by Mark I. Levy, M.D.
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(Expanded version of an article first published in the
November 1995 issue of For
the Defense, the monthly journal of the Defense Research Institute, Chicago,
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
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
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
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.
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
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
b>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.
b>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
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
Note: In young children, trauma-specific reenactment may
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.
b>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
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
Markedly Diminished Interest Or Participation In Significant
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
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.
b>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
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.
b>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
b>Clinically Significant Distress Or Impairment In Social,
Occupational Or Other Important Areas Of Functioning, The "F"
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 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. 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
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.
Psychopharmacotherapy. 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.