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Steven W. Leclair
and
Norma J. Leclair

Abstract

Establishing a valid and reliable impairment rating for persons with mental and behavioral disorders is particularly challenging. This article focuses on the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, Chapter 14, Mental and Behavioral Disorders; because of similarities between the fourth and fifth editions, most comments here apply as well to the fifth edition. The section regarding mental and behavioral disorders is based in the US Social Security Administration (SSA) disability determination. The AMA Guides measures impairment in the same four areas of functioning designated by SSA: activities of daily living; social functioning; concentration, persistence, and pace (ie, focused attention); and deterioration or decompensation in work-like settings (“adaptation”). The assessment of severity of impairment is based on the five-level SSA approach and is applied to each of the four areas of functioning. The authors define and interpret the practical meanings of terminology in the AMA Guides associated with classes of severity: no impairment (self-explanatory); mild impairment (compatible with most useful functioning); moderate impairment (compatible with some but not all useful functioning); marked impairment (significantly impedes useful functioning); and extreme impairment (not compatible with useful functioning). Impairment ratings are truly applicable only when clinicians can approach the process in a consistent manner using consistent terminology and methodology; the latter two will improve both the understanding of the rating process and its reliability and validity.

in AMA Guides® Newsletter
Christopher R. Brigham
and
Norma J. Leclair

Abstract

Fibromyalgia is a perplexing, controversial syndrome with many unanswered questions regarding both etiology and manifestations and impairment and disability issues. This article reviews controversies attending this diagnosis, examines the debates concern etiology, explains why this diagnosis is unratable by the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, and explore issues of disability. Health care professionals debate whether the diagnostic criteria actually define a distinct clinical disorder, but the American College of Rheumatology published, for research purposes, classification criteria for Fibromyalgia Syndrome (FMS) that since have been widely used: FMS has been defined as a complex, chronic condition characterized by widespread noninflammatory musculoskeletal pain, severe fatigue, and sleep disturbances. Many health care professionals maintain that FMS is best understood from a biopyschosocial perspective because of the absence of visible clinical signs and inability to confirm the condition by laboratory tests. FMS may affect between 3 and 6 million people in the United States, with a 10:1 predominance in women, most between 35 and 60 years of age. Section 18.3b, When This Chapter Should Not Be Used to Rate Pain-Related Impairment, advises that “the pain of individuals with ambiguous or controversial pain syndromes is considered unratable” and provides three discriminatory questions.

in AMA Guides® Newsletter
Norma J. Leclair
,
Leclair Steven W.
, and
Christopher R. Brigham

Abstract

According to the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), motivation is a need or desire that causes a person to act and may be a key factor in an individual's physical or mental impairment. Poor motivation can cause poor functioning, and personality characteristics and underlying character are important determinants of an individual's motivation to benefit from rehabilitation. Particularly because of the subjective and highly sensitive nature of most mental and behavioral disorders, examinees have multiple self-interests, and, when one party engages in activities that are inconsistent with the other's expectations, resolution may depend on the employee's and employer's shared perceptions that the return to work is positive and consistent with each party's self-interests, particularly if both believe this step will succeed. Participants are motivated by the real or imagined costs associated with the return to work, and examinees may have concerns about facing coworkers, losing benefits or wages, dealing with labor relations, or simply making a change. When determining an individual's degree of motivation to return to work, the physician should consider the following: the value or usefulness of returning to work; employer's and employee's perceptions of the potential for successful return to work; and the real and perceived costs of work return (functional renewal) for the individual.

in AMA Guides® Newsletter
Arthur Ameis
,
Christopher Brigham
,
Robert J. Barth
,
Norma Leclair
, and
Steven Leclair

Abstract

Several Canadian provinces use the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) to adjudicate workers’ compensation claims, and the Province of Ontario uses the AMA Guides, Fourth Edition, to adjudicate motor vehicle accident personal injury claims. This article focuses on controversies that have arisen in Ontario regarding how the AMA Guides is applied and shows some of the challenges that occur in quantifying psychological impairment. In 2004, the Ontario Superior Court found in the Desbiens v. Mordini trial that the AMA Guides did not provide any direct methodology for estimating percentage impairment in this unique circumstance that involved pre-existing paraplegia and subsequent dramatic loss of residual functions. The judge found that, using the information available, a whole person impairment (WPI) score of 40% could be derived, but Ontario requires a minimum 55% WPI before an individual qualifies for catastrophic impairment benefits. In view of the individual's circumstances and a psychologist's recommendation, the judge awarded an additional 25% WPI. The Ontario model has been interpreted to allow subjective complaints (symptoms) to be included in the impairment evaluation process, but this approach eliminates any expectation of objectivity. If a judicial system aims to force impairment percentages onto a situation that in fact does not warrant such ratings, it should not do so by an inappropriate application of the AMA Guides.

in AMA Guides® Newsletter
Norma J. Leclair
,
Steven W. Leclair
, and
Christopher R. Brigham

Abstract

The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Chapter 14, Mental and Behavioral Disorders, focuses on the particularly challenging process of evaluating a person with a mental or behavioral disorder. This chapter is unique: It does not include numeric impairment ratings because no precise methods exist for assessing impairment in mental disorders. This article focuses on the process of gathering qualitative data and relevant information to substantiate the behavioral impairment assessment, for which the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition–Text Revised (DSM-IV-TR) is used. Impairment ratings in the AMA Guides reflect “consensus-derived estimates that reflect the severity of the impairment and the degree to which the impairment decreases an individual's ability to perform common activities of daily living [ADL]” and designates four relevant areas to consider: ADL; social functioning; concentration, persistence, and pacing; and deterioration or decompensation in complex or work-like settings. The validity of an impairment classification depends on the process used to collect and analyze the data, including clinical treatment records, hospital discharge summaries, community mental health program activity reports, patient and family interviews, reports from work evaluation or rehabilitation centers, supported employment records, and workplace evaluations. Defining maximum medical improvement in patients with mental and behavioral disorders is difficult and, in some instances, may be impossible.

in AMA Guides® Newsletter
Norma J. Leclair
,
Steven W. Leclair
, and
Christopher R. Brigham

Abstract

Most health care professionals who diagnose and treat mental disorders use the diagnostic criteria outlined in the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition–Text Revised (DSM-IV-TR), which uses a multiaxial system to ensure a comprehensive assessment and evaluation of the patient's presenting symptoms, general medical condition, psychosocial and environmental problems, and level of function. The five axes are mental disorders; personality and mental disorders; general medical conditions; psychosocial and environmental problems, and global assessment of functioning (GAF) scale. Psychosocial and environmental problems may affect diagnosis, treatment, and prognosis of mental disorders; the problems or stressors can contribute to the development of a mental disorder or can be the result of a mental disorder. The multiaxial assessment process should result in the following; documentation of the primary and any secondary mental and behavioral disorders; definition of physical disorders that may be present and indication if they are related to or influence the mental and behavioral disorders; identification of environmental stressors that may affect, contribute to, complicate, or exacerbate the mental and behavioral disorder; and a rating of the person's psychological, social, and occupational functioning. A table shows the GAF scale (ratings by deciles from 1 to 100; higher numbers indicate fewer problems) and does not include impairments that result from physical or environmental limitations.

in AMA Guides® Newsletter