Major Neurocognitive Disorder - Cross-Examining Psych Doctors, Tip #110

A Major Neurocognitive Disorder is a relatively new disorder that appears in the DSM-5, which was published in 2013.  According to a reading of pages 602 to 605 of the DSM-5, a Major Neurocognitive Disorder is correctly diagnosed when the individual presents with a substantial impairment in cognitive performance that is measured by the examining physician’s administration of neuropsychological tests or “another quantified clinical assessment.”  Thus, when you are reading a psych report where the examiner diagnosed a Major Neurocognitive Disorder you should immediately look to see if the examiner discussed the administration and results of neuropsychological tests or “another quantified clinical assessment.”  If you find that the examiner has declined to discuss any of these measures, you should question the doctor about their omission on cross-examination.

Prepare Your Own Apricot™ - Cross-Examining Psych Doctors, Tip #109

In 2009 I began to assist attorneys with written pre-deposition/pre-trial consultation reports.  I quickly realized that a “pre-deposition/pre-trial consultation report” is a mouthful, and a simpler, shorter name was needed.  I decided to go with “Apricot™.”  Apricots™ are work-product privileged reports designed to help attorneys cross-examine mental health professionals such as forensic psychologists, forensic psychiatrists, neuropsychologists, psychotherapists, social workers etc.  An Apricot™ describes all of the substantial flaws in a psych report in jargon-free, non-technical language.  Most importantly, an Apricot™ also provides a list of simple questions and techniques that will help get those flaws on the record despite what might be the doctor’s evasive or non-co-operative behavior.  In fact, I’ve made all of the information you need to prepare your own Apricot™ available for free at my website (http://drleckartwetc.com/prepare-your-own-apricot).  Have at it!

Using Multiple Versions of the DSM - Cross-Examining Psych Doctors, Tip #108

The Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV) was published by the American Psychiatric Association in 1994.  The DSM-IV became obsolete when the DSM-IV-TR was published in 2000.  The “TR” in DSM-IV-TR stands for Text Revision.  Most recently, in May, 2013, the DSM-5 was published.  While many of the diagnoses and the diagnostic criteria for disorders have remained the same with each revision of the DSM, substantial differences definitely exist between the manuals.  Typically, many of the substantial differences are outlined on multiple pages in the later sections of the manuals.  Moreover, when you are reading a psych report, find the area in the report where the doctor stated which version of the DSM they used in arriving at their diagnostic conclusions.  When doing so, if it becomes clear that the doctor simultaneously used two different versions of the DSM in evaluating the patient and producing their report you should question the doctor about that substantial flaw on cross-examination.

Where is the Psychological Test Battery? - Cross-Examining Psych Doctors, Tip #107

Objective psychological test data is clearly needed in medical-legal psych reports where the first responsibility of the examiner in either psychology or psychiatry is determining the credibility of the patient's complaints and clinical presentation.  In this regard, the principal method for assessing that credibility is an objective psychological test battery containing such instruments as the Minnesota Multiphasic Personality Inventory (MMPI) and the Cattell Sixteen Personality Factor Test (16PF) that are capable of generating test scores providing information both about the patient's credibility and any possible psychopathology.  Typically, objective psychological test scores are the only information collected by an examiner that is open to public inspection and can be presented to the court in an objective and generally numerical fashion.  Therefore, when you come across a psych report and find that the doctor declined to give any psychological tests, not only is that a clear failure by the doctor to assess the patient’s credibility, but they should be questioned about that substantial flaw on cross-examination.

Somatic Symptom Disorder - Cross-Examining Psych Doctors, Tip #106

A Somatic Symptom Disorder is a relatively new disorder that is only found in the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5), which was published in May, 2013.  In fact, according to page 311 of the DSM-5, the diagnostic criteria for a Somatic Symptom Disorder has replaced what in the DSM-IV-TR was Pain Disorders.  A Somatic Symptom Disorder is correctly diagnosed when the patient presents with somatic or physical symptoms for more than six months that are accompanied by excessive thoughts, feelings or behaviors related to those symptoms or associated health concerns.  A reading of page 311 also reveals that the doctor is required to specify if the individual has this disorder (a) With Predominant Pain, (b) is Persistent in that it has lasted more than six months, and (c) occurs with a severity that is best described as Mild, Moderate or Severe.  When you find that the doctor has diagnosed a Somatic Symptom Disorder, you should look to see if they provided information in their report indicating that the patient met the DSM criteria for that disorder.

MMPI F(Back) Scale - Cross-Examining Psych Doctors, Tip #105

Every validity and clinical scale performance on the Minnesota Multiphasic Personality Inventory (MMPI) is described with a T-Score.  All T-Scores on the validity scales and the clinical scales on the MMPI have a mean of 50 and a standard deviation of 10.  In this regard, it should be noted that it is universally accepted that T-Scores of 65 or larger are clinically significant or interpretable.  There are many books and journal articles on the MMPI that make this point.  In this regard, one of the validity scales on the MMPI is the F(Back) Scale or what is often called the F(b) Scale.  The F(b) Scale is a validity scale that is analogous to the F Scale, except that the items on the F(b) Scale are placed in the last half of the test, hence the name “F(b)” representing an F-like scale at the back of the test.  A score of 65 or higher on the F(b) Scale is indicative of a high probability the patient was trying to appear to have symptoms that do not exist.  In these situations, you should look for the place in the doctor’s report where he/she discussed that the patient’s F(b) Scale score showed they were attempting to simulate symptoms, or what some mental health practitioners would call “faking” or “Malingering.”

Which MMPI Was Used by the Examiner? - Cross-Examining Psych Doctors, Tip #104

The Minnesota Multiphasic Personality Inventory (MMPI) is the keystone of all clinical psychological test batteries where the major question concerns the presence or absence of a Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis.  In this regard, the MMPI is considered the gold standard for psychological test batteries in medical-legal cases because it is capable of providing information not only about psychopathology but about the test-taker’s basic personality, their attitude and credibility, as well as how they are functioning in the world.  The MMPI was published in 1943 and has been widely researched for over 70 years.  In 1989, the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) was published in response to a growing demand for an MMPI with updated wording and phrasing.  Subsequently, the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF), that was created from the MMPI-2, was published in July, 2008, in part, to correct some problems identified with the MMPI-2.  When you are reviewing a psych report it is important to determine which MMPI was used by the examiner and to obtain the patient’s MMPI test scores from the doctor if those scores do not appear in the report.

Operating from the Same Copy of the Report - Cross-Examining Psych Doctors, Tip #103

Cross-examining a psych doctor is typically no simple task.  You definitely don’t want to add unnecessary challenges to the cross-examination process.  Therefore, during cross-examination it is imperative that you confirm that the doctor is using the same copy of the report that he/she submitted to the court.  If even one word is different it could mean that a sentence or a whole section might have an entirely different meaning than what was originally produced by the doctor.  Further, allowing the doctor to use a different copy of their report will cause significant confusion during the cross-examination process and result in a delay in the proceedings.  Thus, if it is discovered that the doctor is operating from a different copy of their report than what was originally submitted to the court, despite however minor the differences are portrayed, you should immediately halt the cross-examination and insist that the doctor use the official version of his/her report to testify.  Otherwise you are comparing apples and oranges.

Identify Inconsistencies in Psych Reports - Cross-Examining Psych Doctors, Tip #102

Medical-legal psych reports can be lengthy and expensive. They can also contain multiple inconsistencies, flaws, or as some might call them, ERRORS!  Those inconsistencies are often confusing and typically decrease the report’s credibility.  Knowing how to identify inconsistencies in psych reports may require a special skill set that can be acquired from experience reading psych reports written for the courts or perhaps from completing a graduate degree in the mental health field.  When you have a problematic psych report but you don’t have a graduate degree in the mental health field and/or extensive experience reading psych reports, no need to fret.  Simply take advantage of the self-help resources I provide for free on my website (http://drleckartwetc.com/freeresources) to help you identify inconsistencies in psych reports and question the doctor on cross-examination.

The Med-Legal Psych Professor - Cross-Examining Psych Doctors, Tip #101

If you are reading this, chances are that you are an attorney or an insurance professional who has an education, training and experience in those areas.  Further, chances are that you do not have education, training or extensive experience as an expert in psychology or psychiatry.  As such, you are probably relatively inexperienced about the intricacies of psychological diagnoses and psychological or psychiatric treatment, which puts you at a disadvantage when deciding the best route to take when handling psych reports that are not in your favor.  No need to worry any longer.  You can access an array of information that will be useful to you in reading psych reports and cross-examining psych doctors who have produced reports not in your favor.  Simply subscribe to the Med-Legal Psych Professor blog where you will find over 100 tips with information about psych reports and taking a psych doctor’s testimony.

Absence of MCMI-III Scores - Cross-Examining Psych Doctors, Tip #100

     The Millon Clinical Multiaxial Inventory-III (MCMI-III) is the most recent revision of that test.  It contains four scales capable of providing information about the validity of the test-taker’s responses.  The data from the four validity scales assess:  (1) “Validity” - Did the individual understand and attend to the content of the questions? (2) “Debasement” - Did the individual attempt to portray him or herself as having more troublesome emotional and personal difficulties than exist? (3) “Desirability” - Did the individual attempt to portray him or herself as being more morally virtuous, socially attractive and more emotionally well composed than they are? and, (4) “Disclosure” - Was the individual inclined to be frank and self-revealing or more likely to be secretive?  The MCMI-III is similar to the MMPI-2 in that the test can only be interpreted to provide information about the individual’s psychological status if their validity scale scores indicate they completed the test in an honest and straightforward manner.  However, when the doctor’s report lacks the actual MCMI-III scores the reader of their report does not know if the test-taker completed the test in an honest and straightforward manner or attempted to distort their true presentation.  Thus, when you encounter a psych report that is devoid of the patient’s MCMI-III validity scale scores, you should ask the psych doctor on cross-examination if there is anything in their report that would allow the reader of that document to confirm the conclusions they drew from the patient’s MCMI-III.

The MMPI F(P) Scale - Cross-Examining Psych Doctors, Tip #99

     The Minnesota Multiphasic Personality Inventory (MMPI) is the gold standard of psychological test batteries used for medical-legal purposes.  The MMPI-2 is the 1989 revision of the original MMPI that dates back more than 70 years and has many proponents who depend on the test’s validity scales to provide information about the individual’s test-taking attitudes and credibility.  The MMPI-2 is also the most commonly used version of the MMPI by psychologists and psychiatrists.  With regard to the MMPI-2, every validity and clinical scale performance is described with a T-Score.  All T-Scores on the validity scales and the clinical scales on the MMPI-2 have a mean of 50 and a standard deviation of 10. In this regard, it should be noted that it is well known and universally accepted that T-Scores of 65 or larger are clinically significant or interpretable. In this regard, the F(P) Scale is one of the validity scales of the MMPI-2. Scores 65 or higher on the F(P) Scale are characteristic of individuals who are “overreporting psychopathology” and attempting to portray themselves as having symptoms that do not exist. 

The MMPI F(P) Scale - Cross-Examining Psych Doctors, Tip #98

     The Minnesota Multiphasic Personality Inventory (MMPI) is the gold standard of psychological test batteries used for medical-legal purposes.  The MMPI-2 is the 1989 revision of the original MMPI that dates back more than 70 years and has many proponents who depend on the test’s validity scales to provide information about the individual’s test-taking attitudes and credibility.  The MMPI-2 is also the most commonly used version of the MMPI by psychologists and psychiatrists.  With regard to the MMPI-2, every validity and clinical scale performance is described with a T-Score.  All T-Scores on the validity scales and the clinical scales on the MMPI-2 have a mean of 50 and a standard deviation of 10. In this regard, it should be noted that it is well known and universally accepted that T-Scores of 65 or larger are clinically significant or interpretable. In this regard, the F(P) Scale is one of the validity scales of the MMPI-2. Scores 65 or higher on the F(P) Scale are characteristic of individuals who are “overreporting psychopathology” and attempting to portray themselves as having symptoms that do not exist. 

Use of The Oswestry Pain Questionnaire - Cross-Examining Psych Doctors, Tip #98

     The Oswestry Pain Questionnaire (OPQ) is a 10-item questionnaire that asks an individual to describe their behavior on ten different variables:  Pain Intensity, Personal Care, Lifting, Walking, Sitting, Standing, Sleeping, Sex Life, Social Life, and Traveling.  In each of the above noted areas, the test-taker is asked to choose one of the following categories for themselves:  “I can tolerate the pain I have without having to use pain killers,” “the pain is bad but I manage without taking pain killers,” “pain killers give complete relief from pain,” “pain killers give very little relief from pain,” and “pain killers have no effect on the pain and I do not use them.”  Clearly, the OPQ is a self-report questionnaire that has no validity scales for assessing the individual’s test-taking attitudes or credibility, rendering it useless in a medical-legal context.   

Neuropsychological Medical-Legal Evaluations - Cross-Examining Psych Doctors, Tip #97

Neuropsychology is both an academic discipline and one of the applied medical arts, often called clinical neuropsychology.  Neuropsychologists are psychologists who have taken postdoctoral training in the area of neuropsychology.  In the forensic cases they are typically given referrals by neurologists who depend on their psychological testing to assess neurological decrements not revealed by the neurologist’s tools.  While neuropsychological testing can provide the neurologist with valuable information about a patient’s neurological condition, to use those testing results to support the conclusion of a “neuropsychological injury” is to open the door to a double recovery for a single neurological injury. 

Read the Apricot™ and Apply the Advice - Cross-Examining Psych Doctors, Tip #96

     I’ve been writing Apricots for about eight years.  Apricots™ are work-product privileged reports designed to help attorneys cross-examine mental health professionals such as forensic psychologists, forensic psychiatrists, psychotherapists, social workers etc.  An Apricot™ describes all of the substantial flaws in a psych report in jargon-free, non-technical language. An Apricot™ also provides a list of questions and techniques that will help get those flaws on the record despite what might be the doctor’s evasive or non-co-operative behavior.  In this regard, any attorney who has commissioned an Apricot™ is strongly urged to read it’s complete contents and to apply the advice I’ve given in the Apricot™ for the best possible outcomes with the case.  I intentionally put strong emphasis on reading the contents and apply the advice.  For instance, you’ll find in the contents of my Apricots™ the recommendation that you focus your questioning on the weakest part of the doctor’s report, which is their diagnosis.  If you don’t take this advice and pursue a different line of questioning on cross-examination you’ve wasted the your client’s money that paid for the Apricot™!

Deviating from DSM Terminology - Cross-Examining Psych Doctors, Tip #95

     The Diagnostic and Statistical Manual of Mental Disorders (DSM) provides a variety of mental disorders with a wide variation of modifiers or specifiers that may be applied to the specific disorder diagnosed.  In addition to modifiers and specifiers, diagnostic codes are also required in association with the diagnosis.  According to page 1 of the DSM-IV-TR and page 23 of the DSM-5, diagnostic codes are essential for increased specificity in identifying the intended diagnosis.  Unfortunately, some psych doctors choose to deviate from DSM terminology and create their own diagnosis by adding modifiers or specifiers that are not outlined or permitted by the DSM.  Further, for some unknown reason, some psych doctors decline to provide a diagnostic code or, even worse, provide diagnostic codes that do not match their verbal diagnosis which results in a situation where their diagnosis is ambiguous.  In situations where the doctor has created diagnostic uncertainty, during their deposition you should ask the doctor where in their report they provided the information about their diagnosis as required by the DSM.

Multiple Sources of Data - Cross-Examining Psych Doctors, Tip #94

     Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnoses are made after considering as many as five different sources of information collected by the evaluating doctor at the time of the examination.  These 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.  By no means whatsoever should a DSM diagnosis be arrived at by simply considering the psychological testing data.  In fact, a review of page xxxii of the DSM-IV-TR explicitly states, “Assessments that rely solely on psychological testing not covering the criteria content (e.g., projective testing) cannot be validly used as the primary source of diagnostic information.”  Thus, if you encounter a psychological evaluation report where the diagnostic conclusions were arrived at solely based on psychological testing data, you should ask the doctor where in their report they considered the patient’s life history and their presenting complaints, the face-to-face Mental Status Examination data, the patient’s medical records or the contents of page xxxii of the DSM-IV-TR.

Psychiatrist v. Psychologist when considering patient’s credibility - Cross-Examining Psych Doctors, Tip #93

     Psychologists typically are trained and have more experience in administration, scoring and interpretation of psychological tests than psychiatrists.  This may be an important factor to consider in medical-legal cases where psychological test data is often the only form of objective information that can be presented for public inspection in open court and is useful in determining the patient’s credibility.  Point in case, a recent deposition transcript reveals a psychiatrist’s response to a question about the Minnesota Multiphasic Personality Inventory-2 (MMPI-2). This is approximately what the doctor said during his/her depo, “I really don’t know much about the MMPI-2.  I’m not a specialist in testing or I would have interpreted the results.  Maybe what you should do is have somebody else provide you with that information, I don’t.”  The MMPI-2, of course, is a version of the Minnesota Multiphasic Personality Inventory, a test that is the gold standard of psychological test batteries for medical-legal examinations.  In fact, the principal method for assessing the patient’s credibility is an objective psychological test battery containing such instruments as the MMPI that are capable of generating objective test scores that can be presented to the court to provide information both about the patient's credibility and any possible psychopathology.  For the reasons described above, considering the use of a psychologist for your medical-legal evaluations is strongly recommended.

The Millon Clinical Multiaxial Inventory-III (MCMI-III) - Cross-Examining Psych Doctors, Tip #92

The Millon Clinical Multiaxial Inventory-III (MCMI-III) is the most recently revised version of the Millon Clinical Multiaxial Inventory devised by Dr. Theodore Millon, a specialist and pioneer in the area of Personality Disorders. The MCMI-III contains a variety of scales which include four validity scales.  The Debasement Scale is a validity scale that measures an individual’s “inclination to deprecate or devalue oneself by presenting more troublesome emotional and personal difficulties than are likely to be uncovered upon objective review.”  On the MCMI-III a BR score of 75 or more is sufficient to conclude that the individual was attempting to simulate symptoms, fake or malinger.  It also should be noted that when an individual is found to be attempting to fake that all further interpretation of the psychological meaning of their scores on the MCMI-III must cease and nothing further can be said about their psychological status beyond the fact that they were trying to appear to have symptoms that do not exist.

Refrain From Asking Open-Ended Questions - Cross-Examining Psych Doctors, Tip #91

During cross-examination of a psych doctor, the attorney can ask questions in a variety of ways.  One strategy to avoid when questioning the psych doctor is asking open-ended questions.  An example of an open-ended question used during cross-examination of a psych doctor is, Doctor, you mentioned that the patient complained of depression. Will you please tell me about the patient’s depression at the time of your examination?  Questioning the doctor in this manner opens the proverbial door for the doctor to provide information that is not in his or her report that could conceivably support their conclusions.  Obviously, the information provided by the doctor’s response may or may not be correct for a variety of reasons and it would be difficult to verify that information.  A recommended alternative is to ask questions that are directed at the doctor’s report.  For example, Doctor, will you please tell me where in your report you stated the frequency of the patient’s symptom of depression or how often the depression occurs?  Questioning the doctor using this method will help expose the report’s lack of evidence supporting the doctor’s diagnosis.

MMPI-370 - Cross-Examining Psych Doctors, Tip #90

The MMPI-370 is a shortened version of the MMPI-2 that is analogous to the MMPI-168.  Like the MMPI-168, the MMPI-370 is not a “test” in and of itself but a particular use of the MMPI-2 that has some serious problems.  The MMPI-370, as the name implies, involves administering the first 370 questions of the MMPI-2.  This allows for the scoring of the Lie Scale, the F Scale, the K Scale, the F-K Scale or Index and the 10 basic clinical scales.  If you assume that the MMPI-2 is a valid and reasonable instrument to use, the scoring of these scales may be acceptable in a general clinical practice where it can be assumed that the person does not have a deviant test-taking attitude.  However, in a medical-legal context this is not a reasonable assumption and it is necessary to score at least the F(p) Scale, the F(Back) Scale, the VRIN Scale and the Revised Dissimulation Scale to determine if the person is responding in an honest and frank manner and not attempting to simulate dysfunction.  Unfortunately, it is not possible to score these scales if the person responds to only the first 370 items on the MMPI-2.  Therefore, the MMPI-370 is virtually useless in forensic circumstances.  

Male Hypoactive Sexual Desire Disorder Due to a General Medical Condition - Cross-Examining Psych Doctors, Tip #89

When the doctor diagnoses a Male Hypoactive Sexual Desire Disorder Due to a General Medical Condition, be sure to look for the data in their report that shows the patient met the diagnostic criteria for that disorder.  According to the DSM-IV-TR, in order to diagnose correctly either Male Hypoactive Sexual Desire Disorder Due to a General Medical Condition (608.89) it is necessary to show that there is a deficit or absence of sexual fantasies as well as a lack of a desire for sexual activity that is judged to be entirely due to the direct physiological effects of a general medical condition.  As such, there must be evidence from the history, physical examination or laboratory findings that the dysfunction is fully explained by the direct physiological effects of an existing general medical condition.  As specified in the DSM-IV-TR, there are a variety of neurological, endocrine, vascular, and genitourinary conditions such as multiple sclerosis, diabetes mellitus and urethral infections that can produce sexual dysfunction in this manner.  However, simply not wanting to engage in intercourse or other sexual behavior because of pain or some other physical condition does not meet the DSM-IV-TR criteria for establishing that there is dysfunction as a result of a direct physiological mechanism.