Posttraumatic Stress Disorder in the DSM-5: Group Difference Commentary

This article provides a commentary on the proposed Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 changes with respect to diagnosing posttraumatic stress disorder (PTSD) in diverse cultural groups in clinical and forensic settings. PTSD is the most common diagnosis in personal injury litigants (Koch et al. 2006). By reviewing the symptoms that have been changed in the DSM-5 draft for PTSD in terms of ethnoracial and minority–cultural factors, this article highlights the lack of data needed in the area and that the DSM project should pay more attention to such factors.     

Posttraumatic Stress Disorder in DSM-5: New Criteria,New Measures,and Implications for Assessment

The diagnostic criteria for posttraumatic stress disorder (PTSD) were substantially revised for Diagnostic and Statistical Manual of Mental Disorders—5th edition (DSM-5). This in turn necessitated revision of DSM-correspondent assessment measures of PTSD. We describe the various changes to the PTSD diagnostic criteria and the corresponding changes to National Center for PTSD measures. We also discuss the implications of the new criteria for assessment of trauma exposure and PTSD. Although the DSM-5 version of PTSD departs significantly in some respects from previous versions, we conclude that there is fundamental continuity with the original DSM-III conceptualization of PTSD as a chronic, debilitating mental disorder that develops in response to catastrophic life events.     

The Minnesota Multiphasic Personality Inventory-2 Restructured Form and Posttraumatic Stress Disorder: Forensic Applications and Considerations

This paper reviews the empirical literature on the use of the Minnesota Multiphasic Personality Inventory-2 Restructured Form (RF; Ben-Porath and Tellegen 2008; Tellegen and Ben-Porath, 2008) scales for the assessment of posttraumatic stress disorder (PTSD) and PTSD comorbidity and discusses the use of the instrument in forensic contexts. We focus on prior work that has examined the association between the RF scales and PTSD, PTSD comorbidity, and the utility of the RF validity scales for detecting feigned symptoms of PTSD. We conclude that though the MMPI-2 RF scales show expected patterns of association with PTSD, their most useful application in the forensic arena may be in the identification of comorbid personality-based psychopathology, and in detecting symptom overreporting. We recommend that the MMPI-2 RF be used in the context of a comprehensive assessment that includes an exhaustive record review, detailed history with an emphasis on past trauma, and structured diagnostic interviews.     

Empirical Limits for the Forensic Assessment of PTSD Litigants

This paper discusses the limits of expert opinion on posttraumatic stress disorder (PTSD) in personal injury claims. The construct of PTSD is hampered by several empirical limitations. Multiple reliable measures of PTSD exist, but have not been evaluated sufficiently within litigating samples and are infrequently used by forensic assessors. Common methods for trauma screening appear insensitive. Opinions about causation of PTSD and disability are complicated by retrospective memory biases, as well as the failure of most anxiety disorders to be detected within primary medical care. PTSD appears to have a steep spontaneous remission curve during the first year, but at least 10% of trauma-exposed people suffer chronic distress. Little is known about the course beyond 1 year. Efficacious psychological treatments have been developed for PTSD, but are not in common use limiting claimants access to rehabilitative treatments. Research on functional disability associated with PTSD is in its infancy, but it seems likely that PTSD will account for only a part of the variance in work disability. We provide suggestions for improving forensic practice, advising the courts about the limitations of forensic opinions, and necessary research.     

Posttraumatic stress disorder in tort actions: forensic minefield

The authors discuss posttraumatic stress disorder (PTSD) as a basis for personal injury litigation. Three case examples raise issues related to: (1) the controversy surrounding expansion of tort liability, (2) the courtroom use of psychiatric nomenclature as represented in the DSM (e.g., PTSD), and (3) ethical concerns regarding psychiatric expert witnesses. Psychiatrists became easy targets when problems related to personal injury "stress" cases developed. A careful analysis, however, demonstrates that the issues are complex and multifaceted. For example, tort liability expansion was primarily instituted to compel a greater provision of liability insurance, not to reward stress claims. The increasing use of psychiatry's DSM in the courtroom has occurred despite explicit precautions against forensic application. Finally, the need for psychiatric expert witnesses has increased because courts have gradually usurped some psychiatric clinical prerogatives and because there has been a trend toward greater consideration of emotional pain and suffering. Although psychiatric expert witnesses have not been beyond reproach, critics have attempted to impeach the entire psychiatric profession for the questionable actions of the minority. The authors provide a detailed analysis of current problems, offer suggestions for improvement, and provide an educational counterpoint to the "hysterical invective" that often greets psychiatric testimony.     

The Evolving Construct of Posttraumatic Stress Disorder (PTSD): DSM-5 Criteria Changes and Legal Implications

In the DSM-5, the diagnosis of posttraumatic stress disorder (PTSD) has undergone multiple, albeit minor, changes. These changes include shifting PTSD placement from within the anxiety disorders into a new category of traumatic and stressor-related disorders, alterations in the definition of a traumatic event, shifting of the symptom cluster structure from three to four clusters, the addition of new symptoms including persistent negative beliefs and expectations about oneself or the world, persistent distorted blame of self or others, persistent negative trauma-related emotions, and risky or reckless behaviors, and the addition of a dissociative specifier. The evidence or lack thereof behind each of these changes is briefly reviewed. These changes, although not likely to change overall prevalence, have the potential to increase the heterogeneity of individuals receiving a PTSD diagnosis both by altering what qualifies as a traumatic event and by adding symptoms commonly occurring in other disorders such as depression, borderline personality disorder, and dissociative disorders. Legal implications of these changes include continued confusion regarding what constitutes a traumatic stressor, difficulties with differential diagnosis, increased ease in malingering, and improper linking of symptoms to causes of behavior. These PTSD changes are discussed within the broader context of DSM reliability and validity concerns.     

Impact of Common Mental Health Disorders on Cognition: Depression and Posttraumatic Stress Disorder in Forensic Neuropsychology Context

The assessment and diagnosis of posttraumatic stress disorder (PTSD) and depression in forensic evaluations may lack an acknowledgement of the neurocognitive impact of these disorders and how they interact with other causative factors, such as traumatic brain injury (TBI), pain or fatigue. Both PTSD and depression have a complex, growing and consolidating neuroscientific and neuropsychological evidence base, and both can affect neuropsychological test results. In forensic neuropsychological assessments, they are often considered to be confounding factors in evaluating TBI and neurodegenerative disorders but not a source of cognitive impairment in their own right. Yet, an accurate neuropsychological assessment of both cognition and affect is vital to causality determination, prognosis and treatment planning. To complicate matters, selective brain injuries, contingent on the location of injury, can produce symptoms of depression that also affect the neurocognitive profile. Therefore, behavior can overlap not only due to overlapping or comorbid diagnoses, but also due to similar neuroanatomical correlates of both conditions. This paper focuses on reviewing and integrating the available empirical evidence from neuroscience and neuropsychology regarding the cognitive impact of PTSD and depression. Our critical review will emphasize the implications of the more recent evidence for forensic assessment determinations regarding causality, diagnosis, and the impact on function, prognosis and treatment. Hence, electronic search engines, PubMed, PsycINFO, and Google Scholar (up to January 2018) were screened and reviewed both for the neuroscience and neuropsychological literature related to depression and PTSD.     

Post-traumatic stress disorder in maltreated youth: a study of diagnostic comorbidity and child factors

The study of post-traumatic stress disorder (PTSD) in maltreated youth has received increased attention, though extensive comparisons to maltreated youth without PTSD and administrations of anxiety-based structured diagnostic interviews remain needed. We examined maltreated youth with or without PTSD using structured diagnostic interviews and standardized child self-report measures. We hypothesized that maltreated youth with PTSD, compared to their peers without PTSD, would experience significantly greater duration of abuse, diagnostic comorbidity, PTSD symptomatology, dysfunctional family environment, and avoidant coping styles. Results indicated that the group with PTSD did indeed experience significantly greater duration of abuse, diagnostic comorbidity, and PTSD symptomatology, though less so dysfunctional family environment or avoidant coping styles. The presence of a mood or anxiety disorder was highly predictive of PTSD in this sample. Results are discussed within the context of evolving etiological and maintenance models of PTSD in maltreated youth.     

PTSD及其法医学相关问题

随着国外对PTSD(posttraumatic stress disorder)的深入研究以及中国心理卫生事业与法医学事业的发展,相关领域的学者开始从事这一方面的研究并取得了不少成就。本文结合国内外的一些理论研究与实践成果,对PTSD的概念、诊断与鉴别以及相关法医学问题作一综述和探讨。     

Detection of Malingered PTSD: An Overview of Clinical,Psychometric, and Physiological Assessment: Where Do We Stand?

ABSTRACT: Posttraumatic stress disorder (PTSD) is a condition that can be easily malingered for secondary gain. For this reason, it is important for physicians to understand the phenomenology of true PTSD and indicators that suggest an individual is malingering. This paper reviews the prevalence of PTSD for both the general population and for specific events, such as rape and terrorism, to familiarize evaluators with the frequency of its occurrence. The diagnostic criteria for PTSD, as well as potential ambiguities in the criteria, such as what constitutes an exposure to a traumatic event, are reviewed. Identified risk factors are reviewed as a potential way to help differentiate true cases of PTSD from malingered cases. The question of symptom overreporting as a feature of the disease versus a sign of malingering is discussed. We then examine how the clinician can use the clinical interview (e.g., SIRS, CAPS), psychometric testing, and the patient's physiological responses to detect malingering. Particular attention is paid to research on the MMPI and the subscales of infrequency (F), infrequency-psychopathology (Fp), and infrequency-posttraumatic stress disorder (Fptsd). Research and questions regarding the accuracy of self-report questionnaires, specifically the Mississippi Scale (MSS) and the Personality Assessment Inventory (PAI), are examined. Validity, usability, and cutoff values for other psychometric tests, checklists, and physiological tests are discussed. The review includes a case, which shows how an individual used symptom checklist information to malinger PTSD and the inconsistencies in his story that the evaluator detected. We conclude with a discussion regarding future diagnostic criteria and suggestions for research, including a systematic multifaceted approach to identify malingering.     

Incidence and Correlates of Posttraumatic Stress Disorder in Australian Victims of Domestic Violence

In recent years, evidence has emerged of the significant incidence of posttraumatic stress disorder (PTSD) among victims of domestic violence. The present study examined incidence and correlates of PTSD in 100 female victims of domestic violence resident in women's shelters in Adelaide, South Australia. Forty-five women were found to meet all diagnostic criteria for PTSD. Women meeting PTSD diagnostic criteria reported having experienced higher levels of violence and were more likely to report having a spouse with an alcohol problem and having believed they would be killed by their spouse than women who did not meet criteria. Diagnosis of PTSD was also associated with higher levels of anxiety and depression.     

DSM-5 proposed diagnostic criteria for sexual paraphilias: tensions between diagnostic validity and forensic utility

In order to prevent sexual crimes, “sexual predator” laws now allow indefinite preventive civil commitment of criminals who have completed their prison sentences but are judged to have a paraphilic mental disorder that makes them likely to commit another crime. Such proceedings can bypass the usual protections of criminal law as long as the basis for incarceration is the attribution of a mental disorder. Thus, the difficult conceptual distinction between deviant sexual desires that are mental disorders versus those that are normal variations in sexual preference (even if they are eccentric, repugnant, or illegal if acted upon) has attained critical forensic significance. Yet, the concept of paraphilic disorders - called “perversions” in earlier times - is inherently fuzzy and controversial and thus open to conceptual abuse for social control purposes. Consequently, the criteria used in diagnosing paraphilic disorders deserve careful scrutiny.The DSM-5 sexual disorders work group is proposing substantial revisions to the paraphilia diagnostic criteria in the DSM-5 nosology. It is claimed that the new criteria provide a reconceptualization that clarifies the distinction between normal variation and paraphilic disorder in a way relevant to forensic settings. In this article, after considering the logic of the concept of a paraphilic disorder, I examine each of the proposed changes to the DSM-5 paraphilia criteria and assess their conceptual validity. I argue that the DSM-5 proposals, while containing a kernel of an advance in distinguishing paraphilias from paraphilic disorders, nonetheless would yield criteria for paraphilic disorders that are conceptually invalid in ways open to serious forensic abuse.     

Trauma and Posttraumatic Stress Disorder Among Substance-Using Women Entering Cook County Jail

In the United States, the number of incarcerated women continues to rise each year, with African American women having the highest incarceration rates. Many women enter prisons and jails with an extensive trauma history, though little is known about the percentage of these individuals suffering from posttraumatic stress disorder (PTSD) and specific trauma exposures they have had based on factors such as homelessness, degree of substance problems, and race. The present study examines a largely African American substance-using population of incarcerated women to determine the impact of various factors on specific traumas reported. We found that individuals reporting symptoms meeting criteria for PTSD had experienced the highest average number of traumas, and those who had ever been homeless also experienced many and varied trauma exposures compared with those who had never been homeless. Higher substance problems were also associated with more trauma exposure. Fewer than 10 percent of the sample met full criteria for PTSD, though those reporting having ever been homeless and those with higher substance problems were significantly more likely to meet all criteria. Results indicate a need to assess previous homelessness as a method for identifying additional trauma exposures and guiding treatment to women's specific needs and trauma profiles.     

Neurocognitive Disorders in DSM-V: Forensic Perspective

Although determination of diagnosis of cognitive impairments constitutes one of the core objectives of forensic neuropsychological assessment, the diagnostic criteria for cognitive disorders provided by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR, American Psychiatric Association 2000) have been of low internal and external validity and limited utility. This paper reviews the evolution of diagnosis of cognitive disorders from current DSM-IV-TR to the proposed DSM-V (American Psychiatric Association 2010). The conceptual framework is tracked, along with the body of literature associated with the DSM-V proposal on Minor and Major Neurocognitive Disorders. The quality of evidence for internal and external validity is reviewed, as well as the fairness and utility of newly proposed diagnoses from both clinical and forensic perspectives. Significant conceptual, evidentiary, psychometric, assessment, and practical questions are raised related to the new classification, and recommendations are offered for improvement to the proposal of the DSM-V Work Group on Neurocognitive Disorders.     

Failings of Trauma‐Specific and Related Psychological Tests in Detecting Post‐Traumatic Stress Disorder in Forensic Settings

Judges and juries tend to be particularly impressed by test data, especially quantitative test data. Psychometric tests specific for assessing the presence of post‐traumatic stress disorder (PTSD) are commonly employed by forensic mental health evaluators. Most of these instruments, however, have been designed to detect PTSD in treatment or research, and not forensic, settings. Those who rely on these measures without adequate awareness of their often significant limits in correctly identifying malingering may induce finders of fact to inordinately confidently accept the presence of PTSD. This article reviews problematic structural and content components of trauma‐specific and related instruments used to evaluate PTSD and discusses the utility of specific techniques liable to be used in forensic settings to “fool” these measures.     

Beyond Traumatic Brain Injury: Advancing Forensic Neuropsychological Assessment

As research on the cognitive impact of medical conditions and mental health disorders advances, it is imperative for forensic neuropsychologists to stay abreast of rapidly accumulating new empirical evidence from neuroscience and neuropsychology to disentangle multiple determinants of cognitive impairment. Although medicolegal neuropsychological assessments traditionally focused on traumatic brain injury (TBI) sequelae, it is equally important to consider the potential impact of any other acquired, or secondarily induced brain impairments, regardless of their source. Such injuries or conditions are at times assumed to cause a lesser cognitive impact than TBIs; however, their effects depend entirely on the factor in question. Injuries and illnesses implicated in civil litigation—and eventually affecting competency—can indeed involve TBI, but also anoxic/hypoxic injuries, pain, depression, posttraumatic stress disorder (PTSD), sensory deficits (e.g., tinnitus), and fatigue, and all, in turn, can affect an individual’s cognitive function and quality of life. Impairments caused by these conditions can be disabling and resistant to treatment, particularly, when the treatment is based on incorrect diagnostic, prognostic, and causality assumptions.     

Occupational exposure to traumatic evidence and posttraumatic stress symptoms in forensic science professionals: Prevalence and patterns

Forensic science professionals are routinely exposed to potentially traumatizing evidence. This study aimed to estimate the prevalence of occupational posttraumatic stress disorder (PTSD) among forensic science professionals, identify job-related correlates of PTSD symptoms, and examine the role of social support in mitigating PTSD symptomology. In response to recruitment through the American Academy of Forensic Sciences, the American Society of Crime Laboratory Directors, and Evidence Technology Magazine, 449 forensic science professionals participated in the current study. Results found that 73.5% (n = 330) of the overall sample experienced at least one work-related traumatic event consistent with meeting Criterion A for PTSD, and these rates were higher for field-based respondents (n = 203, 87.9%). The prevalence of past-month provisional PTSD was 21.6% for the full sample. Disaggregated PTSD rates were 29.0% and 14.5% for field-based and non-field-based respondents, respectively. These rates were 6- to 8-fold higher than the past-year prevalence of PTSD in the general US population, estimated to be 3.5%, and were found to be at least as high as those observed in prior epidemiological research with non-treatment seeking members of the US military deployed to war zones in Iraq and Afghanistan. Results further showed that social support was protective against PTSD symptomology. The high rates of occupational exposure to trauma and consequent PTSD symptomology observed in this large sample of forensic science professionals highlight the under-acknowledged psychological risks of these occupations and the need for enhanced attention to mental health resources for these professionals.     

The Dissociative Subtype of Posttraumatic Stress Disorder: Forensic Considerations and Recent Controversies

Psychological Injury and Law - This article provides an overview of the evidence concerning the dissociative subtype of posttraumatic stress disorder (PTSD) and its relevance in forensic contexts....     

Signs and symptoms of post-traumatic stress disorder in children

Summary Post-traumatic Stress Disorder in children is a complex interaction of cognitive, affective, and physiological responses to an event that is outside the range of usual human experience and would be markedly distressing to almost anyone. Traumatic stress reactions in children are conscious and unconscious efforts to assimilate an overwhelming event and have been identified in the past as panic reaction, acute grief hysterical reaction, and physical shock. PTSD in children is complicated by multiple issues of developmental stages, family dynamics, physical maturity, genetic predisposition, and cognitive skills. Characteristic symptoms of PTSD which must persist for more than one month include re-experiencing (flashbacks, nightmares); avoidance; numbing of general responsiveness; and persistent autonomic arousal. Children exhibit characteristic PTSD symptoms, but research suggests four criteria specific to traumatized children independent of chronological age and the course of the disorder: 1) visualized and repeatedly perceived memories; 2) repetitive behaviors; 3) trauma-related fears; 4) altered attitudes about life and future orientation. These four criteria appear to remain clustered together in childhood trauma victims even when other diagnosis would appear more appropriate. PTSD in children encompasses a complex spectrum of diagnosis and remains technically intricate for the mental health professional.     

The PTSD Stressor Criterion as a Barrier to Malingering: DSM-5 Draft Commentaries

This commentary focuses on the proposed changes to the trauma stressor criterion for PTSD for DSM-5, specifically its likely impact on malingering. PTSD is particularly susceptible to malingering because the diagnosis relies so heavily on a patient’s subjective symptoms. Because the traumatic event that is the trigger of the PTSD syndrome is generally based on objective fact and thus often easily corroborated, this element of the diagnosis is usually more challenging to malinger than subjective reports of symptoms. Therefore, one of the main gateways for limiting the misuse of the PTSD diagnosis in forensic settings is the criterion defining the range of qualifying traumas. Proposed changes to criterion A of PTSD in the draft include modifying the types of qualifying trauma by replacing “threat to physical integrity” with “sexual violation,” and clarifying the modes of exposure by replacing the phrase “confronted with” with two criterion: “learning that the event occurred to a close relative or close friend” and “experiencing repeated or extreme exposure to aversive details of the event.” Each of these changes has the potential to significantly broaden the range of qualifying stressors and consequently expand the potential pool of individuals who might be in a position to malinger the disorder. Given the likelihood that the DSM-5 field trials will be unable to provide information relevant to assessing the impact of making these changes in forensic settings, it would be prudent to resist the inclination to tinker with the wording unless other mechanisms are available to ensure that the wording changes do more good than harm.