside the utility building at 03:00. Nothing is visualized from 03:00 building at 03:00. Nothing is visualized from 03:00 until 04:50. That concludes Video Track 2.”until 04:50. That concludes Video Track 2.”

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Sample surveillanceSample surveillancevideovideo

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Surveillance commentary—Surveillance commentary—with literature citations for supportwith literature citations for support

• ““In addition, information obtained from video surveillance is inherently In addition, information obtained from video surveillance is inherently subjective with no proven inter-rater reliability or statistical validation. This subjective with no proven inter-rater reliability or statistical validation. This particular sequence has particularly significant shortcomings. It is a heavily particular sequence has particularly significant shortcomings. It is a heavily edited, discontinuous, extremely small sample, and is of far less edited, discontinuous, extremely small sample, and is of far less significance than a comprehensively validated psychological test significance than a comprehensively validated psychological test instrument that has been administered to millions of people. Furthermore, instrument that has been administered to millions of people. Furthermore, there are no articles in the there are no articles in the Journal of Occupational and Environmental Journal of Occupational and Environmental Medicine Medicine that address the use of surveillance videos in malingering. In a that address the use of surveillance videos in malingering. In a search of search of PubMedPubMed (the database of all scientific health literature maintained (the database of all scientific health literature maintained by the National Library of Medicine and the National Institutes of Health by the National Library of Medicine and the National Institutes of Health there are only two articles, neither related to the issues in this case.there are only two articles, neither related to the issues in this case.[[11]] Consequently, it is my opinion that the surveillance videos are without Consequently, it is my opinion that the surveillance videos are without substance. By contrast, the MMPI-2 and the SIRS have established validity substance. By contrast, the MMPI-2 and the SIRS have established validity and inter-rater reliability in the detection of malingering and factitious and inter-rater reliability in the detection of malingering and factitious disorders.”disorders.”

• [1] Westbrook LE et al. Nonepileptic seizures after head injury. Epilepsia. [1] Westbrook LE et al. Nonepileptic seizures after head injury. Epilepsia. 1998 Sep;39(9):978-82. 1998 Sep;39(9):978-82. PMID: 9738677 [PubMed - indexed for MEDLINE]PMID: 9738677 [PubMed - indexed for MEDLINE]

• Kurlan R et al. Movement disorder in reflex sympathetic dystrophy: a case Kurlan R et al. Movement disorder in reflex sympathetic dystrophy: a case proven to be psychogenic by surveillance video monitoring. Mov Disord. proven to be psychogenic by surveillance video monitoring. Mov Disord. 1997 Mar;12(2):243-5. No abstract available1997 Mar;12(2):243-5. No abstract available

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Integration of records, Integration of records, interview, literature interview, literature

references, and testingreferences, and testing

Clarity and completenessClarity and completeness

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Sample assignment question Sample assignment question responseresponse• ““Your diagnosis for conditions causally related to this Your diagnosis for conditions causally related to this

industrial injury.”industrial injury.”• Response:Response: “The diagnoses “The diagnoses Major Depressive Disorder, single Major Depressive Disorder, single

episode, moderate/severe episode, moderate/severe and and Pain Disorder associated with Pain Disorder associated with psychological factors and a general medical conditionpsychological factors and a general medical condition are are causally related on a medically more probable than not basis to the causally related on a medically more probable than not basis to the industrial injury. Although Mr. Hxxxx has had serious problems with industrial injury. Although Mr. Hxxxx has had serious problems with adjustment on account of his personality disorder throughout his adjustment on account of his personality disorder throughout his entire life, he has not experienced a Major depression prior to this entire life, he has not experienced a Major depression prior to this industrial injury. His personality disorder and its attendant rigidity industrial injury. His personality disorder and its attendant rigidity rendered him significantly more vulnerable to the development of a rendered him significantly more vulnerable to the development of a Major depression because he has little adaptive capacity. There is a Major depression because he has little adaptive capacity. There is a strong characterologic quality to his depressive disorder, but he strong characterologic quality to his depressive disorder, but he satisfies DSM IV criteria for the diagnosis of MDD, and it is satisfies DSM IV criteria for the diagnosis of MDD, and it is necessary to adhere strictly to diagnostic criteria in order to necessary to adhere strictly to diagnostic criteria in order to maintain consistency. maintain consistency. Whether or not a claimant has Whether or not a claimant has personality traits that are irritating should not be allowed personality traits that are irritating should not be allowed to interfere with an objective rating and diagnostic to interfere with an objective rating and diagnostic process.”process.”

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Category ppd ratings Category ppd ratings discussiondiscussion• ““Mr. Hxxxx presently reflects an impairment that most closely corresponds Mr. Hxxxx presently reflects an impairment that most closely corresponds

to a (high) to a (high) Category 4Category 4 level of mental health impairment, essentially just level of mental health impairment, essentially just below the cutoff for a below the cutoff for a Category 3Category 3 rating. I do not believe that he is fixed rating. I do not believe that he is fixed and stable, however, and this estimate is my impression of his current and stable, however, and this estimate is my impression of his current impairment. With both orthopedic and psychopharmacologic treatment impairment. With both orthopedic and psychopharmacologic treatment (but not with psychotherapy) he could improve to a (but not with psychotherapy) he could improve to a Category 2Category 2 level, level, although the chance of this degree of improvement is probably less than although the chance of this degree of improvement is probably less than 30%; it is more likely that with effective orthopedic intervention and 30%; it is more likely that with effective orthopedic intervention and antidepressant medication (prescribed by his regular physician) that he antidepressant medication (prescribed by his regular physician) that he would plateau at would plateau at Category 3Category 3. His pre-existing level of mental health . His pre-existing level of mental health impairment most closely corresponds to impairment most closely corresponds to Category 2Category 2. Because the criteria . Because the criteria as defined in WAC 296-20-340 utilize archaic language and because the as defined in WAC 296-20-340 utilize archaic language and because the rating scale has not been validated, and because as a result consistency in rating scale has not been validated, and because as a result consistency in mental health impairment ratings has been difficult to achieve in the mental health impairment ratings has been difficult to achieve in the industrial insurance arena, I industrial insurance arena, I excerptedexcerpted a table from a recent article a table from a recent article[1][1] that that proposes a correspondence among two validated rating scales and the proposes a correspondence among two validated rating scales and the WAC ratings. I WAC ratings. I boldfaced and underlinedboldfaced and underlined the criteria satisfied by Mr. the criteria satisfied by Mr. Hxxxx under each of the three rating scales.”Hxxxx under each of the three rating scales.”

•[1][1] Williams CD. “Psychiatric disability assessments.” Williams CD. “Psychiatric disability assessments.” Psychiatric AnnalsPsychiatric Annals,, 2006;36(11) 774-7832006;36(11) 774-783

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GAF 21-40GAF 21-40 AMA Guide Class AMA Guide Class 4—Marked 4—Marked ImpairmentImpairment

WAC 296-20-340WAC 296-20-340

Some impairment in reality Some impairment in reality testing or communication testing or communication (e.g., speech is at times (e.g., speech is at times illogical, obscure, or illogical, obscure, or irrelevant) OR irrelevant) OR major major impairment in several impairment in several areas, such as work or areas, such as work or school, family relations, school, family relations, judgment, thinking, or judgment, thinking, or moodmood (e.g., (e.g., depressed depressed manman avoids friends, neglects avoids friends, neglects family, and is family, and is unable to unable to workwork; child frequently beats ; child frequently beats up younger children, is up younger children, is defiant at home, and is defiant at home, and is failing at school).failing at school).

Behavior is considerably Behavior is considerably influenced by delusions or influenced by delusions or hallucinations OR serious hallucinations OR serious impairment in impairment in communication or judgment communication or judgment (e.g., sometimes incoherent, (e.g., sometimes incoherent, acts grossly inappropriately, acts grossly inappropriately, suicidal preoccupationsuicidal preoccupation) ) OR inability to function in OR inability to function in almost all areas (e.g., stays almost all areas (e.g., stays in bed all day; no job, home, in bed all day; no job, home, or friends). or friends).

Impairment levels Impairment levels significantly significantly impede useful impede useful functioningfunctioning

Very poor judgmentVery poor judgment, marked , marked apprehension with startle reactions, apprehension with startle reactions, foreboding leading to indecision, foreboding leading to indecision, fear of being alone and/or fear of being alone and/or insomnia; insomnia; some psychomotor some psychomotor retardation or suicidal retardation or suicidal preoccupationpreoccupation; fear-motivated ; fear-motivated behavior causing moderate behavior causing moderate interference with daily life; interference with daily life; frequently recurrent and disruptive frequently recurrent and disruptive organ dysfunction with pathology of organ dysfunction with pathology of organ or tissues; obsessive-organ or tissues; obsessive-compulsive reactions causing compulsive reactions causing inability to work with others or inability to work with others or adapt; episodic losses of physical adapt; episodic losses of physical function from hysterical or function from hysterical or conversion reactions lasting longer conversion reactions lasting longer than several weeks; than several weeks; misperceptions including sense misperceptions including sense of persecutionof persecution or grandiosity or grandiosity which may cause which may cause domineering, domineering, irritable or suspicious behaviorirritable or suspicious behavior; ; thought disturbance causing thought disturbance causing memory loss that interferes with memory loss that interferes with work or recreation; periods of work or recreation; periods of confusion or vivid daydreams that confusion or vivid daydreams that cause withdrawal or reverie; cause withdrawal or reverie; deviations in social behavior deviations in social behavior which cause concern to otherswhich cause concern to others; ; lack of emotional control that is lack of emotional control that is a nuisance to family and a nuisance to family and associatesassociates; moderate disturbance ; moderate disturbance from organic brain disease such as from organic brain disease such as to require a moderate amount of to require a moderate amount of supervision and direction of work supervision and direction of work

day activities.day activities.

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SummarySummary

• Detailed and documented record reviewDetailed and documented record review

• Thorough interviewThorough interview

• Appropriate psychological testing and analysisAppropriate psychological testing and analysis

• Literature references to support conclusionsLiterature references to support conclusions

• Carefully explained rationale for conclusionsCarefully explained rationale for conclusions

• Objectivity, detail, and careful reasoning Objectivity, detail, and careful reasoning withoutwithout prejudice prejudice

==

Superior IMESuperior IME

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•Further Issues and Questions?Further Issues and Questions?