The unifying factor in many debates between experts, barristers and the judiciary about psychological diagnosis is that ‘something traumatic or stressful’ in the claimant’s history has been partly responsible for the cluster of psychological symptoms that have allegedly developed into a psychological injury.
Whatever diagnosis is arrived at, the key questions for the Court are:
- Did the claimant at any time develop a recognised psychological disorder? This means a cluster of valid and reliable psychological symptoms which were disruptive socially, psychologically and/or occupational and which met the criteria for one (or more) diagnoses in either of the two main clarification schemes, DSM-5 (APA, 2013) or ICD-10 (WHO, 1992).
- Can this disorder be attributed to a given index event, or did it pre-exist or post-exist the index event.
The group of diagnoses typically considered in civil cases where there has been a significant single event with or without physical injury include the following:
- Post-Traumatic Stress Disorder (PTSD) (DSM-V 309.81)
- Acute Stress Disorder (ASD) (DSM-V 308.3)
- Adjustment Disorder (DSM -V 309.28)
- Other Specified Trauma or Stressor–related disorders (DSM-V 309.89)
- Somatic Symptoms Disorder (DSM-V 300.82)
- Specific Phobia Disorder (DSM-V 300.29)
Post-Traumatic Stress Disorder (DSM-V 309.81)
In this disorder, after a distressing event, the claimant experiences the following (Morrison, 2014):
- Repeatedly reliving the event, in nightmares (upsetting dreams), dissociative flashbacks, with physiological sensations e.g. racing heart or distress.
- Takes steps to avoid the fear: refusing to watch television or to read accounts of the event.
- Becoming negative in their thinking: with persistently negative moods, gloomy thoughts (“’I’m useless,” “The world’s a mess”).
- Experiencing symptoms of irritability and excessive vigilance.
The criteria for ASD are similar to those required for PTSD (Morrison, 2014). If symptoms last 4 weeks or longer, then the PTSD diagnosis is used.
Adjustment Disorder (DSMV 309.28
Whether the index event is as life-threatening as it is in PTSD or ASD, a person who experiences a significant ‘stressor’ can develop symptoms of depression (mood and sleep disturbance, tearfulness, low self-esteem), anxiety (focused or generalised, physical or emotional) and behavioural symptoms of avoidance and poor performance.
This cluster typically starts within 3 months of the index event and stops within 6 months of the stressor’s end.
The quality of this disorder is different from that of PTSD or ASD and is typically seen as less severe. This is reflected in prognosis and quantum assessment.
Other Specified Trauma- or Stressor Related-Disorder (DSMV 309.89)
This diagnosis is used when there is an evident stressor or trauma which has caused significant distress in social, occupational or psychological areas, but the other criteria for an Adjustment Disorder are not necessarily met.
Examples include delayed onset (although this concept is controversial); prolonged duration beyond 6 months and persistent complex behavioural disorder (with several and persistent grief and mourning).
Somatic Symptoms Disorder (DSMV 300.82)
With a proportion of patients, a problematic presentation involving pain is seen which consists of:
• Pain that seems excessive and chronic with no medical cause.
• Pain that doesn’t improve despite treatment that helps most patients
• Excessive concern and preoccupation with pain
• Magnified nonverbal expression
Specific Phobia (DSMV 300.29)
Some claimants develop a significant fear of road travel e.g. driving on motorways, at night, being a passenger, being a pedestrian with associated high anxiety with avoidance of some/all travel situations.
It is also maintained by irrational (albeit understandable) fear of the likeliness of another similar accidents e.g., a phobic driver may think the chance of another accident is 50/50, causing panic.
Psychological assessment of trauma requires a logical and impartial approach to understanding what the claimant has been through. It must also investigate whether the claimant was already supplying a pre-existing psychological disorder or had a vulnerability to developing a trauma-related or anxiety-related disorder.
Being involved in a non-fault significant traumatic event is very distressing and all parties included in describing this with the claimant, whether they be medico-legal experts, lawyers or barristers have a duty to be empathetic to the claimant’s experience over and above their duty to the law to produce independent opinions that are robust, reliable and valid.
- Koch HCH, Adeleye N, Willows J and Harrop C (2019) Post Traumatic Stress Disorder – Contemporary analysis of medico-legal evidential issues. Expert Witness Journal, Summer 2019 42-50
- Morrison J (2014) DSM-5 Made Easy: The clinician’s guide to diagnosis. Guilford Press. New York.