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  1. 1. INADEQUATE DOCUMENTATION OF POSTTRAUMATIC STRESS DISORDER (PTSD) IN LEGAL CASES September 22, 2006 Stuart J. Clayman, Ph.D. Licensed Psychologist 75 Potter Pond Lexington, MA 02421 Tel.: (781) 862-4292 Fax: (781) 861-1993 Introduction I am often asked to review medical records, usually in conjunction with a psychological evaluation of a litigant, in a Worker’s Compensation, Personal Injury or Disability claim. The purpose of the psychological evaluation and records review is to determine if a litigant has a genuine mental disorder or if the litigant might be exaggerating or faking a mental disorder. Occasionally I am asked to conduct a medical records review only, without a face-to-face evaluation of a litigant. The package of medical records provided to me for review often consists primarily of treatment records including both psychotherapy progress notes and psychopharmacological treatment notes. Sometimes there are independent psychological evaluation reports or other documents provided to me in addition to treatment notes. I often find that the medical records provided to me for review do not document the full criteria of the assigned mental disorder as that disorder is defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM- IV). In this article I will discuss how an attorney or case manager can differentiate between complete and inadequate documentation of Posttraumatic Stress Disorder (PTSD) in a mental health clinician’s report of psychological evaluation. What Are The Criteria of PTSD? PTSD, like other mental disorders, is a specific disease entity and is defined by means of distinct criteria which can be found in the Diagnostic and Statistical Manual of Mental Disorders. There are four major criteria that must be met in order to appropriately assign a diagnosis of PTSD to an individual. These are: (A) that an individual has been exposed to an extremely traumatic event and responds with intense emotions such as fear or helplessness; (B) the individual persistently re-experiences the trauma by means of distressing memories, nightmares and distress upon exposure to something that resembles the original trauma; (C) the individual defensively avoids thoughts, activities and situations or people that might arouse memories of the trauma and (D) the individual shows symptoms of anxious arousal such as sleep or concentration problems. Some Examples of Inadequate Documentation of PTSD I often find that psychologists, psychiatrists, social workers and other mental health clinicians do not document the full criteria of PTSD in the written evaluation report. Frequently, I have found that the clinician merely reports the criteria of PTSD as they are described by the litigant. For example, I have seen reports written to document PTSD
  2. 2. 2 that state that the litigant meets the criteria for PTSD because of the following: He was involved in a motor vehicle accident. He has had nightmares. He avoids discussion of the MVA. He can’t sleep since the MVA. Although these findings, on the surface, may appear to document PTSD, they probably do not for the following reasons: (1) No attempt was made by the evaluator to show that the traumatic event meets the required severity criteria. Examples of traumas that might be severe enough to be considered as a possible cause of PTSD are listed in the DSM-IV. Not every traumatic event meets the criteria for this disorder. In addition, further investigation may reveal that the litigant has experienced other traumas in his or her lifetime that are as severe or more severe than the event alleged to be the cause of the psychological symptoms; (2) Even if the traumatic event does meet the required severity criterion, and there is no history of other severe traumas, evaluators fail to document the nature of the litigant’s emotional response to the traumatic event. I find that this required criterion of PTSD is often overlooked by evaluators and is a good point on which to cross-examine the evaluator and the litigant; (3) It is important to show that the content of memories, nightmares and flashbacks are relevant to the trauma under discussion. For the mental health clinician to state only that the litigant has “nightmares” is not enough. Cross-examination of the litigant or the clinician might reveal that frequent nightmares contain content relevant to an earlier trauma, such as having been abused as a child, and that the nightmares do not contain content relevant to the specific trauma alleged in a lawsuit; (4) Symptoms that suggest PTSD can also be exhibited in other mental disorders. For example, sleep problems and concentration problems can also be seen in some types of depressive disorders and could indicate a depressive disorder that might pre-exist or be otherwise unrelated to the traumatic event and (5) DSM-IV clearly states that malingering should be ruled out when considering a diagnosis of PTSD in legal situations when financial rewards are available. My experience is that it is rare that an assessment of malingering is conducted and, when such an assessment is conducted, it is often not done appropriately (that is, with psychological tests designed for this purpose). Please refer to another article on my website entitled “The Importance of using Psychological Tests to Identify Faked, Exaggerated or Malingered Symptoms in Litigation” for additional discussion of the issue of assessing for malingering. Conclusions Even when common sense suggests that a particular litigant might have a mental disorder, such as Posttraumatic Stress Disorder, that is caused by an injury at work or a personal injury, my experience is that the full criteria of PTSD are often not completely documented. There are many reasons why clinicians might not adequately document PTSD in a written report. Some possibilities are incomplete understanding of the criteria for this disorder, lack of time to conduct a comprehensive assessment or to prepare a report, a tendency to “bond” with the patient and uncritically accept what the patient describes about his or her symptoms and an unwillingness on the part of a treating clinician to raise questions about possible exaggeration or faking of psychological symptoms for fear this will disrupt the treatment process. When PTSD is incompletely or poorly documented, attorneys and insurers have the responsibility to challenge this diagnosis and seek better documentation.