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The ACOEM Guidelines support psych referral and treatment for many injured workers. [Ed. Note: all references are to American College of Occupational and Environmental Medicine's Occupational Medicine Practice Guidelines

The ACOEM Guidelines, now presumed correct under California law [see Labor Code §4600], recommend that Primary Treating Physicians refer injured workers for psychological consultation whenever “no specific injury” has occurred and/or pain complaints continue “after the acute lesion should have healed” (p. 105). In order to prevent psychological factors from complicating an injured worker’s subjective experience of pain (and possibly precipitating a chronic pain syndrome), the psych referral should be made at the earliest possible time.

The ACOEM Guidelines recommend psychological consultation whenever complaints of pain have failed to improve after six weeks of medical treatment, as well as whenever it is determined that a psychological reaction to pain may be contributing to the impaired functioning or psychiatric factors may be interfering with an applicant's capacity to benefit from medical treatment. The Guidelines recommend psychological involvement in order to:

  1. Promote the injured worker’s continued involvement in as many activities of daily living as possible (p. 109);
  2. Limit the degree to which “central nervous system factors” (such as feelings of hopelessness, unconscious motivation to avoid unpleasant and/or stressful circumstances, distorted perspective, anxiety, helplessness, and depression-related lethargy) distort the injured worker’s subjective perception of, and response to, physical symptoms (p. 105);
  3. Prevent psychological factors (such as feelings of hopelessness, desire to avoid any pain, and depression-related lethargy) from leading to decreased activity and deconditioning, thereby increasing pain level (p. 105): and
  4. Prevent the medical treatment from becoming palliative rather than rehabilitative, over-relying on opioid and/or muscle relaxant medications that may actually increase overall impairment.

As soon as any delay in recovery is observed, ACOEM recommends “judicious involvement of” and “close communication” with a consulting psychologist in order to “decrease the likelihood that [the injured worker] will go on to develop chronic pain” (pp. 107, 109). In such cases, ACOEM recommends an interdisciplinary rehabilitation approach that emphasizes functional restoration rather than relief of pain, and that promotes continued involvement in as many activities of daily living as possible.

The ACOEM Guidelines also point out that scientific research has demonstrated that “multidisciplinary care is beneficial for most persons” and “likely should be considered the treatment of choice for persons who are at risk” of developing a chronic pain syndrome (p.114). They also indicate that research has shown that multidisciplinary treatment including psychological consultation is “superior to conventional physical therapy alone, had benefits that persisted over time, and was beneficial in improving return to work and decreasing use of healthcare” (p. 114).

The goal of psych consultation in cases of prolonged pain, therefore, is to identify and manage psychosocial factors that may be contributing to the continuing pain. Cognitive-behavioral psychotherapy may be required to reorient an applicant to a rehabilitative approach, and psychotropic medications may in some cases be necessary to provide the injured worker with sufficient emotional stability, energy, and mental control to reasonably participate in their own treatment.

Chapter 15 of the ACOEM Guidelines also recommends mental health treatment in cases where:

  1. The prescription of psychotropic medication is indicated (p. 388);
  2. "Stress management techniques"—such as relaxation training or biofeedback therapy—are indicated (pp. 399-400);
  3. "Behavioral techniques"—such as assertiveness training or conflict resolution—are indicated (p. 400);
  4. "Cognitive therapy" or "stress inoculation therapy" is indicated (pp. 400-401); and
  5. Returning an industrial patient to unrestricted work without treatment would “lead to increased stress, with resultant depression, insecurity, and/or jeopardized employment” (p. 404).

If every Primary Treating Physician were following the ACOEM Guidelines with respect to psych referral, there should be fewer cases in which disability arises due to chronic pain. On the other hand, there might also be fewer cases in which compensable consequence psych injuries go unidentified.

 
 
GAF is often underrated by psych evaluators.

Workers’ compensation regulations currently specify that the Global Assessment of Functioning (GAF) Scale is to be used to generate a Whole Person Impairment (WPI) percentage which is then adjusted for age, occupation, and Future Earning Capacity [see Schedule for Rating Permanent Disabilities, at p. 16]. Many psych evaluators, however, are reluctant to offer GAF scores below the range of “Mild” (61 to 70). A careful reading of the DSM-IV criteria for GAF scoring reveals, however, that whereas a great many injured workers fall into the 61 to 70 GAF range, many others merit GAF scores in the “Moderate” range (51 to 60) or lower.

According to DSM-IV, injured workers qualify for a GAF score of 61 to 70 when they are “generally functioning pretty well” and have “meaningful interpersonal relationships,” but also have “some mild symptoms (e.g., depressed mood and mild insomnia)” or they are experiencing “some difficulty in social, occupational, or school functioning.” This is not a particularly difficult standard to meet. In fact, it may describe most people.

In order to qualify for the GAF range of 51 to 60, an injured worker must be experiencing “moderate symptoms" (e.g., flat affect and circumstantial speech, occasional panic attacks) or must display “moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or coworkers).” It is my experience, however, that even applicants who are experiencing frequent and relatively severe panic attacks (or who are experiencing conflicts with almost everyone) tend be inappropriately categorized in only the “mild” range psychiatric dysfunction.

DSM-IV specifies that in order to qualify for the GAF range of 41 to 50 (“Severe”) an injured worker must be experiencing “serious symptoms" (e.g., suicidal ideation, severe obsessional rituals, etc.) or display “any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job).” Anyone who has provided psych care to a large number of injured workers will have encountered quite a few with musculoskeletal injuries that have caused them to become so hopeless and so persistently distressed that they qualify for the 41 to 50 GAF range. In my experience, however, even injured workers who have been so seriously injured that they have become hopeless and developed recurrent suicidal ideation are frequently categorized above a GAF of 50.

Rarely is an injured worker's GAF rated as below 41, although there certainly are some who would qualify for lower scores based upon the DSM-IV criteria. In order to qualify for the 31 to 40 GAF range, an injured worker must have developed either “some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant)” or must display “major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work…).” This latter description is actually not uncommon in the more severe cases of industrial injury. Yet rarely is a GAF rating below 41 applied to an injured worker.

Even the GAF range of 21 to 30, as described by DSM-IV, is appropriate for those injured workers who have developed psychotic disorders in reaction to the emotional stress created by their industrial musculoskeletal injuries. DSM-IV specifies that a GAF score in the 21 to 30 range is indicated when an injured worker’s “behavior is considerably influenced by the delusions or hallucinations (e.g., sometimes incoherent, grossly inappropriate, suicidal preoccupation)” or the injured worker has developed “inability to function in almost all areas (e.g., stays in bed all day, no job, home, or friends).” In my experience injured workers meeting these descriptions typically receive GAF scores in the 41 to 50 range.

Whether the result of a reluctance to be deposed, or possibly fear of alienating an insurance carrier, psychiatric and psychological evaluators seem to be reluctant to assign extremely low GAF scores to injured workers, even when merited by DSM-IV criteria.

 
 
In the absence of a prior psychiatric disability rating, or other compelling evidence of chronic pre-existing psychiatric disorder, apportionment of psychiatric disability is almost always unreasonably speculative.

On April 19, 2004, Labor Code §4663 was amended to require that apportionment of permanent disability be based upon causation, and Labor Code §4664 was added to require apportionment to any prior comparable disability determination. At the same time, Workers’ Compensation Regulations (Title 8, CCR, §10606) and WCAB case law established by the Escobedo decision require that apportionment of permanent disability be based on pertinent facts, framed in terms of reasonable medical probability, supported by reasoning derived from an adequate examination and history, and not speculative.

Unless a prior psychiatric disability rating exists, or there is clear evidence of chronic pre-existing psychiatric impairment, it is often impossible for a psychiatrist or psychologist to apportion psychiatric disability without being unreasonably speculative. This is especially true in cases in which the injured worker has denied that non-industrial factors have played any role in the causation of their emotional distress. If the injured worker estimates that a non-industrial stress played a 25% role in the causation of the psychiatric condition, this provides the psych evaluator with some evidentiary basis for apportionment. If the injured worker denies any non-industrial causation, the percentage of apportionment offered by the psych evaluator can appear entirely arbitrary and can be quite difficult to defend. It is not so much the decision to apportion that is difficult to defend, as the exact amount of the apportionment, a percentage that often appears to be entirely speculative.

In my opinion, it is also improper to apportion psychiatric disability to personality traits. Unlike Personality Disorders, personality traits do not represent character pathology or psychiatric disability. Everyone has personality traits. Apportioning psychiatric disability to a personality trait would be equally as reasonable as apportioning musculoskeletal disability to a physical trait, such as being short or left-handed.

In my opinion, it is also improper to apportion psychiatric disability to childhood trauma. Childhood trauma can be the cause of later-life psychiatric disability only if it has caused life-long psychiatric disturbance that has lasted into later-life. In that case, the apportionment would appropriately be made to the life-long psychiatric disturbance, not the childhood trauma.

I also find it to be unreasonable to apportion psychiatric disability to Alcohol or Substance Abuse Disorders that have been in sustained remission for many years. Although prolonged abuse of alcohol and/or drugs could certainly result in chronic injury, becoming “clean and sober” is an event that is usually perceived as a triumph, and the psychiatric effects of the substance abuse typically resolve within 18 months.

 
 
Utilization review is for the birds.

There are so many unintended negative consequences to the institution of utilization review in the workers’ compensation system that I don’t know where to begin. One problem is that utilization reviewers typically seem to view their job as denying everything that can conceivably be denied. Sometimes they find elaborate justifications for their denials, but that frequently results because the industrial insurance carrier has supplied the reviewer only with the request for authorization and none of the prior medical reports about the patient in question. This is how my patient who has been wheelchair-bound for 12 years was denied authorization for aquatherapy (virtually the only type of physical exercise available to him) on the grounds that prior aquatherapy had not restored his ability to walk.

Another deleterious aspect of utilization review is the “three session” authorization. The physician prepares and submits a request for authorization. A utilization reviewer then contacts the physician for a “peer-to-peer” in which the physician is required to explain the details of the injured worker’s case, the treatment that has already been provided, the treatment response obtained, and the medical necessity of the treatment for which authorization has been requested. Some utilization reviewers seem friendly and reasonable; others are obnoxious and insulting. In either case, however, the reviewer typically authorizes only a small part of the treatment requested, requiring the physician to repeat the process all over again a month or two later. Multiply this process by 40 to 100 patients, and the physician has little time for anything but preparing authorization requests and talking with reviewers on the telephone. For many physicians, treating injured workers in California has become a demoralizing proposition.

In my experience, about half of my requests for authorization go unanswered. Although the industrial insurance carrier may be lawfully responsible for the treatment requested in such cases, most physicians will not provide consultation or treatment without pre-authorization. As a result, by simply ignoring treatment authorizations an industrial insurance carrier can so frustrate the injured worker and the treating physician that a pervasive sense of hopelessness develops about the industrial injury claim.

My worst experience with utilization review occurred when I was awakened at 5:05 a.m. by a telephone call to my emergency cell phone number. The utilization reviewer, who was calling from the East Coast where it was 8:05 a.m., advised me that this was my one and only opportunity to explain why my patient needed the treatment I had requested. He seemed completely unfazed by the fact that he had awakened me so early and at home in my bed (and without my false teeth, which makes my speech difficult to understand). At least that has not happened again.

 
 
There is a book that can be of help to most injured workers (or anyone else who is struggling to cope with physical disability).

Winning the Disability Challenge: A Practical Guide to Successful Living (2008, New Horizon Press, P.O. Box 669, Far Hills, N.J., 07931) is a book I published last year. The book, which was recently named a finalist in the competition for the National Best Books Awards of 2008, offers understanding, inspiration, hope, practical guidance, and an alternative perspective to those coping with disabling chronic pain and/or impairment. It is designed to either help an injured worker develop a self-rehabilitation plan, or facilitate the efforts of a therapist who is trying to improve patient motivation and perspective, and promote self-improvement activity.

Winning the Disability Challenge presents an “empowerment” strategy that employs aspects of rational therapy, positive psychology, and 12-step recovery philosophy. The book’s Introduction makes it clear that the distressing perceptions and emotions that often accompany disabling injury represent an understandable and normal human reaction, but that they can be successfully managed if approached in a constructive manner. The injured worker is led on a search for reasons to be grateful and hopeful, sources of inspiration, and the opportunities that almost always exist to improve him or herself and the circumstances of his or her life. The book provides tools that assist the injured worker to better structure each day so as to optimize self-care, physical conditioning, mental exercise, spiritual growth, creative and assertive self-expression, constructive activity, and/or personal relationships.

The book sets forth the goal of achieving greater peace of mind by focusing energy and attention on life’s simplest moment-to-moment decisions, and “turning over” and “letting go” of anger about past events or fear of what might occur in the future. The reader is urged to seize control over those aspects of life that might be influenced, and resist the temptation to helplessly “spin wheels” over those disturbing aspects of life that no individual can change. The book emphasizes the importance of staying in, and returning to, the current moment, the only time in which any constructive action is possible. The philosophy presented is the crux of recovery from any loss or trauma, and promotes the rehabilitative approach recommended by ACOEM.



Dr. Tholen has been evaluating and treating injured workers in the Long Beach area for more than 20 years. He has been a QME since the inception of that designation in 1992. He is also author of Winning the Disability Challenge: A Practical Guide to Successful Living (2008, New Horizon Press, P.O. Box 669, Far Hills, N.J., 07931), a new book that offers hope and direction to disabled workers and can be effectively employed in their rehabilitation and psychiatric treatment. The book was recently honored as a finalist in the competition for the National Best Books Awards of 2008.

To order this book, click here.
For Dr. Tholen’s CV and contact information,
click here.




 

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> People Who Made a Difference
> Work Impairment & Disability
> Computer Corner: More Productive
> PD Pain Under SB 899, Part II
Five Facts About Psych Injuries
Every Workers' Compensation
Attorney Should Know

by John F. Tholen, Ph.D.