AMA Guides® Newsletter - Issue Archive

Articles

1. Psychiatric Assessment in Injury and Disability

   Marcia Scott

   Pages 1–3

   DOI: 10.1001/amaguidesnewsletters.1998.MayJun01

   Abstract

   Chapter 14 of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) discusses diagnosis, mental impairment, impairment severity assessment, special impairment categories, report format, and psychiatric impairment evaluation. The chapter differs from others in the AMA Guides insofar as it does not provide percentages for estimates of mental impairment because such usage suggests a certainty that does not exist. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, is a widely accepted classification system for mental disorders, but it omits context. Few clinically standardized tests can identify functional or structural effects, and neuropsychological testing is not the standard for documenting subtle impairment. How individuals manage their illness and cope with life demands are better measures of impairment than diagnostic labels or numbers and kinds of symptoms. Further, assessment requires an evaluation of the context in which the illness unfolds, including premorbid function and previous response to treatment; details about the individual's life course; review of developmental and functional deficits; character style and comorbidities such as anxiety and substance abuse; severity of precipitants, current stage of the episode, and current effectiveness of treatment; and external supports that can moderate impairment. A table lists areas of functional impairment, symptoms to consider, and patient history relevant to symptoms.
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2. Impairment Update: Illness Behavior

   Leon H. Ensalada

   Pages 4–5

   DOI: 10.1001/amaguidesnewsletters.1998.MayJun02

   Abstract

   The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) notes that many methods used to report medical impairments rely on the completeness, accuracy, and honesty of the patient's self-presentations. Symptom exaggeration is best understood in the context of clinical phenomena that lie along a continuum from unconscious and unintentional to conscious and intentional. Illness behavior refers to the ways in which given symptoms may be perceived, evaluated, and acted upon by different persons, and such behavior can be appropriate or inappropriate, depending on context, and can be learned and reinforced. Further, certain illness behaviors potentially confound the association between illness or injury, on the one hand, and impairment or disability, on the other hand. For example, any deficit can be exaggerated, including neuropsychological deficits, pain, and loss of sensation. Specialized assessments include symptom validity testing to assess memory or sensory deficits, and maximum voluntary effort testing assesses strength deficits. In their assessment of illness behavior, physicians should employ the same degree of thoroughness as they would with any condition. Written reports should include not only the conclusion that symptom exaggeration is present but also the basis for this determination. A table shows the characteristics of symptom magnification syndromes and other related conditions vs the presence of symptoms such as seeking gain or deception.
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3. Clinical Update: Subjective Illness and Disability

   Marcia Scott

   Pages 6–7

   DOI: 10.1001/amaguidesnewsletters.1998.MayJun03

   Abstract

   Symptoms are the body's major signaling device, but symptoms often are frustratingly vague, subjective, and ill reported. In addition, challenges attend making decisions about an individual's ability to function based solely on the medical diagnosis, particularly when impairment is subtle or subjective. Chronic fatigue syndrome (CFS) is a model for understanding the limits of the medical approach to determining impairment and disability. A protocol from the Center for Disease Control and Prevention (CDC) is used to define CFS. This protocol is not a list of diagnostic criteria, and some patients with chronic fatigue may not meet the CDC definition. The syndrome reflects dysfunction in the neuroendocrine system similar in some ways to that seen with depressive illness, and most patients seen for this condition fulfill the criteria for depression, which is another illness characterized by fatigue and somatic complaints. Physicians who evaluate and treat patients with subtle persistent illness know that employers and coworkers respond less positively to an employee's needs when illness is subtle than when impairment is obvious. Physicians must be clear about the family, job, and employment risks patients take when they stay out of work for medical reasons; they also must recognize the risk these patients take when they continue to work despite impaired performance.
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4. Literature Review

   Lome Direnfeld

   Pages 7–7

   DOI: 10.1001/amaguidesnewsletters.1998.MayJun04