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PTSD has been officially used since 1988, when introduced in the Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III). It then became a bona fide psychiatric disorder. It is quite limiting to the individual suffering from it. I call it “The Humpty-Dumpty Affliction” in that “he sat on a wall and had a great fall, and no one could put him together again.” PTSD is a serious, debilitating, and chronic condition that is often overlooked. It is not created at will, and it is beyond one’s control.
I refer to an illness that is essentially described by its symptoms, meaning the description of the person’s subjective experiences. The mental health expert’s job during the forensic psychiatric investigation (or independent medical examination, IME) is to confront the presence or absence of signs (objective findings) and thus corroborate or refute the diagnosis of PTSD. These signs connect our direct obser- vation during the examination with that of others’ found while reviewing collateral sources describing the examinee’s different levels of functioning.
The possibility of PTSD being feigned (malingered) must always be considered.
Since the specific criteria of PTSD are easily accessible to any interested person, it would not be too difficult for him/her to report the symptoms the examiner looks for, thus challenging the forensic psychiatrist to produce data that will withstand scientific and legal scrutiny.
Few personal injury cases reach the courts without an expressed or implied alle- gation of malingering, having as primary motivation, financial gain, and then sym- pathy and social support.
Psychological Distress Following Traumatic Events
Many recognize the physical pain after an accident or injury, yet few realize that what goes on in the mind can be just as, if not more, devastating as car crash, a mishap at work, a fall (the physical wounds are often clear), a bad back, a sore neck, etc., but there is more: the mental component.
This sudden, unexpected, and violent assault of one’s sense of integrity and con- tinuity can interrupt the sense of well-being. PTSD is seldom recognized but is commonly concurrent with personal injury. Patients often undergo test after test and take medications that do not improve their condition. If not recognized, these patients sometimes have surgery that does not heal their pain. Eventually, many with PTSD start feeling neglected because doctors, even attorneys, do not know what to do for them.
By understanding the full dimension of a client’s trauma, psychological as well as physical, an attorney can address the legal factor well-armed. PTSD, when pres- ent, broadens the range of vision of what is damaged.
Depressive and anxiety symptoms are part of PTSD, as of adjustment disorder, and the like. The accident or traumatic event triggers a cycle and often people’s minds become totally immersed in their mishaps and pain. There is no more order to life. People become irritable, dysthymic, dependent, scared, disoriented, detached, and paralyzed either physically and/or emotionally.
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The Importance of Individualized Assessment
Not all people who experience upset need treatment. Depending on the pre-trauma personality characteristics and the nature and magnitude of the event, with the help of family and friends, many find they can move on and get better. Others, however, need professional help to recover and move in a positive direction. It is not always the severity of the accident that determines whether one develops PTSD; rather, it is the meaning the person attaches to the experience, and the personality characteris- tics that the individual has when confronted with the mishap. Everyone brings into a trauma-producing situation (triggering situation), predisposing and determining aspects, also called premorbid personality. It is impossible, beforehand, to deter- mine who will absorb the psychological effects of trauma and move on with their lives.
Many PTSD patients have difficulty talking about their trauma, which makes it hard for the disorder to be detected. Sufferers also have repeated episodes in which they re-experience the traumatic event. They have trouble concentrating because of this. They lose interest in activities and become socially withdrawn. People with PTSD avoid daily situations that remind them of the accident. Irritability, sleep disturbances, and restlessness are also part of the disorder.
This condition is treatable. The results are better if these symptoms are approached early on by the clinician. The goal is to help the patient recover to a premorbid level of functioning, by working through the trauma and pain, develop new and better adaptive mechanisms, and resolve the resulting grief.
Case 6a: Work-Related Accident – Loss of Limb While Operating a Machine
The accident took place 3.5 years before the attorney requested a forensic psychiat- ric evaluation; and aftertreatments and deposition of plaintiff were completed.
The question that still concerned the plaintiff’s attorney was whether Mr. Oré was then and is currently psychologically afflicted after the accident that occurred while he was working as a welder at a construction site. As a result of the accident, Mr. Oré’s right forearm, below the elbow, was severed.
Mr. Oré was 17 years old when the accident occurred. He had been diligent and hardworking, rapidly moving from stockpiling to welder in 1 year. He had migrated from the countryside of Chile to the United States, just days before being hired by the construction company, without prior experience or command of the language.
Throughout his orthopedic treatments, Mr. Oré came across as a quiet, reserved, and cooperative young man that did not seem to require psychological help. On the other hand, at the site of the bloody incident, all those involved and concerned, including ambulance, fire, and police personnel, needed crisis intervention of some form.
The examination with me revealed a person that remained seated in the same position through the 3-h interview. This lack of flexibility, spontaneity, and overall
Case 6a: Work-Related Accident – Loss of Limb While Operating a Machine
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stilted demeanor conveyed a gentle, albeit afflicted, and impoverished relating style.
Mr. Oré suffered from PTSD, major depressive disorder, and pain disorder. He depicted the “emotional anesthesia” described in cases of PTSD, characterized by a feeling of detachment or estrangement while maintaining intact his ability to test reality.
Mr. Oré had seen himself as attractive, assertive, young, energetic, driven, and able to start over. His actions before the accident attested to this. He lost it all. The clinically significant distress and impairment in his personal, social, and occupa- tional life were prominent and well documented.
His occupation changed from being a productive worker and a family-oriented adolescent (he lived with his cousin and financially supported his mother and younger siblings in his native country) to being a full-time patient, without possibil- ity of cure and only limited physical improvement.
Mr. Oré was right handed. That hand defined this manual laborer. Without his dominant hand, he saw himself becoming an insignificant person, useless, and hopeless. He lost the most important organizational apparatus (the right hand of a right-handed man) designed for him to achieve adaptation and progress, indispens- able to carrying out specialized activities.
It was essential to describe the “phantom limb” phenomenon affecting him. It refers to the network of nerves in a large and specific area of the brain still gener- ating messages about the missing body parts despite the absence of stimulus- driven input (right hand). This continues throughout life. It evokes images in the mind that tease and prevent Mr. Oré from psychologically working through the loss.
Mr. Oré’s nonreflective persona, coupled with his disconcerted attitude and depressive symptomatology (as described in the body of the narrative report), cur- tailed his ability to express emotional content (phenomenon also known as alexi- thymia); this accounted for his reserved stance and explained the absence of seeking out psychiatric help. It became clear why Mr. Oré appeared to be currently free of psychological ailment to the untrained eye.
Case 6b: Rape of a Woman with Cognitive Impairment
On her way back home from the workshop she attended daily, Ms. Thomas, 27 years old, was raped by the house’s maintenance worker, in the elevator of the building where she lived with her mother.
Some 2 weeks later, Ms. Thomas disclosed the assault to her elderly, still active but fragile mother, a diabetic woman, convalescing from a stroke.
There was no evidence of the sexual attack itself, other than Ms. Thomas not being a virgin, whereas in all prior gynecological exams (due to endocrine defi- ciency) she appeared not to have had sexual intercourse.
The case for her attorney surfaced as somewhat muddled since Ms. Thomas was
“not all that vocal,” per reports; and so she seemed to be calm, young, attractive, well mannered, and, above all, “doing well.”
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Ms. Thomas had said that she would like to go back to “work” (the workshop) where she had been going for years, performing repetitive manual labor and chores like gluing small boxes together. Her social life involved two fellow female “work- ers,” with whom she only met with at work. After the rape, she interrupted the attendance, received psychotherapy and was prescribed paroxetine (antidepressant) and ziprasidone (antipsychotic also used to curb agitation), and then resumed work.
Months later, Ms. Thomas stopped going to work because her mother could no lon- ger escort her downstairs to the van and greet her in the street at the end of the day, as she had started doing after the sexual assault.
A review of all existing records, including medical, gynecologic, psychiatric, and deposition transcripts pointed at Ms. Thomas being emotionally afflicted by the sexual attack. Her demanding responses of taking frequent showers, and becoming restless and aloof, gave way some 8 months later to her resuming attendance at the workshop, until her mother put an end to this routine. Ms. Thomas’ life again changed dramatically.
Using an audiotape interview (also of the mother and sister), it was possible to memorialize the responses. Her ability to recall, concentrate, and think logically was adequate as well.
Taking into consideration the limits imposed by her cognitive impairment, her mental status exam revealed signs and symptoms commonly seen in individuals subjected to extremely dangerous, traumatic, humiliating life experiences. Ms.
Thomas had never complained of any untoward event against her. She appeared to be a truthful and accurate informant. She did not appear to be fabricating any of her history. According to her mother, Ms. Thomas loved to shop and buy clothes.
The opinion was that Ms. Thomas had been and was currently affected by the event. It was central to point out that “mental retardation” (a term riddled through- out the records) was not a psychiatric disorder and that Ms. Thomas had been living to her fullest intellectual potential, emotionally well-adapted, and “in touch”. Her sexuality and sense of femininity had not been hindered by her cognitive impair- ment but by the sexual attack she endured.
Routine activities and predictability of her surroundings are essential to maintain her mental stability. It was documented that her mother had been her “coach” since she was 5 years old. In fact, it was because her mother did such a good job teaching Ms. Thomas; that mom had been hired to work for a nationally recognized group dealing with the intellectually disabled. Her mother was totally invested in the safety and well-being of Ms. Thomas, contributing significantly to her social and support network.
Ms. Thomas had fewer resources to deal with the trauma than the average person.
She was minimally verbal yet able to react and express herself when she was sensi- tively brought into the subject. Her responses were those typically seen in individu- als subjected to submit by force, including the threat of imminent death.
Describing the special bond that Ms. Thomas and her mother had was crucial. The mother successfully invested long and laborious years loving, educating, and protect- ing her daughter. In the process, a “symbiotic” relationship developed between them.
Her mother was the umbrella to keep Ms. Thomas free of danger. The rape affected
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her mother in powerful and meaningful ways separately than it did her daughter.
They both mentally regressed, and the functional capacity of the mother, which fueled that of Ms. Thomas, weakened and neither felt safe any longer. Ms. Thomas became a recluse, shattering her personal, social, and occupational life.
Case 6b: Opposing Forensic Expert Opinion – Rape of a Woman with Cognitive Impairment
The examiner found that Ms. Thomas was being truthful during his deposition with her and, furthermore, she could appreciate the meaning of truth-telling and the importance of such during their “conversation.” She did not know why she was in the (deposition) room, but her recall of past events, school days, year of graduation from the “School for Handicapped Children”, sequence of daily events from school- ing to working, and what her first job entailed “working with rods.” Ms. Thomas also said that her mother was her friend and that she went on the bus to lunch with her “friend Cynthia.” She was able to provide her full address, age, and telephone number.
The examiner took from her deposition her description of the occurrence: “the maintenance man took my pants off and put his penis in vagina.” She said that it happened in the elevator of her apartment and that his name was Charlie. He grabbed her arm, she stated, and took her black leather book bag. Moreover, she described he was wearing a uniform of brown pants and a beige shirt. She said that he raped her in the elevator. She noted that she had bruises on her back, but no cuts or broken bones. She told her mother and sister Beth. Beth took her to the hospital and thera- pist. She took sertraline (Ms. Thomas said “Paxil”). The man in the elevator was a skinny guy who rode a bicycle in the parking lot. She also said that she took a van to go to work.
The examiner noted that 3.5 years after the reported event, Ms. Thomas still lived in the same housing project and the man she accused of raping her was still at work in the development. Yet, she did not appear to be emotionally upset when she talked about seeing him. Ms. Thomas told the examiner that she thought about the rape a lot and that she still felt “nervous and dizzy” but was not able to elaborate on these symptoms.
She only spoke when spoken to and then responded in brief phrases. The exam- iner noted that her cognition appeared seriously compromised. It was further men- tioned that Ms. Thomas’ ability to concentrate and recall memory appeared to be poor. He added that her language production was meager, her logical thinking was impaired, and her affect and mood were normal and appropriate. He also found no evidence of sociopathic thinking or behavior.
As it related to her complaint, the examiner found “PTSD, by history, generally now resolved, not clinically apparent,” as a psychosocial stressor, noted, “occa- sional occurrences of memories about her rape, by history, mild.” Lastly, the exam- iner added that “Ms. Thomas sustained no permanent psychiatric condition or disability, relative to the reported rape.”
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Case 6c: Victim of Police Brutality
Questions: Does José Ríos suffer from post-traumatic stress disorder as a result of the event that took place on February 29, 1998? Is Mr. Ríos currently psychologi- cally afflicted as a result of the event of February 29, 1998? If so, what is his diag- nosis, treatment recommended, the cost for same and prognosis?
It is reported that, on February 29, 1998, Mr. Ríos was driving home from a bar when he noticed a car blocking his path. Moments after having honked at the car, two men dressed in dark civilian clothing came at him, forced him out of his car, restrained him, beat him, and then drove him home with not an explanation but a warning to “Go home and shut the fuck up.” After being contacted by the defense attorney representing one of the two men, later determined to be police officers, I reviewed all of the pertinent information so that I may be able to determine whether José Ríos suffered from PTSD as a result of this event.
Promptly arriving at my office, Mr. Ríos requested that I conduct the meeting in Spanish, to which I agreed. With clarity, he was able to depict to me the sequence of events with vivid descriptions of that February day 3 years earlier. He was driving down a street coming from a bar when he honked at a car that was blocking his path.
Moments later, two men dressed in dark clothing, one holding a gun pointed at him, yelled, “What’s up, motherfucker?” After forcing Mr. Ríos out of the car, the two men threw him on the ground, handcuffed him, and beat him. Finally, Mr. Ríos real- ized the two men were police officers but still had no idea why they were beating him. Mr. Ríos thought quickly and blurted out the name of the sheriff he knew and the police officers brought him into their car and finally drove him home with a warning “Go home and shut the fuck up.”
Shortly after arriving home, he explained to his fiancée what had happened that night. They dropped off their son at his mother-in-law’s and made a stop at the police station on their way to the hospital. He retold his experience to the police over the phone from the hospital where the lacerations on his hand were sutured.
The hospital records indicated that there were “two one-inch lacerations to the dor- sum of the right hand, swollen, and tender.” Now there is only slight scarring. He said the doctors “did a very good job and his hand is fully functional.” The hospital also reports that they located multiple body abrasions, but his mental status exam was unremarkable, and there were no signs of anxiety or agitation.
However, Mr. Ríos said to me that his hand was only a minimal part of his suf- ferings. “I couldn’t sleep for several days… I was scared when in the street… I am vigilant when I go to a bar…” Almost 5 months after the incidence, Mr. Ríos started to see Dr. Perez for treatment twice a month with supportive psychotherapy only.
Dr. Perez reported that Mr. Ríos was well connected to his surroundings, and his occupational functioning has not been affected. He clinically diagnosed Mr. Ríos as having phobias to policemen, and the psychiatric diagnosis was PTSD directly caused by the event of February 1998. He then prescribed clonazepam (mild seda- tive) and psychotherapy based on a brief encounter of 20–30 min approximately once a month. Mr. Ríos had a total of 19 visits to Dr. Perez over a time period of 16 months.
Case 6c: Victim of Police Brutality