Abstract
Post-traumatic stress disorder (PTSD) was first defined in the US Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) in 1983 partly to give recognition and bring justice to Vietnam Veterans. Very much of its time, the diagnosis was politically expedient as it was clinically useful and did much to throw a spotlight on the field of psychological trauma, which, until then had been somewhat neglected. PTSD has very much become the ‘go-too’ diagnosis in the legal arena where it gives validity and recognition to victims as well as the possibility of compensation, pensions and consequent financial advantage, not to mention legitimacy and recognition of suffering. We sometimes forget, however, that DSM-III was intended as a research tool to define homogeneous groups of individuals for research purposes and does not necessarily reflect an as-yet unidentified underlying homogeneous pathophysiology in the brain of our patients.
Since its inception in 1983, the PTSD diagnosis has become the sine qua non of psychological trauma. From the perspective of the Courts, the current strict PTSD diagnostic criteria have the benefit of simplicity (you either have the diagnosis or you don’t), and is a diagnosis that is internationally recognised as well as providing a common language upon which all experts agree. However, it also reduces the complex, multifaceted emotional life of victims to a monochrome, reductionist set of criteria which often fail to capture the full impact of traumatic events on an individual. The recent introduction of complex PTSD 1 into the international taxonomy broadens diagnostic criteria to include the negative impact on relationships, however, the remainder of its diagnostic criteria still rely on the subjective reports of the individual and whether the disorder itself is actually a distinct diagnostic entity remains in dispute, particularly in relation to the Axis-II Borderline Personality disorder with which there can be considerable symptomatic overlap.2,3 One of the problems facing lawyers and doctors is the lack of credible alternatives.
F43.0 acute stress reaction
This is a transient disorder that develops in an individual without any other apparent mental disorder in response to exceptional physical and mental stress and that usually subsides within hours or days, which of course is wrong when the condition persists after months. 4
F43.2 adjustment disorder
Another temporary condition expected to disappear in some months’ time and is a product of life's normal stressors, for example, divorces and other social disturbances and should subside in 6–9 months, which also makes this diagnosis unattractive or the F43.9 reaction to severe stress, unspecified, lacks any definition whatsoever. 5
F62.0, enduring personality change after catastrophic experience (EPCACE)
This condition demands a duration of two years for alteration of personality following a traumatic event, but makes no reference to the extent or severity of this change and will not appear in the International Classification of Diseases 11th Revision (ICD 11).6,7
These alternative diagnoses are weak in comparison with PTSD and frequently fail to do justice to a victim's suffering leaving the lawyer, therapist, psychologist, or psychiatrist with little alternative than to resort to the PTSD diagnosis to give a patient legitimacy. They may not only be a poor representation of a victim's symptoms, who might not meet even their criteria, but may also become the subject of dispute between the expert witness in court, adding further to suffering and potentially re-traumatising already traumatised individuals.
This state of affairs has led to a ‘one size fits all’ approach to treatment, and expert witnesses both in the civil courts, and criminal justice system, applying the PTSD diagnosis to victims who simply don’t meet the strictly defined diagnostic criteria leading to unnecessary courtroom dispute, as well as the unnecessary examination and cross-examination of victims, often re-traumatising them in the witness box subjecting them to unnecessary humiliation with implications of dishonesty and victim blaming, for those with a past psychiatric history.
In the absence of credible alternative diagnoses, the courts should eschew PTSD and introduce a much more loosely defined category of post-traumatic disorders (PTDs) for victims of trauma that not only admits the richness and diversity of individual psychopathology, but allows a credible evaluation of the full impact of trauma on a victim, based upon objective, verifiable measures of psychological and social functioning before and after a traumatic event, and importantly, agreement by claimants and defendants in legal cases on the extent of change suffered by an individual following a trauma, outside the courtroom, sparing victims the possibility of re-traumatisation in the witness box.
Such a formulation-based approach is not without its problems; not least the possibility of cross-examination merely moving from a disputed diagnosis of whether or not the plaintiff has PTSD or not, to unpicking aspects of the formulation instead. However, this would at least allow the possibility of admitting objective, and verifiable social and behavioural criteria, independent of a plaintiff's subjective account of events as well as giving a fuller picture of the impact of traumatic events on the patient's well-being, and consequent change to behaviours and social life. The severity of PTSD symptoms may be dissonant from their impact on illness behaviour and this dimension, currently overlooked, should be taken into account by the courts.
A trauma narrative is far more helpful than an ICD or DSM diagnosis in helping establish quantum. 8 This is similar to the trend in UK Coronial Courts where a narrative cause of death is increasingly employed instead of, or alongside, a categorical conclusion. 9 An agreed view on both sides of the courtroom and before any formal hearing, regarding the victim's condition before and after traumatic events, and most importantly, the extent of any enduring, objectively verifiable change in mental state, personality or social circumstance, including impact on family and loved ones, should determine quantum, without recourse to any specific psychiatric diagnosis. 10
In conclusion, PTSD remains the ‘gold standard’ of trauma diagnoses, especially in the courts, bringing both legitimacy and credibility to individual suffering. 11 However, an ICD-10 (F43.1 PTSD) diagnosis leaves little ‘wiggle-room’ for manoeuvre and is unforgiving of anyone not fitting its strict diagnostic criteria. 12 Within the trauma arena, opinion is divided regarding the classification of PTSD as to whether this should remain unchanged, the criteria narrowed or broadened, or whether new diagnostic categories should be introduced. 13 The important point is that reactions to traumatic events are subject to great individual variation and go well beyond the boundaries of the narrowly defined criteria of PTSD. At present, the diagnostic alternatives are inadequate. By adopting a narrative approach we would not only acknowledge the heterogeneity, complexity and full impact of traumatic events on an individual, but spare already traumatised victims indignity, humiliation and re-traumatisation in the courtroom.
