Psychological Services- ACT 6
REVIEW OF CASE
The primary physician's, Dr. Crow, notes describe "emotional state poor," but without detail. Patient is taking Desyrel, Paxil and Buspar. This was reported later as being related to pre-event psychiatric treatment the source(s) of which was not clarified in any notes or a report from the treating psychiatrist. However, the medications indicate depression and anxiety pre-MVA.
Past medical history of lumbosacral problems, motor vehicle accidents in 1987 and 1988 (including discectomy) and a slip and fall in 1994. History of diabetes, alcohol abuse and abdominal hernia secondary to cirrhosis of the liver. Present complaints of pain in cervical area, mid--thoracic and lumbosacral. CT scan (9/9/96) indicates no evidence of cervical, dorsal or lumbar/pelvic osseous pathology. Report also states "and is aware that this also affects his low back." MRI of lumbar spine (4/1/97) showed no significant change compared to a study on 6/28/94.
Diagnoses listed as neck sprain, myalgia and myositis, brachial neuritis and thoracic sprain.
1 EMG scan 1/7/97:
2 Psychological evaluation 1/7/97 by T. Jones, Ph.D
3 Biofeedback evaluation 1/8/97 by J. Carl, Licensed Social Worker
4 Biofeedback Notes: 1/15/97--7/16/97. These notes are further confusing as they are in handwriting other than Mr. Carl's. It appears that someone else used the biofeedback equipment for treatment and Mr. Carl signed off on this.
In Posttraumatic Stress Disorder, the stressor must be of an extreme (i.e., life-threatening) nature. In contrast, in Adjustment Disorder, the stressor can be of any severity. The diagnosis of Adjustment Disorder is appropriate both for situations in which the response to an extreme stressor does not meet the criteria for Posttraumatic Stress Disorder (or another specific mental disorder) and for situations in which the symptom pattern of Posttraumatic Stress Disorder occurs in response to a stressor that is not extreme (e.g., spouse leaving, being fired).
It is irregular to use both as Axis I diagnoses as PTSD characteristics exceed and replace those of an adjustment disorder.
3. Secondly, since DSM IV publication (1994), the adjustment disorder specified has been altered to 309.28 With Mixed Anxiety and Depressed Mood. This subtype should be used when the predominant manifestation is a combination of depression and anxiety..
4. Dr. Jones signs his report as “Licensed Psychologist,” without
identifying his area of specialty.
5. According to reviewed materials, the patient never received a full DSM IV  multiaxial diagnosis from any source, including the Director, Dr. Hady, who is a psychiatrist. The DSM IV states:
“A multiaxial system involves an assessment on several axes, each of which refers to a different domain of information that may help the clinician plan treatment and predict outcome. The multiaxial system facilitates comprehensive and systematic evaluation with attention to the various mental disorders and general medical conditions, psychosocial and environmental problems, and level of functioning that might be overlooked if the focus were on assessing a single presenting problem. A multiaxial system provides a convenient format for organizing and communicating clinical information, for capturing the complexity of clinical situations, and for describing the heterogeneity of individuals presenting with the same diagnosis.
6. In testing, only the Beck Depression Inventory, the Beck
Anxiety Inventory and McGill-Melzack Pain Questionnaire were given, this without
discovering or stating why Mr. Lerch was receiving psychiatric treatment.
On 1/8/97 a biofeedback "screening" is performed by Mr. Carl, a licensed social
worker with no indication of his biofeedback credentialing.
F. During biofeedback training sessions:
Because insufficient data was gathered through the initial consultation and inadequate testing used, the presence of these other factors were not identified. This confounds the clear need for treatment and/or treatment of this type.
2. Pre- and post- accident personality factors are not considered.
3. Dr. Jones ignores axes IV and V, psychosocial stressors (very significant in this situation) and the GAF, or numerical, rating of the patient’s level of functioning. These axes are helpful as certain stressors would be expected to appear and the GAF is needed to reflect the patient’s level of dysfunction and subsequent improvement.
4. Psychological testing is scant, particularly in the light of this man’s medical and psychiatric history. It includes tests and scales that take minutes to give and score, that ignore test-taking attitude, motivation in answering, and truthfulness and consistency of answers. In litigation situations where secondary motives must be considered, these tests are appropriate only when given with an empirically objective and validated types, such as the MMPI 2. Otherwise they may represent utterly subjective responses. Objective, psychometric testing was not done to validate or explore clinical impressions.
5. The role of personality was never explored.
6. The possible role of various forms of secondary gain (e.g. attention, remuneration, etc.) was never addressed.
7. Assumptions of causation and treatment were made prior to a full gathering of background information.
8. No effort was made to differentiate organic from psychogenic pain. (see Kaplan & Sadock)
9. Little effort was made to comprehensively assess complaints of pain as being possibly false, exaggerated due to other factors or consistent in contrast to other pain patients.
10. Kaplan & Sadock  state the limited usefulness of biofeedback.
11. No post—or interim—re-testing with the Becks was presented to document progress.
Finding that the reviewed materials lack appropriate information-gathering, diagnoses and a supportive psychometric foundation of information that identifies treatment of MVA-related sequelae as opposed to other psychiatric and pre-existing medical conditions, it is my professional opinion that services rendered on and after the psychological evaluation of 7/1/97 (i.e., psychological testing, EMG scan) were not warranted. Treatment pursuant to that date appears equally unwarranted, excessive and, as they stand, neither reasonable nor necessary. Further services would also be considered unnecessary. Consequently, the psychological evaluation (90801) alone should be considered for payment as other services were contingent upon this and are unsupported in their need or appropriateness.
The opinions expressed in this report are based solely on materials provided to me. Reports by allied health professionals (e.g., psychiatrist) were not provided. The final decision regarding payment is solely and exclusively the responsibility of the insurance carrier.
 Although mentioned in Dr. Jones' evaluation, Post-traumatic Stress Disorder does not appear on these forms.
 1994 American Psychiatric Association, Washington, DC
H. I. Kaplan & B. J. Sadock (1991). Synopsis of Psychiatry (6th Ed.).
 When an individual has more than one clinically relevant Axis III diagnosis, all should be reported. For examples, see p. 33. If no Axis III disorder is present, this should be indicated by the notation "Axis III: None." If an Axis III diagnosis is deferred, pending the gathering of additional information, this should be indicated by the notation "Axis III: Deferred."
 (1996)Diagnostic & Statistical Manual of Mental Disorders, Washington: American Psychiatric Association.
 A comprehensive, objective, psychological test was not used. Instead, quick (about 5 minute) specialized anxiety and depression measures were given. These are more commonly used as a pre- and post-treatment measure of anxiety or one that assesses progress in each session rather than as a stand-alone diagnostic tool. This very short questionnaire assumes that the respondent is both accurate and truthful. There is no validity scale to assess truthful as is found in more substantial and widely used tests (such as the Minnesota Multiphasic Personality Inventory) . In this situation, other clinical syndromes and personality factors may have been involved that were overlooked due to the lack of information gathered and specificity of the tool. In light of the delay in entering psychological treatment and patient complaints of overeating and nightmares, other important factors not measured by this test were likely overlooked. This is particularly important as Mr. Lerch was already in psychiatric treatment.
Jeffrey (1986). Clinical EMG: Muscle Scanning for Surface Recordings.
Qualls, P.J. & Sheehan, P.W. (1979). Capacity for absorption and relaxation during electromyograph biofeedback and no-feedback conditions. Journal of Abnormal Psychology, 88, 652-662.
Qualls, P.J. & Sheehan, P.W. (1981a). Imagery encouragement, absorption capacity, and relaxation during electromyograph feedback. Journal of Personality & Social Psychology, 41, 370-379.
Qualls, P.J. & Sheehan, P.W. (1981b). Role of the feedback signal in electromyograph feedback: The relevance of attention. Journal of Experimental Psychology: General, 110, 204-216.
 One—to—One on Quality ( September, 1996, Vol. 1, Issue 3) Treating acute uncomplicated low back pain AHCPR (Agency for Health Care Policy and Research). Treatment guidelines recommendations were developed by an expert panel of health care professionals. Using scientific literature and combining their own experience and clinical judgment to develop specific recommendations for patient assessment and management, biofeedback is not recommended for treating uncomplicated low back pain as it has not yet been proven effective.
 1997 Procedure Terminology Manual, Pennsylvania Blue Shield
 Kaplan & Sadock (1991)
Kaplan & Sadock (1991) Synopsis of
Psychiatry (6th Ed.).
 Copyright © 1995 American Psychological Association.
 These issues are also addressed in Knapp, S. & Tepper, A.M. (1996) Legal and Ethical Issues in Supervision Samuel Knapp, Ed.D., The Pennsylvania Psychologist Quarterly, May 1996.