Mental Health & Behavior Impairment Ratings

Mental Health and Behaviour Impairment Ratings according to American Medical Association AMA guideline

1. Mental Health & Behaviour Impairment Ratings Abdul Rahman Ramdzan

2. Principle of Assessment Assessor Expertise DSM IV Expertise in psychiatry or psychological evaluation of patient Expertise in the diagnosis & treatment of mental & behavioural disorder Diagnosis Diagnosis categories Mood disorder – MDD, bipolar affective disorder Anxiety disorder – GAD, panic disorder, OCD Psychotic disorder - schizophrenia 2

3. Diagnosis 3

4. Psychiatric/ psychological evaluation 4

5. Special features

6. Physician alliance 6 Neutral & unbiased position Avoid serving as IME on behalf of their own patient Source materials Individual ‘s own description Reliable collateral information while doing ADL Records (hospitalization, outpatient) Inconsistencies should be explored Motivation Key factor in severity & extent of individual’s ability to lead productive life despite a challenging impairment

7. Malingering 7

8. Concepts of Impairment Ratings The Guides Sixth Edition uses 3 scales by which M&BD impairment is rated: Brief Psychiatric Rating Scale (BPRS) : 14-8 Global Assessment of Functioning Scale (GAF) : 14-10 Psychiatric Impairment Rating Scale (PIRS) : 14-5, 14-11 until 14-16 8

9. Brief Psychiatric Rating Scale (BPRS) 9

10. Brief Psychiatric Rating Scale (BPRS) – page 357 10

11. 11

12. Brief Psychiatric Rating Scale (BPRS) – page 357 12 18-24 25-30 31-35 36-40 41-50 51-60 61-70 71-168

13. Global Assessment of Functioning Scale (GAF) 13

14. Global Assessment of Functioning Scale (GAF ) 14

15. Psychiatric Impairment Rating Scale (PIRS) 15

16. Psychiatric Impairment Rating Scale (PIRS) – page 352, 358 16

17. (PIRS) – page 359 17

18. Psychiatric Impairment Rating Scale (PIRS) – page 360 18

19. Step 1: BPRS Impairment Score - 24 symptom constructs, each to be rated on a 7-point scale of severity ranging from “not present” to “extremely severe” (Table 14-8). Sum the total of the 24 BPRS symptom construct scores, and find the BPRS impairment score in Table 14-9. Step 2: GAF Impairment Score - Determine the GAF impairment score based on Table 14-10. Methods of Impairment Rating 19

20. Step 3: PIRS Impairment Score - grade the patient from l to 5 in Tables 14-11 through Table 14-16. 1) Patients should receive a score from 1 to 5 in each of the 6 impairment domains (Tables 14-11 to 14-16). 2) Arrange the 6 scores from lowest to highest, for example, 1 2 2 4 4 5. 3) Select the middle 2 scores from the arrangement of 6 scores. In the example “1 2 2 4 4 5.” the middle 2 scores are “2” and “4.” 4) Sum the middle 2 scores. In the example above, the sum of the middle 2 scores would be “6.” 5) Determine the PIRS impairment score from Table 14-17. Methods of Impairment Rating 20

21. Step 4: List BPRS, GAF, and PIRS Impairment Scores BPRS impairment score _______ GAF impairment score ________ PIRS impairment score _______ Of the 3 impairment scores listed in step 4, the M&BD impairment rating is the median (middle) value of the BPRS, GAF, and PIRS impairment scores. Methods of Impairment Rating 21

22. Scenario 1

23. Scenario 1 A 55-year-old high-functioning real estate developer noted a change in his normal outlook where the “sky was no longer blue but gray .” He said that food had no taste , and he could not concentrate on reading or television. Terminal insomnia and feelings of hopelessness and helplessness had developed. He felt his work was not worth the effort because of the futility of life. He withdrew into his home and began to stay in bed . He had no interest in his usual activities . When asked if he were depressed, he would answer “yes” but state that he really had no “feelings at all.” He felt excessive fatigue and at times stated that he would be better off dead. These symptoms were consistently present most of the day over the month before evaluation. 23

24. Scenario 1 He had no past history of mood instability, significant medical problems, or alcohol or substance use. There was no history of personality problems or work difficulties. He was happily married and had raised 3 successful children. He had a first cousin with depression onset in midlife. The patient sought psychiatric evaluation, and medical consultation revealed no medical cause. He was diagnosed with major depression . He was started on antidepressant therapy and had only a partial response. He underwent several antidepressant trials of sufficient length, appropriate dosages, different classes, and augmentive strategies. His response to medication was only partial or inadequate or was limited by side effects. His medication compliance was good and there was no discerned secondary gain. He would not consider electroconvulsive therapy, but did participate in cognitive behavioural therapy. After more than l year of various medicine trials, his symptoms seemed to stabilize and he was thought to have reached Maximum Medical Improvement ( MM I). 24

25. Scenario 1 After the reported treatment course, he reported he slept fairly well with only occasional insomnia (l night per month). He returned to within 10% of his pre-illness body weight. He still had episodic feelings of hopelessness and helplessness, but they were brief. He felt his mood was generally good and he had no passive death wishes. He had returned to work on a half-time basis several months earlier and recently had increased to full time. His ongoing psychiatric difficulties were threefold. First, his ability to concentrate had not fully recovered . The patient estimated that his abilities to concentrate on reading, hobbies, and work projects remained significantly diminished. He felt that his ability to focus at work was diminished by 50%. His work efficiency was approximately two thirds of his premorbid level. 25

26. Scenario 1 Second, he continued to have some anhedonia . He had only minor interest in sexual relations with his wife and minimal interest in social activities that had been a major part of their life together. If his wife pushed him, he would go out reluctantly. Third, he continued to have trouble with fatigue. He reported he could start out strong in the morning but by noon he would have to sit and relax almost to the point of needing a nap. Afterward he would feel good until about 3 PM, when he would again feel the need to rest. He had arranged his schedule around his needs for rest. 26

27. Diagnosis: Axis I : Major depressive disorder, in partial remission. Axis II: None. Axis III: None. M&BD Impairment Rating: Step I: BPRS impairment score Somatic concern: 1, Anxiety: I, Depression: 3 , Suicidality : 1, Guilt: 1, Hostility: 1, Elevated mood: 1, Grandiosity: 1, Suspiciousness: I, Hallucinations: 1, Unusual thought content: 1, Bizarre behavior : 1, Self-neglect: 1, Disorientation: 1, Conceptual disorganization: 1, Blunted affect: 1, Emotional withdrawal: 2 , Motor retardation: 1, Tension: 1, Uncooperativeness: 1, Excitement: 1, Distractability : 1, Motor hyperactivity: 1, Mannerisms and posturing: 1, Sum the total of the 24 BPRS symptom construct scores: 27. Find the BPRS impairment score in Table 14-9: 5%. 27 18-24 25-30 31-35 36-40 41-50 51-60 61-70 71-168

28. Step 2: Determine GAF impairment at MMl A GAF test score of 61 to 70 (mild symptoms or some difficulty in social, occupational, or school functioning) elicits an impairment score of 5% (Table 14-10). Step 3: PIRS rating score Table 14-11: 1, Table 14-12: 2, Table 14-13: 1, Table 14-14: 2, Table 14-15: 2, Table 14-16: 2. Arrange the scores: 1, 1, 2, 2, 2, 2. Select the middle 2 scores: 2, 2. Sum of middle 2 scores: 4. PIRS impairment score (Table 14-17): 10%. 28

29. Step 4: List BPRS, GAF, and PIRS impairment scores BPRS impairment score: 5%. GAF impairment score: 5%. PIRS impairment score: 10%. Of the 3 impairment scores, the M&BD impairment rating is the middle value: 5%. 29

30. Senario 2