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
jay@braindoctor.org
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

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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.