Essentials of a High Quality Psychological or Psychiatric Report
Wednesday, January 16, 2013 | 0
For some time now I have been writing newsletters about flaws that can be found in psychological and psychiatric reports that have been written in the context of workers’ compensation and personal injury litigations. Now I think it’s about time to write something about what should be in a high quality psych report.
In order to understand what should be there, it is necessary to consider how the doctors arrive at their conclusions. Essentially, the cornerstone of any psychological report is the doctor’s diagnosis. If that diagnosis is not supported by the data found in the report then two things are true. First, the report is substantially or significantly flawed. Second, all the conclusions that flow from a correct diagnosis, such as those about temporary or permanent psychiatric disability, the need for psychological or psychiatric care, and the extent of the patient’s disability, are also unsupportable.
Now the key question becomes, “What data should be in a report to support the doctor’s diagnosis?” Essentially, psychological diagnoses utilize as many as five different sources of information. All but the last, collateral sources of information, should appear in each report. These sources are:
- The patient’s life history and their presenting complaints or symptoms.
- The doctor’s report of their Mental Status Examination.
- The psychological testing data.
- A review and discussion of the patient’s medical records.
- Collateral sources of information.
These five potential sources of information are used to arrive at a DSM-IV-TR diagnosis. It is a relatively simple process to determine if a diagnosis is correct. The DSM-IV-TR is a very straightforward and easy to understand manual. It is written in English and you do not have to be a psychologist or a psychiatrist to understand its contents. But you must have a copy. The hardbound version can be bought for about $85, the softcover for about $25 and a Kindle version for $.99. The wonderful thing about the DSM-IV-TR is that for each of the disorders there is a very clear set of criteria that must be met. For example, in order to diagnose any form of a Major Depressive Disorder correctly the doctor must present evidence that the person has at least five of the nine symptoms as well as either symptom 1 and/or symptom 2. These nine symptoms are found on page 356 of the DSM-IV-TR and presented below.
1. Depressed mood, most of the day, nearly every day.
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.
3. Significant weight loss or weight gain when not dieting or a decrease or increase in appetite, nearly every day.
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day.
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt nearly every day.
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day.
9. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt, or a specific plan for committing suicide.
A credible psychological report shows very clearly that the person receiving the diagnosis of a Major Depressive Disorder (or which ever diagnosis was given) meets the diagnostic criteria. To determine if a report diagnosing a Major Depressive Disorder is credible one needs only to sit down with a copy of page 356 taken from the DSM-IV-TR and the doctor’s report and start by turning to the section that discusses the doctor’s description of the patient’s life history and their presenting complaints. If the diagnosis is credible, it will be obvious that the doctor has specified the complaints that indicate that the patient had at least five of the nine symptoms. In doing so, the doctor will not just simply list those symptoms but will provide information about their qualitative nature as well as their frequency, intensity, duration, onset and course over time that were given to them by the patient. Once you’ve determined that this has been done, you can move onto the next set of data, the doctor’s report of their mental status examination.
A Mental Status Examination produces a set of observations of the patient that are made by the doctor under reasonably controlled conditions employing a relatively standard set of examining techniques and questions in the context of a face-to-face interview. If a patient is truly suffering from a Major Depressive Disorder you can expect the doctor to describe the specific observations they observed during this portion of their evaluation. In this regard, the doctor’s report should describe the patient’s orientation i.e., did they know where they were; their appearance; their mood; their memory; their attention or concentration, their ability to think and perform a variety of cognitive tasks, the presence or absence of evidence of a major psychological disorder such as Schizophrenia with such observable signs as delusions and hallucinations; their ability to function in the interview, and their social behaviors. Individuals who are clinically depressed will be observed as showing at least some of the following behaviors:
In talking about themselves, their feelings, their thoughts and their behaviors they will reveal narrative themes or comments that contain evidence of feelings and/or thoughts of worthlessness, hopelessness, helplessness, incompetence, self-reproach, pessimism, failure, excessive and/or inappropriate guilt, death and/or suicide, a loss of interest in pleasure (anhedonia), a lowered self-esteem and/or demoralization. Clearly, not every clinically depressed person will have all of these themes in their narrative and different people will vary widely in the themes they express. However, the doctor who writes a credible report will describe those themes in detail, typically putting some quotes in their report of their Mental Status Examination telling the reader just what the patient said. This is no place for summary conclusions.
In addition to the above, as noted in the DSM-IV-TR definition of a Major Depressive Disorder, the doctor may observe some shortcomings in the patient’s ability to think, concentrate or use other cognitive functions or other abnormalities of behavior. In this regard, the doctor of a credible report will measure the patient’s cognitive functioning with such tasks as asking them to interpret proverbs or to discern the similarities between pairs of objects like a whale and an elephant. They will also measure the person’s ability to concentrate or attend with such tasks as performing mental arithmetic or simply counting backwards from 100 by 7’s. The doctor may also indicate that the person presented with such behaviors as sadness or tearfulness that is outside of the normal range, psychomotor agitation or retardation (excessively rapid or slowed behavior), irritability and/or indecisiveness, all of which can be signs of a clinical depression. However, what the doctor cannot simply do is summarily state that the patient presented with a “depressed mood.” If they wish to make that statement they must back it up with observational data if their report is to be considered high quality.
Third, a credible report should have some form of objective psychological data that can be presented to the court that supports the doctor’s conclusion. Unfortunately, psychological testing in the medical-legal context is severely limited by the fact that most tests used in a non-medical-legal context are not appropriate for use in workers’ compensation or personal injury litigations because they do not contain any methods for assessing the patient’s credibility in completing the tests. Clearly, one test that is highly useful is the Minnesota Multiphasic Personality Inventory (MMPI), which is capable of assessing the patient’s truthfulness as well as any psychopathology that might exist. For a complete discussion of the various MMPIs, I suggest you start by checking out my newsletter of April, 2009 which you can find on my website, http://www.DrLeckartWETC.com. But rest assured, tests that ask the patient to complete sentences, draw figures, or check off complaints on a list of symptoms are not useful in a forensic context since those instruments have no way of determining if the patient was truthful in responding and/or no way of eliminating the doctor’s subjectivity in interpreting the patient’s productions.
Fourth, a credible report may have some medical record support for the doctor’s diagnoses. Specifically, has any other mental health professional provided the same, or at least a similar, diagnosis? If so, is their report credible? Here you have to be careful in accepting reports of psychological complaints from doctors who are neither trained nor qualified in either psychology or psychiatry. In this regard, it is best to remember that an orthopedist’s diagnosis of a clinical depression is no more credible than a psychiatrist’s diagnosis of a torn anterior cruciate ligament in the right knee.
Finally, the last source of information that could conceivably be found in a high quality report are collateral sources of information in the form of interview data collected from friends, relatives and/or co-workers or business associates of the patient. However, only rarely are collateral sources of information available and used. Most typically this occurs when there is some barrier collecting data from the first four sources of information as might occur, for example, with a person who is developmentally disabled and cannot express their feelings, thoughts and behaviors and may not be measurable on Mental Status Examination or psychological tests.
Now to return to where we started, a high quality credible report has support for the doctor’s diagnosis. Moreover, when there is support for the doctor’s diagnosis it is likely that the physician has also taken the time to think through and describe the correlates of their diagnosis, such as the patient’s disability status and their need for treatment. However, without a credible DSM-IV-TR diagnosis, none of the doctor’s conclusions are worth the paper they are printed on.
Dr. Bruce Leckart is a psychologist, researcher and retired college professor who owns the Westwood Evaluation & Treatment Center in Los Angeles. This column was reprinted with his permission from the WETC Psychology Newsletter.
Comments