Manual Posttraumatic Stress Disorder in Litigation: Guidelines for Forensic Assessment

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American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Arlington VA: Author; The development of a clinician-administered PTSD scale. Australian Bureau of Statistics. A pilot study of workplace violence towards paramedics. Emerg Med J ; Compassion fatigue and psychological distress among social workers: a validation study. Am J Orthopsychiatry ; Exposure to human tragedy, empathy, and trauma in ambulance paramedics.

Roger K. Pitman, MD

Rothbaum BO, Davis M. Applying learning principles to the treatment of post-trauma reactions. Ann N Y Acad Sci ; Briere J. Psychological assessment of adult posttraumatic states: phenomenology, diagnosis, and measurement. Price M, van Stolk-Cooke K. Examination of the interrelations between the factors of PTSD, major depression, and generalized anxiety disorder in a heterogeneous trauma-exposed sample using DSM 5 criteria. J Affect Disord ; Phoenix Australia.

Australian guidelines for the treatment of acute stress disorder and posttraumatic stress disorder. The association between posttraumatic stress, coping, and acute stress responses in paramedics. Traumatology ; Symptoms and responses to critical incidents in paramedics who have experienced childhood abuse and neglect.

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J Gen Intern Med ; The University of Minnesota has an arrangement where a percentage of all sales are reinvested in developmental research. This has lead to the MMPI-2 being the most widely validated and psychometrically rigorous measure of psychopathology. Exposure therapy consists of pairing relaxation techniques with exposure to reminders of the original critical incident.

The review recommends that exposure therapy be combined with cognitive behaviour therapy to obtain optimal results. Related to the issue of exposure therapy is the use of eye movement desentisation reprocessing EMDR , which has been in usage for PTSD treatment for the previous fifteen years. Two studies suggested that EMDR was at least as effective as exposure therapy, with three studies demonstrating superior efficacy over relaxation treatments.

How does EMDR compare to trauma focused cognitive behaviour therapy? There is some suggestion that debriefing may increase the risk of PTSD and depression. The ACPTMH review is similarly damning asserting that CISD is ineffective in reducing avoidance and intrusive symptoms flashbacks and nightmares at periods of one month, one to three months and at twelve months.

It is not clear as to the reason that some individuals do develop PTSD, while others do not. Exposure to traumatic events is not unusual. At least 50—65 per cent of community respondents report at least one traumatic event in their lives and yet a very small percentage of these respondents develop full blown PTSD.


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The estimated month prevalence of PTSD was 1. It has been informally recognised since world war one, that previous trauma history affects personality resilience for coping with subsequent traumatic events. Williams nominates four points on how trauma may interact with personality structure. These are:. Changed personality could simply be seen as one of the many cognitive processes that would mitigate against the integration of trauma within the personality structure.

It is not clear how the normal person would actually respond to the experience of a seriously life threatening situation. It is not uncommon for highly symptomatic individuals to remain chronically traumatized; yet there is no evidence pre-morbid dysfunctionality. Cognitive models of PTSD have asserted that individuals with concrete black and white thinking styles or inadequate coping strategies or particularly rigid value systems are vulnerable to the development of post traumatic stress disorder. It is unclear as to how such propositions could be tested which makes them problematic in both a psychological and legal context.

A related issue to validity, is the ability of a psychological test to detect malingered psychiatric symptoms. Again the MMPI-2 is the preferred test of choice. The F scales seem to perform particularly well in the detection of malingering, even under conditions of coaching.


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There were four conditions: a uncoached b coached about PTSD symptoms c coaching about MMPI-2 clinical and content scales d coaching about symptoms and validity scales. Participants in condition d were most successful in avoiding detection of malingered PTSD.

(April 2012)

However even in this condition, the F scales Family continued to have high positive and negative predictive power in detection of malingering. Authors of another study instructed one group of veterans who were seeking compensation for combat related PTSD to exaggerate symptoms. The other group were not provided with instructions to exaggerate.

As previously mentioned there are concerns that wide availability of PTSD criteria has made it easier to generate malingered claims. The range of variation underlines the difficulties in proving that malingering has occurred if appropriate psychometric screening is not used.

It is noteworthy that malingering often occurs in conjunction with antisocial tendencies. Resnick urges caution around a diagnosis of post traumatic stress disorder where the following indications are present:. Genuine PTSD sufferers will find it difficult to discuss the trauma experience without experiencing a high level of physiological arousal and anxiety. This type of discomfiture needs to be distinguished from the evasiveness of not being able to provide specific details about symptoms.

Glossaries

This paper has attempted to use a synthesis of case law and research to address six key challenges around the provision of expert evidence on post traumatic stress disorder. Two of these areas overlap with requirements in Section 79 of Evidence Act concerning the exception for expert evidence, to wit that admissibility of expert evidence is contingent on that expert having specialized knowledge or experience that can assist the court. It was suggested that there are a broad range of health professionals who can produce admissible evidence on mental health matters. A combination of large scale nomothetic surveys, evidence based best practice in treatment and assessment to individual clinical cases was suggested a resolution to the requirement that expert evidence be derived from scientific method.

It was suggested that for a diagnosis of post traumatic stress disorder to be admissible that the factual basis of such an event needed to be established; and that the DSM-IV-TR critierion had formed a clinical framework of the type of event that could be accepted as traumatic. Psychometric assessment with the MMPI-2, as well as cross collaboration of factual evidence and a detailed clinical history covering contraindications of PTSD has been put forward as a strategy for the detection of malingered claims of PTSD.

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