The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) warns physicians against minimizing psychiatric impairments but does not elaborate on this warning against minimizing the contribution of psychological factors to general medical impairment. Claims regarding spinal impairment are a useful example because the AMA Guides cites a study showing there is no general medical explanation for 85% of low-back pain cases. The list of mental illnesses that are commonly associated with complaints of physical pain includes somatoform, mood, anxiety, personality, psychotic factitious, and substance-related disorders. In one study, anxiety disorders accounted for 54% of the variance in pain severity reports and associated claims of disability. Psychological dysfunction leads only to subjective complaints such as pain but also can lead to objective physiological signs, for example, mental illness such as panic disorder, which includes objectively verifiably physical signs such as heart palpitations, sweating, and tremor. Claims of disability also have been associated with hypertension, cardiac issues, concussion, multiple sclerosis, and psoriasis. To credibly assess the possibility of mental illness as the cause of a general medical impairment claim is extremely demanding, and evaluators should think of the evaluation process in terms of days rather than hours. The steps in an evaluation protocol should mirror those described in the March/April 2005 issue of The Guides Newsletter and are summarized in the present article.

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