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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, Illinois.)
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....Introduction
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.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.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.
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 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.
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 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.
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 intoxicating drugs.
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 short time.
b>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).Differential Diagnosis
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 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.
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.