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Part One:
Specialty Information

               

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The ABCs of Managing Psychiatric Disability Cases is a recently updated on-line version of an FHIPA publication distributed to insurance disability specialists and adjusters. Written by Dr. Leonard Grossman and adapted for the web by Mr. Michael Castellano, Part One on Specialty Information furnishes plain language definitions of psychiatric, psychological, and neuropsychological IME practices, professional responsibilities, and procedures.

Part One:
Specialty Information

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© Copyright 2008, The Forest Hills IPA Inc.,  Leonard Grossman, Ph.D.
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Specialty
Information
There are literally dozens of established psychiatric, psychological, and neuropsychological tests and procedures in use today. While it is not necessary for disability specialists to be familiar with each and every one of them, it is important to have a working knowledge of the most commonly used procedures and practices.

The following three sections contain basic information on the psychiatric, psychological, and neuropsychological specialties and the types of testing, practices, and procedures they employ.

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Psychiatry
Psychiatry is a branch of medicine which deals with the identification and treatment of mental illness. Clinical psychiatry is practiced by a licensed medical professional (M.D.) who is board certified in psychiatry. A licensed psychiatrist:

Similarities and Differences between Psychiatrists and Psychologists
A common misconception holds that the clinical opinion of a psychiatrist M.D "outranks" that of a psychologist Ph.D. According to both clinical practice and the law, this is patently wrong:

    Psychologists and psychiatrists are equally qualified to give an opinion on a claimant's psychiatric/mental status, treatment regimen, disability status, and back-to-work prognosis.
The primary difference between psychologists and psychiatrists is not one of credentials but of function: The psychiatrist is licensed to treat mentally ill patients medically (i.e., prescribe psychotropic and other prescription drugs) and admit them to a mental health facility or hospital; the psychologist is licensed to treat mentally ill patients with psychotherapy and related therapeutic regimens, but may not in New York and some other states, admit the patient to a hospital.
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Psychiatric IMEs: The "Good," the "Bad," and the "Ugly"
Most people wouldn't dream of buying a house without first hiring a licensed contractor to thoroughly inspect the property. Yet psychiatric IMEs are performed everyday -- often with hundreds of thousands in benefit reserves at stake -- without having had the case file reviewed by a licensed mental health professional. Even worse, second party IME companies often hired to arrange the IME submit crude generic IME questions letters which yield poorly focused, ineffective reports. To make matters even worse, case files are often incomplete and missing key clinical and diagnostic information from the care givers -- which virtually guarantees a "garbage in/garbage out" report, no matter how good the IME doctor.

Conversely, a truly useful IME report results when the IME examiner:

  • is a board certified practitioner with prior IME experience.
  • has a relatively complete case file and history to work from.
  • has an up-to-date treatment/diagnostic summary from the care giver.
  • is provided with clinically-focused, case-specific IME questions.

What is a Neuropsychiatrist and when should I use one?
There is much confusion in the insurance business as to what constitutes a neuropsychiatrist, and when one should be employed in an IME. Technically speaking, all psychiatrists can present themselves as "neuropsychiatrists" because board certication for psychiatrists includes a "combined (or joint) certification" in both psychiatry and neurology.

However, The American Board of Psychiatry and Neurology issues certificates based on two different tests. Most practicing psychiatrists pass boards which ask two-thirds of their questions on psychiatry, and one-third on neurology. A "true" neuropsychiatrist is an individual who passes the test version which devotes two-thirds of its questions to neurology.

You may wish to use a neuropsychiatrist instead of a psychiatrist for an IME when psychiatric difficulties accompany a head injury, organic brain disease, or some other neurological condition or disorder. Experience also counts when selecting an examiner. There are many practicing psychiatrists who, while not having passed boards devoted primarily to neurology, are well-acquainted with neurological conditions, and would be good choices for IMEs dealing with both psychiatric and neurological issues.

At the same time, it should be noted that psychiatrists and neuropsychiatrists typically do not perform neuropsychological (cognitive) testing, so their usefulness in an IME situation depends on the extent to which cognitive deficits are an issue. My own preference in cases where cognitive impairment from an accident or disease is suspected is to perform a neuropsychological evaluation with testing to objectively quantify the degree of cognitive impairment present.

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Psychology
Psychology is the science of understanding, interpreting, and classifying the various aspects of human behavior.
Clinical psychology is psychology practiced by a licensed professional with a Ph.D. or Psy.D. in psychology. The field of clinical psychology has developed and standardized a host of procedures and practices to detect, evaluate, and treat abnormal behavioral conditions and mental disorders. A licensed psychologist:

As pointed out in the section on psychiatrists, there is no difference in legal standing between psychologists and psychiatrists when it comes to opinions on mental illness, psychological disorders, and psychiatric disability status.

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Standardized Psychological Testing
Standardized psychological testing (also referred to as psychodiagnostic testing) is a clinically established procedure developed to diagnose and quantify the severity and scope of behaviorally-expressed mental conditions, disorders, and diseases.

When we say a test is standardized, we mean the test has been validated in a clinical trial setting according to established professional procedures using a randomly selected control group, adjusting for age and educational background, etc. Resulting standardized psychological tests (hereafter referred to as SPTs) have clinically-validated norms; the amount of deviation from established norms helps determine the severity and scope of the mental condition or pathology being manifested.

SPTs, administered in both oral and written forms, are quantifiable. A quantifiable test presents its data in a percentile or percentage format. When the percentile or percentage recorded in a particular area deviates from established base-line norms, it suggests the presence of a particular mental symptom or pathology.

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Screenings and Battery Testing
Lower-cost psychological screening tests (sometimes referred to as diagnostic syndrome profiles or DSPs) are administered to obtain preliminary information on a patient's psychological and behavioral status. While not intended as a formal (stand-alone) clinical diagnosis, DSPs are able to identify existing underlying pathologies with an extremely high degree of accuracy. DSPs are usually administered to patients not currently exhibiting clear-cut symptoms or serious pathologies.

A psychological test battery is usually administered to patients who exhibit symptoms and/or behavior associated with a serious underlying mental condition or pathology. A typical battery may consist of a dozen or more SPTs, and provides clinical diagnostic information on pathology which is highly detailed and specific. The attending professional selects the specific SPTs included in the battery based on patient history and current symptoms. Battery testing is strongly recommended in hotly-contested, difficult to resolve psychiatric disability.

Standardized psychological tests (both screenings and batteries) are typically administered by a licensed psychologist, and also include an IME component (i.e., the attending professional conducts an interview portion of the examination, and includes in the report observational data and reactions/responses to relevant psychological and behavioral questions).

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About Psychological IMEs
A psychological IME, clinically referred to as a diagnostic interview or diagnostic impression, is a face-to-face observational and oral interview with a patient/claimant conducted by a licensed psychologist.

A typical psychological IME averages between 45 and 60 minutes, but can be longer when required. The attending psychologist will first carefully review the patient's case history and reasons for referral, and then conduct the interview with a special focus on the psychological/behavioral symptoms allegedly being manifested. Immediately after the IME, the attending psychologist will prepare a written report summarizing observational data and patient responses. In a disability or no-fault case, the report will also attempt to answer any specific questions advanced by the referral source.

To improve diagnostic accuracy and increase professional credibility, psychological IMEs can be combined with specific standardized psychological tests. The "dos and don'ts" of psychological IMEs are similar to those of psychiatric IMEs (see Psychiatric IMEs: The Good, the Bad, and the Ugly).

Table of Contents Neuropsychology
Neuropsychology is a highly specialized discipline within the field of psychology. The science of neuropsychology focuses on cognition, i.e., the ability of the mind and brain to think, reason, remember, learn, comprehend, etc. Clinical neuropsychology is practiced by a licensed psychologist specializing in neuropsychology. This specialty field has developed a variety of clinically standardized tests and procedures to evaluate the cognitive and functional effects of brain injury, brain damage, and organic brain disease. A clinical neuropsychologist:

  • may enter private practice and offer various forms of psychotherapy and cognitive rehabilitation to individuals, families, or groups.
  • can administer standardized psychological and neuropsychological tests to patients in office and hospital settings, and interpret and report on their results. 
  • may furnish legally-recognized clinical and diagnostic opinions and conduct diagnostic interviews regarding the presence, scope, and treatment of cognitive/neuropsychological disorders, behavioral disorders, and mental illness.

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The Difference between Neuropsychology and Neurology
Neurology is a field encompassing the science and study of the human brain and nervous system and its diseases. Clinical neurology is a specialty field of medicine; a clinical neurologist is an M.D. who is board certified in neurology. The function and practice of a clinical neurologist differs substantially from that of a neuropsychologist. Since there is great confusion between the two, it is important to carefully note the differences:

The neurologist M.D. deals with the structural and physiological consequences of brain injury and organic brain disease, while the neuropsychologist Ph.D. investigates the cognitive and behavioral impact of such conditions. For example, an individual suffers serious brain damage in a car accident. The neurologist will run tests and make determinations as to the physical impact of injuries: Can the patient ambulate, move limbs and muscles, and maintain hand/eye coordination?; Is an EEG needed? How severe is soft tissue damage?; Is surgery in order?; etc. The neuropsychologist, on the other hand, will examine and test the patient's powers of cognition: Can the patient think and reason clearly?; Is long and short-term memory impaired?; Have reading, learning, and comprehension been compromised?; etc.

It should further be noted that in disability determinations and related procedures, the neurologist is not "more important or qualified" in medical or legal terms than the neuropsychologist. The neurologist M.D. is qualified and licensed to make a clinical assessment regarding a patient's physical disability status as a result of brain damage; the neuropsychologist Ph.D. is qualified and licensed to make a clinical assessment of the patient's cognitive disability status. Both have important, but different, functions in examining and treating individuals suffering from head injuries and brain damage.

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Standardized Neuropsychological Testing and Cognition
Standardized neuropsychological testing is a clinically-established procedure developed to detect and quantify the severity of cognitive impairment and dysfunction present in an individual. The terms cognition and cognitive status refers to the ability of the mind and brain to think, reason, remember, learn, solve problems, etc. Standardized neuropsychological tests (SNTs) are administered by a licensed psychologist (also referred to as a neuropsychologist) who specializes in neuropsychology.

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Neuropsychological IMEs
A neuropsychological IME, clinically referred to as a diagnostic interview or diagnostic impression, is a face-to-face observational and oral interview with a patient/claimant conducted by a licensed psychologist specializing in neuropsychology.

A typical neuropsychological IME without testing (a diagnostic interview only) takes a minimum of one hour. When testing is included, the evaluation can take an entire day with periodic rest brakes. Longer exams are sometimes spread out over a couple of days to reduce stress on the examinee.

The attending neuropsychologist will first carefully review the patient/claimant's case history and reasons for referral, and then conduct the interview with a special focus on the neuropsychological (cognitive) symptoms and deficits allegedly being manifested. Immediately after the IME, the attending neuropsychologist will prepare a written report summarizing observational data and patient responses. In a disability case, the report will also attempt to answer any specific questions advanced by the referral source. The "dos and don'ts" of neuropsychological IMEs are similar to those of psychological and psychiatric IMEs (see Psychiatric IMEs: The Good, the Bad, and the Ugly).

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    Testing and Disability Issues
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    Under Construction

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© Copyright 2008, The Forest Hills IPA Inc.,  Leonard Grossman, Ph.D.
Site design by Michael CastellanobuttonSend site comments to Michael Castellano