Tales from the Couch

Seeing the patient from psychiatry’s perspective

Who Gives a Diagnosis?

Money and the law

Some years ago, I was called upon by a plaintiff’s attorney to evaluate his client in relation to a personal injury lawsuit. She was a 55-year-old woman who had tripped on an ice-covered sidewalk and fractured an ankle. She also bumped her head, but had not lost consciousness or sustained any other physical injury. The attorney wanted to know if in addition to the fractured ankle, she’d sustained any psychiatric injury. If so, he would incorporate my opinion into the court papers he was filing for her lawsuit.  

Mrs. Smith arrived at my office and we talked for an hour and a half. She had undergone appropriate treatment for the fractured ankle. For several months, she’d experienced considerable pain and difficulty from the injury, but had recuperated and was going about her usual routines with no limitations. When I saw her, she was neither depressed nor anxious; and presented with no psychiatric complaints. Of course, there had been pain and the customary problems associated with the injury itself and her rehabilitation; but those difficulties were in the past and did not figure into the life she was leading when she met with me.

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Mrs. Smith did not have a psychiatric problem, so there was no applicable diagnosis. As such, I telephoned the attorney to tell him my opinion. Our conversation was interesting.

“I don’t see any psychiatric issues in Mrs. Smith’s case,” I told the attorney.

“What about the pain and suffering she experienced after the accident?”

“Pain and suffering aren’t psychiatric diagnoses,” I said. “You already have that in your Bill of Particulars.” (Which is the equivalent of a legal Complaint).

“Can’t you find anything wrong with her?”

“No. She dealt with her situation quite well. She’s recuperated. There’s no psychiatric diagnosis that applies.”

“Can’t you give me anything?”

“I can’t make something up.”

“She hit her head on the sidewalk.”

“She didn’t lose consciousness and didn’t sustain a brain injury.”

“C’mon, Doc, can’t you at least give me post-concussion syndrome?” (Headache, slowed thinking, blurred vision).

“No. Only God can give that.”  

The attorney was quite upset. He’d sent his client to me to enhance his case. He fully expected me to “find” or “give” a diagnosis to Mrs. Smith in the service of her litigation. In essence, he wanted an expert to become an advocate for his client, even if it meant manufacturing a diagnosis for presentation to a jury. 

As I look back over a 25 year span as a forensic psychiatrist, I wish I could say this kind of incident is a rare occurrence. Regrettably, the personal injury arena is replete with exaggeration and outright lies on both sides. When money and the law intersect, truth is often the victim.

Mark Rubinstein, M.D., is a former professor of psychiatry at Cornell. His most recent book is the novel Mad Dog House.

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