Transcript Crystallising Psychological Injury

Crystallising
Psychological Injury
Dr Michael J Scott
Consultant Psychologist
[email protected]
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
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 3254% [ 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 openended 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 –
Open-ended Semiinterview structured
interview –
Screen for
malingering -
GP,
Hospital,
Work,
Educational
Intro to
SCID, CAPS
SCID has an
open ended
interview
for
differential
diagnosis
M-FAST, SIRS
if M-FAST is
positive
Synthesis of Four Pillars
Psychosocial
Stressors/overall functioning
Physical/learning difficulties
Platform
Supported by
Pillars
Recommendation and audit
of evidence based treatment
Emotional/personality
disorders
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.