PTSD in Clinical Forensic

Neuropsychology

Bychkova Tetyana, Loizidou Tonia, and Paris Andreas

Presentation Outline1.Definition of PTSD2.Epidemiology3.Neurobiology of PTSD4.The motor vehicle accident and PTSD5.Head injury and PTSD6.“Delayed” PTSD

Presentation Outline (cont.)

• 7. Malingering PTSD• 8. Forensic evaluation of PTSD• 9. The patient interview and PTSD• 10. Clinical Implications of Neuroscience

Research in PTSD• 11. Conclusions

1.Definition of PTSDDSM-IV-TR (2000)

• Criterion A should be met before even proceeding to criteria B-D

Criterion A: STRESSOR

• The person has been exposed to a traumatic event in which both of the following have been present:

• The person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others.

• The person's response involved intense fear, helplessness, or horror. Note: in children, it may be expressed instead by disorganized or agitated behavior.

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Criterion B: intrusive recollection

• The traumatic event is persistently re-experienced in at least one of the following ways:

• Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: in young children, repetitive play may occur in which themes or aspects of the trauma are expressed.

• Recurrent distressing dreams of the event. Note: in children, there may be frightening dreams without recognizable content

• Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes,including those that occur upon awakening or when intoxicated). Note: in children, trauma-specific reenactment may occur.

• Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

• Physiologic reactivity upon exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

Criterion C: avoidant/numbing•Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by at least three of the following:•Efforts to avoid thoughts, feelings, or conversations associated with the trauma•Efforts to avoid activities, places, or people that arouse recollections of the trauma•Inability to recall an important aspect of the trauma•Markedly diminished interest or participation in significant activities•Feeling of detachment or estrangement from others•Restricted range of affect (e.g., unable to have loving feelings)•Sense of foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

Criterion D: hyper-arousal•Persistent symptoms of increasing arousal (not present before the trauma), indicated by at least two of the following:•Difficulty falling or staying asleep•Irritability or outbursts of anger•Difficulty concentrating•Hyper-vigilance•Exaggerated startle response

Criterion E: duration•Duration of the disturbance (symptoms in B, C, and D) is more than one month.

Criterion F: functional significance•The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if:•Acute: if duration of symptoms is less than three months•Chronic: if duration of symptoms is three months or more

Specify if:•With or Without delay onset: Onset of symptoms at least six months after the stressor

1.Definition of PTSD (cont.)

Criterion B: INTRUSIVE RECOLLECTIONS

The traumatic event is persistently re-experienced in at least one of the following ways:Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: in young children, repetitive play may occur in which themes or aspects of the trauma are expressed.

Recurrent distressing dreams of the event. Note: in children, there may be frightening dreams without recognizable content

Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes,including those that occur upon awakening or when intoxicated). Note: in children, trauma-specific reenactment may occur.

Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

Physiologic reactivity upon exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

1.Definition of PTSD (cont.)

Criterion C: AVOIDANT/NUMBING

Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by at least three of the following:

Efforts to avoid thoughts, feelings, or conversations associated with the trauma

Efforts to avoid activities, places, or people that arouse recollections of the trauma

Inability to recall an important aspect of the trauma

Markedly diminished interest or participation in significant activities

Feeling of detachment or estrangement from others

Restricted range of affect (e.g., unable to have loving feelings)

Sense of foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

1.Definition of PTSD (cont.)

Criterion D: HYPER-ARROUSALPersistent symptoms of increasing arousal (not present before the trauma), indicated by at least two of the following:Difficulty falling or staying asleep

Irritability or outbursts of anger

Difficulty concentrating

Hyper-vigilance

Exaggerated startle response

1.Definition of PTSD (cont.)

Criterion E: DURATIONDuration of the disturbance (symptoms in B, C, and D) is more than one month.

Criterion F: FUNCTIONAL SIGNIFICANCEThe disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

1.Definition of PTSD (cont.)

SPECIFIERSAcute: if duration of symptoms is less than three months

Chronic: if duration of symptoms is three months or more

With or Without delay onset: Onset of symptoms at least six months after the stressor

2.Epidemiology

Approximately 30% of individuals who directly experienced events rarely seen by other people will develop PTSD through indirect experience - approximately 10%

2.Epidemiology (cont.)Brewin and colleagues (2000) identifying 14 risk factors:Trauma severity, lack of social support and life stress - the largest effect for developing PTSD

Followed by: adverse childhood events, low intelligence, low SES, childhood abuse, female gender, family and personal psychiatric history, previous trauma, lack of education, younger age, and minority status.

Further analysis showed that peritraumatic dissociation and emotional responses, perceived support and perceived life threat were the strongest predictors. Prior trauma, prior adjustment, and family psychiatric history were weaker and equal predictors.

2.Epidemiology (cont.)Similarly King, King and Foy (1996):

3.Neurobiology of PTSD

“Does stress cause brain damage?”Hippocampus:Research findings regarding whether PTSD causes reduction of hippocampal volume are contradictorySome research supports the idea that smaller hippocampi in PTSD is a preexisting condition

3.Neurobiology of PTSD (cont.)

Physiological reactivity:physiological reactivity is often used as an indirect proof of PTSDin one study (Keane et al., 1998) the results of heart rate and skin conductance identified 75% of MVA with PTSDHowever, reactivity can occur as a response to both true or false emotionally evocative memories

3.Neurobiology of PTSDVeterans who recently returned from Iraq

and Afghanistan underwent functional MR imaging while concurrently exposed to a symptom provocation task, involving alterations between emotional combat-related and neutral civilian scenes, interleaved with an executive processing task.

Activation for emotional compared to neutral stimuli was highly correlated with level of PTSD symptoms in ventral frontolimbic regions (ventromedial prefrontal cortex, inferior frontal gyrus, and ventral anterior cingulate gyrus)

• Conversely, activation for the executive task was negatively correlated with PTSD symptoms in the dorsal executive network (middle frontal gyrus, dorsal anterior cingulate gyrus, and inferior parietal lobule)

• Strong link between the subjectively-assessed behavioral phenomenology of PTSD and objective neurobiological markers.

4.The motor vehicle accident & PTSD

“Can a VMA in which no serious injury is sustained cause PTSD?” Requires severe automobile accidentreports of PTSD tend to be more common among compensation-seeking samples (24.6% vs 8.1%)

5.Head injury and PTSD

Misinterpretation: differentiate between the effects of MHI and PTSD is very difficultReality: they are two separate clinical entitiesEvidence 1: in sports, cognitive capacities following a single concussion return to baseline within 1 weekEvidence 2: research shows that concurrent occurrence of PTSD and MHI is uncommonMost-traumatic amnesia appears to be a protective factor against re-experiencing of symptomsEvidence 3: rate of malingering is about 40%MMPI-2 and TOMM test reveal that malingering in dual diagnosis group was 49.5% to 88%

6.”Delayed” PTSDAccording to DSM-IV-TR delayed onset refers to PTSD symptom presentation more than 6 months after the traumatic eventStrangely may occur closer to the hearing date! (Larrabee’s observation)Makes little neurological sensewas initially introduced as a by-product of the Vietnam War. PTSD was not manifest itself before the veteran returns home. But, many make claims years after the eventA lot of evidence that PTSD symptoms develop within hours or days after the eventMost probably that delay is rather in the help-seeking than in the PTSD symptomsDelayed PTSD in the complete absense of previously unrecognized symptoms is rare

7.Malingering PTSD“It is rare to find a psychiatric diagnosis that anyone wants to have, but PTSD seems to be one of them.” (Andersen, 1995, p.963)more has been written about combat than civil malingeringcompensable nature of PTSD makes it a desirable diagnosisApproximate reported prevalence among veterans ranges from 21.2% to 53.4%literature on malingering PTSD is limitedPTSD is easy to fake94% of naive subjects correctly identifies PTSD symptoms on self-report measure. However, only one subject from 134 malingered enough symptoms for formal diagnosis

7.Malingering PTSDMost common measures of malingering PTSD:

•1. Morel Emotional Numbing Test (MENT) is a forced-choice test where the subjects have to match facial expressions with the words that best describe the face•Morel reports an overall malingering rate of 95.6% in a veteran population. •One civilian study found that 40% failed the MENT, 51% the SIMS and WMT and 25% failed all three. •Limitations: No clear explanation as to why PTSD patients would fail to recognize emotional facial expressions. Plus, methodological difficulty: PTSD patients were given different set of instructions

7.Malingering PTSD (cont.)

• 2. The Detailed Assessment of Posttraumatic Stress (DAPS): is a 104-item self-report PTSD instrument.

• Advantage: Has a validity scale - the Negative Bias Scale (NBS) which captures feigned PTSD

• One study found that 25% of litigants seeking psychological assessment failed NBS

• Limitations: litigants group was very mixed in terms of etiology

7.Malingering PTSD (cont.)

• 3. The Trauma Symptom Inventory (TSI): self-report measure which includes the Atypical Response Scale (ATR).

• The most commonly used measure among self-designated “traumatologists”

• The research shows that is produces high rate of false positives

• Is better able to detect naive fakers• Unclear degree of influence of secondary gain in

“genuine” PTSD group

7.Malingering PTSD• 4.Other Scales• The Miller-Forensic Assessment of

Symptoms• The Structured Interview of Reported

Symptoms (SIRS)• Two structured interviews developed for

the detection of malingering

8.Forensic Evaluation of PTSD

The Practice Guidelines from the International Society for Posttraumatic Stress Studies (ISTSS) provide some assessment recommendations:Multiple measures and methods

1. Assessment of cognitive functions (if needed) and Symptom Validity Tests(SVTs)

2. Personality testing (MMPI)3. A semi-structured or structured interview (CAPS is

recommended)4. Self-report instruments

8.Forensic Evaluation of PTSD (cont.)

• 1.Cognitive Function Assessment• PTSD as any other psychiatric disorder is often accompanied by

cognitive complaints• The typical examination can be short (2.5 h)• includes some neuropsychological tests• gives an opportunity to administer SVTs• The goal is not to detect a brain lesion • persons who feign PTSD may also feign functional disability• 37%-60% disability-seeking pain patients will fail TOMM even

though cognitive disfunction is not at the core of pain complaints

8.Forensic Evaluation of PTSD (cont.)

Generally, the research shows that there is no specific cognitive functioning difference in civilian groups with and without PTSDNo greater impairment than in patients with anxiety or mood disordersmost commonly reported relative weakness is on verbal memory and timed attention measuresHowever, Premorbid cognitive function was found to be a predictor of PTSD!!!The lower the premorbid cognitive ability, the higher the risk for PTSD symptom reportingLower attention, processing speed and verbal memory are the strongest predictors

9. The Patient Interview

Limitations of the PI and Suggestions:• Self-report is problematic because of lack of falsifiability (= scientific

evidence useful for diagnosis)

• Patient knowledge about symptoms of the disorder

• To be done after the completion of tests

• Volunteering of symptoms

• Structured symptom inquiry (the interviewer is asking about each symptom, its onset and progress of it mixing it with physical symptoms)

• Detailed description of the PTSD-causing event (narrative)

• Clinical Assessment of PTSD Scale (CAPS). The most widely used scale for assessment of PTSD and the suggested one from the author.

9. The Patient Interview (cont.)

• Pay extra attention to flashbacks and nightmares• It is improbable for the nightmares be an exact

replication of the traumatic event• Although flashbacks are the only unique symptom of

PTSD they are considered rare according to DSM-IV-TR• Any non-improvement after a period of time in symptoms

should be viewed with skepticism • Interview of a family member (serves the purpose of

revealing information about the person’s symptoms, failure to attend could be a sign of malingering)

10. Clinical Implications of Neuroscience Research in

PTSD• Traumatized individuals are vulnerable toreact to sensory information withsubcortically initiated responses that areirrelevant, and often harmful, in the present.

• Reminders of traumatic experiencesactivate brain regions that support intenseemotions, and decrease activation in theCNS regions involved in: a) the integration of sensory input with motor output,b) the modulation of physiological arousal, and c) the capacity to communicate experience in words.

• Failures of attention and memory in PTSD) interfere with the capacity to engage in the present.

• Effective treatment needs to involve (1) learning to tolerate feelings and sensations by increasing the capacity for interoception, (1) learning to modulate arousal, and (2) learning that after confrontation with physical helplessness it isessential to engage in taking effective action.

10. Clinical Implications of Neuroscience Research in PTSD

(cont)

11. Conclusion