Microsoft word - newsletter for august, 2009 - ptsd.doc

Westwood Evaluation & Treatment Center, 11340 Olympic Boulevard, Suite 303, Los Angeles, California 90064, 310-444-3154, [email protected] “in order to diagnose a Posttraumatic Stress Disorder correctly the doctor must show that the individual meets the DSM-IV-TR criteria” One of the most frequently encountered diagnoses in personal injury and workers’ compensation litigation is a Posttraumatic Stress Disorder (309.81). Clearly, not everyone who has been exposed to the According to the DSM-IV-TR, a Posttraumatic Stress type of stressors that can produce a Posttraumatic Stress Disorder is diagnosed correctly when an individual has been Disorder will invariably develop such a disorder. For exposed to an extreme life-threatening traumatic stressor that example, knowing that someone was exposed to a major has led to the development of a set of characteristic signs automobile accident does not necessarily mean they will and/or symptoms that have lasted more than one month. These develop a Posttraumatic Stress Disorder. In this regard, extreme life-threatening stressors may involve actual or research has shown that only somewhere between 10% threatened death, a serious injury, a threat to one’s physical and 45% of individuals who have survived a serious integrity, witnessing such an event, or learning that a family automobile accident will develop a Posttraumatic Stress member or close associate has experienced such an event. Such traumatic events include, but are not limited to, Similarly, the magnitude of a traumatic event is not a military combat, violent or personal sexual and/ or physical perfect predictor of its psychological effect. Thus, what assaults that may occur during robberies or muggings, being may appear to be a relatively “mild” stressor may have a kidnapped, being taken hostage, terrorist attacks, torture, great effect on a given individual. The variables incarceration as a prisoner of war, natural or manmade responsible for differential effects of the same stressor on disasters, severe automobile accidents or being diagnosed with different people have been researched and it is known a life-threatening illness. Witnessed events include, but are not that factors that may predispose one to develop a limited to, observing a serious injury or the unnatural death of Posttraumatic Stress Disorder include childhood trauma, another person due to a traumatic event such as a major chronic adversity, and familial stressors. In general, accident, a violent assault, a natural disaster, or an act of war. physical proximity to the event, the length of the A Posttraumatic Stress Disorder can also be produced by exposure, the severity of the trauma, and an interpersonal learning that one’s child has a life-threatening illness. trauma also appear more likely to result in the development of a Posttraumatic Stress Disorder. Although between 50% and 90% of the population in the United States will experience a traumatic event of a type that As noted below, a Posttraumatic Stress Disorder can cause a Posttraumatic Stress Disorder, research indicates cannot be diagnosed during the month following the that only 8% of the population will experience such a disorder trauma since research indicates that many of the during their lifetime. The highest rates of occurrence are symptoms a person experiences during that first month among rape victims, combat veterans and individuals who have are normal. These symptoms may include sleep been targeted for political imprisonment or genocide. disturbances, a loss of concentration, anxiety, depression, guilt, anger, irritability, hypervigilance, flashbacks, and disturbances in social, occupational or educational Most importantly, in order to diagnose a Posttraumatic Stress Disorder correctly the doctor must show that the individual meets the DSM-IV-TR criteria that are given A. The person has been exposed to an extreme life- (7) The individual has a sense of having a threatening traumatic event in which both of the shortened future as shown by expectations such as the belief that they will not have a normal life span, career, and/or family. (1) The person experienced, witnessed, or was in some other way confronted with an event in D. The individual shows persistent signs and/or which there was an actual or threatened death or symptoms of increased arousal as indicated by two serious injury to him or herself or others. (2) The person responded to this event with intense (1) Difficulty initiating or maintaining sleep. (2) Irritability and/or outbursts of anger. B. The experience of the traumatic event has been persistently re-experienced in at least one of the (4) Hypervigilance or a state of exaggerated oversensitivity to a class of events the (1) Distressing recollections of the event that are (5) An exaggerated startle response, which is an (2) Distressing and recurrent dreams of the event. (3) Acting and/or feeling as if the traumatic event were recurring, including flashbacks of the event E. The disturbances noted above have been present in which the person may feel cut off from the (4) When exposed to events and/or thoughts and F. The disturbances noted above cause clinically feelings that resemble and/or symbolize the significant distress and/or impairment in social, event, they experience intense psychological occupational and/or other important areas of (5) When exposed to events and/or thoughts and feelings that resemble and/or symbolize the Posttraumatic Stress Disorders can be diagnosed with event, they experience intense physical signs “specifiers.” Specifiers further describe the precise nature of the disorder’s presentation. “Acute” can be specified if the disorder has been present for less than C. The individual persistently avoids stimuli associated three months. “Chronic” is the specifier used if the with the trauma and/or there is a numbing of their disorder has been present for three months or more. general responsiveness, as shown by the presence of “With Delayed Onset” is specified if the onset of the signs and symptoms of the disorder occurred six months or longer after the stressor. “In Partial Remission” is the (1) The individual makes an effort to avoid specifier used if the full criteria for the disorder were thoughts, feelings, and/or conversations previously met, but at the time of the doctor’s evaluation only some of the signs or symptoms remain. “In Full (2) The individual makes an effort to avoid Remission” is the specifier used if there are no longer activities, places, and/or people that bring back any signs or symptoms of the disorder but the disorder’s presence in the past is of clinical interest. (3) The individual displays an inability to recall an In conducting a psychological evaluation to determine (4) The individual shows a marked diminished if someone has a Posttraumatic Stress Disorder the doctor interest and/or participation in significant must follow the normal psychodiagnostic procedures by: activities that they previously engaged in. (5) The individual feels detached and/or estranged 2. taking a complete life history including the (6) The individual has a restricted range of affect or patient’s complaints or, as they are sometimes 3. administering a battery of objective psychological With respect to psychotherapy, a variety of approaches such as exposure therapy and cognitive therapy have been shown to be effective in the 4. reading the available medical records to see what treatment of Posttraumatic Stress Disorders. In this other mental health practitioners have found regard, exposure therapy involves helping the patient 5. obtaining collateral sources of information in the confront their distressing memories in order to form of interviews with the patient’s relatives, facilitate what is called habituation, desensitization or adaptation. Simply put, habituation, desensitization or adaptation are different terms that Once a Posttraumatic Stress Disorder has been all mean that the ability of the memory, and the diagnosed correctly the treatment usually consists of a neurological residual of the traumatic experience to combination of medication and psychotherapy. In this produce symptoms, has been blunted. This blunting regard, selective serotonin reuptake inhibitors (SSRI’s) typically is produced by exposing the patient to such as Celexa, Lexapro, Prozac, Luvox, Paxil and Zoloft thoughts and images of the stressful experience or as well as tricyclic antidepressants such as Elavil, by using in vivo exposures at the trauma’s site. Anafranil, Sinequan, Tofranil, Pamelor and Vivactil have been shown to be effective in reducing the patient’s Similarly, cognitive therapy helps the victim symptoms although they are rarely sufficient in restructure the meaning they attribute to the themselves to produce a complete remission. experience and re-organize their memory of the trauma by helping them to assess the traumatic experience in a more integrated and less distressing manner. This treatment may also require in vivo exposures at the trauma’s site and often uses relaxation techniques to reduce the patient’s adverse reaction to the trauma-related cues and to desensitize or harden them to their anxiety or fears. ____________________________________________________________________________________ This is the seventh of a series of monthly newsletters aimed at providing information about psychological evaluations and treatment that may be of interest to attorneys and insurance February, 2009 –Litigation problems with the GAF adjusters working in the areas of workers’ compensation and March, 2009 – Common flaws in psych reports personal injury. If you have not received some or all of our past April, 2009 – The Minnesota Multiphasic Personality newsletters, and would like copies, send us an email requesting the newsletter(s) that you would like forwarded to you. May, 2009 – Apportioning psychiatric disability in workers’ compensation cases and assessing aggravation in personal injury cases June, 2009 - Subjectively interpreted projective psychological tests July, 2009 – Sleep disorders and psychiatric injuries

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