A series of articles emphasizing practical
knowledge you can't find in practice guides
and interviews with experts who share
their techniques for effective and efficient
Articles emphasizing practical knowledge you
can't find in practice guides
Profiles of people who changed workers’
• Marjory Harris
HARRIS: Dr. Lopez, you are
a Diplomate of the American Board of Psychiatry and Neurology
(Psychiatry) and have long been a psychiatric Qualified Medical
Evaluator. Tell us about your specific practice.
LOPEZ: My background
is really that of a community psychiatrist. I trained at UCSF
because of its
emphasis on cultural psychiatry and working with
underserved populations. My objective was to specialize in the
evaluation and treatment of Latino
patients, something I have done my entire career. To
that end I have been with the City and County of San
Francisco where I have served to this very day.
I almost accidentally stumbled into the workers’
comp arena about 15 years ago, found that I liked it
and could fill a niche in evaluating and treating
Latinos in that subspecialty (which is really what it is)
as well. I devote about half time to each of my
practices. I am based out of San Francisco where I
make my home but for the convenience of the
patients I travel to Fresno, Stockton, Modesto ,
San Jose and Castroville.
In addition to my direct work with patients I maintain
a teaching affiliation at UCSF, where I have been supervising
and teaching for over 20 years.
- specializes in the prevention, diagnosis, and
treatment of mental disorders, emotional disorders, psychotic
disorders, mood disorders, anxiety disorders, substance-related
disorders, sexual and gender identity disorders and adjustment
disorders. Biologic, psychological, and social components
of illnesses are explored and understood in treatment
of the whole person. Tools used may include diagnostic
laboratory tests, prescribed medications, evaluation and
treatment of psychological and interpersonal problems
with individuals and families, and intervention for coping
with stress, crises, and other problems. American
Board of Psychiatry and Neurology
Of possible interest to some of your
readers is my
book, “The Latino Psychiatric Patient, Assessment
and Treatment,” published by the American
Psychiatric Association Press. My personal
background is that I am originally from Mexico,
educated in the US (Stanford MD and USCF residency), and I am
bilingual and bicultural.
You have authored and edited
professional literature on cross-cultural issues.
What is the effect of ethnic and racial factors on
the perception of pain and reaction to disability?
Do some cultural groups tend to have a particular
diagnostic entity instead of another, such as a
somatoform disorder instead of a depressive
LOPEZ: There is
cultural variability in psychiatric
disorders, depending on the condition in question.
Schizophrenia is heavily genetically and
neurologically based and culture has little influence.
On the other hand anorexia nervosa is a disease
much more common among higher socioeconomic
status whites, and rare in Latinas or Blacks. I have
found and literature tends to concur that culture more
affects how symptoms of a condition are expressed.
For example Latinos are more likely to somaticize
[mistake emotional pain for physical symptom] as
an expression of depression than other groups.
What evidence do you like to have when
doing a forensic evaluation? Does it help, for
example, to receive testimony under oath, in the
form of depositions or declarations, or reports of
witnesses or family members?
LOPEZ: It is ideal
to have the medical records before
I see the patient. That way I can ask the patient about
his/her previous treatment as well as evidence of
prior non-industrial stressors (e.g., family problems,
financial worries, etc). Personnel records are
essential if I am being asked to comment on the job
performance or disciplinary issues. It seems most
workers with a psychiatric claim sooner or later are
deposed. If I can see this before I am face to face
with the patient it is a great advantage and can then
ask him or her about it.
Also in looking at the records sometimes I find out
translators were not used where they should have
been or an inappropriate translator was used (e.g.,
family member) or a translator made serious errors,
all of which I have seen.
What process do you follow for analyzing the evidence?
LOPEZ: There are
several important elements to
analyzing the evidence, as you put it. The key word
in this regard is consistency. Is there consistency in
complaints and symptoms throughout the records?
Is there consistency between the patient and family
members? Does psychological testing match up
with the clinical presentation or not? Do the symptoms described
seem appropriate to the
clinical presentation or not? The mental status,
history, records and testing should all hang together
in a way that makes sense from our clinical
experience and knowledge.
Is there any way to reduce or eliminate subjectivity in a psychiatric
cannot be eliminated in any field
of medicine. However it can be reduced. This can be
accomplished by obtaining as much information
from other sources outside of the patient, as we
have said, such as medical and legal records, as
well as psychological testing, investigative
materials and also at times sub rosa videos.
Please note these other sources of information
are not entirely objective either, but the more data
one can gather, the better and more comprehensive
the understanding of the patient.
It seems that human beings have
personality structures composed of useful traits
enabling them to function effectively in the world,
interspersed with dysfunctional and maladaptive
traits. Is it medically or legally appropriate to
apportion to characterological traits or personality
disorders? What if these traits or disorders did not
cause work-related problems in the past?
LOPEZ: I think
one must make the distinction you
mention, namely between personality traits versus
disorders. Your blood pressure is a trait, but does
not become a disorder until it goes beyond certain
limits. It is valid to apportion to personality disorders
(as opposed to traits which are normal) and this has
always been the case. I think we need clarification
from the courts to the extent that there might be
apportionment to preexistent personality disorder
when asymptomatic with respect to work.
Some psychiatrists have been
apportioning based on the underlying
orthopedic or pain disorder, so if the orthopedic
evaluator says that there is 20% apportionment,
the psychiatric evaluator says, since the
psychiatric disorder flows from the physical
disability, 20% of the psychiatric disorder is
apportionable. What you think of that approach to
LOPEZ: I would
not apportion based on the
orthopedic apportionment automatically, although it
might be appropriate at times. Specifically I would
not apportion to an orthopedic factor the patient was
not even aware of. How could there be causation to
factors the patient is not aware of (other than
Do you think that the new rating system
for psychiatric disorders, based on the GAF, makes
more sense than the one we have been using
based on the 8 work functions?
LOPEZ: As subjective
as it might seem, I am sure
the GAF is far more reliable as an instrument than
the eight work functions. Studies have revealed a
fairly good inter-rater reliability. What is nice too is
that the GAF is widely used in psychiatry, not only in
the legal arena, so that all kinds of records one
might come across will have the GAF. I have made
a power point presentation about the GAF that I
would be delighted to present to groups of interested
attorneys or claims representatives.
Global Assessment of Functioning (GAF) is
a numeric scale (0 through 100) used by mental health
clinicians and doctors to rate the social, occupational
and psychological functioning of adults. The scale is
presented and described in the DSM-IV-TR on page 32. Children
and adolescents under the age of 18 are evaluated on the
Children’s Global Assessment Scale, or C-GAS.
91-100 Superior functioning in a wide
range of activities, life's problems never seem to get
out of hand, is sought out by others because of his or
her many qualities. No symptoms.
81-90 Absent or minimal symptoms, good
functioning in all areas, interested and involved in a
wide range of activities, socially effective, generally
satisfied with life, no more than everyday problems or
71-80 If symptoms are present they are
transient and expectable reactions to psychosocial stresses;
no more than slight impairment in social, occupational,
or school functioning.
61-70 Some mild symptoms OR some difficulty
in social, occupational, or school functioning, but generally
functioning pretty well, has some meaningful interpersonal
51-60 Moderate symptoms OR any moderate
difficulty in social, occupational, or school functioning.
41-50 Serious symptoms OR any serious
impairment in social, occupational, or school functioning.
31-40 Some impairment in reality testing
or communication OR major impairment in several areas,
such as work or school, family relations, judgment, thinking,
21-30 Behavior is considered influenced
by delusions or hallucinations OR serious impairment in
communications or judgment OR inability to function in
11-20 Some danger of hurting self or
others OR occasionally fails to maintain minimal personal
hygiene OR gross impairment in communication.
1-10 Persistent danger of severely hurting
self or others OR persistent inability to maintain minimum
personal hygiene OR serious suicidal act with clear expectation
0 Not enough information available to
Overall, has SB 899 made it easier or
harder to assess the work-related psychiatric
LOPEZ: It is obvious
the new law and changes in the
system overall including limitations in treatment are
making the work more complex. Upon completing
an evaluation session recently one of the more
thoughtful patients stated to me words to the effect,
“what you do is really hard!” I would concur.
Alberto G. Lopez, M.D., M.P.H.
Board certified Psychiatrist
• Also evaluates for PI and Social Security.
• Treats and evaluates a broad spectrum of
• Disability treatment- San Francisco.
• Available in: Castroville, Fresno/Clovis, San Francisco,
Stockton, Modesto and San Jose.
To schedule, call 800 245 7899