A comment of the (over)diagnosis of
Post Traumatic Stress Disorder
Robert J. Edelmann
Summary
With regard to personal injury
claims, Post Traumatic Stress Disorder (PTSD) is one of the most frequently
diagnosed mental health problems. This brief comment argues that all too often
far too little care is taken in medico-legal assessments, with PTSD regularly
being misdiagnosed with the diagnosis even being used when the nature of the
index accident does not warrant it. Not only is this likely to increase the
scepticism with which insurance companies view claims it will, in the long
term, be to the detriment of genuine claims for PTSD.
The ‘traumatic’ event
As with all mental health problems,
PTSD can be diagnosed with regard to either the International Classification of
Diseases and Related Problems (now in its 10th Edition as ICD10) or
the Diagnostic and Statistical Manual of the American Psychiatric Association
(now in its 4th Edition as DSMIV). PTSD, unlike any other mental
health diagnosis (with the exception of Acute Stress Disorder) requires a
specific trigger event to initiate the disorder; the nature of this quite
clearly specified by both ICD10 and DSMIV. The necessary characteristics for
the event are regarded as the ‘entry criteria’ for the disorder. In other
words, if the event does not meet such criteria then consideration of any
symptoms the claimant might report in relation to PTSD is inappropriate. ICD10
is quite clear that the trigger event must be “of an exceptionally threatening
or catastrophic nature, which is likely to cause pervasive distress in almost
anyone”. This, one would presume, would rule out minor rear end collisions in
which minimal damage has been caused to the vehicles concerned and any physical
problems (most usually described as ‘whiplash’) have dissipated in a matter of
weeks. However, I have lost count of the number of reports I have seen from
both Psychiatrists and Psychologists which in such instances have insisted that
in their opinion the claimant has developed PTSD.
Entry criteria according to DSMIV
are somewhat more open to interpretation. The two criteria specify (A) the
person experienced, witness, 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 and (B) the person’s response involved
intense fear, helplessness, or horror. This would clearly rule out instances
of injuries sustained by lifting a small box, a car rolling backwards into the
claimant’s vehicle or slipping on a floor, all of which I have seen in Expert
reports as supposedly giving rise to PTSD.
The symptom profile
Having decided whether an event is
of sufficient magnitude to be considered in relation to PTSD the next consideration
is whether the symptoms reported by the Claimant match the profile required for
a full diagnosis. As with the entry criteria, the ICD and DSM differ with
regard to symptoms required for a diagnosis of PTSD. Indeed, research studies
indicate that PTSD is diagnosed twice as often under ICD criteria in comparison
with DSM criteria. This is partly because with ICD the symptoms are less
precisely stated but also because the methods of assessment for DSM have become
more refined. Structured diagnostic interview schedules have been developed to
specifically assess for PTSD according to DSMIV criteria. The advantages of
such schedules are manifold; not only do they allow for the quantification of
symptoms according to agreed criteria hence increasing consistency, they also
allow for probing of reported symptoms. There is for example a major
difference between a report of occasional bad dreams or apparent ‘flashbacks’
(which may well simply imply the person occasionally pictures the event) subsequent
to an index accident and a report of regular intrusive and distressing dreams
and images which are specifically accident related. It is perhaps not
surprising in view of this that structured diagnostic interviews increase the
reliability of diagnosis (it is far more likely that clinicians will agree on a
diagnosis when such a schedule has been used). I have seen expert reports
offering a diagnosis of PTSD when it is unclear whether the reported difficulty
is actually a PTSD symptom and indeed, in spite of insufficient symptoms being
reported in relation to diagnostic criteria.
The gold standard for PTSD
interviews is the CAPS (the Clinician Administered PTSD scale) although there
are others which also have adequate reliability. Clearly unstructured interviews
whether in the form of a Mental State Examination or a Clinical Assessment will
have limitations in medico-legal contexts. Indeed, in a recent paper, Koch,
O’Neill and Douglas (2005) state: “Whereas it is possible, using available
structured interviews and specific psychological tests, to reliably diagnose
PTSD, assessments of PTSD that do not use such empirically supported methods
are likely to be of limited reliability” (p129).
Additional information
Medico-legal assessments in Personal
Injury cases are undertaken months and sometimes years after the index event.
A great deal of psychological research illustrates that people “reconstruct”
memories of past experiences based in part on their current circumstances. Someone
assessed at six month post accident when it is assumed that residual symptoms
of ‘whiplash’ will dissipate over the ensuing months will perceive a comparable
index event quite differently from someone assessed at two years post accident
who is still reporting ‘whiplash’ symptoms which do not seem to be
dissipating. A review of the contemporaneous medical records is essential to
gain a clearer understanding of the index accident and the seeming effects it
has had on the individual. For example, is the complete lack of any reference
in the GP records to psychological difficulties post accident compatible with a
diagnosis of chronic PTSD? It could be if the person has rarely attended their
GP in the past and would be unlikely to report mental health difficulties to
them; it would be less likely if the converse were the
case.
Symptoms of PTSD increase the
likelihood that the person will have work related difficulties. Is an
observation that someone has returned to work shortly after an index accident
and then continued working without any apparent difficulty consistent with a
diagnosis of chronic PTSD? Although this would depend in part on the
characteristics of the individual claimant it would certainly raise concerns
about a diagnosis of chronic PTSD. The bottom line is that it is essential to
obtain as much background and collateral information as possible in order that
any diagnosis can be adequately informed and the risk of misdiagnosis reduced.
I have frequently seen a claimant’s perception of events and the attribution of
all their difficulties to an index event accepted unquestioningly by the expert
with very little attempt made to place the event within the person’s broader
life context.
Conclusions
In my experience PTSD is over
diagnosed in medico-legal contexts with too little thought given to the
reliability of assessments. Insurers are likely to become increasingly and
quite reasonably sceptical of diagnoses of PTSD made in the face of seemingly
trivial RTAs and minor mishaps. This can only be to the detriment of genuine
claims for PTSD which are then unnecessarily questioned. However, unless a
thorough and reliable assessment has been undertaken it is not difficult to see
how even in the latter instance a claim can be undermined.
Reference
Koch, W. J., O’Neill, M &
Douglas, K. S. (2005). Empirical limits for the forensic
assessment of PTSD
litigants. Law and Human Behavior, 29, 121-149.
Robert J. Edelmann is Honorary
Professor at the University of Roehampton and can be contacted via e-mail at r.edelmann@btinternet.com
