1. family and parenting
2. children

MICHAEL C. HILTON, M.D., PSYCHIATRIST
3975 Roswell Road Atlanta, GA 30342 (T) 404-352-4001 (F) 404-352-4009
NOTE: SAMPLE REPORT (SANITIZED)
INDEPENDENT MEDICAL EXAMINATION REPORT ON
JANE R. SMITH
DATE: May 5, 2002
IDENTIFYING INFORMATION: Ms. Smith is a 49-year-old, black female, referred to this
office for psychiatric examination by Psychiatric Consultants, Inc. on behalf of California Life
Insurance Company. Ms. Smith has a claim of disability that dates back to August 25, 1998. I
have been asked to interview Ms. Smith, perform psychological testing, review records and offer
an opinion with regard to her diagnosis, consistency of complaints over time, consistency of
observed behaviors with self-report, consistency of progress relative to diagnosis, secondary
gain/situational factors, appropriateness of current treatment plan and impairment. The
definition of impairment in her policy is:
“The insured cannot do the substantial and material duties of her regular job. The cause
of the disability must be an injury or sickness.”
Ms. Smith’s occupation at the time of her claim was that of a part-owner of a photography
business (Smith’s Photo Lab). Ms. Smith’s present claim of disability is related to a diagnosis of
Major Depression that has been provided by Drs. Cheryl Moore and Herman Johnson.
CONFIDENTIALITY WARNING: Prior to this psychiatric examination, Ms. Smith was
informed that the interview was not private or confidential and that a report would be sent to
California Life Insurance Company. She was informed that this examination was being
performed to specifically address her disability claim.
RELEASE OF INFORMATION WARNING: This psychiatric examination report should not
be released to Ms. Smith, other than under the supervision of a psychiatrist or a psychologist, as
the information in this report may be detrimental to her emotional health.
SOURCES OF INFORMATION:
I.
Ms. Smith was interviewed in a Psychiatric Examination on May 5, 1999 for 2.6 hours.
II.
Ms. Smith was given psychological testing (Minnesota Multiphasic Personality Inventory
– 2) on May 5, 1999.
III.
Claim Summary and referrals to consulting psychiatrists.
IV.
Claimant’s Forms: Attending Physician’s Statement by Dr. Moore and Attending
Physician’s Statement by Dr. Johnson with insurance letter.
V.
Referrals to Ms. Josephine Cates, MA, RNC; her calls to Dr. Moore; and letter to Dr.
Moore with her response.
VI.
Dr. Moore’s treatment notes, evaluation forms and pharmacy.
VII.
Dr. Fuller’s treatment notes.
VIII.
Confirmation of interview and signed statement.
IX.
Dr. Johnson’s treatment notes.
X.
Description of Insured’s Occupational Duties.
FAMILY HISTORY: There is a history of depression in all three sisters who take
antidepressants and in a maternal aunt who was hospitalized and received ECT. Her mother
possibly had untreated depression, but received Valium from a family doctor. A sister had
problems with alcohol and received treatment. Medically, her father had heart disease and high
blood pressure, both of which run in his family. Her mother had arthritis. Some maternal
cousins had diabetes. There have been no familial incarcerations or legal involvements. No
family members have received disability or worker’s compensation.
Her father, Bob Smith, is 82 years old and was described as in “declining” health, secondary to
heart disease and high blood pressure. He went to school through the sixth grade and in his adult
life worked as a successful photographer. He was described as quiet, reserved and “not a very
forceful type.” He did not have a temper of any kind, but she knew he was angry when he would
have rare verbal outbursts. She described her relationship with him as good, but “not very open”
and added, “He doesn’t understand who I am.” He has been married for the last sixty years to
her mother. They live between St. Augustine, Florida and Savannah, Georgia. She described
their marriage as one in which her mother was the dominant force, but that in later years, her
father has let her mother know when she “steps overbounds.” They have loud arguments at
times, but she denied abuses between them or affairs or separations.
Her mother, Judith, is 80 years old and is in excellent health, other than having arthritis, which
creates difficulties in walking. She graduated from high school and was a co-owner in the
photography business. Ms. Smith described her mother as a difficult person who wants things
done her way and has to have control over situations and other people around her. Her mother
had a temper, which showed itself through putting other people down. At other times, she knew
her mother was angry when she would not speak for days at a time. Her mother has been in her
first and only marriage to Ms. Smith’s father. She did not believe she was closer to one parent
more so than the other.
Ms. Smith is the third of four girls born to her parents. As third born, she felt alone and thought
she slipped through the cracks because her parents were so involved with their business.
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The oldest, Caroline, is 59 years old and has had two years of a college education. She is also a
photographer, but is retired, babysitting for her grandchildren. Her daughter has taken on her
photography business. She is widowed from her second marriage. Ms. Smith said this sister has
done very well in life, but had many difficulties with her first husband who was ill. She also
described him as very difficult and abusive with alcohol. Ms. Smith further said that her sister’s
second husband was similar to her first. She described her relationship with her sister as very
close. She lives in Indianapolis.
Lee Ann is 58 years old and has an associate’s degree, which she received within the last few
years. She is married for the second time and works in sales for her husband’s company (which
job she took over when he became unable to work one year ago). She believed this sister has
somewhat struggled through life, as her first marriage ended over an affair, and her second
husband has had financial problems, declaring bankruptcy twice. She described her relationship
with this sister as one of good friends. She lives in Savannah, Georgia.
Debra, the youngest, is 44 and has two years of a college education. She works as a
photographer in what used to be their parents’ business. Ms. Smith and this sister worked
together for twenty-two years. She is married for the first time to her husband who is a minister
and school teacher. When asked about her relationship with this sister, Ms. Smith said they have
not spoken since she left the business. (She had a difficult time in speaking of her, but was able
to after a few minutes of tearful silence.) She said her sister knew that she had had emotional
problems for many years and asked her to do things she could not do, which she later described
as trying to grow the business. Ms. Smith went on to say that she had become unhappy with her
work and had never gotten used to the process of photography and “all the screw-ups that can
happen.” Ms. Smith began scheduling fewer sittings two years ago, and although she thought
her sister was in agreement in decreasing business, her sister wrote her a letter saying that she
wanted to increase the business and wanted them both to go their separate ways. Ms. Smith sold
her share of the business to her sister in February 1999. She lives in Savannah, Georgia.
PARENTAL BEHAVIORS: When asked if she had been criticized, ridiculed or shamed by
either parent, Ms. Smith stated that her mother’s main objective was to see how much she could
get out of the children. She said her mother did not praise her, and things had to be done her
way. Her mother gave her instructions on everything, which seemed to Ms. Smith like implied
criticism. There was little affection in their household, and she did not have a sense of being
loved or approved of by her parents. She thought she might have been able to receive love from
her father if he had been there more. She did not feel accepted or validated by either parent nor
did she believe either to be available to her, emotionally and physically. She thought her oldest
sister, Caroline, was somewhat available to her. There was structure in the family home, and she
believed it was a predictable environment. She began helping around the house from the age of
5. The family had dinner together, and she had a particular bedtime. In her teens, her parents
were strict with many “dos and don’ts” which Ms. Smith believed was related to their religious
beliefs of the Church of Christ. She did not recall significant separations from her parents, but
felt somewhat abandoned by them and recalled times when they would leave her, either at home,
church or school, forgetting to pick her up. Her parents rarely argued, but when they did, it was
over business. She did not recall battering between them. Ms. Smith’s family had a maid, “Suzy
3
M,” who was with the family from the time Ms. Smith was 4 years old until she was in her late
teens. She worked for the family six days a week and was loving and affectionate toward Ms.
Smith. Ms. Smith’s mother fired her, however, because she had a drinking problem and had
shown up to work drunk.
PERSONAL HISTORY: Ms. Smith was born in Savannah, Georgia on June 11, 1949. She
grew up in the Savannah area. From the time she was 10 years old, her family began their
business out of the same house. Her first move out of the family home was when she was 18
years old and married, but continued to live in the Savannah area, where she has lived all her life.
Ms. Smith was raised in an upper middle class environment and as a child enjoyed climbing
trees, playing house and playing with her friends in the neighborhood. She believed she had
enough friendships as a child and had best friend relationships. She stated she was raised by
“Suzy M.” Discipline was meted out by her mother, who would give her spankings with a
switch, which was not severe. Otherwise, she would retract privileges. When asked about
traumatic childhood experiences, Ms. Smith relayed that she was sexually abused by their
postman for a number of years until the family moved. She reported having full memory of it
throughout her life, but was unable to recall at what age the abuse began. She said he used to
take his penis and rub it against her private areas. She was unable to tell anyone because of her
shame around it. She first told her husband about it twenty years ago. When asked how she
believed that affected her in her childhood, Ms. Smith became tearful and said, “It added to my
loneliness.” When asked about the worst experience in her life, Ms. Smith said that what
happened with her sister was her worst experience, particularly the rejection of her pleas for
help, no one realizing how desperately ill she was and how she was working so hard trying not to
let the family down.
Ms. Smith was in good childhood health and did not have surgeries or hospitalizations. She did
not have problems with bedwetting, speech impediments, nervous tics or twitches or a nervous
stomach. She described herself as a shy child, who was always considered quiet, although she
added that she was not painfully shy. When asked if she knew of the circumstances around her
birth, she stated, “I was the one that gave her back trouble.” She believed she was on time with
her developmental milestones. She did not have significant juvenile behavioral problems, other
than some excess drinking as a teenager.
Ms. Smith graduated from high school. She did not have learning disabilities, special education
classes or failures in grades. She described herself as a good student, who usually made A’s and
B’s. She got along “good” with both peers and teachers. She was never suspended or expelled.
She did not participate extracurricularly, but enjoyed sewing and music classes, as well as took
piano and art classes.
Sexual interest developed around the age of 19, with her first sexual involvement at that same
age with a boy her same age. She is entirely heterosexual in her interests. She has had
approximately eight sexual partners in her lifetime. She has had three serious relationships in her
lifetime and has had no affairs during her marriage. Ms. Smith has had sexual difficulties for
many years, having little interest in sex.
4
When asked if she had been verbally or emotionally abused in her lifetime, Mr. Smith said that
her first husband was abusive and had tried to be physically abusive with her, but she stood up to
him. She said he was “into drugs” and “skipped out” when he did not want to be home, so that
he could be with his buddies. She added that her current husband is verbally abusive in that he
has a hard time expressing himself and flies off the handle easily. When they were first married,
he would throw things or put his fist through the wall and curse her. She went on to say he was
an untrusting person, who was always assuming or thinking that she was having an affair. She
denied having been physically abused in her lifetime. She was, as aforementioned, sexually
abused by the postman.
Ms. Smith is married for the second time. Her first marriage was at the age of 18 to Joe, who
was five years older. They were married for three years, and he worked in her family’s business.
They split because he was unfaithful, and Ms. Smith said she was unable to deal with that
anymore. She said he also drank daily and smoked marijuana. They were separated for a few
months, and then she began a relationship with her now-husband, Jimmy, whom she dated for
seven months. He is one year younger, has a high school education and has worked in yard
maintenance for the last five years. Prior to that, he sold tractor equipment, and before that, he
was in business with a photography lab and portrait department, which he sold. She described
her husband as a very caring person, who was lovable, had a good sense of humor and was
outgoing. When asked about their relationship, Ms. Smith stated, “It’s very close now,” and she
explained that it has evolved over the last few years. She said prior to that, it was turbulent
because they were both fighting against each other. She said her husband had a hard time
expressing himself, and she also held things in. She believed since then, they have both grown
up, and he has become more trusting.
Ms. Smith and her husband have two children together. Marci is 24 years old and graduated
from college. She works as a pharmaceutical representative. She is single, never having been
married and does not have children. Ms. Smith said that this daughter has had a hard time
figuring out what she wants to do with her life. Three or four years ago when she was engaged,
she dropped out of school. Ms. Smith and her husband thought that her boyfriend was verbally
abusive, and they had fights about that relationship. More recently, she had been living with a
boyfriend, but had a difficult time in that relationship. She moved back in with Ms. Smith and
her husband a few months ago. She did not have juvenile behavioral or academic problems.
Bo is 20 years old and is in his second year of college. He works with their family’s yard
maintenance business. He is attending the Savannah School of Arts and was described as
“happy.” He was impulsive as a child and was diagnosed with Attention Deficit Disorder. He
tried medications for a while, but did not take them for long. She reported he has been doing
“good overall.” She reported a good relationship with both children and did not believe herself
to be an irresponsible parent in any way.
Ms. Smith is not a veteran.
Her first job was in at the age of 14, working for the Photo Lab that was jointly owned by her
oldest sister, her husband and their parents. She worked there full-time after school and until she
was 24 years old. She then began working in her parents’ photography studio that was solely
5
owned by her parents. She worked there for twenty-two years. Ms. Smith and her next youngest
sister bought their parents out of the business fifteen years ago. Ms. Smith went out of work on
August 23, 1998 and has not worked since. She sold her share of the business to her sister in
February 1999. As aforementioned, Ms. Smith had a difficult time for many years in the
business and began to suffer from anxiety fifteen years ago. She also had problems with
sleeping. Approximately five years ago, she began to have depressive symptoms as well. She
usually worked a four-and-a-half day work week and generally worked thirty-six hours a week,
forty at the most.
Ms. Smith described her current state as her longest period of unemployment. She has never
received unemployment benefits. She has never been fired from any positions.
Ms. Smith has never been injured on the job or received worker’s compensation. She described
herself as a very hard worker and denied having problems with co-workers. She applied for
Social Security Disability in March 1999, which is pending.
LEGAL HISTORY: Ms. Smith has never been arrested, had DUI’s or convictions of any kind.
She has a current Georgia driver’s license, which has never been suspended or revoked. She has
had two speeding violations in her lifetime for which she paid fines. She has never been
involved in a motor vehicle accident.
Ms. Smith denied having problems with lack of truthfulness, aggressiveness or impulsivity. She
does not consider herself to be financially irresponsible nor has she had credit card problems.
She has never filed for bankruptcy.
PRESENT LIVING SITUATION: Ms. Smith lives in Randolph, Georgia in a home she and
her husband have been buying for the last fourteen years.
She has religious beliefs in God and is a member of the Church of Christ. As a child, she
attended three times a week, twice on Sunday and on Wednesday. She said she has not been able
to “emotionally handle” going to church for the last couple of years.
Socially, she and her husband go out to eat once a week or go to the movies two or three times a
year. They go to their friend’s house two or three times a year. She did not know of other social
activities. She considers her support system to be her family, including her children, her husband
and two of her sisters.
Daily, Ms. Smith gets up around 9:00 or 10:00 AM. She writes in her journal every morning,
usually for about an hour. She is able to do light housework, but said she does not have the
energy or stamina to do all of it. They have a housekeeper who helps. During the day, she might
go out on errands, but stated she does very little shopping. She said she has begun taking a
weekly pottery class. She also gardens from time to time. She usually rests every day, but does
not take naps. She reads a lot of novels. In the evening, she sits with her husband, watching
television or a movie. She goes to bed around 11:00 PM.
6
Ms. Smith began receiving disability benefits in February 1999. She has two different policies
from which she receives $2600 a month. When she was working, she made approximately
$2600 a month. Her husband has an income of $50,000 to $60,000 a year. They have no other
source of income.
When asked about future plans, Ms. Smith stated, “I’m just trying to get well and feel better. I
don’t have any energy to do anything.” When asked specifically about her ideas of a return to
work, she stated, “I would like to feel like I could work eventually – that’s what gives you
meaning in your life.” When asked how she would know she is ready to go back to work, she
stated, “When my mind doesn’t feel so confused, and my attention is more than a few minutes,
when I can remember things and I am not as depressed.”
SUBSTANCE USE HISTORY: Ms. Smith does not smoke cigarettes. She stopped a pack-aday habit eighteen years ago. She has one or two glasses of wine every night throughout her
adult years. She denied a period of time in her life when she drank more or regularly. She has
never experimented with or abused illegal drugs of any kind nor has she abused prescription
medication. She has never been involved in a detoxification or rehabilitation program.
MEDICAL HISTORY: Ms. Smith suffers from hypertension that has been diagnosed in recent
years, and hypothyroidism that was diagnosed a few weeks ago. Previous operations include:
(1)
(2)
cervical conization five years ago
removal of a benign mole from her breast twelve years ago
She has had no significant hospitalizations. She is allergic to Premarin. She has had no sexually
transmitted diseases. She has had no head injuries with loss of consciousness or history of
seizures. Medications at present include:
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Synthroid (dosage unknown) taken for the past month, prescribed by Dr.
Christopher
Cozaar 50 mg every morning taken for her blood pressure for the past ten months,
prescribed by Dr. Jones
Flonase nasal spray daily, prescribed for the past year by her children’s
pediatrician, Dr. Peters
Estrace 1 mg daily takes twenty-five days out of a thirty-day period for the past
year, prescribed by Dr. Fuller
Provera 5 mg taken ten days out of a thirty-day period for the past four years,
prescribed by Dr. Fuller
Xanax 0.25 mg taken two to three times per day for the past fifteen years,
prescribed by Dr. White (psychiatrist)
Serzone 150 mg twice a day, prescribed for the past month by Dr. White
PSYCHIATRIC HISTORY: Ms. Smith was initially prescribed antidepressants by Dr. Fuller
(gynecologist) four-and-a-half years ago. He initially prescribed Zoloft, which she took for a
year-and-a-half. She then went off it for a few months and then started Prozac, which she took
for a couple of years.
7
In December 1997, Ms. Smith began seeing Dr. Cheryl Moore (psychologist), initially on a
weekly basis, and then after six months approximately once or twice a month. She then stopped
seeing Dr. Moore in June 1998 and started seeing her again in August 1998.
In August 1998, Dr. Moore recommended that Ms. Smith see Dr. Herman Johnson (psychiatrist).
She saw him on two or three occasions through December 1998. During this period, he started
her back on Prozac and also prescribed Xanax. She then decided that she does not like Dr.
Johnson because he did not spend enough time with her. She then started seeing Dr. White on
referral from Dr. Moore in March 1999. She was subsequently prescribed Wellbutrin, which she
took for three weeks, which was then switched to Serzone. She has seen Dr. White two or three
times since March 1999.
HISTORY OF PRESENT ILLNESS: Ms. Smith has been a part-owner in a family-run
business (Smith’s Photo Lab). She and her sister purchased this business from her parents fifteen
years ago. Prior to purchasing the company, she worked for her parents for seven years. This
company is a portrait business, and she has worked in all roles, including sales, photography and
development of film. Ms. Smith sold her interest in this company to her sister in February 1999.
She has no plans of returning to work for or with this company.
Ms. Smith’s depressive problems have been present for five to six years. She began taking
medications four-and-a-half years ago, when she found herself extremely unhappy and anxious.
She began dreading her work. She wanted to kill herself. She said it was all the “unknown”
aspects of work that were stressful. She had always been concerned with the outcome of her
work and often felt that her work was overscrutinized by her customers and her sister. She said
pressure and stress were always there, and that knowing what her problem was did not seem to
make it any better. She continued to get worse.
Ms. Smith said she and her sister got along well until the end. Her sister knew of her depression.
During the Christmas season of 1997, Ms. Smith described it as a bad season. Things were
extremely busy. One day, she had a traumatic sitting with a black family that manipulated them
into staying late. Following that sitting, Ms. Smith and her sister decided to cut back on their
hours, but in the spring of 1998, things seemed to get busy again. Ms. Smith said she was not
able to handle it. For four to five months, every sitting was filled.
In late July 1998, Ms. Smith said she collapsed one night. She said she was “totally out” and
could not be awakened. She was taken to the emergency room, where her blood pressure was
initially very low, but then gradually returned to normal. Ms. Smith was sent home and took the
next two days off. Following that, she took the next week off, as it was a scheduled vacation.
When she returned from her vacation, she said she still felt exhausted. One week later, she
received a letter from her sister, indicating that she would have to increase her sittings and that
her sister wanted a professional separation in two years.
Ms. Smith described this as a very painful experience. She was very hurt by it and said her sister
knew of her emotional state, and yet it did not matter. She also said her sister could not express
her feelings or talk with her about it. Ms. Smith broke down while taking pictures one day and
8
added, “I couldn’t do it anymore.” She told her sister she could not comply with her demands of
more sittings. At that point, Ms. Smith started back into therapy. (Ms. Smith had been in
therapy from December 1997 through June 1998.) She returned to therapy in August 1998 and
also focused her attention on medication management. She has continued in counseling and has
continued to take medications through to the present.
On August 23, 1998, Ms. Smith filed for disability. She had a three-month waiting period, and
on November 23, 1998 began collecting on her California Life policy ($2600 per month
nontaxable). Her income prior to her disability had been $2500 per month.
In February 1999, her sister bought out Ms. Smith’s share of the business. Ms. Smith believes
she has lost a lot. She lost her sister and friend, and she lost her life’s work. In the buyout, her
sister gave her some assets, a life insurance policy and camera equipment. Her sister took over
the debt. There was no cash exchange. Her sister now works by herself.
In August, when her sister informed Ms. Smith that she planned to terminate their professional
relationship in two years, Ms. Smith said she wanted to die. Her mood got worse. She had
emotional ups and downs she described as “like a roller coaster.” She has also had frustrations in
dealing with her insurance company. There has been the uncertainty of not knowing from month
to month about her income. She is worried about her future. She said, “I’m not capable at this
time. I can’t hold a train of thought.” She said she feels lost and confused when she tries to go
into town. She does not see herself as capable of retraining at this time and complained of “lots
of wounds.” She said she does not ever want to feel trapped again. She would like to own her
own business, but does not want to return to photography. She said she is good at coordinating
things, especially “beauty wise.” She may go into home décor or possibly an art field. She does
not want to have to be responsible for pleasing people. Other symptoms that have been present
have included extreme tiredness, achiness and a sore throat. Her relationship with her mother
has also been stressed. It has never been good, but has been worse in recent times. The financial
stress has also aggravated her depression.
MENTAL STATUS EXAMINATION: This was a nicely dressed, well-groomed woman, who
walked with a normal gait. She exhibited a helpless appearance. She appeared sad and tearful at
times and was very passive. She was, however, cooperative and responsive during the interview.
Rapport was thought to be fair to good. Eye contact was thought to be fair to good. She
appeared calm. There was no psychomotor agitation or retardation. Her speech was of a passive
tone, but of a regular volume and rate. There was no thought disorder. She complained that she
would like to disappear. She admitted to feeling helpless and hopeless, but still enjoys her hobby
of pottery. She said she was always a workhorse in the past. At the present time, however, she
feels overwhelmed and unhappy. She feels anxious. She tires easily. She has trouble falling
asleep. Her appetite has been unaffected. Her weight has been the same for the most part, but
she has gradually gained a few pounds each year over the past few years. Her sex drive has been
very low for a number of years. She said she cries approximately once a day. She sees her
concentration and attention as distractible. Her memory was described as very poor.
Objectively, there appeared to be no clear problems in this area. She complained of occasionally
seeing things out of the corner of her eye, but did not appear to be suffering from any
hallucinations or delusions. She denied obsessions, compulsions or phobias. She denied
9
homicidal thoughts. She said at times that she wished she were not alive. She said she tried to
kill herself as a teenager. She occasionally thinks of methods of how she would do it. In the
past, she has thought that she might “drive up under a semi.” Her sense of self-esteem was seen
as low. Her sense of self-identity was seen as poor. Her motivation for returning to employment
at the present time was seen as poor.
PSYCHOLOGICAL TESTING: The MMPI-2 validity scales indicate that this lady is
exaggerating her report of psychological symptoms to such a degree that the clinical profile does
not appear to be valid. The Supplementary Scales and Content Scales also are invalid due to
what appear to be a careless and exaggerated approach to items in the latter part of the test. She
is certainly claiming more psychological symptoms than most patients do, and this may be due to
efforts to gain attention or treatment. Sometimes an individual involved in litigation will
produce this exaggerated clinical scale profile in order to win the case. In any event, the clinical
profile cannot be considered a valid estimate of her current state since it is so exaggerated.
The clinical profile is quite exaggerated, as indicated by her validity scale responses. She is
claiming marked depression, multiple somatic complaints and marked anxiety, as well as a
strong tendency to develop physical symptoms under minimal stress. She is also reporting that
she is an isolated, introverted woman who is suspicious of others and feels that she will be
victimized. In effect, what she is doing is admitting to a myriad of psychological symptoms,
exaggerating them to a significant degree, and attempting to present herself as a very disturbed
woman who is in considerable distress. Since the clinical profile is likely invalid, a clinical
interview is necessary to determine what her current psychological state is and to ascertain why
she is presenting such an exaggerated self-presentation on the MMPI – 2.
REVIEW OF RECORDS:
I.
Claim Summary and referrals to consulting psychiatrists.
There is a letter to Dr. Kenneth Richards dated March 3, 1999 from Monica Jessup. In this letter,
Ms. Jessup indicated that Dr. Moore had suggested to Ms. Smith that she should quit her job as a
photographer because it made her very depressed. Dr. Moore had subsequently recommended
that Ms. Smith was totally disabled as of August 25, 1998 from working because of her
depression. Ms. Smith had complained prior to going out on disability that she felt trapped into
working at a job she did not like in order to survive financially. Ms. Smith had been described as
overwhelmed in her personal life. She was not assertive with her mother, her sister or her
husband. Ms. Jessup’s review of Dr. Johnson’s records indicated that his opinion was in contrast
with Dr. Moore’s and that Dr. Johnson had never certified the insured as totally or partially
disabled. Dr. Johnson’s impressions were that the insured did not suffer from a major mental
illness. He did, however, prescribe Prozac and saw the prognosis as good. Ms. Jessup’s concern
was that the claimant was not totally disabled as per the policy definition, as burnout was not
considered a medical illness. It was recommended that Dr. Richards review the records to assess
for disability and also for vocational rehabilitation potential.
On March 23, 1999, Dr. Richards responded, noting that there is no occupation that per se
“causes mental illness” and that Ms. Smith had been in the field of photography for twenty-two
10
years without becoming depressed. In the Attending Physician’s Statement, it described Ms.
Smith’s own distaste and resultant stress from the aspects of the business. “To stop a situation is
called life enhancement.” Dr. Richards noted that the treating psychiatrist had been aware of the
depressive problems, had treated with an antidepressant, but did not note any limitations. Dr.
Richards’ impressions were that the claimant’s restrictions not to return to her former occupation
were solely life enhancement issues to deal with her burnout and chronic dislike for her former
occupation.
On March 31, 1999, Ms. Jessup wrote back to Dr. Richards, informing Dr. Richards that Ms.
Smith had, indeed, been taking Xanax since 1989 and had been taking Zoloft for a number of
years as well. It was recommended that Mr. Smith see a forensic psychiatrist for further
assessment.
On April 12, 1999, Dr. Richards responded to the idea of a psychiatric assessment by suggesting
a psychiatrist assess the issue of burnout, alternative forms of photography and what specifically,
if anything, was impairing Ms. Smith’s return to work in photography.
II.
Claimant’s Forms, Attending Physician’s Statement by Dr. Moore and Attending
Physician’s Statement by Dr. Johnson with insurance letter.
On November 9, 1998, Dr. Johnson completed an Attending Physician’s Statement, listing a
diagnosis of Depressive Disorder NOS (311.00). He indicated Prozac and Xanax were being
prescribed. The symptoms had begun prior to August 31, 1998, when Ms. Smith was examined
and that she was still under his care at this time, with her last visit having been on October 5,
1998. He indicated that there were no work restrictions present.
There is a Proof of Claim Form that was completed by Ms. Smith on November 23, 1998, listing
her employer’s name and address, her illness as depression and anxiety, and her symptoms as
having been present for four years. She listed her various treating physicians and her
occupational duties, which included being responsible for all photography of children and family
groups, involvement in talking to customers about their needs, setting up photo sessions, talking
to and entertaining children, positioning lighting, and developing composition of photographs.
She was also responsible for paying bills, dealing with negatives, answering the phone and
booking appointments. She was earning $675 weekly when her disability began. She indicated
that photography was the only work she had ever done.
In an Attending Physician’s Statement by Dr. Moore on December 2, 1998, Dr. Moore listed a
diagnosis of Major Depression with medications including Prozac and Xanax. She
recommended that Ms. Smith avoid working as a photographer due to the stress and anxiety that
it caused. She indicated that she had, indeed, referred her to Dr. Johnson for psychiatric
treatment and that her disability was from August 25, 1998 through to the present. Dr. Moore
also indicated that Ms. Smith would not be able to return to work as a photographer.
There is a letter to Mona from Ms. Jennie Smith dated February 13, 1999 in which she indicated
that she had mistakenly sent the disability forms to Dr. Johnson and meant to send them to Dr.
Moore, that Dr. Johnson had been seen for medication management only and that he did not
11
spend much time talking with her. She complained that she was still very limited in her
capabilities, was easily confused and forgetful. She complained that she was not able to perform
the only job she had ever been trained to do, that it was more than burnout and that, indeed, it
was severe depression and anxiety.
On February 26, 1999, Ms. Smith completed a disability application, indicating the nature of her
sickness was depression and anxiety and that Dr. Cheryl Moore and Dr. Herman Johnson were
treating her. She listed other physicians she had seen and indicated that she was not working at
the time of this application and that her daily activities consisted of sleeping, reading, light
housework, some shopping and walking for exercise. She said she was unable to concentrate for
long periods of time and had trouble with disorientation, confusion and depression.
Dr. Moore completed the medical provider’s statement on March 4, 1999, indicating a diagnosis
of Major Depression, with treatment consisting of individual therapy and recommendations that
she remain in a less stressful environment. It was suggested that she had been unable to work
from August 25, 1998 through to the present.
III.
Referrals to Ms. Josephine Cates, MA, RNC, her calls to Dr. Moore, letter to Dr.
Moore and her response.
There is a notation from Ms. Jessup dated February 5, 1999, listing basic information about Ms.
Smith, including her depression, information on her business and her income.
On February 10, 1999, there is a case notation from Ms. Josephine Cates (registered nurse),
listing a telephone conversation with Dr. Moore to discuss Ms. Smith’s limitations (burnout vs.
Major Depression). Dr. Moore had indicated that Ms. Smith was still suffering from all
symptoms of clinical depression and continued to recommend that she not return to photography.
She had acknowledged that Ms. Smith was suffering from burnout and that even if her
depression were to resolve, she would not choose to return to photography. Dr. Moore
recommended six more months of therapy. Attempts to talk with Dr. Johnson were
unsuccessful. The secretary noted that Dr. Johnson had completed forms in November,
indicating that Ms. Smith was not disabled. A copy of this form was faxed to Ms. Cates.
On February 10, 1999, Ms. Cates wrote a letter to Dr. Moore, thanking her for her time and for
discussing Ms. Smith’s situation and asking that she sign a form acknowledging the
conversation.
On February 23, 1999, Dr. Moore responded to Ms. Cates’ letter to say that the summary of the
conversation was not entirely accurate, indicating that the phrase “burnout from her career” was
incorrect. Dr. Moore’s impressions were of a clinical depression, and she continued to
recommend that Ms. Smith not return to work as a photographer.
IV.
Dr. Moore’s treatment notes, evaluation forms and pharmacy.
These records indicate that Dr. Robert Carpenter prescribed Xanax and Zoloft to Ms. Smith in
August 1993 and that Dr. Fuller prescribed Prozac in January 1997.
12
Treatment notes from Dr. Moore begin on December 3, 1997 with an initial diagnostic interview.
Ms. Smith complained of bouts of depression throughout her lifetime that had worsened with
age. She attempted suicide as a teenager, and she had had suicidal ideations off and on for years.
She had taken Prozac through her medical doctor (Dr. Fuller). Ms. Smith acknowledge that as
long as things were running smoothly, she did okay, but when things became stressful, she would
get very tense and anxious.
Ms. Smith was subsequently seen for several months. On December 17, 1997, she
acknowledged feeling overwhelmed, complained that she felt more artistic and also felt trapped
into working at a job that she did not like in order to survive financially.
On January 15, 1998, Ms. Smith said she was feeling much less overwhelmed. Family
relationship difficulties were discussed, and the issue of assertiveness was addressed. Ms. Smith
then missed a couple of appointments and was seen on March 2, 1998. They discussed her
childhood history of molestation by the family gardener. On March 11, 1998, Ms. Smith missed
her appointment. On March 23, 1998, she said she had been doing better. She was working on
assertiveness with family members. On April 20, 1998, she was feeling a little overwhelmed
again and acknowledged good days and bad days. She was having problems with her mother
and felt manipulated. They discussed her perfectionistic tendencies. On April 20, 1998, Ms.
Smith rescheduled. On May 18, 1998, Ms. Smith said she could not continue counseling due to
financial concerns. She did, however, want to continue to explore her own creative side and
learn more about what she wanted to be and who she wanted to be. It was agreed that therapy
would be discontinued.
On August 26, 1998, Ms. Smith’s sister called Dr. Moore, complaining that Ms. Smith had had a
panic attack and had left work without telling family members where she was going. Family
members were concerned about Ms. Smith’s safety. Later, family members called to tell Dr.
Moore that Ms. Smith was safe.
On August 28, 1998, records were transferred to Dr. Johnson’s office at Ms. Smith’s request.
Ms. Smith called and said she was safe and not thinking about suicide. She said she was happy
about quitting her job, but was uncertain about beginning counseling again because of financial
concerns. Ms. Smith asked Dr. Moore to write a letter on her behalf to the insurance company,
stating that much of her treatment was centered around work-related issues. Later, Ms. Smith
requested that Dr. Moore hold off on that letter.
On September 10, 1998, Ms. Smith started therapy again with Dr. Moore. She complained of
feeling overwhelmed and scared because she had quit her job. She was planning to sell her
house. She had financial worries and felt that her whole life was changing. Ms. Smith
acknowledged that she and her sister had been having disagreements over a number of issues
involving the business and that her sister had responded too aggressively.
On September 21, 1998, Ms. Smith was seen again. They discussed her grief over the loss of her
role as a photographer, something she had done for over twenty years. They discussed old
resentments.
13
On October 5, 1998, Ms. Smith was continuing to deal with feelings and the issue of
assertiveness. Ms. Smith also brought up the details of selling her share of the business to her
sister.
On October 20, 1998, Ms. Smith was encouraged to focus away from negative thinking. Family
relationship issues were discussed, and it was noted that Ms. Smith had learned that she might be
able to get disability if Dr. Moore or Dr. Johnson would certify it.
On November 2, 1998, Ms. Smith indicated that her depression was easing. She and her husband
were communicating better.
On November 16, 1998, Ms. Smith cancelled her appointment, indicating that things were going
“okay.” She was, however, concerned that Dr. Johnson had not filled out her disability papers
adequately. She asked Dr. Moore to review the papers and fill them out.
On December 2, 1998, Dr. Moore indicated that she had filled out the disability papers for Ms.
Smith. On December 30, 1998, Ms. Smith was seen again. She indicates that the business sales
negotiation with her sister was going well.
On January 15, 1999, Ms. Smith indicated that she was back on her Prozac.
In an “Evaluation Form” completed by Dr. Moore dated January 11, 1999, she described Ms.
Smith’s major depressive condition, her previous hospitalizations at the Candler Institute (two
hospitalizations in 1967) and then described her symptoms and her current treatment. She
suggested that Ms. Smith should discontinue working as a photographer and explore other
options. On the Hamilton Depression Scale, Ms. Smith scored 21.
V.
Dr. Fuller’s treatment notes.
These records indicate general medical care from 1994 through to the present and document
prescriptions for Zoloft and Xanax, dating back to at least September 1994. Later, the Zoloft
was changed to Prozac.
On July 31, 1998, Dr. Paris examined Ms. Smith for a vasovagal type syncopal spell. Her blood
pressure was noted to be elevated. It was felt that her vasovagal response was a combination of
volume depletion and diarrhea. On August 28, 1998, she was seen again by Dr. Paris with
complaints of hypertension and depression. It was recommended that she see Dr. Herman
Johnson and that she continue on her Prozac and Xanax.
VI.
Confirmation of Interview and signed statement.
In the Confirmation of Interview Form completed on January 9, 1998 by Ms. Smith, she
described her responsibilities and her daily activities. She described her depressive and anxiety
symptoms that had been developing over the past four years and the treatment she had received
by Drs. Fuller, Moore and Johnson.
14
There is a signed Investigative Statement that was completed by Research Service Bureau, Inc.,
dated January 19, 1999. These investigators visited Ms. Smith and obtained a detailed history of
the circumstances surrounding her disability.
VII.
Dr. Johnson’s treatment notes.
There are four treatment notes from Dr. Johnson dated September 9, 1998; October 5, 1998;
December 30, 1998; and March 24,1999. The first progress note in September indicates good
and bad days. She had not been taking her Xanax, but had been taking her Prozac. Dr. Johnson
indicated there was still conflict and stress present involving the family business. On October 5,
1998, Ms. Smith was described as appearing stable. She was sleeping well and less anxious, but
was still facing conflict. On December 30, 1998, she complained that she was still unable to do
photography. She was continuing her medications and continuing her treatment with Dr. Moore.
On March 4, 1999, she failed to show up for her appointment.
In an undated letter, Dr. Johnson summarized his care of Ms. Smith, noting that her depression
and anxiety had been precipitated by financial and family stress. She had become increasingly
dysphoric and had difficulties with concentration and her abilities to cope with stress, especially
photographing children. She was seen as dissatisfied with her present condition, namely her
unemployment, and her inability to photograph children. She was continuing in individual
counseling with Dr. Moore. Dr. Johnson indicated no gross impairments and stated:
“Patient is certainly capable of obtaining employment elsewhere in the economy. It appears that
the patient is emotionally not able to return to her former employment.”
Diagnosis was of a Depression NOS, Anxiety Disorder NOS, and on Axis II, diagnosis was
deferred.
VIII. Description of Insured’s Occupational Duties.
In this form completed by Ms. Smith, she described her various responsibilities, which included
thirty hours of photography work, two hours of masking negatives, one hour of checking in
orders, a half hour of bill paying and two-and-a-half hours of sales, telephone and bookkeeping
work. Instruments used included cameras, lights, boxes and props, power packs, cords and
tripods. Responsibilities included constant bending and reaching, as well as constant use of
speech, hearing, sight and hands. The capacity to handle stress, time deadlines, personal
competition and interaction with people was listed as constant. Ms. Smith complained that for
several years she had been having increasing difficulty in her work because of depression and
anxiety and that her work had also been aggravating her depressive problems and anxiety.
DIAGNOSIS:
Axis I:
Clinical disorders:
(1)
Dysthymic Disorder.
Axis II:
Personality disorders:
(1)
Personality Disorder NOS with Dependency
15
issues, Self-Esteem issues and Emotional
Volatility.
Axis III:
Physical disorders:
Axis IV:
Psychosocial and
environmental stressors:
Axis V:
(1)
(2)
Self-reported history of hypertension.
Self-reported history of hypothyroidism.
(1)
(2)
(3)
(4)
(5)
Problems with primary support group.
Problems related to social environment.
Occupational problems.
Economic problems.
Problems related to interaction with the legal
system (disability application).
Global Assessment
of Functioning:
65 (current).
DISCUSSION AND OPINION: Ms. Smith grew up in an environment in which she felt
unloved and unsupported. There is a strong family history for depression and to a lesser extent a
family history of alcohol problems. Growing up, Ms. Smith felt she “slipped through the cracks”
and “felt somewhat abandoned.” Ms. Smith was sexually molested as a child on a number of
occasions by the postman. As an adult, she has been involved in two abusive marriages. At the
present time, her second marriage appears to have improved, as she now sees him as more
supportive and emotionally available. Ms. Smith’s work history is notable for having spent all of
the past twenty-two years working in the family business. After an argument with her sister in
August 1998, she quit the business and subsequently sold her share of the business to her sister.
She has not spoken with her sister since then and still feels very hurt and rejected by this sister.
After quitting the business and while in the process of negotiating the sales of her shares of the
business, she filed for disability. She has subsequently been collecting $2600 per month, which
is actually greater than her income prior to going out on disability, as her present income is equal
to the income she was earning and is tax-free. She has also applied for Social Security
Disability. This application is still pending.
Psychological testing indicates that her profile is probably invalid due to an exaggerated
approach to the testing. This test-taking approach is often found in litigation. The results of this
testing suggest a marked focus on depression, somatic complaints and anxiety with tendencies of
developing physical symptoms under minimal stress and of seeing herself as victimized.
Review of records indicates that Ms. Smith has had problems with depression that date back a
number of years. She first appears to have had problems during her teenage years when she
attempted suicide by overdosing on medications. She has been on antidepressants now for
several years, but has only been actively involved in treatment since she quit her job. She did go
into counseling briefly in the nine months before she quit her job, but then terminated that
treatment three months before she quit her job because of financial concerns. Treatment records
indicate depressive problems that revolve around family stress, low self-esteem and to a lesser
extent job stress. In November 1998, Ms. Smith went to her psychiatrist for assistance in
16
obtaining disability. When her psychiatrist failed to support her in her disability claim, she
sought out assistance with her disability application through her psychologist and changed
psychiatrists. Her psychologist has been very supportive in suggesting that Ms. Smith should
seek employment elsewhere and that she is disabled from working as a photographer. Dr. Moore
would suggest that her condition is compatible with that of a Major Depression, while Dr.
Johnson (her initial treating psychiatrist during the fall of 1998) has suggested her condition is
more stress related.
Psychiatric examination in this office indicates that Ms. Smith has suffered a significant blow to
her self-esteem as a result of the dispute she has had with her sister. She feels rejected and to
this date has not spoken with her. Ms. Smith also acknowledged problems handling stress at
work, particularly dealing with individuals and maintaining customer satisfaction. Ms. Smith
now has no job to return to, as she has sold her interest in this business. She is also very
resentful toward her sister and former business partner. Her behavior and complaints during the
examination were more consistent with that of an Adjustment Disorder and chronic depression as
opposed to a Major Depression. Her progress and treatment have not been consistent with the
diagnosis of a Major Depression, but rather that of chronic depression (Dysthymic Disorder) that
has been complicated by personality disordered vulnerabilities, involving invalidism behavior,
resentment and entitlement. There also appear to be some secondary gain issues present in that
she is presently making more money than she was making when she was working. Her current
treatment plan has not been aggressive enough in addressing her invalidism behavior.
It is my opinion that Ms. Smith is capable of performing the substantial and material duties of
her job as a photographer and photography shop owner. The primary roadblocks in terms of her
resistance are:
(1)
(2)
(3)
(4)
(5)
the lack of a job to return to
the ongoing conflict she has with her sister and former co-owner
invalidism behavior
secondary gain issues, including increased financial compensation for continued
disability
her chronic depressive problems (Dysthymia) complicated by personality
disordered vulnerabilities involving low self-esteem, dependency and entitlement
Ms. Smith’s resistance to returning to work in the photography business is not one of disability,
but rather a choice involving quality of life issues and a dissatisfaction and dislike for her work
environment and business partner.
____________________________________________
MICHAEL C. HILTON, M.D.
PSYCHIATRIST
17
MCH:jsc/SmitIME