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The Doctor’s Office

Psychology: Interview with Julie Armstrong, Psy.D., R.N.

In the sixth of a series featuring medical professionals in the workers’ compensation system, Marjory Harris interviews psychologist Julie Armstrong, Psy.D.
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HARRIS: Dr. Armstrong, you were a psychiatric nurse for many years before getting your doctorate in psychology. What effect did your past experience have on your current practice?

ARMSTRONG: I worked in a psychiatric hospital as an RN for more than a decade. I had the opportunity to treat the most psychiatrically ill patients imaginable. Day in and day out, I worked directly with patients who were actively psychotic, severely depressed or had a wide range of unusual psychiatric disorders. My perspective is far more experienced than most evaluators. Even psychiatrists often have the experience of a rotation, not a career, in identifying and understanding psychiatric illness. It is very rare for a psychologist or any evaluator to have this kind of practical experience. This gives me a very clear perspective and a basis for a more accurate comparison when evaluating an injured worker and making a diagnosis or determining impairments.
 
Psychology is an academic and applied discipline that involves the scientific study of human or animal mental functions and behaviors. In this field, a professional practitioner or researcher is called a psychologist. Psychologists are classified as social or behavioral scientists. Psychologists attempt to understand the role of mental functions in individual and social behavior, while also exploring underlying physiological and neurological processes.”
 
HARRIS: 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?

ARMSTRONG: The reality is that I like any evidence I can get! Usually I get medical records. I really like to have an additional source of records, such as personnel records, private medical records or witness statements. I am looking for data points that I can corroborate with other data points. For example if a worker complains that his depression started when he learned he needed another surgery. Then I review the private doctors’ notes and I find the private doctor has documented that the patient is distressed about a second surgery. That is gold! I have the same information corroborated at approximately the same time by two separate and unrelated records.

If I have no records at all, or just treating physicians’ medical records, then the process can be more challenging.

Personnel records offer an additional perspective about an individual’s perception of work events or work behaviors as well. If an event triggers an investigation I like to get witness statements too. Any data that can corroborate or refute other data is very helpful to me.
   
 
HARRIS: What process do you follow for analyzing the evidence?

ARMSTRONG: I work with a nurse who creates a summary of all the records I receive. In the most complex cases I ask her to create a timeline as well. In a systematic way I try to review the summary before my evaluation, and use the timeline when I am in the evaluation. I look for what I think of as moments; when complaints arise, or medical condition changes, or some other pertinent point stands out. When I am interviewing I listen for the same points from the applicant, trying to make the connections that constitute corroboration of data.
   
 
HARRIS: Is there any way to reduce or eliminate subjectivity in a psychological evaluation?

ARMSTRONG: Simply? No. The problem is that the mind and the brain are related but different. This is why corroboration is so very helpful and for me, evidentiary.

Most of the psychological testing used is highly subjective, and therefore of limited value in and of itself. The subjective results need to be corroborated by patient reports, medical records or other tests. And there are very few good tests that can do that.

The MMPI is the one test I have seen most often used that can corroborate self reports. It is a very good test that is hard to fool. Typically in workers’ compensation evaluations only a few selected tests are used. This is primarily because they provide enough data to generate an opinion.

But in order to generate an opinion that constitutes evidence I believe you have to corroborate the subjective with the objective data. This is what gives me the most comprehensive perspective so that I can provide my best opinion. There are other tests out there, but alternative tests can be costly to buy, and they must be used for a period of time to determine whether or not they are of any utility in this process.
   
 
HARRIS: 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?

ARMSTRONG: We all have character traits, to a greater or lesser degree, with a wider or narrower variety. The problem with character traits is that the more extreme degree of character traits are only valuable if the individual is matched with a job that values or requires those traits.

For example, an obsessive person who works in a lab or as an accountant is probably a good match. You want an accountant to be obsessive, because the numbers need to be correct.

But when there is a mismatch, for example when a person who decides he is entitled to change the rules is working at a job that requires rule adherence or consistency, say as a school teacher, then the individual’s character may significantly conflict with the needs or expectations of the job and create conflict for that person. If they are confrontative by nature (or as part of their character) they will create trouble at work. This can lead to conflicts with authority or a misperception of the intentions of others or something similar.

In an obvious mismatch situation, the person is just not hearing the feedback and it may be entirely appropriate to apportion to character traits. In my experience the apportionment is appropriate when, for example, the individual cannot accept correction or criticism and demonstrates no effort to change. They think their way is “right” when they really aren’t in a position to make that decision.

The traits might not have affected a person in the past because the job or the supervisor may have been a better match.
   
 
 
HARRIS: 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 apportionment?

ARMSTRONG: When there is not enough data, or very chaotic data, then I think it is a reasonable approach. It seems to be intended to err on the side of consistency. If there is adequate evidence of a more disabling impairment, then it is rather lazy to simply “match” the psychiatric disability with the orthopedic disability. It seems to be a formulaic and “safe” approach. If the psychiatric impairment is greater than the orthopedic or other impairment then the evaluator has the obligation to make that case and offer the most accurate rating.
   
 
 
HARRIS: Do you think that the current rating system for psychiatric disorders, based on GAF, makes more sense than the one we used before based on the 8 work functions?

ARMSTRONG: Both systems have limitations and benefits. The primary drawback to the GAF is the very subjective nature of the scale. It was not developed for anything but “pure” psychiatric patients. Its utility has been stretched to include the rating of individuals who may have other medical problems. And its use is mandated by the 2005 schedule. I was surprised to learn that there are a few test-retest reliability studies on the GAF and frankly they aren’t bad. Not great, but not bad. The problem is that the inter-rater reliability is poor.

If you read the text in the DSM-IV-TR, it says explicitly that the rating is to consider only psychological, social and occupational functioning. A person is so much more complex than that and they are often not working, so that occupational functioning must be estimated.

A significant problem with the GAF is that it boils down to an “absent-mild-moderate-severe” rating, with decile divisions. It is highly subjective so that a rater who saw the patient early in the injury and a later evaluator may both rate the same number despite improvements or decompensation. This is the inter-rater problem that I mentioned.

Personally I didn’t like the 8 work functions, but in retrospect (after having used the GAF for awhile) I think it may indeed provide a better description for an individual’s capacity to work in the context of any impairment.
 
The 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 concerns.
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 relationships.
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, or mood.
21-30 Behavior is considered influenced by delusions or hallucinations OR serious impairment in communications or judgment OR inability to function in all areas.
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 of death.
0 Not enough information available to provide GAF.
 
 
HARRIS: Some evaluators are using Chapter 14 of the AMA Guides, which deals with mental and behavioral disorders, as an alternative method of evaluating psychiatric disorder, although the rating schedule itself states, “Psychiatric impairment shall be evaluated by the physician using the Global Assessment of Function (GAF) scale ….” (p. 1-12) Do you find that chapter at all helpful, or is the GAF sufficient in all cases?

ARMSTRONG: If I have a case that is clear and convincing, there is corroboration in the points that are important, then I use the GAF outright. If the case is more complex, or if there are elements that the GAF scale does not capture, then I look to Chapter 14 to better describe, capture or support my rating and opinion.
   
 
 
HARRIS: The revision of the permanent disability rating schedule required every five years by Labor Code §4660 is overdue. A new schedule must eventually issue, despite the Administration’s current foot-dragging and violation of the legislative mandate. If you were asked by the AD to designate a system for evaluating work-related psychiatric disorders, what would be your recommendation?

ARMSTRONG: I would definitely want to know what other states are doing. Colorado for example has 9 spheres of daily functioning that are assessed on a baseline-minimal-mild-moderate-marked system with good examples to follow as a guide.

I am not aware of a single scale that can control for the subjective side of the psychiatric permanent impairment rating.

There are other scales that could be used, but each has limitations. The Mental Illness Research Education Center (MIREC) has modified the GAF to include an occupational rating as well. It’s a scale that has good potential use for the WCAB and rating permanent impairment of workers. But it too divides the degrees of impairment into deciles, so that there can be wide variation within a decile, between say 61 and 69.

Perhaps one solution is to offer ratings from 2 different scales, for example the MIRECC GAF and the 8 work factors, with supporting evidence for each rating. Then leave it to the judge to make the final determination.
   
 
Dr. Armstrong is available for Qualified and Agreed Medical Evaluations in Worker’s Compensation, and serves as an expert in Civil Litigation for Personal Injury , Labor law and Emotional Distress allegations.

Look for Dr. Armstrong as the psychology expert on Investigation Discovery’s (IDtv) Wicked Attractions, airing July 8, 2010.


Julie Armstrong Psy.D. QME
Lic. Psychologist
Forensic and Clinical RN
Clinical Specialist
Ca Psy 16001

152 South Lasky Drive
Penthouse Suite
Beverly Hills, CA 90212
Tel: 310.273.9190
www.psychologyexpertwitness.com

Additional offices located in:
• Irvine
• Ontario
• Huntington Beach
• Westlake Village

 
For a detailed CV, click here.