Licensed Psychologist, Clinical Specialty

Board Certified: Senior Disability Analyst

Medical Expert: Social Security Administration


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Telephone:  215-546-6808 or 215-300-2023











(Abbreviated version, names changed: some materials & figures omitted as they are either proprietary or do not  copy well to HTML)

M. Allan Cooperstein, Ph.D.


Reason for IME

The IME was requested by the insurer through Acme Center to:

     Assess Mrs. Moreno's present diagnosis relative to her work injury.
     Provide a prognosis in regard to her work injury.
     Evaluate the intensity of care needed at this time including pain
        management and frequent psychological visits.
     Consider whether a dorsal stimulator indicated for the claimant
        considering psychological factors.
     Consider her caring for her grandchildren and determine if she is
        capable of working in child care in some capacity.
     Assess if she has reached maximum medical improvement.


bullet Interview
bullet Mental Status
bullet Testing
bullet EMG Biofeedback Scan

Records Reviewed
bullet Morriston Hospital: July 12, 1993: Mill Nasa, PT
Letter to Dr. Seller. Patient referred to physical therapy status post lumbar laminectomy. Evaluation findings indicated moderate limitation in all planes. Pain reported in right lumbar paraspinals with radiation down the right leg to the ankle. Patient discontinued in PT for continuing follow-up with Dr. Seller.
bullet Dr. Bob Loan: December 1, 1993
IME at Acme. Dr. Loan reports a 1992 MRI revealing large focal herniated disk in right central canal and right lateral canal at L5--S-1. Also mild concentric protrusion of L4--L5 disk believed to be of no significance.
Report of myelogram/ct scan: ventral impression on dura at L4--5 level. Smaller impressions noted at L5--S-1 and L3--4. A major finding was the poor filling of the right S-1 nerve root.
bullet Dr. Bob Loan: Acme: January 24, 1994
Follow-up visit. Most significant is his report of degenerative disk disease with significant narrowing at L5--S-1. Scar tissue is apparent. There is a question as to whether the etiology of the pain is due to a recurrent disk or scar tissue or both. Some question is raised as to the suitability of a second laminectomy. considering the patient's predisposition towards scarring. Dr. Loan states that, should Mrs. Morrone elect not to undergo surgery, she will be limited to a light Duty classification.
bullet Oncological Hospital: November 20, 1995: Dr. Steven Hoten
Operative report. Injection of right S-1 nerve root sleeve with local anesthetic and steroids. Earlier caudal epidural injection gave 25% relief.


Dr. Bob Loan: February 1, 1996
Report indicates unusual circumstances in which patient's right L5-S1 segment showed a recurrent piece of herniated disk and excess scar tissue at L5--S-1 wrapped around entire right 2/3 of the thecal sac. Second laminectomy performed May, 1994. Prior to surgery, patient reported entire right foot and toes were numb. Numbness disappeared following surgery. Pain was reduced but there was a slow, progressive recurrence Patient has been on Medrol packs until Dr. Seller refused further prescriptions. She was then prescribed Tylenol with codeine and aquatic therapy. Patient continued to show antalgic gait protecting right leg. Severe tenderness and spasm found bilaterally from L4 through S-1 which did not relax with movement. Consistent findings with excess epidural scar tissue. There is no good way to treat individuals with this propensity.
Dr. Loan also mentions that a major problem encountered by Mrs. Morrone is a significant depression related to her current life situation. She has been under the care of a psychologist who, he claims, as been helping. However, she has considerable anger and depression.

Estimated functional capacities indicates limited sedentary capacity, reduced lifting and carrying capacity,

bullet Arnold Park Pain Management: Dr. Hoten: February 2, 1996
Reports leg pain better controlled due to nerve root sleeve injections. Occasional pain in calf and numbness in tones with some decrease. Continued back pain, especially in the morning. Sitting longer than 10--15 minutes produces increased pain. Considered a good euthymic 4 light duty, part--time work with restrictions.
bullet Elmhurst Hospital: Dr. Kane: (pages missing, received February 2, 1996)
Impression of chronic low back pain post laminectomy. Will undergo aquatic therapy.
bullet Arnold Park Pain Management: Dr. Hoten: April 12, 1996
Patient continues to do relatively well. She is "Clearly very relaxed." Continues to work with psychologist, Dr. Brown.
bullet Elmhurst Rehabilitation Services: June, 1996--September, 1996
Patient reports improvement in back.
bullet Gould Radiology Associates: July 14, 1995
Disk herniation at L5--S-1 level with large free fragment extending to the right lateral recess.
bullet Arnold Park Pain Management: October 3, 1996
Considered improved over last year. Considering injection of sacroiliac with local anesthetic.
bullet Arnold Park Pain Management: July 19, 1996
Considered improved over last year. Soreness in low back at end of day. Pronounced tenderness over sacroiliac joints bilaterally. Radicular pain is resolved.
bullet Gould Hospital: October 9, 1996
Trigger point injection.
bullet Arnold Park Pain Management: Dr. Hoten: October 25, 1996
50% benefit from sacroiliac joint injection. Buttocks pain has decreased.
bullet Arnold Park Pain Management: Dr. Hoten: December 3, 1996
Excellent response to Medrol dose pack. Reports spasms in November with pain radiation down legs. Dr. Hoten continues to find her suitable for limited, sedentary employment.
bullet Arnold Park Pain Management: Dr. Hoten: February 4, 1997
S-1 nerve root injection November, 1995 and sacroiliac injection October, 1996. Pain has begun to increase. Still involved in aquatic therapy. Severe pain in early morning. Awakens from sleep between 4--6 a.m. Another Medrol pack prescribed. Another S-1 nerve root and sacroiliac joint injection procedures considered.
bullet Arnold Park Pain Management: Dr. Hoten: April 1, 1997
Pain reported as stable. Patient continues to use Tylenol No. 3 BID.
bullet Marvin J. Brown, Ph.D., Licensed psychologist
Apparently the report stemming from a psychological evaluation, this is an abbreviated report of 1.5 pages. The mental status and clinical observations are extremely abbreviated as well.

There is no history.

Psychological testing included the Multiaxial Pain Inventory. I do not know this test although there is a Yale Multidimensional Pain Inventory (MPI). No clear identifying information is provided nor are the test results added to this brief report. In addition, the Personality Assessment Inventory was administered, this test also being unclear. There is a NEO Personality Assessment Inventory, but once again this is not made clear.

According to Dr. Brown, the PAI indicated a "Moderate level of idiosyncratic responding, often due to confusion or reading difficulty." The clinical scales show, according to Dr. Brown, show a high level of somatic preoccupation, high levels of anxiety and depression, some identity confusion and poor concentration/confusion.

Dr. Brown offers no multiaxial diagnosis, nor does he present any Axis I classifications.

bullet Rebecca Smith, Ph.D.: (there is nothing found in Dr. Smith's letterhead to indicate in which field she has earned a doctorate nor her specialty): May 7, 1997--November 5, 1997

Once again, a formal report is lacking. Clinical impressions and diagnoses are not found among these notes. Depression is identified and the intervention is largely directed towards relaxation and hypnosis. Intervention notes are skimpy, sometimes as little as 3 sentences.

bullet Acme Center: December 1, 1997: Louise Kost, RN
Mrs. Morrone sustained a low back injury lifting during her employment with Ness Rehabilitation Hospital on October 23, 1992.

May 11, 1993: partial hemilaminectomy and excision of herniated disk (L5--S-1) performed by Dr. Seller

Mrs. Morrone is presently being treated by Dr. Steven Hoten of Arnold Park Pain Management Associates. He has recently recommended a dorsal column stimulator. Earlier this summer he apparently believed the claimant to be capable of sedentary employment with short hours initially.

Claimant also continues to receive psychological services through Hermione Smith, Ph.D. Apparently relaxation therapy and self--hypnosis are part of the treatment plan.

Clinical Interview

Mrs. Morrone is a thin, almost gaunt African-American female who is 5'4" tall and weighs 112 pounds. She is left--handed. During the interview, she expressed suicidal ideation at times, but no plan or intent. At one point she cried and said "Why should I have to live like this?"

Mrs. Morrone has one child, Hope (31) who attended the IME. Her granddaughter, presumably the child she cares for while the mother works, is an infant who is still breast-feeding.

Mrs. Morrone completed the 10th grade and a 3 month nursing assistant program at James Martin School (1968).

Regarding the event at Ness Rehabilitation, she said that she was readying a patient for bed, lifting him from a wheelchair from a frontal position. He was a large man and, during the process, she felt a pain down her right leg but ignored it. The following day she had difficulty walking due to this pain and a numbness in her toes. She believed it to be arthritis. She saw Dr. Gold and he diagnosed it as a herniation.

Mrs. Morrone agreed readily to the majority of symptoms mentioned during the interview, indicating that she experienced them to an extreme degree: somatic concerns, compulsive behaviors, depression, anxiety, anger, phobic anxiety, suspiciousness of others intent to harm her.

She is having moderate problems with family relationships, serious problems with her physical health and describes her general happiness and well--being as very poor.

Historically, she claims that she had no health problems prior to her injury while working at Ness, although her history includes a back sprain--approximately 1990--while working. This was a lumbosacral injury to the right spine that caused her to leave work for 4 weeks.

She reports her surgeries as not being helpful. Presently she is taking Buspar (Prescribed by Dr. Gold, her general practitioner) and Tylenol No. 3, which has a depressant effect. She said the right S-1 transforaminal injection of November 10, 1997 helped her pain by approximately 40%.

The family history includes substance and alcohol abuse and a cousin diagnosed with schizophrenia.

Regarding her own contact with mental health practitioners, she saw Dr. German, a psychiatrist, once in 1997 for a Social Security Disability evaluation. She also said that she worked with Dr. Brown for 6--9 months. During that time he used biofeedback. She says that his intervention did not help at all. Further, she commented that he would "Holler at me for not relaxing." Apparently, Dr. Brown did not recognize the extent of this individual's psychodynamics. She did not see Dr. Smith until 1997. She apparently has a better relationship with Dr. Smith and states that she has helped to some extent.

Mrs. Morrone drinks approximately 1 beer per day, smokes approximately 1 pack per day and only drinks 1 cup of coffee in the morning.

Regarding pain, she describes herself as being in constant pain. This is rated at (on a scale from 0--5) 4 (very painful) in the lumbosacral region and right calf. She also reports numbness in her right toes.

She reports headaches now but denies headaches prior to injury. She claims her head aches more than once per day. Typically these aches occur in the evening, but she attempts to block out the pain. According to her description, pain is located at the vertex.

She describes her pain as 3 (painful) at this time. At its worst, it reaches 4. At its least it remains at 3. Pain is experienced in the morning, evening and bedtime. Most movements are associated with pain.

Other somatic reactions include concern over constipation due to the effects of Tylenol and codeine.

When asked if she has learned how to relax effectively during times of emotional stress, she responded that she has but, surprisingly, rather than cite any learning acquired through Drs. Brown or Smith, said that she listens to gospel music.

Mrs. Morrone reports decreased appetite with a weight fluctuation of plus or minus 5 pounds.

She has occasionally difficult with sleep onset due to pain or troublesome thoughts. She uses Buspar as a sleeping aid every day. She always awakens from sleep due to pain and sleeps lightly. This may be verified via polysomnogram and possibly helped with medication.

Sexual interest and performance ability is less than prior to injury.

Mental Status

bullet PHYSICAL: Attire was neat, hygiene was good.
bullet Motor behavior demonstrated a mildly antalgic gait and stiff posture, bracing, grimacing, moving stiffly, pain posturing
bullet Level of responsiveness: alert, but easily distracted
bullet Manner: appropriate, attempted to appear calm.
bullet Attitude: Cooperative, distant, indecisive, passive, rapport--good
bullet Signs of Emotional distress: Anxiety and depression
bullet Primary facial expression during interview: Neutral to worried, anxious
bullet Eye contact during interview. Tended to look elsewhere, more due to distraction that avoidance
bullet Speech quantity: Talkative
bullet Speech quality: Circumstantial, rambling, vague
bullet Mood: neutral to depressed
bullet Affect: Anxious, depressed, emotional
bullet Thought processes: Confused, scattered
bullet Thought content--preoccupations: somatic symptoms
bullet Thought content--possible delusional aspects to somatic ideations.
bullet Attention: Distractible
bullet Concentration: Impaired
bullet Orientation: X3
bullet Memory functions: possible deficit in recent and remote memory
bullet Estimated intellectual abilities: Below average
bullet Fund of information: consistent with background
bullet Level of abstraction: concrete, personalized
bullet Marital status: divorced
bullet Reliability of patient information: questionably: patient prone to overreact and exaggerate, reporting multiple health concerns
bullet Results of examination: reliable and valid
bullet Insight: lacking


Results depict that Mrs. Morrone falls into the Agitated-Depression phenomenological type. Her somatic anxiety score is 16, indicating the probability of an unfavorable response to conventional treatment as the score is greater than the average urban female.

Results support the patient's complaints of (somatic) anxiety. However, the response pattern demonstrated clear emotional overreactivity and ownership of too many symptoms, indicating clinical levels in all 6 syndromal areas.

This 47 year old, divorced woman with some high school education, reports her most recent problems as Ill-Tired and Moodiness; difficulties appear to have taken the form of an Axis I disorder of undetermined course. Her high scores may represent an anxious plea for help as a consequence of her inability to cope with current life stresses. However, results must be considered invalid. Other evaluations are necessary to appraise her current mental state. This is the "idiosyncratic" response pattern mentioned by Dr. Brown, but neither examined nor identified.

A behavioral health measurement portrays Mrs. Morrone as extremely inhibited, introverted and emotionally reactive. She shies away from social contacts and lacks self-confidence. She is openly emotional, with emotions of all types  surfacing quickly. There is a moody, unpredictable response to frustration. At times she is downcast and displays fatigue and lassitude.

Her moods may shift rapidly, becoming irritable and annoyed. When life events are progressing well, her moods stabilize and she may be pleasant and friendly, seeking to meet the needs of others. However, under even moderate stress, she is likely to become sulky and disgruntled, complaining that things never go well, and voicing unhappiness. These changeable moods keep the patient both physically and psychologically in an unstable state, thereby setting the ground for an increased susceptibility to psychosomatic ailments.

She may be preoccupied with health, overreacting to real illnesses and expressing complaints about relatively minor ailments. She may exhibit symptoms dramatically to gain attention and support.

Based upon the above, if there is a medical history of a periodic or persistent pain disorder it is highly probable that traditional outpatient services will lead to a poor result as emotional and psychosocial factors contribute here. A treatment program using behavior modification and psychotherapy are likely to be more effective than medical treatment alone.

Biofeedback Physiological Assessment

Equipment: Dual Channel EMG: Narrow filter (Silver/Silver chloride electrodes)


Abnormal profile. Excessive unilateral, frontalis tension would be associated with reported headaches and probably associated with stress.

Asymmetry: Of 7 possible asymmetries, Mrs. Morrone showed 3, or 43 %.

Averaging readings on both sides, a clear difference is seen, with bracing or splinting notably on the left to a Moderate level. This is worse upon standing, at T10 (bilateral) and L3 (left).



















It should also be noted that, upon performing the scan, the bracing of the left was visible in the T10 area and appears to be a longstanding, postural compensation.


AXIS I: Adjustment Disorder With Mixed Anxiety and Depressed
            Mood 309.28
            Pain Disorder Associated With Psychological Factors 

AXIS II: No diagnosis, hysterical & avoidant features   V71.09

Axis III: (See medical reports)

Axis IV: Primary Support; Occupational problems; Health,
    Psychosocial and Environmental Problems: Moderate

AXIS V (GAF) Emotional Rating Scale
        Present: 50
        Highest in past year: 50


    bullet This woman is coping with the effects of injury and subsequent surgeries as well as a congenital predisposition towards scarring.
    bullet Personality aspects appear to play a detrimental role in her rehabilitation. Personality features should be examined in greater depth to formulate future treatment and planning.
    bullet Mrs. Morrone should have been referred for psychiatric consultation as she appears to require an antidepressant in addition to the Buspar prescribed for her. It is interesting that, according to her report, only her general practitioner recognized her anxiety to the extent that an anxiolytic was prescribed. Although depression was identified by Dr. Loan February, 1996, antidepressant medication was not prescribed for pain, stress or depression.
    bullet Due to the lacunae in psychological information, vitas for Drs. Brown and Smith were requested through Acme following the 12/10/97 examination. As of this date, they have not been received.
    bullet Dr. Brown's report is overly abbreviated; the mental status and clinical observations are extremely abridged as well and there is no history. Psychological test results are not added.
    bullet I found no treatment records for Dr. Brown, although he allegedly used biofeedback in his treatment over a number of months. He also presents no multiaxial diagnosis or Axis I classifications.
    bullet Similar problems are found in Dr. Smith's reports: she does not supply clinical impressions, diagnoses, GAF scores or a rationale as to whether Mrs. Morrone is appropriate for hypnosis and relaxation and why.

bullet A somatosensory examination could prove clinically useful.
bullet I recommend further psychological testing to assess personality factors and that this is done verbally, to avoid the inconsistent responses that may be due to distractibility or reading limitations.
bullet She should also be evaluated psychiatrically for medication, as suggested above.
bullet Medical reports indicate that Mrs. Morrone could return to some form of sedentary employment, at least on a part-time basis. This may be correct medically, but she is psychologically inappropriate an action of this type at this time and requires preparation, both in terms of psychological/psychiatric and vocational counseling.
bullet Regarding intensity of care, referral to a pain management program could be helpful, providing more and diverse treatment exposure. The records do not indicate effective interventions thus far, making continued treatment with the present provider questionable, beyond support alone. However, personality should be assessed and medication considered prior to any further referral.
bullet While appropriate, a dorsal stimulator may not be indicated at this time. It would be more feasible to provide antidepressant medication and effective psychotherapeutic intervention before dealing with this issue.
bullet On the issue of caring for her grandchildren, she has, I believe, one infant grandchild less than a year old. This does not suggest that she is capable of working in childcare.
bullet Although she may have reached maximum medical improvement, psychological barriers have not been appropriately addressed as indicated above.

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Last updated: June 26, 2011 12:55 PM