This document discusses methods for assessing mental health and behavioral impairment ratings. It provides guidance on using three scales: the Brief Psychiatric Rating Scale (BPRS), Global Assessment of Functioning (GAF) scale, and Psychiatric Impairment Rating Scale (PIRS). It also includes a sample case scenario of a man diagnosed with major depressive disorder and applies the three scales to determine a 5% impairment rating.

1. Mental Health &
Behaviour
Impairment Ratings
Abdul Rahman Ramdzan

2. Principle of Assessment
• Assessor
•Expertise DSM IV
•Expertise in psychiatry or psychological evaluation of
patient
•Expertise in the diagnosis & treatment of mental &
behavioural disorder
• Diagnosis
• Diagnosis categories
•Mood disorder – MDD, bipolar affective disorder
•Anxiety disorder – GAD, panic disorder, OCD
•Psychotic disorder - schizophrenia
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3. Diagnosis
3

4. Psychiatric/ psychological evaluation
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5. Special features

6. Physician alliance
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• Neutral & unbiased position
• Avoid serving as IME on behalf of their own patient
Source materials
• Individual ‘s own description
• Reliable collateral information while doing ADL
• Records (hospitalization, outpatient)
• Inconsistencies should be explored
Motivation
• Key factor in severity & extent of individual’s ability to
lead productive life despite a challenging impairment

7. Malingering
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8. Concepts of Impairment Ratings
• The Guides Sixth Edition uses 3 scales by which M&BD
impairment is rated:
• Brief Psychiatric Rating Scale (BPRS) : 14-8
• Global Assessment of Functioning Scale (GAF) : 14-10
• Psychiatric Impairment Rating Scale (PIRS) : 14-5, 14-11 until 14-16
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9. Brief Psychiatric Rating Scale (BPRS)
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Measures major psychotic & non
psychotic symptoms in patients
with major psychiatric illness.
Consist of 24 symptoms
rated on 7 point scale of
severity ranging from not
present to extremely severe.

10. Brief Psychiatric Rating Scale (BPRS) – page 357
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11. 11

12. Brief Psychiatric Rating Scale (BPRS) – page 357
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18-24
25-30
31-35
36-40
41-50
51-60
61-70
71-168

13. Global Assessment of Functioning Scale (GAF)
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Based only to psychological,
social & occupational functioning
Do not include impairment in
functioning due to physical
or environmental limitations

14. Global Assessment of
Functioning Scale (GAF)
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15. Psychiatric Impairment Rating Scale (PIRS)
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Modified version of originally
develop for New SouthWales
Motor Accidents Authority of
Australia.
6 impairment domain rated
from 1-5

16. Psychiatric Impairment Rating Scale (PIRS) – page 352, 358
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17. (PIRS) –
page 359
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18. Psychiatric Impairment Rating Scale (PIRS) – page 360
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19. • Step 1: BPRS Impairment Score - 24 symptom constructs,
each to be rated on a 7-point scale of severity ranging from
“not present” to “extremely severe” (Table 14-8). Sum the
total of the 24 BPRS symptom construct scores, and find
the BPRS impairment score inTable 14-9.
• Step 2: GAF Impairment Score - Determine the GAF
impairment score based onTable 14-10.
Methods of Impairment Rating
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20. • Step 3: PIRS Impairment Score - grade the patient from l to 5 in
Tables 14-11 throughTable 14-16.
1) Patients should receive a score from 1 to 5 in each of the 6
impairment domains (Tables 14-11 to 14-16).
2) Arrange the 6 scores from lowest to highest, for example, 1 2 2 4 4 5.
3) Select the middle 2 scores from the arrangement of 6 scores. In the
example “1 2 2 4 4 5.” the middle 2 scores are “2” and “4.”
4) Sum the middle 2 scores. In the example above, the sum of the
middle 2 scores would be “6.”
5) Determine the PIRS impairment score fromTable 14-17.
Methods of Impairment Rating
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21. • Step 4: List BPRS, GAF, and PIRS Impairment Scores
BPRS impairment score _______
GAF impairment score ________
PIRS impairment score _______
Of the 3 impairment scores listed in step 4, the M&BD impairment
rating is the median (middle) value of the BPRS, GAF, and PIRS
impairment scores.
Methods of Impairment Rating
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22. Scenario 1

23. Scenario 1
• A 55-year-old high-functioning
real estate developer noted a
change in his normal outlook
where the “sky was no longer
blue but gray.” He said that food
had no taste, and he could not
concentrate on reading or
television.Terminal insomnia
and feelings of hopelessness
and helplessness had developed.
• He felt his work was not worth the
effort because of the futility of life.
He withdrew into his home and
began to stay in bed. He had no
interest in his usual activities.
When asked if he were depressed,
he would answer “yes” but state
that he really had no “feelings at
all.” He felt excessive fatigue and at
times stated that he would be better
off dead.These symptoms were
consistently present most of the day
over the month before evaluation.
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24. Scenario 1
• He had no past history of
mood instability,
significant medical
problems, or alcohol or
substance use.There was
no history of personality
problems or work
difficulties. He was
happily married and had
raised 3 successful
children. He had a first
cousin with depression
onset in midlife.
• The patient sought psychiatric evaluation,
and medical consultation revealed no medical
cause. He was diagnosed with major
depression. He was started on
antidepressant therapy and had only a partial
response. He underwent several
antidepressant trials of sufficient length,
appropriate dosages, different classes, and
augmentive strategies. His response to
medication was only partial or inadequate
or was limited by side effects. His medication
compliance was good and there was no
discerned secondary gain. He would not
consider electroconvulsive therapy, but did
participate in cognitive behavioural therapy.
After more than l year of various medicine
trials, his symptoms seemed to stabilize and
he was thought to have reached Maximum
Medical Improvement (MMI).
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25. Scenario 1
• After the reported treatment
course, he reported he slept fairly
well with only occasional insomnia (l
night per month). He returned to
within 10% of his pre-illness body
weight. He still had episodic feelings
of hopelessness and helplessness,
but they were brief. He felt his mood
was generally good and he had no
passive death wishes. He had
returned to work on a half-time
basis several months earlier and
recently had increased to full time.
• His ongoing psychiatric
difficulties were threefold. First,
his ability to concentrate had
not fully recovered.The patient
estimated that his abilities to
concentrate on reading, hobbies,
and work projects remained
significantly diminished. He felt
that his ability to focus at work
was diminished by 50%. His work
efficiency was approximately two
thirds of his premorbid level.
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26. Scenario 1
• Second, he continued to have
some anhedonia. He had only
minor interest in sexual relations
with his wife and minimal
interest in social activities that
had been a major part of their life
together. If his wife pushed him,
he would go out reluctantly.
• Third, he continued to have
trouble with fatigue. He
reported he could start out
strong in the morning but by
noon he would have to sit and
relax almost to the point of
needing a nap. Afterward he
would feel good until about 3 PM,
when he would again feel the
need to rest. He had arranged his
schedule around his needs for
rest.
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27. Diagnosis:
• Axis I: Major depressive disorder, in partial remission.
• Axis II: None.
• Axis III: None.
M&BD Impairment Rating:
Step I: BPRS impairment score
• Somatic concern: 1, Anxiety: I, Depression: 3, Suicidality: 1, Guilt: 1, Hostility: 1,
Elevated mood: 1, Grandiosity: 1, Suspiciousness: I, Hallucinations: 1, Unusual
thought content: 1, Bizarre behavior: 1, Self-neglect: 1, Disorientation: 1, Conceptual
disorganization: 1, Blunted affect: 1, Emotional withdrawal: 2, Motor retardation: 1,
Tension: 1, Uncooperativeness: 1, Excitement: 1, Distractability: 1, Motor
hyperactivity: 1, Mannerisms and posturing: 1,
• Sum the total of the 24 BPRS symptom construct scores: 27.
• Find the BPRS impairment score inTable 14-9: 5%.
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18-24
25-30
31-35
36-40
41-50
51-60
61-70
71-168

28. Step 2: Determine GAF impairment at MMl
• A GAF test score of 61 to 70 (mild symptoms or some difficulty in social,
occupational, or school functioning) elicits an impairment score of 5% (Table
14-10).
Step 3: PIRS rating score
• Table 14-11: 1,Table 14-12: 2,Table 14-13: 1,
• Table 14-14: 2,Table 14-15: 2,Table 14-16: 2.
• Arrange the scores: 1, 1, 2, 2, 2, 2.
• Select the middle 2 scores: 2, 2.
• Sum of middle 2 scores: 4.
• PIRS impairment score (Table 14-17): 10%.
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29. Step 4: List BPRS, GAF, and PIRS impairment
scores
• BPRS impairment score: 5%.
• GAF impairment score: 5%.
• PIRS impairment score: 10%.
• Of the 3 impairment scores, the M&BD impairment
rating is the middle value: 5%.
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30. Thank you
The Guides Sixth Edition AMA
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