Pain, Impairment, and Disability in the AMA Guides

Physicians use the American Medical Association's Guides to the Evaluation of Permanent Impairment, 5th edition to evaluate millions of disability applicants each year. As major contributors to the chapter in the Guides devoted to assessing impairment associated with pain, we confronted the difficulties of incorporating pain into the Guides' overall evaluation system. Analysis of these difficulties is complicated by the paucity of research on the Guides, and by ambiguities and contradictions that pervade it. We propose that the ambiguities can be reduced if impairment is consistently defined in terms of organ or body part derangement, and disability in terms of activity limitations at the level of the whole person. We also propose a distinction between objective factors that may influence a person's ability to perform activities following injury. We suggest that when physicians examine disability applicants, they should evaluate both objective measures of organ or body part dysfunction and subjective reports of applicants -- especially ones regarding pain. We conclude that a comprehensive medical evaluation of disability applicant encompasses more than an impairment assessment.     

Permanent Ocular Injury Following Paintball Pellet Hit: A Medicolegal Case

Paintball is a ubiquitous recreation, with severe and occasionally irreversible injuries. In this study, a rare medicolegal case of paintball‐related closed globe blunt ocular injury was described. An 18‐year‐old boy who was hit in his right eye by a paintball pellet presented with severe eye pain and blurred vision. Ophthalmologic examinations showed lid edema, conjunctival hyperemia, conjunctival laceration, subconjunctival hemorrhage, corneal edema, anterior vitreous hemorrhage, congested sclera, commotio retinae, vitreous hemorrhage, retinal hemorrhage, macular edema, and macular hole. After maximum medical improvement, the patient who sustained incurable maculopathy and decreased visual acuity was referred to the legal medicine center for appraisal of the impairment. AMA Guides was used to assess the impairment of the functional vision. Despite his monocular visual defect, the patient was rated in the range of mild vision loss namely AMA class 1 with 22 percentage visual system impairment.     

Assessing Functional Impairment in ADHD: Concerns for Validity of Self-Report

Comprehensive diagnostic assessment of attention deficit hyperactivity disorder (ADHD) should include consideration of degree of impairment, and documentation of impairment is necessary to make service and accommodation determinations. While there has been increasing use of self-report as a way to document impairment, self-reported impairment could be just as vulnerable to invalid report as self-reported symptoms. We examined the influence of invalid self-report and invalid performance on report of functional impairment in a sample of 49 adults referred for evaluation for ADHD and/or learning disorder concerns. Overall, 26–59% of participants referred for evaluation endorsed at least moderate levels of impairment in the domains of understanding and communicating, household, and school/work. Individuals with evidence of invalid self-report of ADHD symptoms endorsed significantly higher levels of disability/impairment on the WHODAS, particularly in the domains of understanding and communicating, household, school/work, and participation in society. Further, individuals who failed a measure of performance validity reported significantly higher levels of impairment/disability, particularly in the domains of understanding and communicating, school/work, and participation in society. Results emphasize the need to assess for validity of self-report and performance in ADHD assessment. Since self-report of impairment may be suspect, clinicians should include data such as school records, past performance on high-stakes standardized testing, evidence of prior accommodations, and collateral reports before making diagnoses and/or recommendations regarding treatment or academic/workplace accommodations.     

Validity in judgments of high‐ and low‐accurate witnesses of own and other ethnic groups

Purpose. Research has shown that people often have difficulties estimating eyewitness accuracy correctly. In most previous studies examining validity in credibility judgments, participants have assessed the accuracy of witnesses who have been homogeneous in their memory performance. This study investigated validity in judgments of witnesses who varied widely in memory. A further purpose was to examine whether judgmental validity was moderated by the witnesses' ethnic in‐group/out‐group status. Methods. Participants (N = 120) rated the reliability of videotaped testimonies of high‐ and low‐accurate in‐group (Swedish, N = 4) and out‐group (immigrants, N = 4) witnesses who were genuinely trying to recall a criminal event. Results. Participants assigned more reliability to high‐ than to low‐accurate in‐group witnesses, while out‐group witnesses received low reliability ratings regardless of their actual memory performance. Path analyses demonstrated that the subjective confidence of in‐group, but not of out‐group, witnesses predicted participants' accuracy judgments. Conclusions. The results indicate that the validity in judgments of in‐group witnesses can be better than has previously been implied. Investigators may have difficulty distinguishing high‐ and low‐accurate witnesses from other ethnic groups, and they may also systematically underestimate the reliability of ethnic out‐group witnesses. Implications for legal practices are discussed.     

Workers’ Compensation Claimants with Low Back Pain: the Role of Dissatisfaction in the Transition to Disability

Workers’ compensation systems represent naturalistic settings that often are perceived as unjust by the injured workers for which such systems were developed. This study examined the role of dissatisfaction with medical care and employer treatment on disability outcomes among a cohort of workers who had sustained low back injuries. A race-stratified sample of 358 workers (171 African-Americans, 203 Caucasians) with first incident low back pain was evaluated 21 months and again at 72 months after claim settlement. Evaluation included data related to demographics, socioeconomic factors, injury severity, claim settlement, satisfaction with workers’ compensation (WC) processes, and disability status. Multinomial logistic regression analysis was used to predict disability status (no disability vs. early disability vs. late disability) at each of the two time points. Analyses revealed contributions of multiple variables to early disability, including unique variance related to dissatisfaction with medical care and treatment by the employer. At 72 months, only demographic factors (age, race) and the receipt of temporary total disability (TTD) after injury predicted late disability. Results are discussed relative to the contribution of injustice perceptions and systemic factors; directions for future research are proposed.     

Parental Effects on the Exchange of Sex for Drugs or Money in Adolescents

Research has examined risk factors related to involvement in prostitution and sex trafficking using samples of adult prostitutes, runaway and homeless youth, and youth involved in the juvenile system. There is scant research that includes adolescents who cannot be categorized into these groups. Additionally, research is limited related to how parents affect the decision for adolescents to engage in sex for drugs or money. We examine risk factors concerning the exchange of sex for drugs or money from a nationally representative sample of adolescents. The data are structured where responses can be compared to a group of adolescents who indicated never exchanging sex for drugs or money. We used a negative binomial regression analysis to examine how the effects of parental and individual factors influence the exchange of sex for drugs or money among adolescents. Analyses revealed that individual factors were significant while parental factors were not significant; however, parental effects were significant when dimensions of parental involvement were examined.     

Child and adult witnesses with intellectual disability: The importance of suggestibility

Purpose. The main aim of the study was to examine the relationship between learning (intellectual) disability and interrogative suggestibility among children (11‐12 years old) and adults. Method. The Gudjonsson Suggestibility Scale (GSS 2) was administered to 110 children and 221 adults who were categorized into three groups according to fullscale IQ scores: (1) normal IQ (>75); (2) mild impairment (IQ score 55‐75); and (3) moderate impairment (IQ score <55). Results. Highly significant differences in memory and suggestibility emerged in both the child and adult samples across groups. Using memory as a covariate in the analysis eliminated the significant group differences for ‘yield 1’ among the children, but not for adults. There was no significant influence of memory on ‘shift’ in either group. Whereas ‘shift’ was significantly influenced by intellectual disability in children, no significant difference emerged across groups among adults. Conclusions. Children and adults with learning disability have much poorer memory and higher suggestibility scores than their contemporariesof normal intelligence. Differences in suggestibility are only partly explained by poorer memory scores. The findings reveal important differences between children and adults with intellectual disabilities. Children with learning disabilities are more susceptible to altering their answers under pressure than are adults with learning disabilities.     

Erratum to: Trends in Psychological/Psychiatric Injury and Law: Continuing Education, Practice Comments, Recommendations

This literature review of the major topics in the field of psychological/psychiatric injury and law is aimed at developing practice in the area. The field is a fast-developing one, with over ten major topics that it needs to integrate. In particular, the present review focuses on current work on: law (evidence, tort); forensic psychology; assessment and testing; psychological injuries (posttraumatic stress disorder, chronic pain, traumatic brain injury, other); the APA DSM-5 draft (Diagnostic and statistical manual of mental disorders; American Psychiatric Association 2010); malingering; causality; multicultural considerations; disability; the American Medical Association (AMA) Guides to the evaluation of permanent impairment (Rondinelli et al. 2008); models; and treatment. At the end of each section of the article, practice comments introduce critical issues in applying the research to psychological work in the area. Whether undertaking tort evaluations, disability, and treatment plan assessments or treating individuals with psychological injuries, the professional needs state-of-the-art information in all the areas listed in order to remain scientifically informed, comprehensive, and impartial. The article concludes with recommendations for an integrated field in psychological/psychiatric injury and law, study in the field, research in its major areas, best practice policies, for example in assessment and treatment, and model building.     

Association of the MMPI-2 Restructured Form (MMPI-2-RF) Validity Scales with Structured Malingering Criteria

The current study examined the validity scales of the Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-RF; Ben-Porath and Tellegen 2008) in relation to the structured malingering criteria developed to assess malingered neurocognitive dysfunction and pain-related disability. These criteria examined a sample of 251 individuals undergoing compensation-seeking evaluations, who completed a battery of response bias measures. The MMPI-2-RF over-reporting scales yielded large effect sizes in contrasting those in the probable/definite malingering groups from the incentive only groups. The largest effects were found for the Infrequent Responses and Gervais et al. (Assessment, 14, 196–208, 2007) Response Bias Scale, an experimental scale that can be scored on the MMPI-2-RF. Classification analyses were also utilized to examine various cut scores for the individual validity scales, as well as their use in combination. These results suggest that the MMPI-2-RF validity scales can be used to screen for malingering, as they exhibited good sensitivity at lower cutoffs. The implications of these results and their use in forensic evaluations are discussed.     

After 30 Years,What Do We Know about What Jurors Know? A Meta-Analytic Review of Lay Knowledge Regarding Eyewitness Factors

Surveys typically characterize lay knowledge of eyewitness factors as low and highly variable. However, there are notable differences across methodologies, samples, and individual factors. To examine these differences systematically, we took a meta-analytic approach to reviewing the findings of 23 surveys assessing lay knowledge of eyewitness issues. Our analyses examined the beliefs of 4,669 respondents. Overall, respondents correctly agreed with survey items approximately two-thirds of the time. Results revealed significant differences in performance as a function of variable type, question format, and over time. We found few differences as a function of sample type, publication status, or jurisdiction. Although performance varied, a majority of lay respondents achieved “correct” consensus for as many as 11 of the 16 items included in this review.     

Can Jurors Recognize Missing Control Groups,Confounds, and Experimenter Bias in Psychological Science?

This study examined the ability of jury-eligible community members (N = 248) to detect internal validity threats in psychological science presented during a trial. Participants read a case summary in which an expert testified about a study that varied in internal validity (valid, missing control group, confound, and experimenter bias) and ecological validity (high, low). Ratings of expert evidence quality and expert credibility were higher for the valid versus missing control group versions only. Internal validity did not influence verdict or ratings of plaintiff credibility and no differences emerged as a function of ecological validity. Expert evidence quality, expert credibility, and plaintiff credibility were positively correlated with verdict. Implications for the scientific reasoning literature and for trials containing psychological science are discussed.     

Trends in Psychological/Psychiatric Injury and Law: Continuing Education, Practice Comments, Recommendations

This literature review of the major topics in the field of psychological/psychiatric injury and law is aimed at developing commentary for practice in the area. The field is a fast-developing one, with over ten major topics that it needs to integrate. In particular, the present review focuses current work on: law (evidence, tort); forensic psychology; assessment and testing; psychological injuries (posttraumatic stress disorder, chronic pain, traumatic brain injury, other); the APA DSM-5 draft (Diagnostic and statistical manual of mental disorders; American Psychiatric Association 2010); malingering; causality; multicultural considerations; disability; the American Medical Association (AMA) Guides to the evaluation of permanent impairment (Rondinelli et al. 2008); models; and treatment. At the end of each section of the article, practice comments introduce critical issues in applying the research to psychological work in the area. Whether undertaking tort evaluations, disability, and treatment plan assessments or treating individuals with psychological injuries, the professional needs state-of-the-art information in all the areas listed in order to remain scientifically informed, comprehensive, and impartial. The article concludes with recommendations for an integrated field in psychological/psychiatric injury and law, study in the field, research in its major areas, best practice policies, for example in assessment and treatment, and model building.     

Treatment-Related Reductions in Disability Are Associated with Reductions in Perceived Injustice Following Treatment of Whiplash Injury

Emerging evidence suggests that perceived injustice is a risk factor for poor recovery outcomes in individuals with whiplash injuries. The present study examined the relative contributions of treatment-related reductions in pain severity, depressive symptoms, and disability in the prediction of reductions in perceived injustice in individuals with whiplash injury. The study sample consisted of 71 individuals (43 women and 28 men) who sustained whiplash injuries in motor vehicle accidents and who were enrolled in a treatment program designed to promote functional recovery following whiplash injury. For the purposes of this study, only individuals who scored above the risk threshold on a measure of perceived injustice were included in the study sample. Participants completed measures of pain severity, disability, depressive symptomatology, and perceived injustice prior to treatment and after treatment. Change scores were computed for study variables. The results revealed that reductions in pain severity and disability were correlated with reductions in perceived injustice. Regression analyses revealed that only reductions in disability contributed significant unique variance to the prediction of reductions in perceived injustice. Clinical and theoretical implications of the present findings are discussed.     

Racial and ethnic disparities in police-reported intimate partner violence perpetration: a mixed methods approach

The objectives of this study were to examine racial and ethnic disparities in perpetrator and incident characteristics and discrepancies between police charges and reported perpetrator behaviors in police-reported intimate partner violence (IPV). This cross-sectional study used standardized police data and victim narratives of IPV incidents reported to the police in Dallas, Texas in 2004. The sample included non-Hispanic White, non-Hispanic Black, and Hispanic male perpetrators who were residents of Dallas (N = 4470). Offense charges were prioritized in descending order: sexual assault, aggravated assault, simple assault, kidnapping, robbery, and intimidation. Textual data from the victim narratives were coded, based on the revised Conflict Tactics Scales (CTS), and categorized in descending order of priority: sexual (severe, minor), physical (severe, minor), and psychological (severe, minor) assault. Perpetrators were more likely to be Black and Hispanic. Perpetrator and incident characteristics varied significantly by race/ethnicity, particularly age, age difference between partners, marital status, injury, and interracial relationships. Qualitative data revealed that greater proportions of Black and Hispanic men perpetrated severe physical, but not sexual violence, compared with White men. The greatest disparity between CTS categories and police charges occurred among those cases identified by the CTS as severe physical IPV; 84% were charged with simple assault. Significant differences by race/ethnicity were found only for simple assault charges, which were coded as severe physical as opposed to minor physical IPV more often among Black (69% and 31%) compared with White (62% and 38%) men. The disparities revealed in this study highlight the need to enhance primary and secondary prevention efforts within Black and Hispanic communities and to increase linkages between police, community, and public health organizations.     

Legal Representation and Dissatisfaction with Workers’ Compensation: Implications for Claimant Adjustment

This study examined relationships between attorney retention and adjustment outcomes for Workers’ Compensation low back claimants at post-settlement (N?=?1,464; 21 months post-claim settlement) and long-term follow-up (N?=?371; 72 months post-claim settlement). Claimants were classified into three groups: those who had not retained an attorney (no attorney group, 15%); those who had retained an attorney, but for reasons other than dissatisfaction with Workers’ Compensation medical treatment (attorney group, 31%); and those who had retained an attorney specifically because of dissatisfaction with Workers’ Compensation medical treatment (dissatisfied/attorney group, 54%). Groups were compared on demographic characteristics, Workers’ Compensation variables, and adjustment indicators of pain intensity, pain-related disability, general physical and mental health status, and pain catastrophizing. Relative to the no attorney and attorney groups, claimants in the dissatisfied/attorney group were younger, had longer time to settlement, and reported greater post-settlement socioeconomic stress and catastrophizing. At long-term follow-up, the dissatisfied/attorney group reported higher levels of disability and catastrophizing, as well as lower levels of mental health status, relative to the other groups. The results suggest that attorney retention that is motivated by dissatisfaction with Workers’ Compensation medical care is a significant risk factor for poor adjustment, not only in the intermediate time frame following claim settlement, but also over the long term. Findings are discussed in the context of “perceived injustice” in the Workers’ Compensation system and the mechanisms by which dissatisfaction and attorney retention may impact adjustment.     

The More You Say the Less It Means: Overreporting and Attenuated Criterion Validity in a Forensic Disability Sample

A recent publication in Psychological Bulletin by McGrath et al. (Psychological Bulletin 136:450–470, 2010) challenged the necessity of response bias indicators in applied psychological assessment on the grounds that there is insufficient empirical support that shows that they are able to moderate the prediction of substantive measures. The current study challenges their conclusions by examining the effects of response bias in a sample of 2,275 disability litigants. We utilized the validity scales of the Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-RF; Ben-Porath and Tellegen, 2008) in order to establish a group of litigants who did not exhibit evidence of overreporting and compared them to a group of overreporting litigants. The overreporting group scored significantly higher on every Restructured Clinical Scale. Moreover, we compared the criterion validity between various substantive scales on the MMPI-2-RF and extratest measures [e.g., Beck Depression Inventory-II (Beck, Steer, & Brown, 1996)] and found evidence of significantly attenuated criterion validity in the overreporting group. Implications of the study in light of the review by McGrath and colleagues are discussed.     

The Usage of the AMA <Emphasis Type="Italic">Guides</Emphasis> for the Determination of Psychological Injury Within the State and Federal Workers’ Compensation Systems

Psychological injuries, like physical injuries, may occur within the workplace. If those injuries are reported to be a result of a triggering event in the workplace, then a workers’ compensation (WC) claim may be filed by the individual. State WC and the federal WC systems have laws and rules in place to address workplace psychological injury claims. However, because each State has its own WC State laws as does the federal WC system, there is no current standardization in defining either psychological injury or in defining disability. This is because each system has its own definitions. A few States allow workplace psychological injury claims. Some States do not accept WC psychological injury claims. The remaining States recognize workplace psychological injuries but with specific limitations. The federal WC system allows WC psychological injury claims. There are problematic issues that occur in the State and federal WC systems. These issues are utilizing outdated terminology, employing outdated diagnostic criteria, and allowing documentation submission and professional opinion that does not comport with current professional standards of care. In addition, the need for a definitive answer to address causation is not always possible to address with regard to psychological injury. These types of issues introduce imprecision into the determination of psychological injuries. To address these concerns, the American Medical Association developed the Guides to the Evaluation of Permanent Impairment as a means to take a more scientific approach to the assessment of impairment. This stance was a move away from the poorly defined term, “disability”. The focus was on evaluating the individual’s functioning in terms of impairment. The AMA holds that this is a more objective method that provides a balance between clinical opinion and the utilization of a more scientific methodology that increased precision in the determination of psychological injury and purported impairment in functioning that may have resulted from the injury. The American Medical Association’s Guides to the Evaluation of Permanent Impairment are utilized by many States and the federal WC systems to assist in the evaluation of psychological impairment in functioning and in the WC claims process. Some States opt to use earlier editions of the Guides. Other States and the federal WC system require the usage of the most current edition of the Guides. A few States opt to forego the usage of the Guides altogether and develop State-specific guidelines. The complexities that arise within the WC systems as well as usage of the Guides to evaluate and assess psychological injury are explored as well as potential solutions to address the imprecision that occurs within the WC systems.     

《永久性残损评定指南（第六版）》基础概念评介

美国医学会第六版的《永久性残损评定指南》,代表了残损评定领域最新的、革命性进展。《永久性残损评定指南》旨在完善残损等级评定方法、提高评定的准确程度、增强评定结论的可信度,并使评定系数标准化,为残损评定提供稳定的、完备的方法。《永久性残损评定指南》最终目的在于,使利用该指南进行残损等级评定的结论具有权威性、公正性,并为评定所涉及的各方所认可。《永久性残损评定指南》的检查方法、术语以及分析架构以世界卫生组织的《国际功能、残疾和健康分类》为基础,涵盖了当今美国及国际社会最新有关残损等级评定研究成果,包括更为复杂、广泛的医学诊断手段,和更为准确功能丧失系数的解释说明等内容。所有的这些更新内容均有利于帮助鉴定人,在残损等级评定过程中消除争议,提高评定准确率。本文简要介绍了《永久性残损评定指南》第六版的基础概念,为我国法医临床学研究、借鉴《永久性残损评定指南》进行伤残评定提供依据。     

Grooming child victims into sexual abuse: a psychometric analysis of survivors’ experiences

This study sought to examine the psychometric properties of the Grooming subscale of the Computer Assisted Maltreatment Inventory (CAMI) in a sample of adult survivors of child sexual abuse. There are currently no other research measures that examine grooming events as experienced by survivors, which underscores the importance of a reliable and valid way of gathering this information. Participants (n?=?295) were adult survivors of child sexual abuse who completed this anonymous study online. The sample was collected through the use of adult survivor of child sexual abuse websites, trauma blogs, and survivor group pages on Facebook. Exploratory Factor Analysis, Confirmatory Factor Analysis, and Cronbach’s Alpha were used to ascertain the reliability and validity of this subscale. These analyses suggest that the Grooming subscale of the CAMI is a reliable and valid measure. This measure is an important addition to the body of research instruments that measure adult survivor of child sexual abuse experiences, particularly since this is the only instrument that examines grooming from this perspective.     

肩关节损伤致肢体功能障碍程度评价方法比较

目的探讨能客观反映肩关节功能障碍对肢体功能影响的评价方法。方法通过用我国《道路交通事故受伤人员伤残评定》（简称＂《道标》＂）的权重指数法与美国《永久残损评定指南》（Guides to the Evaluation of Permanent Impairment,GEPI）（简称GEPI法）,对133例肩关节损伤后伤残评定案例进行回顾性评价;并用两种评价方法对肩关节不同运动方向及不同活动度对上肢功能影响进行全方位的比较。结果 133例肩关节功能障碍案例,权重指数法达到伤残的总比例高于GEPI法;但在功能丧失不同比例段两者有差异。差异的原因在于,在GEPI法中,肩关节不同运动方向所占的权重不同,前屈上举与外展上举对于肩关节功能相对重要,并考虑关节功能位对肢体障碍程度的影响;而权重指数法,上肢功能的关系与关节活动度呈简单的线性关系,与关节活动方向及功能位无关。结论 GEPI法比权重指数法能更能客观地反映肩关节功能障碍对肢体功能丧失的影响程度。