Posttraumtic Stress Disorder (PTSD) in the Forensic Context

Dr. Zelig | PTSD
Mark Zelig

801-273-3365 (Utah) 907-561-4141 (Alaska)
Fax: 866-907-2822
Office Locations:
Salt Lake City:
6925 Union Park Center, Suite550
Salt Lake City, Utah 84047-6527
4325 Laurel Street, Suite 297
Anchorage, AK 99508
1.     What is Posttraumatic Stress Disorder?

a.    Most people who are exposed to a traumatic event respond with fear and adrenal activation, commonly known as a “flight or fight response.”  Such a response is usually adaptive and may aid in survival.  After the emergency passes, most people return to their pre-traumatic level.  A minority of people, however, remain in some degree of fight or flight mode.  If they remain in this condition for a month or longer, they may meet the criteria for Posttraumatic Stress Disorder (PTSD), which is one of several anxiety disorders listed in the The Diagnostic and Statistical Manual of Mental Disorder – 4th Edition (DSM-IV-TR).

2.    When was PTSD first described?

a.    While PTSD did not become an official diagnosis until 1980, it has a long history.  For example, some historical accounts refer to Da Costa’s Syndrome or “soldier’s heart,” –  continued activation and irritability – in Civil War veterans (Grinage, 2003).

3.    What are the criteria for this diagnosis?

A person must satisfy six criteria (A – F, listed below) – criteria B, C, and D must occur simultaneously:

a.    Exposure to a “traumatic event in which both of the following were present:

i.    the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others

ii.    the person’s response involved intense fear, helplessness, or horror. (Note: In children, this may be expressed instead by disorganized or agitated behavior).”

b.    Persistent reexperiencing.  The person continues to reexperience the fear, helplessness, or horror associated with the event in at least one of the ways:

i.    recurrent and intrusive memories of the event.  “Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed” (DSM-IV).

ii.    “recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content” (DSM-IV).

iii.    Although rare, some individuals experience moments in which they believe they are actually reliving the traumatic experience, even if such “flashbacks” only occur upon awakening or intoxication.   Note: In young children, trauma-specific re-enactment may occur” (DSM-IV).

iv.    intense psychological distress occurs when the person encounters an internal cue or external reminder of the event.

v.    physiological reactions if the person encounters an internal cue or external reminder of the event

c.    Persistent avoidance of stimuli associated with the trauma and/or emotional numbing:  People with PTSD typically adopt strategies of decreasing distress and activation by either avoiding stimuli that trigger memories of the trauma, or by numbing their general emotional responsiveness.  This criterion requires that such is manifested in at least three ways as described below:

i.    They avoid thoughts, feelings, or conversations associated with the event.

ii.    Effort is made to avoid activities, people, or places that trigger recollection of the event.

iii.    They may block out or fail to recall an important aspect of the traumatic event.

iv.    Their level of interest in formerly significant activities decreases (a form of emotional numbing).

v.    Feeling less connected with others (emotional numbing).

vi.    Diminished range of feelings (loss of ability to feel happiness and appropriate sadness).  They may find it more difficult to feel love toward others because numbing is utilized at the expense of diminishing even formerly cherished feelings.

vii.    Expectations for a fulfilling life gives way to sense of “a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)” (DSM-IV).

d.    “Persistent symptoms of increased arousal,” that is, the person is persistently fearful, jumpy, or otherwise anticipating a recurrence of a similar event as manifested by two or more of the following:

i.    Difficulty falling asleep or maintaining restorative sleep

ii.    irritability or outbursts of anger

iii.    difficulty concentrating

iv.    hypervigilance – being overly sensitive to signs of possible threat or danger.

v.    exaggerated startle response

e.    The symptoms contained within criteria B, C, and D simultaneously persist for at least one month.

f.    Like nearly all emotional disturbances, the symptoms must cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning” (DSM-IV).

4.    So, if a person has very significant impairment, but falls short of one symptom on either Criteria B, C, or D, they do not qualify for the diagnosis?

a.    Before I discuss the implications of not obtaining threshold on all of these criteria, it is important to place this question in perspective: Trauma is more complicated than whether or not a person technically satisfies all the criteria for PTSD.  For example,

i.    Several studies (e.g., Norman et al., 2007; Zlotnick et al. 2002)      found that people who have been traumatized, but fail to reach threshold on all of the criteria may be indistinguishable in terms of life impairment with those who meet full criteria.  For example, Norman et al. 2007, who examined two community samples found the following (simplified) criteria were just as capable as the complete symptom set in identifying those needing treatment to deal with trauma:

(1)    One of the following criteria after exposure to life-threatening trauma:

(a)    “Emotional when exposed to reminders of the event(s)
(b)    Intrusive memories about the event(s)”

(2)    One or more of the following is also present :

(a)    Avoidance of thoughts or places that remind the person of the traumatic event.
(b)    Feeling detached from others or emotionally numb
(c)    “Trouble concentrating
(d)    Trouble sleeping
(e)    Feeling nervous or on guard” (Norman et al., p. 51)

ii.    Falling short of one of the DSM-IV criteria may mean that another diagnosis is more appropriate.  People exposed to a trauma often suffer from other anxiety disorders, or may have incurred a mood disorder stemming from the event.  Indeed, as authors like Briere (2004) have pointed out, the psychological damage secondary to trauma can present with several different disorders (other than PTSD).

iii.    DSM-IV is mindful that strict allegiance to all criteria defies common sense.   DSM-IV explicitly states that a clinician may award a diagnosis “even though the clinical presentation falls just short of meeting the full criteria for the diagnosis as long as the symptoms that are present are persistent and severe” (DSM-IV-TR, p. xxxii).

5.    It is possible for two people to have PTSD, yet have completely different symptom pictures?

a.    Almost.  Like many other diagnoses in psychology and medicine, the diagnostic criteria are arranged polythetically, meaning that a person only has to present with a partial list of symptoms to qualify for the diagnosis. So while people may vary considerably regarding the underlying criteria, all of those diagnoses with PTSD (1) have been exposed to a traumatic event, (2) responded with fear, horror, or hopeless for greater than one month, and (3) their symptoms cause distress and/or impairment in daily functioning.

6.    It seems logical that if someone had PTSD they might also be depressed.  How often does a person with PTSD have other diagnosable conditions?

a.    The National Comorbidity Study (Kessler, et al., 1995) found that four out of five people diagnosed with PTSD have more than one disorder, with the most common accompanying disorder being Major Depression in women, and Alcohol Dependence in men.  Making matters worse, 59% of the men and 44% of the women had three of more disorders.

7.    What is the lifetime prevalence of the disorder?

a.    The best study to date – the National Comorbidity Study (Kessler, et al., 1995) — which included nearly 6,000 subjects ranging in age from 15-45 years — found an overall lifetime prevalence of PTSD of 7.8%.  Within their sample, prevalence varied between different subsets of the population, with one of the most significant differences being between men and women.  Twice as many women (10.4%) reporting PTSD as men (5.0%).

8.    Only 7.8% of the United States population has been exposed to a traumatic event.  That number seems low!

a.    Don’t confuse the number of US citizens exposed to a traumatic event and those who develop PTSD.  Indeed 69% of the respondents within the National Comorbidity Study reported being exposed to a traumatic event, with only a minority of those folks developing PTSD.

9.    How long does it persist?

a.    The DSM-IV-TR reports that about 50% of those diagnosed with PTSD improved to such degree that they did not meet all of the criteria within 3 months of initial diagnoses. Kessler’s (1995) study found that psychotherapy significantly shortened duration, but more than one-third of their sample never made a full recovery.

b.    Even though many people with PTSD fall below the symptom threshold for diagnosis soon after exposure, “subthreshold” symptomatology may persist indefinitely, even in psychologically resilient individuals.  For example, Phebe Tucker and colleagues found that only 15% of her sample of Oklahoma City bombing survivors had PTSD approximately 10 years after the bombing.  However, all of her 60 subjects exposed to the event had elevated heart rate in comparison with a community control group.  Those exposed also manifested higher blood pressure when presented with reminders of the incident.

10.    Why do some people develop PTSD, whereas the majority of people exposed to trauma do not develop the disorder?

a.    Good question, and I wish I could cite factors that allow accurate predictions of which people exposed to a traumatic event will develop PTSD.  One study, conducted by Emily Ozer and her colleagues at the University of California and the San Francisco Veterans Affairs Medical Center, pooled the subjects from a number of other published studies into a large aggregation of subjects, hoping to answer this question.  They found a number of factors, all of which were mildly related to risk.  These factors included:

i.    History of prior trauma.  While it didn’t matter if prior trauma occurred in child- or adulthood, prior trauma linked to interpersonal violence had higher rates of risk for subsequent PTSD than those affected by combat exposure or accidents (p. 57).

ii.    Prior psychological problems.  While this was generally a weak predictor, subjects who had depression prior to the event were at highest risk amongst those with prior psychological issues.

iii.    Family history for psychopathology.

iv.    Perceived life threat.  Once again, trauma induced by interpersonal violence increased risk over trauma incurred from accidents.(p. 61).

v.    Perceived support following trauma.  While generally a weak predictor, this factor became more important with greater time after the exposure.

vi.    Peritraumatic emotional responses – that is, reported prevalence of psychological reactions during or closely after the event.

vii.    Peritraumatic dissociation.   Dissociating onself from the event at the time of its occurrence was the most potent predictor of developing PTSD, leading the authors to comment that “the in-the-moment appraisal and meaning of the traumatic stressor may have as much to do with explaining who develops PTSD as do the more static factors such as adjustment, prior exposure, or concurrent psychopathology” (p. 69).

11.    How did these authors explain their inability to find any strong predictors of who would develop PTSD?

a.    Noting that all of these predictors only accounted for 20% of the average person’s response to a traumatic event, they suggested that single or highly predictive factors may simply not exist.   Instead, “the possibility that factors unique to the combination of the person exposed and the nature of the exposure are the determining factors in understanding who becomes symptomatic and who does not” (p. 66).

b.    Another problem in linking trauma to subsequent symptomatology is that while researchers may be able to index the (physical) lethality of a given trauma, the significance that a particular event holds is based on the particular person’s interpretation and unique experience, making it difficult to quantify the psychological severity of a trauma for predictive purposes.  These observations lend credence to the observation made by many clinicians that “trauma is in the eye of the beholder.”

c.    Predicting the outcome of a disease is easier if it’s manifestation of the disorder remains constant.  The authors analogized PTSD, with its waxing and waning symptoms to diabetes, as opposed to the symptom consistency of a heart attack.

12.    Under what circumstances do the authors of DSM-IV recommend that malingering be considered?

a.    “Malingering should be ruled out in those situations in which financial remuneration, benefit eligibility, and forensic determinations play a role.”  Accordingly, one of the roles of a psychologist is to validate claims of the disorder.

13.    Do you think malingering is a significant problem?

a.    My experience is that actual malingering is rare, and more common when there are is no documentation that the person was exposed to a traumatic event – or that the event even occurred.  Symptom exaggeration appears more common than outright malingering.  That is, a person traumatized by an undisputed event puffs-up their reported symptoms for perceived financial or other “secondary gain.”  At the same time, there may be a significant number of PTSD sufferers who downplay or deny legitimate psychological injury.  For this reason, it is important for a forensic psychologist to determine the motivation of a person seeking compensation or special consideration for PTSD, keeping in mind that some people may exaggerate such symptoms while others with severe PTSD may downplay their traumatization because the topic is too painful to discuss.

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