Forensic Validity of a PTSD Diagnosis
A National Center for PTSD Fact Sheet
By Claudia Baker, MSW, MPH and Cessie Alfonso, LCSW
Many types of civil and criminal court cases and litigation involve claims
of Posttraumatic Stress Disorder. The diagnostic validity of these claims can
impact directly upon the defense, plaintiff, or prosecutorial strategy,
depending upon the nature of the case. It is important, therefore, for
attorneys and others involved in the legal system to be able to assess the
validity of PTSD evaluations and diagnoses. Although only an expert in PTSD can
complete an in-depth review of a case and the diagnostic methodology, it is
helpful if those conducting initial reviews know some basic facts about PTSD
and what constitutes a sound diagnosis.
What is the critical component of a PTSD diagnosis?
One of the critical components of a PTSD diagnosis is that the
individual must have been exposed to a traumatic event. This criterion is often
called the "gate-keeper." That is, without it PTSD cannot exist. The
DSM IV is very specific in defining this term. In order to qualify as a
traumatic event (in this context), the event must meet two criteria:
"*the person has experienced, witnessed, or been confronted with an
event or events that involve actual or threatened death or serious injury, or a
threat to the physical integrity of oneself or others."
"*the person's response involved intense fear, helplessness and
horror."
Therefore, traumatic stressors must involve some type of actual or
threatened physical injury or assault. Ongoing poor treatment and verbal
abuse by a boss, discrimination, or ongoing emotional abuse by a spouse, for
example, are not qualifying traumatic stressors in this context. However, if there has also been some fear of
actual serious physical injury or "threat to the physical integrity"
of the individual claiming PTSD (a phrase most often applied to sexual assaults
or threats of sexual assaults), then these situations qualify as traumatic
stressors. It is important to note that the person does not have to have been
the direct victim of the event; witnessing or being confronted with a traumatic
stressor can also meet this criterion.
The existence of symptoms should not be used to establish the fact that an
individual has been exposed to a traumatic stressor. For example, the fact that
someone is experiencing insomnia and angry outbursts should not be used to
establish that he or she has experienced a traumatic stressor. Independent
corroboration of the occurrence of the traumatic stressor should be obtained
when possible.
What are the symptoms of PTSD?
Another critical component of a PTSD diagnosis is that the
person must have symptoms consistent with PTSD. Approximately 25% of
individuals exposed to traumatic stressors go on to develop PTSD; most exposure
to trauma does not result in PTSD. Therefore, evidence of exposure to such a
stressor alone is not sufficient to establish a diagnosis of PTSD.
The DSM IV specifies the pattern of symptoms that must occur in order for an
individual to be diagnosed with PTSD. There are three categories of PTSD symptoms:
reexperiencing, avoidance/numbing, and increased arousal. PTSD can only be
diagnosed if one symptom of reexperiencing, three symptoms of avoidance/numbing,
and two symptoms of increased arousal are present (see the DSM IV for a
complete list of the symptoms in each category). If a person has six symptoms,
for example, but all are in the hyper-arousal category, the diagnostic criteria
have not been met.
Reliable and valid psychometric instruments should be used to determine
whether an individual meets the symptomatic criteria for PTSD. However, data
from psychometric tests should never serve as a stand alone means for
diagnosing PTSD. Rather, the psychometric measures should be used to supplement
and substantiate findings gleaned from interview assessment and other sources
of data. The Clinician Administered PTSD Scale and the PTSD Symptom Checklist
are two widely used PTSD assessments that have been established as reliable and
valid.
A particularly important consideration in the forensic assessment of PTSD is
that the symptoms of the disorder are entirely self-reported, although some of
the increased arousal symptoms (such as an exaggerated startle response) can be
objectively observed. In cases where secondary gain is involved, which include
most forensic cases, it is particularly important for tests of malingering to
be administered in conjunction with the PTSD assessment. If measures of
malingering are not used in the assessment, the individual's report of his or
her own symptoms may be characterized as fabrication or exaggeration.
In addition, recent research has demonstrated that there are specific
biological changes that can be measured in individuals with PTSD, such as
increased heart rate and blood pressure upon exposure to cues reminiscent of
the trauma. Psychophysiological data is particularly convincing evidence of the
existence of PTSD as it eliminates the issue of self-reporting and addresses
the possibility that the individual may be malingering for secondary gain.
However, not all individuals with PTSD exhibit these changes so the absence of
this type of data should not be considered conclusive evidence that PTSD does
not exist.
What other factors are critical for a PTSD Diagnosis?
A third critical component of a
PTSD diagnosis is that the person's level of functioning pre- and posttrauma
must be significantly different. For example, someone who was irritable, could
not sleep, had difficulty concentrating, and felt detached and estranged before
a trauma, and who continued to exhibit these symptoms at the same level of
intensity after the trauma, should not be diagnosed with PTSD. There needs to be evidence of a general
decline in functioning. Changes often observed as a result of PTSD include a
deterioration of work or school performance, changes in one's ability to meet
routine responsibilities of self-care, a worsening of physical health, and
changes in interpersonal relationships, leisure activities, and family role
functioning. A self-reported change in the level of functioning should be
corroborated either with objective records or through collateral information.
The fourth critical component of a PTSD diagnosis is related to the
above issue of a change in the level of functioning. This is the requirement
that symptoms "cause clinically significant distress or impairment in
social, occupational, or other important levels of functioning." In
forensic cases, it is important to obtain corroboration of this distress or
impairment because of the potential for deliberate fabrication or exaggeration.
Corroboration can be obtained either through a records review or through reports
from collaterals.
In addition, the impairment in functioning should be linked to PTSD
symptoms. For example, the fact that after a trauma an individual became
irritable and argumentative at work supports a diagnosis of PTSD. However, the
fact that an individual began stealing things from the worksite after a
traumatic experience does not support a diagnosis of PTSD because stealing is
not a symptom of PTSD. Remember, though,
that other changes noted in this same individual may support the diagnosis.
Finally, the symptoms of PTSD must persist beyond thirty days. An
individual who, after a trauma, experiences a full complement of PTSD symptoms
for three weeks does not meet the diagnostic criteria. The DSM IV does describe
this type of reaction, however, and qualifies it as Acute Stress Disorder.
Conclusion
Proper assessment of PTSD is complex, and in a forensic setting, it should
include substantial attention to corroboration of self-reports through a records
review and collateral information. The ability to evaluate these assessments
can be very helpful for those involved in the legal system. PTSD evaluation
will be particularly practical for those who want to conclusively and convincingly
establish a PTSD diagnosis and for those who need to appraise the accuracy or
veracity of a PTSD claim that seems dubious. By paying attention to the five
areas mentioned above, one can make an initial assessment of the accuracy of
a PTSD diagnosis. In addition, if all five of the above elements are attended
to, counsel can convincingly present evidence that an individual indeed suffers
from the disorder.
Related Fact Sheets
Acute Stress
Disorder
Explains briefly what ASD is, how common it is, who is at risk, how it differs
from PTSD, and effective treatments
Assessment
of PTSD
Provides brief information about how PTSD is assessed
PTSD and criminal
behavior
Describes links between PTSD and criminal behavior, especially for those in
the legal profession
Symptoms of PTSD
Learn about how traumatic experiences affect people, what survivors need to
know, and the common symptoms of PTSD
What is
PTSD?
Answers basic questions about the signs and symptoms of PTSD, who gets it,
how common it is, and what treatments are available
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