crystallising psychological injury dr michael j scott consultant psychologist...
TRANSCRIPT
Crystallising Psychological Injury
Dr Michael J Scott
Consultant Psychologist
Counselling Psychology Division, meeting June 8th 2013, McDonald Hotel
Manchester
The Basic Questions Put To Any Expert Witness
1. What is wrong with ‘x’?
2. To what extent, if at all, are ‘x’s’ difficulties attributable to the index event/s?
3. What is the prognosis, with and without treatment?
4. Will ‘x’ be disadvantaged in the open labour market?
What is wrong with ‘x’?
• The question itself implies a common language about what constitutes ‘wrong’.
• It does not of itself imply a ‘medical model’, but for good or ill the DSM has been used as the lingua franca – the most recent version is DSM 5 was published just days ago by the American Psychiatric Association.
• Many UK Expert Witnesses claim to use the alternative dialect of the World Health Organisation, ICD 10.
• There may be better languages, but you have to watch that you are not talking ‘Esperanto’, when no one else is!
Strengths and Weaknesses of DSM-5
The DSM-5 field trials suggest that post-traumatic stress disorder can be diagnosed with very high reliability, a kappa of 0.67 (higher than any other anxiety disorder or depression) – for illustration if an illness appears in 10% of a clinic’s clients and two colleagues agree on its diagnosis 85% of the time , the kappa statistic is 0.46 (this was actually the kappa for schizophrenia in the field trial)
The kappa, for alcohol use disorder was 0.4, which is reasonable but the kappa for major depressive disorder was only 0.28 and for mixed anxiety-depressive disorder -0.004
The medico-legal system requires categorical statements e.g ‘x is suffering from y’. the DSM can be used in this way, but clinically it is recognised that symptoms are on a continuum of severity and that it is therefore somewhat arbitrary where the cut-off for ‘disorder’ is placed. As a consequence disagreements between Experts are more likely around the ‘cut-off’ i.e as to whether symptoms are mild or sub-syndromal.
Source: American Journal of Psychiatry, January 2013
A DSM 5 Based CBT Model of PTSD – Scott (2013) CBT for Common Trauma Responses London: Sage Publications
Trauma(crit A)
-Re experiencing(crit B)
Hyperarousal(crit E)
MaladaptiveAppraisal
(crit 2D & 3D )
SafetyBehaviour( crit 3 )
Avoidance(crit C)
Terrified Surprise ( crit 3 , 4E ) Emotional numbing/ Dysphoria
( crit 1, 4, 5, 6, 7)D
Social Support
Disagreement Between Mental Health Experts Is The Norm
A study by Large and Nielssen (2008) showed:
I. that reports written by experts engaged by the same adversarial side had good agreement about the prescence of a mental disorder (k =.74) but had only fair agreement about the specific psychiatric diagnosis (average K= .31)
II. Reports written by experts engaged by opposing adversarial sides had poor agreement about the prescence of any mental disorder and also the specific psychiatric diagnosis
Large, M.M and Nielssen, O (2008) Factors associated with agreement between experts in evidence about psychiatric injury. Journal of the American Academy of Psychiatry and Law, 36, 515-521.
Unreliable Assessment
There is no published evidence that PTSD can be reliably diagnosed/excluded without using a standardised structured interview such as the SCID.
Koch, O’Neill and Douglas (2005) state:
‘Whereas it is possible using available structured interviews and specific psychological tests to reliably diagnose PTSD, assessments of PTSD that do not use such empirically supported methods are likely to be of limited reliability’Koch, W.J, O’Neill, M and Douglas, K.S (2005) Empirical limits for the forensic assessment of PTSD litigants. Law and Human Behavior, 29, 121-149.
Comment: Most mental health experts do not include a standardised interview, making disagreement almost inevitable, Scott, M.J and Sembi, S (2002) Unreliable Assessment in Civil Litigation, The Psychologist, 15, 80-81.
The Unreliability of Routine Open-Ended Interviews
Unstructured interviews have levels of agreement of 32-54% [ Beck et al (1962)], this made research impossible and led to the development of standardised semi-structured interviews such as the SCID. Arguably the medico-legal context requires the same degree of rigour as research.
Interviews such as the SCID minimise information variance i.e the range of information considered pertinent and criterion variance i.e the threshold over which a symptom could be considered present at a clinically significant level. In the Beck et al 1962 study, in 32.5% of cases disagreement between clinicians was attributable to information variance and in 62.5% of cases disagreement was because of criterion variance and in only 5.0% of cases was disagreement attributable to patient variance i.e variations within the same client.
Comparison of Usual Disability Examiner Practices for PTSD v’s
Standardized Assessment – Speroff et al (2012)
• Standardised assessments were 85% complete for diagnosis compared to 30% for nonstandardized assessments
• For functional impairment, standardized assessments were 76% complete versus 3% for routine open-ended assessment.
• These authors concluded that the open-ended, unstructured interviews produced incomplete elicitation of diagnostic information.
Source: Journal of Traumatic Stress, 25, 607-615.
Diagnoses from Clinical Evaluations and Standardised Diagnostic Interviews don’t Agree
Rettew et al (2009) Int J Methods Psychiat Res conducted a meta-analyses of agreement between routine interviews and standardised diagnostic interviews. The K statistic is a measure of agreement , K values of 0.6 to 0.8 are generally considered acceptable to good.
In this meta-analyses the K value across all diagnoses was 0.27!
These findings mean that if an SDI or a clinical evaluation produce a positive diagnosis for a particular disorder , the majority of the time the other diagnostic system did not produce the same diagnosis.
The Four Pillars of Reliable Assessment
Review of records –
GP, Hospital, Work,Educational
Open-ended interview -
Intro to SCID has an open ended interview for differential diagnosis
Semi-structured interview –
SCID, CAPS
Screen for malingering -
M-FAST, SIRS if M-FAST ispositive
Synthesis of Four Pillars
Psychosocial Stressors/overall functioning
Physical/learning difficulties
Recommendation and audit of evidence based
treatment
Emotional/personality disorders
Platform Supported by
Pillars
Common Trauma Responses
PTSD
Depression
Substance abuse/dependence
Specific phobia e.g. driving/passenger phobia
Panic disorder
Adjustment disorder
Most typically some combination of the above.
Challenges To An Expert Witness Opinion Can Be Rebutted By The Strength of The Pillars and Cap
Example:
Challenge: ‘the records indicate that x has a long standing history of emotional problems, is it not the case that the incident/s has produced a temporary exacerbation of these difficulties?’
Rebuttal: ‘whilst x has had difficulties in the past, there is no documented evidence of any difficulties in the 12 months before the incident’ (Records Pillar). ‘x’s PTSD is by definition specific to the index event, in that the DSM symptoms of intrusion and avoidance relate to the incident and the symptoms of disordered arousal represent a change of functioning since the incident’ (Semi-structured interview pillar).
Is The Claimant Malingering?
Typical Foundation Stones for A Claim of Malingering:
‘There is nothing in the records about a trauma response’
‘He/she has said something different to the other expert’
‘He/she said they had no previous problems, the records show that is not true’
‘He/she complains of pain, when no source of pain has been identified’
Grand Conclusion
‘It is for the Court to decide on the issue of malingering, but the claimant is not a reliable historian’
The Case for Malingering Is Often Built on Sand
Avoidance of talking about/thinking about their trauma is one of the diagnostic symptoms of PTSD, it is therefore unsurprising that sufferers do not detail the psychological effects. If there are accompanying physical injuries they are likely to be the GP’s focus. GP’s miss 50-70% of psychiatric disorders.
Unless there is a standardisation of questions asked by Experts with specification of a particular time frame, Experts will come to a different view of claimant’s history
There is no published evidence that the standard psychiatric examination can reliably detect malingering
Pain is ultimately a private experience it cannot be proved or disproved by another. It is much more complicated than ever thought e.g. phantom limb pain, pain is not proportional to the amount of tissue damage.
Assessment of malingering should be based on multiple sources, including a standardised screen for malingering e.g. M-FAST, if positive, progressing to full test e.g. SIRS. Such standardised measures are rarely used in Civil Litigation.
Evidence-Based Treatment The evidence based, NICE approved, first line
treatment for depression and the anxiety disorders (including PTSD) is cognitive behaviour therapy (CBT), [see ‘CBT for Common Trauma Responses’ London: Sage Publications, by Michael J Scott just published].
CBT is effective in controlled trials e.g 50% recovery from PTSD, but inspection of treatment notes for alleged CBT in routine practise often suggests sub-optimal treatment
Experts need to examine treatment notes after CBT and re-examine the claimant to determine whether there has been a therapeutic dose of treatment
Engaging The Claimant in The Litigation and Treatment Process
Litigation for a claimant is inevitably stressful, so much so that many will leave it to a family member to open post from a solicitor. If they are given the ‘Justice’ Chapter to read from the self-help book ‘Moving On After Trauma’ Scott (2008) London: Routledge, their ambivalence about litigation is recognised and they are helped not to personalise the adversarial nature of proceedings
In 'Moving On After Trauma claimants can find a person who has suffered a similar trauma and begin to follow in their footsteps. In so doing they are already socialised into any forthcoming CBT.