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PTSD AND THE LAW
Roger K. Pitman, M.D.1
VAMC, Manchester
Harvard Medical School
Landy F. Sparr, M.D.2
VAMC, Portland
Oregon Health Sciences University
A forensic psychologist once remarked that if mental illnesses were rated on
the New York Stock Exchange, PTSD would be a growth stock worth watching (Lees-Haley,
1986). Perhaps more than any other psychologic or medical disorder, PTSD has
influenced, and been influenced by, the law (Stone, 1993).
Civil Law. The concept of mental injury as com-pensable entity, of which PTSD
represents the cul-mination, has gradually emerged out of the histori-cal context
of physical injury (Scrignar, 1996). The recognition of psychologic and emotional
aspects of the causation and manifestation of injury-related disorders has only
been accomplished over the past century (Hoffman et al., 1992). The PTSD diagnosis
represents landmark recognition that an external event can serve as the direct
cause of a mental disorder. This has led one authority to state that ³accurate
assessment of PTSD-specific symptoms forms the basis for defining psychic injury
in law ...² (Raifman, 1983, p.124). Slovenko (1994) noted that PTSD is a favored
diagnosis in tort law because it is incident-specific and easy to understand,
and it tends to rule out other factors potentially involved in causation. Through
PTSD, plaintiffs attempt to establish that the psychologic problems they are
claiming issue from an alleged traumatic event and not from a myriad of other
possible sources. A diagnosis of depression, in contrast, may expose the causation
issue to many etiologic consider-ations. Spaulding (1988) has noted that ³the
further from the diagnosis of PTSD the evaluator strays, the more speculative
the opinion on causation will become² (p.13). Special features of PTSD also
help it overcome legal barriers under workersı compen-sation. Whereas affective
and other anxiety disor-ders may be argued to represent ³ordinary diseases of
life,² the recognition that PTSD is caused by a discrete external event, e.g.,
a workplace accident, removes it from this exclusionary category.
Some see PTSD as threatening to overwhelm the personal injury, workersı compensation,
and dis-ability insurance litigation systems. Between 1980, when PTSD was introduced
into the official psychi-atric nomenclature, and 1987, the number of per-sonal
injury lawsuit filings between private parties in federal courts rose more than
50% (Olson, 1991). Jury awards escalated dramatically during the same time period.
This coincided with psychologic in-jury becoming more widely recognized, and
with courts becoming increasingly willing to compen-sate for emotional distress
in the absence of physi-cal injury or impact. United States Chamber of Commerce
statistics show that the number of men-tal stress claims recorded by employees
under work-ersı compensation jumped nearly 800% between 1979 and 1990, making-stress
related disorders the nationıs fastest-growing disease category (deCarteret,
1994). In a study of more than 700,000 claims filed in 11 states, the National
Council on Compensation Insurance reported that the costs of stress claims averaged
about 52% more than physi-cal injury claims (Calise, 1993).
Faust and Ziskin (1988) have assailed the foren-sic use of PTSD on the grounds
that the disorder lacks proven diagnostic reliability and validity. They opined
that PTSD symptoms may have many alternate explanations and that exaggeration
and malingering are ever possible, and even probable. Public skepticism has
been stimulated by frivolous and sometimes well-publicized workersı compen-sation
claims (Sparr, 1995).
Criminal law. Many fears have been expressed about the misuse of PTSD in criminal
cases, but it is questionable whether such fears have actually come true. Appelbaum
et al. (1993) carefully showed that despite early concerns, the PTSD insanity
defense is raised infrequently, and, like other insanity pleas, is usually unsuccessful.
It appears, however, that the primary thrust of a PTSD criminal defense has
not been as an insanity plea, but instead as a factor in diminished capacity
considerations, pre-trial plea bargaining, or sentencing (Sparr, 1996). In some
self-defense cases, PTSD may aid a defendant in showing that a particular type
of provocation to which she had become especially sensitive in light of previous
traumatization caused her to feel physi-cally threatened and evoked a reasonable
self-de-fensive reaction. The most familiar example is so-called ³battered woman
syndrome²(Dutton & Goodman, 1994).
In criminal trials, PTSD is unique among mental disorders in its invocation
not only by the defense but also by the prosecution. The presence of PTSD in
a victim, e.g., in the form of ³rape trauma syndrome² (Burgess, 1983; Frazier
& Borgida, 1985), may be cited by the prosecution as evidence supporting the
actual occurrence of the alleged criminal act.
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Sparr and Atkinson (1986) noted that in criminal pro-
ceedings involving pleas of not guilty by reason of insan-
ity or by diminished capacity, establishing a valid link
between PTSD and criminal behavior is an imposing task,
because two levels of causation are required: first, the link
between the traumatic stressor and the psychiatric symp-
toms, and second, the link between the psychiatric symp-
toms and the criminal act. In many cases, the PTSD diagno-
sis itself may not be questioned, but its contribution to the
defendant's mental state at the time of the act may be hotly
contested. Prosecutors may point to secondary factors
such as financial problems, interpersonal conflicts, or drug
and alcohol abuse as proximate motivations for criminal
activity. Although these factors may be related to PTSD,
they are not generally regarded as sufficient to relieve an
individual from criminal responsibility.
Based upon a literature review, Pitman et al. (1996)
summarized the factors that tend to support a PTSD-
related criminal defense: (a) the act represents spontane-
ous, unpremeditated behavior uncharacteristic of the indi-
vidual; (b) coherent dialogue appropriately related to time
and place is lacking; (c) the choice of victim is fortuitous or
accidental; (d) the response is disproportionate to the
provocation; (e) the act is rationally inexplicable and lacks
current motivation; (f) the act recreates in a psychologically
meaningful way elements of the original traumatic stres-
sor; (g) the defendant is unaware of the ways in which he
has re-enacted traumatic experiences; (h) the act is precipi-
tated by event(s) or circumstance(s) that realistically or
symbolically force the individual to face unresolved con-
flicts; and (i) there is amnesia for the episode.
Forensic evaluation of PTSD. Psychiatric researchers are
now required to determine the presence or absence of
diagnostic criteria in a systematic, reliable manner by
means of structured interview instruments. Because the
need for reliability in the medicolegal setting is equally
great, forensic evaluations call for a similar approach.
Simon et al. (1995) offer a series of specifically articulated
guidelines for the forensic assessment of PTSD, including
the psychiatric examination of adults, adolescents, and
children, forensic psychologic assessment, and evaluation
of the troublesome issue of malingering. Wilson and Keane
(1997) have assembled treatises on state-of-the-art PTSD
psychometric instruments.
The current diagnostic criteria for PTSD include physical
manifestations, e.g., specific physiologic reactivity and
exaggerated startle response. Pitman and Orr (1993) have
proposed that the laboratory measurement of these criteria
"has the potential to redeem the PTSD diagnosis from its
current subjectivity and to help separate the wheat from
the chaff in the forensic evaluation of PTSD claims" (p. 40).
As with psychometric tests, however, they note that psy-
chophysiologic test results do not stand on their own but
serve as only one component of a comprehensive forensic
psychiatric evaluation.
Pitman et al. (1996) have summarized common errors
leading to the forensic overdiagnosis of PTSD, which in-
clude: (a) failure to separate expectable emotional distress
from mental disorder; (b) application of fewer criteria than
are required for the proper diagnosis; (c) failure to consider
the contribution of earlier, unrelated traumatic events to
the evaluee's illness, with resulting false attribution to the
traumatic event being litigated; (d) failure to diagnose pre-
existing psychopathology; (e) failure to identify a positive
family history of mental disorder that may point to another
etiology; and (f) failure to entertain differential diagnoses.
Common errors leading to the forensic underdiagnosis of
PTSD include: (a) characterization of PTSD symptoms as
mere understandable, normal reactions to the traumatic
event; (b) basing opinion on inadequate, open-ended inter-
views without an adequate attempt to explore details of the
traumatic event and subsequent symptomatology; (c) idio-
syncratic thresholds for diagnosis; (d) failure to acknowl-
edge that the diagnosis of PTSD may be made despite the
presence of major vulnerability factors; (e) mistaking pre-
disposition for pre-existing psychopathology; (f) false at-
tribution of the evaluee's symptoms to other life events; (g)
espousal of narrow or outdated theories of etiology which
may play on popular prejudices, e.g., all mental illness
results from early childhood experience, or all mental
illness is inherited; and (h) failure to consider relevant,
supportive PTSD literature.
Expert PTSD testimony. Legal advocates seem to have a
thirst for expert psychiatric and psychologic testimony
and sometimes attempt to push such experts beyond the
limits of their knowledge (Sparr & Boehnlein, 1990). This
state of affairs emphasizes the need for quality assurance
(American Psychiatric Association, 1997; Hoffman, 1997)
and ethical standards (Appelbaum, 1997) in forensic psy-
chiatric assessments. Mental health professionals who ren-
der testimony on either a willing or unwilling basis can
avoid problems if they stick to describing the evaluee's
history, signs and symptoms, diagnostic conditions, and
mental disabilities and leave the judge and jury to weigh
these in the context of legal standards. The expert should
not attempt to resolve questions of damages, competence,
or criminal responsibility.
Scientific courtroom testimony, including psychiatric
evidence, is governed by expert witness rules that revolve
around three issues. First, courts are concerned with reli-
ability, particularly because they have long experience
with a litigant's ability to find experts to support virtually
any position. Second, courts are concerned with the "aura
of special reliability and trustworthiness" that surrounds
an expert's testimony. Third, courts fear that courtrooms
will be overrun by experts. Expert testimony has added
substantially to the length and cost of trials. Some courts
will resist allowing it unless they are convinced it will aid
the trial process (Murphy, 1992). Prior to 1993, the general
legal standard for the admissibility of scientific evidence
was that it "be sufficiently established to have gained
general acceptance in the particular field in which it be-
longs" (Frye v. United States, 1923). However, in Daubert
v. Merrill Dow (1993), the U.S. Supreme Court held that the
Frye rule had been superseded by the Federal Rules of
Evidence (see also Marwick, 1993; Steinberg, 1993). The
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Court handed down a strict interpretation of these rules as
they pertain to "scientific knowledge." It assigned the job
of determining the reliability of proffered scientific testi-
mony to the trial judge and offered five guidelines for
making such a determination: (1) whether the theory or
technique can be (and has been) tested; (2) whether it has
been subjected to peer review and publication; (3) its
known or potential error rate; (4) the existence and main-
tenance of standards controlling its operation; and (5)
whether it has attracted widespread acceptance within a
relevant scientific community (the former Frye rule).
The material in the abstracts and citations that follow
demonstrate the degree to which the study of PTSD has
advanced since the disorder's introduction in 1980. It be-
hooves psychiatrists and clinical psychologists who plan
to testify about PTSD to be familiar with scientific ad-
vances in the field, and about current standards for PTSD's
assessment. They should also consider how well the testi-
mony they plan to present meets these standards, lest they
be surprised to find their expert opinions ruled inadmis-
sible in court.
LEGAL CASES
Frye v. United States, 293 F. 2d 1013 (D.C. Cir. 1923).
Daubert v. Merrill Dow Pharmaceuticals, 113 S. Ct. 2786 (1993).
REFERENCES
CALISE, A. (1993, August 30). Workers' compensation men-
tal-stress claims in decline. National Underwriter, 8, 3, 31.
DECARTERET, J.C. (1994). Occupational stress claims: effects
on workers' compensation. American Association of Occupational
Health Nurses Journal, 42, 494-498.
OLSON, W.K. (1991). The Litigation Explosion. New York, NY:
Dutton.
WILSON, J.P. & KEANE, T.M. (Eds.) (1997). Assessing psycho-
logical trauma and PTSD. New York: Guilford Press.
SELECTED ABSTRACTS
APPELBAUM, P.S., JICK, R.Z., GRISSO, T., GIVELBER, D.,
SILVER, E., & STEADMAN, H.J. (1993). Use of posttraumatic
stress disorder to support an insanity defense. American Journal
of Psychiatry, 150, 229-234. OBJECTIVE: The authors examine the
allegation that the diagnosis of PTSD is frequently abused in the
legal system as the basis for a defense of not guilty by reason of
insanity. METHOD: Data for the investigation were drawn from
a study of insanity pleas gathered from court records in 49
counties in eight states. Data on the 28 insanity plea defendants
for whom PTSD was diagnosed before or immediately after trial
were compared with data on 8,135 defendants whose insanity
pleas were based on other diagnoses. Results: Insanity pleas by
defendants with diagnoses of PTSD constituted only 0.3 percent
of the cases. There were few significant differences between the
two groups on demographic variables, psychiatric histories, pre-
vious involvement in crime, or current charges. The defendants
with PTSD were more likely to have been married, less likely to
have been arrested as juveniles, and less likely to have been
detained after trial. CONCLUSIONS: Contrary to previously
expressed concerns, PTSD was infrequently associated with an
insanity defense in the cases in this study. In the cases in which
pleas based on PTSD were used, they were no more likely to
succeed than pleas based on any other diagnosis. Defendants
with PTSD-related insanity defenses differed little from other
insanity defendants, contradicting the stereotype of the person
who is driven by PTSD to commit crimes. The data do not support
fears of widespread misuse of the diagnosis of PTSD in connec-
tion with the insanity defense.
BURGESS, A.W. (1983). Rape trauma syndrome. Behavioral
Sciences and the Law, 1, 97-113. Abstracted in PTSD Research
Quarterly, 3, (3) 1992.
FAUST, D. & ZISKIN, J. (1988). The expert witness in psychol-
ogy and psychiatry. Science, 241, 31-35. According to the authors
the involvement of psychologists and psychiatrists within the legal
arena continues to grow rapidly but remains highly controver-
sial. Extensive research on clinical judgment provides a scientific
basis for clarifying the growing disputes about the values of such
professional activities. The authors state that studies show that
professionals often fail to reach reliable or valid conclusions and
that the accuracy of their judgments does not necessarily surpass
that of laypersons, thus raising substantial doubt, according to
Faust and Ziskin, that psychologists or psychiatrists meet legal
standards for expertise. Factors that underlie the research find-
ings and implications for court-room testimony are discussed.
FRAZIER, P. & BORGIDA, E. (1985). Rape trauma syndrome
evidence in court. American Psychologist, 40, 984-993. The authors
state that the use of expert psychological testimony on rape
trauma syndrome in court is a relatively new phenomenon,
although the basic scientific and legal questions that arise in
regard to its admissibility are also associated with the admission
of any type of expert psychological testimony. This article de-
scribes rape trauma syndrome, reviews pertinent case law, and
examines the evidence in light of three criteria for the admission
of expert testimony - scientific status, helpfulness to the jury,
and potential prejudicial impact. Research issues pertaining to
the admissibility of rape trauma syndrome evidence are also
raised.
HOFFMAN, B.F. (1997). Courts and torts: the psychiatrist pre-
paring for trial. Canadian Journal of Psychiatry , 4, 497-501. To outline
how a psychiatric expert can do an impartial assessment and
medicolegal report and then give an effective presentation in court
that can sustain cross-examination. METHODS: The legal prin-
ciples of litigating emotional trauma are reviewed, including prov-
ing causation, characterizing emotional suffering, assessing dis-
ability, and determining a realistic prognosis. RESULTS: Psychia-
trists must understand the interplay of legal and psychiatric
principles when they are asked to assess litigants who are suing
for monetary compensation for a widening range of emotional
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injuries resulting from motor vehicle accidents, slips and falls,
incest and sexual abuse of children, discrimination, unlawful
dismissal, malpractice, human-made disasters, product liability,
and intentional torts, to name a few. CONCLUSION: The psy-
chiatrist can prepare his or her attitude, knowledge, and skills to
give a presentation in court that will be credible, trustworthy, and
dynamic. With adequate preparation, the psychiatric expert can
bring an informed psychiatric perspective to the court that will
have a significant impact on the outcome of the judicial delibera-
tions.
MURPHY, S. (1992). Assisting the jury in understanding
victimization: Expert psychological testimony on battered
woman syndrome and rape trauma syndrome. Columbia Journal
of Law and Social Problems, 25, 277-312. This article proposes a test
for admission of psychological testimony that would enhance
juror understanding of women's experiences, while effectively
limiting value-laden judgments that unduly prejudice juries. Part
II of this Article examines the evidentiary treatment of expert
testimony both prior and subsequent to the adoption of the
Federal Rules of Evidence, and assesses the continuing viability
and value of some older evidentiary doctrines. Part III examines
the insanity defense, the oldest field of psychological expert
testimony, and explores how the law has grappled with scientific
determinations in that area. This section then addresses courts'
experience with psychological testimony on battered woman
syndrome and rape trauma syndrome. Part IV explores the most
recent trend in these cases, and suggests a method of treating
psychological evidence based on that analysis.
PITMAN, R.K. & ORR, S.P. (1993). Psychophysiologic testing
for post-traumatic stress disorder: Forensic psychiatric applica-
tion. Bulletin of the American Academy of Psychiatry and the Law, 21,
37-52. The validity of the PTSD diagnosis is limited by both the
illusory objectivity of the traumatic event and the subjectivity of
the ensuing syndrome. These limitations are especially problem-
atic in the forensic setting. Psychophysiologic measurements
may strengthen PTSD's forensic value by offering a more objec-
tive assessment technique for cases that find their way into the
courtroom. Based upon the results of published research studies
conducted in a range of military and civilian, PTSD and non-
PTSD subjects, psychophysiologic data can provide evidence
helping to establish or refute the presence of the DSM-III-R PTSD
arousal criteria, as well as aid psychiatric experts in estimating
the probability of the disorder's presence in a given claimant.
Psychophysiologic testing should be viewed as one component
of a multimethod forensic psychiatric evaluation for PTSD. It is
likely that it will soon be offered and, given current legal stan-
dards, admitted as evidence in civil and criminal litigation.
PITMAN, R.K., SPARR, L.F., SAUNDERS, L.S., &
MCFARLANE, A.C. (1996). Legal issues in posttraumatic stress
disorder. In B.A. van der Kolk, A.C. McFarlane, & L. Weisaeth
(Eds.), Traumatic stress: The effects of overwhelming experience on
mind, body, and society (pp. 378-397). New York: Guilford Press.
Perhaps more than any other psychological or medical disorder,
post-traumatic stress disorder (PTSD) has influenced, and been
influenced by, the law. Non-psychiatric incentives such as the
prospect of financial gain or avoidance of criminal punishment,
present in all civil and criminal legal systems, have cast a shadow
over the validity of the PTSD diagnosis and delayed its accep-
tance into diagnostic systems in psychiatry. Since this acceptance,
however, PTSD has exerted a dramatic impact on forensic psy-
chiatry and the law. In civil law, the PTSD diagnosis represents
landmark recognition that an external event can serve as the
direct cause of a mental disorder. In criminal trials, PTSD is
unique among mental disorders in its invocation by both pros-
ecution and defense. The dissociative "flashback" experience has
opened a new dimension in insanity and related criminal de-
fenses, insofar as a non-psychotic defendant with PTSD may be
alleged to have briefly lost contact with reality and become
"temporarily insane." The presence of PTSD in a victim may be
cited by the prosecution as "syndrome evidence" supporting the
occurrence of a criminal act such as rape. PTSD is also occasion-
ally invoked as grounds for civil commitment. This chapter
provides an overview and discussion of civil and criminal legal
issues in PTSD. It also discusses forensic psychiatric evaluation
and testimony in this new and rapidly developing area of forensic
psychiatry.
SAVODNIK, I. (1991). The concept of stress in psychiatry.
Western State University Law Review, 19, 175-189. The author
contends that the nature of stress-related diagnoses within psy-
chiatry has taken on enormous proportions in the last decade
considering the large number of worker compensation cases that
continue to be filed. A number of important questions arise
regarding this issue and the answers may provide some surpris-
ing insights into the entire complex of claims, beliefs and expec-
tation on the part of everyone involved. What is stress? What is a
psychiatric disorder? Are psychiatric disorders medical disor-
ders? What is the nature of diagnosis in psychiatry and how does
it differ from diagnosis in the rest of medicine? What is the role of
psychological tests in psychiatric diagnosis? These and other
questions are addressed in this article.
SCRIGNAR, C.B. (1996). Post traumatic stress disorder: Diagnosis,
Treatment, and Legal Issues (3rd ed.). New Orleans: Bruno Press.
This book comprehensively summarizes knowledge about the
epidemiology, etiology, diagnosis, and treatment of PTSD. One
section is devoted to legal issues. Basic information is provided
about how to conduct a forensic evaluation and how to serve as
an expert witness. Separate chapters explore personal injury
litigation and workers' compensation claims. Two additional
chapters address issues related to plaintiffs and to defendants. A
closing chapter presents information about PTSD in criminal
trials. Overall, the book is an excellent single introductory source
for mental health professionals who are preparing to testify about
PTSD in a legal setting. [PPS]
SIMON, R.I. (Ed.) (1995). Posttraumatic stress disorder in litiga-
tion: Guidelines for forensic assessment. Washington: American
Psychiatric Press. The articles presented in this book stem from a
standards development conference on the forensic assessment of
claimants. One chapter discusses new research and its implica-
tions for the diagnosis of PTSD. Another chapter elaborates on the
development of guidelines for the forensic psychiatric examina-
tion of the PTSD claimant. A related chapter sets out standards for
the evaluation of malingering in PTSD and provides indicators of
genuine and malingered PTSD. Guidelines for the examination of
PTSD in children also are provided. These and other issues are
richly discussed in this publication. This book will be of much
interest to a multidisciplinary audience. [Adapted from Text]
SLOVENKO, R. (1994). Legal aspects of post-traumatic stress
disorder. Psychiatric Clinics of North America, 17, 439-446. The
legal requirements for compensable injury in civil law gradually
have loosened over the years from the physical effects of direct
injury to include the emotional effects of direct injury, the emotional
effects of witnessing injury to others, the emotional effects of
knowing of injury to others, and a person's fear that he or she may
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become ill at a later date. Although a psychiatric diagnosis is not
required to bring action, post-traumatic stress disorder (PTSD) has
become the favored diagnosis in cases of emotional distress. Also,
in criminal law, defenses based on PTSD have become increasingly
common, being used as the standard defense in selected situations.
The limits of the use of PTSD as a defense remain to be clarified;
differing judgments have been made in similar cases by different
courts.
SPARR, L. F. (1996). Mental defenses and posttraumatic stress
disorder: Assessment of criminal intent. Journal of Traumatic Stress,
9, 405-425. The author declares that since its formal introduction
into psychiatric nomenclature more than a decade ago, the diagno-
sis of PTSD has become firmly entrenched in the legal landscape. In
part, this is because PTSD seems easy to understand. It is one of only
a few mental disorders for which the psychiatric Diagnostic and
Statistical Manual (DSM) describes a known cause. Since the diag-
nosis is usually based on patients' self-report, however, it creates
the possibility of distortion aimed at avoidance of criminal punish-
ment, and, as a result, has achieved mixed success as a criminal
defense. When providing expert testimony, mental health wit-
nesses must take care to distinguish between mere PTSD and a
causal connection between PTSD and the criminal act in question.
PTSD has not only been used to abrogate or diminish responsibility,
but also to arrange pre-trial plea bargaining agreements or play a
role in sentencing determinations. The author explores various
uses and potential abuses of PTSD in criminal jurisprudence and
offers suggestions regarding retrospective PTSD assessment.
SPARR, L.F. (1995). Post-traumatic stress disorder: Does it exist?
Neurologic Clinics, 13, 413-429. The author notes it is easy for
lawyers, lay people, and psychiatrist alike to confuse legal notions
of mental disability ("stress" cases) that confer eligibility for mon-
etary benefit with the DSM-III-R psychiatric disorder, PTSD. This
is because the lay-legal concept of stress borrows heavily from the
psychiatric concept, which isolates and identifies a specific event
(stressor) and an emotional reaction or series of reactions (symp-
toms) related to that event. Some observers, however, note that
many policies underlining the provision of monetary benefits are
independent of, and sometimes opposed to, therapeutic and re-
search purposes of a medical diagnosis. In many legal cases,
especially in those involving workers' compensation litigation, the
decision as to whether or not a particular stress is detrimental is
determined on moral or ethical grounds. For example, if an indi-
vidual can establish that he or she was treated unfairly, then it is
argued that the experience was stressful and psychiatrically harm-
ful. Even some psychiatrists who conduct disability examinations
may endorse this idea by ignoring requisite criteria and regarding
any emotional disturbance that follows an untoward external event
as tantamount to PTSD. The author observes that the fact that stress
is not a moral or ethical term and has no inherent moral meaning is
often obscured in legal debate.
SPARR, L.F. & ATKINSON, R.M. (1986). Posttraumatic stress
disorder as an insanity defense: medicolegal quicksand. Ameri-
can Journal of Psychiatry, 143, 608-613. The authors note a growing
awareness of PTSD has led to recent use of the disorder as a legal
defense against criminal responsibility for both violent and nonvio-
lent crimes. Diagnosis of PTSD is difficult because the symptoms
are mostly subjective, often nonspecific, usually well publicized,
and, therefore, relatively easy to imitate. Accurate psychiatric
testimony in such cases requires diligent searching for collateral
sources of information. The authors argue that the insanity defense
is appropriate only in the rare instance that a dissociative episode
related to PTSD directly leads to criminal activity.
SPARR, L.F. & BOEHNLEIN, J.K. (1990). Posttraumatic stress
disorder in tort actions: forensic minefield. Bulletin of the American
Academy of Psychiatry and the Law, 18, 283-302. The authors discuss
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 psy-
chiatric expert witnesses has increased because courts have gradu-
ally 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 counter-
point to the "hysterical invective" that often greets psychiatric
testimony.
SPAULDING, W.J. (1988). Compensation for mental disability.
In J.O. Cavenar (Ed.), Psychiatry (Vol. 3, pp. 1-27). Philadelphia:
Lippincott. The author states that mental disability, by definition, is
a disadvantage but it also is a legal basis for compensation intended
to mitigate that disadvantage. This chapter examines the three
principal systems for compensating mental disability: tort dam-
ages for psychic trauma injuries, worker's compensation awards
for occupational stress, and Social Security disability benefits based
on mental impairments. While worker's compensation grew out of
the tort remedy, and Social Security disability benefits grew out of
worker's compensation, all three forms of compensations have
undergone parallel changes with respect to mental disability. In all
three systems mental disability claims have become both more
numerous and more readily accepted.
STONE, A.A. (1993). Post-traumatic stress disorder and the law:
Critical review of the new frontier. Bulletin of the American Academy
of Psychiatry and the Law, 21, 23-36. Since its debut in the psychiatric
nomenclature in 1980, post-traumatic stress disorder (PTSD) has
had a dramatic impact on criminal and civil jurisprudence. PTSD
has created a cottage industry among both criminal and negligence
attorneys and mental health practitioners. The diagnosis first
achieved public notoriety when it was introduced as a new basis for
the insanity defense. More recently "syndrome evidence" of the
subtypes and variations of PTSD has encroached on the substantive
criminal law of self-defense. In addition, the diagnosis may have an
impact on such traditionally legal and factual determinations as the
credibility of witnesses and may undermine conservative tort
doctrine that attempts to cabin psychic injury. The emerging legal
area of victims' rights has been strengthened and paradoxically
divided by PTSD. Yet the newly defined disorder of PTSD has not
borne such a heavy forensic burden easily. Indeed the diagnosis
poses for psychiatry some of the very problems it supposedly
solves for legal purposes, including the illusory objectivity of the
causative traumatic event and the expert's dependence upon the
victim's subjective and unverifiable reports of symptomatology for
the diagnosis.
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ADDITIONAL CITATIONS
Annotated by the Editors
American Psychiatric Association resource document on peer
review of expert testimony (1997). Journal of the American
Academy of Psychiatry and the Law, 25, 359-373.
Describes the problems of how psychiatrists who provide expert
testimony are perceived in popular, medical, and legal domains.
Criticisms center around lack of competence and ethical miscon-
duct. Voluntary peer review of testimony is recommended as a
possible solution, and suggestions are made for implementa-
tion.
APPELBAUM, P.S. (1997). A theory of ethics for forensic
psychiatry. Journal of the American Academy of Psychiatry and
the Law, 25, 233-247.
This article offers a justification for a set of principles that
constitute the ethical underpinnings of forensic psychiatry. The
two principles on which that effort rests are truth-telling and
respect for persons. Psychiatrists cannot simply rely on general
medical ethics, embedded as they are in the doctor-patient
relationship - which is absent in the forensic setting.
DUTTON, M.A., GOODMAN, L.A. (1994). Posttraumatic
stress disorder among battered women: Analysis of legal
implications. Behavioral Sciences and the Law, 12, 215-234.
Demonstrates that the diagnosis of PTSD has recently been
applied to the psychological experiences of victims of intimate
violence, including physical and sexual assault. The use of
trauma theory to explain battered women's responses to vio-
lence has laid a foundation for expert testimony on PTSD. This
article discusses the relevance of the PTSD diagnosis within the
legal context for explaining battered women's responses to
violence.
HOFFMAN, B.F., ROCHON, J.P., & TERRY, J.A. (1992). The
emotional consequences of personal injury: A handbook for psychia-
trists and lawyers. Toronto: Butterworth.
Assessed 400 litigants who were suing for emotional damages
due to motor vehicle accidents and other forms of civilian
trauma. Approximately 70% had evidence of continuing physi-
cal injuries to account for some of the physical and emotional
symptoms. The most common DSM-III-R diagnoses were psy-
chiatric condition affecting physical illness (50%), major depres-
sion (24%), somatoform disorder (11%), and PTSD (8%).
LEES-HALEY, P.R. (1986). Pseudo post-traumatic stress disor-
der. Trial Diplomacy Journal, 9, 17-20.
Argues that some trauma victims are inappropriately diag-
nosed as having PTSD when they actually have "pseudo-PTSD,"
a condition the author proposes is caused by factors that are
unrelated to the original trauma. These factors include personal
characteristics, post-traumatic life events, and treatments in-
tended to alleviate PTSD symptoms.
MARWICK, C. (1993). What constitutes an expert witness?
Journal of the American Medical Association, 269, 2057.
Reviews antecedents of a landmark civil case seeking to keep
"junk science" from influencing deliberations on a variety of
vital matters in the nation's courtrooms. He shows how the
American Medical Association and its journal, JAMA, have each
joined with several other scientific groups in filing amicus curiae
briefs as the US Supreme Court considers the case of Daubert v
Merrill Dow Pharmaceuticals Inc. The questions are: When is
expert scientific testimony to be allowed in court to be heard and
weighed by a jury? When and on what grounds is it to be ruled
out? For the first time, the Court will try to define criteria judges
should use to decide on admitting testimony by expert wit-
nesses.
RAIFMAN, L.J. (1983). Problems of diagnosis and legal cau-
sation in courtroom use of post-traumatic stress disorder.
Behavioral Sciences and the Law, 1, 115-130.
Reviews issues in the forensic use of the PTSD diagnosis, includ-
ing prior vulnerability, stressor identification, symptom assess-
ment, intervening posttraumatic factors, and criminal responsi-
bility. Although some of the author's concerns about validity
have been addressed in the 15 years since the article was pub-
lished, this is a good introductory source for learning about the
forensic application of PTSD.
STEINBERG, C.E. (1993). The Daubert decision: An update
on the Frye rule. Newsletter of the American Academy of Psychiatry
and the Law, 8, 66-69.
Briefly describes the background and content of a Supreme
Court decision regarding the presentation of expert scientific
testimony in court. The new, more liberal, decision is based on
the Federal Rules of Evidence and allows expert testimony that
is not "generally accepted": "if scientific, technical, or other
specialized knowledge will assist the trier of fact to understand
the evidence or to determine a fact in issue, a witness qualified
as an expert by knowledge, skill, experience, training, or
education, may testify thereto in the form of an opinion or
otherwise."
VA Cooperative Study #420:
Group Treatment of PTSD
Paula P. Schnurr, Ph.D.
VA National Center for PTSD and
Dartmouth Medical School
In 1995, Dr. Matt Friedman and I received approval from
the VA Cooperative Studies program to conduct a multisite
randomized clinical trial of group psychotherapy for treat-
ing PTSD in male Vietnam veterans, VA Cooperative Study
(CS) #420. Treatment research has been an ongoing activity
at the National Center for PTSD since we opened in 1989.
In 1993, we began discussing using our resources to plan a
large-scale PTSD treatment study because we felt that a
multisite study would be needed in order to have a suffi-
cient number of participants. Late in 1993 we submitted a
planning request to the VA Cooperative Studies Program
and were fortunate to receive the Program's support in
planning a trial. We officially submitted a proposal in the
summer of 1995 and were notified of approval in Novem-
ber of that year. Funding began in 1996. We are now
enrolling the second of the three cohorts of men we plan to
run in the study.
The planning process was made exciting and enjoyable
by the strength of the team that designed and implemented
the study. Matt and I were able to assemble a group of
experts who have great research and clinical experience in
both PTSD and multisite trials. Dr. David Foy led a team
that developed Trauma Focus Group Therapy. TFGT is
intended to capitalize on the group for support in helping
the veteran get through the exposure work. Each partici-
Prev Page 7 Next
pant receives two in-group exposure sessions, which are
audiotaped, and is asked to do at least 8 additional exposures
as part of the weekly homework that is assigned throughout
treatment. TFGT also includes relapse prevention training
for PTSD symptoms, anger management, psychoeducation,
and coping skills training. Tracie Shea was charged with the
task of developing a non-trauma-focused group therapy that
would control for the nonspecifics of therapy so that we
could attribute any observed effectiveness of trauma-fo-
cused therapy to its active ingredients. The comparison
therapy also had to be credible to both patients and thera-
pists. Looking to what was being delivered in VA, it was clear
that dealing with current social problems was the single most
common activity, and so Tracie and her team developed
Present Centered Group Therapy (PCGT) to focus on current
interpersonal problems while avoiding trauma processing.
In addition to Drs. Foy and Shea, people who contributed
significantly to the planning process included Drs. Terry
Keane, Charlie Marmar, Daniel Weiss, Bruce Rounsaville,
Phil Lavori, Frank Hsieh, Bob Rosenheck, and Ray Scurfield,
as well as Mr. Fred Gusman. Drs. Shirley Glynn, Melissa
Wattenberg, Beth Stamm, and Joe Ruzek, along with Ms.
Sherry Riney and Mr. Joe Rudolph, contributed to the imple-
mentation. Matt and I think they have helped us design a
treatment that is appropriate for VA patients in the context of
the VA system.
CS #420 is a randomized clinical trial designed to assess the
efficacy of TFGT, relative to PCGT, for treating war-zone-
related PTSD in male Vietnam veteran outpatients. TFGT
and PCGT treatment are delivered in weekly group therapy
sessions for 30 weeks according the manuals first-authored
by David Foy and Tracie Shea, respectively. All sessions last
1.5-hours, except for exposure sessions, which last 2 hours.
Monthly 1.5-hr group booster sessions are delivered for the
5 months following active treatment; 15-minute booster
phone calls also are delivered monthly during this period for
the TFGT condition. All participants receive case manage-
ment throughout the study.
Participants are 360 male veterans with PTSD due to
service in the Vietnam theater. These men were targeted
because they represent 90% of the veterans who receive
PTSD treatment in the VA. Interviewers who are blind to
participants' treatment condition perform assessments at
study entry, the end of treatment (7 months), and the end of
booster sessions (12 months). In addition, two-thirds of
participants will be assessed at 18 months and one-third will
be assessed at 24 months following study entry. Participants
complete self-reported questionnaires monthly during the 7
months of active treatment.
Four domains are being assessed: (a) psychological factors,
including PTSD, substance abuse, and distress; (b) psychoso-
cial function, including an individual's work status, marital
functioning, social/interpersonal functioning, legal status,
and quality of life; (c) self-reported physical health status;
and (d) utilization of physical and mental health services.
PTSD symptom severity as measured on the National Center
for PTSD's Clinician Administered PTSD Scale is the pri-
mary outcome measure.
The group-based design creates significant challenges
because it delays treatment for subjects who have been
admitted to the study. Since both TFGT and PCGT are
group rather than individual therapies, it is necessary at
each study site to accrue 12 subjects for a cohort before
treatment can begin. The 12 subjects are then randomized
to either TFGT (N = 6) or PCGT (N = 6). There will be three
cohorts per site. Each successive cohort begins active treat-
ment one month after the preceding cohort has begun
booster sessions.
Two therapists lead each group. To participate in the
study, therapists had to be masters- or doctoral-level clini-
cians with prior experience in treating PTSD in a group
format. We did not require them to have formal training in
exposure techniques, or even cognitive-behavioral therapy.
Our approach to handling the problem of therapist effects,
which often comes up in psychotherapy research, was to
randomize therapists. We plan to examine how therapist
preferences and expertise, as well as protocol adherence,
relate to participants' outcomes. All sessions are video-
taped, and supervision based on the tapes is provided by
Dr. Shirley Glynn at the West Los Angeles VA (TFGT) and
Dr. Melissa Wattenberg at the Boston VA Outpatient Clinic
(PCGT). Drs. Charlie Marmar and Daniel Weiss also are
rating adherence according to a protocol developed by a
team led by Dr. Bruce Rounsaville.
Case management is delivered according to a manual
developed by Dr. Beth Stamm and colleagues. Case man-
agement serves as a point of individual contact for each
participant so that adequate monitoring of clinical status is
ensured and assistance with additional services that may
be needed (e.g., medical, legal, financial) is provided. Dr.
Phil Massad at the White River Junction VA supervises the
20 case managers.
Ten VA sites across the country were chosen to partici-
pate in the study: Boston, Providence, West Haven, Miami,
New Orleans, Minneapolis, Seattle, San Francisco, Menlo
Park/San Jose, and San Diego. Dr. Stamm coordinates the
study for us. She is assisted in this enormous task by Joe
Rudolph.
To our knowledge, CS #420 is one of the largest psycho-
therapy studies that the VA has ever funded. A large and
complicated study like CS #420 could not be planned or
run in any cost-effective manner without the support of the
research infrastructure provided by the program. Data
collection is targeted to finish early in the year 2000. We are
looking forward to learning the results of our study and
share our findings with others at that time.
Prev Page 8 Next
PILOTS UPDATE
It has been more than three years since we last updated the
PILOTS Database User's Guide, and there have been a lot of
changes in the database since then. The PILOTS database is
no longer part of the Combined Health Information Data-
base. The Dartmouth College Library Online System
(DCLOS), which replaced CHID as the principal means of
access to PILOTS, offered a quick and supple command-
driven approach to searching our database. While it is still the
best interface to the database for those performing complex
searches, those whose information needs are not so complex
can choose to use the graphic interface provided by the
Dartmouth College Information System (DCIS). Both DCLOS
and DCIS are now available to users of the World Wide Web,
with access and instructions provided at the National Center's
Web site.
The existence of the World Wide Web, and the rapidly-
changing environment in which the PILOTS database-like
all other information products and services-exists, requires
us to rethink our plans for future editions of the PILOTS
Database User's Guide. Printed publications are expensive to
produce and distribute, and become obsolete very rapidly. It
is difficult to estimate the quantity that will be needed, and
cumbersome to store excess copies. Although we shall pro-
duce a printed version of the new User's Guide, we do not
intend to print more copies than will be needed for an initial
distribution to National Center staff members, VA medical
libraries, Vet Centers, and specialized VA PTSD treatment
programs.
We shall turn to the National Technical Information Ser-
vice (NTIS) for public distribution of the printed User's Guide.
NTIS will keep a single master copy, producing copies in
microfiche or xerographic form as needed. These will be
available for purchase from NTIS.
We shall also offer an alternative form of print-on-de-
mand distribution, free of charge. We intend to produce
the PILOTS Database User's Guide in portable document
format (PDF), which may be viewed on our Web site or
downloaded from it. Like other PDF documents on our
Web site-including this and other issues of the PTSD
Research Quarterly-it will be an exact replica of the original
printed document. To read it on a computer monitor, or to
print it on a PostScript printer, a copy of the Adobe Acrobat
Reader is needed. (This software program is widely avail-
able, free of charge, in versions for almost every computer
platform. For those who have not got it already, our Web
site offers a link to the publisher's site from which it can be
downloaded.) And for those whose computers or termi-
nals will not support PDF documents, we shall post a plain-
text (ASCII ) version as well.
We shall continue to maintain a hypertext version of the
User's Guide on our Web site, which can be revised whenever
changing Internet conditions or new database features make
it appropriate to do so. The biggest change will be the
inclusion of the entire Thesaurus-the annotated list of de-
scriptors used in searching the database for material on a
specific subject. The hierarchical listing of descriptors is a
table of the terms we use to describe the subject content of
each publication we index, arranged to show the relation-
ships between broader and narrower terms. The alphabetical
index explains the way that the PILOTS database uses each
descriptor, and provides extensive cross references from the
terms a user might have in mind to the appropriate descrip-
tors. Thus those users who depend on our Web site for
instructions on using the database will have access to the
same help in planning their searches as those who have got
the printed User's Guide.
These plans are subject to change, either in response to
changes in the Internet environment or as a result of feedback
from readers of this column and other users of the PILOTS
database. We shall be working on the new User's Guide
during the next several months; the sooner we receive any
comments or suggestions, the better chance they have of
influencing the outcome of our work.
Even before the new User's Guide is completed, we have
begun to implement the changes in the PILOTS Thesaurus
that we described in our last "PILOTS Update" column. We
have posted a new hierarchical listing of descriptors on our
Web site, and we invite you to download a copy to replace the
listing on pp. 29-45 of the PILOTS Database User's Guide, 2d
edition.
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