SUMMARY: After Motor Vehicle Accidents (MVA), adults, children and their parents commonly suffer from Post Traumatic Stress Disorder but most are not diagnosed. Acute Stress Disorder, Major Depression, specific Phobia about travel and general Anxiety are individually less common but also generally undiagnosed. A template is suggested for routine psychiatric IME of MVA claimants.
Clinical research studies that are prospective (follow the outcome of a sample of all MVA victims) are consistent that psychological injury is grossly under-diagnosed.
There is considerable overlap among psychiatric conditions following MVA, and at least a third of consecutive Emergency Room attenders suffer persistent psychological injury1.
Post Traumatic Stress Disorder
Post Traumatic Stress Stress Disorder (PTSD) is the commonest psychological injury following MVA.
Between 20% and 25% of consecutive Emergency Room (ER) attenders shortly after a MVA fulfilled Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria for PTSD within the first year2.
About half that number proved to be chronic3 at 3 years1.
Practice PointFactors in Chronic PTSD after MVA:1. Trauma severity 2. Perceived threat 3. “Dissociation” during MVA 4. Female 5. Prior emotional problems 6. Litigation |
Similar proportions of children involved in MVA were diagnosed in an unrelated study4, and 15% of their parents suffered diagnostic PTSD.
More than half the children suffered some symptoms of PTSD, particularly avoiding behaviours5.
However, fewer than half the parents sought psychological help for the affected children, and even fewer consulted for themselves6.
Among adult MVA victims, half the PTSD sufferers had had a previous episode of Major Depression (“thin skull”)2.
Those who have suffered Mild Traumatic Brain Injury in a MVA have more evident post-concussive symptoms if they also develop PTSD6.
Practice PointThe client with prominent Post Concussive symptoms after MVA should be checked for Post Traumatic Stress Disorder |
Acute Stress Disorder, Major Depression, specific Phobia about travel and general Anxiety are individually less common but also generally undiagnosed.
Acute Stress Disorder
This condition, newly recognised in DSM-IV, is only half as common as PTSD but its occurrence at 1 month is highly predictive of PTSD at 6 months following MVA7.
ASD is determined by the victim’s perception and immediate reaction rather than the severity of the MVA 8.
Major Depression
More than half of those who suffer PTSD after MVA also fulfil criteria for Major Depression2.
Although less common than PTSD, it is often unrecognised and may be severe9.
Major Depression, both chronic and untreated, is a common finding during psychiatric medicolegal assessment.
Specific Phobia about Travel
Phobic avoidance, without the intrusive thoughts that are necessary for diagnosis of PTSD, is also very common 10.
There may be disabling avoidance of driving, being driven and of any circumstances that recall the MVA.
In more severe cases, the anxiety may generalise to other forms of transportation and/or travel by other family members.
General Anxiety
As with PTSD, general Anxiety is commoner in women than in men9.
A pre-accident tendency to worry predicts occurrence of the disorder, and it is particularly prevalent after 2 closely spaced MVAs.
It is unclear why some people develop generalAnxiety rather than specific Phobia about travel.
MEDICO-LEGAL IMPLICATIONS
A template is suggested for routine psychiatric IME of MVA claimants.
Because psychological injury occurs in at least a third of all victims of MVA, psychiatric IME should be a standard component of trial preparation for all clients with symptoms that appear to be unexplained or excessive.
The traditional, open-ended psychiatric IME commonly fails to address all the important medico-legal issues.
The psychiatrist should be first asked whether s/he is prepared to structure the report around a template such as the following.
Practice PointBecause psychological injury is grossly underdiagnosed, claimants for Personal Injury following a MVA should routinely undergo psychiatric IME that includes questions based on the following template: |
1. To what extent did or does the client fulfil the DSM-IV criteria for each and every one of the following conditions: Acute Stress Disorder, Post Traumatic Stress Disorder, Major Depression, Anxiety Disorder, Somatoform Disorder, Malingering, any other psychological conditions?
2. For any and all conditions for which the client fulfilled or fulfils all DSM-IV criteria for diagnosis, provide
1. an outline of state-of-the-art treatment, and
2. an Evidence-Based detailed estimate of the probable outcome in this client if such treatment is made available.
3. Based on both your examination and the contemporaneous pre- and post-accident clinical records, would all or any of the psychological conditions that you have diagnosed have occurred in the absence of the Motor Vehicle Accident?
Copyright © 2003 Electronic Handbook of Legal Medicine