Session Abstract: The presenters in this symposium will describe an evidence-based, multi-method approach to the evaluation of PTSD in psychological injury evaluations. Each presenter will describe the strengths and limitations of one method for testing rival hypotheses about the presence or absence of PTSD. Following a didactic presentation, each presenter will provide clinical data for the audience to consider. Combining didactic presentation with a problem-based learning approach, the presenters will engage the audience in considering what constitutes evidence for and against PTSD in personal injury evaluations.
The first presenter will provide data from an open-ended interview and the Clinician Administered PTSD scale-5. The second presenter will discuss the data from the MMPI-2 and MMPI-3. The third presenter will discuss the data from the Rorschach Performance Assessment System.
The presenters will utilize a problem-based learning approach in which data is presented to the audience without the presenter drawing ultimate conclusions about the presence or absence of PTSD. Instead of a discussant, the presenters will engage the audience to considering the evidence, emphasizing the reasoning process in forensic decision-making.
At the end of this workshop, the learner will be able to:
1. Describe the elements of evidence-based assessment of PTSD in psychological injury evaluations;
2. Explain the strengths and weaknesses of various interview and assessment methods for evaluating PTSD in a multi-method test battery;
3. Identify key data points useful for testing rival hypotheses; and
4. Apply the principles of evidence-based, multi-method assessment to a forensic case.
Chair Information: Saul Rosenberg, PhD
Presentation 1 Title: Evaluating PTSD with the Clinician Administered PTSD Scale -5
Presentation 1 Abstract: The presenter will describe data from an unstructured interview and from the Clinician Administered PTSD Scale for DSM-5 (CAPS-5). The following questions will be posed to the audience:
1. Is there evidence of a Trauma or Stressor-Related Disorder that pre-existed the index accident?
2. Does the CAPS support a diagnosis of PTSD?
3. If PTSD was caused by the index accident did it aggravate or exacerbate a pre-exiting disorder or did it cause a new disorder?
Since many plaintiffs are aware of the symptoms and diagnostic criteria for PTSD, they may consciously --or unconsciously -- endorse symptoms that they believe will lead to a diagnosis of PTSD and financial compensation. To avoid suggesting symptoms to the plaintiff, evaluations of PTSD in psychological injury cases should begin with an unstructured, open-ended interview.
The presenter will report data from a comprehensive psychosocial history including potentially traumatic and stressful events in childhood, adolescence and adulthood. The presenter will describe how the plaintiff coped with traumatic or stressful events and problems with emotional regulation, interpersonal behavior and academic, social and vocational adjustment.
The presenter will discuss the rationale for using the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) and then provide selected data from the CAPS-5. For example, for Criterion B1, the plaintiff was asked, “Have you had any unwanted memories of the event ? How does it happen that you start remembering the event? How much do these memories bother you? Were you able to put them out of your mind and think about something else? Overall, how much your problems this for you? How often have you had these memories in the past month in the worst month? The plaintiff’s responses to these questions will be provided with the clinicians rating for the current month and worst month.
Selected data from the Diagnostic Criteria B, C, D and E will be presented, including the plaintiff’s responses and the examiner’s rating. A summary table with for all twenty criteria will be presented along with global ratings.
Saul Rosenberg, PhD | University of California
Presentation 2 Title: MMPI-2 and MMPI-3 Assessment of PTSD in Psychological Injury Evaluations
Presentation 2 Abstract: The strengths and weaknesses of assessing PTSD symptoms and diagnosis on the MMPI-2 and MMPI-3 will be discussed. The plaintiff took the MMPI-2 and then the MMPI-3 one week later. The presenter will provide the audience with data and statements from the interpretive reports on both the MMPI-2 and MMPI-3.
The following questions will be posed to the audience:
1. How does the MMPI-2 data confirm or disconfirm the hypothesis that the plaintiff is currently suffering from symptoms of PTSD?
2. How does the MMPI-3 data confirm or disconfirm the hypothesis that the plaintiff is currently suffering from symptoms of PTSD?
3. What are the areas of agreement and disagreement between the MMPI-2 and MMPI-3
Below is a sample of the data that will presented.
The MMPI-2 Interpretive Report:
SYMPTOMATIC PATTERNS: “The clinical scale prototype used to develop this report incorporates correlates of Scale 3 (Hy = 82T ) and Scale 2 (D = 77T). Because these scales are not well defined in the clinical profile, interpretation of adjacent scales should be considered: Scale 7 (Pt = 77T) and Scale 1 (Hs = 76). Other scales that were elevated include Scale 8 (Sc) = 70, Addiction Admission Scale (AAS = 73), Anxiety (ANX = 74T), Low Self-Esteem (LSE = 76T), Introversion/Low Positive Emotionality (INTR = 73).
The interpretive report stated: “Physical concerns and depressed mood appeared to be primary problems. The client reports feeling nervous, tense, and unhappy, and she is quite worried at this time. She also appears to be quite indifferent to many things she once enjoyed and believes she is no longer able to function well in life. She feels that she has not been treated well. Her depressed mood is accompanied by physical complaints and extreme fatigue. She appears to be inhibited and overcontrolled. She feels that life is no longer worthwhile and that she is losing control of her thought processes.
MENTAL HEALTH CONSIDERATIONS: “The most frequent diagnosis for individuals with this profile type is dysthymic disorder.”
The MMPI-3 Interpretive Report
Her MMPI-3 profile was valid with no indications of over-or-under reporting.
MMPI-3 scale elevations included Malaise (MLS = 70T), Eating Concerns (EAT = 80T), Worry (WRY = 65T), Anxiety-Related Experiences (ARX = 70T), Substance Abuse (SUB equals 60 5T), Social Avoidance (SAV= 60T), Introversion/Low Positive Emotionality (INTR = 65).
Somatic/Cognitive Dysfunction: “She reports a general sense of malaise manifested in poor health, and feeling tired, weak, and incapacitated. She reports problematic eating behaviors. She complains about memory problems, has low tolerance for frustration, does not cope well with stress, and experiences difficulties in attention and concentration.
Emotional Dysfunction: She reports multiple anxiety-related experiences including generalized anxiety, and reexperiencing, and/or panic. She likely experiences significant anxiety and anxiety-related problems, PTSD features including intrusive ideation, nightmares, and panic.
Diagnoses suggested by the MMPI-3:
Anxiety-related disorders, including PTSD.
Paul A. Arbisi, PhD | University of Minnesota
Presentation 3 Title: Assessing PTSD with the Rorschach Performance Assessment System
Presentation 3 Abstract: The presenter will review five interpretative considerations for the assessment of PTSD on the Rorschach: (1) cognitive constriction, (2) trauma-related imagery, (3) trauma-related cognitive disturbances, (4) stress response, and (5) dissociation.
The presenter will pose the following questions about the Rorschach data in this case:
1. Do the R-PAS scores support the presence of PTSD symptoms?
2. Does the content of her responses support the presence of PTSD symptoms?
3. Is the profile consistent with a diagnosis of PTSD?
R-PAS Summary Scores and Profiles – Page 1
Complexity: SS = 106
Perception and Thinking Problems
EII-3: SS =128
Stress and Distress
Y: SS= 126
MOR: SS= 123
R-PAS Summary Scores and Profiles – Page 2
Engagement and Cog Processing
Stress and Distress
CritCont% (Critical Contents): SS= 122
Self and Other Representations
V-Comp (Vigilance composite): SS = 113
AGM: SS = 131
Notable responses including the clarification phase:
“A spine that is bent, the vertebrae is all twisted, like a fusion was done in the middle. The spacing between them where the disc should go; not shown, don’t look like they are facing the right way, they are being stretched and pulled. The curve and that is not natural. Doesn’t have a space, disc not taken out. Does not sound like fun. Actually makes me kind of anxious. I might need a fusion some day. I will probably get arthritis in my neck. Spine stuff makes me uneasy.”
“One of those cow skulls you see in the desert, like desolate, vacant, isolated.”
“Animal skull with fire coming out of its eyes and smoke coming out of its mouth. It looks like it is threatening creatures in front of it.” The fire plus smoke makes it look threatening.”
“A knife above lungs, it could fall and harm the lungs, possibility of danger or injury. It is up there it could fall and harm, but also could not, should I be afraid should I not be afraid? Lack of control over it, the possibility of danger or injury.”
Discussion: Following the third presentation, the symposium chair will lead a discussion with the audience and the presenters about the evidence for and against a hypothesis of PTSD.
Donald J. Viglione, PhD | Alliant University-San Diego