Posttraumatic Stress Disorder (PTSD) – Diagnostic Confusion
Alice M. Adams, RN, LNCC
Although frequently diagnosed by physicians, PTSD does not arise inevitably from a serious personal injury.
Posttraumatic Stress Disorder as a diagnosis emerged after the Vietnam War. Prior to then, shell-shock‚Äù was the terminology used in the WWII and Korean wars. The Diagnostic and Statistical Manual (DSM III) classified the diagnosis as an anxiety disorder, and further refined diagnostic criteria in subsequent editions. The diagnosis as it exists in today‚Äôs DSM-5 utilizes the most specific criteria yet, re-categorizing PTSD as a stress (trauma) related disorder.
In most states, PTSD (or any other mental injury) is not compensable under workers‚Äô compensation without a preceding physical injury. Nonetheless, some employers will authorize an evaluation for a significant emotional trauma (i.e., robbery) in the absence of tissue damage.
As an attorney, you may be bringing or defending a claim of Posttraumatic Stress Disorder. While diagnosing the disorder is a clinical process, as you weigh the evidence for likelihood of PTSD, here are some data to guide your assessment.
More Than One Form of PTSD
Acute Stress Disorder – a trauma that occurred more than three days but less than four weeks ago
Posttraumatic Stress Disorder (Acute) – the symptoms have been present between four weeks and three months
Posttraumatic Stress Disorder (Chronic) – the symptoms have been present longer than three months.
Posttraumatic Stress Disorder (Delayed Expression) – symptoms that first arise > 6 months after the trauma.
Further refinement of the diagnosis depends upon severity and degree of impairment in functioning. Extreme symptoms may include depersonalization, or the feeling of being an outside observer of one‚Äôs body; derealization, or unreal and dreamlike surroundings. Both symptoms fall into the category of Dissociative Symptoms. Children under 18 require a different set of criteria. Children can be very sensitized to the traumas encountered by their parents.
Symptoms & Diagnosis
In personal injury claims, the diagnosis of PTSD is commonly associated with motor vehicle accidents, fires, airplane incidents, amputations, and assaults. Chronic back pain from an injury is unlikely to result in PTSD unless the injury itself was traumatic (such as falling from height or being struck by a car).
What are the criteria for a valid claim of Posttraumatic Stress Disorder, and why is the diagnosis so often misapplied by primary physicians? A review of the eight criteria for true PTSD indicates:
- There must be a triggering event: exposure to actual or threatened death, serious injury, or sexual violence in one or more of the following ways:
- Direct experience of the event
- Witnessing the event as it occurred to others
- Learning that the (accidental or violent) event happened to a close family member or friend
- Repeatedly experiencing personal (not via media) exposure to the trauma (such as 911 first responders)
- A diagnosis of PTSD requires one or more of these symptoms be present following the event:
- Recurrent intrusive memories that are involuntary
- Nightmares of the event ‚Äìpolice officers may dream that their family is in great danger and they are powerless to save them.
- Flashbacks ‚Äì the person feels or acts as though the event is happening again
- Extreme psychological distress with exposure to internal or external cues of the event (smells, sounds)
- Extreme physical reactions to internal or external cues of the event (GI upset or vomiting)
- The patient persistently avoids reminders of the event in one or more ways:
- Avoids memories of the event in all forms
- Avoids external reminders of the event (people, places, objects, etc)
- Changes in mood or cognition in one or more of the following ways:
- Amnesia for important aspects of the event
- Pan-negative beliefs about self or the world
- Irrational self-blame
- Persistent negative emotions of fear, anger or shame
- Withdrawal from activities
- Withdrawal and detachment from others
- Anhedonia, or the inability to experience happiness or pleasure
- One or more of the following behaviors are atypical (not in evidence) prior to the event:
- Extreme irritability or aggression
- Reckless or self-destructive behavior
- Extremely on guard for surroundings/safety
- Exaggerated startle response
- Difficulty concentrating
- The symptoms in Criteria B-E have lasted > 4 weeks
- The symptoms are severe enough to impair functioning in social, occupational or other areas of functioning
- The symptoms are not the result of medication or other medical conditions
Who is the Victim?
Bystander exposure to a horrific event, such as a plane crash, can result in valid symptoms. If the victim tells his wife about the event, which did not happen to him personally, she would not have a valid claim of PTSD. She may, however, have loss of consortium if the husband has ongoing disruptive symptoms.
Often, the patient with PTSD may not be able to describe it in detail. The brain often represses all or part of a traumatic memory, even while the symptoms persist in the absence of conscious thought. This protective repression can contribute to intrusive thoughts that erupt when least expected. Untreated, or treated improperly, Posttraumatic Stress Disorder can become a chronic condition resistant to care.
One treatment for Posttraumatic Stress Disorder is EMDR ‚Äì Eye Movement Desensitization Retraining. The patient forcefully recalls the event while concentrating on a visual distraction ‚Äì blinking lights, repetitive movements, or sounds that disrupt the neural pathways and reprogram the recall of the memory. It works for many, but competently trained clinicians can be difficult to locate.
Slowly re-experiencing or reintroducing a person to the scene of an accident is required if the scene is an unavoidable part of daily life. Over time, the symptoms may diminish and gradually resolve.
Cognitive Behavioral Therapy is a problem-oriented approach to psychotherapy focusing upon practical solutions and identifying the relationship between situations and emotions. PTSD is not responsive to the insight-oriented, inwardly focused approach of traditional psychotherapy.
Some antidepressants lessen the symptoms of PTSD. Paxil, Zoloft, and Seroquel, alone or in combination can lessen the severity of symptoms. Contraindicated are medications that promote vivid dream activity, such as amitriptyline. Ambien (zolpidem) promotes sleep onset, but results in unusual and dysregulated nighttime behaviors in some patients.
Recent research suggests that performing stellate ganglion blocks (injections) at the level of C6 provides partial relief in symptom severity. The term for this usage is off label‚Äù. The stellate ganglion (nerves originating from the cervical spine) has second and third-order neuron connections with the central nervous system nuclei that modulate the manifestations of PTSD…it seems reasonable to us that SGB may reset the area of the brain responsible for anxiety to its pretrauma state…‚Äù Although not definitive, preliminary research is promising.
What does not work…what is counterproductive to any patient‚Äôs welfare…is well-meaning, but excessive handholding that promotes dependency, whether provided by a doctor, family member, or a law practice.
In combination with physical sequela, the symptoms of PTSD may require medication, psychological therapy, job change or on occasion, result in permanent partial disability.
The military history of PTSD: http://www.vva.org/archive/TheVeteran/2005_03/feature_HistoryPTSD.htm
Seventy-two articles/blogs from Dr. David B. Adams on PTSD ‚Äì diagnosis, treatment and complications http://www.psychological.com/forums/search.php?searchid=929502
*Alice Adams, RN BA LNCC is a registered nurse with >25 years experience in both critical care and outpatient psychological management. A Legal Nurse Consult since 2006, Alice is Board certified by the AALNC. Visit her at www.TheLegalnurse.com. She also supervises the forensic practice of David B. Adams, Ph.D., FAACP. Dr. Adams treats patients suffering from Chronic Pain, PTSD, and Mood Disorders.
 Desk Reference to the Diagnostic Criteria from DSM-5, American Psychiatric Publishing, Washington DC, 2013