And bring a ton of quarters. [Cheney 2012]

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1 And bring a ton of quarters [Cheney 2012]

2 Pure Mental harm and the GEPIC Nick Ford BMed Sc Hons, BM BS, FRANZCP Snr Clinical Lecturer Uni Adelaide All case material used with patients permission.

3 Outline The GEPIC The report format Sample Case Maximal Medical Improvement Truth, mistruth and the problems in establishing this The GEPIC Pros and Cons. Brain injury.

4 How things are

5 How things seem

6 Photos courtesy of Manuel Ubler

7 Why is my light withdrawn? Surely I am one before whom men spit? My nights are filled with anguish until the dawn And the pain that gnaws me takes no rest From the Book of Job, Holy Bible ~ 600 BC

8 What I think you see Stigma of psychiatric illness with adverse treatment in most jurisdictions and on occasion woolly, judgemental or inflated opinions. Role of personal responsibility vs a disease of the mind Recommendations for treatment; that don t happen Access and willingness to access treatment The iatrogenic effects of the claims process

9 Traffic accidents and the assessment of Psychiatric impairment The guide to the evaluation of Psych impairment [GEPIC] A psychiatric diagnosis [DSMV] and maximal medical improvement An Injury Severity Value {ISV} Pure Mental Harm only. Observation + Data One examination only

10 The GEPIC& Psychiatric impairment I Introduced in Victoria in 1997 Measures impairment not disability [ accredited] observer rated measures; based on one session + documentation/observation over time Good inter rater correlations BUT problems of bias/rapport/ observational ability remain calibration of the instrument.

11 The GEPIC& Psychiatric impairment II Associations with prognosis in epidemiological studies remains unknown [ the same measures have been used for 50 + years in psych research] HDRS, MDRS, CAPS etc. A psychiatric diagnosis must be made according to DSM 5 DSM V is widely disliked by psychiatrists; lack of prognostic and treatment relevance. [NIGH RDOC matrix] Absence of online guides ;://aworkcovervictimsdiary.com/2014/03/areyou-missing-out-on-compensation-or-a-payout-from-workcover/

12 Factors assessed in the GEPIC Intelligence Thinking Perception Behaviour Judgement Mood Each is linked to a number of anchors in the training manual;

13 E.g. Perception Class 1 Minimal or no altering of sensorium 2 Heightening or dulling or perception to semi dissociative flashbacks 3 Dissociative flashbacks in 1 or more sensory domains. pseudo hallucinations 4 Hallucinations with varying digress of preoccupation and insight

14 I feel dead people

15 GEPIC Classes of psychiatric impairment I 1 MINIMAL 2 MILD 3 MODERATE 4 SEVERE 5 EXTREME

16 GEPIC Classes of psychiatric impairment II intra class ranges 1 Minimal 2 Mild 3 Moderate 4 Severe 5 Extreme Low, Medium and High ranges Low, Medium and High ranges Low, Medium and High ranges Low, Medium and High ranges Low, Medium and High ranges

17 GEPIC Classes of psychiatric impairment II intra class ranges THESE ARE NOT USED IN TRAFFIC ACCIDENTS 1 Minimal 2 Mild 3 Moderate 4 Severe 5 Extreme Low, Medium and High ranges Low, Medium and High ranges Low, Medium and High ranges Low, Medium and High ranges Low, Medium and High ranges

18 GEPIC; Full version The full version provides a percentage impairment, the MAIAS version does not permit this. From this pre existing and consequential mental harm can be subtracted if appropriate [does not occur in the MAIAS} The subtractions are inevitably informed guesses [but do not occur in the MAIAS] Leading to a percentage of pure mental harm [does not occur in the MAIAS]

19 Injury Severity Values A range Pure mental harm ISV [mild, moderate, severe and extreme] Corresponding to GEPIC Levels 1 & 2, 3,4 and 5 a range for each ISV dependent upon severity within the GEPIC level?compensation..at moderate impairment [ISV 7+, GEPIC level 3 i.e. 25% WPI] Cannot be secondary to a physical injury; although a GEPIC report may elevate the range for the ISV

20 Pure and consequential mental harm Consequential follows on from a physical injury There may be a mixture of pure and consequential mental harm in the same patient Dominant injury [ is likely to be physical] The psych report may lift the ISV value to the top of the range Separation of pure vs consequential e.g. separating out fear./horror from pain/loss of function can be described

21 Class Of Normal to Mild Moderate Moderately Impairment slight Severe Mental function Severe

22 Class Of Normal to Mild Moderate Moderately Impairment slight Severe Mental function Intelligence Thinking Perception Judgment Mood Behaviour Severe

23 Percent < >75 Impairment Class Of Normal to Mild Moderate Moderately Impairment slight Severe Mental function Intelligence Thinking Perception Judgment Mood Behaviour Severe

27 Opinion Patient F. 1. Opinion; major depressive disorder, chronic. Chronic PTSD is subsumed by the major depression but is present. Death of companion in bridge collapse and inability to recover the body is noted.. 2. Prognosis; Poor 3. Injury stability; MMI has been reached following comprehensive treatment, and the passage of time. 4. The injury is consistent with the stated cause [see 5 below]. 5. The effect of the accident on any pre existing injury. There is increased pain perception of a pre existing shoulder wound which was previously quiescent 6. The effect of the accident on subsequent injury; there are no subsequent injuries.

28 7. The GEPIC rating with detailed reasoning; patient F F has shown an impaired ability to forward plan business eneavours and some decrease in memory; this is the upper end of class 1. There is diminished speed of thought and speech, with a pre occupation with themes of loss, ruminations of the event which are difficult to suppress. He is in the upper end of class 2. Perceptions are impaired with visual, auditory and somatic flashbacks at least twice weekly. He is in the lower range of class 3. Judgement is impaired with withdrawal, requiring prompts for self care from his friend Sam & alienation from some previous relationships.. He is in class 3, mid range. Mood is pervasively low, with loss of weight, despair, apathy low energy & anhedonia. He is in the mid range of class 3. Behaviour shows fair function but markedly diminished stress tolerance. He is in class 2, high range.

29 7. GEPIC Table; patient F Percent < >75 Impairment Class Of Normal to Mild Moderate Moderately Impairment slight Severe Mental function Severe Intelligence X Thinking X Perception Judgment Mood X X X Behaviour X

30 GEPIC Rating; Patient F. The classes in order are: The median class is 2.5; which is rounded up to 3 according to the training manual. 8. The ISV is thus 12. This is in the lower range of the ISV range.

31 Stability? Unlikely to change substantially, with or without treatment in the next year, or so. Reasonable treatment? Compliance, Access including geography Many illnesses are prone to relapse Vulnerable periods and unpredictable hazards

32 Maximal Medical Improvement Case by case 2 or more antidepressants, at adequate dosage+ a psychotherapy [not just chatting] Time ill Losses incurred [job, family etc] TRD 2 + years PTSD 2+ years More legal than medical

33 Texas Medication Algorithm Project Non Psychotic major depression] 1. Antidepressant [1a +/- augmentation] 2. Different class [2a+/- augmentation] 3. TCA [3a +/- augmentation] 4 Lithium augmentation 5. Combination antidepressants [mirtaz + SSRI/SNRI, Bupropion + SSRI, TCA + SSRI] 6 ECT 7 Other [Lamotrigine, TCA + MAOI]

34 Results of Tertiary treatment of TRD [Fekadu et al 2012] 150 patients; 13 deceased [suicide/cardiovascular], 118 consent to follow up. 60% sustained recovery [ > 6/12 remission] over 3 years [intent to treat analysis] Social support, severity of treatment resistance, MAOI s, SNRI s [duloxetine]

35 Trauma Everyone has their breaking point Willard, you and I have, and he has obviously become insane Herr, Apocalypse Now

36 PTSD Predictors of Poor outcome Late +/- inadequate treatment Deaths, burning and distortion of the human form Entrapment Lack of social support [including self induced] Substance abuse and dependence High conflict claims management Past and family psych history Prior resolved PTSD may inoculate

37 Relapse with incomplete recovery [Judd LL et al 1998]

38 Combined psychotherapy and PharMAIASotherapy [Pampallano et al 2004]

39 Resilience and your genes; COMT alleles&vulnerability to PTSD; Rwanda

40 Sometimes it gets chronic

41 Chronicity & MMI Adequate and thorough treatment failed Access to adequate and thorough treatment Motivation to engage Pre; Prior unresolved trauma or Lack of prior trauma and an entitled privileged background Intra ; loss of loved ones, disabling physical injuries, guilt Post; losses, opiates for pain, poor claims management Patients at >15-20% WPI after adequate Rx are unlikely to recover and continue to be seen ass outpatients/inpatients

42 Credibility and both sides of the fence New ice, A coiled snake, The sons of Kings, And an insurance case These are the things not to be trusted Germanic AD [with modifications]

43 Credibility I False imputation and symptom exaggeration are not common [ 5-10% of claims] Time course of symptoms Consistency of history and affect Response to probe questions Technical language Unusual reactions to treatment interventions Judgement and the gestalt [1+2 always equals 3]

44 Credibility II Evasiveness, and responses to alternative information. Unchanging dreams in PTSD the good old days, idealised prior function. Prior history withheld [ illness, legal issues, and compensation]..some reports are less than complete Resistance to active rather than passive treatments. Wide scatter of impairment classes eg

45 Credibility III Interviewing styles Rapport is respect, interest and compassion Rapport is not judgment, sympathy or humiliation Reassure about how deep the interview might go; and then start probing Explain why a past history is important, but talk about privacy Look for links and observe the emotional response

46 Issues in compensation matters Focus on character weaknesses of the targeted individual Spreading of false information Encroachments on private property; Surveillance open and covert Intimidation Harassment and threats Delays in investigation

47 Zersetzen; Stasi, East Germany; [ Appelbaum 2014 ] Focus on character weaknesses of the targeted individual Spreading of false information Encroachments on private property; Surveillance open and covert Intimidation Harassment and threats Delays in investigation

48 Disability; High and low stress compensation claims at 6 years, low risk grouping [Grant et al 2014]

49 Case Management Issues, decreasing order of prediction of disability at 5 years. [Grant et al 2014] 1. Not understanding requirements and the system. 2. Duration of the process 3. Being listened to. 4. Number of medical appointments 5. Respect and dignity 6. Amount of compensation

50 The GEPIC Pros and Cons One assessor only Medical Panels a or the Hot Tub? Observational..and quite hard to fake good or bad on No longer term data in proper epidemiological studies Where should the compensable point be? Conversion disorder and tremors Who should assess Brain Injury and How? Would a percentage impairment better guide the court, or would it lead to more argument?

51 Questions?

52 KR beating. #1; penetrating injury r eye, traumatic avulsion left middle finger, multiple scars. #2; fracture/malunion L tibia Flashbacks/nightmares, 4 hrs sleep, active/altruistic ++

53 Brain Injury ISV s 5-9 Ranges Minor TBI vs Concussion? Neuropsych impairment?...happens with psych injury too Imaging?.the better the image, the more you find GCS mostly but not always accurate [moderate complex TBI

54 Head injury; Initial Severity markers 54 Glasgow coma scale Post traumatic and retrograde amnesia CSF leak, Anosmia, racoon eyes, battle sign focal neurological signs Skull fracture Multiple injury sites Biomarkers? S100b, GFAP Nick Ford Bed Sc [Hons] FRANZCP 3/24/2017

GEPIC. An Introduction to Guide for the Evaluation of Psychiatric Impairment for Clinicians. Dr Michael Duke Senior Forensic Psychiatrist

GEPIC. An Introduction to Guide for the Evaluation of Psychiatric Impairment for Clinicians. Dr Michael Duke Senior Forensic Psychiatrist 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