1/30/2008

Identifying Key Case Issues from Mental Disorder Diagnoses

Applying Objective Standards to Subjective Claims

By Dr. Steven Carter, PsyD, LP

In the premier issue of Claims Advisor, we took a look at how the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), published by the American Psychiatric Association, could help claim professionals understand emotional harm claims. Here we’ll examine how you can use a mental illness diagnosis to identify case issues that are critical to the equitable resolution of the claim.

Get a Diagnosis
First, get a diagnosis. Unfortunately, many doctors fail to provide any diagnosis even after examining a claimant for hours or days. Insisting on a diagnosis is a key step when analyzing emotional harm claims. Since 1980, the DSM has advised, but not required, mental health professionals to diagnose mental disorders using a multiaxial system. Multiaxial assessment facilitates a comprehensive and systematic evaluation. It provides a convenient format for capturing the complexity of clinical situations and describing the heterogeneity of individuals presenting with the same diagnosis.

Get the Full Story
The DSM multiaxial system has long been accepted in the mental health community. A forensic mental health evaluation should contain diagnostic formulations for Axes I through V even if the opinion on a particular axis is deferred for insufficient information.

Unfortunately, in insurance claims it is relatively common to see diagnoses only on Axis I. A failure to address all five axes is a good clue to the claims examiner that the claimant has not received a thorough evaluation and a comprehensive differential diagnosis.

Understanding the DSM-IV-TR Multiaxial Diagnostic System

Axis I: Clinical Disorders
This axis includes over 200 mental disorders that are further subdivided into groups. Examples of these groups are: Delirium, Dementia, and Amnestic and Other Cognitive Disorders; Mental Disorders Due to a General Medical Condition; Substance-Related Disorders; Schizophrenia and Other Psychotic Disorders; Mood Disorders; Anxiety Disorders; and Somatoform Disorders. Because claimants may present with multiple disorders, multiple Axis I diagnoses may be made.

Many doctors mistakenly diagnose a mental disorder for every symptom reported by the claimant leading to a plethora of overlapping and redundant Axis I diagnoses. These cases can be spotted by noting that the claimant’s daily activities are performed at a level incompatible with the presence of multiple major mental disorders.

Other doctors mistakenly assign a diagnosis whenever the claimant’s symptoms are similar to the name of the disorder. For example, an adult with a short attention span will be diagnosed with Attention-Deficit/Hyperactivity Disorder (A-D/HD) even though the diagnostic criteria require onset before age 7. Post Traumatic Stress Disorder (PTSD) is commonly diagnosed when a claimant is exhibiting normal upset over a traumatic event but without any systematic review of 6 diagnostic criteria and 21 symptoms of PTSD.

Doctors often fail to include substance related disorders on Axis 1, particularly for commonly used substances like nicotine and alcohol. This can provide a valuable clue that the doctor has not considered the impact of substance abuse and dependence on the claimant’s mental health. Commonly overlooked mental disorders include Alcohol-Induced Mood, Anxiety, and Sleep Disorders.

Axis II: Personality Disorders and Mental Retardation
A personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the claimant’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment. There are 10 pathological personality types in the DSM-IV-TR. None of them has its onset in adulthood or can be caused by commonly insured events such as motor vehicle accidents or slip and fall injuries.

Claimants frequently have Axis II personality disorders that preexist the cause of action, drive most of their behavior, and complicate or even prevent efforts to reach an equitable settlement. Despite that fact, claimant’s psychological and psychiatric experts rarely assess claimants for personality disorders. Assessing a personality disorder is a lengthy process that can easily strain the doctor-patient relationship.

This error can be spotted by a diagnosis of “799.9 Diagnosis Deferred on Axis II” or even a complete omission of the entire Axis II in the report. When deposing a mental health expert, ask what methods were used to systematically exclude a personality disorder. A discussion of personality assessment is beyond the scope of this article but usually includes the MMPI-2 or a structured interview (e.g., SCID-2).

Axis III: General Medical Conditions
All past and present physical conditions, injuries and diseases that would impact the claimant’s psychological condition should be listed in this area. Anemia, diabetes, hypertension, hypothyroidism, lupus, and Lyme disease are some of the common general medical conditions frequently associated with psychiatric symptoms.

Rarely is the insured event a proximal cause of these general medical conditions. If the claimant’s medical expert has not listed one of the claimant’s general medical conditions on Axis III then the insurer can be safe in assuming that they have not been thoroughly considered as a nonproximal cause of the claimants emotional symptoms.

Axis IV: Psychosocial and Environmental Problems
All past and current psychosocial stressors that may affect the diagnosis, treatment, and prognosis of mental disorders on Axes I and II are recorded here. Psychosocial stressors often play a significant role in the onset, severity, exacerbation, and maintenance of the claimant’s mental illnesses.

Insurers should compare their knowledge of the claimant’s psychosocial stressors with those documented by the claimant’s medical expert to ensure that neither party is underestimating the impact of those problems on the claimant’s presentation. Unrelated stressors such as marital problems, child behavior problems or chronically ill parents commonly produce psychological symptoms that are mistakenly attributed to the insured event.

Axis V: Global Assessment of Functioning
This 100-point scale rates the patient’s overall level of psychological, social and occupational functioning. When used according to the instructions in the DSM, it does not include impairments due to physical or environmental limitations.

In insurance claims, doctors often provide low GAF ratings because they erroneously include impairments due to physical or environmental limitations when assigning a GAF. Often this error is specifically noted in the record (e.g., “GAF=30 due to inability to walk or drive a car.”). Noting that error is one way to bring severity ratings back in line with the actual level of emotional harm.

Using Chronic vs. Recurrent as Clues to Causality
The DSM system has several specifiers that can be applied to many of the diagnoses most commonly seen in insurance claims. Two of particular interest are “chronic” and “recurrent.” In the case of a Major Depressive Episode, the specifier “chronic” means that the full criteria for a Major Depressive Episode have been continuously met for at least the past two years. This will often put the time of onset before the insured event and provide support for the theory that a premorbid mental disorder is being labeled as a proximally caused injury.

“Recurrent” indicates that the claimant’s condition has followed a pattern of waxing and waning with partial to complete interepisode recovery. When supported by medical records and deposition testimony, this specifier will occasionally demonstrate that the insured event was merely a coincidental occurrence in a longstanding and ongoing pattern of recurrent mental illness. There are many cases where that pattern was neither caused nor even exacerbated by the claimant’s involvement in the insured event.

Don’t Confuse Course with Severity
Neither “chronic” nor “recurrent” refers to the severity of the claimant’s symptoms. Instead, the terms, “mild,” “moderate,” “severe” and others are provided by the DSM for that purpose. For example, a claimant can have a “chronic” condition of “mild” severity or “recurrent” episodes of “severe” depression interspersed with months or years of complete recovery.

Many medical experts fail to make these distinctions. They will diagnose a “recurrent” disorder when they actually mean a severe and chronic disorder. Clarifying the doctor’s use of specifiers for the course and severity of the claimant’s alleged mental disorder is an important deposition task.

Severity Specifiers Can Help in Estimating Damages
In insurance claims there are often discrepancies between the severity specifier used in narrative diagnosis, numerical code billed and signs and symptoms recorded in the medical records. Insurers should make certain that the descriptive label matches the numerical code used in the records and billing statements. Discrepancies, when present, can seriously undermine the validity of the expert’s medical opinion or indicate that the claimant’s treatment is not directed at the correct disorder.

Dr. Steven Carter, PsyD LP is a licensed psychologist and CEO of Expert Advantage. He specializes in clinical and forensic psychology and can be reached at 218.749.3107 or expertadvantage@mchsi.com.



Dr. Steven Carter, PsyD, LP is CEO of Expert Advantage®, which provides medical evidence analysis, independent examinations and testimony nationwide.

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