Competency to make or change a will
Competency to serve as a witness in a trial
Competency to comply with a necessary medical procedure
Competency to function as a custodial parent
Competency to consent in sexual intercourse
Mental capacity for criminal intent
Evaluations for post-traumatic stress disorder

The psychiatrist is not a trier of fact, but an actual link in fact-finding process. The psychiatrist works at the borderline between psychiatry and law, integrating the two perspectives and presenting conclusions in a comprehensive, persuasive and scientific manner. A forensic psychiatrist should be able to tell a story, helping a trier of fact to subject to scrutiny what others may take to be self-evident, through consideration of alternate lines of psychiatric exploration and reasoning.

Post-Traumatic Stress Disorder
In lay terms, PTSD is defined in the 2003 Webster’s New World Medical Dictionary as:
A common anxiety disorder that develops after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened. Family members of victims also can develop the disorder. PTSD can occur in people of any age, including children and adolescents. More than twice as many women as men experience PTSD following exposure to trauma. Depression, alcohol or other substance abuse or other anxiety disorders frequently co-occur with PTSD.

PTSD is a seldom recognize by laypersons, but is often concurrent with personal injury. Patients often undergo test after test and take medications that often do not improve their condition. These sufferers sometimes have surgery that does not heal their pain. Eventually, many individuals with PTSD start feeling neglected because physicians and even attorneys truly do not know what to do with them.

An attorney who represents a physically injured individual should consider whether the client possibly suffer from PTSD as well. Accordingly, a psychiatric evaluation might be in order. By understanding the full dimension of a client’s trauma-psychological as well as physical-an attorney can address the situation as well. PTSD broadens the range of vision of the patient’s injuries.

Depressive and anxiety symptoms are components of PTSD. An accident may trigger a cycle of depression, and often a victim’s mind becomes totally immersed in mishap and pain. There is no more order to live. The patient may become moody, grouchy, dependant, scared and disoriented.

Not all people who experience trauma need psychiatric treatment. Indeed, with the help of family and friends many patients can move on and get better without psychiatric intervention. Other individuals, however, need professional help to recover and move in a positive direction.

It is not the severity of an accident that determines whether one develops PTSD; rather, it is the meaning the person attaches to the experience. It is impossible to determine in advance whether an individual will absorb the psychological effects of the trauma and move on with life without the necessity of psychiatric intervention.

Many PTSD patients have difficulty talking about their trauma, which makes it harder to detect. Sufferers also have repeated episodes in which they re-experience the traumatic event. They might have trouble concentrating because of this situation. They may lose interest in activities and become socially withdrawn.

Often, people with PTSD avoid daily situations that remind them of the injury-causing incident. Irritability, sleep disservices and restlessness are also aspects of this disorder.

An attorney may refer a client to a neurologist or orthopedic far less often there is a referral for a psychiatric consultation and treatment, as indicated.

Despite the potential severity of PTSD, the disorder is treatable, and the results are better if the symptoms are approached early on by a psychiatric expert.

The goal in treatment is to help a patient recover to a pre-morbid level of functioning by working through the trauma and pain, and to resolve the resulting grief. Psychotherapy may be necessary, and may focus on helping a patient examine his or her particular style of dealing with a stressful situation and how the present traumatic event impacted on it. The psychiatric expert may also work to build self-esteem and self-control in the patient, and develop accountability, integrity and pride. Medication may be warranted to help control and alleviate symptoms.

Treatment aims at helping the patient find new and adoptive solutions to the affliction. There is a colossal challenge to the physician (as well as friends, relatives and co-workers of the patient) to understand the chronic neuropathic pain that may occur in the wake of a serious injury. A huge difference between the intensity of the pain felt (the symptom) and the physical manifestation of the injury (the sign) may often widen the distance between the pain sufferer and the observer.

Perhaps more than any other psychiatric disorder, PTSD has influenced and has been influenced by the law. In civil law, the PTSD diagnosis illustrates landmark admission that an external event can serve as a direct cause of a mental disorder. In criminal law, PTSD is unique among other mental disorders in its implication by both the prosecution and the defense. PTSD has been officially used since 1998, when introduced in the diagnostic and statistical manual of mental disorders (DSM-III). At that point, PTSD became a bona fide psychiatric disorder.

Sample of Benefits of Forensic PTSD Evaluation
For illustrative purposes, the following is an example of how an objective PTSD analysis effectively assisted a victim in litigation.

A 28- year old mentally challenged individual who was returning from her weekly workshop meeting was raped by a maintenance worker in the elevator of the building where she lived with her mother. Approximately two weeks later, the victim disclosed the assault to her elderly and fragile mother. There was no physical evidence of the sexual attack itself, other than the victim not being a virgin when in all prior gynecological exams (due to endocrinological deficiency) she appeared not to have had sexual intercourse.

The case for her attorney surfaced as somewhat muddled, since the victim was not all that vocal; hence, she seemed to be calm, young, attractive, well mannered, and above all, doing well. A psychiatrist examined her and came to the conclusion that everything psychologically wrong with her was due to her mental retardation, and that the victim had otherwise recovered from the rape. The victim had said that she would like to go back to the workshop where she had been going for years, performing repetitive chores gluing small boxes together. Her social life involved two fellow female workers. After the rape, she interrupted the attendance, received some therapy and then resumed work. Months later the victim permanently ceased working. Because of her weakness her mother could no longer escort her downstairs to the van and greet her in the street at the end of the day. A review of all existing records, including medical, gynecological, psychiatric, and deposition transcript, gave a sense of the victim being afflicted by the sexual attack. Her earlier responses of taking frequent showers and becoming restless and aloof gave way, some eight months later, to her resuming attendance at her workshop, until her mother put an end to this routine. The victim’s life again changed dramatically.

Using an audiotape interview (also of the mother and sister) the author was able to memorialize the responses, which contradicted the bases for the opinion of the previous psychiatrist who examined her. Taking into consideration the limits imposed by her mental retardation, her mental status exam revealed signs and symptoms commonly seen in individuals subjected to extremely dangerous and humiliating life experiences.

The victim appeared to be a truthful and accurate informant. She did not appear to be fabricating any of her history. Her ability to recall and concentrate, and her logical thinking, was adequate as well, in contrast to what the other psychiatric had found. The author was of the opinion that the victim had been and was currently affected by the event. It was central to point out that mental retardation is not a psychiatric illness, and that the victim had been living to her fullest intellectual potential and was emotionally well adapted and in touch. Her sexuality and sense of femininity were not hindered by mental retardation, but by the sexual attack she endured. Routine activities and predictability of her surroundings were essential to maintain mental stability.

It was documented that her mother had been her coach from the age of five. In fact, because of her teaching the victim her mother was hired to work for the Cerebral Palsy Association. Her mother was totally invested in the safety and wellbeing of the victim. The victim dealt with the trauma in the best way she knew how-by not talking about it, by hiding rape from others and her-self. Her responses were those typically seen in individuals subjected to submit by force, including the threat of imminent death. Describing the special bond the victim and her mother had was crucial.

Her mother successfully invested long and laborious years loving, educating and protecting her daughter. In the process, a symbiotic relationship developed between them. Her mother kept the victim free of danger. The rape affected her mother almost as much as it affected her. They both mentally regressed and the functional capacity of the mother that fueled that of the victim weakened and neither felt safe any longer, and the victim became reclusive, wrecking her personal, social and occupational life. By describing in full the significance of the mother-daughter unique relationship, the attorney was able to turn around what started out as a weak case and explain how what happened to the victim severely compromised current and future functional capacity.

The Problem of Feigned or False PTSD
The expert’s job during the psychiatric legal investigation is to confront the presence or absence of signs (objective findings), and thus corroborate or refute the diagnosis of PTSD. The possibility of PTSD being feigned (malingered) must always be considered. Since the specific criteria of PTSD is easily accessible to any interested person, it would not be too difficult for him or her to report the symptoms the examiners looks for, thus challenging the forensic psychiatrist to produce data that will withstand scientific and legal scrutiny.

Few personal injury cases reach the courts without an expressed or implied allegation of malingering, having as primary motivation financial gain and then sympathy and social support. Malingering is listed in the DSM-IV-TR (fourth edition, text revision) as a condition not attributable to a mental disorder, which may become the focus of clinical attention. It is the “intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as financial compensation.” It is described in two varieties, pure and partial. The former relates to the feigning of disease when it does not exist at all. The latter is the conscious exaggeration of existing symptoms, or the fraudulent allegation that prior genuine symptoms are still present.

No other syndrome is as easily defined, yet so difficult to diagnose as malingering. Pure malingering is uncommon in PTSD cases, but exaggeration of symptoms is not. In addition, the term false imputation refers to ascribing actual symptoms to a cause consciously recognized as having no relationship to the symptoms. For example, the presence of authentic psychiatric symptoms due to clearly defined stresses during the Vietnam War may be falsely attributed to a traumatic event such as a car collision, in order to gain compensation. Another example would be a stressful marital disharmony predating a traumatic event at work, as being consciously designated as emanating from the work issue.

Traditionally, there are two main situations in which the diagnosis of malingering can be confirmed with certainty, when these persons think they are unobserved and are caught in the act and when they actually confess they are faking. A crucial third option, and the one that sheds the most light in an examination, consists of the thorough collection of collateral data, including any prior medical/psychiatric records, and complete progress notes of the therapist, rather than the summary letters. If the clinician possesses more factual information about the case than the claimant believes, it helps the examiner to asses the claimant’s veracity.

It is important to spend time studying the mind of the claimant. Only by assessing how his or her mental apparatus handled past events in general, traumatic and otherwise, are we able to elucidate the character logical makeup, and thus the style of the response that the claimant uses, how adaptive or maladaptive it has been in the past and how it was applied in the present situation.

One has to be quiet versed in what PTSD is to be able to differentiate it from what it is not. Experienced clinicians recognize that there is a large degree of variability among individuals presenting with similar types of problems. The use of psychometric inventories (psychological) to assess psychopathology depends greatly on the honest, accuracy and consistency of self reports. There may be motivation to distort the responses by either exaggerating or minimizing problem areas. MMPI (one of the psychological testing instruments commonly used) is not useful for faked PTSD. In general, they are not as conclusive, reliable, valid and specific as we need them to be.

The administration of sodium amytal has proven not to be fully reliable in unmasking malingering. Hypnosis does not guarantee truth either. Voice stress analyzer is not more accurate than polygraphs. Someone who suffered a personal injury may be motivated to exaggerate and magnify the severity of impairment to gain a higher monetary award or compensation. They may seek financial gain from social security disability, veteran’s benefits, workers’ compensation or damage for alleged psychological injury.

Malingers may seek to avoid conscription into the military, to be relieved from undesirable military assignments or to avoid combat. The defendant in a murder trial might be prone to feign mental illness in an attempt to gain an acquittal by reason of insanity. The parent in a child custody dispute may be prone to give an unrealistic favorable presentation in order to gain custody of the child. The criminal may seek to avoid punishment by pretending to be incompetent to stand trial, insane at the time of the act, worthy of mitigation of penalty or too ill (incompetent) to be executed, and many other situations.

The law is interested only in that which can reasonably be established by facts. Psychic disorder that occurred after a trauma include PTSD, malingering, depressive disorder, anxiety disorders, conversion disorders, post concussion disorder and psychosis. All malingers are actors who portray their illness as they understand it. There are many characteristics that help the experts tease out real PTSD from non-real, aside from the categories described in the DSM. Persons who have had true PTSD may exaggerate their symptoms or allege that symptoms persist when they no longer do. These are most difficult cases to accurately assess, because by having been experienced before, it may not be all that difficult for some to call forth the remembered symptoms and apply them to this new occurrence.

The better the expert understands the phenomenology of PTSD-meaning the formal description of the component features defining this disorder-and the dynamic forces that predispose, determine, trigger , and fuel its presence and evolution, the easier it will be for the examiner to detect faked symptoms. It consists of conducting the study of whether and how these specific symptoms form and interact within the entire personality organization of the individual in question. To conclude feigning, the examiner must look beyond general credibility issues, into the character logical aspects (personality structure) of the examinee to potentially detect a great many inconsistencies.

Summary
Forensic psychiatrists can assist attorneys and courts in a very meaningful way in determining whether an individual suffers from PTSD, as a result of a specific incident, and the consequences of PTSD on that individual’s life in medical probability.

Alberto M. Goldwaser, MD, DFAPA,
Is president of the Forensic Psychiatric Association, with offices in Paramus and West New York. He is a clinical assistant professor of Psychiatric at New York University School of Medicine.