PTSD 1999-2000

SUMMARY: In only a minority of people do stress symptoms persist beyond 3 months after moderate to severe trauma. Post Traumatic Stress Disorder is usually accompanied by other psychological conditions that are often undiagnosed. PTSD sufferers have a significant risk of suicide. The prognostic factors for persistence of PTSD are now well-established.

^Common

Post-Traumatic Stress Disorder (PTSD) is important to personal injury lawyers because it is the commonest form of post-traumatic psychological injury ¹.

Chronic pain is maintained by psychological factors and is commonly accompanied by depressive disorders. Nevertheless, no psychiatric condition is as pervasive after moderate to severe injury as PTSD.

Indeed, the symptoms of PTSD can be viewed as a normal stress response: shortly after violent rape, up to 80% of women fulfill DSM-IV criteria (except duration) ².

That is to say, a psychological Thin Skull determines those in whom symptoms will persist, and probably worsen, as chronic PTSD.

Underdiagnosis

The condition is underdiagnosed by general practitioners and psychiatrists, for a variety of reasons ¹:

1. Overlapping Symptoms

Post Traumatic Stress Disorder is usually accompanied by other psychological conditions that are often undiagnosed.

Symptoms of PTSD are common to other psychological conditions, particularly anxiety and depressive disorders.

Having diagnosed a condition that accounts for all the main presenting symptoms, psychiatrists tend to take a parsimonious approach to further Axis 1 diagnoses (Diagnostic and Statistical Manual, 4th edition [DSM-IV]).

However, the Thin Skull is such that over 90% of PTSD sufferers have a lifetime experience of other psychiatric disorders - an average of between 2.1 ³ and 4.6 ⁴ additional conditions for each patient.

"Pure" chronic PTSD is the exception ^{5; 6}, and it may be useful to think in terms of a cascade of symptoms or syndromes, Caused by either the trauma or by the resulting PTSD ⁷.

Alcohol and substance abuse and generalised anxiety disorder tend to occur earlier in the course of PTSD ⁸, whereas depression and panic disorder usually have a later onset ⁹.

Additional diagnoses may or may not alter therapy, but they usually do change prognosis, and therefore affect potential Quantum of Damages.

2. A Real Diagnosis?

Many psychiatrists remain sceptical about the nosology (distinctness) of PTSD as a diagnosis ¹⁰.

Again, the sharing of symptoms, and even clusters of symptoms, with other psychological conditions causes some physicians to see it as an unwarranted violation of Occam's razor.

14th century William of Occam: "The assumptions introduced to explain a thing must not be multiplied beyond necessity."

Further, the syndrome is relatively new in the history of psychiatry, and some still see it as a political concession to Vietnam veterans ¹⁰

3. If the Psychiatrist Doesn't Ask...

The clinician may fail to enquire about temporal or causal relationship to trauma in assessing psychiatric symptoms ⁶ .

Personal injury claimants tend to recall inaccurately the onset of symptoms, in a pattern that favours traumatic Causation.

Nevertheless, the Causal relationship cannot even be evaluated unless the psychiatrist enquires about preceding traumatic events.

4. Biological Markers

The disturbances in hormone production that are characteristic of PTSD have been confirmed by a number of researchers, but not yet explained.

The levels of stress hormone cortisol are unexpectedly normal or even low, but Corticotropin Releasing Factor (CRF) is produced in increased amounts by the pituitary gland in the base of the brain - the opposite of what would be predicted ^{7; 11}.

It is as though the thermostat has been reset higher, but the furnace is unable to respond.

By contrast, in acute and chronic stress, and in major depressive disorder, production of both CRF and cortisol is increased.

The cortisol "thermostat" appears to be located in the hippocampus, picturesquely named for its supposed visual resemblance to a sea-horse (greek, hippocampos).

Various studies have shown that this area of the base of the brain is smaller in PTSD ⁶ - again this is a paradoxical finding, because it appears to be over-reacting rather than under-reacting.

Whatever the eventual solution of these biological puzzles, PTSD from the medicolegal perspective has physiological and anatomical thumbprints.

These alterations in hormones and size of a part of the brain are statistically significant trends in a population of PTSD sufferers, and are not measurable deviations from normal in an individual client.

Nevertheless, the abnormalities suggest that the disorder is a distinct entity, not merely a variation of a previously recognised mental condition.

PROGNOSIS

Although there are persistent core symptoms that define PTSD, a cascade of secondary symptoms or psychiatric conditions often fluctuate in intensity, and even temporarily or permanently become a major cause of disability ⁷.

Thus, the psychiatric expert opinion should comprise a series of detailed evaluations, rather than a single "snapshot" opinion.

Suicide

PTSD sufferers have a significant risk of suicide. This disorder was the highest risk factor in a study of over 3000 young adult suicide attempters ¹², and in another study of refugees exposed to severe trauma ¹³.

The prognostic factors for persistence of PTSD are now well-established.

Checklist

Although the relative importance of each item is still being evaluated, completion of a PTSD Prognosis Checklist ¹⁴ ensures that all important factors are documented.

This Checklist comprises 54 items in 11 sections that are rated for overall severity.

Copyright © 2003 Electronic Handbook of Legal Medicine