Wednesday, April 25, 2007

Some Implications of Failure to Rule out Malingering

I recently conducted a medical records review of a Worker's Compensation in order to determine if the injured worker in fact suffered from PTSD and Pain Disorder as a result of an industrial accident.

There was only one report in the file I was given for review that contained a clinical psychiatric examination of the injured worker. In that report, based on the clinical interview, the psychiatrist diagnosed Posttraumatic Stress Disorder but did not address or rule out the question of malingering. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), malingering should always be ruled out prior to assigning a PTSD diagnosis.

Several months later, the same injured worker was sent to another psychiatrist who conducted a medical records review without a clinical interview. The second psychiatrist agreed with the earlier diagnosis of PTSD and added a diagnosis of Pain Disorder Associated with both psychological factors and a general medical condition.

As a result of the first psychiatrist's failure to rule out malingering, and the second psychiatrist's assignment of a Pain Disorder diagnosis without any assessment of malingering in the file, I wrote in my report that I could not be sure the PTSD or Pain Disorder diagnoses could be substantiated.

The lessons here are as follows:

1. Plaintiff's attorneys should be careful not to accept, without some scepticism, the notion that their client's diagnosis of PTSD is genuine and adequately documented when malingering has not been ruled out. I have written elsewhere that psychological testing rather than interview is needed to rule out malingering. Failure to obtain a clinical exam in which malingering has been ruled out can help to avoid unpleasant surprises at deposition or trial.

2. Personal Injury and Worker's Compensation defense attorneys and insurance companies should require that an assessment of malingering be conducted as an essential element of all psychological evaluations and especially those in which diagnoses such as PTSD and Pain Disorder are alleged. Failure to do so may result in unnecessary awards and benefits for mental disorders that have not be adequately documented.

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