PI Brief Update

Instructing Experts in Post-Traumatic Stress Disorder (PTSD) - Dr Mark Burgin

06/07/22. Dr. Mark Burgin BM BCh (oxon) MRCGP explains how the new advice on PTSD from the can assist lawyers improve instructions to medical experts.

Instructing medical experts to consider PTSD has been difficult because the previous guidance has led to over and under diagnosis of the condition.

Medical experts have taken different positions in the debate so that there has been little certainty about the outcome.

The new guidance from International Classification of Diseases (ICD) in the ICD11 means that for the first time there is agreement as to how to diagnose PTSD.

A lawyer can use their observations when taking instructions from the client to identify features that are concerning without needing to use a questionnaire.

Instructions should alert the medical expert to possible legal implications of these observations without intruding on the medical role.

How to diagnose PTSD

There are now three core features that must be present to diagnose PTSD – hyper-arousal, re-experiencing and avoidance.

· Agitation (hyperarousal) is common in patients with mental health problems, the person is restless, may tap or rock and find it difficult to relax.

· Flashbacks and nightmares (re-experiencing) on their own are less helpful for the diagnosis than a description of the content of the nightmares and the context of the flashbacks.

· Memory problems (avoidance and numbing) are most obvious to a professional when asking the claimant for details about the events although may result from drugs and alcohol.

The instruction should include a description ‘our client was noted to be agitated, reported nightmares of the accident and had difficulty remembering details, could you please assess the likely cause?’

Complex PTSD and the Equality Act 2010

The ICD11 recommendations for PTSD recognise a more severe version of PTSD called complex PTSD cPTSD which is profoundly disabling.

The client must have PTSD plus three further features of mood disorders, low self-confidence and poor relationships.

The lawyer will recognise this pattern of a chaotic depressed client who is difficult to engage and appears vulnerable.

Complex PTSD (usually from prolonged abuse in childhood or torture) typically indicates that the claimant has the protected characteristic of disability.

The instruction should draw this issue to the attention of the expert by saying ‘our client has a history of depression, low self confidence and finds interacting difficult, could you please ensure that the assessment complies with the Equality Act 2010’

The Generalist (GP/A&E) Report

Generalist expert training has included the new criteria since May 2019 and most experts are now familiar with how to diagnose PTSD and cPTSD.

There will be learning curve as doctors in wider practice undertake training and develop experience in making the diagnosis with the new criteria.

PTSD is an under recognised condition so many new diagnoses will be unrelated to the claimant’s index injury.

The Generalist expert should now be able describe the features of claimants with possible PTSD and give an opinion as to whether there is a reasonable prospect.

Reports that omit material symptoms (nightmares, flashbacks) and signs (appears stressed, vague history) noted by the lawyer should be sent for audit.

Conclusions

ICD11 represents a significant advance in our understanding of PTSD and complex PTSD meaning that assessment is within the generalist’s expertise.

This simplification allows lawyers to recognise the pattern and instruct their experts to consider the likely causes.

The incidence of over (and under) diagnosis is likely to fall as the new criteria are applied to all claimants so treatment can be targeted at the right people.

This benefits the claimants by ensuring that those with missed diagnoses can access effective treatment and experts make reasonable adjustments for disabled claimants.

At a time where the lawyer is being replaced by machines this is one area where a human face can add real value to the claimant’s journey.

This is part of a series of articles by Dr. Mark Burgin. The opinions expressed in this article are the author's own, not those of Law Brief Publishing Ltd, and are not necessarily commensurate with general legal or medico-legal expert consensus of opinion and/or literature. Any medical content is not exhaustive but at a level for the non-medical reader to understand.

Doctor Mark Burgin, BM BCh (oxon) MRCGP is on the General Practitioner Specialist Register and audits medical expert reports.

Dr. Burgin can be contacted This email address is being protected from spambots. You need JavaScript enabled to view it. and 0845 331 3304 website drmarkburgin.co.uk

World Health OrganisationInternational Classification of Diseases ICD11

Presented May 2019 and Adoption date 1 January 2022

6B40 Post-traumatic stress disorder (PTSD) is a disorder that may develop following exposure to an extremely threatening or horrific event or series of events. It is characterized by all of the following: 1) re-experiencing the traumatic event or events in the present in the form of vivid intrusive memories, flashbacks, or nightmares. These are typically accompanied by strong or overwhelming emotions, particularly fear or horror, and strong physical sensations; 2) avoidance of thoughts and memories of the event or events, or avoidance of activities, situations, or people reminiscent of the event or events; and 3) persistent perceptions of heightened current threat, for example as indicated by hypervigilance or an enhanced startle reaction to stimuli such as unexpected noises. The symptoms persist for at least several weeks and cause significant impairment in personal, family, social, educational, occupational or other important areas of functioning.

6B41 Complex post traumatic stress disorder (Complex PTSD) is a disorder that may develop following exposure to an event or series of events of an extremely threatening or horrific nature, most commonly prolonged or repetitive events from which escape is difficult or impossible (e.g., torture, slavery, genocide campaigns, prolonged domestic violence, repeated childhood sexual or physical abuse). All diagnostic requirements for PTSD are met. In addition, Complex PTSD is characterized by severe and persistent 1) problems in affect regulation; 2) beliefs about oneself as diminished, defeated or worthless, accompanied by feelings of shame, guilt or failure related to the traumatic event; and 3) difficulties in sustaining relationships and in feeling close to others. These symptoms cause significant impairment in personal, family, social, educational, occupational or other important areas of functioning.

American Psychiatric Association. (2013) Diagnostic and statistical manual of mental disorders, (5th ed.). Washington, DC: Author.

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