by Mark D. Worthen, Psy.D.
Here are some PTSD facts that are key to understanding Post-Traumatic Stress Disorder from a psychological injury and law perspective:
PTSD Fact #1: Severity of the Traumatic Event
Because the media has focused so much attention on PTSD, some common misconceptions have developed. One of them is that any significant stressor (stressful event) can cause the disorder.
In fact, it must be a particular type of very serious stressor, one that is truly traumatic.1 The official terminology, from the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition), is:
The person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others. (Criterion A1)
In addition, at the time of the trauma or shortly thereafter, the individual must have experienced a particularly strong emotional response:
The person's response involved intense fear, helplessness, or horror. (Criterion A2)
Thus, when investigating a PTSD claim, one must assess PTSD causes to determine if they meet the initial diagnostic criteria.
This step is important for anyone assisting a plaintiff (or claimant) because without a qualifying stressor, the case potentially falls apart. Defense counsel and mental health professionals conducting a PTSD evaluation also need to assess whether this essential component of the diagnosis exists.
PTSD Fact #2: Most People Exposed to a Trauma Do Not Develop PTSD
Rape is the only traumatic event that causes the majority (or close to a majority) of its victims to develop post-traumatic stress disorder. Other traumatic events, e.g., combat, natural disasters, car accidents, and others do not cause a majority of their victims to suffer from the disorder.
This fact is important because some people who have a rudimentary understanding of post-traumatic stress disorder think that if they were exposed to a traumatic situation then they must have PTSD. Often these individuals have psychological symptoms such as depressed or anxious mood but these symptoms have developed for reasons other than the traumatic event.
This phenomenon might be termed "false attribution" because the individual falsely attributes their current psychic distress (depression, anxiety) to a traumatic event when there is, if fact, no causal connection. In these cases, the individual genuinely believes they have post-traumatic stress disorder; they are not malingering.
When the individual knows there is no causal connection but they allege that a traumatic event caused them to develop PTSD it is called "false imputation", which is a form of malingering. This term was coined by psychiatrist Phillip Resnick.
PTSD Fact #3: Importance of a Detailed Diagnostic Interview
The possibility of false attribution and false imputation highlight the importance of a detailed PTSD interview. Without a detailed, focused interview that assesses the frequency, severity, and duration of each of the post-traumatic stress disorder symptoms, its easy for an inexperienced evaluator to be lulled into accepting a claimant's or plaintiff's assertion that he or she has PTSD. (It happens more often than you might think).
One of the best ways to accomplish this goal is to use a PTSD-specific structured interview protocol. Many forensic psychologists and psychiatrists consider the Clinician-Administered PTSD Scale (CAPS) to be the "gold standard" in this regard (although there are other well-validated PTSD structured interview protocols).
PTSD Fact #4: Malingered PTSD
Of course, a structured interview by itself will not detect individuals malingering post traumatic stress disorder. Experienced forensic psychologists therefore always screen for significant exaggeration or feigning of PTSD using instruments such as the MMPI-2 or a PTSD-specific malingering test such as the Morel Emotional Numbing Test for PTSD (MENT).
1. On some occasions a traumatic event does not immediately lead to the development of PTSD symptoms but such symptoms eventually develop. This is known as the "Delayed-Onset" type of the disorder. Sometimes the trigger to such Delayed Onset PTSD is another, less traumatic, stressful event.
American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR Fourth Edition (Text Revision). Arlington, VA: American Psychiatric Publishing.
Morel K. R. & Shepherd B. E. (2008). Developing a Symptom Validity Test for posttraumatic stress disorder: application of the binomial distribution. Journal of Anxiety Disorders, 22(8), 1297-1302.
Resnick, P. J. (1997). Malingering of posttraumatic stress disorders. In: Rogers R. (Ed.), Clinical Assessment of Malingering and Deception, 2nd ed., pp. 130-152. New York: Guilford. > In which the author discusses "false imputation". Note that there is a 3rd edition of this book in which Dr. Resnick also has a chapter on malingered PTSD and in which he discusses this concept.
Tolin, D. F., Steenkamp, M. M., Marx, B. P., & Litz, B. T. (2010). Detecting symptom exaggeration in combat veterans using the MMPI-2 symptom validity scales: a mixed group validation. Psychological Assessment, 22(4), 729-736.
Weathers, F. W., Keane, T. M., & Davidson, J. R. (2001). Clinician-Administered PTSD Scale: A review of the first ten years of research. Depression and Anxiety, 13(3), 132-156.
Author Bio: The author of this web page, Mark D. Worthen, Psy.D. is a forensic psychologist in Asheville, North Carolina. Dr. Worthen provides evaluations and expert witness testimony in several areas of criminal and civil law.
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