Posttraumatic Stress Disorder in Litigation: Guidelines for Forensic Assessment

Article excerpt

ROBERT I. STMON, ED.: Posttmumatic Stress Disorder in Litigation: Guidelines for forensic Assessment. American Psychiatric Publishing, Inc., 2003, 238 pp., $42.00, ISBN 1-58562-066-1.

This book is a second edition edited by Robert I. Simon, M.D., Clinical Professor of Psychiatry and Director, Program in Psychiatry and the Law at Georgetown University School of Medicine. The first edition, published in 1995, was the result of a conference attended by lawyers, psychologists, and psychiatrists to develop standards for the forensic assessment of PTSD claimants. This expanded edition includes four of the five participant authors of the first edition in addition to four new authors who offer guidelines to assess the incident specific nature of PTSD pertaining to children and adolescents, worksettings and neurophysiological verification.

Daniel W. Shuman, J.D., addresses the challenge that stress-produced emotional impairment presents to the law. The legal rules governing the admissibility of evidence changed radically when psychiatry began sharpening the concept of stress-produced emotional pain early in the twentieth century. The expansion of litigation has become inevitable. Shuman insists that psychiatry must continue to refine its tools, as well as relate effectively to the juridical process in order to render justice to both plaintiff and defendant alike.

Dr. Bonnie L. Green's study of risk indicates that intensity of stress and kind of stress, such as rape, increases the risk for development of PTSD. Preexisting factors, such as borderline personality disorder, as well as multiple exposure to objectively defined stress increases risk. Comorbidity is difficult to assess due to its relationship as to cause or effect in the development of PTSD. She urges continued longitudinal research to study duration and prevalence.

Dr. Simon's thorough chapter on assessment guidelines sets out the primary symptomatic PTSD criteria that have undergone clinical scrutiny: intrusive, vivid recall or reexperiencing of the trauma, numbness of feelings, dissociative detachment, and increased arousal. Both Green and Simon, as well as other authors in the book, allude strongly to the requirement that these symptoms must be related specifically and objectively to the stressful event. This is reflected in the more rigorous stress criteria set out in DSM-IV that omits the phrase "outside the range of usual human experiences" (DSM-III-R, 1994, p. 427) but continues to require "an event or events that involved actual or threatened death or serious injury or a threat to the physical integrity of self or others" (DSM-IV, 2000, p. 467). This latter criterion lends itself more to the objective dose-related criterion even though stress not outside the range of common experience increases the possibility of malingering and makes the issue of individual vulnerability and comorbidity a more prominent issue. Dr. Simon addresses the obscure "eggshell plaintiff" (p. 61) concept by citing the legal precedent that recovery is feasible only when the alleged harm could be expected to occur in the "ordinarily" (p. 61) vulnerable person. It is often a daunting forensic task to assess the effect of predisposing or preexisting factors on stress-related emotional pain. Litigation itself rekindles a stress reaction while the lure of financial gain can lead to the exaggeration of symptoms and the motivation for malingering.

Phillip J. Resnick, M.D., a leading authority on malingering, offers clear guidelines on its detection and his chapter is well worth repeatedly reviewing.

Diane H. Schetky, M.D., adds an overview on the neglected area of PTSD Assessment in Children and Adolescents, citing data indicating that sexual abuse is by far the most common cause of PTSD in children and adolescents, particularly female children. …