module 8 part 4

Question 2

What DSM-5 categories are most common in psych WC claims?

Answer 2

PTSD, Major Depressive Disorder, Anxiety Disorders, Adjustment Disorders, Somatic Symptom Disorder.

Question 3

Mnemonic for common DSM-5 work psych

Answer 3

“PAJAS” — PTSD, Anxiety, Joint (adjustment), Affective (depression), Somatic.

Question 4

Why must QME list DSM-5 code?

Answer 4

Required for legal validity; WCAB cannot rate non-coded conditions.

Question 5

Can “burnout” alone qualify?

Answer 5

No — must meet DSM-5 diagnostic criteria (e.g., Adjustment disorder, Major depression).

Question 6

What are compensable consequence psych add-ons after SB 863?

Answer 6

Allowed only if injury is catastrophic or caused by violent act; otherwise psych PD add-ons are barred post-2013.

Question 7

What if physical claim denied?

Answer 7

Psych consequence claim generally fails if base physical injury isn’t accepted.

Question 8

What is “violent act” per SB 863?

Answer 8

Actual physical assault or life-threatening event at work; lower causation threshold and psych add-on allowed.

Question 9

Why is temporal proximity important?

Answer 9

Shorter gap between work event and psych symptoms strengthens causal link.

Question 10

How to handle delayed onset PTSD?

Answer 10

Must show consistent symptom evolution tied to workplace trauma; still compensable if medically explained.

Question 11

Role of pain catastrophizing?

Answer 11

May mediate psych impairment but isn’t itself a diagnosis; QME should describe impact but rate only DSM condition.

Question 12

What is MMI for psych injury?

Answer 12

When mental state is stable and unlikely to change with further treatment; required for PD rating.

Question 13

Mnemonic for psych MMI

Answer 13

“Stable Mind = Rate Time.”

Question 14

What is permanent disability (PD) in psych?

Answer 14

Ongoing mental impairment after MMI affecting ADLs and employability, rated via GAF → WPI → PD.

Question 15

Who decides final psych PD %?

Answer 15

DEU or WCAB judge; QME supplies GAF and medical rationale.

Question 16

What is temporary disability (TD) for psych?

Answer 16

Wage loss benefits while unable to work due to accepted psychiatric condition.

Question 17

Why are TD periods scrutinized?

Answer 17

Must be medically justified; insurers may request updated psych reports to continue TD.

Question 18

How do return-to-work programs affect psych cases?

Answer 18

Modified duty or RTW plans may reduce TD and overall dispute; QME may comment on work capacity.

Question 19

What is good faith personnel action defense in psych?

Answer 19

Lawful, non-discriminatory management actions (eval, transfer, discipline) can bar psych claims if main cause.

Question 20

How to determine if GFPA applies?

Answer 20

Analyze legitimacy, consistency, non-discrimination, and documentation of the action.

Question 21

Mnemonic for GFPA review

Answer 21

“DOCS” — Documentation, Objective, Consistent, Safe.

Question 22

Why are psych claims more litigious than physical?

Answer 22

Subjectivity, causation complexity, stigma, higher defense potential (GFPA, personal stressors).

Question 23

What is an IME in psych WC?

Answer 23

Independent Medical Exam — insurer/defense-ordered evaluation to challenge psych causation or impairment.

Question 24

Difference between QME & IME?

Answer 24

QME is DWC-panel appointed; IME is privately retained by one party (often defense).

Question 25

Why should QME anticipate deposition?

Answer 25

Psych reports are heavily challenged; must defend causation, GAF score, and apportionment.

Question 26

How can QME strengthen report?

Answer 26

Use timeline, objective tests, DSM-5 codes, detailed ADLs, apportionment analysis, and legal threshold explanation.

Question 27

Why is apportionment often complex in psych?

Answer 27

Personal history, childhood trauma, non-industrial stress can overlap with work; needs careful percentage breakdown.