GEPIC

An Introduction to

Guide for the Evaluation of Psychiatric

Impairment for Clinicians

Dr Michael Duke

Senior Forensic Psychiatrist

What is psychiatric impairment?

A psychiatric impairment is any loss

of psychological or mental function.

Mental function impairment includes: Speech

Perception

Judgment

Mood

Thinking

Intelligence

Behaviour

Correlate GEPIC descriptors to MSE

Use GEPIC method to find Whole

Person Impairment (WPI)

Subtract impairment unrelated to

accident

Subtract impairment due to

consequential mental harm

What use is made of the MSE?

Statutory schemes as a:

Threshold trigger

Means for determining level of benefits

A reliable means of measuring psychiatric percentage

impairment is critical for users, tribunals and claimants.

If there is no reliable method then psychiatric injury may be

excluded from statutory schemes. This has happened in NZ and in

SA for WorkCover lump sum benefits

All jurisdictions treat mental injury adversely compared with

physical injury:

? due to prejudice and fears of cheating (can‘t people make

up symptoms and fool the assessor?)

Potential cost blowouts

Why do we assess

psychiatric impairment?

Gate-keepers

Victorian Accident Compensation Act

To determine ―serious injury

To determine compensation for non-economic

loss

Victorian Transport Accident Act

To determine impairment benefits

To allow for common law claims

Threshold for personal injury claims re Victorian Wrongs Act (Civil

Liability legislation)

Reasons for Measurement of Psychiatric

Impairment – the Victorian Experience

Appear to measure impairment

Be based on the MSE

Be easily and rapidly administered

Produce a percentage score

Reliable; different examiners produce similar results

Be resistant to cheating

Equitable – seems fair and not designed to force claimants below a

threshold.

Have broad acceptance as fair and reasonable

Be defensible in court and tribunal settings

Impairment: reduction or loss of a physical/mental function and is

determined by clinicians

Disability: reduction in ability arising from an impairment and is

determined by the courts

Any sensible method of measuring

psychiatric impairment

must

There usually needs to be a diagnosable psychiatric disorder.

The disorder must lead to impairment.

There has to be a clearly established link between the accident

and the psychiatric disorder.

The psychiatric disorder is not secondary to physical injury, in

South Australian terms 'consequential mental harm.‘

Compensable Psychiatric Impairment

No 'gold standard‘

Blurring of impairment and disability

Relies on self-reporting

Overlap between neurological injury and psychiatric injury

Pain disorders

Problems with measuring psychiatric

impairment

1. The mental state examination as used by consultant psychiatrists, is the

prime method of evaluating psychiatric impairment.

2. Diagnosis among the factors to be considered.

3. Consider other factors - educational, financial, social and family situation.

4. Character and value system of the individual of considerable

importance.

5. Motivation for improvement is a key factor in outcome.

6. Review all treatment and rehabilitation methods.

7. Final judgement when history of illness, treatment, rehabilitation and of

current mental and physical status and behaviour considered.

Principles of Psychiatric Impairment

Assessment

Mood - a pervasive lasting emotional state

Affect is mood noted during the period of the mental state examination.

Affect has a number features, including:

Range: Variability of emotional expression over a period of time,

i.e., if only one mood is expressed over a period of time, the affective

range is restricted.

Amplitude: Amount of energy expended in expressing a mood, i.e., a

mild amplitude of anger is manifested by annoyance and irritability.

Stability: Slow shifts of mood are normal. Rapid shifts (affective

lability) may be pathological.

Appropriateness: The ―fit (or congruency) between the affect and the situation.

Quality of Affect: Suspicious, sad, happy, anxious, angry, apathetic.

Relatedness: Ability to express warmth, to interact emotionally and to

establish rapport.

An example of one of the 6 factors

Mood (descriptors only indicative)

Class Impairment Description

1 0 - 5% Normal to Slight

- relatively transient expressions of sadness, happiness,

anxiety, anger and apathy; - normal variation of mood

associated with upsetting life events.

2 10 - 20% Mild

- mild symptoms: some or all of the below

• mild depression;

• subjective distress leading to some mild interference with

function;

• reduced interest in usual activities;

• some days off; reduced social activities;

• fleeting suicidal thoughts;

• some panic attacks;

• heightened mood; - may experience feelings of derealisation or

depersonalisation.

Mood

3 25 - 50% Moderate Impairment - moderate symptoms: some or all of the below: frequent anxiety attacks with

somatic concomitants; inappropriate self-blame and/or guilt; persistent suicidal

ideation or suicide attempts; marked lability of affect; significant lethargy;

social withdrawal leading to major problems in interpersonal relationships;

anhedonia;

appetite disturbance with significant weight change; psychomotor

retardation/agitation; hypomania; severe depersonalisation.

4 55 - 75% Moderately Severe - cannot function in most areas constant agitation; - violent manic excitement;

repeated suicide attempts; - remains in bed all day; extreme self neglect;

extreme anger /hypersensitivity;

- requires supervision to prevent injury to self or others.

5 Over 75% Severe - severe depression, with regression requiring attention and assistance in all

aspects of self care; - constantly suicidal;

- manic excitement requiring restraint.

Mood (cont)

The GEPIC Table

GEPIC Severity Ratings

The GEPIC Table with Severity Ratings

6 mental functions in 5 classes

Each function is allotted a class –consistent with the MSE. e.g

MSE no perceptual problems yet Class 2 in GEPIC!

Determine the median class; the median number is the middle

number.

11 22 33, the middle number is 2.

12 33 33, the middle number is 3.

11 22 22, the middle number is 2.

The final percentage lies within the range of the median class.

Class 2 is between 10-20%.

Use severity ratings to locate impairment in class

Determining Whole Person

Psychiatric Impairment

Acquired brain injury: impairment involves two disciplines,

neurology and psychiatry.

Cognitive Dysfunction and Behavioural Disturbance can

be measured using Chapter 4 AMA 5 and/or the GEPIC

Strong likelihood of overlap.

Behavioural disturbance best measured using Chapter 4

Behavioural disturbance may be a manifestation of

physical injury and is consequential mental harm. It may

be counted using the GEPIC if there is no TBI.

Overlap Between Psychiatric and

Neurological Impairment

Does it measure impairment: YES

Easily and rapidly administered?- YES

Obtains a percentage score? YES

Reliable?- POSSIBLE

Cheating?-UNLIKELY

Equitable – YES

Controversial - NO

Defensible in court and tribunal settings- YES

Does it seem to do the job – YES

How does GEPIC rate as an

impairment guide?

The equivalent terms in Victoria are “impairment secondary or consequential to physical

injury”

Annotations for Determining Non Secondary

Psychiatric impairment: Dr Michael Epstein & Dr Nigel Strauss were recruited to assist with this

process.

Categories

Differentiating ‘pure mental harm’ from

‘consequential mental harm’

Impairment unrelated to the injury

Impairment unrelated to the accident includes:

Pre-existing impairment present at the time of the impairment

assessment (e.g. a chronic schizophrenic disorder)

Pre-existing impairment - no longer present at the time of the

impairment assessment (e.g. a major depressive disorder that

was successfully treated and for which there has been no

ongoing treatment or symptoms)

Pre-existing impairment present at the time of the impairment

assessment exacerbated by the accident (e.g. a chronic anxiety

disorder)

Impairment arisen since the injury and unrelated to the injury

(a non-injury related assault leading to the development of a

post traumatic stress disorder)

Injury from another trauma

Stability is defined as impairment that will not vary by more than

3% in the next 12 months (American Medical Association Guides

to the Evaluation of Permanent Impairment).

The issue of stability is very important.

The whole person impairment can usually only be finalised when

the claimant‘s condition is considered stable. If the injury is not

considered to be stable the claimant is left in limbo.

Stability

The condition is usually stable if:

The claimant‘s accident injury occurred some years previously.

If the claimant has had a variety of treatment with no change in

symptoms.

If the above 2 conditions apply it is unlikely a pain management

program will bring about significant change.

Although psychiatric or psychological treatment may have been

beneficial at some time it is now unlikely to bring about much

change (but may prevent further deterioration).

Stability II

1. Why are there gaps between the percentage levels?

2. What about people who don‘t speak English or who can‘t speak?

3. Do people need to have a psychiatric diagnosis to be assessed?

4. What is the situation with children?

5. Can people fool the assessor?

6. Why do the Guides use the median rather than average scores?

7. Why doesn‘t GEPIC use a list of typical symptoms eg. flashbacks

8. Why is it only used by psychiatrists

9. Is there much consistency between assessors?

10. How long does an impairment assessment take?

FAQs

1. Measurement of psychiatric impairment is an important part of all

benefits schemes

2. Psychiatric illness can arise from a number of causes including work

injury and motor accidents

3. The Guides for the Evaluation of Psychiatric Impairment for Clinicians

and its precursor has been used extensively in Victoria since 1997 with

ready acceptance.

4. The GEPIC is now required to assess psychiatric impairments for

RTW Claims in South Australia.

5. Training of psychiatric assessors in the use of GEPIC will commence

soon.

Conclusions