Children as well as adults suffer PTSD after MVA. A characteristic pattern of hormone changes is present shortly after the trauma, and may pre-exist. Compensable injury is a relatively uncommon cause of PTSD in the community. Following trauma, a number of clinical measures can help establish a causal relationship.
The Disorder may be complicated by suicide and substance abuse. Malingered PTSD can generally be detected with a fair degree of certainty. Pursuit of compensation does not adversely affect treatment outcome, and both antidepressant medication and psychotherapy are effective.
Children as well as adults suffer PTSD after MVA. Two papers from England have documented the commonness in children of Acute Stress Disorder, Post Traumatic Stress Disorder and phobic anxiety following MVA1, 2. At greatest risk were young children, those children who had not yet recovered from their physical injuries and children with a parent involved in the same accident2.
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PRACTICE POINT Post Traumatic Stress Disorder is underdiagnosed in injured children |
A characteristic pattern of hormone changes is present shortly after the trauma, and may pre-exist. Why do some clients develop PTSD while others fail to do so after what are objectively more severely traumatic situations? The pathological basis for the thin skull has been further elucidated. Changes in blood chemistry - stress hormones (cortisol and adrenaline), thyroid and even sex hormones - are distinct from those found in major depression3 and have been confirmed3, 4, 5 by a number of researchers working independently.
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PRACTICE POINT "Thin Skull" susceptibility to PTSD is predictable and detectable |
Initially discovered in war veterans, these alterations are being confirmed in women, children and the elderly5. Not only are the hormonal disturbances seen shortly after the precipitating event, but there is some evidence that the chemical abnormalities precede the injury, having perhaps been initiated by early childhood trauma6.
Compensable injury is a relatively uncommon cause of PTSD in the community. The Personal Injury that is being litigated may not be the cause of the PTSD that has been diagnosed. In a large community survey, the commonest cause was sudden, unexpected loss of a loved one, and assaultive violence carried the greatest risk (21%) of being followed by PTSD7.
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PRACTICE POINT A causal link with the compensable injury should be critically evaluated not assumed post hoc ergo propter hoc |
Following trauma, a number of clinical measures can help establish a causal relationship. Early clinical predictors of the Disorder include raised heart-rate in the emergency room8, ASD9, 10, 11 without9, 10 and with11, 12 Mild Traumatic Brain Injury and various accident and psychological characteristics13.
The Disorder may be complicated by suicide and substance abuse. In refugees, clinically assessed because they had experienced or witnessed extraordinary violence, PTSD was usual and predicted a materially increased risk of suicide, particularly if major depression was also diagnosed14.
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PRACTICE POINT PTSD may be worsened by concurrent psychiatric conditions, and complicated by suicide and substance abuse |
Drug abuse and drug dependence are prevalent among sufferers from PTSD. Evidence from a recent study seems to favour an inadvertent effect from attempting to medicate symptoms rather than a susceptibility to both disorders15. Among cocaine-dependent with PTSD, those in whom the cocaine usage came first generally developed the Disorder during the procurement or usage of the drug, whereas those with PTSD prior to cocaine-dependence had usually suffered childhood abuse16.
Malingered PTSD can generally be detected with a fair degree of certainty. Testing for malingered PTSD has been further refined17, though to a more limited degree if there is also alcohol abuse.
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PRACTICE POINT Malingered PTSD is readily detectable unless there is also alcohol abuse |
Pursuit of compensation does not adversely affect treatment outcome, and both antidepressant medication and psychotherapy are effective. Although the harmful effect of pending or settled litigation on healing includes prevention of recovery from depression and anxiety, PTSD may be spared18, 19. During the year following MVA, improvement in post traumatic stress symptoms occurred whether or not the patients were pursuing compensation claims18. For a wider variety of patients, the benefit of both standard outpatient treatment and short-term inpatient treatment was not adversely affected by litigation19.
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PRACTICE POINT The benefits of traditional therapy are not adversely affected by involvement in litigation and are robust over time |
Review20 of the effects of a variety of antidepressant medications confirmed their efficacy in controlling symptoms of PTSD. A meta-analysis of the benefits of psychotherapy21 showed that significant short-term improvement in the Disorder was maintained at longer follow-up.
Copyright © 2008 Electronic Handbook of Legal Medicine