颅脑损伤后精神障碍伤残程度评定中的若干问题

颅脑损伤后遗留的躯体伤残及精神障碍使受害人生活质量及家庭关系往往受到不同程度损害．根据我国法律规定，受害人可得到相应的经济赔偿，即伤残赔偿．颅脑损伤后遗的躯体伤残比较客观，只要进行相应检查即可得出结论；而精神障碍则无客观的检测方法，对颅脑损伤后精神障碍伤残程度如何进行评定，使评定结论更切合实际，以充分保护双方当事人的合法权益，这是法医临床鉴定中值得探讨的课题．笔者根据多年临床鉴定体会，作如下粗浅探讨，供同仁参考．1把握评定时机颅脑损伤后精神障碍同其它损伤后躯体残废或功能障碍一样，一般有一个康复期…     

脑外伤所致精神障碍伤残评定的分析

目的引起人们对脑外伤所致精神障碍的重视,客观评定其伤残等级。方法本研究为回顾性研究设计,对我院2002年至2003年834例活体损伤鉴定案例进行分析。结果脑外伤发病率:交通肇事25.54%;故意伤害10.65%;意外伤害5.75%;其他0%(χ2=53.816P<0.001)。脑外伤所致精神障碍发病率:交通肇事71.42%,故意伤害38.70%,意外伤害30.76%(χ2=13.864P<0.001)。脑外伤所致精神障碍的分类:神经症样综合征25.75%,智能损害22.72%,人格改变18.18%,脑震荡后综合征16.66%,持续植物状态9.0%,精神病性症状4.5%,癫痫3.0%。鉴定前脑外伤所致精神障碍诊断率的分布:精神病性症状、重度智力损害、癫痫、持续植物状态100%,中度智力损害57.14%,轻度智力损害40%,脑震荡后综合征54.54%,人格改变25%,神经症样综合征0%。结论交通肇事是脑外伤所致精神障碍的主要原因;脑外伤所致精神障碍类型与国内有关报道不尽相同;鉴定前脑外伤所致精神障碍的诊断率与精神损害的严重程度呈正相关关系;现行的伤残评定标准关于精神疾病分类和诊断标准应以《中国精神障碍分类与诊断标准第3版(CCMD—3)》为准。     

脑震荡后综合征及其客观评定技术的发展

脑震荡后综合征诊断具有很大的争议性。轻度创伤性脑损伤后脑震荡综合征的发病机制,涉及神经损伤和心理社会因素。迄今,已有大量的研究对现有的检查方法或工具(包括精神检查、常规CT和核磁共振、神经心理学测试和神经生化检查)的评定和诊断价值进行了分析。轻度创伤性脑损伤的受损部位主要分布在灰白质交界附近和大脑深部中线结构,由于大脑损伤的弥漫性,常规影像学检查无阳性发现。本文对脑震荡后综合征的流行病学研究、诊断现状及争议、常规诊断技术、新型核磁共振成像技术在脑震荡后综合征和轻度创伤性脑损伤诊断中的应用及展望进行了综述。现代大脑成像技术可无创定量评定大脑损伤,并可能成为脑震荡后综合征诊断及法医学鉴定更敏感和更有前途的评定工具。     

脑外伤所致精神障碍与道路交通事故伤残评定

目的　探索道路交通事故伤残评定中脑外伤所致精神障碍的临床症状特点、影响因素及鉴定中应注意的问题。　方法　回溯即往一年半的鉴定资料 ,根据CCMD -3器质性精神障碍的症状分类对被鉴定人临床表现进行整理归纳 ,整理被鉴定人颅脑受伤的类型 ,统计分析评定时机及评定结论。　结果　 65例样本纳入本研究 ,平均评定时机10 .2 3± 7.2个月 ,临床主要表现为智能和记忆损害 ,人格改变和神经症样综合征占有较大的比例 ,精神病性障碍和情感障碍较少 ,未见意识障碍和癔症样障碍 ,Logistic回归分析显示智能损害的严重程度及精神病性障碍与伤残等级负相关。　结论　智能和记忆障碍在脑外伤所致精神障碍的道路交通事故伤残评定中具有重要的地位 ,一般应在伤后六个月才宜进行伤残评定。     

脑外伤所致精神障碍与道路交通事故伤残评定

目的 探索道路交通事故伤残评定中脑外伤所致精神障碍的临床症状特点、影响因素及鉴定中应注意的问题。方法 回溯即往一年半的鉴定资料，根据CCMD-3器质性精神障碍的症状分类对被鉴定人临床表现进行整理归纳。整理被鉴定人颅脑受伤的类型，统计分析评定时机及评定结论。结果 65例样本纳入本研究，平均评定时机10．23&#177;7．2个月，临床主要表现为智能和记忆损害，人格改变和神经症样综合征占有较大的比例，精神病性障碍和情感障碍较少，未见意识障碍和癔症样障碍，Logistic回归分析显示智能损害的严重程度及精神病性障碍与伤残等级负相关。结论 智能和记忆障碍在脑外伤所致精神障碍的道路交通事故伤残评定中具有重要的地位，一般应在伤后六个月才宜进行伤残评定。     

浅谈“道标”胸腰椎椎体压缩性骨折伤残评定——附5则案例分析

对“道标”中胸腰椎椎体压缩性骨折的标准进行细化,有助于促进此类损伤伤残评定的客观、公正.通过5件椎体压缩性骨折案例的分析,依据司法鉴定工作的实践经验,运用临床医学理论知识,结合损伤从轻到重的客观演变规律以及脊柱解剖学、生理学、病理生理学特点,利用叠加（累加）原则,初步拟定胸腰椎椎体压缩性骨折伤残等级评定的操作细则.根据椎体压缩程度结合其功能状况评定道路交通事故伤残等级,有望在司法鉴定工作中应用,提高鉴定意见的客观性与公信力.     

交通事故精神伤残程度重新鉴定51例分析

目的探讨道路交通事故所致精神伤残的伤残程度重新鉴定意见改变的原因。方法回顾性分析绍兴市第七人民医院司法鉴定所2009年10月—2011年10月受理的交通事故致精神伤残的伤残程度重新鉴定案件51例。结果要求重新鉴定的案例中,鉴定意见有改变的共计30例(58.82%),其中伤残等级提高8例,伤残等级降低22例。按鉴定意见改变原因分,鉴定人评定时对精神障碍严重程度的理解差异8例,鉴定人自由裁量差异10例,鉴定人对某些精神症状的认识差异2例,鉴定时间差异10例。结论精神伤残程度鉴定应准确把握鉴定时机,减少鉴定人个体差异引起的鉴定意见改变,正确理解条款规定的要求。     

论法医学鉴定“一鉴多果”的原因与对策

由于各种生物性、化学性、机械性因素作用,可导致人体精神的、生理功能的和解剖结构的异常,以及生活、工作和社会活动能力的不同程度的丧失,因此,人体损伤的法医学鉴定就成了涉及审理刑事、民事案件中人体损伤与残疾程度的评定,公正确定侵权行为人所应承担合理赔偿的法律责任的重要依据。研究人体损伤与残疾程度的评定是法医学、伤残赔偿学的迫切需要,并且对人身损伤与伤残赔偿立法和司法实践具有重要意义。刑事技术2003年第1我国人体损伤与伤残程度鉴定的现状当前,人体损伤与伤残评级鉴定人员分专业司法鉴定人员和未实行司法鉴定人资格制度…     

浅谈人体伤残鉴定标准的统一

人身损害赔偿纠纷是一种常见的诉讼类型，人体伤残等级是案件赔偿数额计算的重要依据，伤残等级鉴定则成为案件审理中的关键一环。而司法鉴定标准是鉴定的根本保证，是衡量鉴定意见正确与否的重要依据。目前，在司法鉴定活动中，对于道路交通事故受伤人员伤残评定以及职工工伤致残程度鉴定已有国家标准，但是对于除此以外的人身伤害致残程度鉴定尚缺乏明确、统一的鉴定标准。本文试图从分析我国人身损害司法鉴定标准存在的问题入手，揭示缺乏相关司法鉴定标准的负面影响，从而论证统一司法鉴定标准的必要性，并提出制定标准的若干意见。     

损伤与疾病共存时的职工工伤伤残评定

新的《劳动能力鉴定职工工伤与职业病致残等级》关于"对原有伤残及合并症的处理"的规定较旧标准更为清晰、明确,在实践中便于把握,且符合职工工伤处理的基本原则。新标准规定,对损伤并发症、损伤加重原有伤残情形的,均需按照最终致残结局评定伤残等级;但对于本次工伤伤情显著轻于原有伤残的,则应以本次工伤所致残情为评定依据。与道路交通事故受伤人员伤残评定相比,新标准规定的伤病关系处理原则有相当的差异,主要在于交通事故伤残评定往往强调按照最终致残结局评定伤残等级,并需说明损伤与伤残的因果关系。虽然职工工伤伤残评定并不属于一般意义上的司法鉴定范畴,但参照新标准进行伤残鉴定仍将是司法鉴定机构在诸如人身伤害的刑事案件以及侵权赔偿民事案件中需要进行的重要工作,司法鉴定人应根据不同情况,准确把握鉴定中的伤病关系处理原则。     

Major depression – a study on the validity of clinicians’ diagnoses in medicolegal assessment

Major depression ranges among the most frequently diagnosed psychiatric disorders. Accordingly, diagnoses of depression are often underlying insurance, compensation or disability claims. This report evaluates the validity of clinicians’ diagnoses of major depression in a sample of claimants. In 2015, n = 127 consecutive cases were examined for medicolegal assessment. For all of them, a diagnosis of major depression had been established by clinicians. All testees underwent a psychiatric interview, a physical examination, they answered questionnaires for depressive symptoms according to DSM-5, embitterment disorder, post concussion syndrome (PCS) and unspecific somatic complaints. Performance and symptom validity tests were administered. Only 31% fulfilled the diagnostic criteria for DSM-5 major depression according to self-report, while none did so according to psychiatric assessment. Negative response bias was found in 64% of cases, feigned neurologic symptoms in 22%. Symptom exaggeration was indiscriminate rather than depression-specific. By self-report, 64% of the participants qualified for embitterment disorder and 93% for PCS. In conclusion, clinicians’ diagnoses of depression seem often confounded by improper assessment of the diagnostic criteria, confusion of depression with bereavement or embitterment and also by response bias.     

Survey of methods for the rating of psychiatric impairment in Australia

One of the enduring clinical issues in the assessment of plaintiffs in personal injury and workers' compensation claims, as well as applicants for social security and disablement benefits, is that of the evaluation of impairment and work incapacity. Many writers on this topic confuse the concepts of impairment and disability, and similar confusion is reflected in a number of the rating methods that purport to evaluate impairment but in reality assess disability. In Australia there are 20 distinct statutory schemes for workers' compensation, motor accident compensation, and social security and other benefits, which utilise a variety of methods for the rating of psychiatric impairment. Recent legislative changes designed to restrict access to personal injury compensation at common law, which in two Australian State jurisdictions require the use of impairment rating scales, also specify the rating methods to be used in the assessment of psychiatric impairment. This article discusses the concepts of impairment and disability as defined by the World Health Organisation, and reviews the various methods for the rating of psychiatric impairment that are specified by statute in the federal and State jurisdictions in Australia.     

11例迷路震荡的法医临床学鉴定分析

目的 探讨迷路震荡的法医临床学鉴定的有关问题。方法 对11例15耳迷路震荡的法医临床学鉴定资料进行回顾性研究。结果 11例迷路震荡伤者,均有头部受伤史,伤后短时间内出现耳鸣、听力下降,其中4例伴前庭症状;常规耳科检查和头颅及颞骨CT扫描无异常;各种听力学检查提示感音神经性聋或混合性聋;选择ABR和/或40Hz AERP检测客观听阂,11例有不同程度听力损失,以高频听力损失为主,其中双耳4例,单耳7例;鉴定时间在伤后2-8个月;鉴定为轻伤6例,重伤5例。结论 头部外伤后短时间内出现耳鸣、听力下降,可伴前庭症状,常规耳科检查和头颅及颞骨CT扫描无异常,以及各种听力学检查提示感音神经性聋或混合性聋,可诊断迷路震荡,损伤程度鉴定至少在伤后2-3个月进行。     

Compensation neurosis

The concept of compensation neurosis developed in the wake of the nineteenth century Industrial Revolution and subsequent enactment of workmen's compensation laws. The nosologic designation of traumatic neurosis was not consensually accepted until after World War II; the compensation label was epithetically applied as a simplistic explanation of puzzling postaccident disability. In diagnostic evaluation of postaccident symptoms not attributable to tissue damage; these factors are relevant: secondary gain and loss; alteration in family dynamics; iatrogenic influences, particularly from industrial medical departments; liberalization of workmen's compensation laws; the symbolic significance of money in our culture; the climate of creeping socialism. One consequence stemming from the conceptualization of a compensation neurosis is implicit adherence to the anachronistic mind-body dichotomy.     

The Impact of Psychosocial and Contextual Factors on Individuals Who Sustain Whiplash-Associated Disorders in Motor Vehicle Collisions

Motor vehicle collisions (MVCs) are very common, and they often result in neck and shoulder injuries that are referred to as whiplash-associated disorders (WAD). The largest percentage of WAD are relatively minor and do not reveal any evidence of objective, structural pathology. However, for a substantial percentage of individuals, WAD evolves into chronic, disabling conditions characterized by pain and other symptoms. A range of pre-morbid, collision-related, biomechanical, and psychosocial responses to the MVC have been investigated to determine the manner in which these responses serve to exacerbate and maintain WAD symptoms. In this article, we review the literature investigating these potential causal, amplifying, and perpetuating factors from a biopsychosocial perspective. We emphasize the range of psychological factors and the post-MVC legal and compensation factors that have been identified as significant contributors to the persistence of symptoms and ensuing disability. We highlight the ways in which psychological and legal factors need to be integrated with biological factors to better understand and prevent WAD and treat individuals who experience WAD to reduce chronicity and disability.     

Expert evaluation of certain immune system disturbances after mild traumatic brain injuries

The authors present results of evaluation of immune disorders in 47 patients presenting with brain concussion (BC) and in 28 subjects with mild cerebral contusion (MCC). It was shown that in patients of the former group all immune characteristics were totally restored within 3 weeks after the injury. In the latter group, the clinical picture of secondary immunodeficiency with impaired parameters of the immune status persisted for at least 28 days after the injury. It is concluded that the dynamics of immune system disturbances after a traumatic brain injury may be used as an objective criterion for the evaluation of not only the severity of the injury but also of the duration of the recovery period after mild traumatic brain injury.     

Pain, Impairment, and Disability in the AMA Guides

Physicians use the American Medical Association's Guides to the Evaluation of Permanent Impairment, 5th edition to evaluate millions of disability applicants each year. As major contributors to the chapter in the Guides devoted to assessing impairment associated with pain, we confronted the difficulties of incorporating pain into the Guides' overall evaluation system. Analysis of these difficulties is complicated by the paucity of research on the Guides, and by ambiguities and contradictions that pervade it. We propose that the ambiguities can be reduced if impairment is consistently defined in terms of organ or body part derangement, and disability in terms of activity limitations at the level of the whole person. We also propose a distinction between objective factors that may influence a person's ability to perform activities following injury. We suggest that when physicians examine disability applicants, they should evaluate both objective measures of organ or body part dysfunction and subjective reports of applicants -- especially ones regarding pain. We conclude that a comprehensive medical evaluation of disability applicant encompasses more than an impairment assessment.     

交通伤后遗智力缺损或精神障碍伤残评定资质问题探讨

近年来,交通伤后遗智力缺损或精神障碍伤残评定日益增多,实际评残操作不规范,造成鉴定意见不一致经常发生,影响鉴定质量和交通事故处理。当前,部分鉴定机构及其鉴定人的资质问题已经受到交通事故处理机关的质疑,也引起司法鉴定管理部门的关注。对此,就精神伤残评定资质问题从程序规定角度和技术操作层面展开讨论,力图为精神伤残评定的规范操作提供一些思路。     

Assessing Functional Impairment in ADHD: Concerns for Validity of Self-Report

Comprehensive diagnostic assessment of attention deficit hyperactivity disorder (ADHD) should include consideration of degree of impairment, and documentation of impairment is necessary to make service and accommodation determinations. While there has been increasing use of self-report as a way to document impairment, self-reported impairment could be just as vulnerable to invalid report as self-reported symptoms. We examined the influence of invalid self-report and invalid performance on report of functional impairment in a sample of 49 adults referred for evaluation for ADHD and/or learning disorder concerns. Overall, 26–59% of participants referred for evaluation endorsed at least moderate levels of impairment in the domains of understanding and communicating, household, and school/work. Individuals with evidence of invalid self-report of ADHD symptoms endorsed significantly higher levels of disability/impairment on the WHODAS, particularly in the domains of understanding and communicating, household, school/work, and participation in society. Further, individuals who failed a measure of performance validity reported significantly higher levels of impairment/disability, particularly in the domains of understanding and communicating, school/work, and participation in society. Results emphasize the need to assess for validity of self-report and performance in ADHD assessment. Since self-report of impairment may be suspect, clinicians should include data such as school records, past performance on high-stakes standardized testing, evidence of prior accommodations, and collateral reports before making diagnoses and/or recommendations regarding treatment or academic/workplace accommodations.     

医疗事故损害赔偿中的残疾生活补助费问题研究——从与一般人身损害赔偿比较的角度

与我们通常的认识不同,因医疗事故致残的,患者获赔的残疾生活补助费与一般人身损害赔偿的残疾赔偿金在金额上互有高低。就残疾生活补助费项目而言,现行的医疗事故损害赔偿规定既与现行人身损害赔偿制度不相吻合,又背离了立法目的,亦无法实现对患者的妥善保护,必须加以修订。