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.
