“And bring a ton of quarters” [Cheney 2012]

Pure Mental harm and the GEPIC

Nick Ford BMed Sc Hons, BM BS, FRANZCP

Snr Clinical Lecturer Uni Adelaide

All case material used with patients permission.

Outline

The GEPIC

The report format

Sample Case

Maximal Medical Improvement

Truth, mistruth and the problems in establishing this

The GEPIC Pros and Cons.

Brain injury….

How things are

How things seem

Photos courtesy of Manuel Ubler

www.seifertuebler.com/welzow-tagebau

“Why is my light withdrawn?”

“Surely I am one before whom men spit?”

“My nights are filled with anguish until the dawn”

“And the pain that gnaws me takes no rest”

From the Book of Job, Holy Bible ~ 600 BC

What I think you see

Stigma of psychiatric illness with adverse treatment in most

jurisdictions and on occasion woolly, judgemental or inflated

opinions.

Role of personal responsibility vs a disease of the mind

Recommendations for treatment; that don’t happen

Access and willingness to access treatment

The iatrogenic effects of the claims process

Traffic accidents and the assessment of Psychiatric

impairment

The guide to the evaluation of Psych impairment [GEPIC]

A psychiatric diagnosis [DSMV] and maximal medical improvement

An Injury Severity Value {ISV}

“Pure Mental Harm” only.

Observation + Data

One examination only

The GEPIC& Psychiatric impairment I

Introduced in Victoria in 1997

Measures impairment not disability

[ accredited] observer rated measures; based on one session +

documentation/observation over time

Good inter rater correlations BUT problems of bias/rapport/

observational ability remain…calibration of the instrument.

The GEPIC& Psychiatric impairment II

Associations with prognosis in epidemiological studies remains unknown [ the same measures have been used for 50 + years in psych research] HDRS, MDRS, CAPS etc .

A psychiatric diagnosis must be made according to DSM 5

DSM V is widely disliked by psychiatrists; lack of prognostic and treatment relevance. [NIGH RDOC matrix]

Absence of online guides ;://aworkcovervictimsdiary.com/2014/03/are-you-missing-out-on-compensation-or-a-payout-from-workcover/

Factors assessed in the GEPIC

Intelligence

Thinking

Perception

Behaviour

Judgement

Mood

Each is linked to a number of “anchors” in the training manual;

E.g. Perception

Class

1 Minimal or no altering of sensorium

2 Heightening or dulling or perception to

semi dissociative flashbacks

3 Dissociative flashbacks in 1 or more

sensory domains. pseudo hallucinations

4 Hallucinations with varying digress of

preoccupation and insight

‘I feel dead people”

GEPIC Classes of psychiatric impairment I

1 MINIMAL

2 MILD

3 MODERATE

4 SEVERE

5 EXTREME

GEPIC Classes of psychiatric

impairment II intra class ranges

1 Minimal Low, Medium and High ranges

2 Mild Low, Medium and High ranges

3 Moderate Low, Medium and High ranges

4 Severe Low, Medium and High ranges

5 Extreme Low, Medium and High ranges

GEPIC Classes of psychiatric impairment II intra class ranges

THESE ARE NOT USED IN TRAFFIC

ACCIDENTS

1 Minimal Low, Medium and High ranges

2 Mild Low, Medium and High ranges

3 Moderate Low, Medium and High ranges

4 Severe Low, Medium and High ranges

5 Extreme Low, Medium and High ranges

GEPIC; Full version

The full version provides a percentage impairment, the MAIAS version does not permit this.

From this pre existing and consequential mental harm can be subtracted if appropriate [does not occur in the MAIAS}

The subtractions are inevitably informed guesses [but do not occur in the MAIAS]

Leading to a percentage of pure mental harm [does not occur in the MAIAS]

Injury Severity Values

A range

Pure mental harm ISV 10-13 [mild, moderate, severe and extreme]

Corresponding to GEPIC Levels 1 & 2, 3,4 and 5

a range for each ISV dependent upon severity within the GEPIC level

?Compensation…..at moderate impairment [ISV 7+, GEPIC level 3 i.e. 25% WPI]

Cannot be secondary to a physical injury; although a GEPIC report may elevate the range for the ISV

Pure and consequential mental harm

Consequential follows on from a physical injury

There may be a mixture of pure and consequential mental harm in the

same patient

Dominant injury [ is likely to be physical]

The psych report may lift the ISV value to the top of the range

Separation of pure vs consequential e.g. separating out fear./horror

from pain/loss of function can be described

Class Of

Impairment

Normal to

slight

Mild Moderate Moderately

Severe

Severe

Mental function 1 2 3 4 5

Class Of

Impairment

Normal to

slight

Mild Moderate Moderately

Severe

Severe

Mental function 1 2 3 4 5

Intelligence

Thinking

Perception

Judgment

Mood

Behaviour

Percent

Impairment

<5 10-20 25-50 55-70 >75

Class Of

Impairment

Normal to

slight

Mild Moderate Moderately

Severe

Severe

Mental function 1 2 3 4 5

Intelligence

Thinking

Perception

Judgment

Mood

Behaviour

Opinion Patient F.

1. Opinion; major depressive disorder, chronic. Chronic PTSD is subsumed by the

major depression but is present. Death of companion in bridge collapse and

inability to recover the body is noted..

2. Prognosis; Poor

3. Injury stability; MMI has been reached following comprehensive treatment, and the

passage of time.

4. The injury is consistent with the stated cause [see 5 below].

5. The effect of the accident on any pre existing injury. There is increased pain

perception of a pre existing shoulder wound which was previously quiescent

6. The effect of the accident on subsequent injury; there are no subsequent injuries.

7. The GEPIC rating with detailed reasoning; patient F

F has shown an impaired ability to forward plan business

eneavours and some decrease in memory; this is the upper end

of class 1. There is diminished speed of thought and speech,

with a pre occupation with themes of loss, ruminations of the

event which are difficult to suppress. He is in the upper end of

class 2. Perceptions are impaired with visual , auditory and

somatic flashbacks at least twice weekly . He is in the lower

range of class 3. Judgement is impaired with withdrawal,

requiring prompts for self care from his friend Sam &

alienation from some previous relationships.. He is in class 3,

mid range. Mood is pervasively low, with loss of weight,

despair, apathy low energy & anhedonia. He is in the mid

range of class 3. Behaviour shows fair function but markedly

diminished stress tolerance. He is in class 2 , high range.

Percent

Impairment

<5 10-20 25-50 55-70 >75

Class Of

Impairment

Normal to

slight

Mild Moderate Moderately

Severe

Severe

Mental function 1 2 3 4 5

Intelligence X

Thinking X

Perception X

Judgment X

Mood X

Behaviour X

7. GEPIC Table; patient F

GEPIC Rating; Patient F.

The classes in order are:122333.

The median class is 2.5; which is rounded up to 3

according to the training manual.

8. The ISV is thus 12. This is in the lower range of the

ISV range.

Stability?

Unlikely to change substantially, with or without treatment in the

next year, or so.

Reasonable treatment?

Compliance, Access including geography

Many illnesses are prone to relapse

Vulnerable periods and unpredictable hazards

Maximal Medical Improvement

Case by case

2 or more antidepressants , at adequate dosage+ a psychotherapy [not

just chatting]

Time ill

Losses incurred [job, family etc]

TRD 2 + years

PTSD 2+ years

More legal than medical

Texas Medication Algorithm Project

Non Psychotic major depression]

1. Antidepressant [1a +/- augmentation]

2. Different class [2a+/- augmentation]

3. TCA [3a +/- augmentation]

4 Lithium augmentation

5. Combination antidepressants [mirtaz + SSRI/SNRI, Bupropion +

SSRI, TCA + SSRI]

6 ECT

7 Other [Lamotrigine, TCA + MAOI]

Results of Tertiary treatment of TRD [Fekadu et al 2012]

150 patients; 13 deceased [suicide/cardiovascular], 118 consent to

follow up.

60% sustained recovery [ > 6/12 remission] over 3 years [intent to

treat analysis]

Social support, severity of treatment resistance, MAOI’s, SNRI’s

[duloxetine]

Trauma

“Everyone has their

breaking point Willard,

you and I have, and he

has obviously become

insane”’

Herr, Apocalypse Now

PTSD Predictors of Poor outcome

Late +/- inadequate treatment

Deaths, burning and distortion of the human form

Entrapment

Lack of social support [including self induced]

Substance abuse and dependence

High conflict claims management

Past and family psych history

Prior resolved PTSD may “inoculate”

Relapse with incomplete recovery [Judd LL et al 1998]

Combined psychotherapy and

PharMAIASotherapy [Pampallano et al 2004]

Resilience and your genes; COMT alleles&vulnerability to PTSD; Rwanda

Sometimes it gets chronic

Chronicity & MMI

Adequate and thorough treatment failed

Access to adequate and thorough treatment

Motivation to engage

Pre; Prior unresolved trauma or Lack of prior trauma and an entitled privileged background

Intra ; loss of loved ones, disabling physical injuries, guilt

Post; losses, opiates for pain, poor claims management

Patients at >15- 20% WPI after adequate Rx are unlikely to recover and continue to be seen ass outpatients/inpatients

Credibility and both sides of the fence

New ice,

A coiled snake,

The sons of Kings,

And an insurance case

These are the things not to be trusted

Germanic 2-500 AD [with modifications]

Credibility I

False imputation and symptom exaggeration are not common [ 5-10%

of claims]

Time course of symptoms

Consistency of history and affect

Response to probe questions

Technical language

Unusual reactions to treatment interventions

Judgement and the gestalt [1+2 always equals 3]

Credibility II

Evasiveness , and responses to alternative information.

Unchanging dreams in PTSD

“ the good old days”, idealised prior function.

Prior history withheld [ illness, legal issues, and

compensation]…..some reports are less than complete

Resistance to active rather than passive treatments.

Wide scatter of impairment classes eg 111333

Credibility III Interviewing styles

Rapport is respect, interest and compassion

Rapport is not judgment, sympathy or humiliation

Reassure about how deep the interview might go; and then start

probing

Explain why a past history is important, but talk about privacy

Look for links and observe the emotional response

Issues in compensation matters

Focus on character weaknesses of the targeted individual

Spreading of false information

Encroachments on private property;

Surveillance open and covert

Intimidation

Harassment and threats

Delays in investigation

Zersetzen; Stasi, East Germany;

1978-1989 [http://zersetzen.wikispaces.com/, Appelbaum 2014 ]

Focus on character weaknesses of the targeted individual

Spreading of false information

Encroachments on private property;

Surveillance open and covert

Intimidation

Harassment and threats

Delays in investigation

Disability; High and low stress compensation claims at 6 years, low risk

grouping [Grant et al 2014]

Case Management Issues, decreasing order of

prediction of disability at 5 years. [Grant et al 2014]

1. Not understanding requirements and the system.

2. Duration of the process

3. Being listened to.

4. Number of medical appointments

5. Respect and dignity

6. Amount of compensation

The GEPIC Pros and Cons

One assessor only… Medical Panels a or the Hot Tub?

Observational..and quite hard to fake good or bad on

No longer term data in proper epidemiological studies

Where should the compensable point be?

Conversion disorder and tremors

Who should assess Brain Injury…and How?

Would a percentage impairment better guide the court, or would it

lead to more argument?

Questions?

KR beating.

#1; penetrating injury r eye,

traumatic avulsion left middle

finger, multiple scars.

#2; fracture/malunion L tibia

Flashbacks/nightmares, 4 hrs

sleep, active/altruistic ++

Brain Injury

ISV’s 5-9

Ranges 0- 100

Minor TBI vs Concussion?

Neuropsych impairment?....happens with psych injury too

Imaging? ….the better the image, the more you find

GCS…mostly but not always accurate [moderate complex TBI

Head injury; Initial Severity markers

Glasgow coma scale

Post traumatic and retrograde amnesia

CSF leak, Anosmia, racoon eyes, battle sign

focal neurological signs

Skull fracture

Multiple injury sites

Biomarkers ? S100b, GFAP

Nick Ford Bed Sc [Hons] FRANZCP 3/24/2017

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