By “medical records” I mean treatment progress notes as well as reports that are based on psychological or psychiatric evaluations.
The purpose of this entry is to provide you with a few tips that will help you to evaluate the authenticity of diagnoses found in psychological and psychiatric medical records in disability, worker’s comp and personal injury suits.
Mental disorders are defined by specific criteria which are found in the DSM-IV. Doctors don’t always document the full criteria of the mental disorder they diagnose. I notice this is especially true in psychotherapy and psychopharmacology notes. For instance, a doctor might indicate in the treatment notes that the patient was involved in an accident and presents with nightmares and, on the basis of this information alone, assign a diagnosis of PTSD. Although the patient may in fact meet the full diagnostic criteria for PTSD, the problem is that these symptoms, by themselves, do not meet all the diagnostic criteria for PTSD and the diagnosis can be challenged on that point.
Doctors sometimes draw conclusions that are not supported by their interview or test findings. This is related to point #1. I recently reviewed a report in which the psychiatrist administered a psychological test measuring depression, found the results to be normal, yet, despite this test finding, assigned a diagnosis of depression to the examinee. When there is a discrepancy between test findings and the diagnosis, there should be an explanation for that discrepancy. This doctor did not provide an adequate explanation. I would challenge the credibility of the diagnosis in my written review of these medical records.
Who did the actual psychological testing? Psychological testing, unlike psychotherapy treatment, is the unique skill of clinical and forensic psychologists. Other professionals, even within the field of mental health, rarely conduct psychological tests. Occasionally, other professionals will administer or utilize psychological testing and this will sometimes result in errors in test selection, administration and in the use of the test results. For instance, I was retained by a lawyer to examine an individual and review the reports of two psychiatrists who had previously evaluated the same individual. I noted that one psychiatrist had administered the MMPI-2 test and sent the test sent to a lab for scoring and interpretation. The lab then produces a narrative (text) report. The narrative report from most labs is clearly identified as consisting of “hypotheses” to be tested against the data from the clinical exam. The narrative report does not provide information pertaining only to the individual who took the test and is not considered to be data. The psychiatrist, perhaps unaware of the nature of the narrative report, then incorporated large sections of the narrative MMPI-2 report into his own report. The second psychiatrist read the laboratory produced narrative report of the MMPI-2 test administered by the first psychiatrist, also incorporated large sections of text from the narrative report and did not make it clear that he had not, himself, administered the report. When a professional who is not trained or not well-experienced in the use of a psychological test uses that test, the risk of error in the administration or interpretation of the results of that test is increased.
The expert fails to consider malingering: Posttraumatic Stress Disorder (PTSD) is diagnosed in some disability, worker’s compensation and personal injury claims when the claimant has experienced a stressful event. According to the DSM-IV, malingering must be ruled out in those situations involving financial incentives. Yet, I very rarely see any mention of malingering or an attempt to assess for malingering in psychotherapy treatment notes even when the psychotherapist has diagnosed PTSD and is aware the patient has a legal claim in which PTSD is an issue. More surprising to me is when a psychologist or psychiatrist, conducting an IME within the context of a legal case, fails to mention or attempt to determine if there if exaggeration, faking or malingering. A PTSD diagnosis in a legal case should be challenged if malingering has not be ruled out.
Stuart J. Clayman, Ph.D. is a licensed psychologist who conducts forensic and clinical examinations in disability, worker’s compensation, employee-employer and personal injury claims. Dr. Clayman can be reached at email@example.com or at