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Robert J. Barth

Abstract

This is the second in a series of articles that address pain complaints and mental illness. The AMA Guides to the Evaluation of Permanent Impairment, Fifth Edition, should not be used if the pain presentation is attributable to mental illness, and the evaluator must distinguish between presentations that should be evaluated using Chapter 18, Pain, and those that should be evaluated using Chapter 14, Mental and Behavioral Disorders. Chapter 14 is unique in its avoidance of numerical impairment ratings but has been praised for its internal consistency and emphasis on following the current edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM). The only section of Chapter 14 that discusses pain complaints is somatoform pain disorders, which presents several problems, including nomenclature (the phrase somatoform pain disorder is antiquated and disappeared from DSM in 1994, and other forms of mental illness are not somatoform disorders). The DSM is the foundation of the evaluation process, and its discussion of any given mental illness is the gold standard definition of that illness; therefore, any attempt to evaluate pain complaints as a possible manifestation of mental illness must use DSM protocols. The article concludes with a discussion of the components of the evaluation process: awareness of the most prominent diagnostic possibilities; presenting complaints; health history; social history; review of records; family history; collateral interviews; and psychological testing.

in AMA Guides® Newsletter
Robert J. Barth

Abstract

This article is part three of a four-part series that examines the rating of pain complaints and mental illness using the AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides). Chapter 18 provides physicians with a method for evaluating impairment associated with “chronic pain states” for which there may be “no demonstrable active disease or unhealed injury,” and Chapter 14 should be considered when symptoms are out of proportion to physical findings. This article focuses on the directions from Chapter 18 and other pain resources. The authors note that Chapter 18 specifically addresses the issue of distinguishing between uses of Chapters 18 and 14, but the directions are contradictory with respect to the key question, Do “psychological factors” play a “major role” in the presentation of pain? Resources such as Bonica's Management of Pain point out that “[t]issue damage and nociception are neither necessary nor sufficient for pain,” suggesting that psychological factors are nearly always present and obviating the use of Chapter 18. A potential solution would be to ask, “Is the presentation of pain consistent with any mental illness as defined in the American Psychiatric Association's Diagnostic and Statistical Manual?” The decision rule then would be if the presentation of pain is consistent with any mental illness, then the mental and behavior chapter should be used.

in AMA Guides® Newsletter
Robert J Barth

Abstract

Impairment evaluations often occur within an adversarial context that involves a claimant or plaintiff vs a defense or benefits system; this adversarial context may precipitate proposals for observations of a clinical evaluation (eg, by an attorney or attorneys for one or both parties, a court reporter, a clinical expert, other consultant; audio or video also may be recorded). Evaluators, judges, and state workers’ compensation systems sometimes allow such observation, but a century of scientific research has reliably demonstrated that any observation changes an examinee's presentation in ways that are not themselves predictable. Such contamination leaves the evaluation results without a scientifically credible analysis, rendering observed evaluations futile exercises at best and sources of misinformation at worst. This article reviews the research in social psychology regarding “social facilitation and inhibition,” which has identified an extensive list of factors that are affected by observation (eg, complexity or novelty of the issue being evaluated, perceptions of the observer as an evaluator, stranger, or ally, number of observers, and other factors). No mechanism allows an evaluator to systematically account for the effects of all such variables for any given evaluation. When observation is mandatory, the evaluator should clearly document and communicate that a credible direct evaluation was rendered impossible, to the detriment of the referring party and the system as a whole.

in AMA Guides® Newsletter
Robert J Barth

Abstract

The American Medical Association's Guides to the Evaluation of Disease and Injury Causation (Causation) is an important component of the AMA Guides library and delineates a type of evaluation that is distinctly different from a diagnostic evaluation, a treatment planning evaluation, a prognosis evaluation, or an impairment evaluation. Causation provides a protocol for determining whether a clinical presentation, in the context of a legal or administrative claim, may be credibly attributed to a claimed cause. This article presents the evaluation protocol from Causation, provides self-assessment questions (so users can check how well they complied with the protocol), highlights the protocol's value as a model for scientifically credible practice in general, and clarifies that the protocol is relevant to claims that involve issues related to forensic causation. Courts and administrative systems have an extremely unfortunate emphasis on opinions from experts rather than on facts. The protocol from Causation is a good example of how clinicians can focus on facts and avoid surrendering to the court or administrative system's emphasis on opinions. The protocol is standardized, objective, fact-based, and scientifically credible and involves the following: establish a diagnosis; apply relevant findings; obtain and assess evidence of exposure; consider other relevant factors; scrutinize the validity of the evidence; and evaluate results and generate conclusions.

in AMA Guides® Newsletter
Robert J. Barth

Abstract

Scientific findings have indicated that psychological and social factors are the driving forces behind most chronic benign pain presentations, especially in a claim context, and are relevant to at least three of the AMA Guides publications: AMA Guides to Evaluation of Disease and Injury Causation, AMA Guides to Work Ability and Return to Work, and AMA Guides to the Evaluation of Permanent Impairment. The author reviews and summarizes studies that have identified the dominant role of financial, psychological, and other non–general medicine factors in patients who report low back pain. For example, one meta-analysis found that compensation results in an increase in pain perception and a reduction in the ability to benefit from medical and psychological treatment. Other studies have found a correlation between the level of compensation and health outcomes (greater compensation is associated with worse outcomes), and legal systems that discourage compensation for pain produce better health outcomes. One study found that, among persons with carpal tunnel syndrome, claimants had worse outcomes than nonclaimants despite receiving more treatment; another examined the problematic relationship between complex regional pain syndrome (CRPS) and compensation and found that cases of CRPS are dominated by legal claims, a disparity that highlights the dominant role of compensation. Workers’ compensation claimants are almost never evaluated for personality disorders or mental illness. The article concludes with recommendations that evaluators can consider in individual cases.

in AMA Guides® Newsletter
Robert J. Barth

Abstract

In the AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), Fifth Edition, two chapters claim relevance for pain complaints that lack an objectively demonstrable general medical basis: Chapter 14, Mental and Behavioral Disorders, and Chapter 18, Pain. Parts 1 and 2 of this four-part series examined forms of mental illness that commonly invoke complaints of pain; Part 2 also evaluations using the mental/behavioral chapter vs the pain chapter, and Part 3 noted the self-negating nature of the pain chapter's rationale (ie, the pain chapter presents a rationale that, taken literally, indicates it should not be used). A detailed case example illustrates how the decision about using the mental/behavioral chapter or the pain chapter often can be clarified by simply performing a thorough clinical evaluation (see Part 2 of this series). Examiners should be aware of the role of thoughts, behavior, and environmental contingencies on presentations of chronic pain even when no scientifically credible and objective general medical findings explain the pain. For example, the AMA Guides points out that in as much as 85% of low back pain cases, no explanatory physical pathology can be identified; therefore, readers are encouraged to be mindful of the professional literature. The authors of this series deny any attempt to move all instances of chronic pain into the category of mental illness but report little reason not to do so.

in AMA Guides® Newsletter
Robert J. Barth

Abstract

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.

in AMA Guides® Newsletter
Robert J. Barth

Abstract

A sidebar titled “Rating Impairment for [complex regional pain syndrome] CRPS Type 1” in the March/April issue of The Guides Newsletter states: “Do NOT use the pain chapter to rate CRPS” because there is no well-defined pathophysiologic basis. That conclusion is contradicted by the pain chapter, which lists CRPS among conditions considered ratable, but accompanying text provides no explanation how this determination was made. This article attempts to resolve the conflict between the sidebar in The Guides Newsletter and the pain chapter. The lack of a well-defined pathophysiologic basis for CRPS is the reason for the position stated in the sidebar, and a review of the relevant professional literature confirms this reasoning. Further, the concept of CRPS itself is ambiguous and was intentionally designed to be “general” and “descriptive” and historically has been diagnosed using nonstandardized, idiosyncratic, or incompatible diagnostic systems. The AMA Guides to the Evaluation of Permanent Impairment is self-contradictory regarding diagnostic criteria and terminology (eg, is CRPS-1 synonymous with RSD, causalgia, or neither?). CRPS lacks any well-defined pathophysiology, is highly ambiguous and controversial, involves characteristics that compromise the credibility of any examinee making such a presentation, and is a good example of a condition that should be evaluated using the mental and behavioral disorders chapter.

in AMA Guides® Newsletter
Robert J. Barth

Abstract

“Posttraumatic” headaches claims are controversial because they are subjective reports often provided in the complex of litigation, and the underlying pathogenesis is not defined. This article reviews principles and scientific considerations in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) that should be noted by evaluators who examine such cases. Some examples in the AMA Guides, Sixth Edition, may seem to imply that mild head trauma can cause permanent impairment due to headache. The author examines scientific findings that present obstacles to claiming that concussion or mild traumatic brain injury is a cause of permanent headache. The World Health Organization, for example, found a favorable prognosis for posttraumatic headache, and complete recovery over a short period of time was the norm. Other studies have highlighted the lack of a dose-response correlation between trauma and prolonged headache complaints, both in terms of the frequency and the severity of trauma. On the one hand, scientific studies have failed to support the hypothesis of a causative relationship between trauma and permanent or prolonged headaches; on the other hand, non–trauma-related factors are strongly associated with complaints of prolonged headache.

in AMA Guides® Newsletter
Robert J. Barth

Abstract

Complex regional pain syndrome (CRPS) is a controversial, ambiguous, unreliable, and unvalidated concept that, for these very reasons, has been justifiably ignored in the “AMA Guides Library” that includes the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), the AMA Guides Newsletter, and other publications in this suite. But because of the surge of CRPS-related medicolegal claims and the mission of the AMA Guides to assist those who adjudicate such claims, a discussion of CRPS is warranted, especially because of what some believe to be confusing recommendations regarding causation. In 1994, the International Association for the Study of Pain (IASP) introduced a newly invented concept, CRPS, to replace the concepts of reflex sympathetic dystrophy (replaced by CRPS I) and causalgia (replaced by CRPS II). An article in the November/December 1997 issue of The Guides Newsletter introduced CRPS and presciently recommended that evaluators avoid the IASP protocol in favor of extensive differential diagnosis based on objective findings. A series of articles in The Guides Newsletter in 2006 extensively discussed the shortcomings of CRPS. The AMA Guides, Sixth Edition, notes that the inherent lack of injury-relatedness for the nonvalidated concept of CRPS creates a dilemma for impairment evaluators. Focusing on impairment evaluation and not on injury-relatedness would greatly simplify use of the AMA Guides.

in AMA Guides® Newsletter