Understanding PTSD for Attorneys

Post Traumatic Stress Disorder (PTSD)

What is PTSD and what does it have to do with my case?

Traumatic events can include, but are not limited to, military combat, violent personal assault (rape, domestic violence), being kidnapped, being taken hostage, terrorist attack, torture, natural or manmade disasters, severe automobile accidents, or being diagnosed with a life-threatening illness.  It can result in substance use, depression, and anxiety.

Trauma can complicate any legal case. Your client may have difficulty participating in the legal process and require therapy. The event precipitating legal action may be the cause of the trauma and need to be considered in a settlement case. PTSD can also be malingered. If you are able to recognize the symptoms of PTSD, you can obtain an expert to help argue a stronger case for your client.

A person should be evaluated for PTSD if they witnessed, experienced, or were confronted with an event that involved actual or possible death, grave injury, or threat to physical integrity. However, having the experience does not in itself lead to a diagnosis of PTSD. The person’s response must have included severe helplessness, fear, or horror. In children, this may be expressed instead by disorganized or agitated behavior. Further, in order to receive a diagnosis of PTSD, the following symptoms must occur for at least one month and interfere with one’s work, family, and/or social life. Several symptoms must occur in a number a categories, it’s actually quite a high bar to be diagnosed with PTSD.

1. Reexperiencing symptoms– at least one must be present:

1. 1. 1. Memories of the trauma which intrude into consciousness repetitively, without warning, without triggers, or reminders to elicit them. In children, repetitive play may occur in which themes or aspects of the trauma are expressed.
      2. Vivid reenactments or flashbacks of the event. In children, trauma-specific reenactment may occur.
      3. Nightmares about the event. In children, there may be frightening dreams without recognizable content.
      4. When faced with actual or symbolic cues related to the event, the person has intense psychological reactions such as terror or physiological responses such as increased heart rate.
      5. The symptoms are viewed as intrusive and distressing because the person has no control over when or how they occur.

2. Avoidance and numbing symptoms– at least three must be present:

1. 1. Avoidance of thoughts and feelings about the trauma.
   2. Avoidance of situations and events that remind the person of the trauma.
   3. The person actually forgets specific aspects of the trauma.
   4. One is cut off from both positive and negative emotions.
   5. These symptoms make it hard to relate to others, enjoy life, remain productive, and plan for the future.

3. Physiological hyperarousal – at least two must be present:

1. 1. A state of fight or flight exists similar to the response during the traumatic event.
   2. One is primed for danger in most situations even when it’s safe.
   3. Difficulties with sleep, concentration, and/or irritability are present.
   4. People can have very strong startle reactions as well.

Can you have trauma and not have PTSD?

Most people exposed to trauma do not develop PTSD. In fact, a major study that surveyed almost 6,000 people found most had experienced at least one major traumatic event. It has been theorized that people who experience trauma who do not develop PTSD have protective factors such as a high level of education and considerable social and emotional support.

What causes PTSD?

Research indicates that about 20% of women and 8% of men who experience traumatic events are likely to develop PTSD. The types of trauma that are more likely to lead to the development of PTSD include rape, combat, childhood neglect, childhood physical abuse, threat with a weapon, sexual molestation, and a physical attack.

There is some research that suggests certain individuals are predisposed to develop PTSD when exposed to trauma. Some people are more prone to perceive a situation as dangerous and to be more physiologically reactive. For example, subjects with PTSD exhibit higher resting heart rates than those without PTSD. There are several risk factors for developing PTSD which include: female sex; neuroticism; lower social support; lower IQ; preexisting psychiatric illness, especially mood and anxiety disorders; childhood physical or sexual abuse; childhood separation from parents; a family history of mood, anxiety, or substance abuse disorders; and family instability. If someone dissociates (mentally disconnects) at the time of the event they are also more likely to develop PTSD.

There are multiple theories for the development of PTSD. An individual with PTSD has learned to associate events related to the trauma with fear, and avoidance with escape. Therefore, when someone encounters a fearful situation they experience the avoidance and numbing symptoms described above. Intrusive reexperiencing symptoms appear related to mental fear structures that form a network in the memory. This fear network is activated by reminders of the trauma and, again, avoidance behaviors are employed. This activation also interferes with daily life because it impacts a person’s belief system and her or his expectations of the world are shattered. These include beliefs about safety, trust, control/power, self-esteem, and intimacy. Therefore the person often blames them self for the event and feels shame or embarrassment.

Does it interfere with someone’s ability to work?

PTSD does not resolve quickly. If symptoms are not resolved within about three months then they tend to persist over time and worsen without appropriate intervention. PTSD can co-occur with a number of problems such as pain, depression, anxiety, substance abuse, and personality disorders. Not only does PTSD affect a person’s emotional and interpersonal functioning but it also affects the body in several different ways. For example, people with PTSD exhibit higher heart rate, blood pressure, and skin conductance (sweaty palms). People with PTSD are more prone to startle in reaction to loud noises as evidenced by larger eye blink and brain wave responses. Exposure to inescapable stress releases chemicals in the brain that blunt sensitivity to pain which may underlie numbing. Acute stress triggers the release of excessive stress hormones which suppresses the immune and metabolic systems thus making someone more prone to illnesses. In other words, if PTSD goes untreated it can interfere with someone’s ability to work. However, with appropriate treatment, most people with PTSD can return to a normal level of functioning, including work.

References:

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: APA.
McNally, R. (1999). Posttraumatic Stress Disorder. In T. Millon, P. Blaney, and R. Davis
(Eds.), Oxford textbook of psychopathology (pp.144-165). New York: Oxford University Press.

Resick, P., and Calhoun, K. (2001). Posttraumatic Stress Disorder. In D. Barlow (Ed.),
Clinical handbook of psychological disorders, third edition (pp. 60-113). New
York: The Guildford Press, NY.

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