Determination of Cause AOOP 07

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Posttraumatic Psychiatric Disorders Determination of Cause

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The Plan Overview of the Independent Medical Evaluation. Overview of Posttraumatic Stress Disorder, diagnostic criteria and information pertaining to cause. Overview of Somatoform Disorders, diagnostic criteria and information pertaining to cause. Case presentation. Discussion of determination of cause.

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Disclosures As a matter of principle I accept no money from corporations other than fee for service. And when Pfizer quit taking me on guided fishing trips I quit seeing their reps. When I come to Utah 35 years ago I seen a new kinda language. I learned ut. If I talk funny I know better. If you haven’t lived in Utah this won’t be funny. I admit I could be influenced by money but so far no one has offered.

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Professional Background For 16 years I have been treating PTSD to remission with a combination of Eye Movement Desensitization and Reprocessing (EMDR) and basic psychoanalytic technique. Single adult trauma ASD and PTSD usually resolves in a few sessions. This experience will influence many of the comments I will be making.

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DSM- IV-TR Fourth Edition 2000 The American Psychiatric Association The Science

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Science and the Parable of the Small, Elderly Woman at the Airport, Legal Version

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Independent Medical Evaluations Psychiatrists may play an essential role in providing public or private agencies, or the legal system with clarification of psychiatric issues for purposes of claims management, employee management or litigation. There is a need to bring psychiatric knowledge expressed in understandable language to the legal framework that defines the issues in question. Issues of scientific probability, uncertainty and controversy that psychiatrists contemplate daily may not be helpful is resolving a specific practical problem. ( IME’s )

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Legal Frameworks for IME’s Workers Compensation Impairment Rating Injury Litigation Disability Determination Fitness for Duty Evaluation Department of Labor 'Referee Examination' Americans with Disability Act Determinations Employee Risk Assessment Posttraumatic Incident Evaluation

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It Is Not About Treatment If you do any IME work, have the evaluee (never 'patient') sign a consent form that says no doctor-patient relationship will be established and no treatment will be provided. Your obligation is to the agency paying for the evaluation. Your obligation as a psychiatrist is to provide an objective report based on evidence. You may have to present evidence to clarify why laws or regulations do not apply to a given case.

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It Is About Evidence Scientific psychiatric evidence is based on groups of persons, numbers and probabilities to reduce uncertainty due to the inherent variability in individuals. Clinical evidence starts with a broad base of evidence, using method to reduce the uncertainty inherent in applying statistical information based on groups, to specific individuals. IME evidence is similar to clinical evidence but it is not about treatment. The usefulness, effectiveness, and defendability of an IME depends on the skill and method used to present information relevant to a specific problem.

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It Is About Teaching Very often the agency personnel who will use the IME for agency or legal purposes know nothing about Psychiatry or the difference between psychiatry and other professions. The IME may be challenged and you may have to justify and defend your conclusions. The challenge may be rigorous, vigorous, and anti-psychiatric. You are the expert representing psychiatry. You may have to teach the evaluee about the nature of an IME and your intent to be objective. Most evaluees arrive with serious misgivings.

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It Is About Diagnosis Build evidence into the report to substantiate the diagnosis. Conclusions will be determined by the diagnosis and the evidence used to support the diagnosis

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It Is About Answering Specific Questions Does the employee have a psychiatric disorder? Did the incident in question cause the psychiatric disorder? Does the psychiatric disorder cause ratable impairment? Does the psychiatric disorder cause inability to perform his occupational duties? Does the employee present a serious risk to self or others in the workplace? Is there an accommodation that would allow the employee to perform essential occupational duties?

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Focus: Posttraumatic Stress Disorder Somatoform Disorders Others: Traumatic Brain Injury Depression

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PTSD PTSD must have an essential external cause. Conversion Disorder Misdiagnosis is common. It is not just a diagnosis of exclusion. 'Internal' psychological or psychodynamic processes and conflicts cause the symptoms. Causation Is Multi-factorial, But...

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Correlation or temporal association does not prove cause and effect. But correlation is sometimes conspicuous and the cause of an event may appear 'obvious' because of correlation. Correlation

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Confirmation Bias 'It turns out that all animals and humans have what researchers call a built-in confirmation bias. Animals and humans are wired to believe that when two things happen closely together in time it’s not an accident; instead the first event caused the second thing to happen…which is why B. F. Skinner called this kind of behavior animal superstition. 'Confirmation bias is built into human brains, and it helps us learn. Coincidence is actually a fairly advanced concept both for animals and for people. The downside to having a built-in confirmation bias is that you also make a lot of unfounded causal connections. That is what a superstition is.' 'Moreover, our brains are wired to believe that a correlation is also a cause. The same part of the brain that lets us learn what we need to know, and find the things we need to stay alive is also the part of the brain that produces delusional thinking and conspiracy theories.' Temple Grandin, Animals in Translation, 2005 .

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…but for the... Wise King Solomon said:

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If a rock falls at a job site and breaks into half a rock you can weigh it and and say, 'Yes, this is half a rock.' If a man falls at a job site and says, 'Now I am only half a man', weighing the man doesn’t help. The difference is the brain, or traditionally, the mind, so said Sherlock. Sherlock Says:

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309.81 - Posttraumatic Stress Disorder A. The person has been exposed to a traumatic event in which both of the following were present: (1) the person experienced, witnesses or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others (2) the person's response involved intense fear, helplessness or horror NOTE - in children this may be expressed instead by disorganized or agitated behavior

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. . . or learning about unexpected or violent death, serious harm or threat of death or injury experienced by a family member or other close associate.

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B. The characteristic symptoms resulting from the exposure to the extreme trauma include persistent re-experiencing of the traumatic event. C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness. D. Persistent symptoms of increased arousal.

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Traumatic events that are experienced directly include, but are not limited to: 1. Military combat. 2. Violent personal assault (sexual assault, physical attack, robbery, mugging). 3. Being kidnapped. 4. Being taken hostage. 5. Terrorist attack. 6. Torture. 7. Incarceration as a prisoner of war or in a concentration camp. 8. Natural or man-made disasters. 9. Severe automobile accidents. 10. Being diagnosed with a life-threatening illness. Traumatic Events

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Events experienced by others, that are learned about include, but are not limited to: 1. Violent personal assault 2. Serious accident 3. Serious injury experienced by a family member or close friend 4. The sudden unexpected death (or suicide) of a family member or close friend 5. That one's child has a life-threatening disease. Events Experienced by Others

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PTSD may be especially severe or long-lasting when the stressor is of human design, such as torture or rape. The likelihood of developing PTSD may increase as the intensity of and physical proximity to the stressor increase. PTSD Severity Factors

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1. Impaired affective modulation 2. Self-destructive and impulsive behavior 3. Dissociative symptoms 4. Somatic complaints 5. Feelings of ineffectiveness 6. Shame 7. Despair 8. Hopelessness 9. Feeling permanently damaged 10. Loss of previously-sustained beliefs 11. Hostility 12. Social withdrawal 13. Feeling constantly threatened 14. Impaired relationships with others 15. Personality change When Trauma Is Intentionally Human Inflicted These symptoms are more likely:

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Posttraumatic Stress Disorder is associated with increased rates of: 1. Major Depression 2. Substance-Related Disorders 3. Panic Disorder 4. Agoraphobia 5. Obsessive-Compulsive Disorder 6. Generalized Anxiety Disorder 7. Social Phobia 8. Specific Phobia 9. Bipolar Disorder These disorders can either precede, follow or emerge concurrently with the onset of Posttraumatic Stress Disorder. Associated Disorders

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Chronic Posttraumatic Stress Disorder may be associated with increased rates of somatic complaints and possibly general medical conditions. Physical Complaints

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Community-based studies reveal a lifetime prevalence of approximately 8% of the adult population in the United States. The highest rates occur among survivors of rape, military combat and captivity, and ethnically or politically motivated internment and genocide. Prevalence of PTSD

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The common feature of the Somatoform Disorders is the presence of physical symptoms that suggest a general medical condition (hence, the term somatoform) and are not fully explained by a general medical condition, by the direct effects of a substance, or by another mental disorder. Somatoform Disorders There is no diagnosable general medical condition or other psychiatric disorder to fully account for the physical symptoms.

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1. Somatization Disorder 2. Undifferentiated Somatoform Disorder 3. Conversion Disorder 4. Pain Disorder Associated with... (psychological factors are judged to have an important role in its onset, severity, exacerbation or maintenance.) 5. Hypochondriasis 6. Body Dysmorphic Disorder 7. Somatoform Disorder, NOS Somatoform Disorders

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A. The essential feature of Conversion Disorder is the presence of symptoms or deficits affecting voluntary motor or sensory function that suggests a neurological or other general medical condition. B. Psychological factors are judged to be associated with the symptom or deficit, a judgment based on the observation that the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors. Conversion Disorder

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C. The symptoms are not intentionally produced or feigned as in Factitious Disorder or Malingering. D. Conversion Disorder is not diagnosed if the symptoms or deficits are fully explained by a neurological or other general medical condition, by the direct effect of a substance or as a culturally sanctioned behavior or experience. Conversion Disorder

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Pseudoneurological : 1. Impaired coordination or balance 2. Paralysis or local weakness 3. Aphonia 4. Difficulty swallowing or sense of a lump in the throat 5. Urinary retention 6. Seizures or convulsions 7. (Cognitive, my experience) Sensory: 1. loss of touch or pain sensation 2. double vision 3. blindness 4. deafness 5. hallucinations Conversion Symptoms

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Somatoform Disorders may be thought of as disorders of perception, motivation and communication.

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Case Study A War Traumatized Iraqi Comes to America

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The claimant is a 33 year old male native of Basra, Iraq who immigrated to the United States in 1997 shortly after being released from 7 years in a concentration camp in Saudi Arabia. He obtained employment in as a dock worker with a major steel manufacturer in Washington state. He reported that the next 3 years in the United States were the 'best years of (his) life'. IME 1/8/04

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On 8/10/2000 he sustained a crush injury to the distal phalanx of the right thumb. Although the injury threatened 'physical integrity' it was not associated with feelings of fear, helplessness or horror nor was it followed by symptoms consistent with acute stress disorder. He was treated medically, and then surgically for complications of osteomyelitis. Eventually the surgeon determined that it was necessary to amputate half of the distal phalanx of the right thumb.

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Following the surgery the pain continued, spreading throughout the right arm and the right side of the face. He reported that he could not use his hand and was unable to grasp things. He still performed tasks of self-care but otherwise felt helpless and nonfunctional. Medical evaluations for the medical cause of the complaints were negative.

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As symptoms continued he began to experience imagery of trauma that he experienced in Iraq regarding the Iran-Iraq war, the Gulf war, the brutal crushing of the Shia uprising, and seven years of imprisonment, beatings and torture in Saudi Arabia. He met criteria for Posttraumatic Stress Disorder.

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An independent evaluation provided by a psychiatrist was initially sympathetic to the concept of industrial causation. However the same psychiatrist subsequently reviewed surveillance videotapes and concluded that the claimant’s purported pain and disability were influenced by malingering.

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The claimant became increasingly non-functional, depressed and socially withdrawn. Pain and dysfunction in the right hand and arm persisted. PTSD symptoms persisted. He moved to Salt Lake City to live with his cousin and his cousin’s wife who provided support in addition to his workers compensation payments.

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Idealization

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'Deer in the headlights' appearance. Deferential, supplicating presentation. Mood depressed. Fearful, very soft spoken with restricted range of emotional expression. Anxious with no signs of panic. No apparent aggravation of anxiety or emotional distress upon discussion of details of industrial injury. Verbal content stressed pain, disability, social withdrawal and fear of leaving his apartment. Mental Status Examination

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I think psychological testing would be of limited value in this case. What do you think?

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(309.1) Posttraumatic Stress Disorder, Chronic (300.11) Conversion Disorder - unexplained motor weakness of the right arm and hand. (307.89) Pain Disorder Associated with Psychological Factors and a General Medical Condition (Non-physiologic pattern of pain.) (311) Depressive Disorder NOS. (300.00) Anxiety Disorder Not Otherwise Specified (Obsessive Compulsive features). (V65.2) Malingering (diagnosed by Dr. Lipscomb after reviewing surveillance videotapes). Multiaxial Assessment

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Axis II (301.9) Personality Disorder Not Otherwise Specified. A lifetime of horrifying trauma has profoundly impacted this man’s personality. (Our concepts of Personality Disorder may be incongruent with this diagnosis.)

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Axis III History of multiple traumatic injuries inflicted by other human beings including beatings and torture. Surgical amputation of 1/2 of the distal phalanx of the right thumb.

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Axis IV The claimant has not worked since the accident. He receives workers compensation disability payments. He lives with his cousin and his cousin’s wife now in Salt Lake City. He reported that he stays home every day in a state of fear, experiencing pain and inability to use his right hand and arm. He is able to perform ADL’s. Axis V GAF 40

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Did the industrial accident of 8/10/2000 Cause the diagnoses?

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Posttraumatic Stress Disorder Did the industrial injury threaten death or a threat to physical integrity? Was the injury associated with fear helplessness or horror? Was there reliving of the industrial event in question? Was there avoidance and emotional numbing? Was there hyper-arousal? Did the mental content reflect pre-existing trauma?

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Aggravation Did the industrial injury aggravate a pre-existing condition (PTSD)? An industrial injury must be present before it can aggravate a pre-existing condition.

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Conversion Disorder Did the industrial accident cause the Conversion Disorder (weakness and inability to grasp things)?

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Pain Disorders Associated with Psychological Factors and a General Medical Condition Was pain disorder caused by the industrial accident?

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Causes of Posttraumatic Somatoform Disorders 1. Removal from undesirable circumstances. 2. Compensation 3. Relief from responsibility. 4. Care-taking by others. 5. Posttraumatic Stress Disorder. 6. Narcotic pain medications.

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Did the industrial accident cause the Depressive Disorder Not Otherwise Specified? Depression

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Anxiety: Obsessive Compulsive Features Did the accident cause the Obsessive Compulsive Features?

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Malingering Is it all just malingering?

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Impairment Did the accident cause ratable impairment attributable only to the industrial accident?

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Disability Is the evaluee disabled from performing the duties of his usual occupation? Is the evaluee disabled from performing any any occupation Is the disability caused by the industrial accident?

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. Discussion

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