One would think from the number of PTSD diagnoses made by family physicians, orthopedists, and neurologists that this condition is rampant if not inevitable for any serious personal injury. It is not that simple.
Posttraumatic Stress Disorder as a diagnosis emerged after the Vietnam War. Prior to the then, “shell-shock” was the terminology used in the WWII and Korean wars. The Diagnostic and Statistical Manual (DSM III) classified the diagnosis as an anxiety disorder, and further refined diagnostic criteria in subsequent editions. The diagnosis as it exists in today’s DSM-5 utilizes the most specific criteria yet, re-categorizing PTSD as a stress (trauma) related disorder.
In most States, PTSD (or any other mental injury) is not compensable under workers’ compensation without a preceding physical injury. Nonetheless, some employers will authorize an evaluation for a significant emotional trauma like a robbery, even in the absence of tissue damage. Morally, it seems the right thing to do, and from a legal (perhaps jaded) perspective, an employer who offers treatment under workers compensation may be shielded from liability.
You may be bringing or defending a claim of Posttraumatic Stress Disorder. While diagnosing the disorder is a clinical process, as you weigh the evidence for likelihood of PTSD, here is some data that may guide your assessment.
More Than One Form of PTSD
If a trauma occurred more than three days but less than four weeks ago, the diagnosis is Acute Stress Disorder.
This is not to be confused with Posttraumatic Stress Disorder – Acute, meaning the symptoms have been present between four weeks and three months.
Posttraumatic Stress Disorder – Chronic means the symptoms have been present longer than three months.
Posttraumatic Stress Disorder – Delayed Expression applies to symptoms that first arise > 6 months after the trauma.
Further refinement of the diagnosis depends upon severity and degree of impairment in functioning. Extreme symptoms may include depersonalization, or the feeling of being an outside observer of one’s body; derealization, or unreal and dreamlike surroundings; both are symptoms and forms of Dissociative Symptoms. Children under 18 are diagnosed by a different set of criteria and they are very sensitized to the traumas encountered by their parents.
Symptoms & Diagnosis
In personal injury claims, the diagnosis of PTSD is commonly associated with motor vehicle accidents, fires, airplane incidents, amputations, and assaults. Chronic back pain from an injury does not result in PTSD unless the injury itself was traumatic (such as falling from height or being struck by a car).
What are the criteria for a valid claim of Posttraumatic Stress Disorder, and why is the diagnosis so often misapplied by primary physicians when pain is the only complaint? Rather than dispute what PTSD is not, let us examine the eight criteria for a valid diagnosis of PTSD:
A. There must be a triggering event: exposure to actual or threatened death, serious injury, or sexual violence in one or more of the following ways:
i. Direct experience of the event
ii. Witnessing the event as it occurred to others
iii. Learning that the (accidental or violent) event happened to a close family member or friend
iv. Repeatedly experiencing personal (not via media) exposure to the trauma (such as 911 first responders)
B. A diagnosis of PTSD requires one or more of these symptoms be present following the event:
i. Recurrent intrusive memories that are involuntary
ii. Nightmares of the event –police officers may dream that their family is in great danger and they are powerless to save them.
iii. Flashbacks – the person feels or acts as though the event is happening again
iv. Extreme psychological distress at exposure to internal or external cues of the event (smells, sounds)
v. Extreme physical reactions to internal or external cues of the event (GI upset or vomiting, for instance)
C. The patient persistently avoids reminders of the event in one or more ways:
i. Avoids memories of the event in all forms
ii. Avoids external reminders of the event (people, places, objects, etc)
D. Changes in mood or cognition in one or more of the following ways:
i. Amnesia for important aspects of the event
ii. Pan-negative beliefs about self or the world
iii. Irrational self-blame
iv. Persistent negative emotions of fear, anger or shame
v. Withdrawal from activities
vi. Withdrawal and detachment from others
vii. Anhedonia or the inability to experience happiness or pleasure
E. One or more of the following behaviors are atypical in presence or severity prior to the event:
i. Extreme irritability or aggression
ii. Reckless or self-destructive behavior
iii. Extremely on guard for surroundings/safety
iv. Exaggerated startle response
v. Difficulty concentrating
F. The symptoms in Criteria B-E have lasted > 4 weeks
G. The symptoms are severe enough to impair functioning in social, occupational or other areas of functioning
H. The symptoms are not the result of medication or other medical conditions
Next time: Treatment and Planning