See Through The Masquerade To Avoid Paying Twice

Transcription

1 See Through The Masquerade To Avoid Paying Twice Vladimir Bokarius, MD, PhD, QME CWCDAA Conference, October, 2018 Las Vegas, NV Agenda Mental Health Mental or Medical? Mental Health Disorders Due to General Medical Condition Identifying Possible Medical Disorders Causing Psychiatric Symptoms What Is The Purpose of Knowing This? What Is Mental Health? Emotions Cognition Perception Behavior ADLs Judgment and Insight 1

2 Emotions Sad, mad or glad? Anxiety Irritability/Anger Elation/Euphoria Dysphoria Alexithymia Avolition Cognition Attention Concentration Memory Level of Consciousness Orientation Perception Illusions Hallucinations Delusions Paranoid Ideation 2

3 Behavior Appropriate Deficit Isolation Retardation Excess Agitation Addictions Inappropriate Aggression (verbal or physical) Disinhibition (verbal or physical) Maladaptive/Emotional Medication Seeking Splitting Ingratiation ADLs Sleep Energy Appetite Sexual Functioning Bathing Dressing Moving around Toileting Judgement and Insight Judgement Insight 3

4 Mental or Medical? FACTS More than 100 medical disorders can masquerade as psychological conditions Medical conditions may cause mental health issues in up to 25% of psychiatric patients And contribute to them in more than 75% IF YOU DO NOT LOOK FOR IT, YOU WILL NOT FIND IT! Non medical mental health professionals organize the world according to psychological symptoms Mental Health Disorders Due to General Medical Condition Definition: A category of psychiatric disorders which are the direct physiologic consequence of a specific medical condition e.g. Thyroid Disease, Diabetes, Seizures, Vitamin Deficiencies, Brain Tumors Thyroid Disease Hypothyroidism Cognitive impairment (memory impairment; decreased attention/concentration) Fatigue/lethargy Weight gain Psychomotor retardation 4

5 Thyroid Disease Hyperthyroidism Irritability Anxiety Cognitive impairment (memory impairment; inattention; decreased productivity) Insomnia Weight loss Psychomotor agitation Epilepsy (recurrent seizures) Reactivity of mood Mania Guilt Aggression Anger and hostility Hallucinations Delusions Paranoia Obsessionalism Viscosity (repetitive and circumstantial talking) Diabetes Hypoglycemia Anxiety Mania Apathy Confusion Impaired judgment Dysphoria Irritability Belligerence Emotional lability Hyperglycemia Agitation Anxiety Anhedonia Fatigue and lethargy Psychomotor retardation 5

6 Vitamin Deficiency Thiamine Deficiency (B1) Wernicke Korsakoff syndrome: Wernicke encephalopathy cognitive impairment, ataxia, and oculomotor dysfunction Korsakoff syndrome anterograde and retrograde memory impairment with conservation of long term memory confabulations Vitamin Deficiency Cobalamin Deficiency (B12) Anxiety/panic disorder Psychosis Mania Hallucinations/delusions Insomnia Memory impairment Disorientation Brain Mass Can cause virtually any mental health symptom! 6

7 Identifying: When a Mental Problem May be Medical Coexistence of chronic disease Change in mood or personality is sudden, not gradual A patient over 40 who has no previous psychiatric history of nor history of similar symptoms History of head trauma Recent travel exposure to infections Any rash, swelling; drooping eyelid; facial tic Standard psychotropic medications or therapy are not effective or patient gets worse What Can An Attorney Do? Always ask psychiatric evaluator to consider possible organic disease if you don t look for it, you will not find it Review the medical record/deposition transcript for history of chronic diseases Don t be afraid to authorize and request diagnostics (labs and imaging) Stay informed regarding treatment progress and outcome if it is not getting better with psychiatric care, consider medical causes or malingering What Can A Physician Do? Look for symptoms which point to medical illness, including: Change in headache pattern Visual disturbance, either double vision or partial visual loss Speech deficits, either dysarthrias or aphasias Abnormal autonomic signs (blood pressure, pulse, temperature) Disorientation and/or memory impairment Fluctuating or impaired levels of consciousness Abnormal body movements Frequent urination, increased thirst (possible symptoms of diabetes) Significant weight change gain or loss 7

8 Summary The presence of potentially causative medical conditions may be important in context of: Causation of psychiatric injury Permanent disability rating (CVC vs addition) Apportionment of permanent disability Accepting liability for treatment How? Deposition of claimant Cover letters to QME/AME Deposition of treating or QME/AME physician Additional panels (Internal Medicine, Neurology, etc) Case Example and Q&A 8