When is a Post Traumatic Stress Disorder Claim Legitimate…and When Is It Not?
When is a Post Traumatic Stress Disorder Claim Legitimate…and When Is It Not?
by Mark I. Levy, M.D. Asst. Clinical Professor Psychiatry
University of California San Francisco
School of Medicine
(expanded version of article published in For the Defense, November 1995)
In prehistoric times, when our earliest ancestors lived in dread of their mortal enemy, the saber-toothed tiger, those cave men (and women) who were fortunate enough to be genetically endowed with the quickest “fight or flight” reactions survived, and became our ancestors. That’s where the story begins… a story which flourishes today in a medical-legal climate where Post-Traumatic Stress Disorder (PTSD) claims comprise a substantial and costly portion of personal injury and employment litigation….
Until recent years, personal injury claims generally alleged orthopedic injuries from automobile, industrial or slip and fall accidents. A small portion alleged neurological injuries, but those involving the brain were limited to closed head injuries and brain trauma: mental trauma, i.e., psychological injury, was rarely a basis for litigated claims. However, the recent sea change in our cultural and social attitudes has resulted in an epidemic of psychological injury claims not only in connection with personal injury suits but also as a by-product of “repressed memory/false memory” hysteria as well as in the field of employment law where sexual harassment and discrimination claims alleging PTSD are growing with leaps and bounds. The dramatic size of several recent psychological injury/ sexual harassment awards (e.g. $7 million punitive damages against the San Francisco law firm Baker and Mckenzie) has not escaped the attention of trial attorneys. As a result, the plaintiff’s bar is developing increased psychological sophistication, both in selecting cases and litigating them. Consequently, in both Personal Injury and Employment Law, Psychological Injuries now comprise an important component of claims. This change in the litigation climate makes it essential for both insurance and employment law defense counsel, as well as claims adjusters, to become knowledgeable about the medical-legal concept of mental trauma.
Among the various psychiatric diagnoses found in psychological injury claims, the major stress diagnosis, PTSD, is one of the most highly compensated. Consequently, in recent years natural disasters (such as earthquakes, floods or fires) or man-made disasters (such as airplane crashes, industrial accidents, assault, rape) as well as workplace allegations of discrimination, abuse or sexual harassment, have generated a rising tide of psychological damage claims with allegations of PTSD. As a result, in order to properly manage these claims, both defense counsel and insurance claims adjusters require a sophisticated and detailed understanding of the psychiatric diagnosis of PTSD: what it is, and — possibly more importantly — what it is not.
The diagnostic criteria for PTSD are complex encompassing event, re-experiencing and numbing phenomena. Although some claimants unquestionably meet these criteria, other individuals may not. Knowing how to distinguish between the two groups will make it easier for a defense team to defeat inappropriate claims as well as rapidly settle and avoid costly litigation of claims that are clearly legitimate.
Since many members of the plaintiff’s bar remain unsophisticated in their understanding of how to assess and litigate psychological injuries (as opposed to the more concrete closed head injuries), the defense team with a good understanding of the nature of this type of injury will have a decided advantage.
WHAT IS DSM-IV?
PTSD, like all psychiatric diagnoses used in medical-legal consultation, derives its authority from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, published by the American Psychiatric Association (DSM-IV, May 1994). This psychiatric diagnostic compendium is divided into chapters covering the entire landscape of mental disorders and conditions. The comprehensive manual assigns all psychiatric diagnoses (as well as assessments of functional impairment) to a 5-axis diagnostic system. At the present time the DSM-IV is considered the diagnostic “Bible” in medical-legal psychiatric evaluations. Consequently, a working understanding of DSM-IV is essential to evaluating and defending any claim of alleged psychological injury.
THE HISTORY OF PTSD
Called PTSD since the Viet Nam War, this condition had a long and interesting history. This stress syndrome has been called many things in the 150 years since it was first recognized but every definition had several characteristics in common, including re-experiencing, numbing and physiological arousal. The process of Darwinian “natural selection” supported the evolution of people with highly developed stress responses; those pre-historic people with the most effective “fight or flight” reflexes became our ancestors. Curiously, during the 19th Century, what is known today as PTSD was called “Railway Spine” and was associated with what we would today call “hysterical” physical symptoms — i.e. “anxiety” expressed as bodily complaints — seen in people who had been involved in railway accidents but who suffered no bodily injuries.
FIGHT OR FLIGHT
“Fight or flight” is driven by the neuro-chemical hormone adrenaline and results in a range of psycho-physiological responses to danger. These include increased pupil size so that more information can enter the eye, increased heart rate so that oxygen can be pumped to the muscles and brain, and the conversion of glycogen to glucose so that rapidly contracting muscles and essential organs are supplied with sufficient energy to function. These physiological changes encourage men and women to become aggressive or rapidly run away when confronted by danger.
Modern man is still “hard wired” with this physiological reflex–it is our legacy from ancient times. However, when a man or woman employed in business or a profession is feeling threatened in their workplace or boardroom, they would be regarded as bizarre if they suddenly rose from their chair and ran from the room or engaged in physical combat with an opponent. Under most circumstances, threats as perceived may not be threats in reality and the threatened person must sit and bear it. This conflict between our minds and our physiological reflexes is responsible for the modern medical entities known as Stress Response Syndromes. Stress is also responsible for a range of secondary illnesses that can arise from the work environment including cardiovascular and immune system diseases.
PTSD is a condition that arises from exposure to life-threatening circumstances and it was first diagnoses among some of the survivors of wartime combat. Throughout W.W.I the syndrome was known as “Shell Shock” and was thought to be primarily motivated by the soldier’s effort at self preservation. In World War II it was called “War Neurosis” or “Combat Fatigue.” The modern diagnosis of PTSD, a by-product of the Viet Nam War, falls within the general DSM-IV category of “Anxiety Disorders,” sub-category of “Stress Disorders.” Listed below are the DSM-IV’s diagnostic criteria for PTSD, followed by my detailed discussion of these criteria.
DIAGNOSTIC CRITERIA FOR 309.81
POST TRAUMATIC STRESS DISORDER
A. THE PERSON HAS BEEN EXPOSED TO A TRAUMATIC EVENT IN WHICH BOTH OF THE FOLLOWING WERE PRESENT:
- THE PERSON EXPERIENCED, WITNESSED OR WAS CONFRONTED WITH AN EVENT OR EVENTS THAT INVOLVED ACTUAL OR THREATENED DEATH OR SERIOUS INJURY, OR A THREAT TO THE PHYSICAL INTEGRITY OF SELF OR OTHERS
- THE PERSON’S RESPONSE INVOLVED INTENSE FEAR, HELPLESSNESS OR HORROR. Note: In children, this may be expressed instead by disorganized or agitated behavior.
B. THE TRAUMATIC EVENT IS PERSISTENTLY RE-EXPERIENCED IN ONE OR MORE OF THE FOLLOWING WAYS:
- RECURRENT OR INTRUSIVE DISTRESSING RECOLLECTIONS OF THE EVENT, INCLUDING IMAGES, THOUGHTS OR PERCEPTIONS. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.
- RECURRENT OR DISTRESSING DREAMS OF THE EVENT. Note: In Children there may be frightening dreams without recognizable content.
- ACTING OR FEELING AS IF THE TRAUMATIC EVENT WERE RECURRING (INCLUDES A SENSE OF RELIVING THE EXPERIENCE, ILLUSIONS, HALLUCINATIONS AND DISSOCIATIVE FLASHBACK EPISODES, INCLUDING THOSE THAT OCCUR ON AWAKENING OR WHEN INTOXICATED). Note: In young children, trauma-specific reenactment may occur.
- INTENSE PSYCHOLOGICAL DISTRESS AT EXPOSURE TO INTERNAL OR EXTERNAL CUES THAT SYMBOLIZE OR RESEMBLE AN ASPECT OF THE TRAUMATIC EVENT.
- PHYSIOLOGICAL REACTIVITY ON EXPOSURE OR INTERNAL OR EXTERNAL CUES THAT SYMBOLIZE OR RESEMBLE AN ASPECT OF THE TRAUMATIC EVENT.
C. PERSISTENT AVOIDANCE OF STIMULI ASSOCIATED WITH THE TRAUMA AND NUMBING OF GENERAL RESPONSIVENESS (NOT PRESENT BEFORE THE TRAUMA), AS INDICATED BY THREE (OR MORE) OF THE FOLLOWING:
- EFFORTS TO AVOID THOUGHTS, FEELINGS, OR CONVERSATIONS ASSOCIATED WITH THE 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
- FEELING 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 LIFE SPAN)
D. PERSISTENT SYMPTOMS OF INCREASED AROUSAL (NOT PRESENT BEFORE THE TRAUMA), AS INDICATED BY TWO (OR MORE) OF THE FOLLOWING:
- DIFFICULTY FALLING OR STAYING ASLEEP
- IRRITABILITY OR OUTBURSTS OF ANGER
- DIFFICULTY CONCENTRATING
- EXAGGERATED STARTLE RESPONSE
E. DURATION OF THE DISTURBANCE (SYMPTOMS IN CRITERIA B,C AND D) IS MORE THAN 1 MONTH.
F. THE DISTURBANCE CAUSES CLINICALLY SIGNIFICANT DISTRESS OR IMPAIRMENT IN SOCIAL, OCCUPATIONAL OR OTHER IMPORTANT AREAS OF FUNCTIONING.
ACUTE: IF DURATION OF SYMPTOMS IS LESS THAN 3 MONTHS
CHRONIC: IF DURATION OF SYMPTOMS IS 3 MONTHS OR MORE
WITH DELAYED ONSET: IF ONSET OF SYMPTOMS IS AT LEAST 6 MONTHS AFTER THE STRESSOR
ref: from The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, published by the American Psychiatric Association (DSM-IV), May 1994.
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PTSD IS A DISCREET PHENOMENON, NOT A CONTINUUM
Like pregnancy, PTSD is defined as something one has or does not have: for medical-legal purposes, there are no “shades of PTSD gray” (even though in actuality and in some current research, the condition is viewed more in terms of a gradient of symptoms). Medical-legally, however, one is either in or out of the diagnosis, according to whether or not the individual fulfills the six specific, detailed criteria, the so-called “A-F” criteria.
THE “A” CRITERIA, THE EVENT: A THRESHOLD CONCEPT
In a nutshell, the “A” criteria require an individual to have been exposed to a life-threatening circumstance. Earlier incarnations of the DSM used a broad and overly inclusive yardstick, “outside of the range of normal human experience,” but this criterion was considered too loose and was easily abused in its interpretation. With the recent publication of DSM-IV , the “A” criteria have been tightened considerably. The new wording requires that “the person experienced, witnessed or was confronted with an event or events that involved actual or threatened death (emphasis added) .” Even the secondary phrase, “or serious injury, or a threat to the physical integrity of self or others” implies a grave degree of bodily threat. It was the intention of the DSM-IV subcommittee to tighten the “A” criteria so that it conformed more closely to the kind of actual life-threatening circumstances, such as combat, where PTSD was first observed. In essence, the trauma must be sufficiently severe that it ruptures a person’s “bubble of invulnerability.” Most of the time people avoid thinking about the possibility of death in order to carry on their daily lives without constant, high levels of anxiety.
THE RE-EXPERIENCING OR “B” CRITERIA
PTSD victims re-experience the trauma over and over and over again, in a variety of different ways. This results from the psyche’s effort to “master” overwhelming perceptual stimuli. The event is revisited repeatedly in an effort to manage and eventually integrate the traumatic stimuli that originally overwhelmed the victim’s psychological equilibrium. The “B” criteria include five different re-experiencing phenomena, any one of which is deemed sufficient to meet this diagnostic criterion.
· RECURRENT OR INTRUSIVE DISTRESSING RECOLLECTIONS OF THE EVENT, INCLUDING IMAGES, THOUGHTS OR PERCEPTIONS. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed
PTSD victims are never able to quite “forget” the event which traumatized them. They think/dream about it intermittently throughout their waking (and sleeping) hours and often feel persecuted by their inability to repress the recurrent distressing images.
· RECURRENT OR DISTRESSING DREAMS OF THE EVENT. Note: In Children there may be frightening dreams without recognizable content.
These recurrent images of the trauma intrude upon the victim’s sleep in the form of disturbing dreams and nightmares. Unlike normal dreams, which utilize symbolism to conceal from consciousness the dreamer’s actual life conflicts and concerns, PTSD dreams are often literal representations of the traumatic event. The starkly realistic presentation of the dreamer’s traumatic experience reflects the psyche’s inability to master, process and integrate these overwhelming stimuli, through the disguising processes of sublimation and symbol formation.
· ACTING OR FEELING AS IF THE TRAUMATIC EVENT WERE RECURRING (INCLUDES A SENSE OF RELIVING THE EXPERIENCE, ILLUSIONS, HALLUCINATIONS AND DISSOCIATIVE FLASHBACK EPISODES, INCLUDING THOSE THAT OCCUR ON AWAKENING OR WHEN INTOXICATED). Note: In young children, trauma-specific reenactment may occur.
The victim frequently feels a sense of deja vu as if reliving the experience, sometimes in the form of illusions or hallucinations, frequently when in physiologically altered states of consciousness such as those induced by alcohol, drugs or sleep. Young children may actually re-enact the traumatic events in their play behavior, alone or with others.
· INTENSE PSYCHOLOGICAL DISTRESS AT EXPOSURE TO INTERNAL OR EXTERNAL CUES THAT SYMBOLIZE OR RESEMBLE AN ASPECT OF THE TRAUMATIC EVENT.
PTSD victims may experience extreme anxiety or even panic upon exposure to circumstances that either literally or symbolically remind them of the traumatic circumstances.
· PHYSIOLOGICAL REACTIVITY ON EXPOSURE OR INTERNAL OR EXTERNAL CUES THAT SYMBOLIZE OR RESEMBLE AN ASPECT OF THE TRAUMATIC EVENT.
Traumatized Viet Nam War combat veterans, for example, frequently confuse their perceptions from ordinary experiences of every day life with those that date back to the traumatic event. For example, a traumatized combat veteran hearing an automobile muffler backfiring, may experience the sound as if it is wartime gunfire. Accordingly, the person may re-experience the full range of psycho-physiological responses known as “combat alert” (akin to “fight or flight reactions”) as if he were back on the battlefield.
THE NUMBING AND AVOIDANCE OR “C” CRITERIA
PERSISTENT AVOIDANCE OF STIMULI ASSOCIATED WITH THE TRAUMA AND NUMBING OF GENERAL RESPONSIVENESS (NOT PRESENT BEFORE THE TRAUMA), AS INDICATED BY THREE (OR MORE) OF THE FOLLOWING:
As a psychological defense against being overwhelmed and feeling helpless, traumatized individuals are constantly oscillating between re-experiencing the trauma and trying to avoid it. Their efforts to avoid may take many forms, of which any three listed below fulfills the “C” criteria.
· EFFORTS TO AVOID THOUGHTS, FEELINGS, OR CONVERSATIONS ASSOCIATED WITH THE TRAUMA
An airline stewardess who was brutally raped and beaten in a hotel during a work related “layover,” for several weeks told no one about the assault, not her fellow employees nor her family, and only admitted the assault when her grown daughter pressed her to explain why her mood was so different.
· EFFORTS TO AVOID ACTIVITIES, PLACES OR PEOPLE THAT AROUSE RECOLLECTIONS OF THE TRAUMA
Typically, someone who suffers from PTSD will avoid revisiting the site of the trauma. A young woman who was savagely beaten, kicked in the head, and believed she was going to be killed by hoodlums who assaulted her in the parking lot of a well known national restaurant chain, avoided ever revisiting not just the particular restaurant where the assault occurred but any other facility with the chain’s name on it.
· INABILITY TO RECALL AN IMPORTANT ASPECT OF THE TRAUMA
Not infrequently, a seriously traumatized person will be amnesic for particular events or periods of time during the trauma. They may say that their memory is like a stop-frame movie from which moments or extended periods of time are lost and the memory jumps from before to after the missing segments.
· MARKEDLY DIMINISHED INTEREST OR PARTICIPATION IN SIGNIFICANT ACTIVITIES
Another young woman who was beaten in the restaurant parking lot incident referred to above underwent a dramatic personality change following the assault: she was transformed from an outgoing, vivacious, independent and “feisty” young person, someone who performed publicly in an entertainment group, to a frightened, withdrawn, isolated girl who would not even leave her house to go food shopping without the protective companionship of family members. In her withdrawn state, she gained fifty pounds, creating an additional “buffer zone” around herself that shielded her from the outside world.
· FEELING OF DETACHMENT OR ESTRANGEMENT FROM OTHERS
More than simple detachment or loneliness, PTSD victims tend to experience themselves as “outside looking in,” as though they are no longer a part of life’s events but are beyond a transparent barrier, restricted to the role of an observer.
· RESTRICTED RANGE OF AFFECT (E.G., UNABLE TO HAVE LOVING FEELINGS)
It is very common for those suffering from PTSD to suddenly lose the ability to experience strong feelings, for example an inability to love or to care about others who are dear to them. This disconnectedness can seriously damage marital, parent-child or workplace relationships.
· SENSE OF FORESHORTENED FUTURE (E.G., DOES NOT EXPECT TO HAVE A CAREER, MARRIAGE, CHILDREN, OR A NORMAL LIFE SPAN)
Not infrequently, people with PTSD no longer think of themselves as having a future. This is not the same as having suicidal feelings, since the victim has neither the plan nor the intention of killing himself. Rather, these thoughts result from the sudden rupture of their “bubble of invulnerability.” Having experienced a close encounter with death, it’s ever presence can no longer be effectively denied. PTSD victims may simply resign themselves to the belief that sooner rather than later, life will end.
SYMPTOMS OF INCREASED AROUSAL, THE “D” CRITERIA
Due to the effects of adrenaline directly upon the central nervous system, PTSD is always associated with signs of increased arousal (not present before the trauma) as indicated by two (or more) of the following:
· DIFFICULTY FALLING OR STAYING ASLEEP
Sleep disturbances usually begin immediately after the trauma, although in some cases upsetting dreams may not occur for days, weeks or even months. Typically, the PTSD patient has difficulty falling asleep or staying asleep, fearing that something terrible may again happen to them if they relax their guard against sleep. Instead of sleeping, they remain alert. One traumatized woman compromised between her conflicting impulses to remain awake and needing sleep by setting her alarm clock to awaken her every two hours, throughout the night, in order to inspect all the rooms of her house and reassure herself that no intruders were present. Soon, however, she awakened throughout the night at two hourly intervals before the alarm sounded. This practice continued for years after the trauma.
· IRRITABILITY OR OUTBURSTS OF ANGER
Irritability and sometimes rapid fluctuations of mood occur with most people who suffer from this disorder. Sometimes it is experienced as “waves of emotion” that cause the PTSD patient to rapidly shift between focused attention and tearfulness. At other times, tempers are short and the victim “snaps” angrily and inappropriately at friends, family or colleagues. This lability of mood is worsened by the ingestion of alcohol or intoxicating drugs.
· DIFFICULTY CONCENTRATING
Typically, PTSD patients have difficulty reading. If they can read, it is only for very brief intervals, or only illustrated magazines. Even watching television, although easier than reading, may be marked by lapses of attention and difficulty staying focused. The attention difficulties are likely to be the result of intrusive thoughts or images that both distract attention and increase feelings of anxiety. The entire process feels “out of control” which, in a self reinforcing manner, further increases anxiety and decreases attention.
Hypervigilance, or the state of being in extreme alert, is partially driven by the central nervous system’s response to increased adrenaline and partially by the confusion of perceptions described above as the re-experiencing or “B” criteria.
· EXAGGERATED STARTLE RESPONSE
This is also a symptom of the physiologically stimulated central nervous system anticipating further frightening experiences , similar to the original overwhelming trauma. In certain natural catastrophes, such as earthquakes, victims are repeatedly re-traumatized for days or weeks as aftershocks recur. Marked anxiety results in brisk physiological reflex responses including an exaggerated startle response. One individual originally traumatized by the San Francisco Loma Prieta Earthquake of 1989 and subsequently by aftershocks, eventually developed large reactions to shocks of even minute magnitude. Eventually, his nervous system was so tense in anticipation of the possibility of another large quake that he remained in a state of high alert: he startled easily, and his feet left the ground if anyone closed a door behind him or made a noise unexpectedly.
THE DURATION OR “E” CRITERION
The duration of the disturbance (i.e. the symptoms in criteria b,c and d) lasts longer than one month. This is a somewhat arbitrary criterion. However, its purpose is to distinguish between brief, transient stress response reactions (called in the DSM-IV Acute Stress Disorder) and the more serious, lasting, Post-Traumatic Stress Disorder. Nevertheless, for practical clinical purposes, if a psychiatrist or other mental health professional strongly suspects a diagnosis of PTSD because of the enormity of the trauma and the presence of sufficient B,C and D criteria symptoms, it would be irrational and medically inappropriate to delay treatment for 30 days until the duration criterion had been fulfilled, especially since the best recoveries from PTSD occur when therapeutic measures are introduced early. For litigation purposes, however, “premature” PTSD diagnoses can be attacked when they are applied to symptoms that have not lasted for a minimum of one month. Often these are Acute Stress Reactions that will resolve spontaneously within a short time.
CLINICALLY SIGNIFICANT DISTRESS OR IMPAIRMENT IN SOCIAL, OCCUPATIONAL OR OTHER IMPORTANT AREAS OF FUNCTIONING, THE “F” CRITERION
The “F” criterion means that simply fulfilling the “A – E” criteria is not, in itself, enough to make the diagnosis of PTSD. In addition, the condition must cause clinically significant distress or impairment in social, occupational or other important areas of functioning. Of course, “clinically significant” is a broad concept that is subject to a wide range of interpretations based upon the examining clinician’s experience and judgment. However, the individual’s family, work, school and social lives are explored in detail to determine if this criterion is met. For practical purposes, it is difficult to conceive of a situation in which the Event Criterion is met and the “B – F” criteria are adequately met and the individual does not demonstrate clinically significant distress or functional impairment in these other areas of their life. If a claimant shows no significant impairment of functioning in work, social or family life, it is highly unlikely that they are suffering from genuine PTSD.
ACUTE, CHRONIC OR DELAYED ONSET
Finally, the PTSD diagnosis requires a specification of “Acute” (if the duration of symptoms is less than three months), “Chronic” (if the duration of symptoms is three months or more), or “Delayed Onset” (if the onset of symptoms is at least six months after the stressor).
As with many psychological conditions, individuals experiencing PTSD may be diagnosed with other problems. These “differential,” or alternative, diagnoses include Adjustment Disorder, Acute Stress Disorder, Obsessive-Compulsive Disorder, Generalized Anxiety Disorder, Mood Disorder, Substance Abuse, Organic Brain Syndrome and Malingering. The existence of nine diverse alternative diagnoses indicates that some of the signs and symptoms of PTSD are also found in other mental conditions. However, this multiplicity of alternatives neither indicates that PTSD is an imprecise diagnosis nor that it is very difficult to accurately determine. Nevertheless, the diagnosis will only be accurate to the extent that the examiner has carefully evaluated a person in terms of the very specific “A” through “F” criteria.
PSYCHOANALYSTS ARE PARTICULARLY WELL SUITED TO TALK TO A JURY
Psychoanalysts are psychiatrists (M.D.’s) or psychologists (Ph.D.’s) who have completed extensive advanced training beyond that required for their psychiatric or psychological certifications. They are specifically trained as careful observers who can understand a person’s present behavior in terms of their past experiences. This perspective enables psychoanalysts to supplement the static DSM-IV diagnosis with a dynamic psycho-historical understanding of why an individual behaves in a particular way. Because this is an explanation drawn ultimately from the individual’s unique life story, it is frequently heard by a jury as more plausible and comprehensible than an assemblage of dry criteria and technical jargon. Simply stated, psychoanalysts are able to “tell a story” that is cohesive, interesting and that makes sense to a careful listener. It is not surprising, therefore, that many of the most effective psychiatric medical-legal experts are also trained psychoanalysts.
TREATMENT OF PTSD
For most individuals suffering from PTSD, the treatment consists of psychotherapy and pharmacotherapy.
Psychotherapy has as its purpose to help the individual master and integrate the overwhelming stimuli generated by the traumatic event. One very effective method is abreaction which is helping the patient discuss and re-experience the ideas and emotions associated with trauma in the safety of a therapeutic setting so that these reactions can be mastered. This therapy may necessitate that the patient review the events that occurred as well as their own actions and emotional reactions to those events. Depending upon the strength of the psychological defenses of a person who has PTSD, psychotherapeutic treatment may be required for a period lasting from six months to several years. Since estimated length of required treatment is an important parameter of any settlement negotiation, it is very important for the psychiatric expert consultant to carefully review these estimates in terms of the plaintiff’s general level of defensive functioning. For example, a PTSD plaintiff who is able to adjust to a new job, successfully manage intimate relationships or embark upon arduous vacation travel is unlikely to have markedly impaired psychological defenses and will probably not require extensive treatment.
Another aspect of psychotherapy is didactic, i.e. educational. The patient is told what he or she is likely to expect in the days, weeks and months ahead, so that those reactions can be anticipated and not experienced as a loss of control or feeling “crazy,” feelings which may further traumatize the victim, by temporarily increasing his/her anxiety and delaying recovery. This aspect of the therapy can be accomplished either in individual sessions or in a group debriefing session lead by a knowledgeable therapist who is experienced both in conducting PTSD debriefings and in treating people with this condition.
Excessive anxiety or sleep disturbance can frequently be managed with temporary prescription of minor anti-anxiety medications such as Xanax (alprazolam) or Ativan (lorazepam). Transient sleep disturbances can be managed with the short term use of mild hypnotics (sleeping pills) such as Dalmane (flurazepam) or Restoril (tamazepam). All of these medications contain the potential for abuse and addiction.
DEPRESSION AND GUILT
Not infrequently, significant depression also develops during the days and weeks following a traumatic event, especially if the traumatized individual feels rational or irrational responsibility for the trauma, feels guilt that he/she survived while others did not (survivor’s guilt), or if the traumatic event and resulting losses resonate consciously and unconsciously with significant earlier life losses experienced by the individual. Under these circumstances, more intensive treatment is required. Psychotherapy must investigate and explore both the early life experiences and losses that have been re-activated by the recent traumatic event. As an adjunct to psychotherapy, anti-depressant medication such as Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine) or Wellbutrin (buproprion) may be very helpful in rapidly relieving depressive symptoms, reducing anxiety and restoring normal sleep. Antidepressant medications are all non-addictive.
HYPOTHETICAL PTSD CASE #1
A male catastrophe adjuster employed by a major property insurer was brought from another jurisdiction to work with customers whose homes had been destroyed in a massive fire covering hundreds of acres of residential property. The adjuster had worked with fire victims in other locations for many years without incident. However, this particular assignment elicited tears, difficulty sleeping and impaired mental concentration. I was asked to consult. Upon taking a detailed history from this adjuster, I learned that a decade earlier, he was engaged to be married to his childhood sweetheart. They had purchased a house in which they were going to live together after the marriage. Suddenly, she was killed in a freak automobile accident. After her death, he sold the house, moved to a different city and tried to put it all behind him. He never adequately mourned her death, never married nor even seriously dated during the decade since she had died. He simply “started over” and dedicated himself to his new job, putting his personal needs “on hold.”
After arriving at this assignment, he discovered that the home that he had purchased to share with his bride was one that had been totally devastated by the fire. The news brought back his terrible and unmourned loss of ten years earlier, which overwhelmed him with its intensity. A consultation and brief psychotherapy enabled him to complete his mourning, make a few life changes, and return to his formerly productive level of functioning.
HYPOTHETICAL PTSD CASE #2
Mrs. A., is an attractive, petite, twice married, high school educated thirty-six year old, Asian-American woman. She is the mother of two children, one from each marriage, and worked as a mail clerk for a major oil company. Part of her responsibilities as a mail clerk were to deliver the company mail to various department heads and supervisors. She was friendly, engaging and enjoyed the positive attention she received from some of the older men in managerial positions.
Her husband is a civil servant who objected to her returning to work. She is the middle daughter of a very large, low income family. She always maintained a particularly close relationship with her father. He worked as a school custodian and, in his spare time, taught her automobile mechanics when she was an adolescent. By returning to work she wanted to demonstrate that she could “become somebody.” She approached her new job with determined enthusiasm and dedication.
After two years of working as a mail clerk, one of the supervisors to whom she delivered mail, Mr. H., “recruited” her to join a half-time machinist training program set up for specifically for minority employees and sponsored by the company. Mr. H. is a heavy set, fifty-seven year old mechanical engineer, married and divorced four times and a twenty-five year “veteran” employee of the company. Mr. H. told Mrs. A. that if she was accepted into the training program and completed it, she would be his prodigy. She was flattered. Mr. B. also made a side bet with one of his colleagues that he could turn her into a qualified machinist “in record time.” During the last three years, two different women have asked for and received transfers away from Mr. H.’s supervision because of what they vaguely described as his “pressure tactics” and “sexually inappropriate” comments. There is also an rumor within the mechanical engineering division that Mr. H. has a “drinking problem,” although he has never been accused of drinking on the job.
Mrs. A. was accepted into the program and worked extra hours in order to maintain her income while pursuing the half-time training. Mr. H. was her supervisor and mentor in the program. After six months of training, he required her to accompany him on a business trip to a refinery in a distant city to repair equipment. He told her that she would assist him and that this assignment would constitute an important part of her training. She made arrangements with her family to be away from home overnight. After completing the first days work at the refinery, according to Mrs. A., Mr. H. knocked on her hotel room door at 7 p.m. and said he needed to show her diagrams of the work for the next day. She opened the door to let him in. As he pushed past her, she noticed the odor of alcohol on his breath. He sat next to her on a sofa to show her the book of diagrams but then, according to Mrs. A., began to caress her hair and cheek and told her how attracted he felt towards her and how much he “knew” that she “wanted” him too. He also stated that she “owed” him sexual favors because of all the effort he had invested to further her career. According to Mrs. A, he said “Where would you be now without me? You owe me!”
When she attempted to push him away but he overpowered her, pulled off her jeans and underpants and forcibly raped her. She says that she pleaded with him to stop. Afterwards, she ordered him to get out of her room. Profoundly shaken, she took a long shower trying to “clean” herself while crying. But she reported the incident to no one. The next morning, he apologized and said that “it will never happen again.”
She explained that she told no one at the company about the rape because she doubted that the mostly middle-aged male supervisors would believe her word against that of a colleague with managerial authority and she was certain that he would deny the incident. She also decided against telling her husband because she feared that he might take matters into his own hands and act violently against Mr. H. She also acknowledged that she was afraid he would insist that she leave her job and the training program which she so desperately wanted to complete.
During the next two years she was required to make approximately ten additional overnight business trips with Mr. H.. On at least two of these trips, under similar circumstances of intoxication, he again raped her. During the interim, she alleges that other acts of harrassment occurred such as his trying to rub her legs under the conference table during meetings.
After the second rape, she did confide the problem to a female friend who urged her to leave the company. After the third alleged assault, she became seriously depressed and refused to work any longer with her supervisor. Consequently, she was reassigned to an office job. Finally, her computer was taken away from her. Enraged and tearful, she was referred by Human Resources to a psychiatrist who examined her, diagnosed Depression with Suicidal Ideas and hospitalized her for two weeks on a psychiatric unit. At the end of her hospital stay, she told her psychiatrist for the first time about the alleged rapes. The psychiatrist changed his diagnosis to Post-Traumatic Stress Disorder.
Although her husband did not know of the alleged sexual assaults, he believed that she had been treated poorly by her supervisor and employer and retained an attorney to represent her. After the attorney interviewed Mrs. A. and she confided in him about the assaults, he filed a civil damages lawsuit on her behalf against the company and the supervisor, alleging PTSD psychological damages resulting from sexual harassment and multiple sexual assaults.
The defendant claims that he and the employee had an affair, that during the affair they had consensual sex, but that the affair ended more than a year. He flatly denies any allegations of sexual coercion, rape or wrongdoing.
The primary medical-legal question is not whether she has a cause for action but whether she indeed is suffering from PTSD? Does she meet the A – F Criteria, in particular the critical threshold “event” criterion? If she does not meet the full criteria for PTSD, is she suffering from any other mental disorder? To what extent did she have pre-existing psychiatric illness(es), that preceded her employment and what role, if any, might they play in her current symptoms? Is she malingering? Is she delusional? If so, from what cause?
HYPOTHETICAL PTSD CASE #3
Mrs. B., a married, 35 year old secretary working for an agency of a municipal government, ate a pastry left for the secretarial pool following a board meeting. After biting into a croissant, she had the sensation in her mouth of a chewy, malodorous substance. She was disgusted and spit out the material. She brought the remaining croissant to a laboratory and was told that it was contaminated by rat feces. She complained to her doctor of anxiety, insomnia and recurrent thoughts of the rat feces. He treated her with a mild sedative and referred her to a marriage and family counselor psychotherapist. The therapist makes the diagnosis of PTSD.
Mrs. B. claimed that she could never work in an office again and filed a workers compensation claim for PTSD resulting from the rat feces contaminated croissant incident. She was awarded $75,000 plus 18 months of private vocational rehabilitation. She then filed a personal injury suit against the municipality, the caterer and the bakery that manufactured the croissant alleging permanent psychological damages.
Of course, the central medical-legal question is again whether or not she is suffering from PTSD? If she is not, does she have any other mental illness or injury? If so what is it? Is it pre-existing or as a consequence of the alleged traumatic incident? If she has no evidence of other mental illness or injury, is she malingering? If she had no industrially related psychological injury, why was she given a substantial workers compensation award?
HYPOTHETICAL PTSD CASE #4
An attractive young woman, Ms. C., who was abused as a child and is the daughter of an alcoholic suffered an unknown degree of psychological problems. She got a job as a secretary in an office. She claimed that she was sexually harassed by a man who is the age of her father. She rejected his attention and initially did not report the problem to her employer because, she said, she feared that by doing so she might lose her job. After some time, her job performance deteriorates and she is terminated. She brought a wrongful termination suit alleging sexual harrassment and discrimination. After filing suit, she was treated by a psychologist who diagnosed PTSD resulting from the alleged sexual harrassment.
Several questions are raised by this case. Although the primary one is whether or not she is indeed suffering from PTSD as alleged, there are important secondary questions as well: a) what were the nature of her psychological problems prior to the alleged sexual harrassment? b) why she did not report the harrassment to her employer? c) if she does have PTSD, could it have been caused by childhood trauma; if she does not have PTSD, is she suffering from any other mental disorder? and d) what role, if any, did the childhood abuse by her alcoholic parents play in the formation of her character, her psychological defenses, and her ultimate difficulties at work?
Of course, in a case of alleged harrassment, the independent psychiatric expert should, in addition to reviewing documents, interview the plaintiff and investigate all of these questions delicately and with sensitivity, without contributing additional trauma to the plaintiff’s life and without giving even the appearance of “blaming the alleged victim.” At the same time, the examiner must respect the presumption of innocence of the accused. In this last regard, it can be helpful and is often essential to a successful defense for the psychiatric expert to not only examine the plaintiff/victim but also the accused harasser.
Post Traumatic Stress Disorder is a psychiatric diagnosis with a long and established medical history as well as a vibrant medical-legal present and future. With increasing frequency, it is being claimed in a widening scope of personal injury, malpractice and employment litigation. It is a complex diagnosis requiring the careful and detailed examination of a plaintiff by an experienced medical-legal psychiatric expert. Psychoanalysts are well trained for the combined tasks of diagnosing, understanding and communicating to others the presence or absence of psychological injuries. Several approaches to treatment are mentioned. A number of hypothetical cases of alleged PTSD are presented. Critical questions about PTSD claims are raised that must be thoroughly addressed by the consulting medical-legal psychiatric expert.
Brief Biography – Mark I. Levy, M.D., F.A.P.A.
Doctor Levy, a graduate of Columbia University College of Physicians and Surgeons and a Board Certified Psychiatrist and Forensic Psychiatrist, is also a graduate of the San Francisco Psychoanalytic Institute. He has been a full-time psychiatrist and psychoanalyst practicing in Marin County, California for more than 25 years, and he also devotes a portion of his practice to psychiatric expert forensic consultation. Doctor Levy is Assistant Clinical Professor at the Department of Psychiatry, University of California, San Francisco, and he is also on the faculty at the S.F. Psychoanalytic Institute. He is Chairman and Past President of the San Francisco Foundation for Psychoanalysis, a community outreach organization of psychoanalysts, and he has helped establish an educational program on psychological issues for attorneys through the Bar Association of San Francisco, where he has consulted on a wide range of psychological topics. Doctor Levy is a member of numerous professional organizations and has been interviewed and quoted nationally by the print and broadcast media including The Wall Street Journal, Business Week, For the Defense, NBC, Fox News and CNN. He has been the HealthBeat Psychiatrist and Psychoanalyst for KRON-TV4, the NBC affiliate in San Francisco, as well as for its cable station, Bay TV.