The Traumatic Truth: Questions for MedicoLegal Reporting regarding PTSD

The Traumatic Truth: Questions for MedicoLegal Reporting regarding PTSD

Traumatic events can be unexpected and sometimes unavoidable. With 50-75% of people facing a traumatic incident at some point within their lifetime, attention needs to be given to treatment and recovery from both a legal and medical perspective.

Dr Glen Smith is a consultant Clinical and Forensic Psychologist who works with MedicoLegal Assessments Group. Recently, he presented to our clients on the topic of Post Traumatic Stress Disorder (PTSD), highlighting factors in diagnosis, management and questions to ask MedicoLegal reporting when having such cases assessed.

As stated above, Dr Smith pointed out the somewhat unsettling statistic that over half the population will experience trauma within their lifetime. He cited the most common potentially traumatic events as the sudden and unexpected death of someone close (35%) and witnessed death (27%). Interestingly, the lifetime prevalence of PTSD in females is higher than in males and is 5-10%[1].

As a result of suffering a traumatic episode, many people will suffer Acute Stress Disorder, however only a minority of this number will continue to suffer symptoms consistent with PTSD. It is therefore important to know the difference between the two conditions.

Dr Smith outlined the symptoms of Acute Stress Disorder, which mirror many of the symptoms of PTSD. Some of the more common symptoms included:

  • sleep disturbance
  • anxiety
  • emotional distress
  • appetite disturbance
  • sadness and guilt
  • re-experiencing the event in forms of memories and nightmares
  • avoidance and social withdrawal.

A presence of the more severe reactions can lead to a diagnosis of Acute Stress Disorder. These symptoms are most prevalent in the first two weeks after the traumatic experience, however would gradually resolve in time, often without need for formal treatment. Having said this, counselling should also be offered. For a diagnosis of Acute Stress Disorder, symptoms need to be present for at least three days, however should not be present for more than one month. If symptoms persist greater than a month, then the diagnosis of PTSD may be made.

This brings us to the diagnostic criteria of PTSD. Dr Smith referenced the DSM-5 and ICD-11 criteria for diagnosing PTSD from the Australian and New Zealand Journal of Psychiatry [2]. Unlike Acute Stress Disorder, symptoms were present for four weeks or longer and result in a functional impairment. Other symptoms included re-experiencing symptoms, active avoidance symptoms, hyperarousal symptoms (hypervigilance or exaggerated startle) and functional impairment.

An important consideration when seeking assessments for patients with PTSD is ‘Criterion H’. Dr Smith indicated that for a diagnosis of PTSD, the symptoms must not be attributable to substance use or a general medical condition. This is a particularly important question to ask when seeking medico-legal reporting, as substance abuse, particularly alcohol abuse, is frequently comorbid with PTSD.

Dr Smith subsequently outlined therapies used in the treatment of PTSD. He focused on the following in treating trauma and its symptoms, namely:

  • the development of new ways of coping with anxiety, including progressive muscle relaxation (PMR) and the slow breathing exercise
  • trauma focused psychological therapypharmacological treatment.

Questions for MedicoLegal assessments and reporting

Having explored the definition of PTSD and expanding on the treatments available for trauma patients, this leads us to the important questions that need to be asked when seeking MedicoLegal assessments and reporting. Dr Smith touched on questions of diagnosis, prognosis, causation and contributing factors to ongoing incapacity – all of which are highly relevant in the medical reporting of PTSD.

Diagnosis

In terms of diagnosis, it is important to ask:

  • Is this Acute Stress Disorder or PTSD?
  • Can it be diagnosed in the context of alcohol dependence?

Prognosis

In terms of prognosis, it is important to ask:

  • Has treatment been offered?
  • Was it appropriate and for an adequate duration?
  • Has the patient ceased alcohol consumption?

Causation

When seeking a report, the following factors relating to causation should be noted:

  • establishing the main or the substantial contributing factor required to establish injury
  • ensuring you refer to the criterion in terms of factors or causes constituting PTSD.

Ongoing Incapacity

Be sure to ask questions relating to ongoing incapacity, such as:

  • Is alcohol or any other factor contributing to the lack of improvement?
  • Is there an employment related exposure to traumatic incidences?
  • Is there a lack of motivation for treatment?

Finding the right doctor to produce your medical report is of critical importance when establishing a claim for PTSD. MedicoLegal Assessments Group (MAG) will provide you with the right doctor, in a timely manner, who is an expert in this field. For more information on how you can access the right doctor to assess your PTSD claim, please contact the MAG team.

[1] Phoenix Australia – Centre for Posttraumatic Mental Health.

Australian Guidelines for the Treatment of Acute Stress Disorder and Posttraumatic Stress Disorder. 2013.

Phoenix Australia, Melbourne, Victoria

[2] Meaghan L O’Donnell et al. Aust NZ J Psychiatry 2015; 49:315-316

Paralympic glory

Paralympic glory

Stop and pause to reflect for these wonderful athletes.
The Winter Olympic Games has finished up in Sochi, but our Paralympic athletes are preparing themselves to compete in two of the six disciplines scheduled at the Winter Paralympic Games. So who are they? And what will they have focused on in the run up to the Games?

The Australian team has a total of 11 athletes, including six alpine skiers, two sighted guides and, for the first time, three snowboarders. The experience level of the alpine skiing component of the squad is strong, with all but one of the athletes having competed previously at a Paralympic Games, and all athletes having won medals over the two most recent World Cup seasons. Victoria (Tori) Pendergast, Australia’s first female sit-skier, will make her Paralympic debut, while Cameron Rahles-Rahbula has come out of retirement to compete in his fourth Games at 30 years of age.

Rahles-Rahbula, a leg amputee, picked up two bronze medals in the slalom and super-combined events four years ago at the Vancouver Games, and will be no doubt be focused on pushing himself to his limits once again in his final Paralympic Games despite an injury yesterday while training on the downhill course.
As the Para-snowboard discipline makes its debut on the Paralympic program in Sochi, so too will Australian snowboarder Ben Tudhope. Tudhope, who was born with cerebral palsy and partial paralysis of his left side, will become the youngest athlete to compete for Australia at a Winter Paralympic Games when he lines up in the new discipline at just 14 years of age.

As expected, there is a lot that is involved in preparing an athlete for such an event. Of course, there are the endless hours of training that have to be put in to ensure that each of the athletes is fit and ready to perform at their peak – but there is also a long list of other, more obscure, factors that need to be taken into account.

Common challenges

Preparation for the Olympics for athletes, whether or not they have a disability, is a huge ordeal.
There is a long list of potential stressors that can have a detrimental impact on athletes’ stress and confidence levels leading up to the event. These include, and are not limited to:
•    the physical and psychological effects of long-haul flights
•    adjusting to new foods
•    sharing a room with others for long periods of time
•    poor sleep quality
•    abiding by team rules
•    home-sickness
•    fatigue and stress that may come with travelling to and from competition venues
•    always being in the company of others.

Unique challenges

Athletes with disabilities face all of these same issues when preparing for the Paralympic Games – but they can also be faced with a unique set of physiological and psychological challenges which have the potential to disrupt their preparation.

In order to combat this, it is essential that the medical and sport science support staff are fully familiar with each individual athlete’s inherent disability and related medical conditions. Further to this, athletes with an intellectual or visual impairment may require additional care and assistance to provide them with the best opportunity to experience a smooth transition into competition.

From a psychological perspective, for some athletes, merely entering a plane or finding their way around the team accommodation or competition venue can be a source of additional stress.
Visually-impaired athletes may require assistance to help them orient to their new environment. When on a long-haul flight, for instance, finding the way to the bathroom facilities and back in a darkened cabin can present them with a challenge that others may not encounter.

Due to the increased amount of cognitive effort that can be required, such experiences may impact upon the athlete’s overall stress and/or energy levels, which can impair performance.

Support staff can relieve some of this pressure by checking in with relevant athletes to see if they have any questions, or by simply ensuring that they feel comfortable in their surroundings.From a physiological perspective, for athletes who are missing limbs and/or wearing prosthetic limbs, good stump care is a key part of the preparation process. It can help to avoid possible infection and the impact this can have upon performance. The overall aim while travelling, as well as prior to competition, is to not place any unnecessary stress on their stumps. Athletes are advised to wear compression garments on their stumps to prevent unwanted swelling during long haul flights, particularly if they remove their prosthesis during the flights.
They should also be reminded to try to avoid excessive walking in the days leading up to their event to prevent unnecessary fatigue, as well as the risk of breaking down the protective outer layer of the skin.

The one universal, whatever the discipline, whatever the circumstances of the athlete, is the desire to achieve Paralympic glory – and for us, the desire to see top-level competition.

This article was co-authored with Caron Jander, a consultant occupational physician affiliated with the Australian Paralympic Swim Team. Dr Caron Jander is an occupational physician who consults at MAG Head Office. She was the ParaOlmpian Team Doctor.