OOP Meeting Archives

History of Current Situation
The following information was obtained directly from Mr. Z and also from his brother, --. Mr. Z stated that he was no longer able to do the job that he used to do, and that he was unable to build his back up to be able to "really function." He stated that a MRI revealed two disks as being bad, and that this caused hip pain.

Mr. Z stated that his job injury and depression led to his divorce. He stated "I don't think she could handle how I was. I was pretty sick - I just wasn't functioning."

Mr. Z stated "When I got off work I got suicidal - real depressed." He began seeing Dr.-in 1992 after being referred by Dr. --. He stated that he did not remember the content of the sessions.

Mr. Z stated that currently he feels much better than he did two years ago. He believes that his current medication regimen is very helpful to him.

Mr. Z specifically denied experiencing any manic episodes, even when they were described in lay terms. He also denied the use of marijuana.

Currently Mr. Z sleeps a total of 5-6 hours, retiring at 9:00 p.m. and arising at 7:00 a.m. He complains of having low energy, and "not real good" concentration. He described his memory as okay. He has had no crying spells for the last two years. He is not irritable, by his report. Regarding thoughts of death by suicide, he states "I think I'm pretty worthless." His most recent plans for suicide were made 18 months ago and included shooting himself. He stated that he has a gun and that two years ago he held it in his hand and pointed it at his head. When asked how much he had improved, he stated "I'm a lot better."

Time loss payments from the Department of Labor & Industries were discontinued in 1996; they had amounted to $1,800 per month. Currently Mr. Z receives SSDI payments of $1,200 per month. He complained rather bitterly "All I've done is work my ass off since I was a kid."

Employment History

Mr. Z's most recent job was that of a driver-salesperson for --- Express, where he earned $18.75 per hour. He worked at this job steadily for a period of 12 years, from 1982 through 1994. He stated that in the last several years he had significant stress and conflict with a supervisor.

Prior to that job Mr. Z worked as a driver-sales representative for ------, from 1971 through 1982. He stated that his employment was continuous. He stated that he always received good performance appraisals.

Current Medications

1. Depakote, 500 mg. b.i.d. (x 1 1/2 yr.)
2. Prozac, 60 mg. q.d. (x 2 yr.)

Past Personal Psychiatric History

Hospitalizations
Although Mr. Z stated that two psychiatric hospitalizations occurred in 1993 and one in 1994, the records as noted in the Records Reviewed section, indicate otherwise. He stated that he had no understanding whatsoever of why he had been diagnosed as having a Bi-Polar Mood Disorder by Dr. --, and specifically denied experiencing cycles. He complained of having a tremor as a result of taking Lithium. He stated that his second hospitalization was involuntary and resulted from a problem with the --- Police Department. He stated that somehow he had overdosed on Lithium, although he denied that it was intentional.

Psychiatric Outpatient Treatment

Mr. Z saw Dr.-in therapy from 1992 until about 18 months ago, meeting with him 1-2 times a week initially, and subsequently on a monthly basis. All psychotherapy was in individual sessions. He also noted that he had previously met with Dr.-while working, but saw her for only 3-4 appointments. Medication was prescribed during this treatment, and consisted principally of antidepressant medication and mood stabilizing medication.

Family Psychiatric History

The claimant stated that there was no history of suicide attempts in the family, but that a younger brother was alcoholic. He denied the presence of any cyclic mood disorders on the part of any family member. He also stated that no family member had any problems with depression, although his brother later stated that he himself became depressed as the result of an injury he received while on the job.

Past Medical History

The orthopedic problems associated with his industrial injury. Developmental History: Mr. Z was born in P--- and raised in G---- and H-------. His parents lived together. His father worked on dams and construction, and also ran a small dairy. His mother was a homemaker.

There were 12 children, including 7 boys and 5 girls. The claimant was the youngest in the family. He stated that there was no maltreatment within the family. His father died when Mr. Z was 22 years old. He stated that he had a close relationship with his mother. He stated that he had close relationships with his siblings, and that he attends a family reunion every year.

He dropped out of school in the 9th grade, although he claims he performed above average academically. He stated that he stopped school because he needed to go to work. He stated that the family did not value education. He worked in an apiary from age 14 through 18 and then joined the union at age 18.

He was married for the first and only time at age 17. He stated that he and his wife got along great until "everything just came apart." He did not volunteer any information about his wife having become involved with a 24-year old. He stated that his wife worked as a cosmetologist, and that she owned her own beauty shop.

Typical Day

Mr. Z prepares no meals whatsoever, eating fast food and at his sister's home. He does all of his laundry, and does a poor job of housecleaning, although he receives no help with it. He is responsible for paying all of his bills. He has no social life, stating that he hides out. He stated that he used to have many hobbies, including hunting and fishing and riding horses. However, he stated that he no longer does any of these things.

Alcohol and Substance Use

Mr. Z stated that he drank "very little" alcohol. This was later contradicted to some extent by the medical records. He smokes less than one pack of cigarettes per day. He denied using any illegal street drugs whatsoever, although when confronted later by information in the medical record, admitted to the occasional use of marijuana. He drinks between 2-4 cups of coffee per day.

Legal

There is no history of his having served time in jail. He stated that he was arrested once for having a loaded gun in a vehicle. The medical records indicate that he was picked up by the ---- Police Department for barricading himself in his home with guns. More information was not available in that connection.

Mental Status Examination

Mr. Z was a well-developed tanned white male who appeared to be his stated age. He appeared to be relatively fit physically. His demeanor was very remarkable in that he made very little eye contact, and seemed to be either depressed, or hostilely withdrawn.

His speech reflected significantly increased latency of response and was marked by poverty of content. He seemed evasive and minimally cooperative. He seemed to harbor considerable resentment toward all outside parties. He feels that he has been given a bum deal. His speech was not rational, but it was coherent, although again, very limited in amount and content. His affect was that of an angry and somewhat depressed man.

Regarding special preoccupations, he thinks of suicide and death, but has no plans. He denied experiencing auditory or visual hallucinations. He stated that he feels frightened, and that he does not want to see anybody but just withdraws. He was oriented to the date and knew the name of the President. He was able to remember three out of three dissimilar objects at five minutes. He was able to correctly perform serial three subtractions. If he were to find a stamped and addressed envelope on a sidewalk, he would place it in a mailbox, indicating intact judgment in non-emotionally loaded matters. He was able to spell the word "world" backwards. He was able to correctly make change from $1 after purchasing three apples at $.15 apiece. He was able to abstract at a simple level, the proverb "spilled milk" revealing "life goes on." He was able to repeat only four digits forward, a significantly substandard performance, reflecting impaired concentration. His fund of knowledge was adequate for a person of his education and background, as he was able to name the south and east bordering states as well as the largest city and the Capitol City of the State of Washington.

Summary and Discussion

Mr. Z has a Bi-Polar Mood Disorder that is currently under good control with his current medication regimen, which includes Prozac and Depakote.

With regard to his appropriateness as a candidate for any type of surgical intervention, I recommend extreme caution. It is my impression that Mr. Z has a severe Personality Disorder with antisocial and narcissistic features, as commented upon by several psychiatrists. I was particularly troubled by his lack of candor during my evaluation. This was specifically evident in his denial of any history of cycling mood disorder and also in his denial of use of street drugs. When confronted later, in his brother's presence, he grudgingly acknowledged that indeed he did use marijuana sporadically, but went on to justify it by stating that he didn't buy it. As noted above, Mr. Z was not forthcoming with regard to direct questioning about mood cycles.

I read lengthy excerpts from the hospital records to Mr. Z and his brother ----, and they confirmed the accuracy of the information presented.

I certainly wish to support Mr. Z receiving any and all orthopedic care that would be of benefit to him. However, as I stated to Mr. Z at the conclusion of my evaluation, his personality disorder will require lengthy and intensive expert therapy to produce change. I also have some question as to how well Mr. Z would respond to any psychotherapy intervention. I base this concern on my having experienced him as a man whom is very difficult to connect with. On some occasions, it is possible with lengthy group psychotherapy to breakthrough this character armor, but more often that is not the case. Antisocial traits are a relative contraindication to therapy, or at least are associated with a negative prognosis as is substance abuse. However, on occasion, such patients are capable of change.

Thank you again for this very interesting complex referral. If you have further questions, please contact me.

Diagnoses

AXIS I	1) Bi-Polar I Disorder, most recent episode depressed DSM IV 296.54 2) Alcohol Abuse (provisional) DSM IV 305.00 3) Cannabis Abuse DSM IV 305.20
AXIS II	Personality Disorder, NOS, DSM IV 301.9 (with antisocial and narcissistic traits)
AXIS III	Status post industrial injury
AXIS IV	PSYCHOSOCIAL AND ENVIRONMENTAL PROBLEMS: social isolation; unemployment; divorce
AXIS V	GAF - 41-50

Discussion

This was an evaluation requested by a surgeon who wanted an evaluation of this patient as a possible surgical candidate. No opinion regarding causality was requested. However, the patient's difficulties are clearly pre-existing, and there is documentation of conflict on the job which set the stage for claiming a job related injury. Because of the patient's lack of veracity, and the improbability of forming any type of effective therapeutic alliance (witness all of the prior failed efforts) treatment beyond simple medication management would not appear to be appropriate, nor would treatment be covered under the workers' compensation claim.

Treatment Considerations

This patient is not a candidate for psychiatric intervention, apart from pharmacotherapy. The degree of narcissism and antisocial traits renders the patient a poor candidate for group or individual therapy. The pharmacotherapy could not reasonably be considered as connected with the industrial injury, nor even as an aid to recovery and return to work, given the patient's lack of motivation.

Case #4
Combination Pre-existing and Related Conditions
A Case of Delayed referral for psychiatric treatment

Synopsis

Initial diagnosis	Major Depressive Episode with Psychotic features; Alcohol abuse in complete remission
Treatment Modalities	Prozac, brief perphenazine, Buspar Group therapy 2x/week; increasingly confrontational Approx. 6 Individual therapy sessions including 3 sessions with girlfriend
Outcome	Returned to work
Charles H.	DOB 7-5-71 DOI 9-16-94

From 2/26/96 initial evaluation:

Identifying Data
The patient is a 24-year-old white single male, living with his mother, who sustained injury to his right hand on a construction job.

History of current situation (partial)

"I don't know where to start-everything is different after the accident." "I've lost the will to go out and do things; I don't have any ambition. For a year and a half I've sat home-my attitude has changed-my temper-I'm pretty short with everybody-I broke up with my girlfriend 3- weeks ago. The main thing was my hand, my self-esteem was really low. I turned into the person I've cussed all my life-depending on the State to take care of me-I've always been independent. We've always been hard workers. I learned how to drive at 7 years old, picking up hay bales. When I say life has changed, it's changed-I've lost interest in going to my girlfriend's house-the only thing that interested me is getting better."

Sleep
3-12 hours per night

Appetite

Increased with 25 lb. Weight gain

Irritability

High, with yelling and screaming, kicking holes in doors and wall, not typical of previous behavior; no violence towards any person.

Suicidal ideation

Present

Crying spells

2-4 per week

Concentration and memory

Poor

Employment History

Continuous since age 16 with no gaps in employment; chiefly construction

Past Psychiatric History

None

Family Psychiatric History

Depression in father; job-related

Developmental History

Intact family; father police chief small town. One sister, four years older. Had best friends beginning 5th grade. Did well academically until the 9th grade when his father died of cancer. He became depressed, and his grades plummeted, going from Bs to Fs. Mother urged psychiatric consultation, but he refused. Failed to graduate from high school by 2 credits. Later, a diploma from a community college was obtained.

Typical Day

Irregular schedule. Partial ADLs.

Alcohol and Substance

Before girlfriend, went to bars 3 times per week. Since girlfriend, 1 time per week. No other substance abuse.

MSE

Neat and cooperative, the patient was coherent and rational. He described his mood as "piss poor." Affect was depressed and angry. Saw things out of the corner of his eyes. He sometimes attributes special meaning to songs he hears on the radio, believing they are directed just at him. These perceptual abnormalities and referential thinking seems real to the patient, not just his imagination. Orientation and cognitive functioning were intact. He met all 9 criteria on DSMIV for Major Depressive Episode.

Diagnoses

Major Depressive Episode, Single Episode, Severe, with mood congruent psychotic features; Alcohol abuse, in complete remission.

Psychiatric Treatment

6/96-6/98

Time Loss Payments

Ended 9 months prior to end of treatment; patient had no income; lived with mother

Discussion

This patient had a sound work history and ethic prior to his workplace injury. However, he had begun to develop a passive sense of entitlement prior to entering psychiatric treatment, which was delayed at least 9 months. He had a basically healthy personality constellation, but was very angry (unconsciously) because of the loss (death) of his father at age 16. Suicidal impulses were strong at the inception of therapy, as the job loss resonated with his prior loss. Denial and alcohol were his primary means of coping, but he possessed the ability to form relationships. His girlfriend was balanced and mature, and valued herself enough to set limits on his behavior; she pointed out deterioration in his self-care, for example, and was not willing to tolerate temper outbursts. He was willing to accept responsibility for his behavior, and was able to form a therapeutic relationship with the other group members after minor initial resistance. Ultimately he was able to work effectively for a brief period in individual treatment, which allowed for a more detailed working through of his developmental issues.

Treatment Considerations

Group therapy was a good beginning for this young adult male patient. The social aspects of the group made treatment far more tolerable for him, and allowed him the opportunity of learning how people can constructively talk about intense feelings in a therapy setting. He was able to practice this himself about 6 months into treatment, and was finally able to do limited but useful work in an individual and couple format. Pharmacotherapy for depression along with antipsychotic medication was essential. There was a brief recurrence of psychotic symptoms at approximately the midpoint of treatment, which responded to the perphenazine.

Case #5
Causal linkage plus pre-existing conditions; alcohol abuse; continuous work history maintained by treatment; inadequate pain management

Synopsis

Initial diagnosis	Major Depressive Episode with Psychotic features; Alcohol abuse
Treatment Modality	Group therapy and pharmacotherapy; Antabuse; AA attendance weekly
Outcome	Continued with full time employment
Harry L.	DOB 12-5-42 DOI 3-15-88

Brief History

This 54-year-old divorced man, employed continuously as a forklift driver at a fruit warehouse for the last 20 years, he fell 10 feet and sustained a comminuted fracture of the left patella and a fracture dislocation of the left elbow. He was treated surgically by radial resection and insertion of a silastic prosthetic prosthesis, followed by a right wrist implant on the left wrist in 1991. A re-injury of the right wrist occurred in 1985. The implant was removed and replaced with a different implant. However, in 1992 it had to be removed. Subsequent to this procedure, he was evaluated by referral from his orthopedist. He was found to be "discouraged", feeling useless, having little energy, and a disrupted sleep pattern with early morning awakening. Memory and concentration were impaired. He was more irritable. Crying spells occur on a daily basis. He described specific suicidal thoughts of "ending it all" and thought of doing so with a gun or knife, and crying as he entertained those thoughts, which occurred twice in the last 2 weeks. He experienced command hallucinations. He felt that "people would be a lot better off without me."

Medications

Darvocet
NSAID

Family Psychiatric History

Positive for suicide by the paternal grandfather. Alcohol problems were widespread-"the whole family." The patient's past history included a milder depression in his 30's, accompanied by suicidal thoughts, but less intense than now. He described heavy alcohol use and a 58-pack year of smoking.

Developmental History

The patient grew up in an intact blue-collar family. The father was distant, the mother was more affectionate. He was the middle of 4 sibs; he had a good relationship with them. School was difficult, and he quit at 16, at which time he went to work. He moved out at 18.

Treatment Course

The patient attended once or twice weekly group therapy with occasional brief individual sessions. Session frequency was increased when he reported more depression, and decreased when he improved. Pharmacotherapy for depression was supplemented with Antabuse at the time of the second hospitalization. He has experienced two relapses, with suicidal behavior, resulting in brief hospitalizations. Severe continuing pain and episodic alcohol abuse (for the second admission) were contributing factors. At the time of the second hospitalization the patient said that he had been lying about his drinking. Subsequently he was required to attend AA. He continued to work on a continuous basis, with employer support.

He described how he would drink, in part, in response to the severe and unremitting pain. He was referred for a second orthopedic and pain consultation. Oxycontin (a potent long-acting narcotic) was prescribed, with 80% relief, in stable non-increasing dosages. In response to a questioning letter from the Department, the consultant stated, "Unfortunately, the Guidelines for Outpatient Prescriptions of Controlled Substances, schedule 11-IV, for Workers on Time-Loss are outside the standard of care for appropriately selected patients." The patient has continued to function well on this stable regimen, with a markedly improved job performance, continuing AA attendance, and flexible group therapy/medication management.

Discussion

I choose to focus on maintenance of full-time employment as the principal objective in this case. While there was a family history of depression, and while the patient had a history of alcohol abuse, the commitment to continue working made the decision to offer treatment under workers' compensation easy for everyone involved, including the employer. Continuous work for 7 years following the initial implant, coupled with continuing work following 7 additional surgical procedures (except for brief periods off for recovery) demonstrated the patient's work ethic. The two psychiatric hospitalizations resulted from poorly controlled pain, escalating alcohol abuse, and depressive relapse. This case also calls attention to another area of deficiency in current patient care-the management of chronic pain. In Washington State the state medical association is in the process of revising the guidelines that currently prohibit the long-term prescription of narcotic pain medication for workers' compensation patients.

Employer support is another feature present in this case. The forklift was modified to allow driving with one arm. I contacted the employer on several occasions to follow up on the patient's performance, and received both support and useful information about deterioration in work-performance and suspected alcohol abuse. This enlightened attitude is a small-scale example of the disability reduction posture illustrated by the Continental Airlines reference in the introduction.

Perhaps one last point to be made is that of "regard for complexity." The patient's condition was determined by a multiplicity of factors. Two psychiatrists found the patient's depression to be causally related to the injury while acknowledging the presence of other factors. Other clinicians, had they been focused on "making a case" might have chosen to place exclusive emphasis on the prior alcohol abuse and the history of a prior depressive episode in an effort to deny treatment. A flexible approach was called for-one that emphasized cooperation among professionals, current knowledge regarding pain management, concurrent alcohol treatment through AA, and an ability to shift in and out of a more active group therapy mode as determined by the patient's condition.

Case #6
IME requested by private disability insurance company

Synopsis

Initial Diagnosis	Depressive Disorder, NOS; Anxiety Disorder NOS
Treatment	None
Outcome	Unknown

---- Insurance
Attn: ---------, IME Coordinator
---- -------- Street - ----
--------, -- -----

RE: C------ ------
Date of Evaluation: 7/31/97
SSN: -----------
D.O.B.: 5/6/--

Dear Mr. --------:

Thank you for allowing me the opportunity to perform an Independent Medical Evaluation on your insured, C------ ------, July 31, 1997. I reviewed your letter of July 18 and the entire file record you submitted for my review. The text of the psychiatric evaluation follows. My answers to your questions will be found in the Summary and Discussion section of the evaluation.

Identifying Data

The claimant is a 56-year-old married white female who lives with her 66-year old retired spouse.

Patient's Chief Complaint

"My shortness of breath hampers me most; I have chronic pain from adhesions."

Reason for Evaluation

An Independent Psychiatric Evaluation was requested in order to answer the following questions

1. Based on her history, do you feel she meets the criteria for a Somatoform Disorder as classified in DSM IV?
2. If you do not feel the patient has a Somatoform Disorder, do you feel the patient has any other psychiatric diagnoses?
3. Is the patient impaired, and if so, what is the primary impairing condition?
4. Is the patient receiving appropriate treatment? If no, what would you recommend?
5. Please complete a mental FCE in full. Reference is made to Supplemental Questionnaire in the cover letter, but no such questionnaire was enclosed in the information packet.

Records Reviewed

1. A telephone encounter sheet dated 12/5/94 through 12/12/94 was reviewed. Reference to the administration of morphine sulfate and Phenergan and admission to an Emergency Room is made. The significance of some of the entries is not clear.
2. A 12/12/94 letter by a physician whose signature is not legible, was reviewed. A past history of fibromyalgia, tachycardia, hernia repair complicated by bowel obstruction, chronic pain, dizziness, and shortness of breath are noted.
3. Progress Notes from May 1995 are reviewed. Fibromyalgia and CMV are noted.
4. A Progress note dated 6/30/95 by J-----------, M.D., was reviewed. Permanent medical disability "as of today" is noted. A diagnosis of COPD, CMV, and fibromyalgia are noted.
5. Numerous additional progress notes are enclosed but not commented upon.
6. A Physical Capacities Evaluation dated 7/10/95 was reviewed. Significant limitations in sitting, standing, and walking are noted. A significant lifting capacity limitation is noted. The patient is noted to be unable to walk long distances.
7. A Physical Capacities Evaluation dated 3/21/96 is noted. Very significant lifting capacity limitations are noted. Continued major restrictions with regard to sitting, standing, and walking are noted.
8. A 4/18/96 letter from ---- to Dr. ------- is reviewed. Flashbacks regarding her illness and past surgery were noted. A part time sedentary work trial of four hours per day three days a week was recommended.
9. A 9/5/96 Progress Note from the ---- --------- Clinic was reviewed. Insomnia and tendonitis in the right elbow were noted. A brief review of the patient's medical history is included.
10. More vocational material is provided for review; it appears to be a job market survey.
11. A 4/1/97 detailed activity listing by ------- -- -------, D.O., was reviewed. This apparently reflected an attempt to evaluate the patient's work capacity.
12. A 5/28/97 activity listing by ------- -- -------, D.O., was reviewed. Questions for psychiatric review were detailed as noted in the "Reason for Evaluation" section outlined at the start of this report.

History of Current Situation

Mrs. ------ stated that her problems essentially began in 1986 when she underwent four surgeries for what was initially was a strangulated hernia. She stated that her bowel apparently ruptured during the initial surgery, resulting in the need to perform and end-to-end anastomosis. The abdominal cavity was effectively sprayed with bowel content, resulting in the development of several abscesses. Two or more were removed with subsequent surgeries, but ultimately her principal problem turned out to be a retroperitoneal abscess, which was not visible by standard CAT scan and radiographic efforts because of flattening. She requested an infectious disease internist subspecialist, who ultimately diagnosed her condition. With the resolution and removal of the abscess, her condition resolved, and she was able to return to work. It is noteworthy that her hospital stay was of some two months' duration. As might be expected, she developed multiple adhesions subsequent to those surgeries. These resulted in considerable abdominal pain, which was relieved for a three-month period subsequent to gall bladder surgery performed about three years later.

Although somewhat compromised by her health, she nevertheless continued to work through 1994 or 1995, when she contracted Cytomegalovirus Hepatitis subsequent to a visit with her grandchildren. At the time, they were experiencing an upper respiratory infection, which her physician later told her was 90% likely to be the source of the CMV infection and hepatitis. She was off work for two months, subsequent to that episode when she returned to work.

She stated that several physicians who knew her well and who practiced at the internal medicine clinic where she had worked for a period of ten years, commented on her diminished endurance, and encouraged her to take a leave of absence. She stated that she resisted this recommendation initially, but ultimately became embarrassed at not being able to carry her own workload. She stated that several of her co-workers covered for her deficiencies, frequently telling her to sit down. She was unable to walk across the parking lot without stopping for a rest immediately prior to her resignation. She stated "I had such a hard time keeping up with the flow of what was happening. I was supposed to check in patients, and answer the phone. I even had patients asking me whether I needed to sit down." She reiterated that this loss of physical endurance had been manageable up until the time of her CMV hepatitis. One co-worker asked her, "Have you thought about going on disability?"

She stated that she had elevated CMV, Epstein Bar, and mononucleosis titers. She stated, "The bottom falls out--you just can't go any further."

She provided a detailed history regarding her surgeries. She stated that initially she had flashbacks, but that she has been essentially free of them for ten years, with the exception of a brief recurrence at the time of her CMV hepatitis. She noted that she had one anxiety attack when she entered an ICU as a part of her teaching duties. However, she stated, "It doesn't bother me now."

Currently she describes her mood as "contented and happy." Her affect, however, was anxious. She stated that two years ago "I would have said frustration." She has no crying spells. She describes her memory as good. She reports having fairly good concentration, but stated that she has always eaten too much. She has gained 70 pounds over the past ten years. Regarding exercise, she states that she tries to walk every day, but adds that she is unable to do enough walking to "do any good." Since being placed on Paxil one month ago, she notes that her pain is significantly reduced.

She reports that she and her husband get along well at present. She has sometimes been troubled by the amount of "mothering" he and her other friends try to provide for her. She wants to feel more independent.

Employment History

Mrs. -------- most recent employment was as a Director of Nursing at an internal medicine clinic associated with a medical teaching facility. She worked in that position for approximately ten years. Twelve resident physicians, eight supervising physicians, and five teaching physicians worked at that location. Responsibilities, included coordinating the teaching and work efforts, working with quality assurance, and working with JCAH.

Her prior three positions were working as a Director of Nursing at different nursing homes for periods ranging from 1-2 years. In each of these jobs she helped either open a new facility or help bring them into compliance with regulations.

She reported that she has never had any gaps in employment. She began working at age 20, and has worked on a continuous basis through approximately 1994.

Current Medications

1. Amitriptylene, 75 mg. q.h.s.
2. Daypro
3. Paxil, 20 mg. q.d. (times 1 month)
4. Estrogen
5. Lozol
6. medication for asthma
7. Vanceril

Past Personal Psychiatric History

Hospitalizations

None

Psychiatric Outpatient Treatment

None

Family Psychiatric History

Mrs. ------ stated that her mother had difficulties with depression in her post-menopausal years. However, she never received any treatment. There is no history of suicide, alcohol, or drug abuse, nor of anxiety disorders within the family, by her report.

Past Medical History

She was diagnosed with fibromyalgia in about 1992. However, she stated that this problem has diminished significantly. She had a strangulated hernia as noted above, and also CMV Hepatitis.

Developmental History

Mrs. ------ was born and raised in ------------. Her parents lived together while she was a child and adolescent. Both of them worked as LPNs at a mental institution. They worked a night shift, and as a consequence she and her 6-year older sister were confined to the home until 1:00 or 2:00 p.m.

She stated that her childhood was like that of a single child. The rules of the house were very strict, as both of the parents were members of a very restrictive religious denomination.

She did not have a close relationship with her mother, and had considerable conflict during her teen years. Her father was quiet. Neither parent showed affection. Academically she earned As and Bs, and received a four-year degree from -------- Union College of Nursing. She was married at about age 20.

Typical Day

She arises between 8:00 and 9:00 a.m. and retires at about 11:00 p.m. Her daily activities include studying the Bible for 1-2 hours in the morning and spending 1-2 hours per day quilting. She does the dishes. Cooking is divided evenly between her husband and herself. She walks down the lane to their house each day for exercise. She baby-sits grandchildren. She reads the newspaper on a daily basis and watches television while quilting. She enjoys the company of her daughter.

Alcohol and Substance Use

She states that she drinks coffee in the wintertime but smokes no cigarettes and consumes no alcohol.

Legal

She has never been arrested.

Mental Status Examination

Mrs. ------ presented as a morbidly obese woman with careful grooming. She fidgeted constantly throughout the interview, shifting posture, and moving her legs and ankles. Her voice was at times dramatic, and underwent frequent and wide shifts of volume and pitch. She laughed nervously. Her speech reflected an above average vocabulary.

She described her mood as good, but her affect was extremely anxious.

Regarding special preoccupations, she denied thinking about death. She denied experiencing auditory or visual hallucinations. There was no evidence of psychotic thought processes.

She was oriented to the date. Remarkably, she was unable to name the President for 10-15 minutes. Her ability to perform serial three subtractions was significantly compromised, and was both inaccurate and slow. She had difficult performing simple arithmetic, although she was ultimately able to do it successfully with encouragement. She was able to abstract at a simple level, the proverb "spilled milk" revealing "something goes wrong, if you can't fix it, just keep going on." Her judgment with regard to simple matters was impaired; if she were to find a stamped and addressed envelope on a sidewalk, she would leave it there or put it in her pocket and use it. The correct answer, of course, is to mail it.

Remarkably, she was unable to spell the word "world" either forward or backwards. She was, however, able to spell the word "truck" backwards. She was able to repeat five digits forward on the first try, but six digits forward only on the third try. This is a significantly substandard performance for an individual of her education and background. She was able to remember only two out of three dissimilar objects at five minutes, also a substandard performance. Her fund of knowledge was less than what one would expect from a person of her background. She was able to remember the bordering states and the largest city of the State of Washington, but not the capital of the State of Washington.

Summary and Discussion

Mrs. ------ is a woman with a solid work history and work ethic. There is nothing in the history to suggest neither symptom magnification nor malingering.

In my opinion, she does not meet the criteria for Somatoform Disorder as classified in DSM IV. The basis for this opinion is that on several occasions she has reported very significant relief associated with specific medical interventions. This occurred at the time of her gall bladder removal when her adhesions were released, at the time of a Prednisone trial, and most recently, when she began Paxil - approximately one month ago. There appears to be a sound physiologic basis for the pain complaints that she reports.

Mrs. ------ does appear to be experiencing an anxiety disorder, most accurately coded on DSM IV as Anxiety Disorder, Not Otherwise Specified. Her anxiety is apparent in her fidgeting, her sometimes pressured speech, and in her difficulty with concentration. It is possible that her anxiety is related to her asthma medication. In addition, although she does not appear to be aware of it, it is my impression that she is experiencing depression, probably most accurately coded as Depressive Disorder, NOS. The etiology of both her anxiety and her depressive disorders are her medical problems, and the associated impairments.

Mrs. ------ specifically denied that she experiences shortness of breath at rest. Inasmuch as she does not claim dyspnea at rest, but only upon exertion, there does not appear to be a significant psychiatric component to her exertional problems. Although mildly depressed and somewhat anxious, she voiced a willingness to work, and specifically voiced a willingness to work on a part time basis if a suitable position could be developed.

Mrs. ------ is receiving generally appropriate treatment for her conditions. However, I recommend that a psychiatrist in her community become involved in her treatment for the purpose of managing her psychotropic medication, treating her mild depression and anxiety supportively, and, if indicated, facilitating a possible part time employment with the assistance of appropriate vocational services.

Neuropsychological testing and general psychological testing would be useful to corroborate the above diagnostic impressions. Specifically, it would be helpful to rule out the presence of any organic neurologic deficit as the basis for her poor performance on her mental status examination. Clearly, if there is an organic basis for this impairment, a successful return to work would be far less likely. In addition, psychological testing would tend to confirm or modify my diagnostic impression of depression and anxiety, as well as providing an additional indicator of its degree. Consultation with her internist might help to identify whether or not her asthma medication is contributing to her anxiety.

Her morbid obesity (>100 lbs. over ideal body weight) is noted. Her depression, inactivity, and anxiety may have contributed, but it implies the presence of other problems of a psychiatric nature. Psychological testing might help to provide additional insight regarding this matter.

Thank you very much for allowing me to perform this Independent Psychiatric Evaluation of Mrs. ------. If you have any additional questions, please feel free to contact me.

Diagnoses

AXIS I	1) Anxiety Disorder, NOS DSM IV 300.0 2) Depressive Disorder, NOS DSM 311
AXIS II	Diagnosis deferred on Axis II
AXIS III	History of CMV Hepatitis; history of complicated hernia repair; history of fibromyalgia
AXIS IV	PSYCHOSOCIAL AND ENVIRONMENTAL PROBLEMS: unemployment; Chronic medical condition
AXIS V	GAF - 71-80

Discussion

What stands out upon initial inspection of this case is that this patient's medical care has been relatively uncoordinated, and that there have been no prior psychiatric evaluations, in spite of the fact that the worker's disability began several years ago. That there were and are significant medical problems is undisputed. Restrictive lung disease and a history of multiple surgeries with complications unquestionably caused this patient serious difficulty. Perhaps her care was rendered somewhat less effective because of the informality of the treatment relationships; physicians at the clinic where she was employed treated her. It appears that they may have become both frustrated by and sympathetic with her medical problems. She was invited to apply for disability, by her report. Her solid work history does not reflect any particular sense of entitlement. She almost seems to have been pressured into retirement, but has begun to accept as fact her disability. There appear to have been either misstatements or misperceptions within the recent past; the insurance company reviewer disputed her dyspnea at rest. The patient also disputed it! She stated that she would be willing to work part time, and there were no non-verbal indicators to the contrary.

I am concerned by her poor performance on the MSE. Her memory and cognition seem impaired. Is this because of anxiety? Does she have an early dementia? She laughed too loud, and possessed neither insight nor self-awareness; the deficits appear too great to explain by anxiety alone. She does appear to utilize repression to a considerable degree, but that is not a convincing explanation either. I would like to have neuropsychological evaluation and a neurology consultation as well if there are positive findings with the neuropsychological testing.

Causality is less of an issue here than accurate diagnosis and assessment. There appears to be a certain lack of definition and crispness in the information presented by the treating physicians. The insurance company could not adequately administer this claim with the information at hand. An IME by a competent internist might be of use as well. Certainly a psychiatric evaluation would have been useful one year earlier.

Treatment Considerations

Before treatment can begin, a secure diagnosis must be obtained. Organicity must be ruled in or out. The initial treatment direction will be determined by the final diagnoses. Beyond that, the IME psychiatrist should not perform the treatment if treatment is indicated. In any event, this patient does not appear to be a candidate for insight oriented therapy, but rather for pharmacotherapy and encouragement. She might be able to learn more about herself in properly constituted group, one where the emphasis was on concrete accomplishment with some discussion of feelings within a non-threatening setting; the social element would be very important to her in the initial stages of her treatment.

Practice Management

Essential to developing a successful workers' compensation evaluation and treatment practice is high quality work. This requires superior documentation, punctuality, and specific knowledge regarding varied patient populations. Guidelines for a successful practice include the following:

• A 3-day turnaround for reports; this will define you as unique among professionals, and make you indispensable to other professionals
• Daily dictation of treatment notes
• The discipline and commitment to produce a report in 24 hours when needed
• One dictation, one proofing to product
• Consistent high quality patient care
• Evaluations that do not compromise of professional standards or shade findings * Same day telephone responses to other professionals
• Actively learning what the needs of the referring professionals are
• Awareness that this is a 3-7 year process of development
• Know the statutes relating to workers' compensation in your state as they relate to evaluation and treatment
• Avoid conflicts of interest
• Separate treatment and evaluation roles-don't do both with the same patient
• If you are the treating psychiatrist, your primary responsibility is to your patient
• If you are conducting an evaluation to address issues of causality, your obligation is to be as objective and balanced as possible-a biased evaluation costs everybody, and renders litigation decisions less efficient
• Define charges and payment arrangements in writing with all new referral sources in advance in order to avoid mutual ill will. Cancellation policy for scheduled testimony, depositions, and required retainers should all be communicated in writing well in advance.

To accomplish the above, the following may be helpful:

• Use templates, cover sheets, flow and log sheets
• Dictate everything
• Initial evaluations
• Group therapy notes
• Individual session notes
• Develop standard phraseology for common procedures, like the MSE

Practical tips for running your practice from a business perspective (with thanks to Dr. Robert P. Grannacher):

• Never do anything you can pay someone else to do at a lower hourly rate than you charge
• "If you are posting accounts and typing....(maybe you should be an accountant or a typist)
• Computerize billing and transcription
• Develop your niche
• Hire a good CPA, attorney, and clinical consultant
• When in doubt, get a second opinion
• Constantly upgrade your clinical skills

1Between 1994 and 1996 Continental Airlines acquired a new management and a new mission, with the following results: Workers' compensation claims decreased by 45%. Sick leave is down 16%. In the 1996 Annual Report, CEO Gordon Bethune stated: "We are Working Together. It is the major difference between a dysfunctional airline with January 1995 market value of $175 million and the "Airline of the Year" with a market value nearing $2 billion that we are today. We must always treat each other with dignity and respect, pull our weight, do our jobs and behave fairly."

2 Leigh, J. P. et al., "Occupational injury and illness in the United States," Arch Intern Med. 1997;157:1557-1568

3 Gallagher, Rollin M., "Referral delay in back pain patients on workers' compensation," Psychosomatics 1996: 37:270-284.

4 Hendler, N. L., and Kozikowski, J. G., "Overlooked physical diagnoses in chronic pain patients involved in litigation," Psychosomatics 1993: 34:494-501.

5 Hendler, N. L., et al., "Overlooked physical diagnoses in chronic pain patients involved in litigation, Part 2," Psychosomatics 1996; 37:509-517.

6 Williams, C. D., "Group psychotherapy in the treatment of injured workers," paper presentation, 1997 APA Annual meeting.

7 Gallagher, R. M., et al., "Workers' compensation and return to work in low back pain," Pain: 1995: 61:299-307.

8 Ibid.

9 Dworkin, R.H., et al., "Unraveling the effects of compensation, litigation, and employment on treatment response to chronic pain," Pain, 1985 23:49-59.

10 Personal Communication, Anne Alonso, Director, The Center for Psychoanalytic Studies, Harvard Medical School-Massachusetts General Hospital.

11 Personal Communication, Charles Mangham, Supervising and Training Analyst, Seattle Institute for Psychoanalysis, and Clinical Professor, University of Washington Department of Psychiatry

12 Infrequent does not mean non-existent, however. An example of a claim that does appear to be fraudulent will be presented later in the course.

13 State Workers' Compensation Anti-Fraud Activity: Survey Results, Minnesota Department of Labor and Industry, 1995 (This is a compilation of a national survey)

14 Ibid.

15 Labor and Industries Annual Fraud Report, Washington State Dept. of L & I, 1996

16 Workers' Compensation System Abuse Complaint Activity, Fiscal Year 1996, Oregon Department of Consumer and Business Services, May 1997

17 Mayer, TG., et al., "A prospective 2 year study of functional restoration in industrial low back pain." JAMA, 1987; 258:1763-1768.

18 Gallagher, R.M. (1996)

19 Thibault, G.E., "Clinical problem solving: failure to resolve a diagnostic inconsistency." N Engl J Med: 1992; 327-36-39.

20 Oldham, J. M., et. al., "Comorbidity of axis I and axis II disorders," Am J Psychiatry 152:4, pp. 571-578, 1995.

21 Grant, B.L. and Robbins, D.B., "Disability, Workers' Compensation, and Fitness for Duty," Mental Health in the Workplace: A Practical Psychiatric Guide, Kahn, J.P. ed., Van Nostrand Reinhold, New York, 1993.

22 Porter, Kenneth M.D. "Combined Individual and Group Psychotherapy, " pp. 314-324, Comprehensive Group Psychotherapy, Kaplan and Sadock, eds., Third Ed., Baltimore, Williams and Wilkins, 1993.

23 Jaffe, J. H., "Opioid-related disorders," p. 843, Comprehensive Textbook of Psychiatry, Kaplan and Sadock, eds., Sixth Ed., Baltimore, Williams and Wilkins, 1995.

24 Groves JE: Taking care of the hateful patient. N Engl J Med 1978; 298:883-887 4 37