Quantum-assessing wisdom on psychological injury from Hugh Koch, Kathryn Newns and Paul Elson
Assessing quantum for an alleged psychological injury is notoriously difficult bringing up many issues for experts and lawyers. Those involved will be faced with a myriad of sometimes conflicting and unreliable evidence. Clinicians wade through this information looking out for particular disorders or warning signs. The clinician will usually go through the following stages: information gathering, creating differential diagnoses, understanding conflicts between information, and resolving uncertainty.
The pointers below have been gathered through 30 years of experience in medico-legal assessment and from relevant research, In particular that of James Morrison, Professor of Psychiatry at Oregon Health Sciences University,
The starting point for a clinician is to obtain and evaluate a variety of different types of information gathered and put the injury into the context of the person’s general mental health and his environment. James Morrison describes this as ‘putting together’.
The clinician needs to:
Review the full spectrum of anxiety and depressive disorders (where relevant). In personal injury work, this is almost always necessary.
Understand family, social and occupational stress. The effects are often subtle both before and after an index traumatic event.
Balance the possibility of longstanding chronic behavioural/personality traits effects on specific diagnoses.
Use examination findings with care considering its context. Symptoms should be considered with care. For instance a claimant could be tearful because of the stress of the interview rather than a sign of clinical depression. Conversely, signs of suicidal interest are highly subtle and need careful investigation.
Look out for substance abuse problems. These have profound effects on psychological experience including mood and anxiety. They do not, in themselves, preclude a psychological injury, per se, but have an influential effect if present.
The foundations for a valid & reliable assessment are:
- Claimant self report
- Clinical/mental state examination
- P (+ other medical) information
- Other non-medical sources of information including surveillance evidence.
Inevitably there will be differences and conflict between information and gained from any two or more sources.
Tips for assessing information
- Recent history may be more reliable and accurate than ‘ancient history’.
- Collateral history may increase the reliability of claimant self report. The claimant will be focused on litigation and this may cause them to over-attribute symptoms to the accident/incident.
- Give equal weight to observed behaviour and the claimant’s self-report of symptoms.
- Understand the effects of stress on claimant perspective and reliability.
- Simplify, where possible, by identifying a single diagnosis that provides the simplest explanation of the available data and considering the more common diagnosis (without ignoring other possibilities).
Most personal injury litigation involves a single trauma or crisis incident (eg road traffic accident, work or medical accident). It is therefore essential that experts and lawyers have an awareness of how crisis or trauma can affect a person’s view of their world. Trauma-related stress can colour the tone, emphasis and recall of an event and its pre/post history and context.
Common road traffic accident diagnoses
- Adjustment disorder (anxiety and/or depression based)
- Phobic anxiety disorder
- Depressive episode or disorder
- Generalised anxiety disorder
- Pain or somatic-based disorder
- Post – traumatic or Acute Stress disorder
The criteria for these need to be reviewed and the ‘best fit’ diagnosis identified.
It is common to find some contradictory data when a comprehensive assessment has been carried out. This may point to some unreliability of claimant self-report commonly due to recall/memory effects and over-rumination on the index event. It is uncommon for a claimant to persistently or comprehensively malinger (ie fabricate symptoms in a way which is for secondary financial gain).
The following ‘red flags’ could indicate that a claimant’s data should not be accepted totally at face value:
- Magnification or extreme language to describe symptoms.
- Criminal behaviour (current, recent past)
- Significant variation or inconsistency in history provided
- History conflicts with usual course of disorder
- Memory loss in absence of cognitive disorder and/or head trauma
- Poor concentration
- Lack of response to advice or treatment
Differential diagnosis of anxiety states is one of the more common activities of psychologists and psychiatrists in a medico-legal context. Differential diagnosis involves observing and discovering signs and symptoms, considering the most likely disorders, then narrowing down the possible diagnoses, eliminating one after another, until typically only one specific diagnosis is left for the patient’s signs and symptoms.
Brief definitions of anxiety disorders are given in table 1 below. (adapted from Morrison 2007):
|Anxiety Disorder||Example Characteristics|
|Anxiety due to a medical condition||Physical illness can cause anxiety symptoms.|
|Anxiety due to use of substance||Alcohol, non prescribed drugs of misuse, and prescribed medications can all cause anxiety.|
|Panic Disorder||Repeated episodes of intense anxiety, (accompanied by a variety of physical symptoms) with worry about having additional attacks.|
|Agoraphobia||Patients fear situations or places (entering a store, being away from home) where the patient might have trouble escaping or obtaining help if they should become anxious.|
|Specific phobia||Particular objects or situations cause anxiety and avoidance which is disruptive to everyday life.|
|Social phobia||Speaking, writing, performing, or eating in public causes significant anxiety and avoidance.|
|Obsessive-compulsive disorder (OCD).||Thoughts or behaviours that appear to be illogical but the patients feels compelled to repeat them.|
|Posttraumatic stress disorder (PTSD)||Reliving a traumatic event, experiencing hyperarousal and avoidance.|
|Generalised anxiety disorder (GAD)||Feeling anxious or tense about a variety of different problems.|
Some disorders may be common for particular cases for instance specific travel phobia related to traumatic road accidents. The characteristics of a travel phobia are:-
- High levels of anxiety when travelling (driver and/or passenger)
- Avoidance of non-essential or longer journeys or in extremis of all journeys
- Disruption of social/family and/or occupational activity.
Care needs to be taken to take into account the effects of pain/physical disability, partner support, and litigation effects including compliance with advice and treatment when understanding ongoing disability.
Finally, when one has the opportunity to be involved in a case which extends over several years, it is important to be open to amending ones opinion, including, diagnosis and prognosis in the light of new information.
The court quite appropriately expects this to be done and ‘seen to be done’.