In assessing claimants’ psychological injuries and preparing a robust psychological report for the court, the expert is faced with many dilemmas in answering key medico-legal questions. In this article, the types of dilemmas are clarified and will be the subject of a series of subsequent articles in this publication.
- What, it any, injuries or medical conditions resulted from the claimant’s index accident?
- Are there injuries and conditions consistent with and attributable to it?
- Are there symptoms that relate to pre-existing conditions, and to what extent have these been exacerbated by the accident or made the claimant vulnerable to accident-related injuries?
- What has been the course and duration to these injuries and medical conditions to date, and have these been within the expected range?
- Was any absence from work in light of the injuries sustained reasonable?
- What treatment has already been received and/or is likely to be needed in the future for these conditions?
- What is the likely extent and duration of any continuing disability?
The dilemmas emanating from these questions largely relate to two issues:
- the availability and reliability of both subjective and objective information; and
- the multifactoral nature of individual psychology, which includes the index event flow of experience, Taking each question in turn, there are specific issues requiring consideration and attention.
Injuries from index accident
- Use of DSM.iV (TR) and/or ICD-IO
Reliability of DSM/ICD criteria
- Impact of actual event
Range of possible opinion
- Trauma/stress and anxiety reaction Stress/anxiety and pain adjustment
- Stress/anxiety and depression
- Clinical condition and normal reaction
Validation by hospital and GP records
Reliability of hospital notes
- Extent and legibility of GP records
Requests made for treatment
- GP attendance for assessment
- Requests for therapy
- Follow up any referral made/not made Adherence to treatment regime
Attributing injuries to index accident
- Accuracy of claimant recall
- Information on contemporaneous significant adverse events (e.g. redundancy) and ‘everyday hassle’ events (e.g. work mild illness) GP records of ‘accident-related’ comments (by GP or by claimant) Proximity in time of symptoms experienced to the date of accident
- Response to accident related treatment
Effects of pre-existing conditions
Accuracy of claimant recall (quantity, detail) and truthfulness
- Access to complete legible GP records
- Reliable historical data about a two-year period and ten year period pre-accident and model for explaining relevance of any ‘vulnerability’
- Relevance of type and frequency of GP attendance (a symptom type, similar symptom type, general symptoms)
- Relevance of history of forensic, or antisocial events and/or non prescribed drug use
- Methods for quantifying exacerbation
Course and duration of accident-related conditions
- Difficulty of retrospective estimation e.g. two years post accident
- Method for estimating length of initial phase and residual phase
- Validity of ‘delayed reaction’ e
- Adherence to/deviation from ‘normal/ expected’ model of course and duration
- Effects of other unrelated adverse events, ‘everyday hassles’ and addictive behaviours (e.g. alcohol, non prescribed drugs)
Absence from work
- Validity of work absence reasons
- Reliability of work record pre-accident
- Evidence of work satisfaction or dissatisfaction pre-accident
- Evidence of non-accident related work stressors (e.g. disciplinary problems, re-organisations)
- Efforts made to mitigate losses and consider phased return to work, with review to work support available
Treatment received or required
- Prior GP visit for treatment discussion
- Follow up of referral made/not made
- Adherence to treatment regime
- Future options for treatment
- Future psychological therapies made available and model EML)R; in vivo exposure; brief solution orientated therapy or intervention)
- Rationale for number of therapy sessions required and review of progress
- Level of disruption by residual symptoms
- Effects of ongoing litigation
- Reliability of symptoms such as ‘flashbacks’, nightmares, ‘avoidance’ and ‘personality change’