Essentials of Psych Reports: Common Inconsistencies & Red Flags
Reports written by a mental health physician following their examination of an individual can be lengthy and expensive. ey can also be riddled with inconsistencies, aws, red ags, or as some might call them, ERRORS! ose inconsistencies are not only confusing and frustrating but they typically prove to be fatal aws in the report’s credibility.
Knowing how to identify inconsistencies, or red ags, in a psych report may require a special skill set that can be acquired from extensive education in reading psych reports written for the courts, or perhaps from completing a graduate degree in the mental health eld. While lawyers and insurance professionals may have neither a graduate degree in the mental health eld or extensive psychological training, it is quite possible for attorneys and insurance adjusters to read a psych report with a critical eye towards identifying red ags. is article discusses the essentials of psych reports and some of the common inconsistencies or red ags that are found in psych reports that may be helpful to attorneys and insurance professionals when reading psych reports.
First, it is important to know that Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnoses are made a er con- sidering as many as ve di erent sources of information collected by the evaluating doctor at the time of the examination. ese sources of information are: the patient’s life history and their presenting complaints or symptoms, the doctor’s report of their face-to-face Mental Status Examination, the objective psychological testing data, the patient’s medical records and any collateral sources of information in the form of interviews with the patient’s friends, relatives and/or co-workers.
Second, it is essential to understand that there must always be data or evidence in the report that supports the doctor’s diagnosis. us, the rst thing to do when reading a psych report with a critical eye is to obtain the diagnostic criteria from the DSM-IV-TR or the DSM-5, whichever is applicable in your jurisdiction. en look at the doctor’s report to nd what they wrote about the individual’s life history and current complaints. At that point you just ask yourself, “Do the data support the diagnosis?” If the history is de cient in providing information about the symptoms in terms of their qualitative nature as well as their frequency, intensity, duration, onset or course over time there is no support for the doctor’s diagnosis.
Along similar lines, it is important to determine that the diagnosis actually exists in the DSM and was not simply made up by the doctor. For example, a commonly diagnosed disorder in psych reports written for the courts is a Major Depressive Disorder. In this regard, the DSM indicates that in order to diagnose any form of a Major Depressive Disorder correctly it is necessary to specify whether the disorder has been of the Single Episode or the Recurrent variety and also to specify the severity of the disor- der. In fact, the DSM indicates that not only must the doctor verbally describe these factors but they must also provide numerical diagnostic codes to unambiguously identify the speci c Major Depressive Disorder they wish to diagnose. When you see that the doctor has provided an incomplete diagnosis of a Major Depressive Disorder, or simply made up their version of a Major Depressive Disorder, such as a “Major Depressive Disorder With Features of Anxiety,” you should ask them where in their report they provided the information about their diagnosis as required by the DSM and of course, you should always make sure that the doctor has provided enough information in their report to indicate that all of the diagnostic criteria were satis ed.
ird, look for the doctor’s description of their Mental Status Examination. Every psych report should contain a discussion of the doctor’s Mental Status Examination. A Mental Status Examination produces a set of observations of the patient that are made by the doctor, during their face-to-face meeting, using a relatively standard set of examining techniques and questions that yield easily reported upon objective data. A Mental Status Examination typically lasts for 20-30 minutes of the doctor’s face-to-face time with the individual. ose doctor-made observations are called “signs,” and should not be confused with the patient-made complaints, since they are o en quite di erent. e nature of the techniques used by doctors is most easily understood in talking about the patient’s memory, concentration, insight and judgment. ese processes are easily measured during the course of a Mental Status Examination with such techniques as asking the patient to recall a series of numbers, asking them to count back- ward by 3’s or asking them to provide interpretations of proverbs or to describe in what way an elephant is similar to a whale. For instance, if the doctor diagnoses some form of depression, individuals who are clinically depressed will o en have signs, or observable behaviors, of dysfunctions in the above-noted areas.
Fourth, look for the doctor’s discussion of their psychological testing data. Usually, the only form of objective data that is open to public inspection and can be presented to the court is the psychological testing data. Accordingly, the manner in which those data are obtained, scored, analyzed and interpreted are of primary importance. Clearly, the rst hurdle that must be overcome in assessing the credibility of the psychological testing data is the manner it was collected. At the very minimum, all psychological testing should be administered under the supervision of a licensed mental health professional who may employ a test proctor to monitor the psychological testing and guard against any irregularities, including the possibility that the testing was not taken by the person to whom it was intended to be administered.
e “gold standard” for psychodiagnostic psychological testing is one of a number of versions of the Minnesota Multiphasic Personality Inventory (MMPI) such as the MMPI-2, the 1989 revision of the original MMPI. With regard to using this instru- ment, the testing manual for the MMPI-2 provides information on the administration of the test, including the required testing conditions on pages 8 through 10 of that manual (Butcher, J.N., Graham, J.R., Ben-Porath, Y.S., Tellegen, A., Dahlstrom, W.G. & Kaemmer, B. MMPI-2 (Minnesota Multiphasic Personality Inventory-2) Manual for Administration, Scoring, and Interpretation, Revised Edition, Minneapolis, University of Minnesota Press, 2001). e manual very explicitly states that the MMPI-2 should not be given to the test-taker to complete at home and that the instrument should be administered with supervision by a quali- ed professional. Most generally, similar “rules” should be followed for all other tests in order to guarantee the credibility of the doctor’s conclusions.
Fi h, examine the doctor’s review of medical records to determine if they cited any documents that support their diagnosis. When there are no such records from a mental health practitioner that is one less data source bolstering the doctor’s nal conclusions. Even worse, the section dedicated to reviewing the individual’s medical records o en reveals that physicians in a wide variety of medical specialties make comments, and even diagnoses, in their reports or chart notes indicating that the patient may be depressed, anxious or was having other psychological problems or disorders. However, with all due respect to our colleagues in the various medical elds, a psychological diagnosis o ered by, let’s say, an orthopedist, is no more credible than a psychologist’s diagnosis of an orthopedic condition.
Another red ag to look out for concerns who actually did the review of the individual’s medical records. For example, I o en nd that doctors provide a statement hidden deep in their report stating that they were assisted by a “Ms. Garcia” who “reviewed and summarized” the records. en, I read on to nd that the doctor stated he or she spent eight hours reviewing the records and is- sued their bill accordingly. Unfortunately, in these situations, I never nd a statement in the doctor’s report describing how much time they actually spent reviewing the records versus how much time was spent by “Ms. Garcia” who assisted in that procedure. Unfortunately, the reader of the report is le to believe that “Ms. Garcia spent eight hours” reviewing records and that the doctor billed the insurance company for time actually spent by “Ms. Garcia,” not the doctor.
Lastly, look for any collateral sources of information provided by the doctor in their report. Collateral sources of information are found in the form of interview data collected from friends, relatives and/or co-workers or business associates of a patient under- going a medical-legal examination. However, only rarely are collateral sources of information available and used in evaluations for the court. Most typically this occurs when there is some barrier to collecting data directly from the patient such as might occur with a person who is developmentally disabled, deceased, or who might be unable to communicate if, for example, they have suf- fered a severe cerebral stroke or other mentally debilitating central nervous system injury.
In summary, reading through a psych report with a critical eye toward identifying inconsistencies or red ags does not necessarily require a graduate degree in a mental health eld. Attorneys and insurance professionals can use the information discussed in this article to question the credibility of a psych report.