Posttraumatic Psychiatric Disorders

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Posttraumatic Psychiatric Disorders
Determination of Cause
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The Plan
Overview of the Independent Medical Evaluation.
Overview of Posttraumatic Stress Disorder,
diagnostic criteria and information pertaining to
cause.
Overview of Somatoform Disorders, diagnostic
criteria and information pertaining to cause.
Case presentation.
Discussion of determination of cause.
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Disclosures
As a matter of principle I accept no money from
corporations other than fee for service. And
when Pfizer quit taking me on guided fishing
trips I quit seeing their reps.
I admit I could be influenced by money but so far
no one has offered.
When I come to Utah 35 years ago I seen a new
kinda language. I learned ut. If I talk funny
I know better. If you havent lived in Utah this
wont be funny.
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Professional Background
For 16 years I have been treating PTSD to
remission with a combination of Eye Movement
Desensitization and Reprocessing (EMDR) and basic
psychoanalytic technique. Single adult trauma
ASD and PTSD usually resolves in a few
sessions. This experience will influence many of
the comments I will be making.
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The Science
DSM- IV-TR
Fourth Edition
2000
The American Psychiatric Association
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Science and the Parable of the Small, Elderly
Woman at the Airport, Legal Version
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Independent Medical Evaluations
( IMEs )
Psychiatrists may play an essential role in
providing public or private agencies, or the
legal system with clarification of psychiatric
issues for purposes of claims management,
employee management or litigation. There is a
need to bring psychiatric knowledge expressed in
understandable language to the legal framework
that defines the issues in question. Issues of
scientific probability, uncertainty and
controversy that psychiatrists contemplate daily
may not be helpful is resolving a specific
practical problem.
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Legal Frameworks for IMEs
Workers Compensation Impairment Rating Injury
Litigation Disability Determination Fitness for
Duty Evaluation Department of Labor Referee
Examination Americans with Disability Act
Determinations Employee Risk Assessment Posttrauma
tic Incident Evaluation
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It Is Not About Treatment
If you do any IME work, have the evaluee (never
patient) sign a consent form that says no
doctor-patient relationship will be established
and no treatment will be provided.
Your obligation is to the agency paying for the
evaluation.
Your obligation as a psychiatrist is to provide
an objective report based on evidence. You may
have to present evidence to clarify why laws or
regulations do not apply to a given case.

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It Is About Evidence
Scientific psychiatric evidence is based on
groups of persons, numbers and probabilities to
reduce uncertainty due to the inherent
variability in individuals.
Clinical evidence starts with a broad base of
evidence, using method to reduce the uncertainty
inherent in applying statistical information
based on groups, to specific individuals. IME
evidence is similar to clinical evidence but it
is not about treatment.
The usefulness, effectiveness, and defendability
of an IME depends on the skill and method used to
present information relevant to a specific
problem.
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It Is About Teaching
You are the expert representing psychiatry.
Very often the agency personnel who will use the
IME for agency or legal purposes know nothing
about Psychiatry or the difference between
psychiatry and other professions.
The IME may be challenged and you may have to
justify and defend your conclusions. The
challenge may be rigorous, vigorous, and
anti-psychiatric.
You may have to teach the evaluee about the
nature of an IME and your intent to be objective.
Most evaluees arrive with serious misgivings.
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It Is About Diagnosis
Build evidence into the report to substantiate
the diagnosis.
Conclusions will be determined by the diagnosis
and the evidence used to support the diagnosis
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It Is About Answering Specific Questions
Does the employee have a psychiatric
disorder? Did the incident in question cause the
psychiatric disorder? Does the psychiatric
disorder cause ratable impairment? Does the
psychiatric disorder cause inability to perform
his occupational duties? Does the employee
present a serious risk to self or others in the
workplace? Is there an accommodation that would
allow the employee to perform essential
occupational duties?
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Focus
Posttraumatic Stress Disorder
Somatoform Disorders
Others
Depression
Traumatic Brain Injury
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Causation Is Multi-factorial, But...
PTSD
PTSD must have an essential external cause.
Conversion Disorder
Misdiagnosis is common. It is not just a
diagnosis of exclusion. Internal psychological
or psychodynamic processes and conflicts cause
the symptoms.
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Correlation
Correlation or temporal association does not
prove cause and effect.
But correlation is sometimes conspicuous and the
cause of an event may appear obvious because of
correlation.
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Confirmation Bias It turns out that all animals
and humans have what researchers call a built-in
confirmation bias. Animals and humans are wired
to believe that when two things happen closely
together in time its not an accident instead
the first event caused the second thing to
happenwhich is why B. F. Skinner called this
kind of behavior animal superstition. Confirmati
on bias is built into human brains, and it helps
us learn. Coincidence is actually a fairly
advanced concept both for animals and for people.
The downside to having a built-in confirmation
bias is that you also make a lot of unfounded
causal connections. That is what a superstition
is. Moreover, our brains are wired to believe
that a correlation is also a cause. The same
part of the brain that lets us learn what we need
to know, and find the things we need to stay
alive is also the part of the brain that produces
delusional thinking and conspiracy
theories. Temple Grandin, Animals in
Translation, 2005 .
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Wise King Solomon said
but for the...
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Sherlock Says
If a rock falls at a job site and breaks into
half a rock you can weigh it and and say, Yes,
this is half a rock.
If a man falls at a job site and says, Now I am
only half a man, weighing the man doesnt help.
The difference is the brain, or traditionally,
the mind, so said Sherlock.
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309.81 - Posttraumatic Stress Disorder
A. The person has been exposed to a traumatic
event in which both of the following were
present
(1) the person experienced, witnesses or was
confronted with an event or events that involved
actual or threatened death or serious injury, or
a threat to the physical integrity of self or
others
(2) the person's response involved intense fear,
helplessness or horror NOTE - in children this
may be expressed instead by disorganized or
agitated behavior
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. . . or learning about unexpected or violent
death, serious harm or threat of death or
injury experienced by a family member or other
close associate.
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B. The characteristic symptoms resulting from the
exposure to the extreme trauma include persistent
re-experiencing of the traumatic
event. C. Persistent avoidance of stimuli
associated with the trauma and numbing of general
responsiveness. D. Persistent symptoms of
increased arousal.
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Traumatic Events
Traumatic events that are experienced directly
include, but are not limited to 1. Military
combat. 2. Violent personal assault (sexual
assault, physical attack,
robbery, mugging). 3. Being kidnapped. 4.
Being taken hostage. 5. Terrorist attack. 6.
Torture. 7. Incarceration as a prisoner of war
or in a concentration camp. 8.
Natural or man-made disasters. 9. Severe
automobile accidents. 10. Being
diagnosed with a life-threatening illness.
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Events Experienced by Others
Events experienced by others, that are learned
about include, but are not limited to 1.
Violent personal assault 2. Serious accident 3.
Serious injury experienced by a family
member or close friend 4. The sudden
unexpected death (or suicide) of a
family member or close friend 5. That one's
child has a life-threatening
disease.
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PTSD Severity Factors

• PTSD may be especially severe or long-lasting
  when the stressor is of human design, such as
  torture or rape.
• The likelihood of developing PTSD may increase as
  the intensity of and physical proximity to the
  stressor increase.

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When Trauma Is Intentionally Human Inflicted
These symptoms are more likely
1. Impaired affective modulation 2.
Self-destructive and impulsive behavior 3.
Dissociative symptoms 4. Somatic complaints 5.
Feelings of ineffectiveness 6. Shame 7.
Despair 8. Hopelessness 9. Feeling
permanently damaged 10. Loss of
previously-sustained beliefs 11.
Hostility 12. Social withdrawal
13. Feeling constantly threatened 14.
Impaired relationships with others 15.
Personality change
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Associated Disorders
Posttraumatic Stress Disorder is associated with
increased rates of 1. Major Depression 2.
Substance-Related Disorders 3. Panic
Disorder 4. Agoraphobia 5. Obsessive-Compulsive
Disorder 6. Generalized Anxiety Disorder 7.
Social Phobia 8. Specific Phobia 9. Bipolar
Disorder These disorders can either precede,
follow or emerge concurrently with the onset of
Posttraumatic Stress Disorder.
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Chronic Posttraumatic Stress Disorder may be
associated with increased rates of somatic
complaints and possibly general medical
conditions.
Physical Complaints
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Prevalence of PTSD
Community-based studies reveal a lifetime
prevalence of approximately 8 of the adult
population in the United States. The highest
rates occur among survivors of rape, military
combat and captivity, and ethnically or
politically motivated internment and genocide.
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Somatoform Disorders
The common feature of the Somatoform Disorders
is the presence of physical symptoms that suggest
a general medical condition (hence, the term
somatoform) and are not fully explained by a
general medical condition, by the direct effects
of a substance, or by another mental disorder.
There is no diagnosable general medical condition
or other psychiatric disorder to fully account
for the physical symptoms.
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Somatoform Disorders
1. Somatization Disorder 2. Undifferentiated
Somatoform Disorder 3. Conversion Disorder 4.
Pain Disorder Associated with... (psychological
factors are judged to have an important role in
its onset, severity, exacerbation or
maintenance.) 5. Hypochondriasis 6. Body
Dysmorphic Disorder 7. Somatoform Disorder, NOS
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Conversion Disorder
A. The essential feature of Conversion Disorder
is the presence of symptoms or deficits
affecting voluntary motor or sensory function
that suggests a neurological or other general
medical condition. B. Psychological factors are
judged to be associated with the symptom or
deficit, a judgment based on the
observation that the initiation or exacerbation
of the symptom or deficit is preceded by
conflicts or other stressors.
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Conversion Disorder
C. The symptoms are not intentionally produced or
feigned as in Factitious Disorder or
Malingering. D. Conversion Disorder is not
diagnosed if the symptoms or deficits are fully
explained by a neurological or other general
medical condition, by the direct effect of a
substance or as a culturally sanctioned
behavior or experience.
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Conversion Symptoms
Pseudoneurological 1. Impaired coordination or
balance 2. Paralysis or local weakness 3.
Aphonia 4. Difficulty swallowing or sense of a
lump in the throat 5. Urinary retention 6.
Seizures or convulsions 7. (Cognitive, my
experience) Sensory 1. loss of touch or
pain sensation 2. double vision 3.
blindness 4. deafness 5. hallucinations
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Somatoform Disorders may be thought of as
disorders of perception, motivation and
communication.
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Case Study
A War Traumatized Iraqi Comes to America
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IME 1/8/04
The claimant is a 33 year old male native of
Basra, Iraq who immigrated to the United States
in 1997 shortly after being released from 7 years
in a concentration camp in Saudi Arabia. He
obtained employment in as a dock worker with a
major steel manufacturer in Washington state. He
reported that the next 3 years in the United
States were the best years of (his) life.
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On 8/10/2000 he sustained a crush injury to the
distal phalanx of the right thumb. Although the
injury threatened physical integrity it was not
associated with feelings of fear, helplessness or
horror nor was it followed by symptoms consistent
with acute stress disorder. He was treated
medically, and then surgically for complications
of osteomyelitis. Eventually the surgeon
determined that it was necessary to amputate half
of the distal phalanx of the right thumb.
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Following the surgery the pain continued,
spreading throughout the right arm and the right
side of the face. He reported that he could not
use his hand and was unable to grasp things. He
still performed tasks of self-care but otherwise
felt helpless and nonfunctional. Medical
evaluations for the medical cause of the
complaints were negative.
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As symptoms continued he began to experience
imagery of trauma that he experienced in Iraq
regarding the Iran-Iraq war, the Gulf war, the
brutal crushing of the Shia uprising, and seven
years of imprisonment, beatings and torture in
Saudi Arabia. He met criteria for Posttraumatic
Stress Disorder.
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An independent evaluation provided by a
psychiatrist was initially sympathetic to the
concept of industrial causation. However the
same psychiatrist subsequently reviewed
surveillance videotapes and concluded that the
claimants purported pain and disability were
influenced by malingering.
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The claimant became increasingly non-functional,
depressed and socially withdrawn. Pain and
dysfunction in the right hand and arm persisted.
PTSD symptoms persisted. He moved to Salt Lake
City to live with his cousin and his cousins
wife who provided support in addition to his
workers compensation payments.
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Idealization
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Deer in the headlights appearance.
Deferential, supplicating presentation. Mood
depressed. Fearful, very soft spoken with
restricted range of emotional expression.
Anxious with no signs of panic. No apparent
aggravation of anxiety or emotional distress upon
discussion of details of industrial injury.
Verbal content stressed pain, disability, social
withdrawal and fear of leaving his apartment.
Mental Status Examination
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I think psychological testing would be of limited
value in this case. What do you think?
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Multiaxial Assessment

• (309.1) Posttraumatic Stress
  Disorder, Chronic
• (300.11) Conversion Disorder - unexplained motor
  weakness of the right arm and hand.
• (307.89) Pain Disorder Associated with
  Psychological Factors and a General Medical
  Condition (Non-physiologic pattern of pain.)
• (311) Depressive Disorder NOS.
• (300.00) Anxiety Disorder Not Otherwise Specified
  (Obsessive Compulsive features).
• (V65.2) Malingering (diagnosed by Dr. Lipscomb
  after reviewing surveillance videotapes).

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Axis II
(301.9) Personality Disorder Not Otherwise
Specified. A lifetime of horrifying trauma has
profoundly impacted this mans personality. (Our
concepts of Personality Disorder may be
incongruent with this diagnosis.)
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Axis III
History of multiple traumatic injuries inflicted
by other human beings including beatings and
torture.
Surgical amputation of 1/2 of the distal phalanx
of the right thumb.
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Axis IV
The claimant has not worked since the accident.
He receives workers compensation disability
payments. He lives with his cousin and his
cousins wife now in Salt Lake City. He reported
that he stays home every day in a state of fear,
experiencing pain and inability to use his right
hand and arm. He is able to perform ADLs.
Axis V
GAF 40
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Did the industrial accident of 8/10/2000 Cause
the diagnoses?
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Posttraumatic Stress Disorder
Did the industrial injury threaten death or a
threat to physical integrity?
Was the injury associated with fear helplessness
or horror?
Was there reliving of the industrial event in
question?
Was there avoidance and emotional numbing?
Was there hyper-arousal?
Did the mental content reflect pre-existing
trauma?
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Aggravation
Did the industrial injury aggravate a
pre-existing condition (PTSD)?
An industrial injury must be present before it
can aggravate a pre-existing condition.
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Conversion Disorder
Did the industrial accident cause the Conversion
Disorder (weakness and inability to grasp things)?
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Pain Disorders Associated with Psychological
Factors and a General Medical Condition
Was pain disorder caused by the industrial
accident?
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Causes of Posttraumatic Somatoform
Disorders
1. Removal from undesirable circumstances.
2. Compensation
3. Relief from responsibility.
4. Care-taking by others.
5. Posttraumatic Stress Disorder.
6. Narcotic pain medications.
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Depression
Did the industrial accident cause the Depressive
Disorder Not Otherwise Specified?
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Anxiety Obsessive Compulsive
Features
Did the accident cause the Obsessive Compulsive
Features?
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Malingering
Is it all just malingering?
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Impairment
Did the accident cause ratable impairment
attributable only to the industrial accident?
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Disability
Is the evaluee disabled from performing the
duties of his usual occupation? Is the evaluee
disabled from performing any any occupation Is
the disability caused by the industrial accident?
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Discussion
.
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