All psychiatric reports evaluate something, but not always the same thing. For example, eligibility for benefits, or fitness to do a job – for HR purposes or wrongful termination litigation. To make sense of the report, the reader must determine what is being evaluated and how it is being done. Psychiatric reports are not created equal. To be meaningful, the diagnoses and conclusions must be supported by data contained in the report.
- The place to start reading a report is its date. How current is the report?
- How much time, if any, was spent in face-to-face interviewing?
- Was the examinee cooperative (or in the case of review of medical records, were they complete and reliable)? Certain psychological tests have reliability scales embedded in them. The MMPI-2 has several, the MCMI-III has one, and comparing certain neuro-psychologic tests can address inconsistent response patterns.
Generally, the more direct information, and collateral information, reviewed by the evaluator, the better the diagnosis. Diagnosis is most often presented at the end of the report. Psychiatric diagnoses usually are expressed along a 5-Axis paradigm:
Axis I – [This is where acute pathology or development disorders are identified]
Axis II – [Personality disorders are described here; these are maladaptive personality styles which significantly interfere with social, school or occupational functioning.]
Axis III – [Medical conditions which affect the Axis I or Axis II diagnoses are given here.]
Axis IV – [Psychosocial stressors. This is a qualitative statement ranging from absent to extreme.]
Axis V – [Global Assessment of Functioning (GAF). This is a non-linear 100 point scale which must be referred to by professionals for coding in the Diagnostic and Statistical Manual for Mental Disorders; the most recent edition DSM IV-TR (text revision), although Edition V is in the offing. In some settings, Worker’s Comp. for example, the GAF can be very important – if misunderstood, however, attorneys may make incorrect assumptions. A score of 71/100 is, “If symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g. difficulty concentrating after a family argument; no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in school work).”
Thus, a 29% decline from superlative functioning, i.e., 100, is still “normal.” I believe the reader must understand this scale is non-linear. I believe a 71 does not describe overall impairment or can be used to say, for example, that a person with a 71 has lost 29% of normal functioning or that a 29% disability exists. Furthermore, a person who is 50/100 is more than 50% disabled: 50/100 is described as“serious symptoms (e.g. suicidal ideation, severe obsessive rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job).” (emphasis added)
By this definition, a person with a 50/100 on the GAF is totally disabled. Furthermore, any number below 50/100 is, by definition, totally disabled. A psychiatric disturbance of 50/100 is not the same as a disability of 50%.
- Once the Axis I and Axis II diagnoses are made, and it should be made with a reasonable medical probability or certainty, i.e., more likely than not (the preponderance of the medical evidence), the reader then should find the diagnostic criteria for the diagnoses if they have been provided by the psychiatrist
- The reader should look to the body of the report for past and present history: psychiatric, medical, legal, military and psycho-social, records which have been reviewed, mental status exam (see below) and psychological testing. Is the reported data congruent with the diagnoses and conclusions? Has important information been reported wrong or omitted? Has psychological testing which is present in records been misinterpreted?
- Mental Status Exam is the equivalent of a physical exam by a physician, over six categories. Many informed observations and measurements of mental status should be assessed and reported within each category:
Speech and Thinking
Often non-mental health professionals rely on forensic mental health consultants to review psychiatric/psychological evaluations because of their complexity. Being informed and prepared to ask about the different areas I have described should help the former to better utilize the services of the latter.