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Determining the validity of traumatic stress.

In the 19th century, railroad workers complained of a condition called railroad spine, supposedly attributed to the mental and emotional consequences of back injuries. During the world wars, soldiers' reactions to the stress of combat resulted in the condition known as shell shock or, during World War II, combat fatigue. Not until 1980 did the American Psychiatric Association coin the term Post Traumatic Stress Disorder (PTSD) to describe the sudden onset of relatively severe mental symptoms arising directly from catastrophic events, military or civilian. In retrospect, concentration camp survivors, combat soldiers, as well as civilians involved in disastrous events, are all considered victims of this disorder.

Today, attorneys and insurers are coping with an increasing amount of claims alleging mental distress due to PTSD. Plaintiffs and workers'compensation claimants allege disability resulting from physical traumas, discrimination and job stress. These diagnoses concern psychiatrists because the symptoms are being applied to more and more claimants.

Contrary to other established diagnoses, PTSD was never field-tested for validity and reliability by the American Psychiatric Association. Meanwhile, the boundaries of PTSD diagnosis remain to be determined and have been twice redefined, the last time in 1987. The next revision is scheduled for late 1992. Because the original diagnostic criteria has never been field tested, subsequent revisions make the diagnosis even more problematic. Psychiatric diagnoses, including PTSD, are interpreted and periodically redefined by committee votes, as opposed to medical diagnoses which are determined by scientifically valid procedures.

Establishing Criteria

The official American diagnostic system, commonly referred to as DSM-III-R, or the Diagnostic and Statistical Manual of the American Psychiatric Association, Third Edition, Revised, establishes the criteria for the diagnosis of PTSD. Reports typically enumerate symptoms of the plaintiff, then attribute PTSD as the cause. The diagnosis is specifically reserved for reactions to certain events of an unusual and catastrophic nature. According to the DSM-111-R, the event must be outside the range of normal human experience." Common mishaps such as minor automobile accidents do not qualify. Claims of mental distress arising from, for example, false arrest regarding an individual with a prior arrest also would not qualify. In this age of horrendous actual and fictitious events which are regularly depicted in the media, the question arises as to which occurrences are actually outside the range of human experience.

Another criteria for diagnosing PTSD is that the event must be markedly distressing to almost everyone.' In other words, if the event would not have disturbed most people, an individual, even though experiencing a significant level of distress, would not qualify for this diagnosis. However, this does not mean that the person must be considered normal,' but that another diagnosis, perhaps adjustment disorder, may be more appropriate.

The DSM-III-R lists several events which qualify as precipitators of PTSD. Interestingly, severe automobile accidents and natural catastrophes are described as only rarely causing PTSD. This is an important point, because PTSD claims are commonly attributed to moderate or even minor automobile accidents.

By all accounts, the event must include a substantial probability of danger to the life and limb of the individual, close friends, relatives or neighbors. To emphasize the point, the diagnosis is for survivors of catastrophic events, collective or individual. An individual catastrophic event, for example, includes rape wherein the victim incurs serious physical harm or is killed. If and only if an individual meets the threshold criteria should an appraisal of the symptoms, or alleged symptoms, be undertaken. Ironically, catastrophe victims often hide symptoms of their distress rather than proclaim them to attorneys, medical examiners and other experts.

Questionable Areas

A problem in evaluating symptoms may be the examining physician's difficulty distinguishing between alleged and bona fide PTSD symptoms. Typically, examiners accept allegations of symptoms at face value. Indeed, this may be appropriate practice in clinical medicine, but it may not be helpful in matters involving litigation if it is fraught with possible inaccuracies. The main problem is that many of the symptoms included in the criteria for PTSD overlap with other mental conditions. For example, symptoms such as sleeplessness are difficult to assess, as studies have shown that up to one-third of the U.S. population has trouble sleeping at one time or another.

Another questionable area involves the issue of whether the plaintiff had the symptoms before or after interviews with attorneys and health professionals. It is extraordinarily easy to cue in the patient to demonstrate certain symptoms, because they too realize that their claim requires distress. Take, for example, the case of a flood questionnaire purporting to determine whether individuals are suffering from distress due to flooding of their homes. The questionnaire is loaded with pathological items that immediately alert any fairly intelligent person as to what they should report to win their lawsuit. It is difficult, perhaps even impossible, to determine the validity of alleged symptoms directly from a plaintiff and his or her family and friends who may have vested interests. It is typical, therefore, for the doctor to give the individual the benefit of the doubt.

Usually, a psychiatrist or psychologist will perform a mental status examination which assesses the individual's current distress. If the individual shows no distress, even if he or she alleges it at other times, the plaintiff's physician will report that although the patient showed no immediate distress, he or she experiences distress at other times. On the other hand, the defense's doctor will state that there was no distress and therefore no PTSD. In other words, it all depends on which side you're on.

However, if the plaintiff exhibits distress during the evaluation, the plaintiff's doctor will certainly regard it as evidence of PTSD. The defense's doctor, on the other hand, does not know whether the individual's distress is genuine, contrived or exaggerated. In actuality, psychiatrists have no reliable method of determining truthfulness. How then can the examiner form an opinion as to the validity of the alleged symptoms? Obviously, in most cases it is a judgment call, which undoubtedly accounts for the wide discrepancies among examiners. Perhaps the best, but least practical, method of confirming an individual's symptoms or impairment is through disinterested witnesses, not friends or relatives.

Psychological testing should also be used to evaluate PTSD claims. However, psychological testing is substantially more subjective than most people realize. The validity scales on the Minnesota Multiphasic Personality Inventory Test can be applied, and there are several new scales which address the issue of exaggeration. Additional information can be obtained by reviewing the responses the individual made to specific questions. For example, a depressed' individual would not answer yes to a statement such as I enjoy exciting activities.

A careful review of medical records can reveal valuable information. It is important to pay attention to whether physicians were consulted directly by the plaintiff or arranged for by the plaintiff's attorney and to the length of time that elapsed since the incident. Treatment records from mental health professionals are also relevant. Yet many of these experts do not take notes or, if they do, do not make them available for subpoena. Therefore, it might be better to question the plaintiff first as to whether the therapist made notes and then subpoena them if possible.

Mental health professionals aligned with the plaintiff s attorneys will usually exclude notes that do not deal specifically with the trauma. Accordingly, information concerning alcoholism, marital distress and drug abuse is missing from their records. If treatment notes from clinicians who are not associated with plaintiff's attorneys indicate that treatment was focused on the trauma at hand, there should be no question that the medical expense was justified. Unfortunately, many times only typewritten reports are available which tend to be clinical in nature. For instance, an individual is usually referred to as a patient even though he or she may be a litigant.

Hospital records should be obtained in their entirety. Frequently, the nurse's handwritten notes are informative in contrast to the physician's typewritten summaries. Attention should also be paid to the frequency and length of the patient's off-ground passes. It is typical for physicians to have a vested interest in helping patients for medical and legal reasons. This does not imply that medical records are spurious and unreliable, but merely illustrates that all evidence must be viewed with a degree of skepticism.

Addressing the Disability

If it is established that the individual truly suffers from PTSD, there is still a gap between that diagnosis and the disability assessment. Contrary to popular belief, a psychiatric diagnosis is not automatically equated with a disability. Severe psychiatric diagnoses can result in little disability and vice versa. The majority of patients seen in psychotherapy are gainfully employed full-time, regardless of diagnosis. Being 'too sick to work' is a condition rarely seen in clinics, although by no means is it unusual in matters involving a lawsuit.

Because PTSD is caused by exposure to overwhelming stimulation of a distressful nature, the human response is to shut out the repercussions of the event by trying to avoid re-experiencing the painful emotions that led to the trauma. Those emotions may be guilt for being a survivor, grief, anger or rage. Treatment, therefore, should focus on helping the individual experience those painful emotions in a safe environment within a controllable range. Such treatment in the military took place three to five days from the front line. However, the farther a soldier was sent from the front line, the more difficult it was for him to return to combat duty. Indeed, when strong secondary gain elements exist, such as winning a lawsuit or possibly receiving care and attention from family, friends, relatives and physicians, there may be less motivation for recovery.

On the other hand, persons motivated for recovery can be treated expeditiously through several techniques. Unfortunately, treatment often consists of merely dispensing medication to help the person feel better,' which can lead to drug dependency and a lack of interest in working to resolve the trauma. One to three months of vigorous psychotherapy followed by several more months of check-ins may be normal. Many mental health professionals are wary of eliciting strong emotions from their patients, and prefer instead to baby sit to help them relax. This does little for patients, except convince them that they are essentially untreatable.

It is well-known in the mental health profession that the more rapid the onset of a mental condition, the more favorable the prognosis. It happens to be the subtle, insidious mental conditions that often become chronic and refractory to treatment. Accordingly, an identifiable stressor, creating a specific condition, yields relatively easily to intervention.

PTSD should not be confused with the normal grieving of a survivor for a loved one. The mourning process can take one to two years and does not mean that the individual is sick.' In these situations, the mourning process may take precedence over focusing on the repressed emotions of PTSD. Regardless of the legitimacy of the PTSD diagnosis, it must be considered a reality by both sides. Accordingly, a competent diagnosis that is promptly applied can do much to rebound the individual to good health. The possibility for conflict between a speedy recovery and maximizing damages should be considered, but by defense and plaintiff's counsel alike.
COPYRIGHT 1990 Risk Management Society Publishing, Inc.
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1990 Gale, Cengage Learning. All rights reserved.

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Author:Marcus, Eric H.
Publication:Risk Management
Date:May 1, 1990
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