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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.
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“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.”
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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. |
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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
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