temporary modified duty in psychological and neuropsychological claims ___________________________...

TEMPORARY MODIFIED DUTY IN PSYCHOLOGICAL AND

NEUROPSYCHOLOGICAL CLAIMS___________________________

David B. Freeman, Ph.D.Cal Psych FMT

16530 Ventura Blvd., Suite 200Encino, CA 91436

Tel: (818) 385-0684Fax: (818) 385-1166

www.calpsychfmt.com

COMMON CAUSES OF STRESS CAUSING PSYCHOLOGICAL INJURIES

• Communication difficulties between workers and managers - lack of formal or effective communication or consultation structures or procedures, with workers feeling unable to voice concerns or problems or feeling insecure if they do.

• Bullying, harassment or intimidation.

• Work overload and underload – unreasonable demands or impossible targets.

• Inadequate time to complete jobs satisfactorily leading to a feeling of being overwhelmed or exhausted.

• Job insecurity – fear of redundancy, lack of permanency, short-term or casual contracts, lack of career opportunities, and lack of recognition or reward for a job well done, particularly where the pay is low.

• Too much change – restructuring of workplace and the way work is organized.

• Inadequate staff levels – staff leaving and not being replaced with the rest of staff expected to pick up the workload.

• Inadequate resources – or equipment that is continually breaking down because it is poorly maintained or overdue for replacement.

• Unresolved health and safety issues, e.g. exposure to chemicals, noise, extremes of temperatures, exposure to potential violence whilst working alone.

Citation: www.disabilitysafe.org.au/hazards-risks/psychological-injury

COMMON CAUSES OF STRESS CAUSING PSYCHOLOGICAL INJURIES

• Excessive performance monitoring and surveillance.• Poor work organization – lack of clear job descriptions, conflicting

demands, too much or too little work, boring or repetitive work, no job satisfaction.

• Insufficient training.• Dangerous hours – required to work overtime or through breaks. Shift

rosters that are unpredictable or make it difficult to balance work and family life.

• Difficulty dealing with clients/general public due to abuse and threats of violence.

• Lack of control over how work is done – lots of responsibility but little authority or decision making; little or no say in how work is done.

• Exposure to prejudice regarding age, gender, race, ethnicity, or religion.• No opportunity to utilize personal talents or abilities effectively.• Chances of a small error or momentary lapse of attention having

serious or even disastrous consequences.• Any combination of the above.Citation: www.disabilitysafe.org.au/hazards-risks/psychological-injury

DSM-IV-TRPOST-TRAUMATIC STRESS DISORDER• 309.81 DSM-IV Criteria for Posttraumatic Stress

DisorderA. The person has been exposed to a

traumatic event in which both of the following have been present: (1) the person experienced, witnessed, or was

confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.

(2) the person's response involved intense fear, helplessness, or horror.

DSM-IV-TRPOST-TRAUMATIC STRESS DISORDER

309.81 DSM-IV Criteria for Posttraumatic Stress Disorder

B. The traumatic event is persistently reexperienced in one (or more) of the following ways: (1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions.(2) recurrent distressing dreams of the event. (3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur upon awakening or when intoxicated). (4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.(5) physiological reactivity at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.


C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: (1) efforts to avoid thoughts, feelings, or conversations associated with the trauma .(2) efforts to avoid activities, places, or people that arouse recollections of the trauma. (3) inability to recall an important aspect of the trauma. (4) markedly diminished interest or participation in significant activities. (5) feeling of detachment or estrangement from others. (6) restricted range of affect (e.g., unable to have loving feelings). (7) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span).


D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following: (1) difficulty falling or staying asleep. (2) irritability or outbursts of anger. (3) difficulty concentrating. (4) hypervigilance. (5) exaggerated startle response.

E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than one month.

F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.• Specify if:

Acute: if duration of symptoms is less than 3 months. Chronic: if duration of symptoms is 3 months or more.

• Specify if: With Delayed Onset: if onset of symptoms is at least 6 months after the stressor.

ORTHOPEDIC INJURIES WITH COMPENSABLE CONSEQUENCE

PSYCHOLOGICAL INJURIES• Orthopedic pain and functional limitations.• Pain Behavior which reinforces disability.• Emotional Distress increases perception of

pain and functional limitations.• Modified duty assignments must find work

that is within the claimant’s orthopedic restrictions but also does not exceed their emotional coping reserves.

DOMAINS OF PSYCHOLOGICAL INJURIES THAT IMPACT MODIFIED DUTY

• Emotional Issues (Depression, Anxiety, PTSD)• Neurovegetative Factors (Sleep, Appetite Libido)• Cognitive Deficits• Interpersonal Conflict• Coping Skills & Fragile Emotional State• Energy, Motivation and Drive• Lack of Structure and Direction• External Reinforcing Factors


Emotional Factors:• Depressed mood: Sad, pessimistic, negative

thoughts/prediction of outcome to return to work.• Anxiety and Depression lead to ruminative thinking

with hypersensitivity to critical comments and perceived lack of acceptance from supervisors and managers.

• Somatic expression of distress reinforces claimant’s perception of illness and disability leading to refusal to return to work on modified duty or to quickly abort a modified duty position if provided.


Neurovegetative and Cognitive Factors:• Impaired sleep (Sleep initiation, maintenance, early

morning awakening).• Impaired appetite with weight loss or gain.• Increased fatigue and daytime sleepiness.• Decreased energy, drive, focus and ability to

complete tasks efficiently and effectively.• Impaired attention and concentration.• Decreased processing speed.• Poor memory with increased forgetfulness.


Interpersonal Conflict:• Claimant’s perception of the County/Employer’s

role as surrogate parent and caregiver.• Impact of early childhood trauma and family

interpersonal conflict on a passive employment stage or interaction with industrial stressor.

• Temporary work preclusions regarding working under an alleged harassing supervisor or in a department with alleged harassing coworkers.


Coping Strategies/Fragile Emotional State:• Temporary modified duty must not exceed the

claimant’s coping skills.• Part-time work.• Less demanding work but, if possible, reasonably

interesting.• Supportive supervisor/staff who can talk with the

claimant and reinforce adaptive work behavior.• Provide psychological treatment (psychiatry and

psychology) as part of return to work and modified duty strategy.


External Reinforcements for Disability Behavior:• Passive-Dependent behavior and activities.• T.V. watching.• Excessive sleeping.• Stressinduced eating with weight gain with deconditioning.• Spouse/family performs claimant’s chores/IADL’s.

External Reinforcements for Proactive Working Behavior:• Quick return to modified duty.• Clear job tasks/duties and expectations with supportive

feedback on performance.• Assign to previous successful positions where new learning is

not essential and perhaps old, positive relationships exist.

DSM-IV-TR DEFINITIONOF MALINGERING

• The intentional production of false or grossly exaggerated physical or psychological symptoms which are motivated by external incentives:- Avoiding work- Obtaining Financial Compensation- Obtaining Drugs


• Malingering should be strongly suspected if:-Medicolegal context (e.g. referred by attorney).-Marked discrepancy between claimed stress or disability and the objective findings.-Lack of cooperation during diagnostic evaluation.-Noncompliance with prescribed treatment. -The presence of Antisocial Personality Disorder.


• Differential Diagnosis-Factitious Disorder: External incentives are absent and there is an assumed intrapsychic need to maintain the sick role.-Conversion & Somatoform Disorders: There is not intentional production of symptoms generated by external gain.

DISCUSSION SECTIONCREDIBILITY

Convergent evidence needed from multiple sources to argue poor credibility1. Self-reported history is discrepant with documented history: e.g., Claimant

reports 70 pound container fell on neck while witnesses say 20 pound).2. Self-reported symptoms are discrepant with known patterns of brain functioning

or psychiatric conditions: e.g., MTBI claims of extended retrograde amnesia without loss of memory for the accident; PTSD with reported flashbacks lasting minutes; Cognitive testing incongruent with depression.

3. Self-reported symptoms are discrepant with behavioral observations: Complaints of severe pain (10/10, 24/7 with no pain behavior during five hour examination or on multiple hours of sub rosa).

4. Self-reported symptoms are discrepant with information obtained from medical records: Claimant complains of severe depression beginning in 2005 through 2008 with no evidence of any reports of depression in extensive multi-disciplinary records during this period of time; No psychiatric or psychological treatment.

5. Evidence of exaggerated or fabricated psychological dysfunction: Self-reported psychological symptoms are contradicted by behavioral observations or test data. Well-validated psychological tests suggest exaggerated distress (e.g., on Symptom Validity or MMPI-2 Fake Bad Scale)

DOMAINS OF MALINGERING

Malingering typically occurs across three domains:1. Cognitive impairment (Symptom Validity Tests

and embedded formal cognitive tests).2. Psychopathology (i.e., MMPI-2: F, Fb, Fp).3. Physical or medical illness – over-reporting of

somatic complaints (MMPI-2: Fake Bad Scale, Fs Scale.)

FORCED CHOICE SYMPTOM VALIDITY TESTS

Forced Choice Symptom Validity Tests:– Word Memory Test (Green, P.)– Computerized Assessment of Response Bias (Allen, L.)– Portland Digit Recognition Test (Binder, L.)– Victory Symptom Validity Test (Slick)– Validity Indicator Profile (Frederick, R.)– Test of Memory Malingering (Tombaugh, T.)– Warrington’s Recognition Memory Test----------------------------------------------------------– All are recognition format tests.– All require that the patient choose between a correct and incorrect answer.– These tests can use the uncorrected Z approximation to the binomial.

SYMPTOM VALIDITY TESTING

• Forced choice measure.• Example: 5 digit number is presented.• Followed by two choices (correct and distractor).• By guessing alone, should get about 50% correct.• Thus, as test scores decrease below chance, it is

likely that the individual is deliberately choosing the wrong answer.

BASIC PREMISE OF SYMPTOM VALIDITY TESTS

• Symptom validity tests appear to challenge memory functioning when in fact they are tests of simple attention.

• Patients can perform below chance based on the binomial probability.

• Nies & Sweet (1994) found that only a minority of malingers actually score this poorly.

• At or above chance performances, however, can discriminate those demonstrating good effort from those demonstrating insufficient effort.


92149


92149 58730


52169


57864 52169

CARB SYMPTOM VALIDITY TEST

Severe Brain Injured Sample:• 28 Patients.• Sample from Edmonton, Alberta.• Documented Brain Damage on CT/MRI.• None of patients were in litigation.

Variable Mean Std DevLOC (hours) 158.6 146.7

PTA (hours) 469.4 754.6

Age 34.3 12.6

VIQ 96.7 14.8

Yrs of Ed 11.6 2.6

Variable Mean Std Dev

CARB BL #1 97.2%

3.9

CARB BL # 2 97.8% 3.9

CARB BL # 3 96.8% 5.1

CARB Total 97.4% 4.7

WORD MEMORY TEST SYMPTOM VALIDITY TESTING

• Two Main Conditions (Immediate & Delayed):

Immediate Recognition Subtest:• 20 word pairs presented. • One word every two seconds.• All word pairs are semantically linked to facilitate

recognition.• Easy: (“Dog” - “Cat”)• Slightly harder: (“Tree” – “Lake”)

• Recognition portion: 40 word pairs are presented. One of the pairs has a previously presented word and a new “foil” word (e.g., “Dog” – “Rabbit”; “Tree – Forest”).


Delayed Recognition Subtest:• 30 minutes later.• 40 word pairs are presented.• Target word and a different foil.• Forced Choice Recognition.• Consistency Measure between immediate and

delayed (e.g., chose “Dog” or “Tree” in immediate recognition trial but not in delayed trial).


Severe Brain Injured Sample:• 28 Patients.• Sample from Edmonton, Alberta.• Documented Brain Damage on CT/MRI.• None of patients were in litigation.

Variable Mean Std Dev

WMT Immediate

Recognition

97.2% 3.9

WMT Delayed

Recognition

96.0% 3.3

Consistency

IR/DR

92.7% 6.0

Pt Type Failed Failed Failed CARB WMT Either

Severe HI(No Litigation)

3.6% 3.6% 7.1%

Mild TBI(Comp Seeking)

23.1% 24.1% 31.5%

Stress/Dep(Comp Seeking)

16.1% 16.1% 22.6%

Chronic

Fatigue Syn(Comp Seeking)

20.0% 33.3% 40.0%

DSM-IV

Pain Dis.(Comp Seeking)

46.2% 50.0% 53.9%

TEST OF MEMORY MALINGERING (TOMM) Tombaugh (1996)

Trial 1:• Presentation of 50 pictures.• Forced choice paradigm (2 pictures; feedback).Trial 2:• Presentation of 50 pictures. • Forced choice paradigm (2 pictures; feedback).Retention Trial (20 minutes later):• Forced choice paradigm (2 pictures; feedback)

Group Trial 1 Trial 2 Retention

Severe

TBI

45.9

(4.7)

49.4

(1.3)

49.6

(1.1)

Dementia 41.0

(6.6)

45.7

(5.3)

47.0

(4.4)

TBI(Seeking Comp)

All performances significantly lower than patient groups

25.3

(10.8)

32.8

(13.4)

35.1

(11.8)

FEIGNED MOTOR IMPAIRMENT• Greiffenstein et al (1996).• Compared Grip Strength, Finger Tapping Test and Grooved Pegboard

performance.• 54 subjects with moderate-to-severe CHI with unambiguous motor

abnormalities on neurological examination (dense hemiplegia excluded).

• 131 litigating postconcussion patients who had a T score lower than 40 on one of the motor measures.

• Moderate-to-severe CHI had normal pattern of deficits with Grip Strength better than Finger Tapping, and Finger Tapping better than Grooved Pegboard.

• PCS patients had opposite pattern with Grooved Pegboard and Finger Tapping better than Grip Strength. The most significant difference between the two groups was Grip Strength.

• Larrabee (2003) found that definite MND and moderate-to-severe TBI significantly differed in raw dominant + non-dominant Finger Tapping. A cutoff score of less than 63 was optimal in discriminating litigants with definite MND from moderate-to-severe CHI.

MALINGERED REY COMPLEX FIGURE

MALINGERED REY 3’ DELAY

PREDICTING BRAIN DAMAGE GROUP AFFILIATION BASED ON TEST RESULTS

• Rohling et al., 2000.• Combined two large data sets of brain damaged

patients spanning different levels of severity (n = 249).• Severity of brain damage ranged from mild to severe.• Compared a patient’s Overall Test Battery Mean

(OTBM) which is a summary score of all the cognitive tests administered to a patient in a neuropsych battery.

• OTBM scores are expressed as a T score with a mean of 50 and a standard deviation of 10.


• Group 1: < 1 hour before able to follow commands.• Group 2: 1-24 hours before able to follow

commands.• Group 3: 1-6 days before able to follow commands.• Group 4: 7-13 days before able to follow commands.• Group 5: 14-28 days before able to follow

commands.• Group 6: > 28 days before able to follow commands.


Brain Damage OTBM SDGroup 1 46.7 5.0Group 2 44.3 5.8Group 3 42.4 6.8Group 4 37.9 7.2Group 5 29.3 7.1Group 6 26.6 5.8

OVER-REPORTING OF PSYCHOPATHOLOGY INFREQUENCY (F) SCALE

F Scale was originally developed to detect deviant or atypical ways of responding to test items:• 60 Items.• Factor analysis suggested 19 content areas, e.g.,

paranoid thinking, antisocial behavior, hostility, and poor physical health.

• Less than 10% of normative sample responded to items in the deviant direction.

• Elevations of T >110 strongly suggest that the profile is invalid. If valid, patient IS obviously grossly impaired.

BACK INFREQUENCY (FB) SCALE

Fb Scale:– Original MMPI did not have a way of measuring infrequent

responding on the second half of the test.– 40 Items that fewer than 10% of the normal subjects

responded to in the scored direction.– Elevated Fb score indicates that the test-taker responded to

items in the 2nd half of the test booklet in an invalid manner.– If F is valid, standard clinical scales can be interpreted.– Elevations of T >110 strongly suggest that the profile is

invalid. If valid, patient is obviously grossly impaired.– IF Fb is invalid, do not interpret content & supplementary

scales.

INFREQUENCY-PSYCHOPATHOLOGY (Fp)

SCALE

Fp Scale:– 27 Items that fewer than 20% of 706 inpatient psychiatric

male patients, a second sample of 423 men and women psychiatric inpatients, and the MMPI-2 normative sample endorsed in the deviant direction.

– Elevated Fb score indicates that the test taker responded to items in the second half of the test booklet in an invalid manner.

– If F is valid, standard clinical scales can be interpreted– Elevations of T >100 likely indicator that the patient is over-

reporting psychopathology.

METHODS FOR ASSESSING OVER-REPORTING OF SOMATIC COMPLAINTS

MMPI-2:Chronic Pain Research Project (Keller & Butcher, 1992):– 502 patients from the Sister Kenny Chronic Pain

Center.– All received the MMPI-2. – Scales 1, 2, 3 (Conversion V): All in T = 70 range.– Remainder of scales were not elevated.– Psychiatric patients had elevations on (F, 2, 4, 6, 7, 8).

OVER-REPORTING OF SOMATIC COMPLAINTS OR EMOTIONAL DISTRESS

MMPI-2 (Fake Bad Scale):Lees-Haley, English & Glenn, 1991: -Lees-Haley selected the items rationally on a

content basis using unpublished frequency counts of malingerers’ MMPI test responses and observations of personal injury malingerers.

-43 items were selected from the MMPI-2.


Lees- Haley & Glenn (1991): • Developed a Fake Bad Scale for MMPI-2.• Personal injury malingerers: N = 25: FBS = 27.6 (4.7). • Personal injury non-malingerers: N = 15.7 (4.1).• Psychiatric Outpatients (Men = 11.7; Woman = 13.8).

Lees-Haley (1992):• Woman > 25 classified 74% as embellished PTSD.• Men > 23 classified 75% as embellished PTSD.


• Larrabee, G.J. (1998):• Evaluated 12 medically and neurologically normal

litigants claiming brain damage with objective evidence of malingering.

• Only 3 had elevated F scale scores.• 11/12 had elevated Fake Bad Scales.• Somatic malingering should be considered when

elevations on Scales 1 and 3 exceed T = 80 and FBS is significantly elevated.


• Berry, D.T. et al. (1996): Journal of Personality Assessment.

• Detection of a cry for help on the MMPI-2.

• Analog Investigation.

temporary modified duty in psychological and neuropsychological claims ___________________________...

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little work

repetitive work

work overload

way work

posttraumatic stress

managers lack

lack of permanency

lack of recognition