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Psychiatric reports – can you challenge the ‘diagnostic’ tests?

9 January 2018

How often in psychiatric reports prepared for medico-legal purposes do experts cite the results of ‘diagnostic’ tests including the Impact of Events Scale (IES) and the Hospital Anxiety and Depression Scale (HADS) to establish whether or not a claimant is suffering from psychiatric injury?

The IES is a 22 item self-report measure that assesses subjective distress caused by traumatic events. Respondents are asked to identify a specific stressful life event and then indicate how much they were distressed or bothered during the past seven days by each 'difficulty' listed. Items are rated on a five point scale ranging from zero ('not at all') to four ('extremely'). The scale is typically used to assess the severity of post-traumatic stress syndrome.

The HADS is commonly used by doctors to determine the levels of anxiety and depression that a patient is experiencing.

In relation to both ‘tests’ however it must be remembered that they have limitations in terms of their diagnostic usefulness – which is particularly important in a medico-legal setting.

The IES surveys symptoms limited to the week prior to an assessment. It is perhaps unsurprising that a claimant who is being sent for assessment in relation to a specific incident (being the subject matter of his/her claim) highlights that incident on an IES. Given that the scale measures symptoms limited to the last seven days it is arguable that this sort of scale is more useful for monitoring progress in treatment because it rates symptoms on a week by week basis but is of less value in a case when trying to assess the impact of trauma that might have taken place many years ago.

Similarly in relation to the HADS, this is a very sensitive scale that is useful as a screening instrument only, to indicate the need for a more comprehensive mental health assessment rather than a diagnostic measure in its own right.

In relation to both of these scales, they are of course subjective only and rely upon the patient’s self-report. They are standardised for use in clinical or research settings where the respondent has no vested interest in the outcome. In a medico-legal setting, that assumption does not apply and such scales arguably act as prompts or leading questions that are likely to lead to over-reporting symptoms.

It is also the case that recollections distort over time and events can acquire a significance years later that they did not have at the time of the alleged event. This can lead a claimant to attribute harm to events which perhaps did not have that significance at the time. It is therefore always useful to consider a claimant’s wider recollection of events at the time – very often claimants can remember the minutiae of events that are later alleged to be the subject matter of a claim, but recollections of surrounding events are less precisely remembered. This may not necessarily be a conscious attempt on the claimant’s part to defraud, but does open the claimant’s evidence up to question on the basis of reliability. Cross-referencing against contemporaneous records is always beneficial in terms of challenging the claimant’s recollection of events.

Finally, we often see experts recommending treatment for example in the form of trauma focussed psychotherapy or cognitive behavioural therapy (CBT). Caution should however be taken before agreeing significant amounts of treatment as, similarly to medication, if a medication is not effective, administering more of it isn’t necessarily going to help!

It is therefore always worthwhile considering critically the evidence being submitted and where necessary challenge it by way of Part 35 questions or by inviting comment from your own expert.

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