The Complete Psychiatric Examination – SEAK Medical Training and Information for Attorneys
© 2014 SEAK, Inc.
I’m Attorney James J. Mangraviti, Jr. Lawyers often think of the psychiatric exam with a range of attitudes from skepticism to outright distrust. The examinee is complaining of emotional or psychiatric problems but there may be little in the way of visible injuries or objective findings. How can an attorney convince a suspicious judge, jury or claims executive if the attorney does not understand or believe in the reliability and validity of the psychiatric examination?
To excel in cases involving a psychological component, attorneys need to understand the complete psychiatric examination and how the examining psychiatrist ultimately forms her opinion. An examinee who is undergoing a complete psychiatric examination will usually first be sent to a psychologist to undergo a battery of psychological tests. We call that psychiatrist a medical doctor or MD, who has followed general medical training, with specialty training in diagnosing and treating mental disorders. Such treatment may include use of medication.
Clinical psychologists in addition to other clinical skills receive specialized training in the construction, administration, and interpretation of tests of intelligence, personality, and psychopathology. It is important to remember that the psychological tests and their results are not, in and of themselves determinative of the psychological condition of the examinee. Think of the test results as a psychological equivalent of laboratory results in general medicine. The psychological test results are only one piece of the data the psychiatrist will use in forming her opinion.
The other components include a detailed history, the results of the mental status examination, and a thorough review of the documentary records. Only after considering all of this evidence, will the forensic psychiatrist be prepared to use his skill, training, and experience to form an opinion. Psychologists are, with increased frequency, being asked by counsel to produce the raw notes or data from the psychological tests. This is true, even though the usefulness of this evidence, especially before a lay jury is controversial. Psychologists may attempt to interpose various defenses to avoid producing this information.
“Doctor, I am making a request that you provide me with a copy of your notes from the interview of my client as well as the raw notes and data from the psychological testing that he underwent.”
Dr. Kochansky: Sir, I cannot release the raw data to anyone other than a psychologist trained in the administration, scoring and, interpretation of psychological tests. The American Psychological Association standards of ethical conduct specifically prohibit this. The standard is designed to prevent the misuse of such data by individuals lacking adequate training.
James J. Mangraviti, Jr: Judicial information may be needed to resolve such disputes. Ultimately, the psychologist may have to produce the raw information. Psychological tests are of two types. Objective tests, where the subject is given a prepared list of questions and is asked whether a given statement does or does not apply to him or to what degree it does or doesn’t, the response then being compared to previously established norms. And projective tests, which are used to develop hypothesis about an individual’s motivations, attitudes and psychological defense mechanisms through analysis of his responses to unstructured, ambiguous stimuli.
From a lawyer’s perspective, self-report tests would standardize answers and interpretations are the object of psychological tests. The project of tests, which are open to a wider variety of interpretations are much more subjective. So, Dr. Gutheil, you based your expert psychiatric opinion on the results of the MMPI2 test?
Dr. Gutheil: No, that’s not correct. I based my opinion on the results of all the psychological tests that were performed by the forensic psychologist, Dr. Kochansky and my review of all of the relevant documents, in addition to my interview and mental status evaluation on the examinee.
James J. Mangraviti, Jr: A critical issue often misunderstood by attorneys is that no one responds, not even any one test, tells an examining psychiatrist what he or she needs to know in order to form a valid opinion. Before a psychiatrist renders an opinion, he or she should review the entire battery of psychological tests, review the relevant documentary evidence, conduct a detailed interview and perform a mental status examination.
I will now describe some of the more common psychological tests. Two common personality tests are the Minnesota Multiphasic Personality Inventory in the Millon Clinical Multiaxial Inventory. The most widely used tool for assessing personality is the Minnesota Multiphasic Personality Inventory or MMPI. This test, first developed in the 1940s, was updated in 1989 as the MMPI2. The MMPI2 consists of 567 items that are answered true or false. The tests can be administered to persons with a sixth grade reading level.
In addition to the multiple validity scales, an MMPI consists of ten clinical scales. Hypochondriasis, depression, hysteria, psychopathic deviate, masculinity/femininity, paranoia, psychasthenia, schizophrenia, hypomania, and social introversion. The MMPI2 can also generate numerous content scales that further assist the psychologist in generating interpretive hypothesis about the subject’s personality in the presence or absence of psychiatric symptoms or disorders. These content scales include: Anti-social practices, anger, anxiety, bizarre mentation, cynicism, depression, family problems, fears, health concerns, low self-esteem, negative treatment indicators, obsessiveness, social discomfort type-A and work interference.
Certain scales are used to evaluate the validity of an MMPI2 profile. These include: the cannot-say scale which measures the number of items left blank by the subject, the F scale which reflects the subject’s confusion or an attempt to fake bad by subscribing to symptoms rarely acknowledged by even the most psychotic patients, the L scale which can detect a response dial in which the individual is inordinately concerned about behaving in socially desirable ways. This kind of defensiveness could be seen as faking good. The K scale which measures defensiveness and guardedness. The variable response inconsistency or VRIN scale, which is the total number of times 49 comparable item pairs are answered inconsistently and the true response inconsistency or TRIN scale, which contains 20 pairs of items to which the same response is semantically inconsistent.
Dr. Kochansky, you’ve testified about the TRIN scale and how it picks up inconsistencies. Can you give me an example of what you mean?
Dr. Kochansky: Sure. For example, if a subject answered true to both most of the time I feel blue, and I’m happy most of the time, that would represent an inconsistency.
James J. Mangraviti, Jr: The Millon Clinical Multiaxial Inventory, third edition was first published in 1994 and addresses the evaluation of long-standing personality traits and other psychological problems the subject may have. It consists of 175 statements to which the subject responds true or false. It yields scores on 24 clinical scales and has three validity scales. Fourteen of the scales are designed to reflect personality disorders that appear on axis II of DSM-4. The Wechsler Adult Intelligence Scale and the Shipley Institute of Living Scale may be used to measure intelligence. The most frequently administered intelligence tests for adults is the Wechsler Adult Intelligence Scale third edition or WAIS III.
Intelligence quotient, that is IQ, is determined by a combination of verbal and performance tests. Performance tests are time tests involving visual and motor skills. There are 14 sub-tests including seven verbal sub-tests in vocabulary, similarities, arithmetic, digit span, information, comprehension and letter-number sequencing. In the verbal portion of the exam, the examining psychologist would ask questions similar to those in the following demonstration.
Dr. Kochansky: I’ll be asking you to do a number of things today like giving some word definitions and solving a few number problems. You’ll find some of these tests easy, whereas others may be more difficult. Also, most people don’t answer every question correctly or finish every item but please give your best effort on all of the items. Do you have any questions?
Male: No.
Dr. Kochansky: All right. What does design mean?
Male: Layout.
Dr. Kochansky: In what ways are a lamp and a flash light alike?
Male: They both shine light.
Dr. Kochansky: How much is $24 and $12?
Male: Thirty six dollars.
Dr. Kochansky: Who is Miles Davis?
Male: Jazz musician.
Dr. Kochansky: Why do highways have speed limits?
Male: So people don’t kill themselves.
Dr. Kochansky: Repeat this sequence after me, L 9 3.
Male: L 9 3.
James J. Mangraviti, Jr: There are seven performance sub-tests, which involve visual and motor skills. These are: picture completion in which the examinee is asked to identify a missing detail in a picture, digit symbol coding where the examinee is asked to match symbols with single digit numbers, block design where the examinee must put together blocks to duplicate designs pictured on cards, matrix reasoning, a new sub-test of performance that measures perceptual organization through geometric design in colors that pose visuals tasks for the subject, picture arrangement where the examinee is asked to place in correct order cards with pictures on them so that they tell a story, symbol search which is supplementary, and object assembly which involves putting together something similar to a jigsaw puzzle and is optional.
The Shipley Institute of Living Scale can give a quick measure of IQ and help detect signs of cognitive impairment. It is a written test that does not need a trained psychologist to administer. It is generally thought to measure verbal and overall intelligence better than non-verbal intelligence. The Bender-Gestalt test is a commonly used neuro-psychological test, which is used primarily as a screening test to detect the presence of organic brain injury. Some clinicians may use the Bender-Gestalt test as a projective personality test. Positive findings would lead to further examinations including more specialized testing and possibly imaging studies such as CAT scans or EEGs. This non-verbal assessment consists of nine stimulus cards, which the examinee views and then tries to copy. Consider the following demonstration, which uses geometric figures similar to those used in Bender-Gestalt.
Dr. Kochansky: Here are some figures for you to copy. Just copy them the way you see them. Okay, here is the next one.
James J. Mangraviti, Jr: Serious errors in copying the figures may reveal neurologic or neuropsychological deficits. For example, a person who copies the following figure as shown might have brain lesion leading to a lowering of information in the right visual field. One of the weaknesses of the Bender-Gestalt test is the possibility that the examinee may deliberately draw more poorly than he’s capable of. Commonly used projective tests include the Rorschach inkblot test, the Thematic Apperception test, the draw a person test, and the Rotter incomplete sentence blank test.
The Rorschach test is a series of ten inkblots designed by Herman Rorschach almost a century ago. This is the best known projective test. It has been in active general use sine 1921. The examinee is shown ten inkblots in sequence and asked to report what images he or she sees in the blots. There are no right or wrong answers. Seven of the blots are exclusively or primarily in black ink.
Three involve color blots as well. Scoring an interpretation of the Rorschach is complex, and it generates rich hypothesis about the emotional function and personality of the examinee. A scoring system developed by John Exner has provided a considerable research foundation for such hypothesis. Consider the following example, which uses an inkblot similar to those used in the Rorschach test.
Dr. Kochansky: What might this be?
Male: This could be two aliens kissing each other or it could be the decaying liver of a very sick woman.
James J. Mangraviti, Jr: Both responses to the previous demonstration are whole responses indicating a relatively global cognitive approach as opposed to a focus on more obvious discrete elements of experience. But the two responses reflect very different levels of reality testing. The first response is of adequate form level in that aliens kissing could be seen as consistent with the form of the blood. While a decaying liver is an idiosyncratic poor form level response having little, if any correspondence to the shape of the blood. The morbid content in the second response could be an indication of depression.
The Thematic Apperception or TAT test is a widely used projective test. The examinee is shown a selection of photographs and pictures from a set of 31 picture cards. The pictures have been taken from the depression era, WPA projects, French impressionists, German expressionists, and random photos chosen from various magazines such as Collier’s, Ladies Home Journal, and the Saturday Evening Post from the 30s and 40s.
The subject is shown a selected group of pictures and instructed to tell a story with a beginning, middle, and end about each picture and something about the thoughts and feelings of each character. This examines two functions. One, is the capacity to construct narratives, which is part of mental functioning. The other is the tendency to project one’s own needs, conflicts, feelings, interactional styles, and so forth onto the picture. Consider the following demonstration, which uses a picture similar to those used in the TAT.
Dr. Kochansky: I am going to show you a series of pictures one at a time, and for each, I want you to make up a story. Tell me something about what led up to the events pictured, what’s happening at the time and an outcome as well as something about the thoughts and feelings of the character’s picture. Here’s the first one.
Male: This is a young couple taking a walk with their son who appears to have some kind of a handicap. Something’s wrong with his left arm. Although they want to accept their son’s problem, their sadness never ends and even feel responsible for the handicap, like it’s something to do with their genes. And when the athletic boy runs past them with the dog, this only highlights their son’s physical problem. They never really get over it and it even affects their marriage. They’re always blaming each other for all sorts of things.
James J. Mangraviti, Jr: A response of this kind, reveals in a rather straight-forward way, that the subject is struggling with sadness, perhaps even depression possibly associated with this child’s handicap or instead through displacement someone else close to them or even himself. Were this person a litigant who did, in fact, have a physically handicap son but was claiming emotional damages resulting from an alleged trauma associated with a work situation, one would, in this TAT response, find some support for a pre-existing depressive condition.
In the draw a person test, the examinee is asked to draw a person. Besides giving some information about hand-eye coordination and visual motor skills as neurologic indicators, the person may reveal attitudes towards persons, bodies, or body parts that have clinical significance. Certain repeated patterns of representation have been associated with psychological concerns and conflicts. For example, if the outline has gaps, like in the example shown here, this may suggest problems with ego boundaries, the limits of a person’s sense of self.
Leaving off the hands entirely may convey conflict around aggression. The validity of this test has also been called into question by some forensic psychologists and psychiatrists. One frequently administered sentence completion test, is the Rotter Incomplete Sentences Blank. The examinee is instructed to complete some of the list of 40 sentences that begin with one to three words. In this projective test, the examinee projects her own thoughts and feelings onto the neutral and ambiguous sentence openings.
The psychologist looks for central themes, unexpected or unusual responses and internal inconsistencies and contradictions. For example, in a case where a candidate for security clearance had been noted in an earlier interview to have few friends, the candidate wrote some reference to friends into almost every sentence. He was apparently, consciously, trying to set the record straight. One of the weaknesses of the Rotter test is that it has no scoring system that relates to any diagnosis found in DSM-4. Consider the following demonstration which uses sentence stem similar to those used in the Rotter test.
Dr. Kochansky: Complete the following sentences: I often…
Male: Hear voices criticizing me.
Dr. Kochansky: I would like…
Male: If people would just leave me alone.
Dr. Kochansky: I rarely…
Male: Need a friend I can count on.
Dr. Kochansky: People can…
Male: Hurt you if they get too close.
James J. Mangraviti, Jr: The responses in the previous demonstration could be consistent with a paranoid and avoidant posture in relation to the world. These responses could also give a clue to the problem this person is likely to have with relationships. Detection of malingering is one of the important uses of psychological testing in forensic cases. We have discussed measuring validity in some of the previously described psychological tests.
In addition to these validity checks, specific malingering assessment instruments are now being used with increased frequency in the forensic setting. I will now describe three such tests namely: the validity indicative profile, the malingering probability scale, and the structured interview of reported symptoms. The Validity Indicative profile test consists of 78 verbal and 100 nonverbal items. It was designed specifically to measure malingering and to provide support for conclusions that may impact that awarding of large sums of money or the determination of competency or culpability.
The test classifies an individual’s performance as valid or invalid. Invalid performance is further defined as careless, irrelevant, or malingered. The Malingering Probability Scale is of recent origin. The MPS consists of 139 true/false questions and is designed to help screen for psychopathology and to determine how likely it is that psychopathology is being exaggerated or feigned by the examinee. It screens for malingering by measuring inconsistent responses and endorsement of inaccurate but plausible psychological problems.
The SIRS test is a 172 item instrument, which was specifically designed to detect malingering. It is popular in forensic settings. The items are of three types: detailed inquiries that assess specific symptoms and the severity, repeated inquiries which look for consistency or inconsistency, and general inquiries. Research has found the SIRS test to be a valid instrument. It provides a systematic approach to detect malingering but requires clinical experience to properly administer. Consider the following demonstration which uses items similar to those used in the Structured Interview of Reported Symptoms test.
Dr. Kochansky: Do you suffer from pains in your body?
Male: Yes.
Dr. Kochansky: And do these only occur when there is a full moon?
Male: No.
James J. Mangraviti, Jr: The final category of psychological testing that I will discuss is designed to detect substance abuse. These include, CAGE Questionnaire, the McAndrew alcohol screening test, and the McAndrew alcoholism scale. The CAGE screen may be used to detect alcoholism. Four questions are asked, each question is scored either a one or zero. A total score of two or more is significant.
Dr. Gutheil: I’d like to ask you some questions about your drinking. First of all, have you ever tried to cut down on your drinking?
Male: Yes.
Dr. Gutheil: Have you ever noticed yourself getting angry or annoyed or irritable when people talk to you about your drinking, what happens when you’re drinking?
Male: Yes.
Dr. Gutheil: Have you ever felt guilt over what people say and what you’ve done during the time you were drinking?
Male: Yes.
Dr. Gutheil: And do you ever find you need kind of an eye opener to get going in the morning?
Male: Yeah.
Dr. Gutheil: Okay.
James J. Mangraviti, Jr: Since the subject answered in the affirmative to all four questions, the score of the screen is four. This would most likely lead to a presumption of alcoholism with further test being ordered to confirm. The McAndrew Alcohol Screening Test is similar to the CAGE screen. It consists of a 25 item list of common signs and symptoms of alcohol abuse, it can be scored in about 2 minutes.
The McAndrew Alcoholism Scale is part of the MMPI2 or can be administered separately in about 10 minutes. Raw scores of 28 and above are strongly suggestive of substance abuse. One advantage of the MAC-R scale is that it arouses less suspicion and provokes less defensiveness than the CAGE and MAST screens.
All of the previously described psychological tests are just tools in the hands of skilled examiners. Psychological tests function as both screening instruments and laboratory data to round out the clinical picture obtained from the clinical examination, which will be described in the remaining portion of this program. The test results will be compared to the results of the mental status exam, history, and documentary records before any expert opinions are offered.
There is some controversy regarding the validity, reliability, and scientific basis for some of the projective psychological tests. However, the projective test, which is most likely to withstand courtroom challenges, is the Rorschach test scored with the Exner’s scoring system. One of the most important functions of the trained forensic psychiatrist is to obtain a detailed and revealing history from the examinee.
In psychological injury cases where there may be few objective findings, the examinee’s history, how he relates it, and the ultimate truthfulness and accuracy of the history will play a crucial role in ultimate diagnosis and opinion. The forensic examiner in many ways acts like a skilled detective trained to draw out the examinee and obtain a history, which paints the complete picture. The areas of inquiry in the detailed history include: chief complaint.
Dr. Gutheil: What’s the main concern that brings you here to this office?
Male: Well, I ripped up my knee at work, and haven’t been able to work since that happened, and as a result of not working and hanging around the house I’m just getting depressed and upset.
Dr. Gutheil: I see.
James J. Mangraviti, Jr: When symptoms started.
Dr. Gutheil: When did you first see the signs of depression?
Male: As soon as they told me that they couldn’t fix it and I really couldn’t go back to work anymore, that this was a permanent situation and that I’m basically out of work.
Dr. Gutheil: And when was that?
Male: That was around six months ago.
Dr. Gutheil: I see.
James J. Mangraviti, Jr: Present illness, in reaction to present illness.
Dr. Gutheil: First, let me get a better idea of what you mean by being depressed. It’s different for different people, how do you feel depressed?
Male: I get up in the morning. I don’t feel like getting out of bed. I move much slower than I did before, everything takes longer to do. I have no motivation to do anything and I just sort of sleepwalk through the day.
Dr. Gutheil: Do you have any changes in your appetite?
Male: I’ve lost around 20 pounds.
Dr. Gutheil: Have you? And how about the things you used to enjoy? Do you find that you don’t have the same zest for them as you used to?
Male: I can’t do anything involving physical activity. I used to work out, run and things like that. I can’t do that anymore. I can’t do a lot of stuff with my kids that I used to do, going and playing sports with them.
Dr. Gutheil: What’s it like for you to have these troubles?
Male: It’s terrible. I mean, I used to be a well adjusted man that worked and was fine and had fun and now I’m sitting at home and watching TV all day and wondering what’s going to happen to me.
Dr. Gutheil: Work was really important to you?
Male: Yeah, I had a good attendance record, I enjoyed it, I was good at it, I was being promoted. I would’ve been promoted even more, but now, I’m out, and I’m out just out.
Dr. Gutheil: Yeah.
James J. Mangraviti, Jr: Past psychiatric history.
Dr. Gutheil: Before coming here, have you ever seen a mental health professional of any kind, a psychiatrist, a psychologist, a counselor of any kind?
Male: No, not really, the only time I went is… I went to a psychologist with my wife for some marriage counseling when my daughter was going through her teenage problem… teenage years and we went a couple of times.
Dr. Gutheil: And did you find that it was helpful?
Male: It did. It put it in perspective. They told me it was a marathon, not a short race and wait till the teenage years were over and we’d survive and we did.
Dr. Gutheil: Okay.
James J. Mangraviti, Jr: Past medical history.
Dr. Gutheil: Before this accident, did you have any major medical problems, illnesses, operations, hospitalizations for medical problems?
Male: No, the only time I had ever been in the hospital was when I was born.
Dr. Gutheil: I see, okay.
James J. Mangraviti, Jr: Education.
Dr. Gutheil: How far did you get in school?
Male: I graduated high school. I attended a community college. I almost finished two years but I dropped out.
Dr. Gutheil: I see. When you were in school, how were your grades?
Male: I wasn’t an A student but they were okay, B minus C plus.
Dr. Gutheil: You passed your courses, did you?
Male: Yes.
Dr. Gutheil: And did you have any trouble in school, what we call now juvenile delinquencies sorts of things?
Male: No, I mean, every once in a while I talked up in class, too much or something but other than that, no not really.
Dr. Gutheil: Okay. And did you ever have to see the high school guidance counselor, anybody like that?
Male: The only time I went to the guidance counselor was they were trying to figure out what I might be good at and what job I should go into but other than that, no.
Dr. Gutheil: Okay.
James J. Mangraviti, Jr: Family and psychological history.
Dr. Gutheil: I want to get some questions about your background here. Anybody in your family ever had to see a psychiatrist, psychologist, counselor, any kind of neuro or mental problems in the family?
Male: Well, I would say technically no, nobody ever went. It’s the kind of stoic type people we are but some of them probably should have.
Dr. Gutheil: Tell me what you mean.
Male: Well my brother, you know he acted out quite a bit when he was in school and got into some trouble with the police but in our family, we took care of our own and we didn’t go to a psychiatrist.
Dr. Gutheil: I see.
James J. Mangraviti, Jr: Social habits and substance abuse.
Dr. Gutheil: Do you have any hobbies that you use for enjoyment, maybe before this came on?
Male: I used to enjoy working out, running, and doing some swimming and things like that, which I can’t do now. The only thing now I can do is, I can sometimes go to the movies but even when I go to the movies because of my leg, I have to sit at the back row in those handicapped seats and people look at you funny, like why are you sitting there when it should be reserved for people in wheelchairs.
Dr. Gutheil: Yeah, and how about your use of alcohol, tell me about that?
Male: Well, I used to like to have a couple of beers when I come home from work, I think like most people. Of course I’m not working anymore. And maybe I have more than a couple of beers now but it’s under control.
Dr. Gutheil: How many? Is it a couple or more than a couple?
Male: Four to five.
Dr. Gutheil: Okay. Is that everyday?
Male: Almost everyday.
Dr. Gutheil: Okay. And how about other kinds of drugs, street drugs, things like that?
Male: I never was really into drugs. The only time I did a little experimenting when I was in the 60’s when I was younger and I think everybody experimented with some marijuana in those times.
Dr. Gutheil: Yeah, but how about anything more serious, cocaine, heroin, some of those, amphetamines.
Male: No, I never really believed in that. I’m a kind of person that likes to be in control and when doing those kinds of things, the drugs control you, you don’t control them.
Dr. Gutheil: That’s not yours, not your thing?
Male: Nah, I like to be in control.
Dr. Gutheil: Okay.
James J. Mangraviti, Jr: Vocational Experience.
Dr. Gutheil: Okay, now what is your present job though, the one you would be doing if you didn’t have this problem?
Male: I was just working as a delivery person for a trucking company. I’ve been doing it for, like 14 or 15 years. I’d worked my way up. I had seniority. I could pick and choose when I wanted to work, where I wanted to work, and could get as much or as little overtime as I wanted and I’d the best job in the shop.
Dr. Gutheil: It sounds like you might have enjoyed it. Is that true?
Male: Oh yeah, it was fun. You’re out and about. You’re not sitting behind a desk, no offense, all day long, and you’re out meeting people, and you get to walk around, get a little free time back and forth and it was fun. It was physical work but it was enjoyable.
Dr. Gutheil: Before that, did you have some jobs that you pursued?
Male: I worked once in a brokerage company doing clerical work but I didn’t like that, I didn’t like sitting around pushing papers.
Dr. Gutheil: How did you leave that job, what were the circumstances?
Male: I just quit.
Dr. Gutheil: Okay. While you were doing the job, were you pretty good at it. Did the employers say they were satisfied with what you did?
Male: I had some problems because they tried to get me to work overtime. I didn’t really want to work overtime and I really, could not see myself pushing papers around a desk for the rest of my life.
Dr. Gutheil: Personality conflicts with anyone there?
Male: Well, maybe I didn’t fit in the best but it’s because I really didn’t fit in with the job.
Dr. Gutheil: I see.
James J. Mangraviti, Jr: Legal History.
Dr. Gutheil: Have you ever been trouble with the law in any form. I don’t mean parking tickets but anything more serious?
Male: Well, I once got stopped for, it was a speeding situation. I was speeding and the officer said that he had waved me over when I was in the left hand lane but I didn’t see him. So, they did kind of take me down to the police station but it was a mistake and they didn’t really write me up for it.
Dr. Gutheil: Okay, and was that the only one?
Male: Yeah.
Dr. Gutheil: Okay.
James J. Mangraviti, Jr: Religious history.
Dr. Gutheil: Tell me a little about your faith.
Male: Well I’m Jewish. I was brought up in a Jewish household and we were fairly observant but once I left my household and I was on my own, I really am sort of a non-practicing Jew.
Dr. Gutheil: Okay, at this point in your life, is your religion of any source of strength to you?
Male: I wish it was but I have a lot of trouble with organized religion and faith because I look at what’s going on in the world and millions of people starving and all kinds of strife and I just wonder how God could let that go on. I mean, it just doesn’t make any logical sense to me.
Dr. Gutheil: Okay. That aside, is there a kind of spiritual side to your nature, by your own sense.
Male: What do you mean?
Dr. Gutheil: Well, are there ways in which you see yourself as a spiritual person. I understand about organized religion but are there other spiritual resources you draw on?
Male: Well, when things have gotten really bad, I guess you pray. I mean, but it has to be pretty bad for that.
Dr. Gutheil: And is that something you’re doing now?
Male: I don’t really like to admit it but I do sometimes, hoping that things could get a little bit better.
Dr. Gutheil: Sure.
James J. Mangraviti, Jr: Military History.
Dr. Gutheil: Have you ever been in the military in any form?
Male: Yes, I was.
Dr. Gutheil: And, did you see combat?
Male: I was in Vietnam in ’68. I got drafted and we were in the midst of the Tet Offensive and I did see… I was a grunt and I did see combat. I saw my share of combat and I was lucky to get out of there alive.
Dr. Gutheil: Did you have any particularly stressful experiences, obviously war is stressful to begin with?
Male: Every minute that you’re in the front line is stressful. The people on the left of you on the right of you are dying.
Dr. Gutheil: You bet.
Male: There’s no rhyme or reason about why they’re dying and why you’re not dying and every time you write a letter back home you don’t know if the letter will get there before you do.
James J. Mangraviti, Jr: Marital conflicts.
Dr. Gutheil: How do you find things going in your marriage?
Male: Well, let’s put it this way, I have been married almost 30 years. So, things, there’s a lot of ebbs and flows.
Dr. Gutheil: Tell me about that.
Male: Well, after being married a few years, I learned the key to a successful marriage is never try to win an argument but, even with that knowledge, since I have been out of work and we’re both around the house at the same time, the house doesn’t seem big enough for the both of us.
Dr. Gutheil: Has your injury had any effect on your sexual relations?
Male: Yes, but I don’t know if I should be talking about that.
Dr. Gutheil: Well, it’s part of your experience. What do you notice?
Male: I can’t be as active because of my leg and my wife has to, sort of, be the initiator.
Dr. Gutheil: What’s her attitude towards your being ill?
Male: She feels sorry for me and that doesn’t help either.
James J. Mangraviti, Jr: Death in family or losses.
Dr. Gutheil: How many people in your family that are important to you either died or have been lost in some other way?
Male: My mother died a couple years ago from cancer from smoking and I was very close with an uncle of mine who passed away recently too.
Dr. Gutheil: Are you yourself a smoker?
Male: No, I’m not that stupid.
Dr. Gutheil: Okay. Were you able to go to your mom’s funeral?
Male: Yes.
Dr. Gutheil: And do you feel at this point you’ve gotten over that or is that still something that’s with you?
Male: You always wished that you would have done things a little differently and visited more and things like that but if somebody dies of cancer there’s not much you can do?
James J. Mangraviti, Jr: Medications.
Dr. Gutheil: Are you taking any medications now for your injury?
Male: I take Darvocet. I’m supposed to take four, five a day. I also developed high blood pressure. I take Zestril 10 mg a day and that’s what I’m taking.
Dr. Gutheil: Have you found that you have been able to keep to the Darvocet frequency dosage that your doctor prescribed for you?
Male: No.
Dr. Gutheil: Do you kind of find yourself going on beyond it?
Male: I’m always calling for more pain medication.
James J. Mangraviti, Jr: Psycho social stressors.
Dr. Gutheil: Besides your injury, have you had any other kind of things that kind of prey on your mind that are disturbing for you, stressors for you?
Male: Well, there’s the ongoing problems with my wife because of this and I’m worried about my future, what’s going to happen to me and I’m worried how I’m going to pay for my children’s education.
Dr. Gutheil: Sure.
Male: They’re not going to be getting you know any athletic or other scholarships. I’m wondering where the money’s going to come for that.
Dr. Gutheil: And in addition to what you are going through now are you involved in any kind of litigation, you suing or somebody suing you for anything?
Male: Well, my lawyer told me really not to talk about that too much but I guess I could say that I, as a result of the accident there is a lawsuit for the person that hit me and there’s also a worker’s compensation claim pending.
Dr. Gutheil: And are you finding that being involved in those particularly stressful?
Male: It doesn’t make it any easier because it’s like we don’t… I don’t know what’s going to happen. I asked the lawyer what’s going to happen and he says we don’t… I can’t make you any guarantees.
Dr. Gutheil: Sure.
Male: So, it’s another thing to worry about, whether I’m going to get money or I’m not going to get money… whether I’m going to win or if we lose and if I do win how much I’m going to get, if it’s going to be enough for the rest of my life.
Dr. Gutheil: So, that’s on your mind too?
Male: Yeah.
Dr. Gutheil: Sure.
James J. Mangraviti, Jr: Work impairment.
Dr. Gutheil: I think you’ve made it clear that this really keeps you from being able to work. Do you find yourself able to do anything? Is there any kind of job you think you could do now?
Male: See, the problem is the pain. The pain is so bad, it wakes me up at night and even during the day when I’m awake, I can’t concentrate enough to do anything.
Dr. Gutheil: I see.
Male: I mean, the pain is so distracting that if I sit down to do something and I have to get up five minutes later, I mean I can’t even… I can’t even write checks. I have my wife pay the bills and write the checks and I always used to do that. I just can’t concentrate for more than a few minutes.
Dr. Gutheil: So, even sitting at a desk job would probably be beyond where you are right now?
Male: Well, I already told you that I don’t really want to do a desk job.
Dr. Gutheil: Sure, I know.
Male: But even if I had to do a desk job I couldn’t do it because of the concentration. I mean, I am right in the middle of things and I get this sharp pain and I stop and I don’t know where I started from and any paperwork and checks I have to keep ripping up… I have to void five checks before I write a check even for the gas company.
Dr. Gutheil: I see.
James J. Mangraviti, Jr: Day in their life.
Dr. Gutheil: It might be helpful for me to sort of visualize how things are for you if we walk you through kind of typical day in your life. Let’s start when you get up in the morning and end where you go to bed at night.
Male: I get up… I still get up pretty early. I used to get up earlier but I get up around between 6 and 7 in the morning. I don’t know why because I have no place to go. So, a lot of times I am awakened by the pain, I have to get up to take pain medication. I go downstairs, so as not to wake up my wife. Sometimes I make a little breakfast and pour some cereal or something. I sit around. I go outside, I get the paper, I read the newspaper, I watch a little TV. My wife wakes up. We talk, I watch more TV. Sometimes I read a book. I read a book if I can concentrate enough. A lot of times I can’t, so I just try to read like simple little magazines with short articles and that… I mean it goes on like that the whole day. I mean, stop for lunch. I try to have a schedule but it’s hard to have a schedule because you don’t know where you’re going to be with the pain.
Dr. Gutheil: Sure.
Male: And basically I sit around and I’m doing nothing.
Dr. Gutheil: Are you able to get out of the house at all… having your wife drive you to places, going somewhere?
Male: I get out to go to the doctors. I get out to go to the lawyers offices. Once in a while, I mentioned before, I try to get out and go to the movies. The movies come out on Friday. My big event for the whole week is waiting for the new movie to come out on a Friday and trying to get there on Friday to see the new movie.
Dr. Gutheil: Right.
Male: So, on Wednesday I am starting to think about it and hopefully… [inaudible 00:45:44] back to the front. They’re packing them up in body bags and shipping them back home.
Dr. Gutheil: What was the closest call you personally had?
Male: I was with Fred. We’re walking along, I went back to get something, he stepped on a claymore mine and they are 700 ball bearings and there wasn’t much left to ship back.
Dr. Gutheil: That scene with Fred, has that stayed with you in any way?
Male: It’s never left me. It is with me 24 hours a day, 7 days a week. From the moment that happened and I saw what was left of him and I smelled what was left of him and it was rotting, burning flesh, I’ve never been able to even eat meats since that day. I haven’t eaten a piece of meat since that day.
James J. Mangraviti, Jr: The mental status exam is designed to systematically examine mental and emotional capacities by observation and inquiry in a standardized manner. The mental status exam is further designed to reach past various defenses and mechanisms of compensation to determine an examinee’s true mental condition and functional capabilities.
The components of the Mental Status Examination may vary from examiner to examiner, however, the categories of inquiry and the data they reveal usually take form along the following lines: appearance which includes dress, grooming and outwardly visible phenomena such as ornamentation, tattoos, scars, etc., behavior such as actions, mannerisms, ticks, presence or absence of eye contact, compulsive rituals, postures, gestures and the like, mood and affect which refers first to the overall emotional tone of the examinee, then to the individual feelings or emotions that is the affects expressed.
Mood is to affect, as climate is to weather. For example, an examinee manifesting generally depressed mood may reveal the affects of sadness, anger and anxiety, speech which may be divided into speech form and speech content. Included under speech form may be illogical or disconnected speech patterns, overly rapid and forceful or pressured speech, markedly slowed speech or the completely jumbled, fragmentary known by the colorful term word salad. Speech content refers to what the examinee talks about.
Under this rubric, might be found hallucinations, that is imaginary sensations such as voices heard when no one is present, delusions that is false beliefs that are firmly held despite logical or factual challenge, obsessions which are intrusive ruminations that preoccupy a person, complaints of psychological distress, and realistic concerns about life events or situations. The final category the examiner will look for is intellectual functions.
Much of the information in the intellectual functions category has usually already been gleaned simply by listening to the examinees narrative answers to the general questions that begin the interview. More precise data are captured in the psychological testing described earlier. However, the systematic testing of the examinee’s cognitive capabilities in several areas more precisely define the relevant mental functions in a quantifiable manner. Consider the following demonstration of an intellectual function examination.
Dr. Gutheil: I’d like to ask you some sort of simple questions to test your thinking. First of all, tell me your full name?
Male: Steven Babitsky.
Dr. Gutheil: Okay. Today’s date?
Male: November 19th.
Dr. Gutheil: Okay.
Male: 2000.
Dr. Gutheil: Okay. And, do you know where we are right now?
Male: I’m in your doctor’s office, 1101 Beacon Street?
Dr. Gutheil: Very good. And you know the month?
Male: The month?
Dr. Gutheil: Right.
Male: Yes, it’s November.
Dr. Gutheil: Okay. And do you know which County we’re in?
Male: Suffolk.
Dr. Gutheil: And do you know what City?
Male: Boston.
Dr. Gutheil: State?
Male: Massachusetts.
Dr. Gutheil: Okay. Do you know who the Governor is?
Male: I know who’s supposed to be Governor, Salucci.
Dr. Gutheil: Okay. Fair enough.
James J. Mangraviti, Jr: The first questions asked were called orientation questions. They are a combination of attention and awareness of current events. Does the person know their name, their location, where the examination is taking place and the current date, month, and year? In addition, an examiner sometimes might ask in more sophisticated individuals, the county, the state, the season and other more explicit details.
The next area of inquiry is going to be the fund of information. This usually has to deal with current awareness of events that are relevant to most citizens, typically a review of the presidents, other political officials, current news events and the like. The queries look at the examinees contact with the real world, as well as testing memory and social attention.
Dr. Gutheil: Okay. Now, let me ask you a little question about some of the things that are going on in the world today, for example what are some of the important news stories today?
Male: Well, we’re involved in the presidential election.
Dr. Gutheil: Yeah.
Male: There’s strife in the Middle East. There’s wars going on in Kosovo.
Dr. Gutheil: Good. Okay. Who’s the present President?
Male: Clinton.
Dr. Gutheil: Can you go back a few presidents in reverse order?
Male: Well there was Clinton, Clinton, Bush, Regan, Regan, Ford…
Dr. Gutheil: Can you keep going a little bit further?
Male: Before Ford I really wasn’t paying much attention.
Dr. Gutheil: Okay. What is a prime number?
Male: Prime number is like a number that’s, you can do the square root of?
Dr. Gutheil: Okay. And, what holiday is celebrated on July 4th?
Male: Independence Day.
Dr. Gutheil: And what is that the date of?
Male: The birth of our nation.
Dr. Gutheil: Okay. Very good.
James J. Mangraviti, Jr: The next area asked for is the ability to manipulate numbers. This is a specific function of certain parts of the brain and may be impaired because of actual brain injury, organic disorder, educational problems, attention problems, or difficulties in concentration. Only by putting this information together with other parts of the mental status can the examiner understand the meaning of the finding.
Dr. Gutheil: How are you at arithmetic?
Male: I used to be okay but I’m not as good as before because of my medication and my concentration and stuff.
Dr. Gutheil: Well, let’s try a few simple ones, for example what’s six times five?
Male: Thirty.
Dr. Gutheil: How about three times 17?
Male: Fifty one.
Dr. Gutheil: Okay. How about 48 minus nine?
Male: Forty eight, 39.
Dr. Gutheil: Okay. What’s the square root of 25?
Male: Five.
Dr. Gutheil: Very good.
James J. Mangraviti, Jr: The examiner may ask further mathematically based questions. However, these would be rooted mostly in the ability to concentrate. These questions present an atypical task that the person must remember during the entire process of the testing. An examiner will not ask an examinee to give, for example, the numbers one to ten, people can actually rattle off one through ten with large amounts of the brain missing. But an atypical mathematical process takes greater attention and thus the examiner is checking concentration and the ability to pay attention.
Dr. Gutheil: Okay. Now, what I’d like to do now is start with the number 100 and subtract seven from that. What’s the answer?
Male: A 100, 93.
Dr. Gutheil: Okay. Now, I would like you to keep subtracting seven from the result and so you are going back down by sevens.
Male: Eighty six, 79, 72, 65…
Dr. Gutheil: That’s fine.
Male: Okay.
James J. Mangraviti, Jr: If the individual appears to be able to subtract the sevens with reasonable speed, the examiner can stop at about 65. If there is some question and if the patient makes an error along the way, the examiner can go right back down to the bottom of the numbers in order to test the ability to concentrate on the issue. If the person seems totally baffled by serial sevens as the test is called for short, the examiner can start with 20 and subtract three.
Again, the idea is to give an atypical mental exercise that lower brain functions cannot take over and which could reveal a deficit. For individuals in whom the numerical functions may be impaired because of a neurological disability, brain injury, or mental retardation in some form, sometimes it is valuable to give a verbal problem, such as asking the months of the year in reverse. An atypical verbal problem is chosen because the months of the year going forward can usually be rattled off with large amounts of brain dysfunction.
Dr. Gutheil: I’d like you now to give me the months of the year in reverse order starting with December.
Male: December, November, October, September, August, July, June, March, April, February, January.
Dr. Gutheil: Okay.
James J. Mangraviti, Jr: Memory testing is also used to measure attention level and concentration. The examinee is given three things to remember. After about five minutes, during which time the examinee is distracted talking about something else, the examinee is asked to recall the three things he was asked to remember. This tests short term delayed recall.
Dr. Gutheil: I’m going to give you three to remember and I’d like to first of all say them back right now. We’ll talk about some other things and then I’ll ask you to see if you recall those three things. The three things are green, lamp and 79 Park Street. First of all say them back to me now.
Male: Green, lamp, 79 Park Street.
Dr. Gutheil: I’m going to talk about something else with you for a bit and then I’ll ask you if you remember those three things. You try to remember them.
Male: Okay.
Dr. Gutheil: Now, we’ve been talking about some other things for a bit and I wonder if you remember those I asked you a few minutes ago?
Male: Oh yeah, green, lamp, 79 Park Street.
Dr. Gutheil: Very good.
James J. Mangraviti, Jr: A test to measure sustained comprehension and attention is having the examinee repeat a story. Some people can remember the entire story but most cannot. The Repeat a Story Test is a test of fixed attention, quick memorization, and quick recall. If the person repeats the story back perfectly, then there is probably nothing with much of the person’s attentional capacities. Most people cannot repeat the entire story perfectly the first time.
Dr. Gutheil: I’m going to tell you a short story. I’d like you to try to memorize the story as I tell it and then say it back to me. The story is this. About 300 years ago, at the time of the coronation of one of the Popes, a small boy was chosen to play the part of an angel and in order that he would look as splendid as possible, he was covered from head to foot in shining gold foil. Now, the boy fell ill and although everything was done to revive him except removal of the fatal gold foil, the boy died. Please try and say it back to me.
Male: About 300 years ago, at the coronation of a pope, a small boy was chosen and he was given some gold foil and he had, then, they didn’t… That’s as far as I could get.
Dr. Gutheil: Okay. And can you try and give me a sense of what that story says, what it means?
Male: That, you can never tell what’s going to happen when you’re chosen.
Dr. Gutheil: Okay.
James J. Mangraviti, Jr: Proverb Testing involves the examiner asking the subject what certain proverbs or clichés are trying to say about people. Consider the following examples for Proverb Testing.
Dr. Gutheil: Now, I’d like to ask you some sayings or clichés that people have used and have you tell me what the person who made this saying up is trying to say about the human condition. So, if I tell you, “No use crying over spilled milk,” what does that say?
Male: When something happens, it happens.
Dr. Gutheil: Okay. How about a “Rolling stone gathers no moss?”
Male: You want to keep moving so things don’t catch up with you.
Dr. Gutheil: Okay. How about “People in glass houses shouldn’t throw stones?”
Male: If you have your own problems you shouldn’t be casting aspersions on somebody else.
Dr. Gutheil: Very good. And how about “a golden key can open an iron door?”
Male: If you have the right answer to a problem you can overcome any problem.
Dr. Gutheil: Very good.
James J. Mangraviti, Jr: Proverb Testing looks for various specific capacities and some general data. The capacity to abstract is the latest human function to develop, usually around the age of seven or eight. It is also the first mental function to go when progressive insult to the nervous system occurs from brain damage, mental illness, and especially schizophrenia, which specifically singles out abstracting capacity. Beyond this, Proverbs acts as tiny projective tests in which individuals actually reveal certain aspects of themselves by the particular nuance they give to the proverb. What we saw in the previous demonstration were abstract interpretations of all the proverbs.
Concrete interpretations are an alternative response. Concrete interpretations in alternative response would be the inability to get away from the stone in the moss and that would be the inability to say anything but as the stone keeps moving, the moss can’t stick to it, or the equivalent, literal minded answer in each of those proverbs. It’s also valuable to alter the proverbs in a series of increasing complexity and abstraction. “Look before you leap” is probably the least abstract proverb. It’s the one whose words are closest to its actual implication. The golden key proverb is at a very high level of abstraction and requires a significant abstracting ability.
Our demonstration shows the ability to abstract at most of the levels that we asked. The examiner can actually perform a somewhat quantitative assessment by noting the point in the series where the abstracting ability cuts out. If proverbs become difficult and the person is unable to grasp the proverb, an alternative way to test for abstraction is similarities. In similarity testing, the examiner asks the subject what a certain list of things has in common. The examiner would go from progressively simple comparisons to more abstract ones. Such a sequence gives him a semi-quantitative sense of where the persons’ abstracting ability begins to cut out.
Dr. Gutheil: Now, I’d like you to tell me what two things have in common. For example, what do an apple and an orange have in common?
Male: Both fruits.
Dr. Gutheil: Now, how about a chair and a table?
Male: Both furniture.
Dr. Gutheil: Door and a window?
Male: Both things you find in a house.
Dr. Gutheil: A watch and a yard stick?
Male: Things you use to measure.
Dr. Gutheil: Okay. A fly and a tree?
Male: Both things you find outside.
Dr. Gutheil: Okay, and liberty and justice?
Male: They’re both sort of abstract concepts.
Dr. Gutheil: Okay.
James J. Mangraviti, Jr: The subject may also be asked what the differences between two things.
Dr. Gutheil: Now, I’d like you to tell me how two things are different. For example, what’s the difference between a cable and a chain?
Male: A cable and a chain, a cable is made up of inter round materials and chain has links.
Dr. Gutheil: Okay, and what’s the difference between a painting and a statue?
Male: A statue is made up of a physical metal or molded material and a painting is made up of oil and canvas.
James J. Mangraviti, Jr: Insight simply means that the person understands that he has symptoms, has an illness, is in a hospital and is seeking help or understands at the very least that the hospital is there to help him. Insight does not mean having a sense of man’s role in the cosmos. The following is a demonstration of a subject with insight.
Dr. Gutheil: You know why you’re here today?
Male: Yeah, my depression got worse.
James J. Mangraviti, Jr: Considering the following demonstration where the subject does not have insight.
Dr. Gutheil: You know why you’re here today?
Male: No, I don’t. The police just grabbed me and brought me here for no reason.
James J. Mangraviti, Jr: The final area of testing is the question of judgment. Judgment is tested by giving hypothetical scenarios and having the individual demonstrate their judgment in that area. Of course, some sense of an examinee’s judgment will also be conveyed by the history provided.
Dr. Gutheil: At this time, I’d like to give you some situations and have you tell me how you would handle the situation that I described. For example, suppose you’re walking along the street and you saw a stamped sealed addressed envelope lying on the sidewalk. What would you do?
Male: I’d pick it up and throw it in the mailbox.
Dr. Gutheil: Okay, suppose you were lost in a strange city. What would you do?
Male: I’d ask somebody who probably could help me with directions, like a mailman.
Dr. Gutheil: How about if you were lost in the woods?
Male: I’d try to navigate with the stars.
Dr. Gutheil: Alright. And how about if you were the first person in the movie theater to see a fire break out?
Male: I would leave the theater as soon as possible and notify somebody in authority.
Dr. Gutheil: That’s fine.
James J. Mangraviti, Jr: The examiner in the previous demonstration has asked a few hypothetical situations to see how the person basically handles himself. He didn’t notice any signs of paranoid interpretation. He noticed no sign of thought disorder. He noticed the ability to give reasonable explanations. Once again, however, individuals do describe themselves somewhat in these answers. For example, we heard our subject describe leaving the theater. Other individuals might well say, scream “fire”, or panic, or run out, or seek an usher or various other kinds of reactions.
All of them influenced by certain personality traits that they might demonstrate. No one piece of the mental status examination is definitive or conclusive. The entire database must be taken as a whole. The trained forensic psychiatrist will take and evaluate a detailed history, review the results from the battery of psychological test and the mental status exams and then compare the results with the documentary or corroborative evidence before forming an opinion.
Let’s take a minute to see how a forensic psychiatrist forms his or her opinion in a case.
Once this review is completed, this program will conclude with answers to some commonly asked questions. The trained forensic psychiatrist first screens and evaluates the results of a battery of tests administered by a psychologist. These could include personality test, such as the MMPI2 and MCMI3, intelligence tests such as the WAIS3 and SILS, neuropsychological screening test such as the Bender-Gestalt test, Projective test such as the RISB, draw a person, TAT and Rorschach, malingering tests for example, VIP, MPS and SIRS and substance abuse test such as CAGE, MAST, and MAC-R.
The psychologist takes some or all of the previously mentioned tests or others as may be indicated and summarizes the result. Putting together what one can conclude from the totality of the information and supplies the psychiatrist with a report. That information is held up against the patient’s clinical presentation. The clinical presentation is determined by the extensive interviewing plus the mental status exam. The psychiatrist is looking for consistencies, inconsistencies, elaborations, further details, and discussions. For example, the examinee may strike an observer as eccentric because he is giving unusual responses.
Then the Rorschach may demonstrate that when the stimulus is unstructured, the person reveals himself as really disturbed, though holding it together. So his slight eccentricity on clinical interview could now be understood to mask a latent problem with psychosis underneath. The trained forensic psychiatrist will compare the results of the testing, history and mental status exam with the documentary evidence and records.
The key records will include medical and mental health records, hospital records, school records, vocational and employment records, military records, legal police or witness documents, psychological records and pharmaceutical records. The forensic examination goes beyond the individual by looking for corroborative or discorroborative information in the social field. For example, reports of employers, school, family members, and witnesses to the civil action or crime may all contribute to the final opinion.
That opinion may lead in turn to diagnosis, prognosis, causation, damages, competency, criminal responsibility, and other conclusions as the legal circumstances may determine. Let’s take a few moments to ask Dr. Gutheil and Dr. Kochansky some important questions. On the mental status exam that we demonstrated in this program, are there any right or wrong answers?
Dr. Gutheil: Up to a point, yes. In general, the mental status examination is not a projective test. In projective test there are in fact, no right or wrong answers and what’s really important is what the patient attributes to a neutral stimulus. For example, in psychological testing, there’s the inkblot test, the Rorschach test, which we’ve spoken about and in that test, there is no right answer. The patient is invited to describe what they see in the inkblot. Similarly in the TAT test, which is another projective test, the patient is asked to tell a story about the pictures, to project unto the pictures.
Again, there is no right or wrong answer. The test is designed to have the person place their issues into the neutral pictures. Now, in contrast in the mental status exam, obviously some of the quantitative answers have to be correct. For example, there’s only one correct serial sevens answer. There’s only one correct answer of the sequence of presence and so on. And certain areas for example what the proverbs mean are capable of wide range of interpretation.
For example, the proverb, “The grass is always greener on the other side of the fence,” might be interpreted in terms of envy, in terms of pessimism or optimism, in terms of rivalry or competition, in terms of conflict, in terms of self-esteem or self-deprecation and the like. And none of those would necessarily be a failure to abstract the proverb but each interpretation shows a variation of the theme that’s meaningful in terms of the personal issues that that examinee is bringing to the proverb.
James J. Mangraviti, Jr: How does neuropsychology fit into the forming of an expert opinion?
Dr. Kochansky: When there are initial indications of organic brain injury, for example by an initial Bender-Gestalt screening, additional test specifically design to assess neuropsychological function and impairment may be indicated.
James J. Mangraviti, Jr: What are the confounding factors in the tests that we have described?
Dr. Gutheil: Confounding factors that may influence the test results include intoxication, hearing impairment, mental retardation, the effects of medications, the examinee’s education, their anxiety, their language skills, especially if English is a second language, their uncooperativeness, malingering or faking and the influence of the examiner.
James J. Mangraviti, Jr: What are the expected ways to minimize the confounding factors that you’ve just listed?
Dr. Gutheil: In general, the examiner attempts to identify or reverse those factors that are reversible. For example, the examiner may have to wait for intoxication to clear or for medication effects to wear off. Irreversible condition such as mental retardation must simply be taken into account when forming an opinion.
James J. Mangraviti, Jr: When you talk about reliability and validity, doctor, what do you mean?
Dr. Gutheil: Reliability or repeatability refers to getting the same results consistently. We use the test, retest and alternate forms of questions to check on reliability. Some of the factors that might impinge reliability include learning the test, change in mental status and black market information, smuggled from other patients from the inpatient unit but in general, these results should be reliable or repeatable because they test stable capacities in the examinee.
Validity is the term for the fact that what a test measures is actually what’s out there. When checking validity, we make sure the items adequately sample the key content area and since each of these tests require that the examinee is actually meeting the requirements in the test, the test can be considered valid in demonstrating that particular ability. In other words, if the person can abstract several other proverbs, then they can in fact abstract and there’s no way to take that away from them.
If the person cannot abstract, then may or may not demonstrate an impairment. They may not have grasped the task or there may be a problem with attention deficit or hearing or in the abstraction capacity itself. They may forget the proverb. They pretend to be listening to the proverb and be distracted by hallucination. Many other factors may be involved but basically, if the patient tests out positively correctly on mental medical status examinations those are highly valid results.
James J. Mangraviti, Jr: Doctor, how would you pick up on a patient, “faking it?”
Dr. Gutheil: The mental status examination itself can be used indirectly to test for malingering, faking, or feigning symptoms or simulating responses. A typical response for a malingerers or fakers is they have trouble with the easy questions but not the hard ones. That is, they have an uncharacteristic pattern of difficulty with the questions that should be easier and an ease with the questions that should be more difficult. Highly atypical answers are another clue to faking.
These are mental status questions which can be used to elicit atypical beliefs not found in real mental illnesses. For example, you’d ask about unusual beliefs or beliefs others do not share. After getting some answers you might say, “have you ever have the belief that automobiles are part of organized religion?” A person who says “yes” to that almost certainly malingering since no actual mental patient actually believes that kind of statement. There are a number of similar questions that can be asked that will suggest malingering but keep in mind, malingering is a complex and often exclusion based diagnosis.
A sufficiently sophisticated malingerer could produce clinically correct answers on the mental status examination. Now, separately there’s also a phenomenon known Ganser’s syndrome, which is seen in various high stress situations such as inmates on death row. In this syndrome, Ganser’s syndrome, the individual basically has what’s called the syndrome of inexact answers. You might ask them, how many weeks are there in a year? And the person says 51. That is they gave a wrong answer that suggest some awareness of the correct answer. But there’s a slight change in that correct answer to pretend to have difficulty with it. And that is a form of probably hysterical illness rather than actual malingering. Ganser’s syndrome, though rare, is a reported phenomenon almost a century old and we recognize it as real.
James J. Mangraviti, Jr: What part does the skill, training, and practical experience of a doctor play in the kinds of tests we have discussed in this program?
Dr. Gutheil: Administering some of these tests can be easily done by an artificial intelligence program on the computer because they’re fairly standard straight forward questions with fairly standard responses. In fact, if a patient is speech or hearing impaired, that is not uncommonly done. However, in terms of interpretations, the actual skill and training matter a great deal because the question often is, how much emphasis or weight to give to a kind of impersonal laboratory data?
One could find certain mild problems on parts of the mental status examination which either can be seen as within the variance of normal or as clues to require further investigation to detect more serious psychopathology. For example, many seriously paranoid individuals can do superbly well on all parts of the mental status examination except the proverbs where the underlying paranoia emerges either in a paranoid interpretation of the proverb or the curious finding that individuals once they start interpreting seem unable to stop. They essentially keep firing off interpretations because the problem stir up profound and distressing emotional issues in the paranoid patient.
James J. Mangraviti, Jr: Doctor, how would you use memory test to pick up on somebody trying to pull one over on you?
Dr. Gutheil: Memory test can be used for that purpose. For example, an examinee may say they really can’t do the short term memory test, yet they could rattle off the proverbs without any trouble. A task which would also require understanding, comprehension, interpretation and a memory. In a sense the person who fails all the normal tests yet who give you a perfectly fluent and coherent interview raises a red flag. For example, one is always comparing the interview itself, which goes on for a period of time with what we can demonstrate, in another context from the mental status examination.
The person who can say, “My boss fired me.” And you say, “Well what do you think he was up to?” “Well I think he thought I was a member of the communist party and that’s why he got rid of me.” In a way that response is paranoid but it’s also abstract. It requires you to get into the boss’ head. Now, if that same person claims then to have difficulty with simple proverbs, then there’s an inconsistency between the interview and the mental status examination.
Similarly, if their memory appears to be much worse than it would seem from the way they handle the memory factors intrinsic to the history that would be grounds for suspicion. In some, you’re looking at internal consistency, both within the mental status and between the mental status and the examination itself.
James J. Mangraviti, Jr: What is the psychologist’s role in helping you form your expert psychiatric opinion?
Dr. Gutheil: Psychological tests, which are administered by psychologists, are important part of the examination. Psychologists are scientifically trained to do this particular form of lab work as it were in relation to psychiatry. The psychiatrist usually uses the report from the psychologist about the results of the testing. So, the patient goes first to a psychologist to administer a series of tests such as those we have talked about in this program.
The psychologist who administered those tests is specifically trained at test administration and interpretation. The psychologist gives a report on that testing to the psychiatrist. The psychiatrist then factors that report in together with the clinical picture. It’s really important to understand that testing is not magic. It’s merely a form of systematic examination of certain features often not examined or not examined in sufficient depth by the mental status examination.
Psychological testing is something used by the psychiatrist as a kind of laboratory data and just as a surgeon would not operate because of one abnormal blood chemistry. A psychiatrist should not, nor should a psychologist conclude anything from one result. It’s the group of results taken together in what’s called a battery of psychological tests that together make a report presentation and that report is factored together with the clinical observations of the patient to generate the opinion of what this patient’s condition is.
James J. Mangraviti, Jr: What advantages do psychological testing have over the standardized psychiatric interview that we’ve demonstrated in this tape?
Dr. Kochansky: There are many advantages. These include the validity and reliability of the data gathered.
James J. Mangraviti, Jr: Why doesn’t the psychiatrist administer the psychological tests?
Dr. Kochansky: A psychiatrist is usually not extensively trained in the construction, principles, administration, and interpretation of standardized psychological test.
James J. Mangraviti, Jr: How would you respond to a skeptic of this process who claims that psychiatry is so subjective that you can get an expert psychiatrist to testify to almost anything?
Dr. Kochansky: There’s really two issues combined in your question. First, while good psychiatry has always benefitted from its subjective and personal aspect, there are also some relatively objective aspect such as the psychological testing we’ve been discussing, the diagnostic criteria which has a high reliability, medical tests and procedures, as well as the weight of literature. Second, while there surely are some expert witnesses called hired guns who will say anything for a fee, ethical witnesses are obliged to tell the retaining attorney whether or not the case has any psychiatric validity. Attorneys reviewing this tape are urged to seek out the second type of witness.
James J. Mangraviti, Jr: Could the expert psychiatric opinion’s validity be called into question if the psychologist improperly administered or improperly interpreted the psychological tests?
Dr. Gutheil: Theoretically, yes, but in point of fact, if any element or any fact that went in the expert’s opinion should prove false or invalid, that may or may not change the expert’s opinion depending how critical that particular factor was.
James J. Mangraviti, Jr: Would you consider any expert psychiatric opinion that is not based on all of the evidence discussed in this tape that is a complete battery of psychological tests, a detailed interview in mental status examination and a review of the documentary evidence?
Dr. Gutheil: It’s certainly true that the more complete the available data, the more confidence the expert can have in the eventual opinion. However, not every evaluation requires testing, some cases are straight forward. Recall also that some litigants, for example, in a suicide malpractice case or a will contest, the litigant is dead and not easily examined. Similarly, in psychiatric cases, not everyone general medical record may be directly related to the issue. The basic rule should be all relevant documents should be examined.
James J. Mangraviti, Jr: What is the difference between a forensic psychiatrist and a regular psychiatrist?
Dr. Gutheil: The forensic psychiatrist should have advanced training over and above general psychiatry and medical/legal issues and the relationship of clinical data skills and knowledge to legal issues and criteria. Forensic psychiatrist should be able to translate clinical material first into legal context and then into laid context for the fact finder, judge or jury. There are now board certifications, review courses and national meetings now available in forensic psychiatry, as well as the national organization, the American Academy of Psychiatry and Law.
James J. Mangraviti, Jr: Are there any texts in forensic psychiatry that some of your colleagues may consider authoritative in that field?
Dr. Gutheil: Yes, these are a few. The Psychological Examination for the Courts by Melton and his colleagues, The Clinical Handbook of Psychiatry and the Law by myself and Paul Appelbaum, MD, Principles and Practices of Forensic Psychiatry edited by Richard Rosner, MD and the Clinical Psychiatry and Law Series by Robert Simon, MD.
James J. Mangraviti, Jr: What is meant by the terms compensation and de-compensation?
Dr. Gutheil: Compensation and de-compensation are terms borrowed by psychiatry from general medicine to convey the dynamic nature of physiology comparable to the dynamic nature of psychology. If medical conditions such as congestive heart failure may be present but the patient may be stable, their bodily systems are compensating for the problem maintaining a balance.
Stressors may upset that balance and lead to resurgence of symptoms, hence a de-compensation. Psychiatrically, a person’s schizophrenia say may be controlled with medications and therapy, that is, the illness is compensated for by treatment mechanisms, which may break down on the occasion of, say the death of the patient’s mother, which might lead to a return of psychosis, a de-compensation.
James J. Mangraviti, Jr: What is the meaning of fake good and fake bad?
Dr. Gutheil: Those are shorthand terms involving malingering or feigning. Fake good involves a person who plays down or minimizes his or her symptoms in order to seem better than they are, perhaps for a job qualification. Fake bad involves a person who exaggerates symptoms or creates new ones in order to seem more ill or impaired than they really are for a particular purpose.
James J. Mangraviti, Jr: How does a subject’s ability to draw affect the result of drawing test?
Dr. Gutheil: Now, how well they draw is not significant. What is put in and what is left out is what is important.
James J. Mangraviti, Jr: How reliable and scientifically valid are projective psychological tests?
Dr. Gutheil: These tests again, provide just a piece of a puzzle and help the psychiatrist form an opinion. Now, while some of them lack a solid research basis for interpretation, that’s more art than science, the Rorschach has such a basis and can generate rich and well-founded hypothesis about the patient’s clinical condition.
James J. Mangraviti, Jr: To prove and defend psychological cases counsel must be familiar with the complete psychiatric examination. This program was designed to introduce you to such examinations. We hope you have found it to be useful.
