TEMPORARY MODIFIED DUTY IN PSYCHOLOGICAL AND NEUROPSYCHOLOGICAL CLAIMS ___________________________

1. TEMPORARY MODIFIED DUTY IN PSYCHOLOGICAL AND NEUROPSYCHOLOGICAL CLAIMS___________________________ David B. Freeman, Ph.D. Cal Psych FMT 16530 Ventura Blvd., Suite 200 Encino, CA 91436 Tel: (818) 385-0684 Fax: (818) 385-1166 www.calpsychfmt.com

2. COMMON CAUSES OF STRESS CAUSING PSYCHOLOGICAL INJURIES • Communication difficulties between workers and managers - lack of formal or effective communication or consultation structures or procedures, with workers feeling unable to voice concerns or problems or feeling insecure if they do. • Bullying, harassment or intimidation. • Work overload and underload – unreasonable demands or impossible targets. • Inadequate time to complete jobs satisfactorily leading to a feeling of being overwhelmed or exhausted. • Job insecurity – fear of redundancy, lack of permanency, short-term or casual contracts, lack of career opportunities, and lack of recognition or reward for a job well done, particularly where the pay is low. • Too much change – restructuring of workplace and the way work is organized. • Inadequate staff levels – staff leaving and not being replaced with the rest of staff expected to pick up the workload. • Inadequate resources – or equipment that is continually breaking down because it is poorly maintained or overdue for replacement. • Unresolved health and safety issues, e.g. exposure to chemicals, noise, extremes of temperatures, exposure to potential violence whilst working alone. Citation: www.disabilitysafe.org.au/hazards-risks/psychological-injury

3. COMMON CAUSES OF STRESS CAUSING PSYCHOLOGICAL INJURIES • Excessive performance monitoring and surveillance. • Poor work organization – lack of clear job descriptions, conflicting demands, too much or too little work, boring or repetitive work, no job satisfaction. • Insufficient training. • Dangerous hours – required to work overtime or through breaks.  Shift rosters that are unpredictable or make it difficult to balance work and family life. • Difficulty dealing with clients/general public due to abuse and threats of violence. • Lack of control over how work is done – lots of responsibility but little authority or decision making; little or no say in how work is done. • Exposure to prejudice regarding age, gender, race, ethnicity, or religion. • No opportunity to utilize personal talents or abilities effectively. • Chances of a small error or momentary lapse of attention having serious or even disastrous consequences. • Any combination of the above. Citation: www.disabilitysafe.org.au/hazards-risks/psychological-injury

4. WORK RESTRICTIONS FOR PSYCH INJURIES • Part-Time Schedule/More Frequent Breaks • Flexible Schedule (allowing for some flexibility related to psych issues and mood problems) • Reduced Workload (e.g., number of cases) • Increased supervisory direction and support • More frequent feedback on performance given poor coping skills, low self-esteem and hypersensitivity to criticism or perceived failure

5. WORK RESTRICTIONS FOR PSYCH INJURIES • Allow injured worker to assist in the development of the modified duty given that they may well know what job tasks are most stressful. • Include the psychologist and psychiatrist in the formulation of the modified duty. Untapped resource. • Increase psychological and psychiatric treatment in the beginning phases of return to work to deal with emotional issues that come up and reinforce prosocial and adaptive behavior. Same for return to full-time employment. • Address alleged issues of harassment and excessive monitoring and develop approaches with the injured worker and management to deal with these perceptions of harassment or a hostile work environment.

6. WORK RESTRICTIONS FOR PSYCH INJURIES • Provide a slow increase in job duties and tasks and let the claimant set the pace for taking on more work and more complex and demanding tasks. Should be done with treating psychologist or psychiatrist. • Supervisors should have regular meetings with the claimant to check in and receive feedback on how the modified duty is going and if there are any changes that might be needed for a successful outcome. • Try to have a time frame for the progression of the modified duty • Build in an early warning procedure (with the agreement of the claimant) that allows management to hear if the claimant is beginning to decompensate. Signs of such decompensation is calling in sick, coming late, seeing a reduction in the productivity of even the modified duty levels, increased irritability or coworker strain.

7. WORK RESTRICTIONS FOR PSYCH INJURIES • Manage orthopedic work restrictions because this often triggers emotional reactions that lead to aborting modified duty. Coworkers may be resentful and this can lead to emotional distress, feelings of anger and guilt. • Explore vision of what the injured worker liked about their position so as to tap into their motivation for working. • Modified duty period is a good opportunity for education, training and skill development. (Be careful not to reinforce disability behavior). • Consider the injured worker as a resource and may assist in training, supervising or performing other company/management oriented tasks. • Cognitive Dissonance

8. WORK RESTRICTIONS FOR PSYCH INJURIES • Take careful consideration of the assignment and who the injured worker will spend their work week with. The claimant is vulnerable to social influence and negativity which can adversely shape their view of modified duty. • Avoid excessive work hours, overtime and insist on taking normal breaks and a lunch. Injured workers need time to reconnect with staff, management as well as time alone to process what is going on.

9. DSM-IV-TRPOST-TRAUMATIC STRESS DISORDER • 309.81    DSM-IV Criteria for Posttraumatic Stress Disorder A. The person has been exposed to a traumatic event in which both of the following have been present:  (1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. (2) the person's response involved intense fear, helplessness, or horror.

10. DSM-IV-TRPOST-TRAUMATIC STRESS DISORDER 309.81    DSM-IV Criteria for Posttraumatic Stress Disorder B. The traumatic event is persistently reexperienced in one (or more) of the following ways:  (1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. (2) recurrent distressing dreams of the event. (3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur upon awakening or when intoxicated). (4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. (5) physiological reactivity at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

11. DSM-IV-TRPOST-TRAUMATIC STRESS DISORDER C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:  (1) efforts to avoid thoughts, feelings, or conversations associated with the trauma . (2) efforts to avoid activities, places, or people that arouse recollections of the trauma.  (3) inability to recall an important aspect of the trauma.  (4) markedly diminished interest or participation in significant activities.  (5) feeling of detachment or estrangement from others.  (6) restricted range of affect (e.g., unable to have loving feelings).  (7) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span).

12. DSM-IV-TRPOST-TRAUMATIC STRESS DISORDER D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:  (1) difficulty falling or staying asleep. (2) irritability or outbursts of anger. (3) difficulty concentrating. (4) hypervigilance. (5) exaggerated startle response. E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than one month. F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. • Specify if: Acute: if duration of symptoms is less than 3 months. Chronic: if duration of symptoms is 3 months or more. • Specify if: With Delayed Onset: if onset of symptoms is at least 6 months after the stressor.

13. ORTHOPEDIC INJURIES WITH COMPENSABLE CONSEQUENCE PSYCHOLOGICAL INJURIES • Orthopedic pain and functional limitations. • Pain Behavior which reinforces disability. • Emotional Distress increases perception of pain and functional limitations. • Modified duty assignments must find work that is within the claimant’s orthopedic restrictions but also does not exceed their emotional coping reserves.

14. DOMAINS OF PSYCHOLOGICAL INJURIES THAT IMPACT MODIFIED DUTY • Emotional Issues (Depression, Anxiety, PTSD) • Neurovegetative Factors (Sleep, Appetite Libido) • Cognitive Deficits • Interpersonal Conflict • Coping Skills & Fragile Emotional State • Energy, Motivation and Drive • Lack of Structure and Direction • External Reinforcing Factors

15. DOMAINS OF PSYCHOLOGICAL INJURIES THAT IMPACT MODIFIED DUTY Emotional Factors: • Depressed mood: Sad, pessimistic, negative thoughts/prediction of outcome to return to work. • Anxiety and Depression lead to ruminative thinking with hypersensitivity to critical comments and perceived lack of acceptance from supervisors and managers. • Somatic expression of distress reinforces claimant’s perception of illness and disability leading to refusal to return to work on modified duty or to quickly abort a modified duty position if provided.

16. DOMAINS OF PSYCHOLOGICAL INJURIES THAT IMPACT MODIFIED DUTY Neurovegetative and Cognitive Factors: • Impaired sleep (Sleep initiation, maintenance, early morning awakening). • Impaired appetite with weight loss or gain. • Increased fatigue and daytime sleepiness. • Decreased energy, drive, focus and ability to complete tasks efficiently and effectively. • Impaired attention and concentration. • Decreased processing speed. • Poor memory with increased forgetfulness.

17. DOMAINS OF PSYCHOLOGICAL INJURIES THAT IMPACT MODIFIED DUTY Interpersonal Conflict: • Claimant’s perception of the County/Employer’s role as surrogate parent and caregiver. • Impact of early childhood trauma and family interpersonal conflict on a passive employment stage or interaction with industrial stressor. • Temporary work preclusions regarding working under an alleged harassing supervisor or in a department with alleged harassing coworkers.

18. DOMAINS OF PSYCHOLOGICAL INJURIES THAT IMPACT MODIFIED DUTY Coping Strategies/Fragile Emotional State: • Temporary modified duty must not exceed the claimant’s coping skills. • Part-time work. • Less demanding work but, if possible, reasonably interesting. • Supportive supervisor/staff who can talk with the claimant and reinforce adaptive work behavior. • Provide psychological treatment (psychiatry and psychology) as part of return to work and modified duty strategy.

19. DOMAINS OF PSYCHOLOGICAL INJURIES THAT IMPACT MODIFIED DUTY External Reinforcements for Disability Behavior: • Passive-Dependent behavior and activities. • T.V. watching. • Excessive sleeping. • Stressinduced eating with weight gain with deconditioning. • Spouse/family performs claimant’s chores/IADL’s. External Reinforcements for Proactive Working Behavior: • Quick return to modified duty. • Clear job tasks/duties and expectations with supportive feedback on performance. • Assign to previous successful positions where new learning is not essential and perhaps old, positive relationships exist.

20. DSM-IV-TR DEFINITIONOF MALINGERING • The intentional production of false or grossly exaggerated physical or psychological symptoms which are motivated by external incentives: - Avoiding work - Obtaining Financial Compensation - Obtaining Drugs

21. DSM-IV-TR DEFINITIONOF MALINGERING • Malingering should be strongly suspected if: -Medicolegal context (e.g. referred by attorney). -Marked discrepancy between claimed stress or disability and the objective findings. -Lack of cooperation during diagnostic evaluation. -Noncompliance with prescribed treatment. -The presence of Antisocial Personality Disorder.

22. DSM-IV-TR DEFINITIONOF MALINGERING • Differential Diagnosis -Factitious Disorder: External incentives are absent and there is an assumed intrapsychic need to maintain the sick role. -Conversion & Somatoform Disorders: There is not intentional production of symptoms generated by external gain.

23. DISCUSSION SECTIONCREDIBILITY Convergent evidence needed from multiple sources to argue poor credibility • Self-reported history is discrepant with documented history: e.g., Claimant reports 70 pound container fell on neck while witnesses say 20 pound). • Self-reported symptoms are discrepant with known patterns of brain functioning or psychiatric conditions: e.g., MTBI claims of extended retrograde amnesia without loss of memory for the accident; PTSD with reported flashbacks lasting minutes; Cognitive testing incongruent with depression. • Self-reported symptoms are discrepant with behavioral observations: Complaints of severe pain (10/10, 24/7 with no pain behavior during five hour examination or on multiple hours of sub rosa). • Self-reported symptoms are discrepant with information obtained from medical records: Claimant complains of severe depression beginning in 2005 through 2008 with no evidence of any reports of depression in extensive multi-disciplinary records during this period of time; No psychiatric or psychological treatment. • Evidence of exaggerated or fabricated psychological dysfunction: Self-reported psychological symptoms are contradicted by behavioral observations or test data. Well-validated psychological tests suggest exaggerated distress (e.g., on Symptom Validity or MMPI-2 Fake Bad Scale)

24. DOMAINS OF MALINGERING Malingering typically occurs across three domains: • Cognitive impairment (Symptom Validity Tests and embedded formal cognitive tests). • Psychopathology (i.e., MMPI-2: F, Fb, Fp). • Physical or medical illness – over-reporting of somatic complaints (MMPI-2: Fake Bad Scale, Fs Scale.)

25. FORCED CHOICE SYMPTOM VALIDITY TESTS Forced Choice Symptom Validity Tests: • Word Memory Test (Green, P.) • Computerized Assessment of Response Bias (Allen, L.) • Portland Digit Recognition Test (Binder, L.) • Victory Symptom Validity Test (Slick) • Validity Indicator Profile (Frederick, R.) • Test of Memory Malingering (Tombaugh, T.) • Warrington’s Recognition Memory Test ---------------------------------------------------------- • All are recognition format tests. • All require that the patient choose between a correct and incorrect answer. • These tests can use the uncorrected Z approximation to the binomial.

26. SYMPTOM VALIDITY TESTING • Forced choice measure. • Example: 5 digit number is presented. • Followed by two choices (correct and distractor). • By guessing alone, should get about 50% correct. • Thus, as test scores decrease below chance, it is likely that the individual is deliberately choosing the wrong answer.

27. BASIC PREMISE OF SYMPTOM VALIDITY TESTS • Symptom validity tests appear to challenge memory functioning when in fact they are tests of simple attention. • Patients can perform below chance based on the binomial probability. • Nies & Sweet (1994) found that only a minority of malingers actually score this poorly. • At or above chance performances, however, can discriminate those demonstrating good effort from those demonstrating insufficient effort.

28. SYMPTOM VALIDITY TESTING 92149

29. SYMPTOM VALIDITY TESTING 58730 92149

30. SYMPTOM VALIDITY TESTING 52169

31. SYMPTOM VALIDITY TESTING 52169 57864

32. CARB SYMPTOM VALIDITY TEST Severe Brain Injured Sample: • 28 Patients. • Sample from Edmonton, Alberta. • Documented Brain Damage on CT/MRI. • None of patients were in litigation.

33. Variable Mean Std Dev

34. Variable Mean Std Dev

35. WORD MEMORY TEST SYMPTOM VALIDITY TESTING • Two Main Conditions (Immediate & Delayed): Immediate Recognition Subtest: • 20 word pairs presented. • One word every two seconds. • All word pairs are semantically linked to facilitate recognition. • Easy: (“Dog” - “Cat”) • Slightly harder: (“Tree” – “Lake”) • Recognition portion: 40 word pairs are presented. One of the pairs has a previously presented word and a new “foil” word (e.g., “Dog” – “Rabbit”; “Tree – Forest”).

36. WORD MEMORY TEST SYMPTOM VALIDITY TESTING Delayed Recognition Subtest: • 30 minutes later. • 40 word pairs are presented. • Target word and a different foil. • Forced Choice Recognition. • Consistency Measure between immediate and delayed (e.g., chose “Dog” or “Tree” in immediate recognition trial but not in delayed trial).

37. WORD MEMORY TEST SYMPTOM VALIDITY TESTING Severe Brain Injured Sample: • 28 Patients. • Sample from Edmonton, Alberta. • Documented Brain Damage on CT/MRI. • None of patients were in litigation.

38. Variable Mean Std Dev

39. Pt Type Failed FailedFailed CARB WMT Either

40. TEST OF MEMORY MALINGERING (TOMM)Tombaugh (1996) Trial 1: • Presentation of 50 pictures. • Forced choice paradigm (2 pictures; feedback). Trial 2: • Presentation of 50 pictures. • Forced choice paradigm (2 pictures; feedback). Retention Trial (20 minutes later): • Forced choice paradigm (2 pictures; feedback)

43. Group Trial 1 Trial 2 Retention

44. FEIGNED MOTOR IMPAIRMENT • Greiffenstein et al (1996). • Compared Grip Strength, Finger Tapping Test and Grooved Pegboard performance. • 54 subjects with moderate-to-severe CHI with unambiguous motor abnormalities on neurological examination (dense hemiplegia excluded). • 131 litigating postconcussion patients who had a T score lower than 40 on one of the motor measures. • Moderate-to-severe CHI had normal pattern of deficits with Grip Strength better than Finger Tapping, and Finger Tapping better than Grooved Pegboard. • PCS patients had opposite pattern with Grooved Pegboard and Finger Tapping better than Grip Strength. The most significant difference between the two groups was Grip Strength. • Larrabee (2003) found that definite MND and moderate-to-severe TBI significantly differed in raw dominant + non-dominant Finger Tapping. A cutoff score of less than 63 was optimal in discriminating litigants with definite MND from moderate-to-severe CHI.

50. MALINGERED REY COMPLEX FIGURE