Psychiatric Evaluation of Workers' Compensation Claimants Part 2

Saturday, May 6, 2006 | 1

By Rene Folse JD, Ph.D.

2) Forensic Psychiatry Issues

At our last seminar, Larry Fields Esq., asked some specific questions about some indicators for malingering. His level of sophistication in this area was exceptional. He specifically told his attorneys that they should read the text written by Jay Ziskin, LLB, Ph.D. Thus, I would like to spend a few minutes discussing these topics.

The Work of Dr. Jay Ziskin

Coping With Psychiatric and Psychological Testimony w/1997 &2000 Supplement (3 Volume set) (5th ed) by Jay Ziskin (ISBN: 1879689049), This three volume work, updated by supplements, is an invaluable addition to the bookcase of the lawyer with an interest in litigation involving evidence from psychiatrists, psychologists or those in related fields. It provides a detailed overview of the methodology, terminology and techniques of the various practitioners the trial lawyer is likely to encounter, along with practical examples of cases concerning evidence from such witnesses. A supurb work of scholarship. While you may not agree with him, knowledgeable lawyers will have read his three volumes, and at some time forensic psychiatric experts will face being "Ziskinized" on a witness stand.

For example, Ziskin takes on the mental health expert who makes claims that are not supported by scientific research. For example, what is the validity and reliability of a mental health expert who claims to be able to detect malingering by clinical judgment unaided by any psychological testing? He points out that there are no scientific studies showing that this can be done with any measure of validity or reliability, and he cites examples of how every time an experiment was undertaken to prove this, the experiment failed.

The following was taken from the Wikipedia on the Rosenhan experiment which is one study discussed by Ziskin.

"The Rosenhan experiment was an investigation into the validity of psychiatric diagnosis conducted by David Rosenhan in 1972. It was published in the journal Science under the title On being sane in insane places.

Rosenhan's study consisted of two parts. The first involved the use of healthy associates or 'pseudopatients', who briefly simulated auditory hallucinations in an attempt to gain admission to 12 different psychiatric hospitals in 5 different states in various locations in the United States. The second involved asking staff at a psychiatric hospital to detect non-existent 'fake' patients. In the first case hospital staff failed to detect a single pseudopatient, in the second the staff falsely detected large numbers of genuine patients as impostors. The study is considered an important and influential criticism of psychiatric diagnosis.

The pseudopatient experiment

For the purposes of the study, eight 'pseudopatients' (associates of Rosenhan selected to be a group of varied and healthy individuals) attempted to gain admission into psychiatric hospitals. During psychiatric assessment they claimed to be hearing voices that were often unclear, but noticeably said the words "empty", "dull" and "thud". No other psychiatric symptoms were claimed, and apart from giving false names and employment details, further biographical details were truthfully reported. If admitted, the pseudopatients were asked to 'act normally', report that they felt fine and no longer heard voices.

All eight were admitted, seven with a diagnosis of schizophrenia. None of the pseudopatients was detected during their admission by hospital staff, although other psychiatric patients seemed to be able to correctly identify them as impostors. All were discharged with a diagnosis of schizophrenia "in remission".

During their stay, hospital notes indicated that staff interpreted much of the pseudopatient's behaviour in terms of mental illness. For example, the note-taking of one individual was listed as "writing behaviour" and considered pathological.

The non-existent impostor experiment

For this experiment, Rosenhan used a well-known research and teaching hospital, whose staff had heard of the results of the initial study but claimed that similar errors could not be made at their institution. Rosenhan arranged with them that during a three month period, one or more pseudopatients would attempt to gain admission and the staff would rate every incoming patient as to the likelihood they were an impostor. Out of 193 patients, 41 were considered to be impostors and a further 42 were considered suspect. In reality, Rosenhan had sent no pseudopatients and all patients suspected as impostors by the hospital staff were genuine patients (unless they were other imposters unknown to the study, which seems quite unlikely).

Impact

Rosenhan published his findings in Science, criticising the validity of psychiatric diagnosis and the disempowering and demeaning nature of patient care experienced by the associates in the study. His article generated an explosion of controversy.

Many defended psychiatry, arguing that as psychiatric diagnosis relies largely on the patient's report of their experiences, faking their presence no more demonstrates problems with psychiatric diagnosis than lying about other medical symptoms. In this vein psychiatrist Robert Spitzer claimed in a 1975 criticism of Rosenhan's study:

If I were to drink a quart of blood and, concealing what I had done, come to the emergency room of any hospital vomiting blood, the behaviour of the staff would be quite predictable. If they labeled and treated me as having a peptic ulcer, I doubt I could argue convincingly that medical science does not know how to diagnose that condition.

However, Spitzer believed that despite the perceived shortcomings of Rosenhan's study, there was still a laxness in the field. He played an important role updating psychiatric diagnosis, eventually resulting in the DSM-IV, in an attempt to make it more rigorous and reliable.

Lauren Slater claimed in her 2004 book Opening Skinner's Box to have repeated Rosenhan's study by presenting at the emergency rooms of multiple hospitals with a single auditory hallucination. She claimed that she was not admitted to any of the hospitals but was given prescriptions for antipsychotics and antidepressants. Her claims were questioned by Robert Spitzer and others, and she replied through her attorney to say that she considered her work to be an "anecdote, not systematic research, and certainly not a 'replication' of Rosenhan's study."

EDITOR'S NOTE: Dr. Ziskin has passed away and his text is out of print. WorkCompCentral has purchased the last remaining books by Dr. Ziskin and has these available for sale to the public. There are a very limited number left and are available first come, first serve only at WorkCompOutlet - credit card orders only.

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The views and opinions expressed by the author are not necessarily those of workcompcentral.com, its editors or management.