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Hearing impairment rating determination is described in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, Section 11.2a, Criteria for Rating Impairment Due to Hearing Loss. A hearing impairment evaluation for adults who have acquired language skills is derived from a pure-tone audiogram and always is based on the functioning of both ears even though hearing loss may be present in only one ear. Audiometers should be properly calibrated, and technicians should be appropriately trained to obtain accurate measurements. Audiograms typically are obtained at four frequencies (test frequencies): 500, 1000, 2000, and 3000 Hz, which are considered to be representative of everyday auditory speech ranges. The evaluator tests the individual's right and left ears at the test frequencies and adds the decibel levels for each of these frequencies for each ear separately; consults Table 11-2, Computation of Binaural Hearing Impairment; and finally consults Table 11-3, Relationship of Binaural Hearing Impairment to Impairment of the Whole Person. Tinnitus can be rated if the individual experiences hearing loss in the ear and this loss affects speech discrimination; loss is limited to a maximum of 5% loss. The AMA Guides provides no correction in the hearing section for age-related loss of hearing, although the latter may be apportionable. A table presents a model hearing impairment report.

The assessment of impairment due to alteration in mental status, cognition, and highest integrative function may be challenging. A review of impairment assessments performed by others can provide valuable insights, including an appreciation of how evaluators may misapply the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition. As a teaching example, this article presents an erroneous rating for a claim of cognitive impairment. The authors point out that most of the misdirection in the case example could be identified with reference to the AMA Guides, Sixth Edition, which reveals discrepancies between the rating processes in this case and actual sixth edition methodology. Nevertheless, the case example involved certain components that were so unconventional that it would have been impossible for the sixth edition contributors to anticipate the need to write a text that would have prevented these errors. The process of sorting out this misdirected rating revealed a previously unanticipated need to clarify sixth edition methodology, and the present article provides such clarification. The concluding section of this article provides a step-by-step protocol for the AMA Guides, Sixth Edition, methodology that involves rating cognitive impairment using Section 13.3d, Mental Status, Cognition, and Highest Integrative Function. The fourteen steps outline a meticulous process based on appropriate clinical assessment, application of evidence-based medicine, and the process outlined in the AMA Guides, Sixth Edition.

Scientific findings have indicated that psychological and social factors are the driving forces behind most chronic benign pain presentations, especially in a claim context, and are relevant to at least three of the AMA Guides publications: AMA Guides to Evaluation of Disease and Injury Causation, AMA Guides to Work Ability and Return to Work, and AMA Guides to the Evaluation of Permanent Impairment. The author reviews and summarizes studies that have identified the dominant role of financial, psychological, and other non–general medicine factors in patients who report low back pain. For example, one meta-analysis found that compensation results in an increase in pain perception and a reduction in the ability to benefit from medical and psychological treatment. Other studies have found a correlation between the level of compensation and health outcomes (greater compensation is associated with worse outcomes), and legal systems that discourage compensation for pain produce better health outcomes. One study found that, among persons with carpal tunnel syndrome, claimants had worse outcomes than nonclaimants despite receiving more treatment; another examined the problematic relationship between complex regional pain syndrome (CRPS) and compensation and found that cases of CRPS are dominated by legal claims, a disparity that highlights the dominant role of compensation. Workers’ compensation claimants are almost never evaluated for personality disorders or mental illness. The article concludes with recommendations that evaluators can consider in individual cases.

The American Medical Association's Guides to the Evaluation of Disease and Injury Causation (Causation) is an important component of the AMA Guides library and delineates a type of evaluation that is distinctly different from a diagnostic evaluation, a treatment planning evaluation, a prognosis evaluation, or an impairment evaluation. Causation provides a protocol for determining whether a clinical presentation, in the context of a legal or administrative claim, may be credibly attributed to a claimed cause. This article presents the evaluation protocol from Causation, provides self-assessment questions (so users can check how well they complied with the protocol), highlights the protocol's value as a model for scientifically credible practice in general, and clarifies that the protocol is relevant to claims that involve issues related to forensic causation. Courts and administrative systems have an extremely unfortunate emphasis on opinions from experts rather than on facts. The protocol from Causation is a good example of how clinicians can focus on facts and avoid surrendering to the court or administrative system's emphasis on opinions. The protocol is standardized, objective, fact-based, and scientifically credible and involves the following: establish a diagnosis; apply relevant findings; obtain and assess evidence of exposure; consider other relevant factors; scrutinize the validity of the evidence; and evaluate results and generate conclusions.

Many of the methods used to assess impairment rely on the completeness, accuracy, and reliability of patients’ self-presentations, and evaluators should be able to identify behavioral factors such as illness behavior and malingering; the latter is not ratable, but its presence complicates appropriate case management. This article focuses on the clinical data and the analysis that can be helpful in identifying malingering, as well as validity problems during document and medical file reviews. According to the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, examiners always should be aware of the possibility of malingering during impairment evaluations, and the possibility of avoiding responsibility and/or obtaining monetary awards increases the likelihood of exaggeration and/or malingering. Current methods for assessing malingering in general assess the probability of malingering based on comparisons to research statistics and free the evaluator from any reliance on expert opinion. Correlating multiple clinical sources is useful in assessing the validity of a clinical presentation and includes the individual's pre-existing status; information about the injury; the history of the presenting illness, past medical and social histories, physical examination, questionnaires and scales, functional capacity evaluations, and video surveillance. Coherence analysis is a method of clinical data review that uses multiple themes to determine if data provide an integrated presentation. Evaluators should highlight issues of discontinuity, inconsistencies, incongruencies, noncompliance, or poor effort.

The increasingly severe epidemic of overuse, abuse, and death involving prescription narcotics is of specific relevance to workers’ compensation, which is the primary venue for use of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). Because of the scientific knowledge base regarding prescription narcotics for chronic benign pain, evaluators may question how any patient could credibly be considered to have reached maximum medical improvement (MMI) if that patient has a prescription for a narcotic. Hyperalgesia associated with narcotics does not appear to be permanent, but evidence indicates that prescription narcotics cause significant problems in addition to worsening pain: endocrine disruption, sleep abnormalities, immune system compromise, cognitive impairment, substance abuse, and generalized ill health and disability, among others. Evaluators may worry that refusing to evaluate a person who is not at MMI because they are receiving a prescription narcotic may unintentionally delay resolution of the person's claim. In a more efficient approach, an evaluator could undertake the complete evaluation process, including creating an impairment rating, and document in the evaluation report that the rating is being provided despite reasons to be concerned that the impairment is artificially inflated in a nonpermanent way by the unjustifiable narcotic prescription. Evaluators should not state that the impairment from side effects of the opioids is permanent.

The application of the processes defined in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) should result in reliable impairment ratings, ie, reproducible impairment ratings when the AMA Guides is applied appropriately. This article reviews some of the causes of erroneous impairment ratings based on misapplication of the fifth edition. The first two chapters of the AMA Guides provide the principles of assessing impairment, a key of which is that physicians must be independent and unbiased. Treating physicians cannot be unbiased because they inherently have a patient advocacy role, and they may use approaches that will increase the patient's impairment rating. Clinical and causation errors are common in evaluations; the greatest source of error is examiner inexperience. Evaluations should take place only when the patient is at maximum medical improvement, and evaluators must distinguish between impairment related to the alleged injury and that due to other injury, degenerative disease, or illness, not self-reports. A box shows common causes of erroneous impairment ratings based on the fifth edition. Both the rating physician and the party requesting the rating should recognize the high likelihood of error and should become knowledgeable about the AMA Guides, and the evaluating physician should have had formal training regarding use of the AMA Guides and should possess demonstrated competency in assessing impairment.

Complex regional pain syndrome (CRPS) is a controversial, ambiguous, unreliable, and unvalidated concept that, for these very reasons, has been justifiably ignored in the “AMA Guides Library” that includes the AMAGuides to the Evaluation of Permanent Impairment (AMA Guides), the AMA Guides Newsletter, and other publications in this suite. But because of the surge of CRPS-related medicolegal claims and the mission of the AMA Guides to assist those who adjudicate such claims, a discussion of CRPS is warranted, especially because of what some believe to be confusing recommendations regarding causation. In 1994, the International Association for the Study of Pain (IASP) introduced a newly invented concept, CRPS, to replace the concepts of reflex sympathetic dystrophy (replaced by CRPS I) and causalgia (replaced by CRPS II). An article in the November/December 1997 issue of The Guides Newsletter introduced CRPS and presciently recommended that evaluators avoid the IASP protocol in favor of extensive differential diagnosis based on objective findings. A series of articles in The Guides Newsletter in 2006 extensively discussed the shortcomings of CRPS. The AMA Guides, Sixth Edition, notes that the inherent lack of injury-relatedness for the nonvalidated concept of CRPS creates a dilemma for impairment evaluators. Focusing on impairment evaluation and not on injury-relatedness would greatly simplify use of the AMA Guides.

If a patient reports not having back pain before lifting an object at work but having chronic disabling pain thereafter, an examiner may conclude without further questioning that an injury took place when the object was lifted and therefore is work related. This article reviews relevant scientific findings and provides recommendations for making disability determinations in a manner that is more credible than basing conclusions on an examinee's reports. The author specifically recommends that future editions of the AMAGuides to the Evaluation of Permanent Impairment (AMA Guides) should emphasize that clinical and forensic conclusions cannot be based on reports from an examinee and instead must be based on more credible sources of information. Research has shown that, among individuals who believe that a specific event (eg, an accident) caused the current complaints, the individual is likely to underreport their health history for the time preceding that event and to overstate the extent of their problems following the event. Other researchers found that claimants systematically underreported every preclaim health issue that might have provided a non–injury-related explanation for their complaints. Any basis for a conclusion of injury should be based on objective and scientifically credible findings that would have indicated that an injury had occurred even in the absence of any information having been reported by the patient.

“Posttraumatic” headaches claims are controversial because they are subjective reports often provided in the complex of litigation, and the underlying pathogenesis is not defined. This article reviews principles and scientific considerations in the AMAGuides to the Evaluation of Permanent Impairment (AMA Guides) that should be noted by evaluators who examine such cases. Some examples in the AMA Guides, Sixth Edition, may seem to imply that mild head trauma can cause permanent impairment due to headache. The author examines scientific findings that present obstacles to claiming that concussion or mild traumatic brain injury is a cause of permanent headache. The World Health Organization, for example, found a favorable prognosis for posttraumatic headache, and complete recovery over a short period of time was the norm. Other studies have highlighted the lack of a dose-response correlation between trauma and prolonged headache complaints, both in terms of the frequency and the severity of trauma. On the one hand, scientific studies have failed to support the hypothesis of a causative relationship between trauma and permanent or prolonged headaches; on the other hand, non–trauma-related factors are strongly associated with complaints of prolonged headache.

Chapter 14, Mental and Behavioral Disorders, in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, defines a process for assessing permanent impairment, including providing numeric ratings, for persons with specific mental and behavioral disorders. These mental disorders are limited to mood disorders, anxiety disorders, and psychotic disorders, and this chapter focuses on the evaluation of brain functioning and its effects on behavior in the absence of evident traumatic or disease-related objective central nervous system damage. This article poses and answers questions about the sixth edition. For example, this is the first since the second edition (1984) that provides a numeric impairment rating, and this edition establishes a standard, uniform template to translate human trauma or disease into a percentage of whole person impairment. Persons who conduct independent mental and behavioral evaluation using this chapter should be trained in psychiatry or psychology; other users should be experienced in psychiatric or psychological evaluations and should have expertise in the diagnosis and treatment of mental and behavioral disorders. The critical first step in determining a mental or behavioral impairment rating is to document the existence of a definitive diagnosis based on the current edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders. The article also enumerates the psychiatric disorders that are considered ratable in the sixth edition, addresses use of the sixth edition during independent medical evaluations, and answers additional questions.

The Global Assessment of Functioning (GAF) is part five of the multiaxial diagnostic system for mental disorders outlined in the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition–Text Revised (DSM-IV-TR). The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) notes the use of DSM-IV-TR in rating an individual's global functional capacity, which, like disability, is related directly to the effects of impairments. The AMA Guides, Fourth and Fifth Editions, do not provide numeric psychiatric impairment, and shortcomings plague the use of GAF to define disability—but even so, authorities ranging from the State of California to the Veterans Administration rely on GAF scores. A table shows the 100-point scale Global Assessment Scale in which higher scores indicate better functioning. The GAF has been modified to address deficiencies; a decision tree has been added and is summarized; and the editor of DSM-IV-TR has developed a computerized version that reportedly improves reliability and validity. Evaluators should bear in mind that the GAF helps evaluate the individual's functioning in three areas: psychological, social, and occupational (including the activities of daily living). The resulting score facilitates the creation of a treatment plan, evaluates its effectiveness, and predicts outcomes, but evaluators should be aware of its significant limitations.

Several Canadian provinces use the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) to adjudicate workers’ compensation claims, and the Province of Ontario uses the AMA Guides, Fourth Edition, to adjudicate motor vehicle accident personal injury claims. This article focuses on controversies that have arisen in Ontario regarding how the AMA Guides is applied and shows some of the challenges that occur in quantifying psychological impairment. In 2004, the Ontario Superior Court found in the Desbiens v. Mordini trial that the AMA Guides did not provide any direct methodology for estimating percentage impairment in this unique circumstance that involved pre-existing paraplegia and subsequent dramatic loss of residual functions. The judge found that, using the information available, a whole person impairment (WPI) score of 40% could be derived, but Ontario requires a minimum 55% WPI before an individual qualifies for catastrophic impairment benefits. In view of the individual's circumstances and a psychologist's recommendation, the judge awarded an additional 25% WPI. The Ontario model has been interpreted to allow subjective complaints (symptoms) to be included in the impairment evaluation process, but this approach eliminates any expectation of objectivity. If a judicial system aims to force impairment percentages onto a situation that in fact does not warrant such ratings, it should not do so by an inappropriate application of the AMA Guides.

Complex regional pain syndrome (CRPS) is a controversial, ambiguous, and often unreliable concept that presents significant clinical and rating challenges, to the extent that, for any individual case, many of the differential diagnostic issues provide a far more probable explanation of symptoms than does CRPS. The International Association for the Study of Pain (IASP) introduced CRPS in 1994 specifically to replace “reflex sympathetic dystrophy” [RSD] and “causalgia.” The IASP diagnostic protocol for assessing CRPS has led to overdiagnosis, as well as questions regarding the protocol's reliability, validity, and high error rate during field trials. Using the IASP protocol and the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, the authors discuss the mental health and general medical evaluations that are part of the differential diagnosis of CRPS, which involves both psychological and general medical components. Finally, examiners should be aware that the probability rates for a diagnosis of CRPS following a thorough and extensive differential diagnosis is very small and is further limited by the general lack of scientific credibility for the concept of CRPS. A diagnosis of CRPS in the absence of ruling out all potential differentials is not credible. A sidebar discusses several chapters that are relevant to rating impairment due to causalgia, RSD, and CRPS.

Impairment evaluations often occur within an adversarial context that involves a claimant or plaintiff vs a defense or benefits system; this adversarial context may precipitate proposals for observations of a clinical evaluation (eg, by an attorney or attorneys for one or both parties, a court reporter, a clinical expert, other consultant; audio or video also may be recorded). Evaluators, judges, and state workers’ compensation systems sometimes allow such observation, but a century of scientific research has reliably demonstrated that any observation changes an examinee's presentation in ways that are not themselves predictable. Such contamination leaves the evaluation results without a scientifically credible analysis, rendering observed evaluations futile exercises at best and sources of misinformation at worst. This article reviews the research in social psychology regarding “social facilitation and inhibition,” which has identified an extensive list of factors that are affected by observation (eg, complexity or novelty of the issue being evaluated, perceptions of the observer as an evaluator, stranger, or ally, number of observers, and other factors). No mechanism allows an evaluator to systematically account for the effects of all such variables for any given evaluation. When observation is mandatory, the evaluator should clearly document and communicate that a credible direct evaluation was rendered impossible, to the detriment of the referring party and the system as a whole.

The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) warns physicians against minimizing psychiatric impairments but does not elaborate on this warning against minimizing the contribution of psychological factors to general medical impairment. Claims regarding spinal impairment are a useful example because the AMA Guides cites a study showing there is no general medical explanation for 85% of low-back pain cases. The list of mental illnesses that are commonly associated with complaints of physical pain includes somatoform, mood, anxiety, personality, psychotic factitious, and substance-related disorders. In one study, anxiety disorders accounted for 54% of the variance in pain severity reports and associated claims of disability. Psychological dysfunction leads only to subjective complaints such as pain but also can lead to objective physiological signs, for example, mental illness such as panic disorder, which includes objectively verifiably physical signs such as heart palpitations, sweating, and tremor. Claims of disability also have been associated with hypertension, cardiac issues, concussion, multiple sclerosis, and psoriasis. To credibly assess the possibility of mental illness as the cause of a general medical impairment claim is extremely demanding, and evaluators should think of the evaluation process in terms of days rather than hours. The steps in an evaluation protocol should mirror those described in the March/April 2005 issue of The Guides Newsletter and are summarized in the present article.

A sidebar titled “Rating Impairment for [complex regional pain syndrome] CRPS Type 1” in the March/April issue of The Guides Newsletter states: “Do NOT use the pain chapter to rate CRPS” because there is no well-defined pathophysiologic basis. That conclusion is contradicted by the pain chapter, which lists CRPS among conditions considered ratable, but accompanying text provides no explanation how this determination was made. This article attempts to resolve the conflict between the sidebar in The Guides Newsletter and the pain chapter. The lack of a well-defined pathophysiologic basis for CRPS is the reason for the position stated in the sidebar, and a review of the relevant professional literature confirms this reasoning. Further, the concept of CRPS itself is ambiguous and was intentionally designed to be “general” and “descriptive” and historically has been diagnosed using nonstandardized, idiosyncratic, or incompatible diagnostic systems. The AMA Guides to the Evaluation of Permanent Impairment is self-contradictory regarding diagnostic criteria and terminology (eg, is CRPS-1 synonymous with RSD, causalgia, or neither?). CRPS lacks any well-defined pathophysiology, is highly ambiguous and controversial, involves characteristics that compromise the credibility of any examinee making such a presentation, and is a good example of a condition that should be evaluated using the mental and behavioral disorders chapter.

From the previous issue, this article continues a discussion of the potentially confusing aspects of the diagnostic formulation for complex regional pain syndrome type 1 (CRPS-1) proposed by the International Association for the Study of Pain (IASP), the relevance of these issues for a proposed future protocol, and recommendations for clinical practice. IASP is working to resolve the contradictions in its approach to CRPS-1 diagnosis, but it continues to include the following criterion: “[c]ontinuing pain, which is disproportionate to any inciting event.” This language only perpetuates existing issues with current definitions, specifically the overlap between the IASP criteria for CRPS-1 and somatoform disorders, overlap with the guidelines for malingering, and self-contradiction with respect to the suggestion of injury-relatedness. The authors propose to overcome the last of these by revising the criterion: “[c]omplaints of pain in the absence of any identifiable injury that could credibly account for the complaints.” Similarly, the overlap with somatoform disorders could be reworded: “The possibility of a somatoform disorder has been thoroughly assessed, with the results of that assessment failing to produce any consistencies with a somatoform scenario.” The overlap with malingering could be addressed in this manner: “The possibility of malingering has been thoroughly assessed, with the results of that assessment failing to produce any consistencies with a malingering scenario.” The article concludes with six recommendations, and a sidebar discusses rating impairment for CRPS-1 (with explicit instructions not to use the pain chapter for this purpose).

Complex regional pain syndrome-type 1 (CRPS-1) is a problematic diagnosis of a characteristic burning pain that is present without stimulation or movement, occurs beyond the territory of a single peripheral nerve, and is disproportionate to the inciting event. This article highlights some challenging aspects of the diagnostic formulation for CRPS-1 by the International Association for the Study of Pain (IASP) and provides recommendations to address the issues. First, the terminology, CRPS-1, was created specifically to replace the previous term, “reflex sympathetic dystrophy.” Unfortunately, no gold standard diagnostic tests exist for CRPS-1, and the concept itself has a long and continuing history of controversy, not the least factor of which is the lack of reliable diagnostic schemes. Next, IASP's criteria for CRPS-1 do not standardize the diagnostic process and depart from epidemiologic guidelines, particularly regarding continuing pain, allodynia, or hyperalgesia disproportionate to any inciting event. Further, the IASP protocol overlaps diagnostic criteria for somatoform disorders, eg, those in the American Psychiatric Association's diagnostic manual, DSM-IV-TR. Finally, according to the IASP protocol, the majority of CRPS-1 patients present with symptoms that are indistinguishable from those in the DSM-IV-TR guidelines, and the majority of CRPS-1 cases are indistinguishable from the formal definition of malingering.

In the AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), Fifth Edition, two chapters claim relevance for pain complaints that lack an objectively demonstrable general medical basis: Chapter 14, Mental and Behavioral Disorders, and Chapter 18, Pain. Parts 1 and 2 of this four-part series examined forms of mental illness that commonly invoke complaints of pain; Part 2 also evaluations using the mental/behavioral chapter vs the pain chapter, and Part 3 noted the self-negating nature of the pain chapter's rationale (ie, the pain chapter presents a rationale that, taken literally, indicates it should not be used). A detailed case example illustrates how the decision about using the mental/behavioral chapter or the pain chapter often can be clarified by simply performing a thorough clinical evaluation (see Part 2 of this series). Examiners should be aware of the role of thoughts, behavior, and environmental contingencies on presentations of chronic pain even when no scientifically credible and objective general medical findings explain the pain. For example, the AMA Guides points out that in as much as 85% of low back pain cases, no explanatory physical pathology can be identified; therefore, readers are encouraged to be mindful of the professional literature. The authors of this series deny any attempt to move all instances of chronic pain into the category of mental illness but report little reason not to do so.

This article is part three of a four-part series that examines the rating of pain complaints and mental illness using the AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides). Chapter 18 provides physicians with a method for evaluating impairment associated with “chronic pain states” for which there may be “no demonstrable active disease or unhealed injury,” and Chapter 14 should be considered when symptoms are out of proportion to physical findings. This article focuses on the directions from Chapter 18 and other pain resources. The authors note that Chapter 18 specifically addresses the issue of distinguishing between uses of Chapters 18 and 14, but the directions are contradictory with respect to the key question, Do “psychological factors” play a “major role” in the presentation of pain? Resources such as Bonica's Management of Pain point out that “[t]issue damage and nociception are neither necessary nor sufficient for pain,” suggesting that psychological factors are nearly always present and obviating the use of Chapter 18. A potential solution would be to ask, “Is the presentation of pain consistent with any mental illness as defined in the American Psychiatric Association's Diagnostic and Statistical Manual?” The decision rule then would be if the presentation of pain is consistent with any mental illness, then the mental and behavior chapter should be used.

In accordance with the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Chapter 18, Pain, pain that is attributable to mental illness does not also qualify for an additional pain-related evaluation. Evaluators must discriminate between presentations of pain that represent mental illness vs those that do not and must decide whether to rate using Chapter 18 or 14. Dichotomous thinking often opposes the notion of psychological vs physiological-organic presentations, but all presentations of pain include psychological aspects, and all mental illnesses include physiological aspects. One type of illustrative mental illness involves conditions that are overtly mental but have been found via extensive scientific study to have a physiological basis (eg, schizophrenia and Alzheimer's disease). Another presentation that is claimed to be of a medical nature actually overlaps with psychological issues (eg, complex regional pain syndrome, type 1 [CRPS-1] and fibromyalgia). Further, the AMA Guides summarizes the lack of a strong correlation between tissue damage or physiology and pain: Pain can exist without tissue damage, and tissue damage can exist without pain. Pain, chronic pain, and impairment from pain are largely, even primarily, psychological phenomena. Accordingly, the determination whether to rely on the pain chapter or the mental/behavioral chapter in the evaluation of a pain presentation cannot be reduced to a misleading dichotomy of psychological vs organic pain.

This is the second in a series of articles that address pain complaints and mental illness. The AMA Guides to the Evaluation of Permanent Impairment, Fifth Edition, should not be used if the pain presentation is attributable to mental illness, and the evaluator must distinguish between presentations that should be evaluated using Chapter 18, Pain, and those that should be evaluated using Chapter 14, Mental and Behavioral Disorders. Chapter 14 is unique in its avoidance of numerical impairment ratings but has been praised for its internal consistency and emphasis on following the current edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM). The only section of Chapter 14 that discusses pain complaints is somatoform pain disorders, which presents several problems, including nomenclature (the phrase somatoform pain disorder is antiquated and disappeared from DSM in 1994, and other forms of mental illness are not somatoform disorders). The DSM is the foundation of the evaluation process, and its discussion of any given mental illness is the gold standard definition of that illness; therefore, any attempt to evaluate pain complaints as a possible manifestation of mental illness must use DSM protocols. The article concludes with a discussion of the components of the evaluation process: awareness of the most prominent diagnostic possibilities; presenting complaints; health history; social history; review of records; family history; collateral interviews; and psychological testing.