5 October at 20:36 from atlas

    26 October 2017

    The AMA Guides have established that numerical ratings are not assigned, since these spheres of functioning are most indicative of disability rather than impairment, in respect of psychological/psychiatric assessments. PIRS has been integrated and allows a more objective and reproducible assessment not requiring WAIS or MMPI-2 (as advised by lawyers) to provide some 'validity' and 'objectivity'.

    Qualitative assessment of mental and behavioural impairments depends on assessing the degree of functioning in four spheres : (i) ADL, (ii) social functioning , (ii) concentration , and (iv) adaptation.The degree of functioning as described ordinarily  in terms of none, mild,moderate,marked,and extreme impairment. Extreme impairment in one or marked impairment in 2 or more spheres, probably represents a preclusion to the performance of most complex tasks, such as work,without considerable support or accommodation.Effects of medication may increase the impairment rating in accordance with chapter 2 of the Guides, but only if they are necessary AND impact on ADLs.An individual with somatoform pain disorder does not receive an additional rating in the Guides Pain chapter and is diagnosed only for individualls meeting DSM-IV criteria.

    The Guides acknowledge that inter alia, assessing and separating medical impairment from the disability of mental and behavioural disorders is very problematic and has not been successfully achieved.IN THE MENTAL AND BEHAVIOURAL chapter the distinctions between impairments (e.g. brain function) and disability (e.g. interaction of one's mental functions with the environment) become blurred and an assessment of solely permanent impairment is difficult and probably not very meaningful.

    The assessor must obtain information from medical and non medical sources that indicate the individual's ability to concentrate, be persistent, pace oneself, and tolerate mental demands including stress.

    Well established psychological tests such as the Weschler Adult Intelligence Scale (WAIS) and the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) , mat improve diagnostic acumen.Lawyers however advise that the role of WAIS and MMPI-2 is considered necessary to establish 'objectivity' in the evaluation. This is not  advice that inspires validity in the process.

    The degree of impairment is defined in the Guides as : none-no impairment in function; mild-the impairment is compatible with most useful functioning; moderate-the impairment is compatible with some , but not all , useful functioning ; and extreme-the impairment is not compatible with useful functioning.Extreme signifies complete dependence on another person for care.

    How can the assessor address work ability? If an individual has an extreme impairment in one or more areas or a marked impairment in two or more spheres, it is unlikely that individual will be able to perform complex activities, such as work, without considerable support and accommodation.

    Determination of the ability to function within the workplace requires the assessment of general and specific workplace skills.General skills or capacities, as defined by the SSA and adapted by the AMA Guides, include (i) understanding and memory, (ii) sustained concentration and persistence, (iii) social interaction, and (iv) adaptation.lawyers advise that the determinatioof the ABILITy to work is NOT part of the impairment evaluation, although it may be part in those state systems that apply a mathematical or algebraic number multiplier to the Guide's % of WPI to determine a disability rating.Depression, substance abuse, personality disorders require assessment as to the extent that these disorders affect the 4 areas (ADL,social, pace,persistence & concentration and adaptation.

    Somatoform Pain Disorders refer to a preoccupation with pain in the absence of physical findings that adequately account for the pain and its intensity, as well as the presence of any psychological factors that are judged to have a major role in the onset, severity, exacerbation and maintenance of pain(AMA 5 p 366).The individual is not rated by the Pain chapter in AMA Guides.-if a patient with another condition is found to have a somatoform disorder the guides require that a qualitative assessment, based on the 4 spheres of functioning be given ,but would not be assigned an additional , numerical IR.

    Malingering refers to the simulation or exaggeration of physical illness for an external gain , such as disability payments, obtaining controlled opioids or other perceived benefits.With malingering the individual intentionally produces symptoms and signs and is aware of their motivation in doing so.malingering is not considered a mental disorder according to DSM because , under some circumstances , malingering may be beneficial and adaptive e.g. feigning illness as a prisoner of war camp.Consider malingering when there is a discrepancy between the objective findings and subjective complaints, or when symptoms are ill defined or overly dramatised(Goldstein LS et al.psychiatry for Primary Care physicians.AMA;1998:286).Lawyers advise that whilst malingering may be described in the AMA and DSM Guides, it may be defined differently under relevant state laws.

    The Psychiatric impairment ratings scale (PIRS) determines the behavioural consequences of a psychiatric disorder assessed on 6 scales, each of which evaluates an area of functional impairment:

    (i) Self-care and personal hygiene (Table 11.1)

    (ii) Social and recreational activities (Table 11.2)

    (iii) Travel (Table 11.3)

    (iv) Social functioning (relationships) (Table 11.4)

    (v) Concentration (Table 11.5)

    (vi) Employability (Table 11.6)

    Note that (iii)+ (iv) are ADLs.

    PIRS allows for rating in each Table from Class 1-5, in accordance with severity.PIRS is used to measure psychiatric impairment- a 2 step process. Firstly a median class score is determined in each of the 6 areas(ascending order and average of 2 middle ).The aggregate score is calculated and using the PIRS conversion Table a % impairment is arrived at.validation of PIRS to my knowledge has not been undertaken, however it is in wide current use.

    Patients and IMEs are advised to follow the advice of their treating medical practitioner / indemnity insurer  at all times.The opinions stated herein are those of the author.

    Dr Michael Coroneos is a senior Brisbane neurosurgeon with six surgical Fellowships and was honoured to be elevated to Master CIME status by the American Board of Independent Medical Examiners (by  3 examinations and training) in May 2017.

    Qualifications and Memberships : MCIME  FRACS  FACS(USA)  FRCS(Glasg)  FRCS(IRE)  FRCS(ENG) FRCS(EDIN)SN MB BS(1st Cl Honours, 1980, UQ)  MNSA  MNSQ  MAPS

    Senior Clinical RACS  OSCE Examiner/ Mortality Assessor RACS (QASM)/ Honorary  Clinical Adjunct Assistant Professor and Examiner / Senior Neurosurgeon/ Master CIME.


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