Psychotherapy for Psychological Injury: A Biopsychosocial and Forensic Perspective

This article reviews the predominant psychological approaches to therapy and other treatments in the field of psychological injury. Mostly, they concern cognitive behavior therapy and its variants. However, because of the simultaneous physical injuries or physiological effects that accompany these types of injury, practitioners should adopt an integrated biopsychosocial approach in treatment (Sperry, L., Treatment of chronic medical conditions: Cognitive-behavioral therapy strategies and integrative treatment protocols. Washington, DC: American Psychological Association, 2006; Treatment of chronic medical conditions: Cognitive-behavioral therapy strategies and integrative treatment protocols. Washington, DC: American Psychological Association, 2009). The paper presents a componential model of therapy that integrates the cognitive-behavioral, biopsychosocial, and forensic approaches. More research needs to be undertaken that takes into account the difficulties of conducting therapy with individuals who are expressing psychological injury. This will help in the quest to formulate evidence-based but flexible practice guidelines. The paper concludes with a model that may serve to scaffold the numerous psychotherapies that are available into a more coherent framework.     

Erratum to: Trends in Psychological/Psychiatric Injury and Law: Continuing Education, Practice Comments, Recommendations

This literature review of the major topics in the field of psychological/psychiatric injury and law is aimed at developing practice in the area. The field is a fast-developing one, with over ten major topics that it needs to integrate. In particular, the present review focuses on current work on: law (evidence, tort); forensic psychology; assessment and testing; psychological injuries (posttraumatic stress disorder, chronic pain, traumatic brain injury, other); the APA DSM-5 draft (Diagnostic and statistical manual of mental disorders; American Psychiatric Association 2010); malingering; causality; multicultural considerations; disability; the American Medical Association (AMA) Guides to the evaluation of permanent impairment (Rondinelli et al. 2008); models; and treatment. At the end of each section of the article, practice comments introduce critical issues in applying the research to psychological work in the area. Whether undertaking tort evaluations, disability, and treatment plan assessments or treating individuals with psychological injuries, the professional needs state-of-the-art information in all the areas listed in order to remain scientifically informed, comprehensive, and impartial. The article concludes with recommendations for an integrated field in psychological/psychiatric injury and law, study in the field, research in its major areas, best practice policies, for example in assessment and treatment, and model building.     

Trends in Psychological/Psychiatric Injury and Law: Continuing Education, Practice Comments, Recommendations

This literature review of the major topics in the field of psychological/psychiatric injury and law is aimed at developing commentary for practice in the area. The field is a fast-developing one, with over ten major topics that it needs to integrate. In particular, the present review focuses current work on: law (evidence, tort); forensic psychology; assessment and testing; psychological injuries (posttraumatic stress disorder, chronic pain, traumatic brain injury, other); the APA DSM-5 draft (Diagnostic and statistical manual of mental disorders; American Psychiatric Association 2010); malingering; causality; multicultural considerations; disability; the American Medical Association (AMA) Guides to the evaluation of permanent impairment (Rondinelli et al. 2008); models; and treatment. At the end of each section of the article, practice comments introduce critical issues in applying the research to psychological work in the area. Whether undertaking tort evaluations, disability, and treatment plan assessments or treating individuals with psychological injuries, the professional needs state-of-the-art information in all the areas listed in order to remain scientifically informed, comprehensive, and impartial. The article concludes with recommendations for an integrated field in psychological/psychiatric injury and law, study in the field, research in its major areas, best practice policies, for example in assessment and treatment, and model building.     

Ill-Treatment of Pain in the DSM-5

The just-published psychiatric diagnostic manual, the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), American Psychiatric Association (2013), has been lauded by its organizers (e.g., Regier, Kuhl, and Kupfer in World Psychiatry 12, pp. 92–98, 2013), but has been criticized on multiple grounds, as well. Several of its major diagnostic categories concern the area of psychological injury and law (e.g., tort cases involving posttraumatic stress disorder (PTSD), chronic pain, and traumatic brain injury (TBI)). The one for chronic pain seems the one most greatly changed. The approach to chronic pain in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (American Psychiatric Association 2000) and the DSM-5 are compared, leading to an alternative diagnostic criteria list partly based on the changes in the DSM-5. The DSM-5 should be used with caution in forensic assessments. This applies especially to the psychological injury patient, including the pain one, given the high stakes involved and the need for accuracy in assessment based on a reliable and valid diagnostic system. Future iterations of the manual should be improved in both these regards.     

Breaking Bad: DSM-5 Description, Criticisms, and Recommendations

The special issue on the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th edition, American Psychiatric Association, 2013) in the journal Psychological Injury and Law has considered its changes relative to the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision, American Psychiatric Association, 2000) from both a clinical utility and scientific point of view. Although the manual did not undergo wholesale change, the changes to diagnostic categories relevant to the area of psychological injuries (especially posttraumatic stress disorder, mild traumatic brain injury, and chronic pain) present both practical and forensic conundrums, complicating clinical and legal work in the area. The articles in the special issue number nine (including the present one), and involve ones on the major psychological injuries, as well as personality. Separate articles deal with forensics and ethics, with a final one considering forensic psychiatric work using the DSMs. The authors collectively indicate that the DSM-5 is rife with utility and scientific difficulties, although it still might be used in practice and for court in the context of careful, comprehensive assessments and critical analysis. More importantly, ongoing and future research should be considered in revising the DSM-5. Some of the articles review in depth the extant research on their topics and all make recommendations that are useful. The articles include those (in order in the special issue) by: Zoellner et al. (Psychological Injury and Law, 6, 2013); Biehn et al. (Psychological Injury and Law, 6, 2013); Schultz (Psychological Injury and Law, 6, 2013); Young (2013); Hopwood and Sellbom (Psychological Injury and Law, 6, 2013); Thomas (Psychological Injury and Law, 6, 2013); Gordon and Cosgrove (Psychological Injury and Law, 6, 2013); and an opinion piece by Frances and Halon (Psychological Injury and Law, 6, 2013), the chief chair of the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th edition, American Psychiatric Association 1994).     

Primary, Secondary, and Tertiary Losses in Chronic Pain Patients

Treating individuals with chronic illness and disability requires attention to physical, psychological, and social factors. These unique challenges are optimally addressed by utilizing a biopsychosocial approach, while considering the potential array of both gains and losses that chronic pain patients experience. The benefits a patient receives from remaining ill are often referred to as secondary gain. In medicolegal settings, a common example of a secondary gain issue is the effort to obtain financial compensation. While secondary gain can be one factor that contributes to perpetuating illness and disability, there are often more powerful losses that lead to such perpetuation. The losses associated with pain and disability are not frequently discussed. The overall purpose of this paper is to identify primary, secondary, and tertiary loss issues in chronic pain patients, and address issues related to how these factors are important within a medicolegal/forensic context.     

Psychological Injury and Law: An Integrative Model

This article briefly reviews the literature on three areas of psychological injury, post-traumatic stress disorder, chronic pain, and traumatic brain injury, preparatory to presentation of an integrated biopsychosocial and forensic model of multifactorial causality. The model is the first in the field to (a) cover in one model the three types of psychological injury, (b) while including a full range of causality factors relevant to forensic psychology (such as pre-event, event-, post-event, and unrelated factors), and (c) while addressing the relevance of biopsychological and stress as a cohering factors in all conditions. (d) The model emphasizes the importance of individual differences, for example, in causality of symptom presentation. (e) The model acknowledges that in individual evaluations, psychologists need to consider threats to validity, response biases, and possible malingering, and verify whether pre-event factors fully explain post-event presentation.     

Personality Disorder in Psychological Injury: A Biopsychosocial and Forensic Perspective

The present paper explores personality disorder from a biopsychosocial and developmental perspective, in particular, while considering forensic applications. It reviews criticisms of the current approach to classification, especially about its categorical in nature. Then, the paper focuses on the Five-Factor Model of personality dimensions and the attempts to relate it to understanding and assessing personality disorder (Costa and Widiger 2002). Developmental research is revealing that from early in life, temperament and personality seem to conform to a five-factor structure akin to the Big Five, although there are exceptions. Next, the paper examines the biopsychosocial model of personality and considers how personality disorder in the healthcare context affects treatment, relations with providers, and so on. Lastly, the paper examines Young’s (1997) stage model of development in relation to the Big Five and shows how the manner in which it deals with the development of the self may facilitate understanding of personality development and its disturbance. Recommendations and implications are considered.     

The Usage of the AMA <Emphasis Type="Italic">Guides</Emphasis> for the Determination of Psychological Injury Within the State and Federal Workers’ Compensation Systems

Psychological injuries, like physical injuries, may occur within the workplace. If those injuries are reported to be a result of a triggering event in the workplace, then a workers’ compensation (WC) claim may be filed by the individual. State WC and the federal WC systems have laws and rules in place to address workplace psychological injury claims. However, because each State has its own WC State laws as does the federal WC system, there is no current standardization in defining either psychological injury or in defining disability. This is because each system has its own definitions. A few States allow workplace psychological injury claims. Some States do not accept WC psychological injury claims. The remaining States recognize workplace psychological injuries but with specific limitations. The federal WC system allows WC psychological injury claims. There are problematic issues that occur in the State and federal WC systems. These issues are utilizing outdated terminology, employing outdated diagnostic criteria, and allowing documentation submission and professional opinion that does not comport with current professional standards of care. In addition, the need for a definitive answer to address causation is not always possible to address with regard to psychological injury. These types of issues introduce imprecision into the determination of psychological injuries. To address these concerns, the American Medical Association developed the Guides to the Evaluation of Permanent Impairment as a means to take a more scientific approach to the assessment of impairment. This stance was a move away from the poorly defined term, “disability”. The focus was on evaluating the individual’s functioning in terms of impairment. The AMA holds that this is a more objective method that provides a balance between clinical opinion and the utilization of a more scientific methodology that increased precision in the determination of psychological injury and purported impairment in functioning that may have resulted from the injury. The American Medical Association’s Guides to the Evaluation of Permanent Impairment are utilized by many States and the federal WC systems to assist in the evaluation of psychological impairment in functioning and in the WC claims process. Some States opt to use earlier editions of the Guides. Other States and the federal WC system require the usage of the most current edition of the Guides. A few States opt to forego the usage of the Guides altogether and develop State-specific guidelines. The complexities that arise within the WC systems as well as usage of the Guides to evaluate and assess psychological injury are explored as well as potential solutions to address the imprecision that occurs within the WC systems.     

Psycholegal Assessment of Co-occurring Chronic Pain and Schizophrenia Post-MVC: Analysis of Causation Using Two Case Examples

The key aspect of any psycholegal assessment is the analysis of causation, which requires consideration of important legal constructs such as the but for test, material contribution test, thin skull, and crumbling skull. An analysis of causation can be especially helpful in determining overall liability when evaluating the impact of two major co-occurring conditions. This paper focuses on the utility of conducting an analysis of causation using two case examples in which chronic pain and schizophrenia co-occurred following a motor vehicle collision (MVC). Collision-related injuries often lead to the development of chronic pain and could result in permanent and serious impairment and disability. Schizophrenia is a rare psychological occurrence in the collision context and is associated with its own unique and overwhelming physical, psychological, and cognitive challenges. In the psycholegal context, evaluating the impact of two major co-occurring conditions can be problematic and lead to conceptual challenges. In the two cases presented, some assessors attributed nearly all post-collision changes to schizophrenia as if it were pre-existing or in a latent state and failed to assess or even consider the contribution of MVC-related sequelae to the onset of schizophrenia. As part of addressing these conceptual challenges, we present a model of psycholegal assessment that takes into account the pre-, peri- and post-MVC variables that best explain the occurrence of these two conditions. The model also allows the assessor to determine the current and future needs of injured persons, the permanent physical, psychological, and cognitive sequelae that impact quality of life and/or work, and prognosis for the near and distant future.     

The DSM-5 Draft: Critique and Recommendations

The series of articles in this special topic on the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) draft (American Psychiatric Association 2010), which is preparatory to publication of the DSM-5, deals with issues and disorders and conditions pertinent to the field of psychological injury and law. The articles describe and critique the changes anticipated for the diagnoses of posttraumatic stress disorder, pain disorder, and neurocognitive disorder, in particular. Further, changes suggested in the draft for personality disorder are analyzed with a critical eye. In addition, the articles examine the lack of change for dealing with malingering and the general lack of consideration of group differences such as for race, in areas pertinent to psychological injury and law. This summary of the articles concludes that some of the changes in the DSM-5 draft are premature, and it calls for continued research and evidence-informed bases for recommended changes for the DSM-V.     

Compensation System Experience at 12 Months After Road or Workplace Injury in Victoria,Australia

Seeking or receiving compensation after injury is frequently associated with poor recovery. Previous research has shown that the stressful nature of compensation procedures and perceived injustice may cause secondary harm. This study examined compensation system experiences in compensation claimants in Victoria, Australia, and explored the relationship between these experiences and injury outcomes. One hundred and sixty compensable patients (120 male, 75.0 %) aged 18–67 years (M?=?43.01, SD?=?14.31), hospitalized for an injury in a motor vehicle crash (n?=?137) or at work (n?=?23), participated. Participants completed questionnaires about compensation system experience, pain, and psychological symptoms 12 months after injury. Principal component analysis (PCA) of the compensation system experience items revealed three components explaining 66.64 % of the variance in compensation experience: (1) “negative procedural experience” (47.29 %), (2) “compensation supported recovery” (10.43 %), and (3) “positive procedural experience” (8.92 %). Worse experience on all components was associated with worse pain (severity, interference, catastrophizing, disability) and psychological symptoms (anxiety, depression, PTSD, perceived injustice). Compensation system experience reflected both negative and positive procedural factors, and feeling supported through recovery. Most participants reported having positive experiences; however, those who were frustrated or stressed from compensation procedures had worse pain and psychological health outcomes. While this association is likely to be bidirectional with “non-recovery” also impacting on compensation experience appraisals, compensation schemes should nonetheless address modifiable sources of procedural injustice (e.g., arduous paperwork and approvals processes) and reinforce procedures that generate perceptions of support (e.g., timely and appropriate access to health services).     

Excellence in Psychological Injury and Law: Book Review of Motor Vehicle Collisions by Duckworth, Iezzi, and O’Donohue (2008)

In several ways, the book on motor vehicle collisions by Duckworth, Iezzi, and O’Donohue (2008) breaks new ground and should be considered a must-read for workers in the area of psychological injury and law. The editors have assembled a team of expert authors who have cogently analyzed the scientific evidence in the area of motor vehicle collisions and their aftermath, while calling for more research. The book is replete with information that will help practitioners understand and deal with cases involving conditions such as chronic pain, posttraumatic stress, and traumatic brain injury. Practitioners will learn about complications in such cases, including threats to validity and legal aspects. The inclusion of chapters from a medical perspective is a welcome innovation. The book is only lacking in that, although assessment is considered throughout, chapters specifically addressing this topic are not included. The book review concludes that the Motor vehicle collisions book by Duckworth et al. should be included as part of the growing list of excellent resources in the area of psychological injury and law.     

Psychological Injury and Law: Editorial on What Mental Health Clinicians/Practitioners Need to Know

Mental health clinicians and practitioners often deal with cases of psychological injury (e.g., PTSD, pain, TBI), but frequently remain unprepared for the intricacies of providing adequate quality of service and of potential legal challenges of such cases. The editorial lists the areas in which specified knowledge is needed in working with cases of psychological injury and the dangers of being unprepared for court. At the same time, the list constitutes guides to central topics of the journal, Psychological Injury and Law, and its parent organization, the Association for Scientific Advancement in Psychological Injury and Law (ASAPIL). Professionals in mental health should be aware of the risks inherent in working in the field, as well as remedies, such as this journal.     

Motor Vehicle Collisions and Their Consequences—Part 1: Common Physical,Psychosocial, and Cognitive Outcomes

Motor vehicle collisions (MVCs) have a significant impact on injured persons and society. MVCs generally result in property damage, but more serious MVCs often result in physical injuries that have significant physical, psychosocial, and cognitive consequences, all of which may result in long-standing functional impairment and disability as well as marked changes in quality of life. This article represents the first part of a two-part review of MVCs; the complex and interactive array of physical, psychosocial, and cognitive changes that occur consequent to injury-causing MVCs; and the person and environmental factors that best predict functional impairment and disability following an MVC. The current article provides an overview of the scope and significance of MVCs and summarizes the literature related to the physical injuries and the physical, psychosocial, and cognitive impairments that are most commonly experienced consequent to MVCs. Physical injuries reviewed in the current article include fractures, whiplash-associated disorders (WADs), traumatic brain injury (TBI), multiple traumatic injuries or polytrauma, and chronic pain conditions. These injuries and conditions are reviewed because of the relative quantity and quality of existing research related to these injuries and conditions. This article also provides a review of those psychological disorders that more commonly begin, recur, or are exacerbated in the aftermath of an MVC. The following psychological disorders are reviewed: posttraumatic stress disorder, complex posttraumatic stress disorder, major depressive disorder, somatic symptom disorder, and major neurocognitive disorder and mild neurocognitive disorder. Finally, this article ends with a brief discussion of changes in quality of life that can occur in relation to the physical injuries and psychological and neurocognitive disorders that are common consequences of MVCs. The final section of this article will serve to introduce part II of this review of MVCs and their consequences, in which predictors of MVC-related impairment and disability are discussed.     

Motor Vehicle Collisions and Their Consequences—Part II: Predictors of Impairment and Disability

A significant number of persons involved in motor vehicle collisions (MVCs) evidence persistent changes in physical, psychosocial, and cognitive functioning consequent to physical injury. While post-injury impairment and disability can sometimes be predicted with knowledge of injury type and injury severity, post-injury experiences of pain, psychological distress, cognitive dysfunction, and role disruption have been determined to contribute to injury-related impairment and disability. This article represents the second part of a two-part review of MVCs and their consequences. In part I of the review, research findings related to physical, psychosocial, and cognitive changes that occur consequent to injury-causing MVCs are described. In this article, measures used to document the severity of physical injuries are reviewed, along with the most widely accepted definitions of impairment and disability. Models that have been proposed to explain the progression from injury to impairment and disability are reviewed, including a more recently proposed model created specifically to guide the assessment and management of MVC-related outcomes. The greater part of this article is devoted to the review of findings related to physical, psychological, and cognitive predictors of post-MVC impairment and disability. The relation of these predictors to post-MVC impairment and disability is described across three specific injury contexts: (1) whiplash-associated disorders, (2) traumatic brain injury, and (3) polytrauma. In each context, findings related to recovery of function in the form of return to work are summarized, along with findings related to the contribution of compensation to injury-related symptoms and impairments. Although not characterized as a physical injury, chronic pain serves frequently as the post-injury symptom that persists beyond all injury management and rehabilitation efforts and that contributes significantly to MVC-related functional impairment, disability, and emotional distress. It is appropriate, therefore, to include in this review a discussion of those MVC studies that specifically address impairment and disability occurring in relation to chronic pain. The article ends with the identification of ongoing research challenges and future directions for both the study of MVCs and their associated sequelae and clinical practice with persons who are experiencing the consequences of MVC-related injuries.     

Psychometric Properties of a Brief Instrument to Assess Perceptions of Injustice Associated with Debilitating Health and Mental Health Conditions

The present study examined the psychometric properties of a shortened and simplified version of the Injustice Experience Questionnaire (IEQ). The instructional set of the original IEQ was modified to make it better suited to the context of debilitating health and mental health conditions that do not necessarily arise as a result of injury. The number of items was reduced from 12 to 5, and the response scale was simplified. The Injustice Experiences Questionnaire – Short Form (IEQ-SF) was administered to individuals diagnosed with a chronic musculoskeletal (MSK) condition (N?=?88) or major depressive disorder (MDD) (N?=?87). The internal consistency of the IEQ-SF was acceptable. The IEQ-SF was significantly correlated with measures of pain severity, depressive symptom severity and disability in both samples. Individuals with MDD scored higher on the IEQ-SF than individuals with MSK. The IEQ-SF was shown to be sensitive to treatment-related reductions in perceived injustice. Preliminary analyses suggest that the IEQ-SF is a reliable and valid measure of disability-related injustice perceptions associated with debilitating health and mental health conditions.     

DSM-5 Neurocognitive Disorders: Validity, Reliability, Fairness, and Utility in Forensic Applications

A previously published paper (Schultz Psychological Injury and Law 3: 271–288, 2010) on forensic considerations regarding neurocognitive disorders within the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5; American Psychiatric Association, 2013) reviewed evidence for internal and external validity, as well as the fairness and utility of the proposed classification. Given recent publication of the DSM-5, in May 2013, the current paper provides an update on this review. It focuses on changes in the final version of the neurocognitive disorders section of the DSM-5 as compared with the earlier proposal in 2010 and raises a range of new conceptual, methodological, and clinical practice issues related to this classification. An examination of forensic neuropsychologists’ diagnostic choices and their associated pitfalls follows. Discussion extends to the unresolved issue of disorder threshold, associated risks of overdiagnosis of mild neurocognitive disorder and underdiagnosis of major neurocognitive disorder, and the absence of a moderately severe disorder classification. Methodological concerns in diagnostic determinations, especially with DSM-5 Criteria A and B, issues associated with subtypes and specifiers, as well as functional assessments of activities of daily living, now embedded in the diagnosis, follow. Subtype omissions and methodological inconsistencies are highlighted.The vulnerability of neuropsychologists and psychiatrists during courtroom testimony on neurocognitive disorders-particularly with conceptual, methodological, and practical issues-will be addressed through clinical and forensic practice recommendations.     

Ontario Psychological Association Guidelines for Assessment and Treatment in Auto Insurance Claims

The Ontario Psychological Association Guidelines for Assessment and Treatment in Auto Insurance Claims was published on the Ontario Psychological Association website in July, 2010 (Smith, A., and OPA Auto Task Force, 2010, Ontario Psychological Association Guidelines for Assessment and Treatment in Auto Insurance Claims. Ontario Psychological Association, Toronto, Ontario. Retrieved from http://www.psych.on.ca/files/members/OPA_Auto_Practice_Guidelines_July292010_July_30_2010.pdf). Excerpts are reproduced in the journal because of the comprehensive nature of the document. To our knowledge, this is the first time that state or provincial guidelines have included all the major psychological diagnoses in rehabilitation work with motor vehicle accident survivors (chronic pain, post-traumatic stress disorder, traumatic brain injury, depression). Space limitations preclude publishing of the full document, but it should be consulted. The present excerpt focuses on the nature of the psychological injuries and the best practices in treating them, along with cautions for assessment, comorbidities and polytrauma, litigation distress and barriers and complications in recovery.     

Update on Neuroimaging and Cognitive Functioning in Maltreatment-Related Pediatric PTSD: Treatment Implications

This article reviews maltreatment-related pediatric posttraumatic stress disorder (PTSD) neuroimaging and neuropsychology research. Existent interventions that target brain networks associated with PTSD and cognitive impairment are highlighted. Furthermore, the benefits of combining neuroimaging and neuropsychology research in treatment outcomes are discussed. To conduct this review, a literature search was done utilizing the words MRI, structural, functional, neuropsychological testing, children, maltreatment, treatment, and PTSD. This was supplemented with a direct search of developmental trauma experts. Results from the neuroimaging studies found differences in the total cerebral volume, prefrontal cortex, hippocampus, cerebellum, superior temporal gyrus, corpus callosum, and other regions in maltreatment-related childhood PTSD. Neuropsychological findings demonstrate deficits in memory, attention, learning, and executive function that correspond to these brain regions. Existent and novel psychotherapeutic interventions address these deficits. These interventions may be directed at key networks associated with cognitive processing. Future directions include the implementation of treatment outcome research integrating psychotherapy with putative biological and psychological markers.