Mental Health: When emotional factors are central to a case, attorneys should consider using the
“Diagnostic and Statistical Manual.” This book covers more than 400 mental disorders.
Richard M. Samuels, Ph.D.
The “Diagnostic and Statistical Manual” is considered the “Bible” of the mental-health profession. Its use in court by an expert witness can often influence the outcome in cases where emotional factors play a role. The more an attorney knows about the uses and limitations of the DSM, the better he or she can represent the client.
The DSM was initially published by the American Psychiatric Association in 1952 and was the first official manual of mental disorders to focus on clinical utility. It was designed to be consistent with the World Health Organizations’ publication Internal Classification of Diseases, which, by that time, was the standard for diagnostic nomenclature of all diseases.
The manual, in its fourth edition, is referred to as DSM-IV, providing specific diagnostic criteria for about 440 different mental disorders.
While there is an imperfect fit between these categories and specific questions of ultimate concern to the law such as competence, criminal responsibility or disability, the DSM-IV criteria can still be a great utility in many types of forensic matters.
The DSM-IV uses a multiaxial assessment system. Each axis refers to a different domain of information and may predict prognosis. The five axes included in the DSM-IV are discussed below.
Axis I, “Clinical Disorders and Other Conditions Which Are the Focus of Clinical Attention.” Axis I disorders are the primary diagnoses in most cases and usually the ones that would bring an individual to be initially diagnosed or treated. Among the examples of Axis I diagnoses are depression, anxiety (including post-traumatic stress disorder), phobias, schizophrenia, sexual and gender identity disorders, substance abuse, and adjustment disorders.
Diagnoses of depression, post-traumatic stress disorder, generalized anxiety, adjustment disorders, phobias, panic disorder and somatoform disorders may possibly be caused by the emotional impact of an accident, medical malpractice, sexual assault, or other traumatic event. Axis I disorders often emerge in response to specific situational stresses and may vary in intensity based on environmental conditions and time.
An example of an obvious trauma-related Axis I disorder occurred to a young man who was seen as a patient by this writer. The 32-year-old married man had been driving his car over a bridge, which was undergoing renovation, when a piece of scaffolding fell onto his vehicle. While escaping physical injury, he developed a fear, or phobia, o crossing that bridge that generalized to other bridges and tunnels. He became unable to work at his former job as an outside salesman.
His suit against the firm handling the construction included claims of emotional damage, which led him to leave his job. Ultimately successful in the treatment of his phobic condition, he suffered financially from its effects. He had to find a lower-paying job in a field that did not require him to be on the road.
An Axis I diagnosis by itself does not carry any necessary implications regarding the causes of an individual’s mental disorder or degree of control over the associated behaviors. Axis II diagnoses and Axis III and IV conditions and problems, however, can add sufficient information to permit the linkage of the primary diagnosis of Axis I with the related fact pattern of the case.
Axis II, “Personality Disorders, Mental Retardation.” Axis II codes personality disorders and mental retardation. Mental retardation is usually diagnosed in childhood and will not be covered here. Personality disorders refer to the existence of a pattern of personality traits that are inflexible and maladaptive, thus causing significant functional impairment or subjective distress. Personality disorders often first appear in adolescence or early adulthood and tend to remain stable over time. Many individuals with personality disorders do not see their characteristics as being problematic.
The existence of normal personality traits that do not qualify for a maladaptive disorder, or personality disorders that are not likely to produce certain Axis I conditions, can often help the forensic psychologist attribute Axis I disorders to a specific trauma. There are several types, or groupings, of personality disorders, but their description lies outside the scope of this article.
Axis III, “General Medical Conditions.” Axis III reports general medical conditions that are potentially relevant to the understanding of the individual’s mental disorder. For example, this writer recently evaluated a case for a plaintiff’s attorney in which a young woman underwent a purportedly simple, same-day laser surgery procedure on her back. She wound up temporarily paralyzed, experiencing great pain in her back and one of her legs. She underwent a lengthy hospitalization, extensive rehabilitation, and two additional back surgeries.
Seven years later, she remains on disability and still experiences pain, requiring narcotics to remain mobile. At this point, her life and thinking revolve around pain. Since some of her symptoms do not respond to medical treatment, she suffers from anxiety and depression; this condition magnifies her pain, while the pain itself leads to episodes of panic. The condition, as well as her preoccupation with physical problems, was diagnosed on Axis I as a “somatoform disorder.” A description of her general medical condition on Axis III helps to reference her Axis I disorder.
AXIS IV, “Psychosocial and Environmental Problems.” Axis IV is used for reporting psychosocial and environmental problems that may affect the prognosis of mental disorders on Axes I and II. A psychosocial or environmental problem usually relates to the context in which a person’s difficulties have developed and are helpful in conveying to the jury the specific circumstances that caused the Axis I disorder.
For example, a young single woman was living in an apartment complex that claimed to have outstanding security, including restricted assess to the property. On a hot summer day while she was preparing a cooling bath, an intruder climbed into her open kitchen window and raped her. She became pregnant and had an abortion, a procedure forbidden by her religion and her minister father. She developed a post-traumatic stress disorder, severe guilt, and depression. She has been unable to establish a healthy heterosexual relationship due to anxieties that developed as a consequence of the rape. The Axis IV coding permitted the jury to understand the impact of the alleged negligence by the housing management and helped her to obtain a settlement on the basis of emotional damage.
AXIS V, “Global Assessment of Functioning.” Axis V reports the clinician’s judgment of the individual’s overall level of functioning, using the GAF scale. This Axis is especially useful in forensic settings where both emotional and physical damages are claimed, as it specifically does not include impairment due to physical or environmental limitations. The GAF scale is rated on psychological, social and occupational factors only.
Typically, the score, which can range from zero to one hundred, is reported for the current period (the time of the psychological evaluation). Specific criteria for scoring are provided in the DSM-IV. However, and again most useful in forensic settings, one can estimate the GAF score for the preaccident, pretrauma period based upon the client report, and to some degree, the more stable personality factors of Axis II.
Jurors can quickly grasp the implication of a lower, posttrauma score. Forensic mental health specialists often overlook the utility of this simple score and the astute attorney should request it from the diagnostician.
T he DSM-IV and its multiaxial assessment system has proven to be useful in forensic settings, although it was originally designed for clinical purposes. Its careful and thoughtful use can help an attorney demonstrate the relationship between trauma and subsequent emotional damage within reasonable psychological or medical certainty. This same approach is also important to the defense attorney, who may be able to show that claimed Axis I disorders may likely have predated a trauma, or that an individual may be prone to exaggeration or engaging in malingering.
The forensic mental health expert is in a unique position to provide this data. The attorney who understands the strengths and limitations of the DSM-IV will be in the best position to use this information.