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How do forensic psychiatrists come to a conclusion?
A traditional psychiatric exam is often insufficient

Dr. Michael MacIntyre
December 2021

Forensic psychiatric experts apply their extensive medical training and clinical experience in psychiatry to assist a court or attorney in answering legal questions. We typically aim to provide opinions with a reasonable degree of medical certainty. Though this term has no officially accepted definition, it has been described as the level of certainty upon which a physician relies when making a diagnosis and starting treatment, supported by current medical and psychiatry practice and state of knowledge.[1]

The cornerstone of a psychiatric evaluation is the psychiatric exam, sometimes referred to in court as an independent medical evaluation. A psychiatrist begins an exam by obtaining a history and chronology of an evaluee’s symptoms, as well as by documenting observed signs and behavior during the mental status exam. In some cases, lab tests, neuroimaging, or neuropsychological testing may be performed for additional data. With this information, a forensic psychiatrist opines on whether or not an evaluee’s presentation is consistent with those seen in certain conditions or responses to trauma.

Considerations for legal evaluations

In a clinical setting, the result of a psychiatric exam allows the psychiatrist to create a biopsychosocial formulation, provide a diagnosis, and begin treatment. In legal settings, however, more information is often needed to fully understand an evaluee. There, the ultimate goal is not treatment, but rather to provide the legal system with a scientifically supported opinion to assist a judge or jury (generally, a trier of fact) in making decisions.

For such purposes, a face-to-face evaluation on its own may be insufficient. For example, an evaluee may have poor insight into their own mental health or a limited understanding of their illness. This can result in a biased or inaccurate self-report and, without additional information, an erroneous conclusion. An evaluee may have a conversion disorder (the unconscious production of symptoms without a known medical cause) or a factitious disorder (the intentional production of symptoms to obtain the benefits of being in the sick role). Or—of particular concern during litigation—they may simply be malingering (intentionally presenting with feigned symptoms for some secondary gain, such as money or a lesser sentence).

A prudent forensic psychiatric expert therefore relies on collateral information to produce an objective report. Helpful data may include neuropsychological testing (including those to provide data about malingering or personality disorders), medical records and doctors’ reports, and assessment of neuroimaging findings. Additional information is gained from review of deposition testimony of witnesses and other experts, review of sub rosa footage, and interviews with people who know the evaluee well. These may include family and friends as well as colleagues, teachers, and employers. Information not originally obtained for medical purposes—such as employee performance reviews or school report cards—often provides valuable information about an evaluee’s mental health and behavior. Psychiatrists will also review legal records pertinent to the question at hand.

Understanding an evaluee’s prognosis—the likely future developments of their mental health condition—is often essential in legal situations. Examples of prognosis include: how long damages will last; what type of treatment will be needed; what is the impact on family, future earnings, and quality of life; and what is the risk of recidivism.

All of this data, together with a personal evaluation, helps the expert provide a formulation and diagnosis (or the absence of one), which drives understanding of a person’s mental health, behavior, reactions to events, and prognosis. The forensic examination consolidates all of this complex data (the exam, testing, collateral reports) into a form easily understood by the trier of fact.

Diagnosis

Often, an expert will uncover symptoms of emotional distress or impairment that do not rise to the level of a diagnosable mental illness. In these cases, it is important that the expert explain these findings, their significance, and the reasons a mental illness cannot be diagnosed—rather than force the symptoms to fit a diagnosis that may be misleading or incorrect. I’ll discuss this further in a future article.


  1. Alternatively, Black’s Law dictionary describes a reasonable degree of medical certainty as an opinion that an injury was more likely than not caused by a specific insult based on the general consensus of current medical knowledge. ↩︎

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