The Psychological Aspects of Personal Injury Assessment Related to Post Traumatic Stress Disorders
Article by Dr Ludwig Lowenstein
Abstract & Summary:
The author is concerned with the psychological repercussions of personal injuries when these result in PTSD (Post Traumatic Stress Disorder). The result of such physical injuries is the potential affect on cognitive, emotional (psychological) and behavioural functioning when compared with the previous behaviour before the injury occurred. Psychological tests as well as interviews contribute to the evaluation of the individual, following trauma. PTSD is defined. Some individuals are more prone to long term disturbing symptoms than others. This is due to genetic predisposition as well as past experiences. Some tests such as the MMPI are especially useful to reveal psychological disturbances as well as the potential for malingering or exaggerating of symptoms.
One essential feature of Post Traumatic Stress Disorder (PTSD) is the loss of control which leads to a chronic state of emotional and psychological arousal. This is perceived as unpredictable and dangerous (Veraldi, 1992) in such things as whiplash following motor vehicle accidents (Friedenberg et al., 2006). The result is frequent mood and anxiety disorders, chronic pain, adjustment disorders and somatoform disorders (Mendelson, 1988).
Psychological personal injuries arise frequently when physical injuries occur and especially those that affect the brain functioning. A typical illustration is the occurrence of post traumatic stress disorder (PTSD) responsible for psychological disorders. Sometimes physical injuries, especially when they are to the head, affect cognitive, emotional and behavioural functioning (Koch et al., 2006; Kuhn, 2005).
Assessments require neuro-psychological testing. Both of the most commonly used tests are the Wechsler IQ and Memory Scales. Others are the MMPI, the Eysenck Personality Questionnaire, the Rorschach, the Bender Gestalt, the TAT as well as other tests for minimal brain dysfuction and assessing PTSD. Sspecialised tests which assess PTSD are also used.
Post traumatic stress disorders: What are the effects?:
According to the DSM-IV (American Psychiatric Association 1994), Post Traumatic Stress Disorders are defined by the fact that “the person has been exposed to a traumatic event in which the person experienced, witnessed, or was confronted with an event or events that involved actual and threatened death or serious injury, or a threat to the physical integrity of the self, and the person’s response involved intense fear, helplessness or horror. In children this may be expressed by disorganized or agitated behaviour.”
The traumatic event is persistently re-experienced in one (or more) of the following ways.
Distressing recollections of the event:
“Recurrent and intrusive distressing recollections of the event…” In young children “repetitive play may occur in which themes or aspects of the trauma are expressed. There are recurrent distressing dreams of the event”. In children these may be “frightening dreams without recognizable content” The person may be “acting or feeling as if the traumatic event were recurring” This includes “a sense of reliving the experience, illusions, hallucinations, and dissociate flash-back episodes, including those that occur in awakening or when intoxicated”. In young children, “trauma specific re-enactment may occur.”
Intense psychological distress may occur when exposure to internal or external cues are similar to all or part of the traumatic event. They may also react in physiological ways. There may also be “persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma).” This is indicated by three (or more) of the following symptoms: “efforts to avoid thoughts, feelings or conversations associated with a trauma; efforts to avoid activities, places, or people that arouse recollections of the trauma: inability to recall an important aspect of the trauma; markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; restricted range of affect (e.g. unable to have loving feelings); sense of foreshortened future (e.g. does not expect to have a career, marriage, children or a normal lifespan).
Symptoms of increased arousal:
Persistent symptoms of increased arousal (not present before the trauma) may be indicated by two or more of the following: “difficulty falling or staying asleep; irritability or outbursts of anger; difficulty concentrating: hypervigilance; exaggerated startle response”.
Duration of disturbance and its effects on daily life:
The duration of the disturbance and types of symptoms is important to note as well whether the disturbance causes “clinically significant distress or impairment in social, occupational, or other areas of functioning.”
The condition can occur in children and adults of any age and may be exacerbated by age with older people and women more prone to suffer PTSD (Hagstrom, 1995). Also important are innate and developmental personality feature including high levels of neuroticism (Ackerman & Kane, 1998). It is for this reason, that a full investigation must consider pre and post-trauma experiences and history. Hence we must be concerned with whether there were similar problems before the trauma occurred; how the individual functioned and behaved before the PTSD; how the trauma affected him/her and was likely to do in the future; how much the individual was supported by others such as family, friends, professionals ; how much the individual exaggerated his/her symptoms on a conscious or unconscious level.
The question frequently asked is whether some individuals are more susceptible to PTSD than others. According to the research there is with some degree of certainty that some individuals with particular personalities and previous history of psychological problems are more disposed to gaining PTSD than those without such personalities or problems (Briere, 1997; Young et al., 2006; Koch & Haring, 2008). Contributions to proneness to PTSD are sometimes due to genetic and previous stresses via the environment, or via personal relationships (Scrignar, 1996). There may also be a family history of psychological problems in individuals who are more prone to suffer from PTSD (Ozer et al., 2003).Victims of violent crimes (Frost, 1995) showed female victims suffered more with higher PTSD scores than males.
Assessing personal psychological disturbances such as PTSD:
When assessing PTSD self-report cannot always be taken at face value (Rosen, 1995).
The validity scales of the MMPI-2 are likely to be useful and could indicate whether an individual is exaggerating or feigning symptoms sometimes termed “malingering”(Young & Yehuda. 2006; Nair & Ribner, 2002; Lees-Haley,1992, 1989).. This may be for the purpose of gaining maximum compensation, financially speaking, rather than experiencing undue suffering (Butcher & Miller, 1999). The MMPI-2 can therefore identify faking symptoms. It also has an ‘L’ (Lie) scale and and ‘F’ scale to detect exaggeration or malingering due to choosing items infrequently ticked by the normal population or even by psychiatric patients (Sweet & Morgan, 2009; Marsham, 2001; Arbisi & Ben- Porath, 1995). Symptom validity testing is therefore essential (Nies, 2005).
The MMPI-2 test should be used alongside the Wildman test which is another measure of malingering which contains unusual or unlikely symptoms presented by individuals prone to faking unlikely disturbances. High scores on the MMPI-2 scales 1, 2, 3, and 7 are indicative of positive PTSD unless the anxiety scales are also very high.
Another inventory which can be used alongside the MMPI-2 is the Personality Assessment Inventory (PAI). Those identified with PTSD appear to have high anxiety subtest results. Interviews with clients allegedly suffering from PTSD reveal that they suffer from: recurrent and disturbing dreams, a loss of interest in activities previously enjoyed, feeling detached from other significant people etc. When anywhere near to where a traumatic experience occurred, the PTSD sufferer will exhibit hypervigilance and have a tendency to be irritable. They will also appear to have difficulty concentrating, and have unprovoked and uncontrolled anger outbursts based on aggressive thoughts.
Other measures developed were The Trauma Symptom Inventory (TSI) (Briere, 1995) which consists of 100 items measuring post traumatic stress. Briere (1996, 1995) also developed the Trauma Symptom Checklist for Children (TSCC) and the Post Traumatic Stress Scale (PTSS). Foa (1995) developed a Traumatic Stress Diagnostic Scale (PTS) and Blake et al (1995) developed the “Clinicians Administered PTSD Scale (CAPS).These tests can be used to assess the effects of trauma resulting from domestic abuse, physical assault, rape, suffering from a serious accident and the effect of natural disasters etc.
Another measure, The TSI (Thematic Symptom Inventory) was found to be relatively valid in 85.5% of the time relating to its relationship to PTSD. It contains 10 clinical scales as well as 3 validity scales (Briere, 1997, 1995) measuring defensiveness, and atypical responses, psychoses or dissimulation, and inconsistency responses. The 10 clinical scales are thought to measure anxiety, depression, anger, intrusive experience (flashbacks, nightmares etc), defensive avoidance, dissociation (depersonalisation), sexual concerns including dysfunction such as stress and lack of satisfaction sexually, and dysfunctional sexual behaviour generally. Sometimes impaired self-reference (identity confusion and tension as well as such behaviour as self-harming, aggression and manipulative and suicidal behaviour) also develops.
The Trauma Symptoms Checklist, (TCCL) can be used with children. This measures under-responding and hyper-responding, anxiety, depression, anger as well as dissociation but does not contain items of a sexual nature and cannot be used for children in this respect.
There are a number of other inventories and checklists such as that of Foa’s (1995), Post Traumatic Stress Diagnostic Scale. This is a 49 item questionnaire. Another is the Clinician-Administered PTSD Scale (CAPS) created by Blake et al. (1995) and Koch et al., 2006. It identifies 17 disturbing symptoms. The inventory rates items from 0 – 4. It has been especially used with combat veterans. Finally, there is the Impact of Experience Scale (IES) developed by Horowitz et al., 1979 and consisting of 15 items. These items deal with “intrusion and avoidance”. This has been used with trauma survivors.
PTSD and the Courts:
The court needs a meaningful diagnosis and an explanation of how PTSD is manifested via symptoms such as anger, nightmares, recurring thoughts, problems with concentration, sexual problems, and pain (Middleton et al., 2002) which were not present before the traumatic experience occurred. In order to measure anxiety, memory and concentration problems, the subtests Arithmetic and Digit Symbol on the Wechsler Test can be used.
Severe PTSD is also likely to affect executive functioning. This includes problem-solving, concept formation, abstract reasoning, planning, organization, goal setting, estimation, behaviour regulation, common sense, creativity, working memory, inhibitions or lack of inhibitions, self-monitoring, initiative, self-control, and attentional control and anticipation (Baron 2004). Early intervention to treat the condition is recommended (Blanchard et al., 2004). About 25% of individuals injured in motor vehicle accidents are likely to develop PTSD in the short term following the accident and another 5% later on. About half of those with initial PTSD remit fully or partially a year later with no formal treatment. Those who do not remit tend to have a slow recovery and require psychological and medical care (Blanchard & Hickling, 1999). In fatal accidents some feel guilty for surviving when others did not (Lundin, 1995).
Should a case of PTSD proceed to a Court of Law it is not only crucial that lawyers find an expert witness with the right experience to help them, but the specific symptoms need to be described for that particular client, as they vary significantly for different individuals. There can be no generalization. It is important for Court to know that the number of symptoms, the severity of symptoms and the length of time they will continue, will vary from one person to another. Regular re-evaluation of the individuals condition over time needs to be undertaken in order to consider how much improvement or lack of improvement has occurred.
Personal injury and most of all those injuries causing minimal and major brain dysfunctions affect individuals differently. PTSD is one of the more well known reactions from trauma. PTSD affects the individual cognitively, emotionally, and often behaviourally. It is difficult to establish how long the symptoms will continue and whether they can be totally and permanently relieved. Only continued observation and assessment over time can establish the degree or lack of improvement.
In this review of the research the symptoms of PTSD have been delineated and the main assessment procedures currently used by psychologists have been described. Some cases may proceed to court. It is important to stress that constant re-evaluation needs to be made to see what progress has been made and to make a decision on future prognosis and how this will affect the victim of the trauma. Litigation can therefore be a long drawn-out process and usually only occurs in very serious cases where the trauma and injuries suffered have caused permanent damage to the victim and have impacted on their quality of life and ability to function as they did prior to the trauma.
Dr Ludwig Lowenstein is an experienced clincal, educational and forensic consultant psychologist based in the south East of England. You can find an expert witness and view his profile at X-Pro UK, the innovative expert witness directory.