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SpringerBriefs in Psychology

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Behavioral Criminology is a multidisciplinary approach that draws on behavioral research for the application of behavioral theories and methods to assessment,
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More information about this series at http://www.springer.com/series/10850

Laurence Miller

PTSD and Forensic


Psychology
Applications to Civil and Criminal Law

13

Laurence Miller
Miller Psychological Associates
Boca Raton
Florida
USA

ISSN 2192-8363
ISSN 2192-8371 (electronic)
SpringerBriefs in Psychology
ISBN 978-3-319-09080-1ISBN 978-3-319-09081-8 (ebook)
DOI 10.1007/978-3-319-09081-8
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Introduction

In many ways, we have never been safer or healthier. People living in modern industrial societies can access advances in nutrition, medicine, transportation, and
communication technologies undreamed of even a century ago. Yet, the traumas
of human life continue to afflict us. Some are as old as human society: disease,
warfare, criminal aggression, and natural disasters. Others are new: motor vehicle
accidents, medical mishaps, cyberstalking.
Arguably, one of the advances of modern civilization consists of the form of
codes of law to guide fair and productive interactions among humans living in increasingly complex societies. And all such societies contain laws that strive to determine just penalties for persons who commit crimes and reasonable compensation
for the victims of aggression, exploitation, or willful neglect.
Many of the victims of unfair actions suffer psychological as well as physical
injuries, and most legal codes contain remedies that can be applied to mitigate the
damage for victims through the civil courts. In other cases, criminal offenders may
appeal to extenuating circumstances or inner and outer forces beyond their control
to exculpate (completely excuse) or mitigate (lessen the blameworthiness of) their
actions.
In all these circumstances, claims of posttraumatic stress disorder (PTSD) may
be asserted: in civil cases, to argue for psychological injury meriting a damage
award; in criminal cases, to lessen the penalty for a felonious act. Posttraumatic
Stress Disorder and Forensic Psychology: Applications to Civil and Criminal Law
concisely but comprehensively addresses these issues for professionals in both the
mental health and legal fields. Chapter1 describes the history and concept of PTSD,
Chap.2 delineates the main clinical features of the syndrome, and Chap.3 describes
the subtypes and variants of PTSD that may be seen in clinical and forensic settings,
providing guidelines for differential diagnosis of PTSD from a variety of syndromes
and disorders that may be confused with it in both civilian and military cases.
Next, the book discusses applications of PTSD to civil law, particularly personal
injury and Workers Compensation cases. Chapter4 describes how PTSD can be
used to make a case for compensable psychological injury, as well as describing
measures for refuting these claims. Chapters5 and 6 describe applications of PTSD
to criminal law, delineating the various ways PTSD may predispose, trigger, or
v

vi

Introduction

maintain criminally violent behavior, and describing practical applications of PTSD


claims to the defenses of not guilty by reason of insanity and diminished capacity.
Finally, Chap.7 provides practical advice and guidelines for forensic psychological
examiners on how to conduct their evaluations, present their findings, and testify
in court.
This book will be of value to forensic psychologists, attorneys, judges, and military personnel, as well as to researchers and instructors in the fields of criminology,
psychology, medicine, rehabilitation, and mental health law. It provides a comprehensive and scholarly, yet concise and practical guide to the application of psychology and the law to PTSD and other traumatic disability syndromes.

Acknowledgements

I wish to thank series editor Dr. Vincent Van Hasselt for encouraging this project,
as well as the editorial staff at Springer for their courteous and efficient work on the
book. Many of the clinical and forensic concepts described herein have been vicariously honed by the incisive questions and comments from students in my classes
throughout the years, and the practical applications further creatively challenged,
enhanced, and expanded through working with a fine group of attorneys, law enforcement officers, and mental health clinicians. Finally, as always, I am grateful
to my family for spotting me the time necessary to work on this kind of project
when not busy with my day job, and, as mental health clinicians themselves,
offering valuable contributions in the form of suggestions, ideas, or just collegial
encouragement.

vii

Contents

1 History of the PTSD Concept and Its Relation to the Law


Early Conceptualizations of Traumatic Disability
Wartime Trauma
Posttraumatic Stress Disorder
Practice Points

1
1
3
4
7

2 Posttraumatic Stress Disorder: The Syndrome 9


Demographics of PTSD 9
Clinical and Diagnostic Features of PTSD 10
PTSD Diagnostic Criteria 10
Acute Stress Disorder 13
Evolution of the Trauma Response 13
Military Posttraumatic Stress Disorder 15
Civilian Posttraumatic Stress Syndromes 15
Medical Procedures 16
Pain 16
Traumatic Brain Injury 16
Toxic Trauma and the Toxic Stress Syndrome 17
Motor Vehicle Accidents 17
Disasters 18
Crime Victim Trauma 18
Workplace Violence 18
School Violence 19
Terrorism 19
Law Enforcement and First Responder Critical Incident Stress 20
Neurobiology of PTSD 20
Risk and Resiliency Factors for Traumatic Stress Responses 21
Risk Factors 21
Resiliency Factors 22
Treatment of PTSD 22
Practice Points 23
ix

Contents

3PTSD and Other Traumatic Disability Syndromes:


Differential Diagnosis 25
Traumatic Brain Injury and the Postconcussion Syndrome 27
Anxiety Disorders 27
Mood Disorders 28
Personality Disorders 30
Dissociative Disorders 32
Somatoform Disorders 32
Factitious Disorder 35
Malingering 36
Incidence and Prevalence of Malingered PTSD 36
Types of Malingering 37
Indicators of PTSD Malingering 38
Practice Points 41
4 PTSD in the Civil Litigation System 43
The American Legal System 43
Torts and Psychological Injury 45
Torts, Negligence, and Damages 46
Causation and Responsibility 46
Diagnosis of PTSD in the Litigation Setting 49
Clinicians, Lawyers, Patients, and Significant Others 50
Workers Compensation and Military Claims 51
Practice Points 52
5PTSD in the Criminal Justice System I: Signs,Symptoms,
and Syndromes 55
PTSD and Violent Crime: Populations and Risk Factors 55
Military Veterans 55
Nonmilitary Populations 56
Risk Factors for Violent Behavior 56
Impulsivity 57
Negative Emotionality 57
Antisocial Behavior and Attitudes 57
Alcohol and Substance Abuse 58
Unstable Interpersonal Relationships 58
Psychosis 58
Poor Treatment Compliance 58
Neurological Injury 59
Demographic and Contextual Factors 59
Injury-related Factors 59
PTSD and Violent Crime: Patterns and Causes 60
Dissociation/Flashback-Related Violence 61
Limbic Psychotic Trigger Reaction 61
Combat Addiction/Sensation-Seeking Syndrome 62

Contents

xi

Mood Disorder-Associated Violence.................................................... 63


Sleep Disorder-Associated Violence.................................................... 64
REM Sleep Behavior Disorder............................................................. 64
Night Terrors......................................................................................... 65
Sleepwalking........................................................................................ 65
Confusional Arousals............................................................................ 65
Noncombat Trauma-Associated Violence............................................ 66
Active Shooter PTSD........................................................................... 66
Practice Points.............................................................................................. 67
6PTSD in the Criminal Justice System II: The Insanity
Defense and Diminished Capacity............................................................ 69
Criminal Forensic Psychological Evaluations............................................. 69
The Insanity Defense.................................................................................... 70
Insanity Defense Standards.................................................................. 70
Diminished Capacity............................................................................ 72
Guilty but InsaneGuilty but Mentally Ill.......................................... 73
AutomatismUnconsciousness........................................................... 74
Self-Defense......................................................................................... 74
Utilizing PTSD as an Affirmative Defense or Mitigatory Factor in
Criminal Cases............................................................................................. 76
Establishing the Connection Between PTSD and an Impaired
Mental State.......................................................................................... 76
Making the Case for PTSD as a Criminal Defense.............................. 76
Special Considerations for Military Veterans....................................... 78
PTSD and Designer Defenses........................................................... 80
Practice Points.............................................................................................. 81
7 PTSD Cases: Evaluation, Interpretation, and Testimony...................... 83
Being an Expert Witness.............................................................................. 83
The Forensic Psychological Evaluation and Report.................................... 84
Deposition Testimony.................................................................................. 86
May it Please the Court: Testifying Tips for Expert Witnesses.................... 87
Types of Witnesses and Testimony....................................................... 87
Preparing for Testimony....................................................................... 88
Testimony Sequence............................................................................. 88
On the Stand......................................................................................... 88
Cross-Examination Tricks and Traps.................................................... 89
Practice Points.............................................................................................. 90
Erratum............................................................................................................E1
References......................................................................................................... 91
Index.................................................................................................................. 115

About the Author

Laurence Miller, PhD is in independent practice in Boca Raton, Florida, specializing in clinical psychology, neuropsychology, forensic psychology, police psychology, and business psychology. Dr. Miller is a consulting psychologist for the West
Palm Beach Police Department, the Palm Beach County Sheriffs Office, and the
Florida Highway Patrol. Dr. Miller also consults with local, regional, and national
law enforcement agencies on cases involving law enforcement stress, officer misconduct, fitness for duty, work-related disability, psychological services for police
officers and their families, and law enforcement management and administration.
Dr. Miller is a court-appointed forensic psychological examiner for the Palm Beach
County Criminal, Juvenile, and Family Court, and he serves as an independent
expert witness in civil and criminal cases involving brain injury, traumatic stress
syndromes, psychological disorders, civil and criminal competencies, criminal culpability, workplace violence and harassment, workplace stress, psychological disability, fitness for duty, workers compensation, and personal injury.
Dr. Miller is an adjunct professor at Florida Atlantic University and at Palm
Beach State College, where he teaches courses in abnormal psychology, neuropsychology, forensic psychology, criminal psychology, police psychology, business
psychology, and clinical psychology. He is also an adjunct instructor at the Criminal Justice Institute-Police Academy of Palm Beach County, where he has taught
courses in law enforcement stress management and law enforcement crisis intervention. In addition, Dr. Miller conducts training seminars and continuing education
programs regionally and nationally on topics pertaining to the brain, health, law,
psychology, and organizational management.
Dr. Miller is the author of over 300 publications, including books, book chapters,
professional journal articles, popular publications, and on-line resources. He is the
past editor of the International Journal of Emergency Mental Health and serves as
a peer reviewer for several other professional journals. He is a frequent guest on
regional, national, and international radio and television, and serves as a script and
media consultant to television shows and movies. Dr. Miller writes the Practical
Police Psychology column on the PoliceOne.com website. Relevant books by Dr.
Miller include the following:
xiii

xiv

About the Author

Psychotherapy of the Brain-Injured Patient: Reclaiming the Shattered Self (Norton,


1993). http://www.amazon.com/Psychotherapy-Brain-Injured-Patient-ReclaimingProfessional/dp/0393701581/ref=la_B001IU4W9Q_1_4?ie=UTF8&qid=1370346
965&sr=1-4
Shocks to the System: Psychotherapy of Traumatic Disability Syndromes (Norton,
1998). http://www.amazon.com/Shocks-System-Psychotherapy-Disability-Professional/dp/0393702561/ref=la_B001IU4W9Q_1_9?ie=UTF8&qid=1370346965&
sr=1-9
Practical Police Psychology: Stress Management and Crisis Intervention for
Law Enforcement (Thomas, 2006). http://www.ccthomas.com/details.cfm?P_
ISBN13=9780398076375
METTLE: Mental Toughness Training for Law Enforcement (Looseleaf Law,
2008). http://www.amazon.com/METTLE-Mental-Toughness-Training-Enforcement/dp/1932777628/ref=la_B001IU4W9Q_1_7?ie=UTF8&qid=1370799148&
sr=1-7
Counseling Crime Victims: Practical Strategies for Mental Health Professionals
(Springer, 2008). http://www.amazon.com/Counseling-Crime-Victims-StrategiesProfessionals/dp/0826115195/ref=la_B001IU4W9Q_1_3?ie=UTF8&qid=1370346
965&sr=1-3
From Difficult to Disturbed: Understanding and Managing Dysfunctional Employees (Amacom, 2008). http://www.amazon.com/Difficult-Disturbed-UnderstandingDysfunctional-Employees/dp/0814416675/ref=la_B001IU4W9Q_1_6?ie=UTF8&
qid=1370346965&sr=1-6
Criminal Psychology: Nature, Nurture, Culture (Thomas, 2012). http://www.ccthomas.com/details.cfm?P_ISBN13=9780398087159
Dr. Miller can be reached at 561-392-8881 or at docmilphd@aol.com.

Chapter 1

History of the PTSD Concept and Its Relation


to the Law

An awareness that traumatic events can leave long-lasting effects on the human
psyche has been recognized for as long as people have faced the adversities of ancient and modern life. However, in todays clinical and forensic mental health practice, as well as in the popular culture, it seems like posttraumatic stress syndromes
are everywhere. Is this concept new or are clinicians and attorneys merely taking
proper note of a phenomenon that has always been there?
Historically, the pendulum of interest in posttraumatic stress syndromes has
swung back and forth between military and civilian traumas (Evans 1992; Finley
2011; Holbrook 2011; Jones and Wessely 2007; Miller 1998c, 2007d, e, f, 2008a,
b, 2012a, c, 2013b; Modlin 1983; Pizarro etal. 2006; Rosen 1975; Sherman 2005;
Trimble 1981; Wilson 1994). During warfare, rulers and generals have always had
a stake in knowing as much as possible about the factors that might adversely affect
their fighting forces. To this end, doctors of every era have been pressed into service
to diagnose and treat soldiers, with the aim of getting them back to the front lines
as quickly as possible. In peacetime, attention turns to the everyday accidents and
individual acts of mayhem that can produce stress, pain, and trauma in the lives of
civilians (Table1.1).

Early Conceptualizations of Traumatic Disability


One of the first modern conceptualizations of posttraumatic stress was put forth by
the army surgeon Hoffer, who, in 1678, developed the concept of nostalgia, which
he defined as deterioration in the physical and mental health of homesick soldiers.
The cause of this malady was attributed to the formation of abnormally vivid images in the affected soldiers brain by battle-induced overexcitation of the vital
spirits.
With the eighteenth and nineteenth centuries came the mechanized progress of
the Industrial Revolution, bringing with it new and dangerous machines to crush,
grind, flay, and terrify the scores of workers who tended them, producing a new
The Author 2015
L. Miller, PTSD and Forensic Psychology, SpringerBriefs in Psychology,
DOI 10.1007/978-3-319-09081-8_1

1 History of the PTSD Concept and Its Relation to the Law

Table 1.1 History of Traumatic Stress Syndromes


1678

NostalgiaHoffer

1865

Irritable heartDa Costa

1882

Railway spineErichson

1887

HysteriaCharcot

1890

Sensory overloadOppenheim

1895

Nervous shockpage

1918

Shell shockWorld War I

1920

Traumatic fixationFreud

1945

Battle fatigueWorld War II

1951

BrainwashingKorean War

1980

Posttraumatic stress disorderVietnam War

1991

Gulf War syndromeFirst Gulf War

1990present

Increasing recognition of civilian PTSD syndromes

2003present

Resurgence of PTSD and TBI as the signature injuries of the Second Gulf
War

catalog of physical and psychological injuries. At about the same time, a new form
of high-speed transportation, the railroad, began to reveal a disturbing propensity
to rattle and strew its passengers about in derailments and collisions. Physicians of
the day noted that, all too often, after the physical scars had healed, or even when
injury to the body was minor or nonexistent, many accident victims showed lasting
mental and physical disabilities.
For example, in 1882, Erichson introduced the concept of railway spine, which
he believed could be traced to as-yet unobservable perturbations in the structure of
the central nervous system caused by blows to the body, despite the fact that many
cases lacked any evidence for such bodily concussions. Others among Erichsons
colleagues considered that these strange disorders of sensation and movement might
be due to small hemorrhages or disruptions in the blood flow to the spinal cord.
While these organically-minded physicians were squinting to discern structural
microtraumas in nervous tissue, others expanded their gaze to view the origin of
these posttraumatic impairment syndromes as a psychological phenomenon, albeit
straying none too far from the home base of neurophysiology. This was reflected
in the theory of nervous shock, introduced by Page in 1895, which posited a state
of overwhelming fright or terror, not physical injury, as the primary cause of traumatic impairment syndromes in railway and industrial accidents. Similarly, at about
the same time, Oppenheim (1890) theorized that a stimulus perceived through the
senses alone, if strong enough, might jar the nervous system into a state of disequilibrium. Charcot (1887) regarded the effects of physical trauma as a form of hysteria, the symptoms arising as a consequence of disordered brain physiology caused
by the terrifying memory of the traumatic event.
Even Sigmund Freud weighed in after observing the physical and psychological
carnage of the First World War. No stranger to neuroscientific theory and practice himself (Miller 1984, 1991b); Freud (1920) regarded the tendency to remain

Wartime Trauma

fixated on traumatic events as having a biological basis. But recurring recollections and nightmares of a frightening nature seemed to fly in the face of Freuds
theory of the pleasure principle. Consequently, he was forced to consider a psychogenic causethat traumatic dreams and other symptoms served the function of
helping the traumatized person master the terrifying event by working it over and
over in the victims mind (Horowitz 1986).

Wartime Trauma
Attention, however, soon shifted back to the fields of battle. The American Civil
War (18611865) introduced a new level of industrialized killing and, with it, a dramatic increase in reports of stress-related nervous ailments. Jacob Mendes Da Costa
described a syndrome in traumatized American Civil war soldiers that he called
irritable heart. Later, Frazier and Wilson (1918) and Mearburg and Wilson (1918)
attributed this condition to overstimulation of the sympathetic (fight-or-flight)
branch of the autonomic nervous system. A contemporaneous study noted a marked
increase in the number of men sentenced to prison during the years following the
Civil War. More generally, crime epidemics were reported to follow wars or other
social upheavals, such as in France after the French Revolution (1848), in Germany
following the Franco-Prussian War (18701871), and in England after the Second
Boer War (18991902).
Further advances in weapons technology during the First World War (1914
1918) produced an accumulation of new and horrifying battlefield casualties from
machine guns, poison gas, aerial bombardment, and long-range artillery. The latter
led to the widely applied concept of shell shock, a form of cognitive and emotional
incapacitation initially thought to be produced by the brain-concussive effects of
exploding shells.
The experiences of the Second World War (19391945) contributed substantially
little to the development of new theories and treatments for wartime trauma, now
renamed battle fatigue, combat neurosis, or combat exhaustion. In fact, resistance
to these concepts, with their implications of mental weakness and lack of moral
resolve, was widespread in both medical and military circles. Utilizing advances in
psychological testing, the US military in WWII rejected 1.6 of 20million draftees
on psychological grounds, a rate nearly eight times than in WWI. Moreover, WWII
soldiers diagnosed with combat trauma were discharged at five times the rate of
those in WWI.
Following each of the world wars, the USA and its European allies braced for
a civilian crime wave as battle-hardened veterans returned to the home front. After WWII, researchers in New York City reported a substantial increase in violent
crime, although it was unclear whether this was specifically due to the toughening
effect, or lost morality, of war on returning veterans, or simply to the fact that
there were suddenly so many young males simultaneously flooding back into civilian life and competing with one another for jobs and mates.

1 History of the PTSD Concept and Its Relation to the Law

Nevertheless, the traumatic effects of wartime experiences began to make their way
into the criminal justice system between and following the two world wars. For example, in People v. Gilberg (1925), a WWI veteran pled insanity as a defense against
the charge of child molestation, on the basis of his having incurred shell shock during
the war. His attorneys retained medical experts to opine on the neurological and psychological effects of shell shockwhich they appear to have conflated with the effects
of epilepsyand argued that this rendered the defendant not legally responsible for his
crimes. In People v. Danielly (1949), an argument for reducing a murder conviction
to the lesser charge of manslaughter was entered by a WWII veteran on the basis that
amnesia for the crime was caused by his nervous disability acquired in combat.
By the time of the Korean War (19501953), military medicine had formalized a
set of treatment protocols for combat exhaustion that included temporary hospitalization with return to duty as soon as possible. In addition, combat tours in Korea
were shortened to 9 months. As a consequence of these measures, the incidence rate
of psychological stress casualties dropped significantly. However, the Korean War
also introduced a new type of psychological warfare, called brainwashing, which
involved isolation and psychological indoctrination of detainees by the enemy.
The experiences of American soldiers in the Vietnam War (19651973) highlighted the stress of battle through the new medium of television. However, due to a
combination of fixed duty tours, frequent rest and relaxation breaks, and concerted
efforts to apply mental health services to soldiers, psychological casualty rates in
the Vietnam War were actually lower than in prior conflicts. Nevertheless, additional strain on service members stemmed from the general unpopularity of this
war and the absence of the kind of heroic homecomings that had greeted soldiers in
earlier conflicts. After their service, many Vietnam veterans went to work for government agencies like the US Post Office, and a few isolated reports of disgruntled
ex-service members becoming violent at workgoing postalled to the stereotype of Vietnam vets as ticking bombs, ready to explode at the slightest provocation.
In the case of Kemp v. State (1973), a Vietnam veteran shot his wife in bed and
then pled not guilty by reason of insanity, claiming that the attack took place while
he was dreaming of being surrounded by the Vietcong. The defendant claimed to
have witnessed multiple companions killed by a land mine in Vietnam, which allegedly caused him to develop battle neurosis during his combat tour. After discharge, he began to drink heavily, experienced bouts of amnesia, and had recurring
nightmares. Although, the defense-retained psychiatrist and two court-appointed
psychiatrists all testified that the defendant was legally insane at the time of the
crime, the jury nevertheless found him guilty and was convicted of murder; however, the case was appealed to the Wisconsin Supreme Court.

Posttraumatic Stress Disorder


Prior to 1980, criminal defendants faced the challenge of relating the experience of
traumatic stress to a recognized psychiatric disorder in order to fulfill the mental
disease or defect criteria of most insanity standards (see Chap.6). Shell shock,

Posttraumatic Stress Disorder

combat fatigue, and similar syndromes were not officially recognized medical or
psychiatric diagnoses, and defense counsel experts often had to force these dramatic
clinical presentations into the procrustean bed of an officially-sanctioned anxiety
disorder, mood disorder, psychotic disorder, brain syndrome, or other recognized
medical or psychiatric syndrome.
With the publication of the Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition (DSM-III) in 1980, this clinical-forensic hurdle was overcome
by the introduction of posttraumatic stress disorder (PTSD) as a distinct diagnostic category, enabling veterans and other PTSD claimants to mount exclupatory or
mitigatory defenses for charges ranging from murder and kidnapping to drug trafficking and tax fraud. By 1985, up to a million US veterans had been diagnosed with
PTSD, and use of this syndrome had enabled 250 Vietnam veterans to obtain acquittals, sentence reductions, or diversion to treatment programs in criminal cases.
For example, in State v. Heads (1981), the defendant was convicted of murder
in 1978, pre-DSM-III, but the case was later appealed on the basis that the defense
was denied the opportunity to demonstrate that the defendants behavior during
the crime was Vietnam-like, i.e., that it represented a severe posttraumatic stress
reaction. By the time the case was retried, the newly minted DSM-III diagnosis of
PTSD was available to invoke as a medically sanctioned psychiatric disorder and
thus could form the basis for an insanity defense. The defendant, it was argued,
was in a dissociative state of consciousness during the crime, which rendered him
unable to distinguish right from wrong. At the second trial, a Louisiana jury found
the defendant not guilty of murder by reason of insanity due to his retrospectively
diagnosed PTSD.
During the 1980s, PTSD became a victim of its own success, as increasing numbers of civilian and military PTSD claims came to be invoked as exclupatory or
mitigatory defenses in criminal trials, as well as being used as the basis for claiming
psychological damages in civil tort cases. A kind of trauma creep (Miller 2008c,
2012c) began to emerge, as an expanding catalog of life events came to be used as
the basis for Criterion 1, the stressor criterion, of the PTSD diagnosis (Chap.2),
including transportation accidents, natural and manmade disasters, crime victimization, financial crises, health problems, and even vicarious traumas (Miller 1998c,
2007d, f, 2008b, c). Indeed, the subjective nature of the traumatic stressor criterion
made it possible to claim PTSD on the basis of almost any kind of unpleasant experience. At the same time, evidence was emerging that many claims of military
PTSD were unfounded and that a sizable proportion of military PTSD claimants
had never even seen combat; in fact, some claimants had no military record at all.
Finally, by the late 1980s and early 1990s, as a national crime wave began to peak,
public opinion began to grow frustrated with insanity defenses in general, and it became harder to persuade juries and judges to exculpate or mitigate charges against
a defendant claiming PTSD or any other psychiatric diagnosis.
In the first Gulf War of 19901991, many cases of PTSD appear to have been
somatized (see Chap.3) in the form of Gulf War syndrome, which produced an array of physical, cognitive, and emotional symptoms, including weakness, sensory
disturbances, headaches, dizziness, memory loss, and depression. Unable to pin
down a precise cause, many military medical authorities attributed this syndrome

1 History of the PTSD Concept and Its Relation to the Law

either to the toxic effects of munitions, paint, or other chemicals, or, alternatively,
to hysterical reactions by psychologically unstable service members (Miller 1993a,
c, 1995b; Morrow etal. 1989, 1991). As this war was otherwise relatively short in
duration, low in American casualties, and generally successful in its limited aims,
few cases of PTSD-related contact with the criminal justice system seem to have
emerged from this conflict.
The more recent Iraq (20032011) and Afghanistan (20032015) theaters have
seen longer tours, multiple deployments, unconventional combat tactics, and greater contact with civilian populations. Ironically, advances in military medicine have
enabled more service members to survive what would previously have been fatal
injuries, and to live on with chronic, disabling physical and psychological impairments. Thus, up to 20% of todays US veterans suffer from PTSD, and incident
rates are generally related to the number of firefights or other combat experiences
the service member has experienced (Holbrook 2011). Correspondingly, PTSD as
both an exculpatory and mitigating defense has made a comeback in the criminal
courts, abetted by a generally more sympathetic social attitude toward returning
veterans than was the case with the Vietnam generation.
For example, in State v. Bratcher (2009), the defendant allegedly stalked, hunted, and killed a man whom he believed had raped his girlfriendordinarily, all the
elements necessary for a charge of first-degree, premeditated murder. However, an
Oregon jury found this former Army National Guard veteran guilty but insane
due to the combat trauma he purportedly suffered during his deployment. Following the jurys verdict, the defendant was transferred to an Oregon state hospital for
treatment.
Around the same time, the case of Porter v. McCollum (2009) presented the US
Supreme Court with the argument that a convicted murderers Sixth Amendment
right to counsel had been violated by his attorneys failure to introduce evidence
at his sentencing of significant combat experience that might have influenced the
Florida sentencing judge to mitigate the imposed death sentence. In addition, a neuropsychologist testified that the defendant had sustained brain damage in combat,
rendering him unable to control his impulsive, violent behaviorwhich actually
served to conflate the separate issues of posttraumatic stress disorder and traumatic
brain injury in this case (see Chap.3).
This is not just an American phenomenon. In R. v. Bosch (2006), a Canadian
jury heard the case of a defendant who was charged with kidnapping, raping, and
murdering a 13-year-old girl, and acquitted him on the grounds of insanity. This
was based on his claim that he developed PTSD after witnessing atrocities while
serving as part of the peacekeeping mission in Bosnia in the 1990s, despite the fact
that he was unable to corroborate many of these reported events (Grover 2007). At
trial, the defense took great pains to dramatically describe for the jury the severity
of the traumatic stress the defendant allegedly suffered in the cause of his military
serviceagain, without definitively documenting that these combat experiences
had actually occurred.
These cases illustrate a problematic trend that runs through many recent military
PTSD cases in the criminal justice system: Are military veterans granted exculpation

Posttraumatic Stress Disorder

or mitigation for serious charges due to the clinical-legal facts of the case, that is, do
they meet the strict criteria for PTSD and, as a direct result, was their mental state at
the time of the crime sufficiently impaired to meet the high standards of an insanity
defense? Or do courts simply grant a special kind of dispensation in PTSD cases
involving veterans, as a sort of general thank you for the service and sacrifice of
veterans everywhere? Indeed, the Supreme Court basically stated as much in its
opinion in the Porter case: Our nation has a long tradition of according leniency
to veterans in recognition of their service, especially for those who fought on the
front lines as Porter did (cited in Holbrook 2011, p.276). It is this tilt toward the
presumed special circumstances of military veterans in the criminal justice system
that has given rise to the recent proliferation of special Veterans Courts and the
arguments for categorical elimination of the death penalty for all military veterans
(Giardino 2009; Holbrook 2011; Wortzel and Arciniegas 2010); this controversy
continues to the present day (see Chap.6).
Meanwhile, workers compensation, military compensation, and civil tort cases
invoking PTSD continue to expand, as does the range of life experiences being proposed as precipitating stressors, from vehicle accidents to workplace harassment,
domestic violence to child abuse, natural disasters to media violence, and so on.
This book will explore the clinical phenomenon of posttraumatic stress disorder and
provide the theoretical foundations and practical guidelines for forensic evaluation
of PTSD cases.

Practice Points
Forensic clinicians who evaluate PTSD cases should be familiar with the history
of this diagnosis and the various forms it has taken in diverse places and times.
Broad scholarship in the field of clinical and forensic traumatology contributes
to the accuracy and validity of a case evaluation and enhances the examiners
credibility as an expert witness when presenting ones findings in a written report
or in testimony.

Chapter 2

Posttraumatic Stress Disorder: The Syndrome

One of the themes that informs this book derives from Thibaults (1984) observation that the first step to making an accurate diagnosis is to think of it. That is,
no psychometric test or printed decision tree can substitute for solid scholarship
and experience in the field that the clinical therapist or forensic examiner practices
in. Unfortunately, many psychological experts, not to mention attorneys, judges,
case managers, and the ordinary people that form the juror pools that many posttraumatic stress disorder (PTSD) cases depend on, have an incomplete or erroneous
understanding of exactly what PTSD, is and what it is not.
Remember, if you are conducting a forensic psychological evaluation in a PTSD
case, you will probably be called upon to explain the basis for your findings in a
written report and/or testimony at deposition or trial (Chap.7). This chapter will
explain the phenomenology, diagnostic criteria, and theoretical models of PTSD
and associated syndromes. The next chapter will place PTSD in the context of a variety of mental disorders that may be confused with PTSD or that may comorbidly
complicate its diagnosis, treatment, and forensic analysis.

Demographics of PTSD
The estimated lifetime prevalence of PTSD in the American population is 7.8%,
with women more than twice as likely as men to receive a PTSD diagnosis (10.4 vs.
5.0%) over their lifetime. Whether or not a diagnosis of PTSD is made, the lifetime
prevalence of having at least one traumatic event is over 60% for men and over
50% for women. Men are more likely to report experiencing combat trauma, physical attacks, and being threatened or kidnapped, while women more often report
rape, sexual molestation, and neglect or abuse in childhood. Higher rates of traumatic events and subsequent development of PTSD are found in subjects with major mental illnesses and severe personality disorders, and multiple lifetime traumas
and sexual abuse in childhood have been found to be most predictive of developing
PTSD later in life. The lifetime prevalence of PTSD among Vietnam War veterans
The Author 2015
L. Miller, PTSD and Forensic Psychology, SpringerBriefs in Psychology,
DOI 10.1007/978-3-319-09081-8_2

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2 Posttraumatic Stress Disorder: The Syndrome

is estimated to be 31% for men and 27% for women. The overall rate for recent
Iraq and Afghanistan theater veterans so far appears to be somewhat lower, with
estimates ranging from 15 to 20%. In civilian contexts, the occurrence rate of PTSD
for motor vehicle accidents ranges from 9 to 39%; for rape and sexual assault, up
to 80%; and for a terrorist attack, 1035% (Friel etal. 2008; Guriel and Fremouw
2003; Hall and Hall 2007; Holbrook 2011; Kessler etal. 1995; Kulka etal. 1990;
McNally 2004; Nash 2007).
In the overwhelming majority of cases, PTSD is a recoverable syndrome, with
fewer than 15% of diagnosed cases showing clinically significant or functionally
disabling symptoms 18 months after first diagnosis. Effective treatment accelerates
recovery (Bowman 1997, 1999; Dyregrov and Regel 2012; Miller 1994a, 1998c,
1999a, c, d; 2007f, 2013b; Rosen and Lilienfeld 2008).

Clinical and Diagnostic Features of PTSD


In medical classification, a sign is an objective finding on a clinical examination or
specialized test, such as a bump on the head after a car accident, or reduced voice
volume in a psychiatric patient. A symptom is a subjective experience reported by
the patient, not subject to direct observation or verification. For example, the car accident victim reports headache and dizziness, while the psychiatric patient says she
feels hopeless and has trouble concentrating. Finally, a syndrome is a set of signs
and symptoms that occur in a fairly regular pattern from patient to patient, under a
given set of circumstances, and with a specific set of causes, even though individual
variations may be seen. Therefore, the car accident victim may be diagnosed with
a concussion, and the psychiatric patient may receive a diagnosis of depression.
Where the syndrome produces significant impairment in that persons functioning,
it is called a disorder, e.g., cognitive disorder in the first case, major depressive
disorder in the second.
In this conceptualization, posttraumatic stress disorder is defined as a syndrome
of emotional and behavioral disturbance that follows exposure to a traumatic stressor or set of traumatically stressful experiences which are typically outside the range
of normal, everyday experience for that person, and that causes distress or impairment in life functioning (APA 2000, 2013).

PTSD Diagnostic Criteria


PTSD is associated with a characteristic pattern of signs and symptoms (APA 2000;
Meek 1990; Merskey 1992; Miller 1994a, 1998c, 2007f, 2012c, 2013b; Modlin
1983; Parker 1990; Weiner 1992). No one particular sign or symptom is specific
to PTSD; rather it is the combination of these features following a traumatic event
that defines the syndrome; note that there is some degree of overlap among the
diagnostic criteria in each category. Recently, the diagnostic criteria have been

Clinical and Diagnostic Features of PTSD

11

Table 2.1 Posttraumatic Stress Disorder (PTSD)DSM-5 Revision


Criterion Aprecipitating traumatic
stressor

The person has been exposed to a traumatic event


in which he/she was confronted with death or
injury to self or others and which involved the
experience of intense fear, helplessness, or horror

Criterion Bpersistent reexperiencing


symptoms

The person persistently or repeatedly reexperiences the traumatic event through waking recollections, disturbing dreams, dissociative reliving
experiences (flashbacks), and/or psychological
or physiological hyperreactivity to stimuli that
directly or symbolically resemble the traumatic
experience

Criterion Cpersistent avoidance


symptoms

The person: (1) behaviorally avoids a range of


situations which remind, resemble, or symbolically represent the traumatic event, leading to a
constriction of social activity; and/or (2) experiences a psychological numbing to outside stimuli
which constricts his/her emotional responsivity
and interpersonal interaction

Criterion Dnegative alterations in cognitions and mood

The person experiences impaired concentration


or memory, exaggerated negative mood states,
persistent and distorted ideas or feelings about
the event (personal guilt, paranoia), emotional
detachment from others, loss of enjoyment of
life activities, and inability to experience positive
emotions

Criterion Emarked alterations in arousal


and reactivity

The person experiences increased anxiety,


hypervigilance, irritability and anger, exaggerated startle response, difficulty sleeping, and/or
impaired attention, concentration, and/or memory

Onset of PTSD may be acute (duration less than 3 months), chronic (duration more than 3
months), or delayed (onset is 6 months or more following the traumatic stressor)

modified in DSM-5 (APA 2013); these are summarized in Table2.1. Attention to


these diagnostic criteria is crucial for distinguishing PTSD from a variety of other
syndromes whose clinical manifestations may overlap with it and be confused with
it (see Chap.3).
Criterion APrecipitating Traumatic StressorThe subject has been exposed to
a traumatic event in which he/she was confronted with death or injury to self or
others and which involved the experience of intense fear, helplessness, or horror.
Note that PTSD is one of only two diagnoses in the entire DSM classification system that requires the presence of a known precipitating stressor; the other is called
Adjustment Disorder. Because many of the component symptoms of PTSD (anxiety, depression, withdrawal, rumination, agitation, dissociation, etc.) are nonspecific and occur in a wide variety of syndromes, any combination of these symptoms
do not necessarily equate diagnostically to PTSD, unless they can be attributed to a
specific precipitating event or set of events.

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2 Posttraumatic Stress Disorder: The Syndrome

Criterion BPersistent Reexperiencing Symptoms Despite efforts to keep it out of


his or her mind, the subject repeatedly reexperiences the traumatic event through
waking recollections, disturbing dreams, dissociative reexperiencing, and/or psychological or physiological hyperreactivity to stimuli that directly or symbolically
resemble the traumatic experience. In the most extreme cases, the subject may experience flashbacks, or dissociative reliving experiences, in which he seems to be
mentally transported back to the traumatic scene in all its sensory and emotional
vividness, sometimes losing touch with current reality. More commonly, the intrusive recollection is described as a persistent cognitive and/or emotional intrusion
that wont let me stop thinking about the terrifying events surrounding the trauma.
Disturbing dreams are a common reexperiencing feature of PTSD. Sometimes
the patients nightmares replay the actual traumatic event; more commonly, the
dreams echo the general theme of the trauma, but differ in terms of specific content.
For example, a patient traumatized in an auto accident may dream of falling off a
cliff or of having a wall collapse on him. A sexual assault victim may dream of being attacked by wild animals or drowning in a muddy pool. The emotional intensity
of the original traumatic experience is retained but the dream partially disguises the
event itself. This symbolic reconfiguration of dream material is, of course, one of
the main pillars of Freudian psychodynamic theory (Horowitz 1986; Miller 1991b).
Criterion CPersistent Avoidance Symptoms Partly in response to the intrusive
reexperiencing symptoms, the subject behaviorally avoids a range of situations
which remind, resemble, or symbolically represent the traumatic event, leading to
a restriction of social activity. A second type of avoidance is more internal: the
subject experiences a psychological numbing to outside stimuli which constricts
his or her emotional responsiveness and interpersonal interaction; people may
describe him as spaced-out much of the time. In general, the subject tries to blot
out the event from his mind. He avoids thinking about the traumatic event and shuns
news articles, radio programs, or TV shows that remind him of the incident. I just
dont want to talk about it, is the standard response, and the subject may claim to
have forgotten important aspects of the event. Over 90% of PTSD subjects report
decreased sexual activity and interest; this may further strain an already-stressed
relationship. In some cases, complete impotence or frigidity may occur, especially
in cases where the traumatic event involved sexual assault.
Criterion DNegative Alterations in Cognitions and Mood The subject complains
of having gotten spacey, fuzzy, or ditsy. She may have poor memory or distorted recollections of the traumatic events or surrounding events, as well as poor
concentration and memory for present circumstances. For example, she has trouble
remembering names, tends to misplace objects, loses the train of conversations,
or cant keep her mind focused on work, reading material, or family activities.
She may worry that he has brain damage or that Im losing my mind. Clinicians
should be careful to assess for comorbid traumatic brain injury (Chap.3). Emotionally, the subject shuns friends, neighbors, and family members and just wants to be
left alone. She has no patience for the petty, trivial concerns of everyday lifebills,
gossip, news eventsand gets annoyed at being bothered with these piddles. The

Evolution of the Trauma Response

13

hurt feelings this engenders in those she rebuffs may spur reactive avoidance, leading to a vicious cycle of rejection and recrimination.
Criterion EMarked Alterations in Arousal and Reactivity The subject experiences
increased anxiety, hypervigilance, irritability, anger, exaggerated startle response,
difficulty sleeping, and/or impaired attention, concentration, and memory. The subject describes a continual state of free-floating anxiety or nervousness. There is
a constant gnawing apprehension that something terrible is about to happen. He
maintains an intense hypervigilance, scanning the environment for the least hint of
impending threat or danger. Panic attacks may be occasional or frequent. About onehalf of PTSD subjects show a classic startle reaction: surprised by an unexpected
door slam, telephone ring, sneeze, or even just hearing his name called, the patient
may literally jump out of his seat. There may be a pervasive chip-on-the-shoulder
edginess, impatience, loss of humor, and quick anger over seemingly trivial matters.
Friends may grow annoyed with this pervasive bad attitude, coworkers may shun
the subject, and family members may feel abused and alienated. A particularly common complaint is the patients increased sensitivity to childrens noisiness or the
familys bothering questions. Impulsive behavior and substance abuse may be seen,
especially where there has been a premorbid history of these problems.
Onset of PTSD may be acute (duration less than 3 months), chronic (duration
more than 3 months), or delayed (onset is 6 months or more following the traumatic
stressor).

Acute Stress Disorder


Acute Stress Disorder (ASD) was introduced as a diagnostic category into the DSMIV (APA 1994) primarily to help identify those at risk of developing later PTSD.
ASD is defined as a reaction to the traumatic stress that occurs within 4 weeks following the index trauma. Although ASD focuses more on dissociative symptoms
than does PTSD, it also includes symptoms of reexperiencing, avoidance, and hyperarousal. Between 60 and 80% of individuals meeting criteria for ASD following
a traumatic event will meet criteria for PTSD up to 2 years later (Koch etal. 2006).

Evolution of the Trauma Response


Depending on the circumstances, the reaction to a traumatic event can begin within
the first few moments of the crisis. Hollywood portrayals to the contrary, during
most emergencies, the majority of people involved do not become overwhelmed or
paralyzed by intense fear or shock; in fact, many behave quite adaptively and even
heroically (Aldwin 1994; Weiner 1992; Miller 1998c, 2003, 2004, 2013b). In an
acute crisis, the entire organism seems to go on automatic and is directed toward
survival. A certain degree of adaptive depersonalization or dissociation may take

14

2 Posttraumatic Stress Disorder: The Syndrome

place, a self-protective mental detachment from the surrounding events that enables
the person to deal with the practical survival needs of the situation; this is often
described in retrospect as like being in a dream or happening in slow motion.
After the event, the subject may experience the wrenching emotional seesaw
of painful intrusion alternating with numbing denial, along with the other posttraumatic stress symptoms described above. In the best cases, the major symptoms
and disturbances diminish in the course of weeks to months as the event becomes
integrated into the life narrative and personal history of the individual. However, in
some cases, a number of cognitive and emotional roadblocks may stand in the way
of the trauma survivors making peace with himself and the world (Everstine and
Everstine 1993; Matsakis 1994; McCann and Pearlman 1990; Miller 1994a, 1998c,
2001d, 2008c, 2012b), as follows.
Guilt and Stigma Many trauma survivors believe that they could have somehow
prevented the traumatic event from occurring. Others interpret the event as a kind
of hard knocks wake-up call for their poor judgment or as cosmic punishment for
present or past misdeeds. Many survivors feel marked by fate, especially if this is
not their first traumatic experience. Still others experience a violation of their bodily
and territorial integrity. They feel fragmented and scattered, and the slightest upset
makes them anxious, irritable, and isolative.
Existential CrisisThe traumatic event and its aftermath comprise a shattering
existential experience (Herman 1997). The trauma survivor is starkly confronted
with his or her own vulnerability and mortality in a way that most people evade by
using the normal, adaptive denials of everyday life. The victims existential violation may be all the more painful if the trauma took place at the hands of another
person; worse still if the actions of the malfeasor were maliciously intentional or
uncaringly negligent. And even more devastating may be traumas perpetrated by a
known and heretofore trusted person, such as a family member, friend, workmate,
neighbor, doctor, or clergy member (Miller 1998c, 2008c, 2012c; Neustein 2009;
Plante 2004).
Trauma Generalization Many trauma survivors generalize the helplessness of the
cognitive survival state to other aspects of their lives, now feeling powerless to control even their own behavior or to influence the actions of others. They may impute
domineering or retaliatory motives to anyone who tries to exert even the normal,
socially appropriate influence or control over them, e.g., bosses, doctors, parents, or
spouses. In some cases, outright paranoia and hostility may develop.
Uneven Recovery Course Even after things seem to have calmed down, when the
trauma survivor has achieved some measure of delicate equilibrium, the stresses of
returning to the normal routines of work and family life may trigger PTSD reactions. Also, delayed PTSD reactions may crop up years or even decades after the
event, as a superimposed illness, injury, loss, or just the aging process begin to
deplete the individuals adaptive reserves (Bonwick and Morris 1996; Christenson
etal. 1981; Hamilton 1982; Kaup etal. 1994; McLeod 1994).

Civilian Posttraumatic Stress Syndromes

15

In general, the more severe the trauma and the longer the trauma response persists, the more unfavorable the outcome. That is why it is important for all traumatic
disability patients to receive quick, effective treatment (Miller 1998c, 2008c). And
even after a delay, or when the trauma syndrome takes time to surface, proper treatment can still have a significant impact, so no situation should ever be considered
categorically hopeless.

Military Posttraumatic Stress Disorder


The National Vietnam Veterans Readjustment Study (NVVRS; Kulka etal. 1990)
estimated that the lifetime prevalence of PTSD amongst Vietnam War veterans was
30.9% for men and 26.9% for women. Higher rates of traumatic events and subsequent development of PTSD are found in those with preexisting or co-occurring major mental illnesses such as psychotic disorders or borderline personality d isorder.
Military PTSD sufferers may experience more persistent symptoms than civilian subjects. The NVVRS estimated that 15% of Vietnam veterans diagnosed with
PTSD still had the full or partial syndrome 15 years after returning from Vietnam
(Kulka etal. 1990). The National Comorbidity Study (Kessler etal. 1995) showed
that more than a third of those with service-related PTSD never fully remit, with
or without treatment, even after many years, although there is no information as to
whether symptom severity and overall disability decline over time. Many veterans
may experience PTSD symptoms for decades (Bonwick and Morris 1996; Lee etal.
1995; Miller 1999d; Nichols and Czirr 1986; Potts 1994; Schnurr etal. 2005).
More contemporaneously, approximately 1520% of military service members,
or up to 300,000 of the 1.64million veterans who have served in the Iraq and Afghanistan theaters since 2001, suffer from PTSD. Researchers have documented
a dose-effect relationship, in that the incidence of PTSD cases correlates with the
number of combat exposures, from a rate of 9.3% for soldiers involved in one or
two firefights to 19.3% for those involved in five or more firefights (Holbrook
2011; Koren etal. 2007; MacManus and Wessely 2012). Nevertheless, soldiers who
experience persistent, disabling PTSD symptoms as a consequence of combat are
still clearly in the minority.

Civilian Posttraumatic Stress Syndromes


Although, historically, much of the initial interest in traumatic stress reactions has
come from the field of military psychology and psychiatry, most of the PTSD cases seen by practitioners in routine mental health practice, and that comprise the
caseloads of most forensic examiners, involve civilian instances of PTSD from a
variety of sources (Miller 1998c, 1999e, 2002b, 2007d, 2008c, 2012b, 2013b).

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2 Posttraumatic Stress Disorder: The Syndrome

Medical Procedures
Emergency medical care, lifesaving though it may be, often employs procedures
for which the patient has little or no preparation (Shalev etal. 1993). The emotional
impact of a serious illness or injury may be compounded by these invasive, painful, and frightening medical procedures, such as occurs in emergency treatment for
a heart attack, motor vehicle accident, or workplace injury. Intrusive recollection
and avoidance of stimuli are frequently observed among hospitalized survivors of
trauma, but tend to be time-limited and self-remitting. However, medical conditions
or procedures themselves may constitute possible traumatic stressors, as they are
often associated with sudden onset, feelings of helplessness, lack of control by the
patient, and/or a perceived or actual threat to life (Miller 1994a, 1998c; Patterson
etal. 1990; Shalev etal. 1993).

Pain
In addition to fear and threat to life, one of the most traumatically stressful aspects
of injuries, or the treatments for them, may be the unavoidable physical pain that is
sometimes involved (Miller 1990c, 1993b, 1994a, 1998c, 2002b). Research shows
that the prevalence of PTSD among physically injured survivors of stressful events
is higher than that of survivors without physical injury in both military and civilian
traumas, and that pain can be the most stressful aspect of a traumatic injury (Helzer
etal. 1987; Malt etal. 1989; Pitman etal. 1989; Schreiber and Galai-Gat 1993),
although in some cases, physical injury may actually defuse and limit the stress response by giving the patient something real on which to focus his or her concern
(Modlin 1983).

Traumatic Brain Injury


A physical injury that produces pain may also result in a traumatic brain injury
(TBI) that is followed by a postconcussion syndrome (PCS). Although this syndrome is usually conceptualized by neuropsychologists in terms of cognitive impairment, the emotional and social effects may be equally or even more traumatizing (Denney and Sullivan 2008; Miller 1990a, b, 1991a, 1992, 1993c, 1994b,
2002b, 2012c; Parker 1990, 2001; Raskin and Mateer 2000; Small 1980; Varney
and Roberts 1999; Vasterling etal. 2012). Brain injury is a distinct form of stressor because the persons very organ of coping has been damaged. Thus, the subjects ability to maintain vocational, domestic, or academic responsibilitiesones
normal hold on realityis impaired. Physical effects of PCS include headaches,
dizziness, impaired equilibrium, tinnitus (ringing in the ears), sleep disturbances,
and hypersensitivity to light, sound, and temperature changes. Cognitive effects of
PCS include impairment of attention, concentration, memory, complex reasoning,

Civilian Posttraumatic Stress Syndromes

17

organization, impulse-control, and self-pacing of activities. Significant emotional


and stress reaction features of PCS include anxiety, depression, anger, intrusive
thoughts, preoccupation with the trauma, self-deprecation, social withdrawal, disintegration of selfhood, and behavioral regression. Impulsivity, egocentricity, and
lack of insight into deficits and behavior may lead to antisocial behavior and alienation from family and care providers.
Note that many of the symptoms of PCS overlap with those of PTSD, confounding the diagnosis in many cases. A further complication is that, especially with military injuries and civilian vehicle accidents, PCS and PTSD can co-occur, the symptoms of each exacerbating those of the other (Miller 1998d; Vasterling etal. 2012).

Toxic Trauma and the Toxic Stress Syndrome


Exposure to toxic substances in the home or workplace may produce a variety of
neurological, cognitive, and emotional disturbances that may in some cases be
wholly or partly attributed to the direct physical effects of toxic materials on the
nervous system (Eskanazi and Maizlish 1988; Hartman 1995). Additionally, however, the experience of a potentially life-threatening or health-impairing chemical
poisoning episode can be overwhelmingly frightening, leading to the development
of a PTSD-like toxic stress syndrome (Miller 1993a, 1995, 1998c; Morrow etal.
1989, 1991, Schottenfield and Cullen 1985). Symptoms include anxiety, depression, impaired concentration, somatic preoccupation, intrusive recollections, and
traumatic dreams. Often, symptoms are triggered by specific trauma-reminders,
especially exposure to certain odors. Emotional disturbance and psychological and
behavioral impairment are often uncorrelated with level and duration of toxic exposure: in fact, even where there has been no actual exposure, the mere belief that one
has been contaminated may precipitate the syndrome.

Motor Vehicle Accidents


We live in a car culture and motor vehicle accidents (MVAs) are a major cause of
injury and death in the USA and other industrialized nations, especially for people
under 30 (Blanchard and Hickling 2003). A wide variety of post-MVA traumatic
psychological symptoms have been described, including anxiety, panic attacks, intrusive recollections, dissociative flashbacks, driving and riding phobias, traumatic
nightmares, and disruption of work and family life (Blanchard etal. 1994; Brom
etal. 1989; Foeckler etal. 1978; Hodge 1971; Kuch 1987; Kuch and Swinson 1985;
Malt etal. 1993; Munjack 1984; Parker 1996) Since MVAs can result in multiple
injuries, there often occurs an unholy trinity of post-MVA effects, consisting of:
(1) postconcussion syndrome due to head trauma; (2) chronic pain due to low back
or cervical whiplash injury; and (3) posttraumatic stress disorder. These syndromes
often exacerbate one another in a vicious cycle (Miller 1998c, 1998d).

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2 Posttraumatic Stress Disorder: The Syndrome

Disasters
While the posttraumatic reactions to natural and man-made disasters in many ways
resemble those to other traumatic stressors, several features make the disaster experience unique (Abueg etal. 2000; Aldwin 1994; Freedy etal. 1992; Green 1991;
Miller 1998c; Raphael 1986; Reijneveld 2003; Smith etal. 1990; Ursano etal.
1995; Weiner 1992).
First, there is often little or no warning, such as in an earthquake or building collapse. Even when advance notice is available, as with a hurricane that is tracked for
days, people often display a stupefying capacity for denial and minimization until it
is too late to act effectively. Second, most natural and man-made disasterschemical
spills, tornadoes, tsunamis, nuclear power plant meltdowns, terrorist attacks
generally occur within a relatively short time frame. By the time the full extent of
the threat is realized, the worst may be over and the aftermath must now be dealt
with. Third, disasters typically involve extreme danger, including loss of life. At
the very least, people lose something of value, often in both material and emotional
terms. Fourth, both natural and technological disasters provide very little chance for
people to exert any kind of meaningful human control, so that actual and perceived
helplessness magnify the traumatic effect of disasters. Finally, disasters happen to
many people at once, often causing victims to feel that the whole world is coming
to an end, or that the larger world has abandoned them. On the positive side, a sense
of communal purpose and mutual support can be important in mitigating the effects
of disaster-related traumatic stress.

Crime Victim Trauma


The effects of trauma are often amplified when the harm comes through intentional
human malevolence. These psychic injuries violate our sense of security, stability,
and community. As difficult as it may be to bear the traumas of injury and loss that
occur in accidents and mishaps of nature, far more wrenching are the wounds that
occur as the result of the callous and malicious acts of our fellow human beings.
Trauma due to interpersonal violence can thus be especially severe and long-lasting
(Falsetti and Resnick 1995; Foa and Riggs 1993; Freedy etal. 1994; Hough 1985;
Miller 1994a, 1998c, 2008c, 2012b; Rothbaum etal. 1992; Spungen 1998).

Workplace Violence
Many people spend most of their waking hours at work, so not feeling safe on the
job can result in both chronic stress and acute trauma. The National Institute of
Occupational Safety and Health (NIOSH) reports that homicide is the second leading cause of death in the workplace. Murder is the number one workplace killer of
women and the third leading cause of death for men, after motor vehicle accidents

Civilian Posttraumatic Stress Syndromes

19

and machine-related fatalities (Kinney 1995; Labig 1995; Mantell and Albrecht
1994). Annually, robberies account for the greatest number of deaths, followed by
business disputes, personal disputes, and law enforcement line-of-duty deaths. The
majority of workplace homicides are committed by firearms. For every actual killing, there are anywhere from 10 to 100 sublethal acts of violence committed at work
(Flannery 1995; Labig 1995). Workplace violence combines crime victimization
with a violation of the expectations of safety and security we come to expect at a familiar worksite, similar to violence that occurs at home (Blythe 2002; Dennenberg
and Braverman 1999; Miller 1998c, 1999f, 2001b, c, 2008d, 2012c).

School Violence
According to the National School Safety Center (Bender and McLaughlin 1997),
the Federal Bureau of Investigation (FBI 2004) and other sources (Cornell 2006;
Devoe etal. 2005), there has been an overall decline in rates of juvenile violent
crime since the mid-1990s. Incidents of mass violence, involving high-powered
weaponry and multiple casualties, are still rare events on school campuses, with less
than 1% of youth homicides occurring in schools. However, almost three million
crimes of every type are committed on or near a school campus each year, comprising 11% of all reported crimes in America. These include rape, sexual assault,
robbery, aggravated assault, and simple assault. In general, youths under age 18
account for approximately 16% of violent crimes in the USA The number of children who carry guns to school on a daily basis is estimated to range from 135,000
to 200,000. And while the incidence, or frequency, of youth violence as a whole
has been decreasing since the 1970s, during the same period, the severity of juvenile violence has dramatically increased, including a greater number of homicides,
involving more potent weapons. In addition, students are committing violence at
increasingly younger ages.
The psychologically traumatic effects of school violence extend far beyond the
incidents themselves (Miller 2002a, 2007b, 2008c, 2012c). For example, in the first
year following the Columbine High School shooting, there were a disproportionately high number of vehicular accidents, suicide attempts, assaults, and several
student deaths (Cullen 2009; Johnson 2000). Following a sniper attack on an elementary school playground, schoolchildren exhibited traumatic responses similar
to those of adults exposed to mass violence (Pynoos etal. 1987). Posttraumatic
symptoms can also affect teachers and other school personnel (Ardis 2004; Daniels
etal. 2007; Dworkin etal. 1988; Newman etal. 2004).

Terrorism
Although we may think of it as a recent phenomenon in this country, terrorism is as
old as civilization and has existed ever since some people discovered that they could

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2 Posttraumatic Stress Disorder: The Syndrome

intimidate the many by targeting the few. However, terrorism has achieved special
prominence in the modern technological era, beginning in the 1970s as international
terrorism, continuing in the 1980s and 1990s as American domestic terrorism, and
apparently coming full circle in the twenty-first century with mass terror attacks on
the US soil by foreign nationals. Arguably, the two culmination points of domestic and international terrorism in the past decades have been the 1995 Oklahoma
City and the 2001 World Trade Center and Pentagon attacks, with the recent 2013
Boston Marathon bombing heightening fears of a new wave of terrorism in which
the lines between foreign and domestic are blurred. Indeed, some terrorism experts
believe that the worst is yet to come (Bolz etal. 1996; Kuzma 2000; Savitch 2003),
although others assert that the overall threat has been exaggerated (Mueller 2005).
Essentially, terrorism is the perfect traumatic stressor, because it combines the
elements of malevolent intent, extreme harm, and unending fear of the future. Mass
terror attacks further combine the features of a criminal assault, a disaster, and an
act of war. Accordingly, much of our clinical knowledge in treating terror victims
is adapted from experiences in treating these other kinds of traumas, and terrorism will be an important part of trauma psychology into the twenty-first century
(Bongar 2007; Cromartie and Duma 2009; Kratcoski etal. 2001; Miller 2003, 2004,
2006f, g, 2012c; Silke 2003; Stebnicki 2001).

Law Enforcement and First Responder Critical Incident Stress


Special challenges are faced by the men and women in law enforcement, firefighting, paramedic, mental health, and other civilian emergency services who regularly
deal with the most violent, impulsive, and predatory members of society, and also
with their victims. Handling of both routine stresses and episodic crises requires
a certain adaptively defensive toughness of attitude, temperament, and training.
Sometimes, however, the stress becomes too great, and the very toughness that facilitates smooth functioning in their daily duties now becomes an impediment to
these helpers seeking help for themselves. Accordingly, specialized forms of treatment have been developed for this first responder population (Blau 1994; Bohl
1995; Dunning 1999; Henry 2004; McMains 1991; Miller 1995a, 1998c, 2000a,
2006a, b, c, d, 2007a, 2008a, b, 2009a, 2013c, 2013d, in press-a, in press-b; Mitchell
and Everly 1996; Paton and Smith 1999; Reese 1987; Sheehan etal. 2004; Silva
1991; Solomon 1995; Toch 2002; Williams 1991).

Neurobiology of PTSD
In the last few decades, advances in brain research have led to a variety theoretical models that describe the neural mechanisms that may account for the trauma
response and the symptoms of PTSD and other traumatic disability syndromes
(Bremner 2002, 2005, 2006; Bremner and Vermetten 2002; Bremner etal. 1993,

Risk and Resiliency Factors for Traumatic Stress Responses

21

1995, 1996, 1997, 1999, 2005, 2006; Charney etal. 1993; Deitz 1992; Dowden and
Keltner 2007; Etkin etal. 2005; Frewen and Lanius 2006; Kolb 1987; Kretschmer
1926; Lobo etal. 2011; Ludwig 1972; Lyons etal. 1993; McFarlane 1997; McNally
2007; McNally and Shin 1995; Miller 1993d, 2007d, 2013b; Nutt and Malizia 2004;
Paris 2000; Parker 1990; Perry 2002; Rosen and Lilienfeld 2008; Roth and Champagne 2012; Sapolsky 1996; Sapolsky etal. 1984, 1990; Shin etal. 2006; van der
Kolk 1994; van der Kolk 2003; Vermetten and Bremner 2002a, b; Weiner 1992;
Weiss 2007;Yang etal. 2004; Yehuda and LeDoux 2007; Yehuda 1998, 1999, 2002)
Although the neurophysiological details are beyond the scope of this book (interested readers should consult the references listed in this section), these models
all mainly focus on the interaction between the hypothalamicpituitaryadrenal
axis of endocrine system and the cortical-limbic system of the brain, especially
the medial prefrontal cortex, amygdala, and hippocampus. It should also be noted
that some postulations (e.g., whether PTSD causes direct anatomical changes in
the hippocampus or whether such anomalies represent premorbid vulnerability factors to PTSD) are still controversial. As neuroinvestigative technologies become
more refined, evidence of brain changes in PTSD may be useful in forensic cases.
However, it should be noted that such evidence is hardly essential in documental
the presence of the PTSD syndrome, as long as a rigorous diagnostic process is
appropriately applied.

Risk and Resiliency Factors for Traumatic


Stress Responses
As noted earlier, not everyone who experiences a traumatic critical incident develops the same degree of psychological disability, and there is significant variability
among individuals in terms of their degree of susceptibility and resilience to stressful events. While many individuals are able to resolve acute stress and traumatization through the use of informal social support or appropriate short-term clinical intervention (Bonano 2004; Bowman 1997, 1999; Carlier and Gersons 1995;
Carlier etal. 1997; Gentz 1991), in other cases, traumatic stress that is not resolved
adequately or treated appropriately in the first few days or weeks may evolve into a
number of disabling psychological traumatic disability syndromes (Miller 1998c).

Risk Factors
Risk factors for PTSD or other traumatic disability syndromes (Carlier 1999; Paton
etal. 2000) include: (1) a biogenetic predisposition to heightened physiological reactivity to various stimuli; (2) a history of prior exposure to trauma or other coexisting
adverse life circumstances; (3) characteristically poor coping and problem-solving
skills, learned helplessness, and a history of dysfunctional interpersonal relationships;
and/or (4) inadequate or dysfunctional family, clinical, workplace, or social support.

22

2 Posttraumatic Stress Disorder: The Syndrome

Resiliency Factors
Resiliency or protective factors are traits, characteristics, and circumstances that
make some people more resistant than others to traumatic stress effects (Bowman
1997, 1999; Hoge etal. 2007; Miller 1998c, 2007f, 2008e, 2013d). General trait
factors associated with resilience to adverse life events in both adults and children
(Antonovsky 1979, 1987, 1990; Bifulco etal. 1987; Brewin etal. 2000; Garmezy
1993; Garmezy etal. 1984; Kobassa 1979a, b; Kobassa etal. 1982; Luthar 1991;
Maddi and Khoshaba 1994; Rubenstein etal. 1989; Rutter 1985, 1987; Rutter etal.
1976; Werner 1989; Werner and Smith 1982; Zimrin 1986) include: (1) good cognitive skills and high intelligence, especially verbal intelligence, as well as good
verbal communication skills; (2) self-mastery, an internal locus of control, good
problem-solving skills, and the ability to plan and anticipate consequences; (3) an
easy temperament, a not overly reactive emotional style, good sociability, and positive responses to and from others; and (4) a warm, close relationship with at least
one caring adult or mentor, other types of family and community ties and support
systems, and a sense of social cohesion as being part of a larger group or community.

Treatment of PTSD
Although specific treatment methods are beyond the scope of this book (see Anderson etal. 1995; Ball and Peake 2006; Blau 1994; Bohl 1995; Borders and Kennedy
2007; Dyregrov 1989; Dyregrov and Regel 2012; Everstine and Everstine 1993;
Figley and Nash 2007; Freeman etal. 2009; Gilliland and James 1993; Hoge 2010;
James 1989; Johnson 1989; Matsaks 1994; McCann and Pearlman 1990; Miller
1998c, 2006d, 2008c, 2010; Miller etal. 2010; Mitchell and Everly 1996; Mitchell
and Levenson 2006; Moore 2011; Rudofossi 2007; Violanti etal. 2000), a few comments can be made with respect to treatment recommendations as part of a forensic
psychological evaluation for PTSD (see also Chap.7).
First, in most cases, PTSD is a fully or partially recoverable syndrome. The
rate and extent of recovery among individual subjects will vary greatly depending
on: (1) the individuals biological and psychosocial vulnerabilities to trauma (e.g.,
hyperreactive nervous system and/or prior psychopathology); (2) the nature and
degree of family and social support (e.g., family or workplace makes light of it or
takes it seriously); (3) the circumstances under which the trauma occurred (e.g., natural disaster or personal attack); (4) the psychological and material incentives (e.g.,
control of a family member, satisfaction of dependency needs, desire for monetary
compensation); and (5) the speed and effectiveness of therapeutic interventions provided (e.g., on-scene first response, short-term mental health treatment, longer-term
follow-up psychotherapy, and broader psychosocial interventions).
Second, appropriate mental health treatment almost always accelerates recovery
and reduces the overall level of psychological disability in PTSD cases, which is
why some form of treatment recommendation is typically part of a forensic PTSD

Treatment of PTSD

23

evaluation. In addition to its direct clinical effects, providing access to treatment


shows the PTSD subject that someone (military branch, civilian employer, insurance company) takes his situation seriously and that recovery is expected and anticipated within a reasonable amount of time. Providing adequate treatment in a timely
manner thus serves to prevent the development of entrenched traumatic disability
syndromes, where the subject feels she must intensify or prolong her symptoms and
disabilities in order to get proper attention to his needs. Also, subjects who refuse
treatment or fail to cooperate may be revealed to have ulterior motives (e.g. monetary compensation or exculpation from criminal responsibility) that will color the
forensic interpretation (see Chap.3).
Treatment for PTSD usually involves a combination of pharmacotherapy and
psychotherapy, and the two often have synergistic effects (Antai-Otong 2007; Bradley etal. 2005; Dowden and Keltner 2007). For example, early application of arousal-reducing pharmacological agents, such as beta-blockers, following psychological trauma can significantly reduce the extent and severity of later PTSD reactions.
Selective serotonin reuptake inhibitor (SSRI) mood stabilizing medication has been
hypothesized to reverse stress-induced hippocampal impairment and improve memory functioning (Asnis etal. 2004; Bremmer 2006; Javitt 2004).
Psychotherapeutic modalities, such as relaxation training and cognitive-behavioral therapies, when applied early and consistently, have been postulated to have a
trauma-mitigating effect on the neurobiological substrates of PTSD (Charney etal.
1993; Ehlers and Clark 2000; McNally 2007; Taylor 2006). Some studies suggest
that psychotherapy may actually reverse the neural changes associated with traumatic memories and enhance growth of new neural synapses and networks (Centonze etal. 2005; Cozolino 2002; Etkin etal. 2005; Farrow etal. 2005). While these
neurobiological effects are still being studied, the positive clinical effects of proper
therapy have been well-validated.

Practice Points
Be aware of the demographics of PTSD. Who is likely to develop the syndrome
following a traumatic exposure (a minority of those exposed) and what are the
individual risk and resiliency factors that affect a particular subjects likelihood
of developing the syndrome and remaining disabled from it?
Understand the broad range of posttraumatic symptoms and reactions, including
the formal diagnostic criteria for full PTSD, as well as the partial and atypical
syndromes that may occur in individual cases. Remember that a particular subject may meet all the diagnostic criteria for PTSD and still not be disabled; conversely, one or two severe symptoms can disable a subject, even if not formally
diagnosed with full-blown PTSD. In such cases, the forensic examiner should
carefully explain the relationship between the type and degree of disability, the
specific symptoms and impairments that cause or contribute to the impairment,
and any premorbid or comorbid factors that may influence the onset, course, and
recovery from the traumatic disability.

24

2 Posttraumatic Stress Disorder: The Syndrome

Be familiar with the range of military and civilian posttraumatic syndromes that
may be encountered in forensic practice, how they are similar, and how they differ from one another. For example, be prepared to explain why the reaction of a
military veteran following a battlefield injury may not be the same as a homeowner whose house and neighborhood have been destroyed by a tornado.
Be conversant with the basic neurobiology of PTSD so as to provide the trier of
fact, or fact-finder (i.e., those persons who make a decision on a case, usually a
judge or jury, but also sometimes an insurance adjuster or other clinician) a basic
scientific rationale for your findings of PTSD. However, also know enough of
the basic neuroscience to be able to refute spurious claims by opposing experts
(e.g., Scientific studies have conclusively shown that exposure to traumatic
stress always damages the brain. Well, actually, no, they do not).
In addition to your forensic role, if you are also a clinician who treats PTSD
cases, you will hopefully be aware of the range of short- and long-term treatment
options for subjects with this syndrome. In fact, you will probably be asked as
part of your forensic evaluation to make specific treatment recommendations, so
if this is not a part of your daily practice, educate yourself as to the empirically
validated treatments for PTSD and know how to scrutinize other experts treatment recommendations to detect and refute their prescriptions for undertreatment, overtreatment, or unvalidated therapies.

Chapter 3

PTSD and Other Traumatic Disability


Syndromes: Differential Diagnosis

As noted in Chap.2, none of the individual signs and symptoms of posttraumatic


stress disorder (PTSD) are specific for that syndrome; it is only the combination
of features following a documented traumatic event that defines PTSD as an autonomous diagnosis. However, a variety of syndromes other than, or in addition to,
PTSD can arise following a traumatic experience. Also, the presence of other preexisting or coexisting disorders can affect the onset, course, and resolution of PTSD.
Finally, other non-PTSD syndromes may be misdiagnosed as PTSD. For example,
PTSD has been shown to have a 6598% comorbidity rate and can co-occur with
any of the following disorders: adjustment disorder, anxiety disorder, bipolar disorder, conduct disorder, dementia, dissociative disorder, dysthymia, eating disorders,
major depressive disorder, personality disorders, psychotic disorders, somatization
disorder, substance abuse, and traumatic brain injury (APA 2013).
Especially in forensic contexts, it is important for evaluating experts to be able
to tease apart these diagnostic entities. Bear in mind that a claim of psychological disability need not rely solely on a PTSD diagnosis: if a subjects anxiety,
depression, manic episodes, substance abuse, phobic avoidance, cognitive impairment, or psychotic decompensation has been precipitated or worsened by a
traumatic event, that may still justify a claim for compensation in a civil case or
be grounds for exculpation or mitigation in a criminal case, as long as the connection can be made between the disabling psychological injury and the traumatic
event (Table3.1).

The Author 2015


L. Miller, PTSD and Forensic Psychology, SpringerBriefs in Psychology,
DOI 10.1007/978-3-319-09081-8_3

25

Disturbances in attention, concentration, memory, and mood regulation may mimic the cognitive and emotional impairment
seen in some cases of PTSD. Look for a history of head injury or other physical trauma. Also note that TBI and PTSD frequency co-occur in both military and civilian traumatic events

Generalized anxiety disorder may be confused with PTSD arousal symptoms; PTSD subjects may develop phobias to traumatically-themed stimuli or situations; and panic attacks can occur following exposure to a traumatic stressor, or occur spontaneously without it. Check for premorbid history of any of these disorders, which may be worsened in the context of PTSD

PTSD withdrawal may be confused with major depressive disorder, and posttraumatic mood swings may mimic bipolar disorder. As a rule, it is rare for these disorders to arise abruptly and spontaneously, so assess for exposure to a traumatic stressor
that may have precipitated them

The subject experiences episodes of depersonalization, derealization, amnesia, and/or disturbed identity. Although dissociation is
often reported in the context of PTSD, it may occur as an independent syndrome in some subjects, so check for premorbid history

Histrionic and borderline personality may overdramatize PTSD symptoms for attention or manipulation, and the latter is
susceptible to dissociation; avoidant and dependent personalities may embrace the sick role as a way out of uncomfortable
responsibilities or to solicit social support; obsessivecompulsive personalities may fixate on their impairment and the harm it
has done to their lives; narcissistic personalities typically insist that their cases be treated as unique and special, and complain
about inadequate clinical care; paranoid personalities will be mistrustful and oppositional to clinical treatment and may insist
that the system is out to get them; antisocial personalities are likely to malinger PTSD symptoms and other impairments for
material gain or to avoid legal consequences; schizoid and schizotypal personalities often present bizarre and baffling symptoms that are difficult to classify

The defining feature of this group of syndromes is that the subjects intention and motivation for feigning or exaggerating
impairment is unconscious: they really believe there is something wrong with them. In somatization disorder, there is likely
to be a long history of excessive medical evaluation and treatment for multiple disorders predating the PTSD index event;
subjects with hypochondriasis will obsessively worry about one or two symptoms and be impervious to reassurance; in conversion disorder, look for a symbolic connection between a syndrome of impairment and a repressed psychological conflict; pain
disorder represents a magnification of chronic pain due to psychological factors, but check for the real painful effects of physical injury comorbid with PTSD; in body dysmorphic disorder, the subject is consumed with self-perceptions of defectiveness
or ugliness, but note that traumatic events often include physical injuries that can leave real and disturbing disfigurement

The intention to magnify or feign impairment is conscious, but the subject assumes the sick role for the primary purpose of
receiving the care, support, love, and devotion from others that ordinarily is bestowed on someone who is ill or injured

Here, the subject also consciously and knowingly feigns or distorts symptoms, but the motive is for some material gain, such
as a cash award in a civil lawsuit, access to narcotic medication, relief of work or military responsibility, or exculpation from a
criminal charge. Look for a history of previous marginal or antisocial behavior

Traumatic brain injury


(TBI)

Anxiety disorders

Mood disorders

Dissociative disorder

Personality disorders

Somatoform disorders

Factitious disorder

Malingering

Table 3.1 Differential Diagnosis of Posttraumatic Stress Disorder (PTSD) from Other Syndromes

26
3 PTSD and Other Traumatic Disability Syndromes: Differential Diagnosis

Anxiety Disorders

27

Traumatic Brain Injury and the Postconcussion Syndrome


In the USA, an estimated 400,000 people are admitted to civilian hospitals with
closed head injuries (CHI) every year, and about 1.7million suffer from resulting
traumatic brain injury (TBI) at any given time (Faul et al. 2010; Slagle 1990). With
returning military veterans from the Iraq and Afghanistan theaters, this number is
likely to swell in the coming years (French etal. 2010). The constellation of somatic, cognitive, and behavioral symptoms seen with a TBI was first termed the postconcussion syndrome (PCS) by Strauss and Savitsky (1934), and included irritability, poor concentration, loss of confidence, anxiety, depression, and hypersensitivity
to light and noise. Today, PCS describes a particular cluster of symptoms that occur
following a CHIsometimes a seemingly mild head injuryand it continues
to be a source of clinical and forensic controversy (Dinn etal. 2009; Evans 1992;
Levin 1990; Miller 1990a, b, 1991, 1992, 1993c, d, 1994b, 2002b).
Commonly reported PCS symptoms include headache, dizziness, fatigue, slowness and inefficiency of thought and action, impaired attention, concentration
and memory, irritability, anxiety, depression, impaired sleep patterns, nightmares,
heightened somatic concern, hypersensitivity to noise and light, blurred or double
vision, concrete thinking, cognitive inflexibility, impulsivity, poor judgment, poor
organization and planning, impaired problem solving, lack of self-control, irritability, emotional lability, problems in sustaining motivation, egocentricity, lack of
empathy, unawareness of personal impact on others, and socially inappropriate behavior.
Many of these symptoms are nonspecific and can occur in a variety of syndromes, ranging from depression to attention deficit hyperactivity disorder; as with
PTSD, it is only their pattern of co-occurrence following a known head trauma that
identifies them as components of PCS. In addition, many PCS symptoms overlap
with those seen in PTSD cases, especially where the latter includes prominent cognitive and memory impairment, as in the new cognitive impairment PTSD criterion
in DSM-5. Compounding the diagnostic issue further is that, especially in military
service members and civilian assault or accident victims, PCS and PTSD may be
comorbid and mutually exacerbate one another, often further aggravated by chronic
pain from physical injuries (Barth etal. 2010; Eslinger 1998; Koren etal. 2007;
Miller 1990c, 1993b, c, d, 2007f, 2013b; Parker 1990; Stuss and Benson 1984;
Vasterling etal. 2010, 2012). For cases of known or suspected PCS, a competent
neuropsychological evaluation is essential.

Anxiety Disorders
Normal levels of anxiety serve as an adaptive warning system for most people.
Anxiety disorders are characterized by heightened worry, fear, and arousal that produce distress or dysfunction in the persons life.

28

3 PTSD and Other Traumatic Disability Syndromes: Differential Diagnosis

Generalized anxiety disorder (GAD) involves a pervasive feeling of anxiety that


is not necessarily tied to any specific event or circumstance, sometimes referred to
as free-floating anxiety. These individuals are always anxious about something,
although the level of anxiety may wax and wane in response to different circumstances. Others may perceive these individuals as never being able to relax or be at
peace.
Some individuals, with or without GAD, may suffer from panic disorder, which
involves brief episodes of extremely elevated physiological arousal and fear. The
affected individual may experience several minutes of a racing, pounding heart,
profuse sweating, rapid, shallow breathing, numbness and tingling in the face and
extremities, and faintness or lightheadednessall the hallmarks of sheer terror.
Many subjects fear they will pass out during an attack, although this is extremely
rare (but look for evidence of syncope, a medical disorder that can involve fainting,
and that sometimes follows a TBI). Panic attacks may occur in response to specific
events or triggers, or they may strike randomly, with no clear precipitant. Panic
attacks are also likely to occur in the context of depression, often in response to
perceived abandonment or loss of support.
If anxiety or panic are associated with particular places or situations, the individual may develop one or more phobias, which are excessive, extreme fears of
particular persons, places, or things. Phobias may be generalized, involving fears
of a wide variety of circumstances that usually have some features in common; or
they may be quite specific, e.g., to a particular location, class of objects, species of
animal, or type of person. Phobias to trauma triggers (e.g., fear of enclosed spaces
in a crime victim who was attacked in a parking garage) are common posttraumatic
manifestations, and forensic examiners should assess the role of a pre- or comorbid
vulnerability to anxiety disorders (see Chap.2).

Mood Disorders
All healthy people show a range of moods, but like any trait or syndrome, it is the
extremes of mood that characterize a disorder, especially when these mood disturbances impair healthy life functioning or produce unreasonable conflict with others.
Major depressive disorder is characterized by episodes of depressed mood that
may last for weeks or months at a time. In severe cases, the individual may be
virtually immobilized. More characteristically, subjects feel dejected, demoralized,
helpless, and hopeless. Sleep and appetite may be impaired; alternatively, some
individuals become hypersomnic (sleep virtually all the time) or may binge-eat.
Concentration and memory may be affected to the point where the individual feels
he or she has dementia. Motivation or enthusiasm for work, play, or family activities deteriorates.
Accompanying emotions may include sadness, helplessness, hopelessness,
worthlessness, anxiety, panic, irritability, or anger. The disorder usually recurs in

Mood Disorders

29

cycles over the lifespan, and, in most cases, is responsive to proper treatment, which
optimally consists of some combination of mood-stabilizing medication and psychotherapy. The greatest risk is suicide. For some individuals, a first depressive
episode may be precipitated by a traumatic event, or such event may accelerate the
reappearance of a subsequent episode in a subject who has already been diagnosed
with depression. Also, symptoms of depression may resemble the numbing/avoidance symptom of PTSD.
Bipolar disorder, formerly called manic-depressive disorder, is characterized
by extreme shifts in mood, from elation (sometimes anger) to depression. Some
subjects experience a normal mood in between episodes; for others, there are only
highs and lows. The hypomanic phase typically begins with the individual feeling
energized and overconfidentpumped. He becomes hyperactive and grandiose,
but increasingly impulsive and distractible. Thinking and speech become rapid and
forced. Need for sleep decreases and the individual may become hypersexual; all
appetites are on sensory overdrive, although need for sleep is often sharply reduced.
The overall impression is of someone on stimulant drugs, and indeed, such individuals may abuse amphetamines, cocaine, or alcohol to enhance the natural high
and try to keep it going. In severe cases, the subject becomes frankly delusional
and may develop overt delusions and hallucinations, in which case the episode is
diagnosed as full-blown mania.
At the beginning of the hypomanic phase, the individual may appear quite engaging and entertaining in a kind of gonzo-comic way. However, as the manic phase
progresses, he becomes increasingly short-tempered, irritable, anxious, and paranoid. Inevitably, the crash comes as the subject cycles into the depressed phase. At
this point, he may increase his use of stimulant drugs or alcohol to try to prolong the
high, but eventually even this is not enough to stave off the onset of the depressed
phase. Suicide is a distinct risk at this stage. In other bipolar patients, the manic
episodes do not involve much elation at all, but are characterized mainly by irritability, anger and paranoia, and may be misdiagnosed as schizophrenia or antisocial
personality disorder.
Subjects with bipolar I disorder experience both manic and depressed phases,
whereas those diagnosed with bipolar II swing mainly into the depressed phase,
sometimes alternating with milder hypomanic symptoms. It is the rapidity of the
mood change (hours to days) that distinguishes the depression of bipolar disorder from that of unipolar major depressive disorder (which typically evolves over
weeks or months). Manic-like symptoms may be seen in some dissociative episodes
of PTSD subjects; this may especially be the case in subjects that might have premorbid or comorbid diagnoses of a psychotic disorder, such as schizophrenia.
For the forensic examiner, the high emotionality, pressured speech and behavior, impulsivity, impaired judgment, and sometimes delusional psychosis of mania
implicates this syndrome as a high risk factor for impulsive criminal behavior and
substance abuse (Barzman etal. 2007; Calabrese etal. 2003; Dean etal. 2007; Graz
2009; Lewinsohn etal. 1995; Modestin etal. 1997; Pliszka etal. 2000; Quanbeck
etal. 2004, 2005b; Solomon and Draine 1999).

30

3 PTSD and Other Traumatic Disability Syndromes: Differential Diagnosis

Personality Disorders
Personality disorders are not traumatic disability syndromes per se, but may strongly influence the psychological reaction to injury and thereby complicate treatment
and legal disposition. Although all human beings are characterized by different
clusters of personality traits, a personality disorder is defined as an enduring pattern of inner experience and behavior that deviates markedly from the expectations
of the individuals culture, is pervasive and inflexible, has an onset in adolescence
or early adulthood, is stable over time, and leads to distress or impairment (APA
2013; Sperry 1995).
Antisocial personality disorder is a pattern of disregard for, and violation of,
the rights of others. It is typically associated with impulsivity, criminal behavior, sexual promiscuity, substance abuse, and an exploitive, parasitic, and predatory lifestyle. These psychopaths or sociopaths will have no qualms about
malingering PTSD or other impairment syndromes for monetary gain, to obtain
drugs, or to avoid legal consequences, and they may be quite slick, engaging, and
convincing in their performances, often eliciting sympathy from well-meaning
doctors, lawyers, and family members. In clinical settings, there is a high association of antisocial personality disorder with malingering (see below) and medication-seeking behavior, and common comorbidities include alcohol and substance
abuse.
Histrionic personality disorder is a pattern of excessive emotionality and attention-seeking. PTSD or other symptoms will typically be reported by these subjects
with theatrical flamboyance, and all attempts at medical explanation or reassurance
will be evaded or resisted by persistent complaints of total, catastrophic, and heartwrenching disability. If engaged in treatment, therapeutic progress may be impeded
by excessive bids for attention, reassurance, nurturance, and support. Common comorbidities include depression and somatization disorder.
Borderline personality disorder is a pattern of instability in interpersonal relationships, impaired and inconsistent self-image, and emotional lability and mood
swings, along with marked impulsivity, including self-injury and suicidal gestures.
The pervasive mistrust, anger, and cynicism of many borderline subjects, along
with their tendency to alternately idealize and devalue others, may impel them to
pursue lawsuits with righteous fury to punish treacherous employers, doctors, or
insurance companies whom they blame for hurting or betraying them. Borderlines
may also alternately overidealize and devalue their doctors and attorneys, thereby
complicating clinical and legal cooperation. Common comorbidities include panic
disorder, bipolar disorder, and substance abuse, and these subjects highly dramatic
reactions to most events make them prime candidates for development of PTSD and
other traumatic disability syndromes.
Paranoid personality disorder is a pattern of pervasive distrust and suspiciousness, so that others actions and motives are almost invariably interpreted as persecutory or malevolent. Believing that the system is out to get me, this subject

Personality Disorders

31

may feel no compunction about beating the bastards at their own game by
exaggerating impairment and making excessive disability claims. In the criminal
justice system, paranoid subjects may react violently to perceived threats and be
mistrustful of their own lawyers and the legal system in general. Common comorbidities include mood disorders and psychotic disorders, and posttraumatic dissociative reexperiencing symptoms may take on an especially bizarre delusional
quality in these subjects.
Narcissistic personality disorder is a pattern of grandiosity, entitlement, need
for admiration, and lack of empathy. How dare the military disability review board
or insurance company deny them compensation for their loss and suffering! These
subjects may feel they have the right to feign or exaggerate disability in order to
win their case and get what they deserve. Less calculatingly, their wounded narcissistic pride at not being able to return to work or other important roles may spur
exaggerated claims of injury simply to save face by presenting themselves as totally
disabled from work. In clinical settings, they may present themselves as special and
entitled, and try to take partial or full control of the treatment plan: Its my bodyI
know whats best for me. In legal contexts, they may try to tell the attorney how
to run his or her case. Common associated diagnoses include bipolar disorder and
substance abuse.
Dependent personality disorder is a pattern of submissive and clinging behavior
that stems from an excessive need to be taken of. These subjects may latch onto the
sick or injured role as a way of conscripting and prolonging the nurturing care and
support of doctors, family members, and solicitous attorneys. Comorbid anxiety
and mood disorders are common.
Avoidant personality disorder is a pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation or criticism, often accompanied
by anxiety disorders, panic disorder, phobic disorders, and alcohol abuse as selfmedication. Schizoid personality disorder is a pattern of aloof detachment from
social interaction, with a restricted range of emotional expression, which may
represent a clinically less severe phenotypic variant of schizophrenia. Avoidant
subjects fear people and schizoid subjects do not need people. Consequently, both
of these types may welcome the enforced invalidism and isolation of a traumatic
disability syndrome to maintain their distance from unwanted social interaction.
Their PTSD manifestations may show a predominance of numbing-avoidance
symptoms.
Obsessivecompulsive personality disorder is a pattern of preoccupation with
orderliness, perfectionism, and control. These subjects may drive doctors and lawyers crazy with their incessant and repetitive demands for medical information and
details about the progress of their cases. Heightened anxiety and obsessive hypochodriacal preoccupation may lead to the overinterpretation of mild symptoms or
impairments as catastrophic. Comorbid diagnoses include anxiety disorders, mood
disorders, and somatoform disorders, and some will abuse substances for self-medication.

32

3 PTSD and Other Traumatic Disability Syndromes: Differential Diagnosis

Dissociative Disorders
This group of syndromes is characterized by episodic disturbances in consciousness, orientation, memory, or personal identity which occur for psychological reasons. Any of these syndromes can occur independently of PTSD in predisposed
subjects, and, except for dissociative identity disorder, the symptoms of any of them
may overlap with those of PTSD.
Dissociative Amnesia The disturbance consists of one or more episodes of inability
to recall important personal information, usually surrounding traumatic or stressful
circumstances, that is too extensive to be explained by ordinary forgetfulness, and
that often includes details of personal identity (Who am I?), yet occurs with few
or no signs of associated neurological injury that would normally be expected with
this severity of cognitive impairment.
Dissociative Fugue This involves abrupt confusion about personal identity, sometimes including the assumption of an alternate identity, usually combined with
unexpected travel away from home or workplace, sometimes for days or weeks at
a time. There is often partial or complete amnesia for the episode. Note that some
cases of alcoholic blackout may resemble a dissociative fugue state.
Depersonalization DisorderThe subject experiences recurring episodes of feeling unreal and detached from the environment (depersonalization), or feeling as
if the environment itself is fading away (derealization). The whole experience is
described as having an other-worldly, dreamlike quality to it.
Dissociative Identity Disorder Sometimes called multiple personality disorder, in
this syndrome, the subject experiences two or more alter personalities that alternately take control of the subjects behavior. The alter personalities may know about
one another or not. This is not likely to be confused with a typical PTSD presentation, but a history of traumatic childhood abuse has been hypothesized as an important causative factor for this syndrome. Serial killer Ted Bundy tried unsuccessfully
to fake multiple personality disorder as a criminal defense (Miller 2012c).

Somatoform Disorders
The common feature of the somatoform disorders is the presence of subjective
physical symptoms that suggest a medical illness or syndrome, but that are not fully
explainable by, or attributable to, a general medical condition, substance abuse,
or other type of mental disorder (APA 2013; Miller 1984, 2002b; Trimble 2004).
Needless to say, a thorough medical workup is necessary to rule out actual physical illness or injury, and there is no clinical rule that says that somaticizing patients
cannot also develop a real illness or sustain a real injury. Indeed, otherwise minor
injuries sustained in a traumatic event may become the exaggerated focus of one or

Somatoform Disorders

33

more somatoform disorders, as the subject now projects all of his or her past and
present lifes problems onto the index traumatic event. Somatoform disorders include several subtypes. Although these tend to be relatively consistent from subject
to subject, it should be recognized that a given subject may show more than one
subtype, a combination of subtypes, or alternation between several subtypes as a
continuum of coping style (van der Kolk 1991).
Somatization Disorder Once referred to as hysteria, this syndrome involves a
history of multiple unexplained physical symptoms and complaints, beginning
before age 30, and often traced to childhood and adolescence. Outbreaks of numerous and varied symptoms may occur in clusters that wax and wane over time, often
in response to interpersonal, vocational, and other stressors. Associated features
include anxiety, depression, impulsivity, relationship problems, and possibly substance abuse.
Symptoms in somatization disorder may closely mimic true medical disorders
or they may be atypical or bizarre in quality, location, or duration. The subjects
typically describe their symptoms in exaggerated, florid terms, and several physicians may be consulted concurrently, leading to secondary problems associated
with medication abuse and unnecessary surgical treatment. Forensic psychological examiners, or treating clinicians who review the medical records of these subjects, will be impressed by the sheer number and variety of past injuries, illnesses,
and unexplained symptoms, covering a wide range of organ systems and medical
diagnoses.
In forensic disability cases, evaluating experts should try to determine whether
the present symptoms developed in the aftermath of the traumatic event or fall into
a prior longstanding pattern and history of multiple symptoms and complaints. In
pure somatization disorder, the patient genuinely believes that he or she is ill or
impaired and that all or most of the disability is related to the traumatic event.
The underlying motivation is typically a quest for support and reassurance, or to
manipulate the affection of a significant other. The psychodynamic goal is the satisfaction of dependency needs by reliance on caretakers or on the protective role of
medical and/or judicial authority. In such cases, being a victim can have multiple
meanings, including the need to be treated with extra special care, consideration,
and love. Underlying histrionic personality disorder is a frequent comorbidity.
Conversion Disorder The essential feature is the presence of sensory or motor deficits that appear to suggest a neurological or medical illness or injury, but with an
absence of corroborating physical findings. In conversion disorder, the patient is
unshakably convinced of his or her disability, and the underlying motivation typically involves the attempted resolution of psychological conflicts, such as those
involving dependency wishes or denial of disturbing aggressive or sexual impulses,
by unconsciously channeling the conflict into physical impairment. Frequently,
there may be an actual symbolic conversionhence the nameof a particular
psychological conflict into a representative somatic expression, as in psychogenic
paralysis of an arm in a subject who wishes to repudiate a hostile retaliation fantasy,

34

3 PTSD and Other Traumatic Disability Syndromes: Differential Diagnosis

or severe, incapacitating back pain in a worker who believes that I was a stand-up
guy, but my spineless company didnt back me up when my coworker knocked me
flat on my back.
Other examples of symbolic conversion symptoms include visual or auditory impairment; genitourinary and sexual dysfunction, most frequently seen in victims of
sexual assault; disturbances in consciousness or cognition, such as impaired memory; and psychogenic seizures or fainting spells. Unlike the anxious, agitated, angry,
or depressed emotional state of many injured and traumatized subjects, those with
conversion disorder often display a bland, eerily unconcerned and nonchalant demeanor, known as la belle indifference. This attitude seems to suggest that, despite
his or her protests of catastrophic ruin, the serious impairment is of little concern to
the subject, seeming, in fact, to be a relief from having to deal consciously with
the conflicts and challenges of everyday life.
Pain DisorderHere, chronic pain causes significant distress or impairment in
social, occupational, or other important areas of functioning, and psychological
factors are judged to play a significant role in the onset, severity, exacerbation, or
maintenance of the pain. The pain is not intentionally produced or feigned as in
malingering or factitious disorder (see below), but rather expresses, represents, or
disguises an unconscious need, fear, or conflict, closer to somatization disorder, of
which it is generally considered a subset. In addition, pain caused by documented
physical injury can be exacerbated by psychological stressors, setting up a vicious
cycle. In many cases, however, no legitimate medical explanation for the degree
of severity and/or length of persistence of the pain can be discovered, and subjects make the rounds from doctor to doctor until they are eventually shunted into
the mental health system or rejected outright from further treatment (Miller 1993b,
1998c). Problems with overuse of narcotic pain medication and with alcohol and
drug abuse may compound the problem by producing toxicity and addiction. Inasmuch as many cases of PTSD, especially in military settings, are accompanied by
physical injury (as well as by traumatic brain injury), somatoform pain syndromes
need to be assessed and properly dealt with in any traumatic event involving physical injury.
HypochondriasisThe conviction that one has a serious illness or injury, in the
face of repeated negative findings on medical exams, is the defining characteristic
of hypochondriasis. Patients are preoccupied with the fear of pathology, injury,
disease, or deterioration, and tend to misinterpret normal bodily signals as signs
of dire illness or injury. Unlike the varied and changing clinical presentations of
somatization disorder, hypochondriacs tend to focus on one or a few specific symptoms and remain preoccupied with them; although, the focus may shift over time
from one symptom or disorder to anothere.g., from memory impairment to dizziness, to headaches, to back pain, and back againand the associated anxiety
may wax and wane over time. Unlike conversion disorder, there may be no actual
observed or experienced impairment per se: it the fear of illness or injury that is
the problem. The unconscious motivation in hypochondriasis typically involves a
deflection of anxiety away from broader issues surrounding the subjects life which

Factitious Disorder

35

may seem insoluble, such as family, romantic, or career issues. This emotional redirection is achieved psychodynamically by focusing the anxiety on a more limited,
and hence controllable source of concern in the form of a somatic symptom or
feared illness.
Body Dysmorphic Disorder Many traumatic injuries leave victims physically disfigured or disabled, sometimes severely, other times almost imperceptibly. Diagnostically, body dysmorphic disorder involves a preoccupation with an imagined
defect in appearance or overconcern with a minor defect that has resulted in some
degree of disfigurement or loss of function that impacts the patients self-image.
More broadly, such overvalued impairments may include facial or other bodily disfigurement, lost physical prowess, reduced work capacity, or weight changes due to
immobility after an injury or mood-related changes in appetite. It may also present
itself as a form of cognitive dysmorphic disorder associated with the PCS following
a TBI (Miller 1993c), in which diminished intellectual skills, interpersonal functioning, or employment status are the main sources of self-deprecation.
Unconsciously, the motivation for such preoccupation with self-perceived ugliness or worthlessness may involve deep-seated and longstanding feelings of selfloathing which are now, posttraumatically, projected onto a more objectifiable
physical or mental impairment that serves as the new focus of the subjects self-perceived unworthiness. Alternatively, the physical disfigurement may come to represent a concrete, physical symbolization of a more general and ill-defined existential
fear and loathing that the trauma victim is struggling with. Focusing ones attention
on an ugly face may actually be less threatening than confronting the prospects
of an ugly life. The physical disability or disfigurement becomes a permanent
reminder of what has happened to the trauma survivor and assails the victim every
time he or she looks in the mirror. Especially in the case of facial injury that results
from violent assault, victims may be at an increased risk for PTSD, depression, and
other traumatic disability syndromes (Bisson etal. 1997; Fukunishi 1999; Jaycox
etal. 2004; Levine etal. 2005; Roccia etal. 2005; Wong etal. 2007).

Factitious Disorder
Factitious disorder, once known as Munchausens syndrome, is defined as the deliberate production, manipulation, or feigning of physical or psychological signs
and symptoms in order to satisfy psychological needs, rather than for material gain.
Because the intentionality of symptom production is conscious and deliberate, it is
diagnostically separated from the somatoform disorders, where subjects truly believe themselves to be impaired in some way (i.e., they are fooling themselves, as
well as others). However, unlike malingering (see below), in which the evaluator
can discern a utilitarian motive for the deception (e.g., money, drugs, avoidance of
jail), the motive in factitious disorder is primarily to assume the sick role, with all
the attendant care, solicitous concern, and relief from the responsibilities of normal

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3 PTSD and Other Traumatic Disability Syndromes: Differential Diagnosis

life that this entails, sometimes even at the price of substantial cost in money, health,
or freedomthat is, the motive would be viewed by most people as senseless or
even self-defeating in terms of significant practical gain. In many cases, the subject
also appears to derive satisfaction, perhaps only partly unconscious, from manipulating the medical system and fooling the experts.
The manifestations of factitious disorder are limited only by the imagination
and ingenuity of the subject (Sparr and Pankratz 1983). Medically sophisticated
subjects, such as nurses or mental health clinicians, may be quite clever in feigning
credible medical and psychiatric illnesses and injuries by the surreptitious use of
chemical substances or medical apparatus, or by faking realistic physical or psychiatric symptoms. Less knowledgeable subjects may resort to cruder methods such as
drinking toxic concoctions, bruising or cutting themselves to simulate injuries, or
acting like their best approximation of a brain-damaged or crazy person. Trauma survivors may incorporate their new disability status into their existing lifelong
victim role by exaggerating symptoms and impairments, and presenting themselves
as a uniquely challenging (and therefore special) case to clinical and forensic personnel (Weissman 1990).

Malingering
Malingering is not classified as a true psychiatric disorder per se, but rather is defined as the conscious and intentional simulation of illness or impairment for the
purpose of: (1) obtaining financial compensation or other reward; (2) evading duty,
responsibility, or obligation; or (3) being relieved of the consequences of ones
criminal actions or other illicit behavior. In other words, there is a practical and
sensiblealbeit ill-intendedmotive for the subterfuge and therefore it does not
represent a true symptom of psychopathology, although malingering may co-occur
with a variety of medical and psychiatric syndromes. Thus, unlike somatoform disorder, in which the subject truly believes in the false claims of illness he conveys,
and unlike factitious disorder, where the subject deliberately feigns disability but
for predominantly psychological reasons, in malingering the subject is deliberately
lying for profit or to escape the consequences of his or her behavior.

Incidence and Prevalence of Malingered PTSD


While the lifetime prevalence of exposure to traumatic events ranges from 50 to
60%, the lifetime prevalence of PTSD is approximately 520%, depending on the
subject pool (military, civilian, criminal assault, natural disaster, etc.). About half
of those who develop PTSD will also be diagnosed with three or more additional
disorders, and in half of PTSD-diagnosed subjects, symptoms will largely resolve
within 3 months (Acierno etal. 1999; Hall and Hall 2007; Kessler etal. 1995; Sweet

Malingering

37

2009). Thus, as noted in Chap.2, only a minority of trauma-exposed individuals


develop persistent PTSD.
The incidence of malingering differs widely across various clinical and forensic
settings and populations, with estimates ranging from 1 to 50% (DeViva and Bloem
2003; Franklin and Thompson 2005; Frueh etal. 2000, 2003, 2005, 2007; Resnick
1995, 1997, 1999; Schretlen 1988). Many experts view malingering in terms of
a continuum, based on the degree to which the subject is consciously aware of
his actual motivation (Nies and Sweet 1994; Travin and Potter 1984), and in any
given subject, there may be a combination of motivational factors. For example,
most people do not like to think of themselves as liars, so even though they may
be consciously feigning disability, they convince themselves that they are really
impaired. Others, such as those with antisocial personality disorder, will have no
qualms about fabricating whatever story they think will help them get their way, and
may take special delight in fooling the authorities.
In civil cases, malingering in PTSD claimants typically occurs where the traumatic event has led to a civil suit for monetary damages against a third party or
to argue for a greater military or employment disability award. In these cases, the
more impaired the plaintiff appears, the greater the anticipated payoff (Chap.4).
Alternatively, a criminal defendant may claim severe PTSD to argue for exculpation or a lighter penalty for a criminal charge (Chap.5). In military settings, Iraq/
Afghanistan War veterans are more familiar with PTSD than their Vietnam-era forebears because of expanding consciousness of the diagnosis in clinical contexts and
in popular culture, as well as the easy access to information on the Internet (Gover
2008); civilian plaintiffs are often savvy about the syndrome as well.

Types of Malingering
Based on an integration of a number of published malingering typologies (Appelbaum etal. 1993; Lipman 1962; Resnick 1995, 1997, 1999) and my own clinical
experience (Miller 1996a, b, 1998a, b, 1999b, e, 2001a, 2002b, 2008c, 2013b, in
press-b), I have categorized malingering into four main categories, as follows: (1)
fabrication: the subject has no symptoms or impairments resulting from the traumatic event, but fraudulently represents that he has; symptoms may be atypical,
inconsistent, or bizarre, or they may be perfect textbook replicas of real syndromes; (2) exaggeration: the subject has real symptoms or impairments caused by
a documented injury, but represents them to be far worse than they really are; (3)
extension: the subject has experienced real symptoms or impairments caused by the
injury, and these have now recovered or improved, but he falsely represents them
as continuing unabated, or even as having worsened over time; (4) misattribution:
the subject has symptoms or impairments that preceded, postdated, or are otherwise
unrelated to the traumatic event, but he fraudulently attributes them to that event.
Malingered exaggeration or extension of existing symptoms is more frequent
than pure fabrication of totally nonexistent illnesses or injuries. Also, more than

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3 PTSD and Other Traumatic Disability Syndromes: Differential Diagnosis

one category of malingering may be observed in the same subject at the same or
different times. To compound matters further, more than one syndrome may be
the subject of different types and degrees of malingering, e.g., PCS, chronic pain,
anxiety, depression, PTSD, or others. Finally, malingering can co-occur with other
psychological syndromes, such as the somatoform disorders or personality disorders. In many cases, malingering is suspected when subjects exaggerate impairment beyond the level of clinical believability, or when they are observed (e.g., on
insurance company surveillance cameras) to be performing activities that they are
supposedly incapable of doing.

Indicators of PTSD Malingering


Authorities on malingering detection agree that there are only two ways to determine malingering with absolute certainty: (1) the subject admits to it; or (2) the subject is caught doing precisely what he claims he is unable to do (Larrabee and Berry
2007; Stone and Boone 2007; Sweet 2009). There are a plethora of psychometric
tests and measures purported to detect malingering, but bear in mind that no single
indicator is a sure-fire lie-detector. In assessing for malingering, the clinician or
forensic evaluator should first try to ascertain a motive for the subterfuge, e.g., a
monetary claim in a civil case or exculpation/mitigation of a criminal charge. A
careful history should be taken that includes both the index event and larger life historical features. To assess for malingering, multiple data sources should be utilized,
including direct clinical interview, psychometric testing, interview of collaterals
(people who know the subject) and, if possible, direct observation of the subject in
his natural environment, e.g., through court-ordered surveillance and recording. In
this way, a combination of indicators, gleaned in the context of a competent forensic
evaluation, can yield valuable clues to the veracity of a PTSD claimants report.
These principles apply also to a range of other potentially malingered syndromes,
such as concussive brain injury and chronic pain (Miller 1993c, 1998c).
Collated from a variety of sources (Appelbaum etal. 1993; Atkinson etal. 1982;
Burkett and Whitely 1998; Cima etal. 2004; Esposito etal. 1999; Fairbank etal.
1983; Frankel 1994; Frueh etal. 2000, 2007; Garfield 1987; Hall and Hall 2006;
Hall and Poirier 2001; Hall and Pritchard 1996; Hellawell and Brewin 2004; Jones
etal. 2003; Knoll and Resnick 1999; 2006; Kozaric-Kovacic and Borovecki 2005;
Kuch and Cox 1992; Lowenstein 2001; Lynn and Belza 1984; Merckelbach etal.
2003a, 2003b; Pillar etal. 2000; Resnick 1995, 1997, 1999; Roemer etal. 1998;
Ross etal. 1989, 1991; Rothbaum and Mellman 2001; Schreuder etal. 2000; Silva
etal. 1998; Sparr and Atkinson 1986; Taylor 2001; van der Kolk etal. 1984; Watson
2004; Wessely etal. 2003; Zervos and Saldatos 2005), the following are some indicators that should raise red flags about possible PTSD malingering.
Flashbacks Subjects descriptions of flashbacks may range from simple recollections of the traumatic event, to hallucinatory sights, sounds, or smells in relatively
clear consciousness, to dissociative states where the subject actually believes he is

Malingering

39

back in the traumatic scene. In true dissociative flashbacks, the subject typically
recalls the events that took place during the dissociative state, including acts of violence or other illegal activity he may have committed. During the flashback itself,
the PTSD subject will often be observed to talk about past events in the present
tense and report an enhanced cognitive, perceptual, and emotional state.
Malingered flashbacks typically have a dramatic, cinematic flavor, with hallucinatory images of explosions and flying bodies, much like in a Hollywood war
movie. The malingerer will often claim total amnesia for any violent or illegal acts
that he supposedly committed while in the dissociative flashback state (I blacked
out, and the next thing I knew, I was sitting in the stolen car with the dead guy
next to me), when, in fact, true dissociative amnesia occurs in less than 5% of
veridical PTSD flashback cases. Nevertheless, up to 40% of violent criminal offenders of all types, whether claiming PTSD or not, report partial or total amnesia
for their criminal actions. What they may not realize is that the law does not regard
impaired memory for a criminal act as automatically exculpatory, even when associated with a known medical or psychiatric condition (Miller 2012c; Smith and
Resnick 2007).
Dreams There appear to be some differences between posttraumatic dreams associated with military vs. civilian traumatization. Military PTSD subjects, especially in
the early stages, are more likely to report stereotypic, repetitive dreams replicating
the traumatic event, which may represent more of a nocturnal flashback than a dream
per se. With the passage of time, dream content may become more varied. Civilian
PTSD subjects are more likely to have dreams that vary in content from night to
night, but whose themes reflect the emotions, reactions, and symbolic expressions
associated with the trauma, as in the sexual assault victim who dreams of being
attacked by wild animals. Typical emotional themes of PTSD dreams involve fear,
helplessness, guilt, and/or rage. Combat soldiers with PTSD experience nightmares
more often than waking flashbacks, while the ratio seems about equal for civilian
PTSD. In both cases, PTSD-related dreams are often associated with more body
movement, sleep talking, and recurrent awakenings than ordinary nightmares. For
both combat and civilian PTSD, the intensity and frequency of posttraumatic nightmares tend to diminish over several weeks and months.
Malingerers often report stereotypic, unvarying nightmares that persist for
months or years; alternatively, the images reported may vary wildly from retelling to retelling. The dreams often involve themes of anger and resentment against
authority figures for injustices committed against the subject (This would never
have happened if those bastards hadnt sent me out there). Alternatively, the dream
themes may be focused on the grandiose heroism of the subject. Unless acting in
collusion with the claimant, sleep partners of the malingering PTSD subject will
typically fail to confirm an observation of disturbed sleep patterns.
HistoryPTSD malingerers often show histories of past irregular employment,
involvement with the criminal justice system, prior injury claims and lawsuits, and/
or previous diagnoses of narcissistic, histrionic, borderline, or antisocial personality
disorder. Malingerers often show a prior history of substance abuse and narcotic

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3 PTSD and Other Traumatic Disability Syndromes: Differential Diagnosis

medication misuse, and this typically continues and even escalates following their
pursuit of a compensatory or exculpatory PTSD claim. Note that many true PTSD
sufferers may also have had a pre-incident substance abuse history, and this will
likely escalate as the emotionally injured subject attempts to quell his symptoms
with drugs or alcohol. In addition, a disabled person has a lot of free time, and
substance use often emerges as a vacuum activity to relieve simple boredom as
well as the disturbing PTSD symptoms that rush in to fill the empty spaces. Many
substances can cause symptoms of their own, either directly or upon withdrawal,
exacerbating or adding to the already existing PTSD symptoms, in a vicious cycle.
On close inspection of their service records, some military PTSD compensation
claimants turn out to have seen no combat at all, and a few have not even been in
the military. When confronted with his gap in their record, a number of subjects
have resorted to the claim that they were on top-secret special missions that could
not be recorded, referencing the kind of black ops assignments often portrayed
in movies. However, it should be noted that, even if the details about such missions
are classified, the special training required to qualify for being chosen for such an
assignment in the first place is always listed in a service members record. In many
cases, a degree of clinical-forensic detective work may be required to confirm the
objective facts.
Clinical PresentationDuring the clinical interview, the PTSD malingerer may
be sullen, evasive and uncooperative, or, alternatively, he may be animated and
voluble, overwhelming the evaluator with vivid descriptions of the traumatic event
and the multiple and dramatic effects it has had on his life. In still other cases, the
malingerer may attempt to seize control of the interview, behaving in an intimidating and confrontational manner. It is not uncommon for a given subject to cycle
through all three presentationssullen, animated, and confrontationalin a single
session.
True PTSD sufferers are often plagued by feelings of helplessness, hopelessness,
and survivor guilt. PTSD malingerers are more likely to express anger, outrage, and
blaming of others for their predicament. Many true PTSD claimants are reluctant
to talk about their experiences and may downplay their symptoms, whereas the
malingerer will typically bring up the index event early in the interview and regale
the examiner with multiple symptoms and disabilities. Malingerers descriptions of
the index event often have a dramatic, theatrical tone, like a scene from a movie,
and PTSD symptoms may be reported as textbook-like descriptions with formal
diagnostic names, as if the recounting had been rehearsed, which is often has. Alternatively, the subject may report atypical and frankly bizarre symptoms that have
no bearing on PTSD; much depends on the sophistication of the malingerer and his
access to reliable information about PTSD or coaching by someone more knowledgeable.
There is a tendency for the malingerer to overidealize all pre-incident aspects of
his life, i.e., all his problems are presented as being caused by the effects of the index event. Symptoms are constant and nonvarying, and no improvement is reported,
even after many months or years; in fact, many claimants report a worsening of the

Malingering

41

condition over time. Typically, treatment has been sought only in connection with
the current case, i.e., after a lawsuit or compensation claim has been filed or after a
criminal charge has been brought; then, the subject may fly into treatment and become a pseudocompliant patient, giving every outward appearance of cooperating
with the various therapies, but not getting any better, thereby starkly highlighting
the utter hopelessness of his plight.
In the course of multiple retellings, exaggerations and contradictions in the malingering claimants story will frequently emerge. Be careful to distinguish legitimate fear-based posttraumatic avoidance of painful topics from deliberate evasion.
When internal inconsistencies and contradictions are pointed out, the malingerer
will often display hurt, indignation, or outrage; alternatively, he may grin and even
laugh as he buys time and mentally gropes for a way to fill in the gaps. External inconsistencies may also be found, i.e., the claimant is seen doing things in his natural
environment that he claims he cannot do, or disturbing symptoms seen or reported
during the clinical examination evaporate when the subject thinks he is unobserved,
e.g., no one else notices the reported five flashbacks a day, or his sleep partner
does not observe any sign of the claimants supposed nightly thrashings in bed.
Malingerers who claim total disability from work may be observed or reported to
be able to engage in recreational activities; if confronted about this, they typically
rationalize that, after all Ive suffered, dont I deserve a vacation? I have to do
something to take my mind off the pain.
Comorbidity of PTSD with psychotic symptoms is reported to occur in up to
40% of combat veterans, and true PTSD sufferers often express the fear of going
crazy; in fact, it is this fear that often leads them to initially conceal such symptoms. Civil tort or work disability PTSD malingerers rarely report psychotic symptoms per se because this would conflict with their heroic struggle narrative, as well
as placing them at risk of being administered unwanted psychotropic medication or
even confined to a mental health facility. False claims of psychosis may be higher in
criminal populations, where a defendant is feigning PTSD or some other syndrome
in order to be adjudicated incompetent to stand trial or to pursue an insanity or diminished capacity defense. In these cases, confinement to a mental health facility is
seen as a less aversive alternative to incarceration in prison.

Practice Points
Just as it would be clinically and forensically irresponsible to miss an important
diagnosis of PTSD or other traumatic disability syndrome, it would be equally
unfortunate to overattribute a subjects distress to the index traumatic event and
overlook co-diagnoses or contextual factors that might complicate his or her
response to the trauma or impede recovery.
Forensic clinicians need to take into account the PTSD claimants personality,
comorbid psychopathology, social environment, and cultural factors for accurate
forensic assessment and proper treatment.

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3 PTSD and Other Traumatic Disability Syndromes: Differential Diagnosis

The subjects history is very important in determining the onset of posttraumatic symptoms and thereby attributing causality to the index event. Be aware of
which signs and symptoms have predated the index event and which followed it;
also be aware that a preexisting impairment or disability may be aggravated by a
supervening traumatic event, in which case the event may be contributory to the
resulting disability, even if it did not completely cause it.
PTSD claimants may malinger, but be aware that there is a broad range of nonveridical syndromes, each with their own degrees of intentionality and motivation. When suspecting a subject of a questionable report of disability, assess for
possible somatoform disorder and factitious disorder, as well as malingering.

Chapter 4

PTSD in the Civil Litigation System

Clinicians and forensic examiners who negotiate the legal system need to have
some understanding of the forensic issues involved in diagnosing, treating, and
forensically evaluating traumatically disabled subjects involved in civil litigation
and criminal prosecution. At the same time, attorneys may appreciate some insight
into the sometimes untidy real-life psychological worlds their clients inhabit while
pursuing civil claims or asserting criminal defenses (Barton 1990; Koch etal. 2006;
Miller 1990b, 2012a, c, 2013a; OBrien 1998; Pitman etal. 1996; Schouten 1994;
Simon 1995, 2003; Slovenko 1995; Sparr 1990; Sparr and Pittman 2007; Stone
1993; Young and Yehuda 2006).
This chapter will first summarize the main differences between the civil and
criminal court systems, then describe how posttraumatic stress disorder (PTSD)
is used as a claim in civil court and what the proper role of the examining psychological expert should be. PTSD in the criminal justice system will be covered in
Chaps.5 and 6.

The American Legal System


The US court system is divided into two major branches. Civil courts deal with matters between citizens: contracts and wills, divorce and custody, civil competencies,
compensation claims, and personal injury. In civil cases, one party, the plaintiff,
files a lawsuit against a second party, the defendant. The standard of proof in most
civil cases is preponderance of the evidence, that is, the jury deciding the case must
only be a little more certain than not about their verdict, which is generally interpreted as just over 50% sure. Attorneys may be retained by either side, and in
such cases, the attorney directly represents his or her client. Where the defendant
cannot afford an attorney, he/she may proceed pro se, that is, on their own behalf,
as there is no Constitutional guarantee of right to counsel in civil cases as there is in
criminal cases (in some cases, even where funds exist, a plaintiff or defendant may
elect to proceed pro se, but this is generally not advised).
The Author 2015
L. Miller, PTSD and Forensic Psychology, SpringerBriefs in Psychology,
DOI 10.1007/978-3-319-09081-8_4

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44

4 PTSD in the Civil Litigation System

In a civil case, the jury may find for the plaintiff or for the defendant. In cases
of personal injury or compensation claims, if the jury finds for the plaintiff, a cash
award usually results; if they find for the defendant, no such award is granted. In
many jurisdictions, the losing side is responsible for paying court costs and other
fees. Some personal injury cases are tried by a jury; other cases are decided by a
judge, which is also the case with most workers compensation claims. Prior to trial,
every effort is usually made to reach a settlement between the parties, in order to
avoid a potentially costly and time-consuming court battle.
In civil personal injury cases, plaintiffs attorneys typically work on contingency,
meaning that they do not get paid unless they win an award for their client, in which
case, they take a proportion of the collectibles, averaging around 40%, plus expenses. One of these expenses is the fee paid to expert witnesses for their evaluations and
testimony (also see Chap.7). Defense attorneys are usually paid an hourly fee by
the party being sued, who in many cases, is represented by an insurance company,
as in product liability or medical malpractice lawsuits.
In criminal courts, it is the state or the federal government who brings a criminal
charge against a citizen or organization for violating the law. The accused party is
still called the defendant, but the side bringing the charge is the prosecution, whose
legal representative is the prosecutor, state attorney, district attorney, or federal attorney. Unlike civil cases, the Sixth Amendment to the US Constitution guarantees
the right of a defendant to be represented by counsel in criminal cases; he or she can
either retain their own lawyer or, if indigent, the court will appoint a public defender
to the case. The standard of proof in most criminal cases is beyond a reasonable
doubt, which is usually interpreted to mean at least 9095% sure.
If the jury finds for the prosecutions side, the defendant is convicted. If they
find for the defendant, he or she is acquitted. Prior to trial, every effort is made to
arrive at a plea-bargain, i.e., getting the defendant to plead guilty to a lesser charge
to avoid a potentially costly and laborious trial. In fact, over 90% of criminal cases
are pled out; if every defendant asserted their Constitutional right to a trial by a
jury of their peers, the criminal justice system would grind to a halt. Prosecutors are
paid a salary by the state or federal government jurisdiction they work for, as are
public defenders. Where the defendant can afford one, he or she may retain a private
defense attorney.
In criminal cases, the defense attorney represents the defendant, but the prosecutor represents the state or federal government, not the victim of a crime. In some
cases where the victim or her family has suffered some compensable damage or
loss, a civil suit will be filed following, or simultaneously with, the criminal charge
(this process was made famous by the O.J. Simpson case). The substantial difference in burden of proof between the two systems accounts for the seemingly paradoxical phenomenon of many criminal defendants being acquitted in criminal court,
but then being successfully sued in civil court. Some studies (e.g., Des Rosiers etal.
1998) suggest that the primary goal of many crime victims who pursue civil litigation is not just monetary compensation, but to be heard and to obtain some sort of
apology; most are sorely disappointed. An associated motive may be to obtain facts
about the case during civil trial discovery (the data-gathering process that precedes
the trial) that were excluded from evidence in the criminal trial (Table4.1).

Torts and Psychological Injury

45

Table 4.1 The American Legal System


Civil justice system

Criminal justice system

Covers all aspects of civil law, such as wills and The contest is between a government
entity, usually either the state or the federal
estate law, family law, contract law, personal
government, and a second party, the alleged
injury, and workers compensation
criminal
The contest is between two private citizens or
corporate or government entities (e.g., a citizen
sues the US Post Office for losing a medical
sample; a corporation sues a smaller company
for copyright infringement; one neighbor sues
another neighbor for damaging her property)

In a criminal action, the state/federal government, represented by the state/federal attorney or prosecutor, brings a criminal charge
against a defendant

In a civil action, such as a personal injury


lawsuit, a plaintiff files a lawsuit for damages
against a defendant

The prosecutor represents the state or federal


government (often termed the people),
and the defendant is represented either by a
private defense attorney, or, if indigent, by a
court-appointed public defender

The plaintiffs attorney works on behalf of the


plaintiff, and the defense attorney works for the
defendant

The evidentiary standard of proof in criminal


trials is beyond a reasonable doubt, i.e., the
jury has to be much more certain than not
(9095% certain) of the defendants culpability in order to render a verdict of guilty, in
which case the defendant has been convicted

The evidentiary standard of proof in civil trials


is preponderance of the evidence, i.e., the jury
has to be only a little more certain than not
(even 51/49% certain) that one side has the prevailing argument in order to render their verdict

If they jury cannot unanimously arrive at


a guilty verdict by a preponderance of the
evidence, then they will render a verdict of
not guilty, in which case the defendant has
been acquitted

If the jury finds for the plaintiff, then the


defendant is liable for some kind of damages,
the nature and amount of which are usually
determined by the same jury

If they believe that evidentiary or procedural


violations have occurred during the trial, the
defense side may appeal the guilty verdict.
In the US, the prosecution cannot appeal a
not guilty verdict (although, in some countries, they can)

If the jury finds for the defendant, the defendant is not liable, but may still have incurred
substantial costs in defending him or herself.
In some jurisdictions, the loser pays the court
costs of the winner
If they believe that evidentiary or procedural
violations have occurred during the trial, either
side may appeal the verdict

Torts and Psychological Injury


With the exception of divorce actions, it is estimated that half of all civil cases
pending on American court dockets are personal injury cases (Modlin 1983). Along
with military and civilian compensation cases, tort cases will comprise the bulk of
a psychological examiners civil forensic PTSD caseload.

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4 PTSD in the Civil Litigation System

Torts, Negligence, and Damages


The law of torts covers a variety of possible actions or inactions, such as trespass,
invasion of privacy, plagiarism, negligence, false representation or deceit, slander,
libel, and malicious prosecution (Modlin 1983). Most personal injury lawsuits are
pursued under the theory of negligence that is, unintentional breach of duty, which
is the most common basis for third-party negligence suits (e.g., cases of poorly-lit
premises, lax security, slip-and-fall). In cases of direct traumatic victimization, e.g.,
as in a criminal assault, the legal claim may include intentional infliction of emotional distress. To pursue a personal injury lawsuit successfully, the plaintiff must
assume the burden of proof and must establish the four essential elements of a tort
claim: duty, breach, causation, and damages.
1. A legal duty of care existed. For example, as a restaurant owner, I am required to
sterilize utensils to a certain temperature for a certain amount of time in order to
prevent spread of disease.
2. The defendant breached that duty willfully or fulfilled it negligently. It was a
heavy lunch hour, so I cut the time in the sterilizer for some utensils and merely
rinsed off some others.
3. The breach of duty caused an event that affected another person(s). One of the
cutting utensils I failed to sterilize was infected with hepatitis B that made a
dozen customers sick.
4. The event caused by the breach of duty produced significant damages. Many of
the infected customers incurred medical bills for treatment, and some have had
their livelihoods and quality of life affected by the illness. Some are so traumatized that they cannot eat at restaurants anymore, and thus cannot entertain business clients; others are fearful of dying early or of being disabled for life.
The testimony of medical and psychological experts, especially with respect to causality and damages, expressed in a written report, deposition, or trial appearance,
can often make or break a plaintiffs case (Barton 1990; Feigenson 2000; Modlin
1983; Simon 1995; Taylor 1997).

Causation and Responsibility


Causation need not be all-or-nothing, and the law attempts to manage complex causation by the chain of events concept: if the index event set off a chain of events
beyond the plaintiffs control, the tortfeasor (the party allegedly responsible for
the damages) may still be held responsible for the adverse outcome. In some cases,
this can get complicated; for example, what percentage of the disability from a
traumatic injury was caused by physical blows to the head and body, the fear and
pain attendant to the injury, inept or insensitive handling of the incident by law
enforcement officers, rescue workers, clinicians, and the courts, or preexisting or
concomitant medical or psychosocial problems?

Torts and Psychological Injury

47

The legal approach to causation may appear to differ markedly from the clinical approach to which most mental health practitioners are accustomed (Feigenson
2000; Harsha 1990). In viewing a patients current symptoms and syndromes, medical and mental health clinicians typically search for both basic and complex causes
which underlie the disorder, and they try to understand all aspects of their patients
condition. By contrast, judges, juries, and attorneys seek to determine whether one
or more specific events precipitated or aggravated the plaintiffs current condition,
and they limit their concern to the precise proportion of the plaintiffs condition that
allegedly has been precipitated, hastened, or exacerbated by the index event. That
is, clinicians tend to think in terms of twists and turns; the legal system typically
wants a straight line.
With regard to causation, the law is concerned with proximate cause, the legally
definable cause for the claimed disability. A reasonable time relationship between
cause and effect is usually sought, although, in cases of delayed reaction, the
psychological expert should be prepared to explain that a latency period is possible
and symptoms of PTSD may not emerge fully until several weeks or months postinjury (Everstine 1986; Everstine and Everstine 1993; Modlin 1983). As noted in
Chap.2, although rare, some cases of PTSD or other traumatic disability syndrome
may be triggered months, years, or decades later by a subsequent intervening traumatic event.
With regard to a claimants preexisting or predisposing conditions, the law of
torts states that the tortfeasor is equally liable whether the injury totally caused the
disability, activated a latent condition, or worsened a preexisting condition. Any prior disorder that is exacerbated and produces significantly greater physical or emotional pain, discomfort, or distress than before the injury may still be grounds for
damages. This is the well-known but-for principle that essentially states that, even if
the plaintiff was already susceptible to impairment (via, say, weak bones or a weak
ego), the present level of disability would not have occurred but for the injury in
question. This concept is often articulated as the thin skull or fragile eggshell principle: the tortfeasor takes the victim as he finds him, prior weaknesses, vulnerabilities,
and susceptibilites notwithstanding (Meek 1990; Modlin 1983, 1990; Sparr 1990).
Further, as noted above, psychological traumatization in one incident may render the subject more susceptible to the effects of future traumatic events (Bursztajn
etal. 1994), which may have implications for the structure and amount of damage
claims. For example, a history of child abuse may render a subject more susceptible
to combat trauma when she grows up and joins the military, and the child abuse and
combat trauma may, in turn, increase her vulnerability to subsequent traumatization in a civilian motor vehicle crash or sexual assault. As expected, in many cases,
just what constitutes a preexisting or coexisting condition or susceptibility can be a
complex clinical and forensic knot to disentangle.
Another issue relates to just what exactly constitutes a physical or mental injury (Melton etal. 1997; Miller 1999b, e; Schouten 1994; Simon 1995; Slovenko
1994; Sparr 1990; Stone 1993). In the recent past, compensation for mental pain and
suffering in a civil action was recognized only as an ancillary, or so-called parasitic
element of damages. Thus, where the tortious (damaging) conduct inflicted bodily

48

4 PTSD in the Civil Litigation System

harm, the ensuing emotional distress could be taken into account in assessing damages. Emotional distress could be the sole basis of a claim only in cases of intentional wrongdoing for assault, defamation, false imprisonment, invasion of privacy,
or malicious prosecution. In the mid-1950s, courts in various states began to allow
an action for the intentional infliction of emotional distress itself, as in the case of a
malicious jokester who intentionally traumatizes a mother by falsely telling her that
her child has been killed in an accident.
Also, beginning in the mid-twentieth century, an increasing number of states
have removed the physical impact or injury limitation in tort and Workers Compensation actions, opening the way for so-called mental-mental claims, where a mental
event (e.g., witnessing a shocking scene) causes a damaging mental outcome (developing PTSD or other traumatic disability syndrome). In 1968, some courts began
allowing legal action for mental distress even for those who witness a traumatic
negligent injury, as in the case of someone who sees a workmate or family member
hurt or killed. Standards were set out for this kind of bystander action, that is: (1)
a close relationship to the person injured; (2) close proximity to the scene; and (3)
a sensory and contemporaneous observation of the incident (Melton etal. 1997;
Slovenko 1994; Sparr 1990).
Even this latter requirement that the plaintiff has to be at the scene of the act that
caused the mental suffering has been relaxed in a number of jurisdictions. In 1980,
the Massachusetts Supreme Court allowed a wife and child to sue for mental distress arising out of seeing their injured husband and father at a hospital hours after
an accident that was allegedly caused by the defendant. In the 1972 Buffalo Creek
disaster case, in which a dam broke owing to the alleged negligence of the defendant, there was a settlement of claims brought by a number of plaintiffs who suffered emotional distress when they heard the news and feared for their loved ones,
even though they were miles away when the disaster occurred. Recent decades have
seen a frightening succession of school and workplace violence incidents and acts
of terrorism, and it will be intriguing to see how some of these cases work themselves out in civil court.
The credible fear of becoming ill or incurring worsening disability at a later date
may also be compensable. The question of this kind of delayed reaction arises most
commonly in so-called toxic tort cases (Miller 1993a, 1995b, 1999e, 2002b; Morrow etal. 1989, 1991), where the ultimate effects of exposure to toxic substances or
radioactive materials may not be felt or fully realized for decades, and the affected
persons must live with the fear of cancer later in their lives or birth defects in their
offspring.
In all tort actions, when courts decide that a defendant is not liable for damages
due to an intentional or negligent act, they most often cite the following factors:
The injury is too remote from the source of the action, e.g., a firefighter today
claims to have just developed PTSD from the 9/11 terrorist attack 15 years ago.
The injury is wholly out of proportion to the defendants culpability, e.g., a teenager carjacks a womans SUV without physical injury, but she becomes physically paralyzed and bedridden for the next year.

Torts and Psychological Injury

49

It appears extraordinary that the action would have brought about the harm, e.g.,
as a joke, a workmate drops an empty paper cup on the plaintiffs head from a
distance of 6in and the latter claims severe cognitive impairment (nobodys skull
is that thin).
Allowing recovery would place an unreasonable burden on the defendant, e.g.,
a man makes an off-color remark at work to a fellow male coworker, and a female employee sitting nearby overhears it, then goes on to claim total disability
from work based on traumatization from the sexist comment, demanding that she
receive compensation for the rest of her life in the form of a permanent garnishment of the potty-mouth coworkers salary.
Allowing recovery would likely open the way for fraudulent claims. This is
the Pandoras box argument: in the case above, every time an employee said
something stupid but harmless to another worker, a ruinous harassment lawsuit
would ensue from some oversensitive eavesdropper.
Allowing recovery would create a field having no sensible or just stopping
point. This is the slippery slope argument: should we compensate any person
who hears a remark he or she doesnt like or thinks someone looked at them the
wrong way?

Diagnosis of PTSD in the Civil Litigation Setting


Unlike the case with the insanity defense in the criminal justice system (see
Chap.5), an actual accepted psychiatric diagnosis is not essential in a civil court
action, as long as it can be shown that the plaintiff has suffered some kind of harm.
However, in psychological injury cases, plaintiffs attorneys typically strive for a
precise diagnosis to enhance the clinical credibility of the claim: My client developed major depressive disorder sounds more convincing to a jury than, My client
became very, very depressed. Plaintiffs attorneys especially like to invoke PTSD
in pursuing an award for mental stress because this diagnosis is thought to give
the claim more medical legitimacy. Recall from Chap.2 that a defining feature of
the PTSD diagnosis is criterion A, the stressor criterion. Therefore, in tort litigation,
if a diagnosis of PTSD can be related to a specific incident, it confers greater credibility to the plaintiffs argument that all of his or her psychological distress and
subsequent problems arose from the index traumatic event. In contrast, a diagnosis
of anxiety disorder or depression may dilute the issue of causation because many
factors other than, or in addition to, the index event can determine the onset and
course of these disorders, thereby potentially blurring the causation element of the
plaintiffs tort case.
Plaintiffs attorneys also prefer to have a formal PTSD diagnosis because it
sounds more objective and scientific than just mental stress. Indeed, in the face
of impending tort reform threatening to limit or even exclude damages for nonobjective and noneconomic losses such as pain, suffering, and emotional distress,
PTSD may be seized upon as a bona fide neuropsychiatric diagnostic entity with a

50

4 PTSD in the Civil Litigation System

putative central nervous system basis (see Chap.2), thus scientifically skirting
this threat by assuming the status of a legitimate medical disability, warranting
compensation.
However, some authorities have asserted that, especially in the forensic context,
PTSD should be diagnosed only if the clinical facts warrant such a conclusion;
otherwise, both the diagnosis and the concept of PTSD risk becoming overutilized,
diluted, and trivialized. In this view, an important role for the forensic clinician
is to communicate to insurance carriers, Workers Compensation claims adjusters,
military compensation review boards, attorneys, judges, and juries that the plaintiff
is experiencing psychological distress and impairment; the precise diagnosis may
be less important than a thorough phenomenological description of the symptoms
that demonstrate disability and attribute causation to the index event. Where diagnoses other than PTSD exist, these should be specified and the relationship to
the disability carefully explained (Simon 1995; Sparr 1990). Experts should also
be prepared to describe how participation in the legal system itself can produce
its own set of stressors, the so-called legal stress syndrome (Bernsten and Rubin
2007; Bursztajn etal. 1994; Huffer 1995; Miller 2008f.; Vesper and Cohen 1999;
Winick 2000).

Clinicians, Lawyers, Patients, and Significant Others


It is the responsibility of the independent forensic psychological examiner to remain objective throughout the evaluation process and in testifying as to his or her
findings, conclusions, and opinions. However, many PTSD claimants in civil tort
and compensation cases will have their own private counselor, therapist, or mental
health clinician whose role is primarily to function as a support and advocate for
their patient. Ideally, the subjects clinician and attorney should work together for
the benefit of the trauma victim under their care and guidance. This is not collusion,
but rather collaboration in pursuing what is legally justifiable and clinically sound
(Stolle etal. 2000). According to Vesper and Cohen (1999), litigation need not be a
destructive or negative experience. It can and should be an empowering process that
provides the individual and the family with a voice in what no doubt seems to them
an unjust situation. An attorney trained in litigating PTSD and a clinical psychologist or other mental health professional specializing in the treatment of PTSD comprise a formidable team that can help the victim and the victims family overcome
the emotional consequences of the trauma by promoting self-esteem, dignity, and
stability, while building a litigation case that can secure fair compensation.
Everstine (1986) believes that therapists should generally support their patients
informed decisions to pursue civil claims. In many cases, there is a certain symbolic
and healing value in a victims reestablishing control by bringing a wrongdoer to
justice. However, any decision to pursue civil litigation should not be made lightly.
One needs to consider that many aspects of the claimants personal and professional life are discoverable in civil cases, including past medical, mental health,
and employment records. In fact, there may be an obligation on the clinicians part

Workers Compensation and Military Claims

51

not only to advise the patient to consult with an attorney but, when appropriate, to
educate that attorney about the subtleties of how the patients psyche has become so
deleteriously affected by the trauma and what might occur during the legal process.

Workers Compensation and Military Claims


PTSD is sometimes presented as the basis for a civilian Workers Compensation
(WC) or military benefits claim (De Carteret 1994; Drew etal. 2001; Gold and Shuman 2009; Mossman 1994, 1996). By claiming that a condition is work-related or
service-connected, an employee or veteran becomes eligible for treatment benefits
and sometimes a cash award. In the case of military service members, a veteran
deemed fully disabled by PTSD can receive a monthly cash payout, tax free, in
some cases for life (Greiffenstein 2010). This has led some critics to decry PTSD as
post-dramatic stress disorder (Slovenko 2004).
In cases of civilian WC, the rationale of this system was originally intended to
provide a government-based compensation system for the care of workers injured
on the job so they would not have to sue their employers for aid. However, WC
administration has been increasingly privatized to corporate insurance companies,
whose shareholder-motivated agenda may focus on maximizing profit by restricting
claims, thus denying injured workers treatment for their injuries or compensation if
they cannot work. The counter-explanation is that the promise of easy money may
motivate many otherwise minimally injured workers to exaggerate and malinger
disability in order to collect a check. As a result of what are probably abuses of the
system by both sides, the very rationale of the WC systemsmooth access to care
without litigationhas been subverted, as a whole new legal industry of WC lawyers have sprung up to file compensation suits against the WC insurance companies
for failure to pay. In essence, a WC claim has become another variety of personal
injury tort case, and most of the same forensic psychology principles apply to these
cases as to personal injury cases. To complicate matters further, there are different
standards for WC claims in different states, as well as a separate federal WC system.
There are some distinguishing features of WC cases, a number of which apply
directly to the evaluation of PTSD (Drukteinis 2003; Gold and Shuman 2009). First,
the scope of the WC evaluation and recommendations is narrower than in a typical personal injury lawsuit. That is, a WC assessment seeks to determine: (1) if the
employees work-related injury prevents him from working; (2) what measures will
restore his ability to work at his present job or a job like it; or (3) if the employee
is permanently unable to work, what will be just compensation for the wages lost
due to the injury. It is the latter point that is most frequently debated in litigated WC
cases. WC assessments are generally not concerned with a claimants total life disability or with pain and suffering, only with how this particular work-related injury
affects the employees ability to function at his current job. Results of a WC evaluation are expressed along a matrix of temporary or permanent disability x partial
or total disability. For example, an employee who is temporarily partially disabled

52

4 PTSD in the Civil Litigation System

will be amenable to rehabilitation and will probably recover sufficiently to return to


work, albeit perhaps at a reduced level. An employee with permanent total disability will have sustained an injury so severe that it prevents him from ever returning
(permanent) to any kind of productive work (total).
Another potentially problematic aspect of WC evaluations is that they typically ask for a specific impairment rating, a quantifiable expression of disability,
sometimes in the form of categories (mild, moderate, severe), but often as a numeric percentage (e.g., 25% impairment). These measures were initially developed
for physical impairments associated with manual labor (e.g., 35% impairment in
amount of weight lifted; 15% impairment in angle of knee rotation), but they are
far more difficult to apply to the kinds of psychological impairment associated with
PTSD and other psychological disability syndromes (45% impairment in mood?).
In ordinary civil tort cases, quantification of disability for purposes of predicting future need is also necessary to make a claim for monetary damages, but this is more
likely to be expressed in terms of cost of future need (e.g., number of recommended
psychotherapy sessions x fee per session), not percentage of impairment.
Furthermore, most WC standards require the evaluator to parse out what
proportion of the current disability is due to the work-related injury and what part
represents a preexisting condition. So, WC will compensate the employee for the
percentage of loss of ambulatory capacity caused by the right knee injury he sustained in his fall at work, but not for the percentage due to preexisting osteoarthritis
of the left hip. As frustrating as this solomonic apportionment might be for such a
physical injury, it is more bedeviling still for a psychological injury. For example,
how much of the middle-aged PTSD claimants work-disabling intrusive imagery
and hyperarousal symptoms experienced at his jobsite is due to the work-related
trauma, and how much is due to his history of mild anxiety and obsessivecompulsive disorder that he was treated for back in high school? How much of the
spacey detachment and impaired concentration of the female Army sergeant has
been caused by the traumatic sexual assault by her captain, and how much is related
to a prior diagnosis of ADHD? Finally, how much of the claimed psychological
disability is due to the work-related injury and how much may be exaggerated or
malingered for personal gain? Forensic clinicians who conduct WC evaluations of
workplace psychological injuries and military disability must be prepared to untangle these clinical-forensic Gordian knots and to reinforce their conclusions with
data and clear conceptual reasoning.

Practice Points
There are important differences between the civil and criminal legal systems in
the US, and the forensic clinician must be aware of how each system functions.
The essential elements of a civil personal injury lawsuit are duty, breach, causation, and damages. An evaluation for PTSD psychological disability must address each of these factors.

Practice Points

53

In making determinations of psychological injury or traumatic disability, it is important to differentiate PTSD from other syndromes with which it may overlap,
accompany, or be misdiagnosed (also see Chap.3).
Because most personal injury and workplace disability claims will ask for some
type of compensation, it is important for the forensic clinician to frame his or her
diagnostic conclusions in a predictive format. For example, the present claimants moderate PTSD from an assault while working as a nurse on a psychiatric
ward will prevent her from returning to a job involving institutional health care
settings. However, she may still be able to work in an office setting or in other
locales where she does not hasve to deal directly with patients, e.g., reviewing
records as a medical claims adjuster.
Understand the similarities of the Workers Compensation (WC) system to the
civil litigation system, but be aware of the important differences in terms of
limited scope of the evaluation, apportionment of disability, and quantification
of disability and future work capacity in WC evaluations.

Chapter 5

PTSD in the Criminal Justice System I:


Signs,Symptoms, and Syndromes

Is there an association between posttraumatic stress disorder (PTSD) and violent


criminal behavior? And if so, is the association causative, i.e., does PTSD produce
or precipitate the violent behavior, or is it merely correlative, i.e., are emotionally
unstable people more prone to both impulsive violence and the development of
PTSD?

PTSD and Violent Crime: Populations and Risk Factors


As noted throughout this book, only a small proportion of individuals who are exposed to a traumatic stress or develop clinically significant PTSD; and an even
smaller proportion of those go on to commit acts of aggression or other antisocial
behavior following their traumatic event. Who are the subjects in this violent subset
and how can we identify them?

Military Veterans
The overwhelming majority of research on PTSD and crime comes from studies
of military populations (Calhoun etal. 2004; Card 1983; Holbrook 2011; Kehrer
and Mittra 1978; Kulka etal. 1990; National Center for PTSD 2010; Pentland and
Rothman 1982; Shaw etal. 1987; Taft etal. 2009). As noted in Chap.1, an association between military exposure and subsequent civilian violence has been observed
in American conflicts since the Civil War. More recent systematic studies from the
Vietnam War era have demonstrated that veterans with a history of combat exposure, and especially those who had been diagnosed with PTSD, show a much higher
rate of conviction and incarceration for violent crimes than nonveterans or noncombat exposed veterans. PTSD-diagnosed veterans also self-report more feelings of
anger and hostility than other groups.
The Author 2015
L. Miller, PTSD and Forensic Psychology, SpringerBriefs in Psychology,
DOI 10.1007/978-3-319-09081-8_5

55

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5 PTSD in the Criminal Justice System I: Signs, Symptoms, and Syndromes

More recent studies of Iraq and Afghanistan theater veterans show similar trends,
with up to 35% of these veterans showing symptoms of PTSD, depression, alcohol
and drug abuse, suicidal ideation, completed suicide, and self-reported aggression 6
months after deployment. In both Vietnam and Iraq-Afghanistan veterans, there is a
special correlation between experiencing PTSD hyperarousal symptoms and having
greater difficulty controlling ones anger, aggressive impulses, and violent behavior.
Among Vietnam combat veterans, those who experienced heavy combat have had
a higher arrest rate than light combat or noncombat veterans. In most cases, these
same heavy-combat arrestees had little or no premilitary arrest record, seeming to
argue for a direct effect of heavy combat exposure on later propensity to commit
crimes. However, more than 80% of these arrests have been for nonviolent crimes.
The association between PTSD and aggression is reflected in studies of prison
populations, where a significant proportion of inmates are military veterans, particularly Vietnam-era veterans, probably reflecting that fact that these veterans have
been around longer than Iraq-Afghanistan service members and so have had more
time and opportunity for contact with the criminal justice system. Compared to
nonveterans, veteran prison inmates are more likely to have been convicted of murder, rape, or assault, but they are less likely to have been convicted of robbery or
burglary. Veteran support groups typically attribute this to the greater incidence of
service-related PTSD in incarcerated veterans. Histories of drug abuse are common
in incarcerated inmates, slightly less so for veterans than nonveterans, although
Vietnam-era veterans are more likely than nonveterans to have abused heroin.

Nonmilitary Populations
Some research has shown increases in aggressive behavior following civilian traumatic experiences; however, all of these have involved mass casualties that affected
large groups of people, even whole populations (Ardis 2004; Calhoun etal. 2004;
Cullen 2009; Daniels etal. 2007; Dworkin etal. 1988; Goenjian 1993; Johnson
2000; Newman etal. 2004; Nims 2000; Pynoos etal. 1987; Reijneveld etal. 2003).
These include an increased incidence of accidents, suicides, reckless driving, physical assaults, stabbings, and deaths following a caf fire in the Netherlands, the Columbine school shootings in the USA, and the Armenian earthquake. Posttraumatic
symptoms have affected both direct and indirect victims of these disasters. Little or
no information is provided about the specific characteristics of subjects who did and
did not experience these kinds of posttraumatic effects.

Risk Factors for Violent Behavior


Criminal psychologists have consistently identified a set of risk factors for criminal
behavior that appear to apply fairly universally to diverse populations and cultures
(Andrews and Bonta 2006, 2010; Appelbaum etal. 1999, 2000; Barratt 1994; Caprara etal. 1996; Dodge etal. 1990; Douglas and Skeem 2005; Douglas and Webster

PTSD and Violent Crime: Populations and Risk Factors

57

1999; Link and Stueve 1994; Lipsey etal. 1997; McNiel etal. 2003; Miller 1987,
1988, 1994b; Monahan 2001, 2002; Monahan etal. 2001; Novaco 1994; Skeem
etal. 2005; Steadman etal. 1998; Swanson etal. 1990, 1996, 2006; Webster and
Jackson 1997; Wolf and Shi 2010). Most of these risk factors have also been identified in military personnel, with or without PTSD, who have committed violent or
other antisocial acts post-deployment (Beckham etal. 1998; Begic and Jokic-Begic
2001; Carlson etal. 2008; Chapin 1999; Dileo etal. 2008; Dohrenwend etal. 206;
Elbogen etal. 2008, 2010; Freeman and Roca 2001; Grafman etal. 1996; Hartl etal.
2005; Hiley-Young etal. 1995; Jakupcak etal. 2007; Kilgore etal. 2008; Kulka
etal. 1990 Lasko etal. 1994; Lehmann etal. 1999; McFall etal. 1999; McGuire
and Clark 2011; Moss 1989; Pardek and Nolden 1983; Pasternack 1971; Roca and
Freeman 2002; Taft etal. 2007, 2009; Teten etal. 2009; Windle and Windle 1995;
Yesavage 1983, 1984; Zatzick etal. 1997). Therefore, when evaluating cases of alleged PTSD-related violence, the examiner should always be alert for evidence of
premorbid traits such as the following.

Impulsivity
This is the tendency to respond to situations without sufficient reflection or consideration of consequences. It is also associated with poor frustration tolerance and
weak self-control. Many of these individuals may be observed to have hair-trigger tempers and to leap before they look. They will often endorse and self-justify
these actions, seemingly heedless of their own role in their interpersonal and legal
difficulties, or in some cases actually self-applauding their wanton activities, despite the destructive effects of this behavior on their lives and those around them.

Negative Emotionality
Many offenders have a characteristically dour, edgy, anxious, agitated, pessimistic,
suspicious, and hostile emotional tone that makes them highly prone to overreacting
to even mild provocations. They tend to attribute malign motives to others and to react accordingly. Consequently, they often find themselves in conflict with multiple
adversaries, are avoided and mistrusted by most people, and then they complain that
they cannot trust anybodya classic self-fulfilling prophecy.

Antisocial Behavior and Attitudes


Many chronic offenders take great pride in their rebel status and do their best to
advertise it to the world. They often see themselves as noble warriors in a hostile
environment, deserving praise (and the status, money, and sexual conquests that
go with it), for being clever enough and strong enough to outwit or outfight rivals

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5 PTSD in the Criminal Justice System I: Signs, Symptoms, and Syndromes

and take what they want. Many have histories of antisocial behavior dating back to
childhood.

Alcohol and Substance Abuse


This can be a direct factor for criminal violence by lowering inhibitions to antisocial
behavior while intoxicated, or a proxy factor, i.e., impulsive, thrill-seeking people
who commit violence for kicks are also highly likely to enjoy getting drunk and
high; the two factors are correlated but not necessarily causative. So well-associated
is the connection between alcohol and criminal behavior that virtually all probation
and parole agreements mandate abstention from substances and avoidance of establishments where alcohol is served and of persons who are associated with drug use.

Unstable Interpersonal Relationships


Again, this may represent a case of bidirectional influence. Impulsive, violent, and
unstable people are less likely to enter and remain in long-term relationships in the
first place and, at the same time, the absence of those relationships may deprive
them of one last buffer against violent behavior.

Psychosis
Psychosis by itself is a weak predictor of criminal violence, but when associated with paranoia, delusions of thought control, and command hallucinationthe
threat/control-override syndrome (Link and Stueve 1994; Link etal. 1992, 1998;
Swanson etal. 1996)this can represent a particularly dangerous situation. In addition, psychosis increases the risk of violent behavior in subjects who are comorbid
for antisocial personality disorder (Miller 2012c).

Poor Treatment Compliance


For those at-risk offenders who have been receiving treatment, failure to adhere to
clinical recommendations or to follow through with their treatment is a strong risk
factor for recidivistic criminal behavior. Again, the effect may be another bidirectional vicious cycle: impulsive, unstable people have a hard time staying with any
treatment program, and absence of treatment makes these behavioral disturbances
worse.

PTSD and Violent Crime: Populations and Risk Factors

59

Neurological Injury
Traumatic brain injury, particularly that which affects the brains frontal lobes, can
have a disinhibitory effect on aggressive behavior, although the relationship may
be complex. That is, a higher incidence of traumatic brain injuries is most likely to
occur in those young males who are already most prone to risky and confrontational
behavior such as automobile speeding and fighting. In the military, more impulsive,
thrill-seeking personnel may volunteer for the most dangerous missions and take
greater risks during their deployments. However, where the behavioral impulsivity
follows a brain injury in the context of a previously normal personality and behavioral pattern (as in a military explosive injury by a roadside bomb), a causal link to
the injury itself, rather than premorbid factors, is easier to make (Miller 1987, 1988,
1990a, 1992, 1993c, 1994b, 2012a, 2012c; Vasterling etal. 2010, 2012).

Demographic and Contextual Factors


These include male sex, younger age, lower educational level, lower socioeconomic
status, possession of firearms, history of frequent unemployment or homelessness,
history of childhood abuse and/or early exposure to extreme violence, and dysfunctional family of origin.
Note that any or all of these risk factors may coexist in a given subject with
PTSD without there being any causal connection to the syndrome. In fact, the existing evidence suggests that the criminogenic traits of emotional instability, impulsive reactivity, and negative emotionality may actually contribute to a heightened
risk for developing PTSD in the first place (Bowman 1997, 1999; Koch etal. 2006;
Miller 1987, 1988, 1990a, 1992, 1993c, 1994b, 2012a, c). At the time of the clinical
examination, a clinician who hears his subject report violent behavior in connection
with his trauma symptoms may erroneously conclude that the bad behavior was a
direct consequence of the index traumatic event, which is why a thorough understanding of a subjects prior history is so important.

Injury-related Factors
These risk factors for violence in traumatized subjects, studied most intensively
with military personnel, may exist independently or co-occur with the dispositional
risk factors described above. Injury-related risk factors for violence include: (1)
greater number of life-threatening combat exposures, the so-called dose effect;
(2) seeing people killed, injured, or maimed; (3) killing another person; and (4)
a high prominence of hyperarousal and/or numbing PTSD symptoms following
traumatic exposure. When these factors are present, and premorbid risk factors are
largely absent, it can be more confidently asserted that there is a direct relationship
between trauma-induced PTSD and subsequent criminal behavior (Table5.1).

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5 PTSD in the Criminal Justice System I: Signs, Symptoms, and Syndromes

Table 5.1 PTSD and Criminal Violence: Possible Associations


Dissociative flashback

The subject attacks another person in a delusional and hallucinatory


state, in which he believes himself to be in actual danger replicating his experience during the index traumatic event. If confirmed,
this is probably the closest clinical correlate to the legal concept of
temporary insanity, and is the most common affirmative defense
offered in PTSD cases

Limbic psychotic trigger


reaction

A very rare subvariant of dissociation in which violence or other


bizarre behavior occurs in a delusional state triggered by a cue that
reminds the subject of a past traumatic event. LPTR may contain
elements of dissociation and temporal lobe seizure activity, and this
syndrome is still incompletely understood

Combat addiction

The subject becomes habituated to the thrill of violent combat in


wartime, and returns to civilian life with an overwhelming compulsion to satisfy his taste for battle, impelling him into confrontational situations on the home front. Always check the subjects
premorbid history, since naturally aggressive people may opt for
violence with or without combat experience

Mood disorder

This usually involves violence committed during a bipolar manic


episode or a suicide-homicide carried out in a state of posttraumatic
despair. Assess prior history of mood disorders

Sleep disorders

In REM-sleep behavior disorder, the subject may act out a violent


dream, injuring someone nearby. During a confusional arousal or
during an episode of somnambulism (sleepwalking), the subject
may carry out complex behavior, including violence, during a state
of slow-wave sleep. Always try to ascertain whether the subject
was truly asleep during the episode, and assess for a prior history of
sleep disturbances

PTSD and Violent Crime: Patterns and Causes


In recent years, two very similar typologies of PTSD-related violence have been
preferred, that of Wilson and Zigelbaum (1983) and Silva etal. (2001). Although intended to apply to military veterans, similar phenomena have been reported to occur
in civilian law enforcement trauma (Miller 2006a, b, c, d, 2007a, e, 2008a, b; Violani
1999). The categories are: (1) dissociative/flashback-related violence, where the
subject acts defensively in response to what is essentially a delusional re-enactment
of a prior traumatic event; (2) combat addiction/sensation-seeking syndrome, where
the subject has become dependent on the adrenalinized rush of combat and seeks,
deliberately or unconsciously, to recreate that stimulation through dangerous and
aggressive behavior; (3) mood disorder-associated violence which can range from
manic agitation to suicidal depression; and (4) sleep disorder-associated violence
which may involve either a lowered threshold to violence caused by insomnia and
impaired sleep cycles, or, alternatively, the presence of specific parasomnias, such
as sleepwalking or REM sleep behavior disorder. These will be described below.

PTSD and Violent Crime: Patterns and Causes

61

Dissociation/Flashback-Related Violence
Studies have shown that the symptom of dissociation, whether as part of the PTSD
syndrome or not, is associated with an increase in violence in a wide range of populations (Moskowitz 2004). The experiencing of dissociative states, while an uncommon presentation of PTSD in general, seems to be the most common manifestation
of PTSD related to criminal behavior. In this scenario, the subject re-experiences elements of the trauma in dreams, uncontrollable and emotionally distressing intrusive
images, episodes of reliving the traumatic event, and in behavioral re-enactments
of the traumatic situation. In most of these reported cases, the victim of the attack
is misidentified as a former enemy who is perceived to be threatening the subject
during the dissociative flashback which replicates the original traumatic event, such
as a firefight in a war zone or a civilian first responder deadly encounter (Auberry
1985; Friel etal. 2008). For example, an Afghanistan veteran dining at a Middle
Eastern restaurant may mistake the waiter holding a teapot for an enemy combatant
wielding a grenade and attack the employee to protect himself. Amnesia may be
reported for the dissociative violent episode, although, in any particular case, it may
not be immediately clear how much of this is a self-serving description when criminal charges are pending, inasmuch as many other subjects with noncriminal-related
flashbacks can clearly recall their episodes (Moskowitz 2004; Silva etal. 2001).
With all dissociative syndromes, the forensic challenge is to demonstrate that the
criminal behavior indeed occurred in such an impaired state of consciousness that
the subject literally did not know what he was doing or was unable to control his
actions (Miller 2012a, c; Slobogin 2010). For example, many subjects may lose
it, go ballistic, go postal, or otherwise attack another person in a fit of rage,
but extreme anger or other emotional disturbance, in and of itself, is not evidence of
dissociation or of an exculpatory or mitigatory impairment of the mind. This will be
discussed further in Chap.6.

Limbic Psychotic Trigger Reaction


A very rare syndrome that might be considered a subset of the dissociation/flashback-related category of PTSD-related violence is the limbic psychotic trigger reaction (LPTR), which has been described largely through the work of Pontius (1981,
1984, 1987, 1996, 1997). LPTR is characterized by sudden eruptions of violent
behavior that occur in response to a seemingly innocuous event which, however, represents an idiosyncratic trigger to a severe traumatic memory in a subset of
young males described as shy loners. In response to this symbolic trigger, the
individual may attack total strangers without an apparent plan, motive, or provocation. The attack is often preceded by several minutes of confusion and disorientation, which may include an aura, such as sounds, flashing lights, or strange bodily
sensations. The next phase may include delusions, hallucinations, and out-of-character acts, including robbery, sexual assault, or murder. These paroxysmal episodes

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5 PTSD in the Criminal Justice System I: Signs, Symptoms, and Syndromes

may last up to 20min and may include autonomic nervous system symptoms of dizziness, nausea, sweating, cold sensations, and uncontrolled urination, erection, or
ejaculation. These manifestations, along with the violent act itself, occur seemingly
without emotion, but are usually well-remembered. Upon recovery, most subjects
are frightened and remorseful about what they have done.
Although the term limbic psychotic trigger reaction would seem to imply some
kind of neurophysiological dysfunction, there is no specific brain abnormality that
has been identified to explain this disorder, although some features of the syndrome
are reminiscent of temporal lobe seizure phenomena. The psychotic component
relates to the fact that there is a delusional and hallucinatory quality to the episodes,
but between episodes, these subjects do not resemble patients with schizophrenia
or other psychotic disorders. The trigger part refers to the fact that each subject
has very individualized eliciting stimuli, typically relating to prior traumatic experiences in the subjects life that had been repressed. Similar to a PTSD flashback,
the trigger evokes a reliving of the traumatic experience, from which the subject attempts to defend himself with a violent reaction. LPTR is a very rare syndrome and
has been definitively diagnosed in only 18 out of 200 criminal felony cases referred
for evaluation of an exculpatory brain syndrome or mental disorder (Pontius 1987,
1996). Its precise relationship to the more common manifestations of PTSD is as
yet unclear.

Combat Addiction/Sensation-Seeking Syndrome


This category describes the veteran who has become addicted to the violence he
experienced and/or perpetrated in wartime and therefore finds it hard to leave the
aggressive mindset behind when he returns to the civilian world. Individuals affected by this type of combat addiction will seek out or create circumstances where they
can re-experience the dangerous thrill of previous combat encounters by engaging
in repeated patterns of aggressive behavior. Preoccupation with weapons, fighting,
sexual offending, and domestic violence are typical expressions of this kind of this
stimulation-seeking behavior. The episodes of heightened violence-related excitement are typically followed by a letdown period, and these ups and downs occur cyclically. While some of these individuals may be trying to master disturbing
traumatic memories by acting them out, most will describe a never-ending quest to
recapitulate the rush they felt in combat. There is usually no dissociation per se
and most of these subjects realize that their antisocial activities can get them into
trouble, but they report being nevertheless driven to pursue them (Auberry 1985;
Friel etal. 2008; Grossman and Christensen 2007; Moore etal. 2009; Solursh etal.
1991). Note that this pattern has no diagnostic correlate in the formal PTSD criteria.
In a sample of 100 Vietnam War veterans attending outpatient clinics at a Veterans Administration Center (Solursh etal. 1991), 81% reported being unable
to stay away from their weapons, 94% described their re-experiencing phenomena as exciting and associated with a rush or a high, followed by a down

PTSD and Violent Crime: Patterns and Causes

63

feeling when the sensation has passed, and 59% reported seeking physical fights
for excitement after leaving military service. The authors conclude that heightened
arousal states might cause these men to become addicted to violence. However, as
noted earlier, in many cases, the direction of the cause-and-effect pattern may not
be straightforward. That is, subjects who are already predisposed to antisocial and
sensation-seeking behaviors are more likely to actively pursue activities that provide thrills through sexual activity, drug use, and aggressive power displays (Hare
1999, 2006; Lykken 1995; Miller 1987, 1988, 2012c; Zuckerman and Kuhlman
2000); these are the same subjects who were probably most likely to seek out dangerous combat situations or take the greatest risks during their military service and
to have carried back to civilian life their taste for violent confrontation, whetted and
intensified by their wartime experiences.
The other question is whether or not a hunger for repeated violence, however
predisposed, acquired, triggered, or reinforced, truly represents an addiction in
the sense that is generally described for dependence on chemical substances. And
even if the psychobiological bases for addiction to combat could be demonstrated to
be equivalent to that for a narcotic, the law is still resistant to exculpating criminal
responsibility merely on the basis of addiction to alcohol or drugs alone, no matter
how strongly some clinicians may argue that such an addiction is a disease. The
laws attitude seems to be that people are responsible for managing those personal
risk factors, even medical ones, that they can reasonably be expected to control.For
example patients with epilepsy or diabetes must take their medications and nearsighted persons must wear their glasses while driving. Failure to control a dangerous impulse is not the same as the inability to do so, and, for the latter determination
to be made, the burden of proof is on the defendant, whether the proposed exculpatory or mitigatory syndrome is drug addiction, schizophrenia, dementia, or PTSD
(Miller 2012c; Slobogin 2006, 2010; Treadwell 2010).

Mood Disorder-Associated Violence


Mood disturbance is a common, if nonspecific, symptom of PTSD. Therefore, it
would not be surprising if the irritability and emotional lability of PTSD subjects
caused them to display a hair-trigger reaction to provocation, which would no doubt
be exacerbated in those who have had a longstanding angry, hostile, and impulsive
temperament to begin with (Chemtob etal. 1994; Friel etal. 2008; Lasko etal.
1994), what Silva etal. (2001) have termed mood lability-associated violence. An
alternative scenario involves a depressed veteran who suffers from such severe survivor guilt that he desires death to end his misery. This subject might engage in
poorly planned or executed criminal activity for the chief purpose of getting caught
or killed (Auberry 1985), as in suicide by cop perpetrators who threaten police officers with deadly force in order to provoke the officers into killing them (Homant
etal. 2000; Kennedy etal. 1998; Lord 2000; Miller, 2006a, d). However, the clinical
syndrome of depression can occur with or without PTSD, and veterans can become

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5 PTSD in the Criminal Justice System I: Signs, Symptoms, and Syndromes

depressed and suicidal for reasons that are: (1) directly related to their service (survivor guilt, physical disability); (2) indirectly related to their service (inability to socially or vocationally adjust to civilian life) or (3) entirely unrelated to their service
(family problems, financial stresses, premorbid psychopathology).

Sleep Disorder-Associated Violence


Although characterized by a state of unconsciousness, sleep is actually a very
complex psychophysiological process. Every night, most people go through several sleep stages, ranging from the light sleep one experiences when just drifting
off, to the deeper, restorative slow-wave sleep stage that rejuvenates us, and the
rapid eye movement (REM) sleep stage associated with most dreaming. These sleep
cycles occur several times throughout the night. There are a variety of disorders of
sleep, called parasomnias, that can disturb the normal sleep rhythm, ranging from
simple insomnia to prolonged sleepwalking, and a small number of these parasomnias have been associated with violent behavior during sleep. While disturbed sleep
and nightmares are common symptoms of PTSD, a number of violence-associated
parasomnias may occur with no special relationship to a known PTSD history, although it is possible that a traumatic experience or series of traumatic events might
trigger these parasomnias in susceptible individuals, with or without a co-occurring
PTSD diagnosis (Friel etal. 2008; Moore and Krakow 2009; Schenck and Mahowald 1995; Schenck etal. 1986, 2009).

REM Sleep Behavior Disorder


Most vivid dreaming occurs during rapid eye movement, or REM sleep, and a special REM paralysis mechanism in the brainstem normally keeps us from moving
around in response to dream images. REM sleep behavior disorder (RSBD) is characterized by the malfunctioning of this movement-dampening brain mechanism,
disinhibiting the sleeper to literally act out his or her dreams (Schenck and Mahowald 1995; Schenck etal. 1986, 2009). Most violent activity in this state tends
to occur in response to a bedmate trying to rouse the sleeper, although spontaneous
acts of aggression may occur, as when the sleeper is dreaming of being attacked and
grabs the bedmate, thinking he or she is the attacker in the dream. Documented acts
committed during RSBD episodes include choking or headlocking the bed partner,
jumping from the bed into a wall or furniture, or throwing the bed partner out of
a window. Silva etal. (2001) describe a patient with combat PTSD who, during a
vivid combat dream, began swinging his arms forcefully, fracturing his wifes rib.
In RSBD, the dreamer typically recalls the events of the dream itself, but is unaware
of his real-world behavior while he is doing it in his sleep.
Slow-wave sleep (SWS) disorders of arousal do not usually involve the actingout of a dream. They occur during slow-wave sleep, not REM sleep, but they share

PTSD and Violent Crime: Patterns and Causes

65

the feature of disinhibition of movement that characterizes both disorders (Cartwright 2004; Guilleminault etal. 1995; Pressman 2007). SWS disorders of arousal
include sleepwalking, confusional arousals, and night terrors. In most cases, the acts
committed during these episodes are noncriminal and nonaggressive; However, in
a small proportion of cases, extreme violence has been documented, including assault and murder.

Night Terrors
Unlike nightmares that occur during REM sleep, night terrors occur in SWS and
are distinguished from REM-stage nightmares by a predominance of physiological
manifestations of fearful arousal (shaking, sweating, heart palpitations, screaming),
and a paucity of dream content or coherent dream narrative; that is, there is a lot of
emotion with very little dream story, and, upon awakening, the subject is typically
unable to recount what he or she was so terrified about. However, brief fragments
of frightening visual imagery may occur during night terrors, impelling the sleeper
to try to escape or to defend himself violently, which may result in a confusional
arousal or sleepwalking episode (see below).

Sleepwalking
In this syndrome, also called somnambulism, the individual gets out of bed and
may wander a few feet or several miles, although most sleepwalkers remain within
the confines of their sleeping environment, most commonly their home. The sleepwalkers eyes are often open (unlike in REM sleep, where they are almost always
closed) and there is often an automatistic and confused aspect to the subjects behavior. Violent or sexual acts have been documented to occur in a small proportion
of cases during these episodes, the former usually triggered by attempts to arouse
the sleepwalker, the latter often having no clear precipitant other than opportunity
and stimulus. Arousal from the SWS state is more gradual than from REM sleep,
and the subject typically does not recall any significant dream content or remember
his or her behavior during the episode.

Confusional Arousals
These involve the same disturbances in consciousness as sleepwalking, except that
the sleeper does not leave the bed. In cases of violence, the only ones at risk are
typically those who share sleeping quarters with the subject.
In a few cases, SWS phenomena have been successfully used as a defense of
diminished capacity (Schenck and Mahowald 1995; Schenck etal. 1986, 2009), but

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5 PTSD in the Criminal Justice System I: Signs, Symptoms, and Syndromes

no special relationship to PTSD is noted for these parasomnias, although they may
occur as part of the PTSD syndrome in some cases.

Noncombat Trauma-Associated Violence


Not included in the above categories, perhaps because they are rarely used in cases
of criminal defense, are instances of noncombat trauma-associated violence, such
as that which has been reported to follow fires (Reijneveld etal. 2003), school shootings (Cullen 2009; Johnson 2000), and natural disasters (Goenjian 1993). Also not
included are cases of law enforcement critical incident-associated violence (Miller
2000, 2006b, d, 2007e, 2012c, 2013c, d, in press-a), although an analogy with combat trauma has been made explicitly for this group (Violanti and Paton 1999).

Active Shooter PTSD


Even in circumstances where an act of killing is socially sanctioned, such as in
the military and law enforcement, soldiers and police officers often go through a
series of stages following the service-related taking of a human life (Campsie and
Campsie 2006; Grossman 1996; Miller 2006d, 2008a, 2012c, 2013c; Moore etal.
2009; Nielsen 1991; Rodgers 2006; Williams 1999), including: (1) concern about
being actually able to pull the trigger; (2) the actual killing experience; (3) a stage
of exhilaration; (4) a remorse and nausea stage; (5) a recoil and remorse phase; and
(6) a final phase of rationalization and acceptance.
For civilian police officers, feelings of guilt or self-recrimination may be especially likely in cases where the decision to shoot was less than clear-cut or where
the suspects actions essentially forced the hand of the officer into using deadly
force, such as in a botched robbery, domestic dispute, or suicide-by-cop scenario
(Kennedy etal. 1998; Lindsay and Dickson 2004; Miller 2006d; Perrou and Farrell 2004; Pinizzotto etal. 2005). Military service members may be able to feel
more justification in killing on a traditional battlefield, but may experience many of
the same kinds of self-recrimination in the nontraditional fighting arenas that have
characterized most wars since the Vietnam era, in which targets are often elusive
and ambiguous, with blurred lines between combatants and civilians.
In the worst case, adequate resolution may never occur, and the police officer or
soldier enters into a prolonged posttraumatic phase, which may effectively end his/
her law enforcement or military career. In less severe cases, a period of temporary
stress disability allows the service member to seek treatment, to eventually regain
his or her emotional and professional bearings, and to ultimately return to the job.
Still other service members return to work right away, but continue to perform marginally or dysfunctionally until their actions are brought to the attention of superiors
(Anderson etal. 1995; Bender etal. 2005; Blum 2000; Campsie and Campsie 2006;
Cohen 1980; Geller 1982; Honig and Sultan 2004; Kelly and Vogt 2009; Koren

Practice Points

67

etal. 2007; Miller 2006d, 2008a, g 2013c; Nielsen 1991; Rudofossi 2007; Russell
and Beigel 1990; Violanti 1999; Williams 1999).
Finally, although we naturally think of those who commit violence as the purveyors of traumatic stress, not its victims, even some criminal offenders may suffer
PTSD-like symptoms as the result of the traumatizing effects of their own actions,
or of experiencing the consequences of their crime, i.e. arrest, interrogation, and
incarceration (Byrne 2003; Friel etal. 2008; Grey etal. 2003; Harry and Resnick
1986; Papanastassiou etal. 2004; Pollock 1999). These are not typically offenders
with antisocial personality disorder who are unlikely to feel much anxiety or remorse over their aggressive actions, but rather characteristically nonaggressive individuals who committed their acts of violence during an episode of loss of control,
as an unplanned, impulsive or provoked crime of passion. The violence is thus out
of character for the perpetrator, which contributes to its self-traumatizing effect, and
a number of these defendants may actually be willing to plea-bargain rather than
face further traumatization by reliving the crime at trial.

Practice Points
Only a small proportion of individuals who are exposed to a traumatic stressor
develop clinically significant PTSD. And an even smaller proportion of those
go on to commit acts of aggression or other antisocial behavior following the
traumatic event.
Both military and civilian populations are at risk for PTSD-related violence, but
this has been studied far more thoroughly in military service members, and we
need more research on civilian populations.
In any given subject, a number of direct and indirect risk factors for violence
may exist independent of, and/or interacting with, a diagnosis of PTSD, and
these must be factored into any clinical-forensic evaluation.
Several PTSD and PTSD-like subsyndromes have been associated with violent
behavior, as have a variety of clinical syndromes that are unrelated or partially
related to PTSD. Forensic clinicians need to be aware of these.

Chapter 6

PTSD in the Criminal Justice System II: The


Insanity Defense and Diminished Capacity

The fields of psychology and criminal justice are like two twins, separated at birth,
who discover later in life that they have been living on the same block and working
in the same place their entire lives. Both fields concern themselves with the nuances
of human thought, emotion, intention, volition, behavioral expression, and self-controlin one case as it applies to clinical diagnosis and treatment, in the other, as it
relates to criminal motivation, blameworthiness, and punishment (Miller 2012c).

Criminal Forensic Psychological Evaluations


Although forensic psychologists and psychiatrists may be called upon to conduct evaluations in a wide range of legal contexts, the majority of psychological evaluations for
the criminal court involve three main areas: (1) competency to stand trial; (2) mental
status at time of offense, or insanity evaluation; and (3) prediction of dangerousness
and risk of future offending (Miller 2012c). The most frequent context of posttraumatic
stress disorder (PTSD) claims in the criminal justice system relates to the sanity of the
defendant at the time of the crime. In this regard, two basic principles apply.
First, the presence, absence, or severity of any diagnosed mental disorder, condition, or state does not by itself make a legal determination. That is, just because a defendant suffers from verifiable PTSDor any other mental disorder, such as schizophrenia, bipolar disorder, or an organic brain syndromethis does not automatically
mean he/she is not guilty by reason of insanity. It is the examining experts responsibility to assert or refute the connection between the defendants mental state at the
time of the offense and the relevant insanity criteria or other legal question.
Second, any conclusions about the relevance of the defendants mental state to
the legal question at issue must consider the point in time of that issues relevance.
This explicitly addresses the time element. The defendants mental state at the time
of the forensic psychological examination may be similar or very different from his
or her mental state at the time of the alleged offense, which might have occurred
months or years earlier. In one case, a defendant who committed murder while in
the throes of a PTSD dissociative flashback or in a suicidal depression-fueled rage
The Author 2015
L. Miller, PTSD and Forensic Psychology, SpringerBriefs in Psychology,
DOI 10.1007/978-3-319-09081-8_6

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may have undergone treatment and is now, at the time of the examination, sufficiently recovered as to show only minimal or no symptoms. Conversely, shortly
following a traumatic event, the subject may have shown minimal symptoms at
the time he committed the index offense, but as months roll by and treatment is
delayed, his condition worsens, so by the time of the forensic examination, he is in
a severely deteriorated state. In both cases, what is relevant to an insanity defense
is the subjects mental state at the time of the index offense, no matter what it may
be right now. That is, an insanity evaluation always entails a retrospective diagnosis
(Gutheil 2002).

The Insanity Defense


Despite isolated media accounts of flagrant abuses of the insanity defense letting
hard-core criminals go free, in reality, the defense of not guilty by reason of insanity
(NRGI), or not guilty by reason of mental disease or defect, or simply the insanity
defense, is raised as an affirmative defense in about one out of every 100 felony
cases. In about half of these, the defendant is so obviously disturbed that both prosecution and defense sides agree to adjudicate the case as NGRI without trial. It is
only in the other half of 1% of cases that the two sides disagree and a TV-style
battle of the experts ensues. And, in about half of these contested casesone in
400the jury finds the defendant NGRI following a trial. Thus, the law sets a relatively high legal bar with regard to a persons criminal responsibility (Miller 2012c;
Gover 2008; Slobogin 2006, 2010).

Insanity Defense Standards


A basic tenet of the American legal system is that, to be justly punished for a crime,
a defendant must be proven to (1) have actually committed the offense in question,
called actus reus, or guilty act; and to (2) have had the mental capacity to have
committed the act consciously, knowingly, autonomously, and purposefully, known
as mens rea, or guilty mind. Note that, a verdict of NGRI is not an excusatory or
mitigating factor; it is literally a verdict of not guilty, i.e., the defendant is just as
legally blameless as if he or she did not commit the act at all. That is because the
law recognizes a subtle but crucial psychological and philosophical principle of
human nature: for an act to be consciously (I know Im doing it) and purposefully
(I decide to do it) committed, requires the presence of identity (it is I who am
doing it) and agency (it is my free choice to do it, not otherwise compelled). This
principle, tacitly or overtly, underlies the major NGRI standards of the USA and
most Western societies.
The two major principles that guide insanity evaluations in the USA are the
MNaghten test and the American Law Institute (ALI) test; different states employ
one or the other standard. The first goes back to the 1843 British case of Daniel

The Insanity Defense

71

MNaghten, who was acquitted by reason of insanity for killing Edward Drummond, secretary to Prime Minister Sir Robert Peel, during an attempt to assassinate
the prime minister himself. At the time, MNaghten was laboring under the delusion that Peel and the Tory party were involved in a plot to kill him and that he was
only defending himself by preemptively attacking the prime minister (Allnutt etal.
2007). In response to the public outcry in this case, Queen Victoria ordered the British House of Lords to come up with a more rigorous standard for insanity, which
ultimately became the one that bears the defendants name.
According to the MNaghten test, in order to establish a defense on the grounds
of insanity: It must be clearly proved that, at the time of committing an act [at that
specific time, no matter what the mental state may have been prior or subsequent to
the act], the party accused was laboring under such a defect of reason [his powers
of perception and/or cognition were severely impaired], from disease of the mind
[there must be an identifiable, diagnosable syndrome, recognized by the medical
community, to account for the mental disturbance], as to not know the nature and
quality of the act he was doing [he literally did not know what he was doing], or
if he did know it, that he did not know he was doing wrong [he literally could not
tell right from wrong based on the prevailing laws and moral standards of his community and culture].
In 1962, the American Law Institute drafted the Model Penal Code, under which
their insanity standard came to be known as the ALI test: A person is not responsible for criminal conduct if at the time of such conduct, as a result of mental disease
or defect [same as MNaghten], he lacks substantial capacity [he may not be totally
lacking in capacity, but sufficiently impaired] either to appreciate the criminality
(wrongfulness) of his conduct [same as MNaghten] or to conform his conduct to
the requirements of the law [even if he understands what he is doing and knows that
it is wrong, he is effectively powerless to control it].
The chief differences between the two standards is that MNaghten is a purely
cognitive test, according to which the defendant either did not know what he was
doing during the commission of the crime, or else he could not distinguish right
from wrong. The ALI preserves the cognitive right-wrong standard but adds a volitional prong, i.e., even if the defendant understood what he was doing, and that it
was wrong, he was substantially powerless to control himself. What is often debated
in criminal cases involving the ALI standard is just what degree of lack of control
qualifies as substantial. What both standards share is a fairly strict set of exclusion
criteria to invoke a NGRI defense, as well as the requirement for presence of a recognized medical, neurological, or psychiatric disorder to account for the cognitive
or volitional impairment.
Clinically, there are very few mental disorders whose symptoms are sufficiently disabling to produce such an exculpatory level of impairment. Most qualifying
syndromes would fall into the category of severe psychosis or some type of organic
brain syndrome. In those cases where a murder defendant might claim NGRI on the
basis of PTSD, the only PTSD component that might meet either the MNaughten
or ALI standard would be a dissociative flashback in which the defendant literally
believed he was experiencing the original trauma and genuinely felt in fear for his
life, causing him to defensively retaliate by killing the victim (Friel etal. 2008;

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6 PTSD in the Criminal Justice System II

Packer 1983; Sparr 1996); essentially, this would be equivalent to responding to a


severe delusional psychosis. The presence of other PTSD symptoms, such as anxiety, irritability, nondissociative flashbacks, nightmares, and hyperarousal, would
not in themselves create grounds for an insanity defense, any more than would a
mood disorder, anxiety disorder, personality disorder, or other nonpsychotic psychiatric condition. The level of traumatization, i.e., how severe the original ordeal
the defendant went through or the symptoms he has suffered afterwards, would be
irrelevant, as being in severe emotional pain is not in itself grounds for insanity, any
more than would be suffering from a severe toothache.
Because of these strict exclusionary considerations, PTSD is very infrequently
raised as an insanity defense (Miller 2012c; Slobogin 2006), somewhat more commonly in the USA than in the European countries, and more often in military than
civilian contexts, probably because of the American Vietnam legacy (Mackay and
Kearns 1999). In one sample of 8163 defendants pleading NGRI, only 28 (0.3%)
had received a primary diagnosis of PTSD, and these defendants were slightly more
likely to be found guilty that NGRI defendants with other psychiatric diagnoses,
such as schizophrenia (Applebaum etal. 1993).
Of four PTSD/NGRI cases that I have personally declined to take (Miller 2012c),
one defendant was grossly malingering (see Chap.3), two did indeed suffer PTSD
(one military, one civilian law enforcement-related), but showed no evidence of
dissociative flashback phenomena during the crime (one involved a bar fight with
serious injury to the victim, the other a domestic battery, both fueled by alcohol),
and the fourth was observed by witnesses to commit the murder in what appeared
to be a rageful frenzy, but there was no evidence of impaired mental status other
than extreme anger, and there had been a long prior history of bad blood between
the defendant and the victim, related to an ongoing workplace dispute. In all these
cases, I informed the respective defense attorneys that I could not credibly make
a case for PTSD-related NGRI. One attorney suspected as much and was actually
relieved to be off the hook. Another was summarily fired by his client for sending
him to a quack (me), and the other two lawyers went off to seek further opinions.

Diminished Capacity
At the conclusion of a trial in which the jury has found the defendant guilty, the
judge sets a date for the sentencing hearing. In some jurisdictions, the jury who
decided on the defendants guilt also deliberates and determines the sentence. In
other jurisdictions, the judge, sometimes utilizing mandated guidelines, determines
the sentence and outlines his or her reasoning in a sentencing report that summarizes the facts of the case and provides the rationale for the judges decision. In
cases where there is judicial discretion, the sentencing hearing is the forum in which
third parties can present evidence or personal appeals, in the form of aggravating or
mitigating factors, that are intended to influence the sentencing decision in either a
stricter or more lenient direction.
Aggravating factors, typically presented by the prosecutions side, may include
the defendants past criminal history (usually excluded at trial), the particularly cruel

The Insanity Defense

73

and callous manner in which the crime was committed, the lasting impact of the
crime on the victim or survivors, the lack of a stable family or social structure that
the defendant can safely return to, and so on. Mitigating factors, typically presented
by the defense side, seek to portray the defendant as overall less malevolent and
dangerous, e.g., he was influenced by bad peers, his mind was impaired by drugs
or mental illness, he did not cause unnecessary harm or injury during the crime, he
played a peripheral role in the crime (e.g., drove the getaway car, but did not participate in the holdup), he has a stable job and family structure to return to, and so on.
One type of potentially mitigating factor is the claim of diminished capacity, that
is, the defendants mental state at the time of the crime was sufficiently impaired as to
lessen his overall culpability or blameworthiness for the criminal act. Since the purpose
of the sentencing stage is not to determine legal guilt or innocence, as in an insanity
defense, issues of mitigation due to diminished capacity typically require a less severe
degree of impairment than NGRI. Often, the same type of evidence is presented at
sentencing that may have originally been offered at trial to form grounds for an insanity
defense, but did not at that time rise to the standard necessary for acquittal by NGRI.
These may include a history of early childhood abuse, dysfunctional family of origin,
susceptibility to undue influence by antisocial peers, limited intellectual capacity, or
any number of medical or mental disorders (e.g., schizophrenia, traumatic brain injury)
sufficient to affect ones actions but not severe enough to meet the NGRI standard. In
some jurisdictions, diminished capacity may be asserted ahead of trial to argue for a
lesser charge, e.g., reducing a murder charge to manslaughter.
In arguing for diminished capacity due to the presence of PTSD as a diagnosis, one might expect these defendants to receive greater sympathy than those with
other syndromes, especially if the PTSD defendant suffered his or her trauma in
the course of his service to his community or country, (police officer or military
veteran), or at least was an innocent victim of a traumatic event (civilian noncombatant injured in a terrorist attack or parent who observed her child murdered), unlike
the defendant who appeals for mercy on the basis of having been in the throes of
a substance addiction, which is far less likely to garner sympathy, or unlike even
schizophrenia or bipolar disorder, which are regarded as at least morally neutral.
In a few cases of military PTSD, defense counsel may attempt to use the combat
addiction syndrome discussed in Chap.5 as a mitigating factor, although this is not
a recognized diagnostic category and does not meet either the clinical diagnostic
criteria for PTSD, nor any of the legal standards for a mental disease or defect that
would qualify for an NGRI defense, unless linked to another recognized disorder,
e.g., bipolar mania.

Guilty but InsaneGuilty but Mentally Ill


Some states allow a verdict of guilty but insane, or guilty but mentally ill, which has
the effect of imposing a verdict of guilt, but allows for commitment to a forensic
mental health facility for treatment, in lieu of a criminal sentence. In theory and
practice, this ruling preserves the actus reus component of adjudicative guilt, but
has much the same effect on the practical disposition of the case as a traditional

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6 PTSD in the Criminal Justice System II

insanity defense. A recent PTSD case is that of Iraq war veteran Jesse Bratcher, who
claimed he killed an unarmed man during a dissociative flashback, and whom, in
2009, an Oregon jury found guilty but mentally ill due to military-related PTSD,
sparing him a 25-year prison term, instead committing him to a psychiatric facility
(McGuire and Clark 2011).

AutomatismUnconsciousness
In the UK and some other countries, courts allow the defense of automatism. Here,
the crime is alleged to have been committed in a state where the defendant had no
conscious control of his or her bodily actions and consequently there cannot have
been a mens rea at the time of the crime. In England and Wales, there are two types
of automatism. A sane automatism results from an external cause that robs the actor of conscious will and control over his actions, such as a blow to the head or a
toxic-metabolic delirium. If the causal connection can be made, this usually results
in what is termed a complete acquittal, meaning the defendant is not mandated for
mental health treatment. An insane automatism results from an internal cause, such
as idiopathic epilepsy or sleepwalking, and is argued much in the same way as is a
traditional insanity defense. Because of the stressor criteria, PTSD-related impairment of volition and control during a violent criminal act, such as occurs during a
dissociative state, would technically be considered a sane automatism, strictly on
the basis that the cause (the triggering traumatic stressor) technically came from
outside the person (Gover 2008).
In the USA, some jurisdictions allow a similar defense of unconsciousness, where
the defendants conduct is out of his voluntary control due to a physical event, such
as an epileptic seizure, a bodily movement during sleep, or during a hypnotic trance
(Gover 2008). Note that many of parasomnias discussed in Chap.5 would probably
fit under this definition. The implication is that if a dissociative flashback related to
PTSD is regarded as akin to a hypnotic trance, one could argue exculpation under
the unconsciousness standard. Like a sane automatism, unconsciousness typically
results in a complete acquittal. It is not hard to see how criminal cases involving
these standards might serve to overwhelm juries with abstruse psychological and
philosophical arguments about free will and personal responsibility.

Self-Defense
To the extent that a subject experiencing a dissociative PTSD flashback truly believed that an otherwise innocent person was attacking him, and used deadly force
to defend himself, does it matter that no actual threat existed, even if the defendant thought it did? Most cases of verifiable dissociation will probably be argued
under the insanity or diminished capacity standard, but self-defense may offer attorneys one more instrument to pull out of the defense toolbox if the other defenses
fail (Gover 2008, see Table6.1).

The Insanity Defense

75

Table 6.1 PTSD and the Insanity Defense


Not guilty by reason
of insanity (NGRI)

A complete defense, i.e., the defendant is literally not guilty and is


acquitted. Often followed by an evaluation to determine the need for
involuntary civil commitment. Two main standards are used in the USA

MNaghten standard

Contains two cognitive prongs. The subject does not understand the
nature and quality of his act, or does not understand that it is wrong.
Purely a cognitive test because it relies on the subjects understanding and says nothing about the subjects ability to control his or her
actions. A subject who commits a violent act during a full-blown dissociative flashback might meet this standard

ALI standard

Contains a cognitive prong: the subject does not appreciate the wrongfulness of his act (similar to MNaghten); and also a volitional prong:
the subject lacks substantial capacity to control his actions. This leaves
open to interpretation what substantial means in each individual
case. Many defendants will claim they lost control of their anger
during the commission of a violent crime, but is this a substantial
loss of control?

Diminished capacity

The defendants mental state at the time of the alleged offense was not
sufficiently impaired to rise to the level of an exculpatory (completely
excusing) insanity defense, but may be presented as a mitigating
(lessening the blameworthiness) factor during plea bargaining or
sentencing. PTSD claims are far more likely to be accepted as mitigatory during sentencing than as complete NGRI defenses, and are more
likely to be successful if the traumatic event happened in a patriotic or
other heroic context

Guilty but mentally


Ill (GBMI)

A few states allow such a bifurcated verdict, in which factual guilt or


innocence is first adjudicated, and if guilty, a separate examination
and hearing is held to determine if the defendant has a sufficiently
severe mental illness to warrant being committed to a forensic mental
health treatment facility in lieu of a criminal sentence. Note that, even
in jurisdictions without a GBMI provision, almost all defendants
adjudicated NGRI undergo a follow-up evaluation for involuntary
civil commitment, under the theory that if someone is so impaired as
to not know what they are doing or be able to control themselves, then
society cannot let them back into the community until the underlying
disorder can be successfully treated, if ever. Ironically, many NGRI
acquitees spend far more time confined to a forensic mental health
facility than they would have spent in prison if they were convicted

Automatismuncon- In some jurisdictions, this describes a criminal act that is carried out
sciousness
in a complete state of unawareness and/or lack of volitional control by
the defendant, as in during a temporal lobe epileptic seizure or perhaps
one of the sleep disorders discussed in Chap.5. That is, the defendant was on automatic when he or she committed the crime. There
have been a few attempts to use PTSD flashbacks as the basis for an
automatism defense, with variable success
Self-defense

Justified self-defense requires no impairment of mental state to argue


for acquittal, but in some ambiguous cases, defense attorneys may try
to use PTSD or another disorder to argue for increased susceptibility to
provocation on the part of the defendant. This strategy may backfire,
however, if the jury is reluctant to release such a loose cannon back
into society

PTSD posttraumatic stress disorder

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6 PTSD in the Criminal Justice System II

Utilizing PTSD as an Affirmative Defense or Mitigatory


Factor in Criminal Cases
Assuming a defense attorney has obtained a forensic psychological experts opinion
that his or her client suffers from PTSD, how could that information be utilized
practically in arguing for the clients exculpation or mitigation?

Establishing the Connection Between PTSD and an Impaired


Mental State
Recall the principle that the presence, absence, or severity of any mental disorder,
condition, or state does not by itself render a legal determination. Whatever legal
purposes a diagnosis of PTSD might be put to in reducing responsibility for a crime,
it is vital that a defense psychological expert witness be able to credibly draw a
clear, bright line connecting the symptoms of the disorder to the criminal behavior
in question (Appelbaum etal. 1993; Friel etal. 2008; Slovenko 1994; Sparr 1996;
Sparr etal. 1987). For example, assault or murder committed during a fearful, dissociative flashback, absent any evidence of premeditation or prior hostile relationship
between perpetrator and victim, might qualify as an NGRI defense, but probably
not where there was a history of animosity between the parties or where the defendant was heard making threats to the victim. A PTSD-afflicted military veterans
extreme irritability, hair-trigger temper, sleeplessness, and attempts to self-medicate
with alcohol might be grounds for mitigation at sentencing on an assault or murder
conviction, but not if witnesses attest to the fact that he was pretty much an angry,
hard-drinking trouble-maker long before his military service. As in every aspect of
a forensic psychological evaluation, adequate attention to all details of the case, especially a careful consideration of preexisting risk factors for violence, as described
in Chap.5, is essential.

Making the Case for PTSD as a Criminal Defense


In advising practicing attorneys on how to utilize PTSD as a defense against criminal charges, Auberry (1985) recommends focusing on five factors that supposedly
point to the crime being directly and uniquely related to PTSD. These are enumerated below, along with my own comments and caveats.
The crime occurred as a spontaneous reaction. That is, there appears to have
been no detectable premeditation or obvious provocative factor to explain the criminal act. The problem is that spontaneous eruptions of violence can occur for a wide
variety of reasons, such as bipolar disorder, schizophrenia, organic brain syndrome,
and personality disorder that can co-occur with, or have nothing to do with, PTSD.
A seemingly benign incident triggered the bout of violence. Because PTSD
claimants are thought to have hair-trigger reactions to traumatic meaning-laden

Utilizing PTSD as an Affirmative Defense or Mitigatory Factor in Criminal Cases

77

stimuli, their overreaction to a seemingly innocuous comment or gesture is taken


as evidence that it must be trauma-connected. However, the PTSD claimants may
also appropriately react to ordinary provocative stimuli (e.g., somebody starts a
fight and the PTSD subject retaliates). In addition, characteristically angry, aggressive, or crazy people, with or without PTSD, are often avoided precisely because
they are so unpredictably spurred to violence by seemingly innocuous events. Having a temperamentally short fuse is not itself an indicator of PTSD, much less an
automatic exculpatory factor to a charge of criminal violence.
The defendant has a history of alcohol or substance abuse. Another assumptive
leap is that because someone is reported to suffer from PTSD, the substance abuse
must stem directly from that disorder. However, PTSD is hardly the only precursor for abuse of drugs and alcohol, and many more people abuse these substances
than have PTSD. Moreover, as noted earlier, substance abuse may just as easily be
viewed as an aggravating factor rather than a mitigating one (he committed the assault in a drunken rage) and could work against the defendant.
The defendant is unable to give a logical or coherent explanation for the criminally violent behavior. The assumption here is that ordinary crimes of violence,
even if inexcusable, have some understandable rationale behind them, e.g., material
gain, revenge, sexual conquest, or defense of ones honor, while the criminal acts
committed by the PTSD claimant are inherently senseless because their genesis
stems directly from a remote traumatic event. However, many ordinary criminals
are unable to explain the reasons for their violent outbursts, either because the act
occurred impulsively in response to strong emotion, or because they may have had
a good reason for it at the time, but are concealing this to give the impression of
spontaneity and uncontrollability in order to argue for exculpation or mitigation. In
addition, subjects with severe psychotic disorders such as bipolar mania or schizophrenia are frequently unable to coherently account for their actions, without PTSD
having anything to do with it.
The defendant has no previous criminal record. Violence or other criminal involvement occurring for the first time in an adult (assuming this history can be
confirmed) may be developmentally atypical, but this hardly points to it being the
exclusive result of a particular traumatic experience or related to the syndrome of
PTSD. In addition, lack of a criminal record does not necessarily mean lack of a
history of violence, as the majority of such crimes may go unreported, as in domestic violence, or records may be expunged, especially if the offenses had occurred
while the subject was a juvenile. Careful historical exploration is always essential
in investigating such cases.
Auberry (1985) correctly identifies the need to establish a connection between
the initial traumatic event, the posttraumatic symptoms, the defendants life since
the traumatic event, and the actual or symbolic similarity of the criminal act to the
initial traumatic event. However, Auberry (1985) appears to believe, either naively
or disingenuously, that recounting the defendants life since exposure to the stressor,
and demonstrating the increase in PTSD-related symptoms prior to the commission
of the criminal activity, will automatically negate any inferences of malingering or
fabrication made by the prosecution.

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6 PTSD in the Criminal Justice System II

In fact, as noted in Chap.3, along with many psychological disorders, PTSD


symptoms are notoriously easy to fake in both civil and criminal legal contexts
because the symptoms are almost entirely subjective (Campsie etal. 2006; Finley
2011; Friel etal. 2008; Hall and Hall 2007; Hall and Pritchard 1996; McCann 1998;
Miller 1998c, 2002b, 2012a; Rogers 1997; Resnick 1995, 1997; Rosen and Lilienfeld 2008; Sparr 1995, 1996; Sparr and Atkinson 1986; Sparr and Bremner 2005;
Sparr and Pankratz 1983; Sparr and Pitman 2007; Sweet 2009). Even Criterion A,
the stressor criterion, is not absolute, as many defendants will embellish or outright
lie about their supposed trauma history. Often, doing some forensic detective work
will uncover these deceptions. This may require delving into medical, legal, and
military records of the defendant and interviewing collaterals who have known the
defendant in the past and currently.
Auberry (1985) advises attorneys to solicit peers and witnesses who can regale
the jury with gripping accounts of the horrific battlefield events (in military cases)
that led to the development of the defendants PTSD. However, as discussed earlier, the sheer intensity of a traumatic experience is not by itself a predictor of the
presence or severity of a posttraumatic stress reaction. Much has to do with the
individuals premorbid personality and other risk factors for the development of
PTSD or other psychopathology (Bowman 1997, 1999; Koch 2006; Miller 2012c).
Finally, should an affirmative defense of NGRI based on PTSD fail, Auberry
(1985) recommends utilizing the mitigatory factor of diminished capacity at sentencing. As noted above, in jurisdictions that permit this, diminished capacity is a
common means for the defense to utilize psychological information that does not
rise to the level of an NGRI affirmative defense. Nevertheless, evidence for the existence of a veridical PTSD syndrome that would qualify as constituting diminished
capacity must be rigorously examined.
More recent recommendations have been offered by Gover (2008) and Roth
(2008), who emphasize the need for defense attorneys to apply due diligence by
carefully analyzing and understanding their potential clients in PTSD cases. This
includes documenting a history of traumatic exposure, establishing a diagnosis of
PTSD, ruling out premorbid or comorbid medical and psychiatric syndromes, and
establishing the all-important link between the reported traumatic event, the onset
of the clients PTSD, and the relationship to the alleged criminal act.

Special Considerations for Military Veterans


The US public support for members of the armed forces is currently the highest
it has been since the Second World War, two generations ago. A growing trend,
especially since the beginning of the Iraq-Afghanistan wars, is for courts to apply
special consideration to veterans with combat exposure, sometimes accepting any
claim of mental distress putatively attributed to such exposure as a mitigating factor in sentencing for felony crimes, whether or not a formal diagnosis of PTSD has
been made (Aprilakis 2005; Frazier and Haney 1996; Goldberg 1994; Heath etal.

Utilizing PTSD as an Affirmative Defense or Mitigatory Factor in Criminal Cases

79

2003; Leal 2005; Marciniak 1986; McAllister and Bregman 1986; McGuire and
Clark 2011; McCollum 2009; Robinson and Darley 1995; Russell 2009; Slovenko
2004; Sparr and Atkinson 1986; Sparr etal. 1987; U.S. v. John Brownfield 2009;
Weiner etal. 1998; Wilson etal. 2011).
According to this research, mock jurors (volunteers presented with a staged trial
or the transcript of a real trial) view military PTSD defendants as being less criminally responsible than defendants with other psychiatric diagnoses or no diagnosis. Especially for low-level offenses, prosecutors view military veterans as less
blameworthy and less criminally culpable than nonveteran defendants, and offer
more favorable pretrial plea agreements and diversion programs (e.g., to treatment
programs in lieu of prison). Combat experience per se, and not necessarily a diagnosis of PTSD, is often sufficient to elicit this sympathy. In fact, Wilson etal.
(2011) reports that, in many prosecutors minds, there appears to be an explicit or
unconscious hierarchy of least-to-most blameworthy and culpable defendants: (1)
veterans with PTSD; (2) veterans without PTSD; (3) nonveterans with PTSD; and
(4) nonveterans without PTSD.
This exceptionalist bias is further expressed in the proliferation of special Veterans Courts over the past decade (Aprilakis 2005; Clark etal. 2010; Russell 2009;
Wortzel and Arciniegas 2010), modeled after mental health courts and drug courts.
However, unlike the latter two systems, which exceptionalize their target populations based on the need for a balance between jurisprudence and clinical therapy,
veterans courts often confer special legal treatment based on a defendants status
as a military service member per se. These courts are not for mentally ill veterans, or substance abusing veteransor even, for that matter, only for veterans with
PTSDbut eligibility for such special judicial treatment is often based solely on
the defendants military experience. This raises the question of whether other special status courts would be equally or appropriate for professional service members
who society admires, e.g., police officer courts, first responder courts, doctor courts,
teacher courts, clergy courts, and so on. And what about defendants who have been
severely traumatized in nonmilitary settingsdo they not deserve special crime
victims courts, battered spouse courts, and abused children courts, as well?
The special consideration granted to service members clearly has less to do with
formal criteria for diminished capacity than with expressing a general thank-youfor-your-service leniency applied to military veterans, especially combat veterans,
charged with a crime. It is true that veterans charged with serious felonies such as
homicide or rape, are excluded from Veterans Courts; however, while it is laudable to honor military veterans for their service and to want to give them a second
chance, especially if the crime was not a serious one, affording military service
members special treatment in the legal system based on their service record alone
risks subverting the very principle of equal treatment under the law that our justice
system relies on. Those truly concerned about the welfare of veterans might devote
more of their energies to ensuring that adequate access to such services as mental
health counseling and job training programs are available to those who have served
honorably, thereby hopefully mitigating many of the circumstances that would impel a military veteran into committing a crime in the first place.

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6 PTSD in the Criminal Justice System II

PTSD and Designer Defenses


As noted earlier, both major US versions of the insanity defense (MNaghten and
ALI) require that a defendants cognitive and/or volitional impairment be severe
and that it be caused by a recognized medical or psychiatric syndrome. Defenses
of diminished capacity typically require less proof of total cognitive or volitional
impairment, but also commonly cite some known diagnostic entity. Yet, over the
years, creative attorneys have tried to apply novel defenses based on syndromes that
heretofore have not existed in the psychiatric and psychological literature, and these
have come to be termed designer defenses (Apel 2002; Browne 1987; Foster 1997;
Godklang 1997; Miller 2012c; Slovenko 1995, 2004; Sneirson 1995; Walker 1984).
Some examples are summarized below.
Battered Spouse Syndrome Repeated abuse by a violent husband or other intimate
partner produces a state of learned helplessness in the physically and emotionally
battered victim and leads her to perceive that she has no choice but to kill her
persecutor out of fear for her own life. On the one hand, this homicide occurs not
during a direct confrontation, when it might be considered simple self-defense, but
surreptitiously while the husband is asleep, intoxicated, incapacitated, or distracted.
On the other hand, this is not conceptualized as mere revenge, but as a kind of
preemptive self-defensive strike combined with diminished capacity, and might be
argued as a form of justifiable homicide.
Battered Child Syndrome Similar to the above, children who kill one or more parents argue that years of torturous abuse have induced a prisoner-of-war survival
mentality that impels them one day to defensively erupt and slay the tyrantsagain,
typically while the parents are preoccupied or asleep.
Holocaust Syndrome Children of parents who survived Nazi concentration camps
have, over the years, been so inculcated with a hypervigilant, self-protective, suspicious, and even paranoid mindset by their traumatized parents that they come to
regard even the slightest provocation as a life-threatening attack, and so one day
lash out and kill an otherwise innocent person, whether a family member, acquaintance, or stranger.
Black Rage Syndrome From years of personal discrimination, as well as centuries
of enculturated subjugation, many African-Americans harbor a smoldering rage and
resentment against the larger white society (whether they consciously realize it or
not), until, one day, with minor provocation, one of these citizens snaps and commits violence against an otherwise blameless white person, often a total stranger.
The incident in question may have had nothing to do with prejudice, insult, or discrimination and there may have been no contact at all between assailant and victim
prior to the attack; the victim was just in the wrong place at the wrong time.
The premise of all of these designer defenses is that, as with PTSD, the affected
individuals have been exposed to a single or repeated overwhelming traumatic experience that impairs their mental state sufficiently to eliminate or diminish their

Practice Points

81

capacity to understand the nature of their violent act or to control it. According
to some authorities (Frances 2013; Slovenko 1995, 2004) this expanding catalog
of traumatic experiences has been aided and abetted by psychiatrys broadening
of the definition of trauma, from horrific events clearly outside the range of usual
experience, to various and sundry irritations and frustrations of daily life. Unless
both mental health and legal experts agree on a reasonable definition of a traumatic
stressor, such trauma creep (Miller 2012c) threatens to undermine the validity of
the PTSD diagnosis itself.

Practice Points
There are two essential concepts undergirding all criminal forensic psychological evaluations: (1) the presence, absence, or severity of any diagnosed mental
disorder, condition, or state does not by itself make a legal determination; and
(2) any conclusions about the relevance of the defendants mental state to the
legal question at issue must consider the point in time of that issues relevance.
The most common reasons PTSD is evoked by a defendant in the criminal justice
system is for purposes of exculpation (affirmative defense of NGRI) or mitigation (diminished capacity to argue for a lesser charge or for leniency in sentencing).
Different legal standards apply in different states in the USA, the MNaughten
standard with two cognitive prongs, and the ALI standard with a cognitive prong
and a volitional prong.
If a defendant with PTSD does not meet the criteria for an affirmative NGRI defense, he or she may still utilize the clinical data to argue for diminished capacity
or other defenses (e.g., guilty but mentally ill, in jurisdictions that permit this).
The forensic clinician can advise the defense attorney on how to best utilize a
diagnosis of PTSD as an exculpatory (insanity) or mitigatory (diminished capacity) defense, as well as testify as to his or her findings at trial. Conversely, psychological experts for the prosecution can explain why they believe a diagnosis
of PTSD does not exist or why it does not rise to the level of severity to warrant
exculpation or mitigation.
Forensic clinicians should be aware of a variety of designer defenses that may
be proferred in a criminal case, and understand how to deal with them.

Chapter 7

PTSD Cases: Evaluation, Interpretation,


and Testimony

After completing your forensic psychological examination, you will usually be


asked to prepare a written report of your findings that may be read by multiple parties in the litigation process, including attorneys, judges, case managers, and other
clinicians. This chapter touches on some of the main practical points involved in
being an effective forensic psychological evaluator and expert witness.

Being an Expert Witness


There are a few major differences between a forensic evaluation for legal purposes
and a clinical evaluation for treatment. If a patient voluntarily goes to a psychologist
for help, a fiduciary relationship exists between the doctor and the patient and the
purpose of any formal evaluation is to diagnose and effectively treat that patients
disorder or to help him or her with the presenting problem. The content of the examination and any additional treatment records are confidential, and informed consent must be obtained for the clinician to release the results of any examination to a
third party (family member, other clinician, etc.). The patient is free to terminate the
evaluation or treatment process at any time.
In the forensic setting, however, the fiduciary relationship exists between the
examining psychologist and the court and/or the referring attorneys involved in the
case. The purpose of the exam is to assess those aspects of the defendants mental
status that are relevant to the legal issue in question, not necessarily to treat the disorder, although the examining psychologist may make treatment recommendations
as part of his or her conclusions. The results of the evaluation will typically go to the
court or to the attorney who ordered it, although the opposing attorney will usually
get a copy of the report, as part of the pretrial discovery process. In many cases, it
will be the defendants own attorney who requests the evaluation to document some
mental condition that he or she feels will affect the case, e.g., an insanity defense in
a criminal case or documentation of psychological injury in a civil case.
Experts in civil cases are typically retained by either the plaintiff or defense side;
in most cases, each side will have their own expert who will conduct his evaluation
The Author 2015
L. Miller, PTSD and Forensic Psychology, SpringerBriefs in Psychology,
DOI 10.1007/978-3-319-09081-8_7

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7 PTSD Cases: Evaluation, Interpretation, and Testimony

of the claimant. The expert is paid directly by the attorney who retains him, and in
cases of defense experts, the fee may be paid by the insurance company of the party
being sued, as in premises liability or medical malpractice cases. In criminal cases,
experts may be retained by either prosecution or defense. It is more common for
private defense attorneys to retain experts because clients who can afford private
representation can usually afford to hire experts as well. In cases where a public
defender is appointed, clients are likely to be indigent and thereby not be able to afford the best (i.e., higher-priced) experts; in these cases, experts may be appointed
by the court from a pool of psychologists who have agreed to be on a panel that
perform such evaluation at court fees (usually less than private fees).

The Forensic Psychological Evaluation and Report


The exact procedures and measures utilized in the psychological evaluation will depend on the specific referral question. However, the basic components of a forensic
psychological evaluation are similar across contexts, and include the following (see
also Table7.1).
Review of Records This will provide the necessary background for the examination
and may determine what questions are asked and which measures are used. It is
inadvisable for examiners to go into an evaluation blind, i.e., without sufficient
background information, but in some cases, full records may not be available until
after the examination, in which case the psychologist should do his or her best to put
the findings in context retrospectively. For example, background records allow the
examiner to assess the veracity of the subjects self-reports as to prior educational,
work, medical, and mental health history, as well as to pertinent aspects of the index
event.
Clinical Interview This is the meat of the evaluation, and can range from a few
minutes to many hours over several days, depending on the nature and complexity
of the case and the responsiveness of the subject. The psychologist will observe the
subjects behavior and ask him to explain his account of events, typically followed
by a series of clinical and case-relevant questions. In a criminal case, the interview
assesses the defendants ability to provide a coherent narrative, his understanding of
relevant legal criteria, his version of events and his explanations for them, his medical, academic, and employment history, any current signs and symptoms he may be
experiencing, and a set of mental status exam questions to assess the defendants
orientation, memory, reasoning, and emotional state.
Psychological Tests and MeasuresDiscussion of individual tests is beyond the
scope of this book (e.g., see Wilson and Keane 2004). However, while there may
be many such measures, selection of particular tests will depend on the nature of
the examination and the characteristics of the subject. Formal psychometric testing
can range from only a few standardized measures in an uncomplicated case, to an
extensive, hours-long battery of neuropsychological and personality tests in cases

The Forensic Psychological Evaluation and Report

85

Table 7.1 Components of a Forensic Psychological Evaluation


Review of records

These include records specific to this case, such as history of the traumatic event, subsequent immediate and long-term events, medical and
psychological treatment, and impact on education, employment, and
quality of life. It also includes background records, such as medical and
mental health history, education and employment, past legal history,
if any, and relevant family history. The more complete the history, the
better you will be able to put your examination findings into the proper
context. Being familiar with the subjects background in advance also
helps you frame your interview questions and understand the subjects
responses

Clinical interview

This can be tightly structured or loosely conducted, depending on the


style of the examiner and the responsiveness of the subject. As a general rule, many examiners begin with open-ended questions to allow
the subject to tell his/her story, then follow-up with more focused and
detailed inquiries

Psychometric tests
and measures

These should be chosen based on their relevance to the specific case


and may include general tests of cognition, personality, and psychopathology, as well as specific measures for PTSD. Quantitative test data
should always be interpreted in light of the totality of clinical findings
in each individual case

Interview of
collaterals

These may be persons who were witnesses to the index traumatic event
or were involved with the subject following the event (first responders,
medical and mental health clinicians, family members). In addition,
they may include people who have known the subject throughout different pre-incident periods of his/her life (teachers, employers, coworkers, neighbors, and, again, family members)

Case
conceptualization

This is where you put it all together, integrating data from records, test
results, subject interview(s), collateral interviews, and other relevant
information, in order to formulate your conclusions (evidence of
clinically significant PTSD), on the basis of which you will render
your clinical-legal expert opinion (in a civil case: evidence for/against
compensable psychological injury; in a criminal case: impairment of
mental state at time of the crime meets/does not meet relevant insanity
criteria), and offer pertinent recommendations (medication management and 18 months of outpatient psychotherapy; examination for
involuntary civil commitment, etc.)

Report

Put it in writing. In general, the sections of the report replicate fairly


closely the stages of the evaluation enumerated above. The best reports
combine the elements of comprehensiveness (cover all the bases),
conciseness (make your points without rambling), transparency (allow
the reader to follow your reasoning all the way to your conclusions),
and clarity (be mindful that many eyes, trained and untrained, will
be viewing your report, so make it as readable as possible to avoid
misinterpretation)

Testimony

Although most cases are settled before trial, you may be called upon
to present and defend your findings at deposition and/or trial. The
more thoroughly you have analyzed and reviewed your case, the more
prepared, confident, and poised you will be on the stand

PTSD posttraumatic stress disorder

86

7 PTSD Cases: Evaluation, Interpretation, and Testimony

involving possible brain damage, severe psychopathology, or atypical syndromes.


This may include specific posttraumatic stress disorder (PTSD) measures, general
tests of personality and psychopathology, and measures to assess malingering. Clinicians should remember not to let the tests make the diagnosis, but to utilize psychometric data as part of comprehensive clinical-forensic decision making (Nesca
and Dalby 2013).
Collateral Data In addition to clinical, legal, and historical records, the examining
psychologist may want to interview persons with knowledge that may be relevant
to the case, including crime victims and witnesses, arresting officers, jail personnel,
first responders, treating clinicians, workmates, friends, and family members of the
subject.
Written Report Once the relevant clinical and forensic data have been compiled,
interpreted, and synthesized, the psychologist will usually then present his or her
findings to the court or referring attorney in the form of a written report. In many
cases, this can be the most labor-intensive and time-consuming aspect of the evaluation, as the examiner strives for the important goals of (1) comprehensiveness:
the report includes all relevant data and conclusions; (2) conciseness: irrelevant
and redundant information is carefully winnowed out; (3) transparency: the report
allows the reader to follow the evaluators reasoning and to understand how conclusions were arrived at from the available data; and (4) clarity: the report is written
in a professional but not overly technical and jargony style, so it can be read and
understood by attorneys, judges, administrators, and other clinicians The report will
typically contain a review of case data, results of the clinical interview and examination, psychological test findings, diagnostic formulation, a section addressing the
legal issue in question (e.g., psychological injury or insanity), and a set of recommendations for clinical treatment and/or case disposition.
Following the collection of all relevant data in pretrial discovery, attorneys from
both sides will usually try to reach a settlement in a civil case or a plea bargain in a
criminal case. Where this proves impossible, the examining psychologist and other
evaluating experts may be called to testify at deposition or trial court concerning
his or her findings.

Deposition Testimony
A deposition is part of the pretrial discovery process that involves a mini-trial
which takes place out of court, usually being held at an attorneys office or courthouse office when plaintiffs, civil and criminal defendants, or witnesses are deposed, and often occurring at the clinicians office, when experts are deposed. Those
present at a deposition are typically the opposing attorneys, the deponent (the one
being deposed), and a court reporter. The reason for the latter is that testimony given
at a deposition has the full weight of testimony presented at trial, and all the rules of
legal procedure apply in a deposition, except that there is no judge or jury present.

May it Please the Court: Testifying Tips for Expert Witnesses

87

That is, the deponent is subpoenaed (legally summoned) to testify at the deposition,
he or she is sworn in, then examined and cross-examined by opposing attorneys,
and the proceedings are transcribed by the court reporter and become part of the
permanent case record.
The main purposes of a deposition of an expert witness are to find out how that
witness will fare under questioning in court and to get the witness to state certain
things on the record that may later be used at trial to contradict his or her testimony
there. In some cases, especially where a witness may be unavailable for trial, deposition testimony may be read in court lieu of trial testimony; in cases where possible
witness unavailability for trial is anticipated, the deposition may be videotaped.
Note that the basic principles of effective expert witness testimony apply fairly
equally to the deposition or trial setting.

May it Please the Court: Testifying Tips for Expert


Witnesses
Since most legal cases are settled out of court, the courtroom testimony role of an
expert witness may actually be the least frequent. Nevertheless, after you have completed your forensic psychological evaluation and submitted your report, and perhaps reinforced or modified your conclusions in deposition testimony, you may be
subpoenaed to testify about your findings and conclusions in court. Your task now
becomes to ensure that the facts and interpretations you present tell the complete
story and that your delivery of these facts makes your testimony clear, credible, and
convincing (Barton 1990; Blau 1984; Miller 2006e, 2009b; Mogil 1989; Posey and
Wrightsman 2005; Simon 1995; Taylor 1997; Vinson and Davis 1993).

Types of Witnesses and Testimony


A fact witness is someone who has personal knowledge of events pertaining to the
case and can only testify as to things he or she has personally observed (I saw
Fred arguing with his supervisor in the break room). Fact witnesses may not offer
opinions, which are interpretations and extrapolations of the available facts (Fred
looked mad earlier that morning, and that kind of hothead is likely to fly off the
handle and attack someone). These opinions are the province of the expert witness, who, in a criminal case, is likely to be appointed by the court, although either
prosecution or defense may retain an independent expert witness; in civil cases, the
plaintiff and defense sides typically each retain their own experts. In either system,
in presenting their opinions, expert witnesses are allowed to make statements about
aspects of the case that they have not personally observed but in which they have
specialized knowledge and training that can assist the fact finders (usually a jury
in most adult criminal and civil cases, but sometimes a judge, as in juvenile court
or some family courts) in rendering their decision. Although experts are typically

88

7 PTSD Cases: Evaluation, Interpretation, and Testimony

allowed more leeway than fact witnesses, the content of their testimony may be
carefully vetted by the court for admissibility prior to their testimony.

Preparing for Testimony


Review your notes on the case as many times as necessary so you will be ready
for any kind of question; there is no such thing as too much preparation. In most
cases, prior to the trial date, you will probably have one or more meetings with the
attorney who retained you to go over your testimony for purposes of clarification
and narrative flow, and to get a sense of what youll be asked by both sides. Use
role-play and rehearsalmany attorneys do itto make yourself comfortable with
verbally articulating your points.

Testimony Sequence
Prior to taking the stand, you will be sworn in, promising to tell the truth, the whole
truth, and nothing but the truth. You will probably first be questioned on direct
examination by the attorney who retained you. First, you will be asked some professional biographical questions that confirm your qualifications as an expert (known
as voir dire), then asked about your involvement in the case, the activities you performed with regard to the case, and your conclusions. When your attorney is done,
the other sides attorney will subject you to cross-examination, looking for holes
and inconsistencies in your testimony and trying to get you to make statements
favorable to their side. In some instances, when the cross-examination is done, the
first attorney may want to follow with a re-direct examination; more rarely, there
will even be a re-cross, and so on, until both attorneys have finished getting whatever they hope to obtain from your testimony.

On the Stand
To the average juror, a doctor or other professional conveys an air of authority and
respect, so use this to your advantage. In the witness box, your general attitude
and communication style should be one of confidence, but not cockiness. Maintain
composure and dignity at all times and act like a professional; avoid either being
cowed into submission or baited into an angry overreaction. Remember that it is
not you who will ultimately decide the case for the prosecution or defense; your
responsibility is to clearly present the facts, your conclusions, and the evidence that
supports them to the fact finders, and then let them do their job.
Body language is important. Sit up straight and try not to slouch or fidget. If
there is a microphone in front of you, sit close enough so that you dont have to
lean over every time you speak. If you are in a swivel chair, try to avoid twisting

May it Please the Court: Testifying Tips for Expert Witnesses

89

and spinning; make a conscious effort to plant your feet firmly on the floor while
speaking. Keep your presentation materials neatly organized in front of you, so you
can find documents and exhibits when you need them.
While testifying, look at the attorney while he or she is questioning you, then
switch your eye contact to the jury while answering the question; jurors tend to find
a witness more credible when he or she looks straight at them. Let your facial engagement of the jurors be neither overly detached nor overly intense. Open, friendly, and dignified are the attitudinal words to remember. Speak as clearly, slowly,
and concisely as possible to be understood. Keep sentences short and to the point.
Maintain a steady voice volume and use a normal conversational tone. Your general
attitude toward the jury should convey a sense of collegial respect, that is, you are
there to present the facts as you know them to a group of mature adults who you are
confident will make the right decision.

Cross-Examination Tricks and Traps


Listen carefully to each of the cross-examining attorneys questions before you respond. If you do not fully understand the question, ask the attorney to repeat or
rephrase it. Do not be baited into giving a quick answer; if you need a couple of
seconds to compose your thoughts, take them. Answer each question completely,
but do not over-elaborate or ramble. If you do not know the answer to the question,
state plainly, I dont know. Do not try to bluff your way out of a tricky question.
Do not become defensive. Above all, maintain credibility by always being honest.
Attorneys will often phrase questions in a way that constrains your answers in
the direction they want you to go by asking you yes-or-no questions. If you feel
you cannot honestly answer the question by a simple yes-or-no answer, say so:
Sir, if I limit my answer to yes or no, I will not be able to give factual testimony.
Surely, thats not what you wish me to do. Sometimes, the attorney will voluntarily
reword the question. If he or she presses for a yes-or-no answer, at that point either
your attorney may voice an objection or the judge may intervene. The latter may
instruct the cross-examining attorney to allow you more leeway in responding, or
to rephrase the question, or the judge may simply order you to answer the question
as it has been asked, in which case that is what you dowith a resigned look on
your face.
Another attorney ploy is to phrase questions in such a way as to force you to
respond in an ambiguous manner by prefacing your answer with such phrases, as I
believe, I estimate, To the best of my recollection, and so on. If the facts warrant it, be as definite about your answers as possible; if they do not, honestly state
that this particular piece of your testimony may not lend itself to precise quantification or may not be a clear perception or recollection, but be firm about what you are
sure about. Again, if you do not know the answer to a question, just say you dont
know. Jurors will respect and appreciate honest ignorance of a few details far more
than a disingenuous attempt to make everything fit with your testimony.

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7 PTSD Cases: Evaluation, Interpretation, and Testimony

Finally, remember that most citizens, which includes most jurors, want to believe
that the people they place their trust inwhich includes most doctors and other
healthcare professionalshave their best welfare in mind. This means that they
will mentally bend over backward to give you the benefit of the doubt if you can
give them a credible reason to do so. It is common to walk out of court wishing you
could have better answered this or that question or made this or that point clearer,
and a little bit of constructive second-guessing and self-review will keep you sharp.
However, try not to obsess; just prepare carefully for your case, be clear and honest
in your testimony, maintain dignity and decorum at all times, and in most cases you
will emerge from the courtroom with the satisfaction of a job well done.

Practice Points
Forensic clinicians should understand the differences in the fiduciary relationship that exist between a psychological evaluation conducted on behalf of ones
clinical patient and an evaluation of a forensic subject ordered by a third party.
Forensic clinicians should master the elements of a forensic psychological evaluation, including review of records, clinical interview, tests and measures, diagnostic and forensic conclusions, and recommendations. Analyzing, interpreting,
and expressing these findings in a written report that is both comprehensive and
concise is part art, part science.
Also part art and sciencewith a dose of practical experience thrown inis
how to be an effective expert witness when testifying in court. This involves
understanding the differences between a fact witness and an expert witness, and
attending to attitude, communication style, and body language when presenting
your findings.

Erratum
Laurence Miller
Miller Psychological Associates
Boca Raton
Florida
USA
The Author 2015
L. Miller, PTSD and Forensic Psychology, SpringerBriefs in Psychology,
DOI 10.1007/978-3-319-09081-8_3
The Author 2015
L. Miller, PTSD and Forensic Psychology, SpringerBriefs in Psychology,
DOI 10.1007/978-3-319-09081-8_4
The Author 2015
L. Miller, PTSD and Forensic Psychology, SpringerBriefs in Psychology,
DOI 10.1007/978-3-319-09081-8_5
DOI 10.1007/978-1-4939-2202-4_8
The Publisher regrets for the following errors in chapter 3, 4 and 5.
DOI 10.1007/978-3-319-09081-8_3
In chapter 3, incorrect line was printed on page 40 as :
diagnostic names, as if the recounting had been rehearsed, which is often has.
The correct line should be:
diagnostic names, as if the recounting had been rehearsed, which it often has.
DOI 10.1007/978-3-319-09081-8_4
On p. 45, in Table 4.1, both column headings read Civil Justice System which was
printed incorrectly.
The correct second heading should be Criminal Justice System.
DOI 10.1007/978-3-319-09081-8_5
On page 63, incorrect line appeared as
For example patients with epilepsy or diabetes must take their medications and
near-sighted
But, the correct version should be:
For example, patients with epilepsy or diabetes must take their medications and
near-sighted
The online version of the original book can be found at
http://dx.doi.org/10.1007/978-3-319-09081-8
The Author 2015
L. Miller, PTSD and Forensic Psychology, SpringerBriefs in Psychology,
DOI 10.1007/978-3-319-09081-8_8

E1

E2

Erratum

Table 4.1 The American Legal System


Civil Justice System

Criminal Justice System

Covers all aspects ofcivil law, such as wills


and estate law, family law, contract law,
personal injwy, and Workers Compensation.

Covers all aspects ofcriminal law, such as


homicide, sex offenses. robbery, financial
crimes, and family violence.

The contest is between two private citizens or


corporate or government entities (e.g., a citizen
sues the US Post Office for losing a medical
sample; a corporation sues a smaller company
for copyright infringement; one neighbor sues
another neighbor for damaging her property)

The contest is between a government entity,


usually either the state or the federal government, and second party, the alleged criminal

In a civil action, such as a personal injury


lawsuit, a plaintiff files a lawsuit for damages
against a defendant

In a criminal action, the state/federal government, represented by the state/federal attorney or prosecutor, brings a criminal charge
against a defendant

The plaintiffs attorney works on behalf of the


plaintiff, and the defense attorney works for the
defendant

The prosecutor represents the state or federal


government (often termed the people),
and the defendant is represented either by a
private defense attorney, or, if indigent, by a
court-appointed public defender

The evidentiary standard of proof in civil trials


is preponderance of the evidence, i.e., the jury
has to be only a little more certain than not
(even 51/49% certain) that one side has the prevailing argument in order to render their verdict

The evidentiary standard of proof in criminal


trials is beyond a reasonable doubt, i.e., the
jury has to be much more certain than not
(9095% certain) of the defendants culpability in order to render a verdict of guilty, in
which case the defendant has been convicted

If the jury finds for the plaintiff, then the


defendant is liable for some kind of damages,
the nature and amount of which are usually
determined by the same jury

If they jury cannot unanimously arrive at


a guilty verdict by a preponderance of the
evidence, then they will render a verdict of
not guilty, in which case the defendant has
been acquitted

If the jury finds for the defendant, the defendant is not liable, but may still have incurred
substantial costs in defending him or herself.
In some jurisdictions, the loser pays the court
costs of the winner
If they believe that evidentiary or procedural
violations have occurred during the trial, either
side may appeal the verdict

If they believe that evidentiary or procedural


violations have occurred during the trial, the
defense side may appeal the guilty verdict.
In the US, the prosecution cannot appeal a
not guilty verdict (although, in some countries, they can)

References

Abueg, F. R., Woods, G. W., & Watson, D. S. (2000). Disaster trauma. In F. M. Dattilio & A.
Freeman (Eds.), Cognitive-behavioral strategies in crisis intervention (2ndedn., pp.243272).
New York: Guilford.
Alarcon, R. D., Deering, C. G., Glover, S. G., Ready, D. J., & Eddleman, H. C. (1997). Should
there be a clinical typology of posttraumatic stress disorder? Australian and New Zealand
Journal of Psychiatry, 31, 159167.
Aldwin, C. M. (1994). Stress, coping, and development: An integrative perspective. New York:
Guilford.
Allnutt, S., Samuels, A., & ODriscoll, C. (2007). The insanity defense: From wild beasts to
MNaghten. Australasian Psychiatry, 15, 292299.
American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders
(3rd ed.). Washington, DC: American Psychiatric Association.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders
(4th ed.). Washington, DC: American Psychiatric Association.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders
(4th ed., text revision). Washington, DC: American Psychiatric Association.
Anderson, W., Swenson, D., & Clay, D. (1995). Stress management for law enforcement officers.
Englewood Cliffs: Prentice Hall.
Andrews, D. A., & Bonta, J. (2006). The psychology of criminal conduct (4thed.). Cincinnati:
Anderson.
Andrews, D. A., & Bonta, J. (2010). Rehabilitating criminal justice policy and practice. Psychology, Public Policy, and Law, 16, 3955.
Antai-Otong, D. (2007). The art of prescribing: Pharmacological management of PTSD. Perspectives in Psychiatric Care, 43, 5559.
Antonovsky, A. (1979). Health, stress, and coping. San Francisco: Jossey-Bass.
Antonovsky, A. (1987). Unraveling the mystery of health: How people manage stress and stay
well. San Francisco: Jossey-Bass.
Antonovsky, A. (1990). Personality and health: Testing the sense of coherence model. In H. S.
Friedman (Ed.), Personality and disease (pp.155177). New York: Wiley.
Apel, D. (2002). Memory effects: The Holocaust and the art of secondary witnessing. Piscataway:
Rutgers University Press.
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, 229234.
Appelbaum, P. S., Robbins, P. C., & Monahan, J. (2000). Violence and delusions: Data from the
MacArthur violence risk assessment study. American Journal of Psychiatry, 157, 566572.

The Author 2015


L. Miller, PTSD and Forensic Psychology, SpringerBriefs in Psychology,
DOI 10.1007/978-3-319-09081-8

91

92

References

Appelbaum, P. S., Robbins, P. C., & Roth, L. H. (1999). Dimensional approach to delusions: Comparison across types and diagnoses. American Journal of Psychiatry, 156, 19381943.
Aprilakis, C. (2005). The warrior returns: Struggling to address criminal behavior by veterans with
PTSD. Georgetown Journal of Law and Public Policy, 3, 541566.
Ardis, C. (2004). School violence from the classroom teachers perspective. In W. L. Turk (Ed.),
School crime and policing (pp.131150). Upper Saddle River: Pearson Education.
Asnis, G., Kohn, S., Henderson, M., & Brown, N. (2004). SSRIs versus non-SSRIs in posttraumatic stress disorder: An update with recommendations. Drugs, 64, 383404.
Atkinson, R. M., Henderson, R. G., Sparr, L. F., & Deale, S. (1982). Assessment of Viet Nam veterans for posttraumatic stress disorder in Veterans Administration disability claims. American
Journal of Psychiatry, 139, 11181121.
Auberry, A. R. (1985). PTSD: Effective representation of a Vietnam veteran in the criminal justice
system. Marquette Law Review, 68, 647675.
Ball, J. D., & Peake, T. H. (2006). Brief psychotherapy in the U.S. military. In C. H. Kennedy &
E. A. Zillmer (Eds.), Military psychology: Clinical and operational applications (pp.6173).
New York: Guilford.
Barratt, E. S. (1994). Impulsiveness and aggression. In J. Monahan & H. J. Steadman (Eds.), Violence and mental disorder: Developments in risk assessment (pp.6179). Chicago: University
of Chicago Press.
Barth, J. T., Isler, W. C., Helmick, K. M., Wingler, I. M., & Jaffee, M. S. (2010). Acute battlefield
assessment of concussion/mild TBI and return-to-duty evaluations. In C. H. Kennedy & J. L.
Moore (Eds.), Military neuropsychology (pp.127174). New York: Springer.
Barton, W. A. (1990). Recovering for psychological injuries. Washington, DC: ATLA Press.
Barzman, D. H., DelBello, M. P., Fleck, D. E., Lehmkuhl, H., & Strakowski, S. M. (2007). Rates,
types, and psychosocial correlates of legal charges in adolescents with newly diagnosed bipolar
disorder. Bipolar Disorders, 9, 339344.
Beckham, J. C., Feldman, M. E., & Kirby, A. C. (1998). Atrocities exposure in Vietnam combat
veterans with chronic posttraumatic stress disorder: Relationship to combat exposure, symptom severity, guilt and interpersonal violence. Journal of Traumatic Stress, 11, 777785.
Begic, D., & Jokic-Begic, N. (2001). Aggressive behavior in combat veterans with posttraumatic
stress disorder. Military Medicine, 166, 671676.
Bender, W. N., & McLaughlin, P. J. (1997). Weapons violence in schools: Strategies for teachers
confronting violence and hostage situations. Intervention in School and Clinic, 32, 211216.
Bender, L. G., Jurkanin, T. J., Sergevnin, V. A., & Dowling, J. L. (2005). Critical issues in police
discipline: Case studies. Springfield: Charles C Thomas.
Bernstsen, D., & Rubin, D. C. (2007). When a trauma becomes a key to identity: Enhanced integration of trauma memories predicts posttraumatic stress disorder symptoms. Applied Cognitive Psychology, 21, 417431.
Bifulco, A. T., Brown, G. W., & Harris, T. O. (1987). Childhood loss of parent, lack of adequate
parental care and adult depression: A replication. Journal of Affective Disorders, 12, 115128.
Bisson, J. I., Shepherd, J. P., & Dhutia, M. (1997). Psychosocial sequelae of facial trauma. Journal
of Trauma, 43, 496500.
Blanchard, E. B., Hickling, E. J., Taylor, A. E., Loos, W. R., & Gerardi, R. J. (1994). Psychological morbidity associated with motor vehicle accidents. Behavior Research and Therapy,
3, 283290.
Blau, T. H. (1984). The psychologist as expert witness. New York: Wiley.
Blau, T. H. (1994). Psychological services for law enforcement. New York: Wiley.
Blum, L. N. (2000). Force under pressure: How cops live and why they die. New York: Lantern
Books.
Blythe, B. T. (2002). Blindsided: A managers guide to catastrophic incidents in the workplace.
New York: Portfolio.
Bohl, N. (1995). Professionally administered critical incident debriefing for police officers. In
M. I. Kunke & E. M. Scrivner (Eds.), Police psychology into the 21st century (pp.169188).
Hillsdale: Erlbaum.

References

93

Bolz, F., Dudonis, K. J., & Schultz, D. P. (1996). The counter-terrorism handbook: Tactics, procedures, and techniques. Boca Raton: CRC Press.
Bonanno, G. (2004). Loss, trauma, and human resilience. American Psychologist, 59, 2028.
Bongar, B., Brown, L. M., Beutler, L. E., Breckenridge, J. N., & Zimbardo, P. G. (Eds.). (2007).
Psychology of terrorism. New York: Oxford University Press.
Bonwick, R. L., & Morris, P. L. P. (1996). Posttraumatic stress disorder in elderly war veterans.
International Journal of Geriatric Psychiatry, 11, 10711076.
Borders, M. A., & Kennedy, C. H. (2006). Psychological interventions after disaster in trauma. In
C. H. Kennedy & E. A. Zillmer (Eds.), Military psychology: Clinical and operational applications (pp.331352). New York: Guilford.
Bowman, M. L. (1997). Individual differences in posttraumatic response: Problems with the
stress-adversity connection. Mahwah: Erlbaum.
Bowman, M. (1999). Individual differences in posttraumatic stress: Problems with the DSM-IV
model. Canadian Journal of Psychiatry, 44, 2133.
Bradley, R., Greene, J., Russ, E., Dutra, L., & Westen, D. (2005). A multidimensional meta-analysis of psychotherapy for PTSD. American Journal of Psychiatry, 162, 214227.
Brady, K., Killeen, T., Brewerton, T., & Lucerini, S. (2000). Comorbidity of psychiatric disorders
and posttraumatic stress disorder. Journal of Clinical Psychiatry, 61, 2232.
Bremner, J. D. (2002). Neuroimaging of childhood trauma. Seminars in Clinical Neuropsychiatry,
7, 104112.
Bremner, J. D. (2005). Does stress damage the brain? Understanding trauma-related disorders
from a mind-body perspective. New York: Norton.
Bremner, J. D. (2006). The relationship between cognitive and brain changes in posttraumatic
stress disorder. Annals of the New York Academy of Sciences, 1071, 8086.
Bremner, J. D., & Vermetten, E. (2002). Stress and development: Behavioral and biological consequences. Development and Psychopathology, 13, 473489.
Bremner, J. D., Southwick, S. M., Johnson, D. R., Yehuda, R., & Charney, D. S. (1993). Childhood
physical abuse and combat-related posttraumatic stress disorder in Vietnam veterans. American Journal of Psychiatry, 150, 235239.
Bremner, J. D., Randall, P., Scott, T., Bronen, R., Seibyl, J., & Southwick, S. (1995). MRI-based
measurement of hippocampal volume in patients with combat-related posttraumatic stress disorder. American Journal of Psychiatry, 152, 973981.
Bremner, J. D., Krystal, J., Charney, D., & Southwick, S. (1996). Neural mechanisms in dissociative amnesia for childhood abuse: Relevance to the current controversy surrounding false
memory syndrome. American Journal of Psychiatry, 153, 7182.
Bremner, J. D., Staib, L., Kaloupek, D., Southwick, S., Soufer, R., & Charney, D. (1999). Neural
correlates to exposures to traumatic pictures and sounds in Vietnam combat veterans with and
without posttraumatic stress disorder: A positron emission tomography study. Biological Psychiatry, 45, 806816.
Breslau, N. (2012). Post-traumatic syndromes and the problem of heterogeneity. In C. S. Widom (Ed.), Trauma, psychopathology, and violence: Causes, consequences, or correlates?
(pp.320). New York: Oxford University Press.
Brewin, C. R., Andrews, B., & Valentine, J. D. (2000). Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology,
68, 748766.
Brom, D., Kleber, R. J., & Defares, P. B. (1989). Brief psychotherapy for posttraumatic stress
disorder. Journal of Consulting and Clinical Psychology, 57, 607612.
Browne, A. (1987). When battered women kill. New York: Free Press.
Burkett, B. G., & Whitely, G. (1998). Stolen valor: How the Vietnam generation was robbed of its
heroes and history. Dallas: Verity Press.
Bursztajn, H. J., Scherr, A. E., & Brodsky, A. (1994). The rebirth of forensic psychiatry in light
of recent historical trends in criminal responsibility. Psychiatric Clinics of North America, 17,
611635.

94

References

Calabrese, J. R., Hirschfield, M. A., & Reed, M. (2003). Impact of bipolar disorder on a US community sample. Journal of Clinical Psychiatry, 64, 425432.
Calhoun, L. G., & Tedeschi, R. G. (1999). Facilitating posttraumatic growth. Mahwah: Erlbaum.
Calhoun, P. S., Bosworth, H. B., Grambow, S. C., Dudley, T. K., & Beckham, J. C. (2002). Medical
service utilization by veterans seeking help for posttraumatic stress disorder. American Journal
of Psychiatry, 159, 20812086.
Campsie, R. L., Geller, S. K., & Campsie, M. E. (2006). Combat stress. In C. H. Kennedy & E.
A. Zillmer (Eds.), Military psychology: Clinical and operational applications (pp.215240).
New York: Guilford.
Caprara, G. V., Barbaranelli, C., & Zimbardo, P. G. (1996). Understanding the complexity of human aggression: Affective, cognitive, and social dimensions of individual differences in propensity toward aggression. European Journal of Personality, 10, 133155.
Card, J. J. (1983). Lives after Vietnam: The personal impart of military service. Lexington: Lexington Books.
Carlier, I. V. E., & Gersons, B. P. R. (1995). Partial PTSD: The issue of psychological scars and
the occurrence of PTSD symptoms. Journal of Nervous and Mental Disease, 183, 107109.
Carlier, I. V., Lamberts, R. D., & Gersons, B. P. (1997). Risk factors for posttraumatic stress symptomatology in police officers: A prospective analysis. Journal of Nervous and Mental Disease,
185, 498506.
Carlson, E. B., Lauderdale, S., Hawkins, J., & Sheikh, J. I. (2008). Posttraumatic stress and aggression among veterans in long-term care. Journal of Geriatric Psychiatry and Neurology,
21, 6171.
Cartwright, R. (2004). Sleepwalking violence: A sleep disorder, a legal dilemma, and a psychological challenge. American Journal of Psychiatry, 161, 11491158.
Centonze, D., Siracusano, A., Calabresi, P., & Bernadi, G. (2005). Removing pathogenic memories: A neurobiology of psychotherapy. Molecular Neurobiology, 32, 123132.
Chapin, M. G. (1999). A comparison of violence exposure and perpetration in recruits and high
school students. Military Medicine, 164, 264268.
Charcot, J. M. (1887). Lecons sur les maladies du system nerveux (Vol.3). Paris: Progress Medical.
Charney, D. S., Deutsch, A. Y., Krystal, J. H., Southwick, S. M., & Davis, M. (1993). Psychobiologic mechanisms of posttraumatic stress disorder. Archives of General Psychiatry, 50,
294305.
Chemtob, C. M., Hamada, R. S., Roitblat, H. L., & Muraoka, M. (1994). Anger, impulsivity and
anger control in combat related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 62, 827832.
Cima, M., Nijman, H., Merckelbach, H., Kremer, K., & Holnack, S. (2004). Claims of crime-related amnesia in forensic patients. International Journal of Law and Psychiatry, 27, 215221.
Clark, S., McGuire, J., & Blue-Howells, J. (2010). Development of veterans treatment courts: Local and legislative initiatives. Drug Court Review, 7, 171208.
Cohen, A. (1980). Ive killed that man 10,000 times. Police, 3, 4.
Cornell, D. G. (2006). School violence: Fears versus facts. Mahwah: Erlbaum.
Cozolino, L. (2002). The neuroscience of psychotherapy: Building and rebuilding the human
brain. New York: Norton.
Cromartie, R. S., & Duma, R. J. (2009). High-tech terror: Recognition, management and prevention of biological, chemical, and nuclear injuries secondary to acts of terrorism. Springfield:
Charles C Thomas.
Cullen, D. (2009). Columbine. New York: Hachette.
Daniels, J. A., Bradley, M. C., & Hays, M. (2007). The impact of school violence on school personnel: Implications for psychologists. Professional Psychology: Research and Practice, 38,
652659.
De Carteret, J. (1994). Occupational stress claims: Effects on workers compensation. American
Association of Occupational Health Nurses Journal, 42, 494498.
Denenberg, R. V., & Braverman, M. (1999). The violence-prone workplace: A new approach to
dealing with hostile, threatening, and uncivil behavior. Ithaca: Cornell University Press.

References

95

Denney, R. L., & Sullivan, J. P. (Eds.). (2008). Clinical neuropsychology in the criminal forensic
setting. New York: Guilford.
Des Rosiers, N., Feldthusen, B., & Hankivsky, O. (1998). Legal compensation for sexual violence: Therapeutic consequences and consequences for the judicial system. Psychology, Public
Policy, and Law, 4, 433451.
DeVoe, E., Dean, K., Traube, D., & McKay, M. (2005). The SURVIVE community project: A
family-based intervention to reduce the impact of violence exposures in urban youth. Journal
of Aggression, Maltreatment, and Trauma, 11, 95116.
Dileo, J. F., Brewer, W. J., Hopwood, M., Anderson, V., & Creamer, M. (2008). Olfactory identification dysfunction, aggression and impulsivity in war veterans with post-traumatic stress
disorder. Psychological Medicine, 38, 523531.
Dinn, W. M., Gansler, D. A., Mosczynski, N., & Fulwiler, C. (2009). Brain dysfunction and community violence in patients with mental illness. Criminal Justice and Behavior, 36, 117136.
Dodge, K. A., Bates, J. E., & Pettit, G. S. (1990). Mechanisms in the cycle of violence. Science,
250, 16781683.
Dohrenwend, B. P., Turner, B., & Turse, N. A. (2006). The psychological risks of Vietnam for US
veterans: A revisit with new data and methods. Science, 313, 979982.
Douglas, K. S., & Skeem, J. L. (2005). Violence risk assessment: Getting specific about being
dynamic. Psychology, Public Policy and Law, 11, 347383.
Douglas, K. S., & Webster, C. D. (1999). Predicting violence in mentally and personality disordered individuals. In R. Roesch, S. D. Hart, & J. R. P. Ogloff (Eds.), Psychology and law: The
state of the discipline (pp.175239). New York: Plenum.
Dowden, J. S., & Keltner, N. L. (2007). Biological perspectives: Psychobiological substrates of
posttraumatic stress. Perspectives in Psychiatric Care, 43, 147150.
Drew, D., Drebing, C. E., & Van Ormer, A. (2001). Effects of disability compensation on participation in and outcomes of vocational rehabilitation. Psychiatric Services, 52, 14791484.
Drukteinis, A. (2003). Disability determination in PTSD litigation. In R. Simon (Ed.), Posttraumatic stress disorder in litigation (2ndedn., pp.157172). Washington, DC: American Psychiatric Publishing.
Dunning, C. (1999). Postintervention strategies to reduce police trauma: A paradigm shift. In J.
M. Violanti & D. Paton (Eds.), Police trauma: Psychological aftermath of civilian combat
(pp.269289). Springfield: Charles C Thomas.
Dworkin, A. G., Haney, C. A., & Teschow, R. L. (1988). Fear, victimization, and stress among
urban public school teachers. Journal of Organizational Behavior, 9, 159171.
Dyregrov, A. (1989). Caring for helpers in disaster situations: Psychological debriefing. Disaster
Management, 2, 2530.
Dyregrov, A., & Regel, S. (2012). Early interventions following exposure to traumatic events:
Implications for practice from recent research. Journal of Loss and Trauma, 17, 271291.
Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour
Research and Therapy, 38, 319345.
Elbogen, E. B., Beckham, J. C., Butterfield, M. I., Swartz, M., & Swanson, J. (2008). Assessing risk of violent behavior among veterans with severe mental illness. Journal of Traumatic
Stress, 21, 113117.
Elbogen, E. B., Fuller, S., Johnson, S. C., Brooks, S., Kineer, P., Calhoun, P., & Beckham, J. C.
(2010). Improving risk assessment of violence among military veterans: An evidence-based
approach for clinical decision-making. Clinical Psychology Review, 30, 595607.
Eskenazi, B., & Maizlish, N. A. (1988). Effects of occupational exposure to chemicals on neurobehavioral functioning. In R. E. Tarter, D. H. Van Thiel, & K. L. Edwards (Eds.), Medical
neuropsychology: The impact of disease on behavior (pp.223264). New York: Plenum.
Eslinger, P. J. (1998). Neurological and neuropsychological bases of empathy. European Neurology, 39, 193199.
Esposito, K., Benitez, A., Barza, L., & Mellman, T. (1999). Evaluation of dream content in combat-relate PTSD. Journal of Traumatic Stress, 12, 681687.

96

References

Etkin, A., Pittenger, C., Polan, H., & Kandel, E. (2005). Toward a neurobiology of psychotherapy:
Basic science and clinical applications. Journal of Neuropsychiatry and Clinical Neuroscience,
17, 145158.
Evans, R. W. (1992). The postconcussion syndrome and the sequelae of mild head injury. Neurologic Clinics, 10, 815847.
Everstine, D. S. (1986). Psychological trauma in personal injury cases. In L. Everstine & D. S.
Everstine (Eds.), Psychotherapy and the Law (pp.2745). New York: Grune & Stratton.
Everstine, D. S., & Everstine, L. (1993). The trauma response: Treatment for emotional injury.
New York: Norton.
Fairbank, J. A., Keane, T. M., & Malloy, P. F. (1983). Some preliminary data on the psychological
characteristics of Vietnam veterans with posttraumatic stress disorders. Journal of Consulting
and Clinical Psychology, 51, 912919.
Falsetti, S. A., & Resnick, H. S. (1995). Helping the victims of violent crime. In J. R. Freedy & S.
E. Hobfoll (Eds.), Traumatic stress: From theory to practice (pp.263285). New York: Plenum.
Farrow, T., Hunter, M., Wilkinson, I., Gouneea, C., Fawbert, D., & Smith, R. (2005). Quantifiable
change in functional brain response to empathic and forgivability judgments with resolution of
posttraumatic stress disorder. Psychiatry Research, 140, 4553.
Faul, M., Xu, L., Wald, M. M., & Coronado, V. G. (2010). Traumatic brain injury in The United
States. Washington, DC: US Department of Health and Human Services.
Federal Bureau of Investigation. (2004). Crime in the United States, 2003. Washington, DC: Federal Bureau of Investigation.
Figley, C. R., & Nash, W. P. (Eds.) (2007). Combat stress injury: Theory, research, and management. New York: Routledge.
Finley, E. P. (2011). Fields of combat: Understanding PTSD among veterans of Iraq and Afghanistan. Ithaca: Cornell University Press.
Flannery, R. B. (1995). Violence in the workplace. New York: Crossroad.
Foa, E. B., & Riggs, D. S. (1993). Posttraumatic stress disorder and rape. In J. Oldham, M. B. Riba,
& A. Tasman (Eds.), American Psychiatric Press review of psychiatry (Vol.12, pp.273303).
Washington DC: American Psychiatric Press.
Foeckler, M. M., Garrard, F. H., Williams, C. C., Thomas, A. M., & Jones, T. J. (1978). Vehicle
drivers and fatal accidents. Suicide and Life-Threatening Behavior, 8, 174182.
Foster, T. Y. (1997). From fear to rage: Black Rage as a natural progression from and functional
equivalent of battered woman syndrome. William and Mary Law Review, 38, 18511881.
Frances, A. (2013). Saving normal: An insiders revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma, and the medicalization of ordinary life. New York: William Morrow.
Frankel, F. (1994). The concept of flashbacks in historical perspective. International Journal of
Clinical and Experimental Hypnosis, 42, 321336.
Frazier, P. A., & Haney, B. (1996). Sexual assault cases in the legal system: Police, prosecutor, and
victim perspectives. Law and Human Behavior, 20, 607628.
Frazier, F., & Wilson, R. M. (1918). The sympathetic nervous system and the irritable heart of
soldiers. British Medical Journal, 2, 2729.
Freedy, J. R., Shaw, D., Jarrell, M. P., & Masters, C. (1992). Towards an understanding of the
psychological impact of natural disaster: An application of the conservation resources stress
model. Journal of Traumatic Stress, 5, 441454.
Freeman, T. W., & Roca, V. (2001). Gun use, attitudes toward violence, and aggression among
combat veterans with chronic posttraumatic stress disorder. Journal of Nervous and Mental
Disease, 189, 317320.
Freeman, S. M., Moore, B. A., & Freeman, A. (Eds.). (2009). Living and surviving in harms way:
A psychological treatment handbook for pre- and post-deployment of military personnel. New
York: Routledge.
French, L. M., Spector, J., Stiers, W., & Kane, R. L. (2010). Blast injury and traumatic brain injury.
In C. H. Kennedy & J. L. Moore (Eds.), Military neuropsychology (pp.101125). New York:
Springer.

References

97

Freud, S. (1920). Beyond the pleasure principle. In J. Strachey (Ed. & Transl.), The standard edition of the complete psychological works of Sigmund Freud (Vol.XVIII, pp.764). New York:
Norton.
Frewen, P., & Lanius, R. (2006). Toward a psychobiology of posttraumatic self-dysregulation:
Reexperiencing, hyperarousal, dissociation, and emotional numbing. Annals of the New York
Academy of Sciences, 1071, 110124.
Friel, A., White, T., & Hull, A. (2008). Posttraumatic stress disorder and criminal responsibility.
Journal of Forensic Psychiatry and Psychology, 19, 6485.
Frueh, B. C., Elhai, J. D., & Gold, P. B. (2003). Disability compensation seeking among veterans
evaluated for posttraumatic stress disorder. Psychiatric Services, 54, 8491.
Frueh, B. C., Elhai, J. D., & Grubaugh, A. L. (2005). Documented combat exposure of U.S. veterans seeking treatment for combat-related post-traumatic stress disorder. British Journal of
Psychiatry, 186, 473475.
Frueh, B. C., Grubaugh, A. L., Ethai, J. D., & Buckley, T. C. (2007). U.S. Department of Veterans
Affairs disability policies for posttraumatic stress disorder: Aministrative trends and implications for treatment, rehabilitation, and research. American Journal of Public Health, 97,
21432145.
Frueh, B. C., Hammer, M. B., & Cahill, S. P. (2000). Apparent symptom overreporting among
combat veterans evaluated for PTSD. Clinical Psychology Review, 20, 853885.
Fukunishi, I. (1999). Relationship to cosmetic disfigurement to the severity of posttraumatic stress
disorder in burn injury or digital amputation. Psychotherapy and Psychosomatics, 68, 8286.
Garfield, P. (1987). Nightmares in the sexually abused female teenager. Psychiatric Journal of the
University of Ottawa, 12, 9397.
Garmezy, N. (1993). Children in poverty: Resilience despite risk. Psychiatry, 56, 127136.
Garmezy, N., Masten, A. S., & Tellegen, A. (1984). The study of stress and competence in children: A building block for developmental psychopathology. Child Development, 55, 97111.
Geller, W. A. (1982). Deadly force: What we know. Journal of Police Science and Administration,
10, 151177.
Gentz, D. (1991). The psychological impact of critical incidents on police officers. In J. Reese, J.
Horn, & C. Dunning (Eds.), Critical incidents in policing (pp.119121). Washington DC: US
Government Printing Office.
Giardino, A. E. (2009). Combat veterans, mental health issues, and the death penalty: Addressing
the impact of posttraumatic stress disorder and traumatic brain injury. Fordham Law Review,
77, 29552995.
Gilliland, B. E., & James, R. K. (1993). Crisis intervention strategies (2nd ed.). Pacific Grove:
Brooks/Cole.
Goenjian, A. (1993). A mental health relief programme in Armenia after the 1988 earthquake:
Implementation and clinical observations. British Journal of Psychiatry, 163, 230239.
Gold, L. H., & Shuman, D. W. (2009). Evaluating mental health disability in the workplace:
Model, process, and analysis. New York: Springer.
Goldberg, S. B. (1994). Sentencing guides: Leniency for disturbed Vietnam vet. ABA Journal, 80,
8687.
Goldklang, D. L. (1997). Post-traumatic stress disorder and Black Rage: Clinical validity, criminal
responsibility. Virginia Journal of Social Policy and Law, 5, 213243.
Gover, E. M. (2008). Iraq as a psychological quagmire: The implications of using post-traumatic
stress disorder as a defense for Iraq War veterans. Pace Law Review, 28, 561587.
Grafman, J., Schwab, K., Warden, D., & Pridgen, A. (1996). Frontal lobe injuries, violence, and
aggression: A report of the Vietnam head injury study. Neurology, 46, 12311238.
Graz, C., Etschel, E., Schoech, H., & Soyka, M. (2009). Criminal behavior and violent crimes in
former inpatients with affective disorder. Journal of Affective Disorders, 117, 98103.
Green, B. L. (1991). Evaluating the effects of disasters. Psychological Assessment, 3, 538546.
Greenstone, J. L. (2008). The elements of disaster psychology: Managing psychosocial trauma.
An integrated approach to force protection and acute care. Springfield: Charles C Thomas.

98

References

Greiffenstein, M. F. (2010). Noncredible neuropsychological presentation in service members and


veterans. In C. H. Kennedy & J. L. Moore (Eds.), Military neuropsychology (pp.81100). New
York: Springer.
Grey, N. S., Carmen, N. G., Rogers, P., MacCulloch, M. J., Hayward, P., & Snowden, R. J. (2003).
Post-traumatic stress disorder in mentally disordered offenders by the committing of serious
violent or sexual offense. Journal of Forensic Psychiatry, 14, 2743.
Grossman, D. A. (1996). On killing: The psychological cost of learning to kill in war and society.
New York: Little, Brown.
Grossman, D., & Christensen, L. W. (2007). On combat: The psychology and physiology of deadly
conflict in war and in peace (2nd ed.). Portland: LWC Books.
Grover, S. (2007). Its a crime: Reexamining the successful use of posttraumatic stress disorder
as a legal defense to child sexual assault in the Canadian Case of R. v. Borsch. Ethical Human
Psychology and Psychiatry, 9, 513.
Guilleminault, C., Moscovitch, A., & Leger, D. (1995). Forensic sleep medicine: Nocturnal wandering and violence. Sleep, 18, 740748.
Guriel, J., & Fremouw, W. (2003). Assessing malingered posttraumatic stress disorder: A critical
review. Clinical Psychology Review, 23, 881904.
Gutheil, T. G. (2002). Assessment of mental state at the time of the criminal offense: The forensic
examination. In R. I. Simon & D. W. Shuman (Eds.), Retrospective assessment of mental states
in litigation: Predicting the past. Washington, DC: American Psychiatric Press.
Hall, R. C. W., & Hall, R. C. W. (2006). Malingering of PTSD: Forensic and diagnostic considerations, characteristics of malingerers, and clinical presentations. General Hospital Psychiatry,
28, 525535.
Hall, R. C. W., & Hall, R. C. W. (2007). Detection of malingered PTSD: An overview of clinical,
psychometric, and physiological assessment. Where do we stand? Journal of Forensic Science,
52, 717725.
Hall, H. V., & Poirier, J. G. (2001). Post-traumatic stress disorder and deception. In H. V. Hall & J.
G. Poirer (Eds.), Detecting malingering and deception: Forensic distortion analysis (2nd ed.,
pp.171204). Boca Raton: CRC Press.
Hall, H. V., & Pritchard, D. A. (1996). Detecting malingering and deception: Forensic distortion
analysis. Delray Beach: St. Lucie Press.
Hare, R. D. (1999). Psychopathy as a risk factor for violence. Psychiatric Quarterly, 70, 181197.
Hare, R. D. (2006). Psychopathy: A clinical and forensic overview. Psychiatric Clinics of North
America, 29, 709724.
Harry, B., & Resnick, P. J. (1986). Posttraumatic stress disorder in murderers. Journal of Forensic
Sciences, 31, 609613.
Harsha, W. (1990). Understanding and treating low back pain. In R. S. Weiner (Ed.), Innovations
in pain management: A practical guide for clinicians (pp.9.19.17). Orlando: PMD Press.
Hartl, T. L., Rosen, C., Drescher, K., Lee, T. T., & Gusman, F. (2005). Predicting high-risk behaviors in veterans with posttraumatic stress disorder. Journal of Nervous and Mental Disease,
193, 464472.
Hartman, D. E. (1995). Neuropsychological toxicology: Identification and assessment of human
neurotoxic syndromes (2nd ed.). New York: Plenum.
Heath, W. P., Stone, J., Darley, J. M., & Granneman, B. D. (2003). Yes, I did it, but dont blame me:
Perceptions of excuse defenses. Journal of Psychiatry and Law, 31, 187226.
Hellawell, S., & Brewin, C. (2004). A comparison of flashbacks and ordinary autobiographical
memories of trauma: Content and language. Behavioral Research and Therapy, 42, 112.
Helzer, J. E., Robins, L. N., & McEnvoi, L. (1987). Post-traumatic stress disorder in the general
population. New England Journal of Medicine, 317, 16301634.
Henry, V. E. (2004). Death work: Police, trauma, and the psychology of survival. New York:
Oxford University Press.
Herman, J. L. (1997). Trauma and recovery. New York: Basic Books.
Hiley-Young, B., Blake, D. D., Abueg, F. R., & Rozynko, V. (1995). Warzone violence in Vietnam:
An examination of premilitary, military, and postmilitary factors in PTSD in-patients. Journal
of Traumatic Stress, 8, 125141.

References

99

Hodge, J. R. (1971). The whiplash neurosis. Psychosomatics, 12, 245249.


Hoge, C. W. (2010). Once a warrior, always a warrior: Navigating the transition from combat to
home, including combat stress, PTSD, and mTBI. Guilford: GPP Life Press.
Hoge, C. W., Terhakopian, A., Castro, C. A., Messer, S. C., & Engel, C. C. (2007). Association
of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism
among Iraqi war veterans. American Journal of Psychiatry, 164, 150153.
Holbrook, J. (2011). Veterans courts and criminal responsibility: A problem-solving history and
approach to the liminality of combat trauma. In D. C. Kelly, S. Howe-Barksdale, & D. Gitelson
(Eds.), Treating young veterans: Promoting resilience through practice and advocacy
(pp.259300). New York: Springer.
Homant, R. J., Kennedy, D. B., & Hupp, R. T. (2000). Real and perceived danger in police officer
assisted suicide. Journal of Criminal Justice, 28, 4352.
Honig, A. L., & Sultan, E. (2004). Reactions and resilience under fire: What an officer can expect.
The Police Chief, December, pp.5460.
Horowitz, M. J. (1986). Stress response syndromes (2nd ed.). New York: Jason Aronson.
Hough, M. (1985). The impact of victimization: Findings from the British Crime Survey. Victimology, 10, 498511.
Huffer, K. (1995). Overcoming the devastation of legal abuse syndrome: Beyond rage. Fulkort
Press.
James, B. (1989). Treating traumatized children: New insights and creative interventions. New
York: The Free Press.
Javitt, D. (2004). Glutamate as a therapeutic target in psychiatric disorders. Molecular Psychiatry,
9, 984997.
Jaycox, L. H., Marshall, G. N., & Schell, T. (2004). Use of mental health services by men injured
through community violence. Psychiatric Services, 55, 415420.
Johnson, K. (1989). Trauma in the lives of children. Alameda: Hunter House.
Johnson, K. (2000). Crisis response to schools. International Journal of Emergency Mental
Health, 2, 173180.
Jones, E., & Wessely, S. A. (2007). A paradigm shift in the conceptualization of psychological
trauma in the 20th century. Journal of Anxiety Disorders, 21, 164175.
Jones, E., Vermaas, R., & McCartney, H. (2003). Flashbacks and posttraumatic stress disorder:
The genesis of a 20th-century diagnosis. British Journal of Psychiatry, 182, 158163.
Kehrer, C., & Mittra, S. (1978). Pennsylvania offers a good approach to assisting incarcerated
veterans. American Journal of Corrections, 40, 69.
Kelly, M. M., & Vogt, D. S. (2009). Military stress: Effects of acute, chronic, and traumatic stress
on mental and physical health. In S. M. Freeman, B. A. Moore, & A. Freeman (Eds.), Living
and surviving in harms way: A psychological treatment handbook for pre- and post-deployment of military personnel (pp.85106). New York: Routledge.
Kemp v. State, 211 N.W. 2d 793 (Wis. 1973).
Kennedy, D. B., Homant, R. J., & Hupp, R. T. (1998). Suicide by cop. FBI Law Enforcement Bulletin, August, pp.2127.
Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic stress
disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 10481060.
Killgore, W. D. S., Cotting, D. I., Thomas, J. L., Cox, A. L., McGurk, D., & Vo, A. H. (2008). Postcombat invincibility: Violent combat experiences are associated with increased risk-taking propensity following deployment. Journal of Psychiatric Research, 42, 11121121.
Kinney, J. A. (1995). Violence at work: How to make your company safer for employees and customers. Englewood Cliffs: Prentice-Hall.
Knoll, J., & Resnick, P. J. (1999). US v. Greer: Longer sentences for malingerers. Journal of the
American Academy of Psychiatry and the Law, 27, 621625.
Knoll, J., & Resnick, P. J. (2006). The detection of malingered post-traumatic stress diorder. Psychiatric Clinics of North America, 29, 629647.
Kobasa, S. C. (1979a). Personality and resistance to illness. American Journal of Community Psychology, 7, 413423.

100

References

Kobasa, S. C. (1979b). Stressful life events, personality, and health: An inquiry into hardiness.
Journal of Personality and Social Psychology, 37, 111.
Kobasa, S. C., Maddi, S. R., & Kahn, S. (1982). Hardiness and health: A prospective study. Journal of Personality and Social Psychology, 42, 168177.
Koch, W. J., Douglas, K. S., Nicholls, T. L., & ONeill, M. L. (2006). Psychological injuries: Forensic assessment, treatment, and the law. New York: Oxford University Press.
Koch, W. J., ONeill, M., & Douglas, K. S. (2005). Empirical limits for the forensic assessment of
PTSD litigants. Law and Human Behavior, 29, 121149.
Kolb, L. C. (1987). A neuropsychological hypothesis explaining posttraumatic stress disorders.
American Journal of Psychiatry, 144, 989995.
Koren, D., Hillel, Y., Idar, N., Hemel, D., & Klein, E. (2007). Combat stress management: The
interplay between combat, physical injury, and psychological trauma. In C. R. Figley & W. P.
Nash (Eds.), Combat stress injury: Theory, research, and management (pp.119136). New
York: Routledge.
Kozaric-Kovacic, D., & Borovecki, A. (2005). Prevalence of psychotic comorbidity in combatrelated post-traumatic stress disorder. Military Medicine, 170, 223226.
Kratcoski, P. C., Edelbacher, M., & Das, D. K. (2001). Terrorist victimization: Prevention, control,
and recovery. International Review of Victimology, 8, 257268.
Kretschmer, E. (1926). Hysteria. New York: Basic Books.
Kuch, K. (1987). Treatment of posttraumatic stress disorder following automobile accidents. Behavior Therapy, 10, 224225.
Kuch, K., & Cox, B. J. (1992). Symptoms of PTSD in 124 survivors of the Holocaust. American
Journal of Psychiatry, 149, 337340.
Kuch, K., & Swinson, R. P. (1985). Posttraumatic stress disorder after car accidents. Canadian
Journal of Psychiatry, 30, 426427.
Kulka, R. A., Schlenger, W. E., Fairbank, J. A., Hough, R. L., Jordan, B. K., Marmar, C. R., &
Weiss, D. S. (1990). Trauma and the Vietnam War generation: Report of findings from the
National Vietnam Veterans Readjustment Study. New York: Brunner/Mazel.
Kuzma, L. (2000). Trends: Terrorism in the United States. Public Opinion Quarterly, 64, 90105.
Labig, C. E. (1995). Preventing violence in the workplace. New York: Amacom.
Larrabee, G. J., & Berry, D. T. R. (2007). Diagnostic classification statistics and diagnostic validity
of malingering assessment. In G. J. Larrabee (Ed.), Assessment of malingered neuropsychological deficits (pp.1426). New York: Oxford University Press.
Lasko, N. B., Guruits, T. V., Kuhne, A. A., Orr, S. P., & Pitman, R. K. (1994). Aggression and its
correlates in Vietnam veterans with and without chronic posttraumatic stress disorder. Comprehensive Psychiatry, 35, 373381.
Leal, D. L. (2005). American public opinion toward the military: Differences by race, gender, and
class? Armed Forces and Society, 32, 123138.
Lee, K. A., Vaillant, G. E., Torrey, W. C., & Elder, G. H. (1995). A 50-year prospective study of
the psychological sequelae of World War II combat. American Journal of Psychiatry, 152,
516522.
Lehmann, L. S., McCormick, R. A., & Kizer, K. W. (1999). A survey of assaultive behavior in
Veterans Health Administration facilities. Psychiatric Services, 50, 384389.
Levine, E., Degutis, L., Pruzinsky, T., Shin, J., & Persing, J. A. (2005). Quality of life and facial
trauma: Psychological and body image effects. Annals of Plastic Surgery, 54, 502510.
Lewinsohn, P. M., Klein, D. N., & Seeley, J. R. (1995). Bipolar disorder in a community sample of
older adolescents: Prevalence, phenomenology, comorbidity, and course. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 454463.
Lindsay, M. S., & Dickson, D. (2004). Negotiating with the suicide-by-cop subject. In V. Lord
(Ed.), Suicide by Cop: Inducing Officers to Shoot (pp.153162). Flushing: Looseleaf Law
Publications.
Link, B. G., & Stueve, A. (1994). Psychotic symptoms and the violent/illegal behavior of mental
patients compared to community controls. In J. Monahan & H. Steadman (Eds.), Violence
and mental disorder: Developments in risk assessment (pp.137159). Chicago: University of
Chicago Press.

References

101

Link, B. G., Cullen, F. T., & Andrews, H. (1992). The violent and illegal behavior of mental patients reconsidered. American Sociological Review, 57, 275272.
Link, B. G., Stueve, A., & Phelan, J. (1998). Psychotic symptoms and violent behaviours: Probing
the components of threat/control override symptoms. Social Psychology and Psychiatric
Epidemiology, 33, 495560.
Lipman, F. D. (1962). Malingering in personal injury cases. Temple Law Quarterly, 35, 141162.
Lipsey, M. W., Wilson, D. B., Cohen, M. A., & Derzon, J. H. (1997). Is there a causal relationship
between alcohol use and violence? A synthesis of evidence. Recent Developments in Alcoholism, 13, 245282.
Lobo, I., de Oliveira, L., David, I. A., Pereira, M. G., Volchan, E., Rocha-Rego, V., Figueira, I.,
& Mocaiber, I. (2011). The neurobiology of posttraumatic stress disorder: Dysfunction in the
prefrontal-amygdala circuit? Psychology and Neuroscience, 4, 191203.
Lord, V. B. (2000). Law enforcement-assisted suicide. Criminal Justice and Behavior, 27, 401419.
Lowenstein, L. F. (2001). Factors differentiating successful versus unsuccessful malingerers. Journal of Personality Assessment, 77, 333338.
Ludwig, A. M. (1972). Hysteria: A neurobiological theory. Archives of General Psychiatry, 27,
771777.
Luthar, S. S. (1991). Vulnerability and resilience: A study of high-risk adolescents. Child Development, 62, 600616.
Lykken, D. T. (1995). The antisocial personalities. Hillsdale: Erlbaum.
Lynn, E., & Belza, M. (1984). Factitious post-traumatic stress disorder: The veteran who never got
to Vietnam. Hospital and Community Psychiatry, 35, 697701.
Lyons, M. J., Goldberg, J., Eisen, S. A., True, W., Tsuang, M. T., & Meyer, J. M. (1993). Do genes
influence exposure to trauma? A twin study of combat. American Journal of Medical Genetics,
48, 2227.
Mackay, R. D., & Kearns, G. (1999). More facts about the insanity defense. Criminal Law Review,
36, 714725.
MacManus, D., & Wessely, S. (2012). Trauma, psychopathology, and violence in recent combat
veterans. In C. S. Widom (Ed.), Trauma, psychopathology, and violence: Causes, consequences, or correlates? (pp.267287). New York: Oxford University Press.
Maddi, S. R., & Khoshaba, D. M. (1994). Hardiness and mental health. Journal of Personality
Assessment, 63, 265274.
Malt, U. F., Hoivik, B., & Blikra, G. (1993). Psychosocial consequences of road accidents. European Psychiatry, 8, 227228.
Mantell, M., & Albrecht, S. (1994). Ticking bombs: Defusing violence in the workplace. New
York: Irwin.
Marciniak, R. (1986). Implications for forensic psychiatry of post-traumatic stress disorder: A
review. Military Medicine, 151, 434437.
Matsakis, A. (1994). Post-traumatic stress disorder: A complete treatment guide. Oakland: New
Harbinger.
McAllister, H., & Bregman, N. (1986). Plea-bargaining by prosecutors and defense attorneys: A
decision theory approach. Journal of Applied Social Psychology, 71, 686690.
McCann, J. T. (1998). Malingering and deception in adolescents. Washington, DC: American Psychological Association.
McCann, I. L., & Pearlman, L. A. (1990). Psychological trauma and the adult survivor: Theory,
therapy, and transformation. New York: Brunner/Mazel.
McFall, M., Fontana, A., Raskind, M., & Rosenheck, R. (1999). Analysis of violent behavior in
Vietnam combat veteran psychiatric inpatients with posttraumatic stress disorder. Journal of
Traumatic Stress, 12, 501517.
McFarlane, A. C. (1997). The prevalence and longitudinal course or PTSD: Implications for the
neurobiological models of PTSD. Annals of the New York Academy of Sciences, 821, 1023.
McGuire, J., & Clark, J. D. (2011). PTSD and the law: An update. PTSD Research Quartery, 22,
26.

102

References

McMains, M. J. (1991). The management and treatment of postshooting trauma. In J. T. Horn & C.
Dunning (Eds.), Critical Incidents in Policing (rev ed., pp.191198). Washington DC: Federal
Bureau of Investigation.
McNally, R. J. (2004). Conceptual problems with the DSM-IV criteria for posttraumatic stress
disorder. In G. M. Rosen (Ed.), Posttraumatic stress disorder: Issues and controversies
(pp.114). Hoboken: Wiley.
McNally, R. J. (2007). Mechanisms of exposure therapy: How neuroscience can improve psychological treatments for anxiety disorders. Clinical Psychology Review, 27, 750759.
McNally, R. J., & Shin, L. (1995). Association of intelligence with severity of posttraumatic stress
disorder symptoms in Vietnam combat veterans. American Journal of Psychiatry, 152, 936938.
McNiel, D. E., Eisner, J. P., & Binder, R. L. (2003). The relationship between aggressive attributional style and violence by psychiatric patients. Journal of Consulting and Clinical Psychology, 71, 399403.
Mearburg, J. C., & Wilson, R. M. (1918). The effect of certain sensory stimulations on respiratory
and heart rate in cases of so-called irritable heart.. Heart (British Cardiac Society), 7, 1722.
Meek, C. L. (1990). Evaluation and assessment of post-traumatic and other stress-related disorders. In C. L. Meek (Ed.), Posttraumatic stress disorder: Assessment, differential diagnosis,
and forensic evaluation (pp.961). Sarasota: Professional Resource Exchange.
Melton, G. B., Petrila, J., Poythress, N. G., & Slobogin, C. (1997). Psychological evaluations for
the courts (2nd ed.). New York: Guilford Press.
Merckelbach, H., Dekkers, T., Wessel, I., & Roefs, A. (2003a). Dissociative symptoms and amnesia in Dutch concentration camp survivors. Comprehensive Psychiatry, 44, 6569.
Merckelbach, H., Dekkers, T., Wessel, I., & Roefs, A. (2003b). Amnesia, flashbacks, nightmares,
and dissociation in aging concentration camp survivors. Behavioral Research and Therapy,
41, 351360.
Merskey, H. (1992). Psychiatric aspects of the neurology of trauma. Neurologic Clinics, 10, 895905.
Miller, L. (1984). Neuropsychological concepts of somatoform disorders. International Journal of
Psychiatry in Medicine, 14, 3146.
Miller, L. (1987). Neuropsychology of the aggressive psychopath: An integrative review. Aggresssive Behavior, 13, 119140.
Miller, L. (1988). Neuropsychological perspectives on delinquency. Behavioral Sciences and the
Law, 6, 409428.
Miller, L. (1990a). Major syndromes of aggressive behavior following head injury. Cognitive Rehabilitation, 8(6), 1419.
Miller, L. (1990b). Litigating the head trauma case: Issues and answers for attorneys and their
clients. Cognitive Rehabilitation, 8(3), 812.
Miller, L. (1990c). Chronic pain complicating head injury recovery: Recommendations for clinicians. Cognitive Rehabilitation, 8(5), 1219.
Miller, L. (1991a). Psychotherapy of the brain-injured patient: Principles and practices. Journal of
Cognitive Rehabilitation, 9(2), 2430.
Miller, L. (1991b). Freuds brain: Neuropsychodynamic foundations of psychoanalysis. New York:
Guilford.
Miller, L. (1992). Neuropsychology, personality, and substance abuse in the head injury case:
Clinical and forensic issues. International Journal of Law and Psychiatry, 15, 303316.
Miller, L. (1993a). Toxic torts: Clinical, neuropsychological, and forensic aspects of chemical and
electrical injuries. Journal of Cognitive Rehabilitation, 11(1), 620.
Miller, L. (1993b). Psychotherapeutic approaches to chronic pain. Psychotherapy, 30, 115124.
Miller, L. (1993c). Psychotherapy of the Brain-Injured Patient: Reclaiming the Shattered Self.
New York: Norton.
Miller, L. (1993d). The trauma of head trauma: Clinical, neuropsychological, and forensic aspects of posttraumatic stress syndromes in brain injury. Journal of Cognitive Rehabilitation,
11(4), 1829.
Miller, L. (1994a). Civilian posttraumatic stress disorder: Clinical syndromes and psychotherapeutic strategies. Psychotherapy, 31, 655664.

References

103

Miller, L. (1994b). Traumatic brain injury and aggression. In M. Hillbrand & N. J. Pallone (Eds.),
The Psychobiology of aggression: Engines, measurement, control (pp.91103). New York:
Haworth.
Miller, L. (1995a). Tough guys: Psychotherapeutic strategies with law enforcement and emergency
services personnel. Psychotherapy, 32, 592600.
Miller, L. (1995b). Toxic trauma and chemical sensitivity: Clinical syndromes and psychotherapeutic strategies. Psychotherapy, 32, 648656.
Miller, L. (1996a). Malingering in mild head injury and the postconcussion syndrome: Clinical,
neuropsychological, and forensic considerations. Journal of Cognitive Rehabilitation, 14(4),
617.
Miller, L. (1996b). Malingering in mild brain injury: Toward a balanced view. Neurolaw Letter,
6, 8591.
Miller, L. (1998a). Not just malingering: Recognizing psychological syndromes in personal injury
litigation. Neurolaw Letter, 8, 2530.
Miller, L. (1998b). Malingering in brain injury and toxic tort cases. In E. Pierson (Ed.), 1998 Wiley
expert witness update: New developments in personal injury litigation (pp.225289). New
York: Wiley.
Miller, L. (1998c). Shocks to the system: Psychotherapy of traumatic disability syndromes. New
York: Norton.
Miller, L. (1998d). Motor vehicle accidents: Clinical, neuropsychological, and forensic aspects.
Journal of Cognitive Rehabilitation, 16(4), 1023.
Miller, L. (1998e). Ego autonomy and the healthy personality: Psychodynamics, cognitive style,
and clinicial applications. Psychoanalytic Review, 85, 423448.
Miller, L. (1999a). Treating posttraumatic stress disorder in children and families: Basic principles
and clinical applications. American Journal of Family Therapy, 27, 2134.
Miller, L. (1999b). Mental stress claims and personal injury: Clinical, neuropsychological, and
forensic issues. Neurolaw Letter, 8, 3945.
Miller, L. (1999c). Posttraumatic stress disorder in child victims of violent crime: Making the case
for psychological injury. Victim Advocate, 1(1), 610.
Miller, L. (1999d). Posttraumatic stress disorder in elderly victims of violent crime: Making the
case for psychological injury. Victim Advocate, 1(2), 710.
Miller, L. (1999e). Psychological syndromes in personal injury litigation. In E. Pierson (Ed.), 1999
Wiley expert witness update: New developments in personal injury litigation (pp.263308).
New York: Aspen.
Miller, L. (1999f). Workplace violence: Prevention, response, and recovery. Psychotherapy, 36,
160169.
Miller, L. (2000). Law enforcement traumatic stress: Clinical syndromes and intervention strategies. Trauma Response, 6(1), 1520.
Miller, L. (2001a). Not just malingering: Syndrome diagnosis in traumatic brain injury litigation.
Neurorehabilitation, 16, 109122.
Miller, L. (2001b). Workplace violence and psychological trauma: Clinical disability, legal liability, and corporate policy. Part I. Neurolaw Letter, 11, 15.
Miller, L. (2001c). Workplace violence and psychological trauma: Clinical disability, legal liability, and corporate policy. Part II. Neurolaw Letter, 11, 713.
Miller, L. (2001d). Treating and compensating victims of posttraumatic stress disorder. Nexus,
7(2), 13, 68.
Miller, L. (2002a). Posttraumatic stress disorder in school violence: Risk management lessons
from the workplace. Neurolaw Letter, 11, 33, 3640.
Miller, L. (2002b). What is the true spectrum of functional disorders in rehabilitation? In N. D.
Zasler & M. F. Martelli (Eds.), Functional disorders (pp.120). Philadelphia: Hanley & Belfus.
Miller, L. (2003). Psychological interventions for terroristic trauma: Symptoms, syndromes, and
treatment strategies. Psychotherapy, 39, 283296.
Miller, L. (2004). Psychotherapeutic interventions for survivors of terrorism. American Journal of
Psychotherapy, 58, 116.

104

References

Miller, L. (2006a). Suicide by cop: Causes, reactions, and practical intervention strategies. International Journal of Emergency Mental Health, 8, 165174.
Miller, L. (2006b). Critical incident stress debriefing for law enforcement: Practical models and
special applications. International Journal of Emergency Mental Health, 8, 189201.
Miller, L. (2006c). Officer-involved shooting: Reaction patterns, response protocols, and psychological intervention strategies. International Journal of Emergency Mental Health, 8, 239254.
Miller, L. (2006d). Practical police psychology: Stress management and crisis intervention for law
enforcement. Springfield: Charles C Thomas.
Miller, L. (2006e). On the spot: Testifying in court for law enforcement officers. FBI Law Enforcement Bulletin, October, pp.16.
Miller, L. (2006f). The terrorist mind: I. A psychological and political analysis. International Journal of Offender Rehabilitation and Comparative Criminology, 50, 121138.
Miller, L. (2006g). The terrorist mind: II. Typologies, psychopathologies, and practical guidelines
for investigation. International Journal of Offender Rehabilitation and Comparative Criminology, 50, 255268.
Miller, L. (2007a). Line-of-duty death: Psychological treatment of traumatic bereavement in law
enforcement. International Journal of Emergency Mental Health, 9, 1323.
Miller, L. (2007b). School violence: Effective response protocols for maximum safety and minimum liability. International Journal of Emergency Mental Health, 9, 105110.
Miller, L. (2007c). Workplace violence: Practical policies and strategies for prevention, response,
and recovery. International Journal of Emergency Mental Health, 9, 259279.
Miller, L. (2007d). Stress, traumatic stress, and posttraumatic stress syndromes. In L. Territo &
J. D. Sewell (Eds.), Stress management in law enforcement (2ndedn., pp.1539). Durham:
Carolina Academic Press.
Miller, L. (2007e). Law enforcement traumatic stress: Clinical syndromes and intervention strategies. In L. Territo & J. D. Sewell (Eds.), Stress management in law enforcement (2ndedn.,
pp.381397). Durham: Carolina Academic Press.
Miller, L. (2007f). Traumatic stress disorders. In F. M. Dattilio & A. Freeman (Eds.), Cognitivebehavioral strategies in crisis intervention (3rd ed., pp.494527). New York: Guilford.
Miller, L. (2008a). Military psychology and police psychology: Mutual contributions to crisis
intervention and stress management. International Journal of Emergency Mental Health, 10,
926.
Miller, L. (2008b). Wounded warriors: Stress and crisis management for military and law enforcement personnel. Crisis Management and Traumatic Stress Report, 1, 1122.
Miller, L. (2008c). Counseling crime victims: Practical strategies for mental health professionals.
New York: Springer.
Miller, L. (2008d). Workplace violence: Practical policies and strategies for prevention, response,
and recovery. International Journal of Emergency Mental Health, 9, 259279.
Miller, L. (2008e). Stress and resilience in law enforcement training and practice. International
Journal of Emergency Mental Health, 10, 109124.
Miller, L. (2008f). Juror stress: Symptoms, syndromes, and solutions. International Journal of
Emergency Mental Health, 10, 203218.
Miller, L. (2008g). METTLE: Mental toughness training for law enforcement. Flushing: Looseleaf
Law Publications.
Miller, L. (2009a). Criminal investigator stress: Symptoms, syndromes, and practical coping strategies. International Journal of Emergency Mental Health, 11, 8792.
Miller, L. (2009b). Testifying in court: Practical strategies for public safety, emergency services, and
mental health professionals. International Journal of Emergency Mental Health, 11, 263269.
Miller, L. (2010). Psychotherapy with military personnel: Lessons learned, challenges ahead. International Journal of Emergency Mental Health, 12, 179192.
Miller, L. (2012a). Posttraumatic stress disorder and criminal violence: Basic concepts and clinical-forensic applications. Aggression and Violent Behavior, 17, 354364.
Miller, L. (2012b). Criminal victimization. In L. Lopez-Levers (Ed.)., Counseling survivors of
trauma: Theories, interventions, and collaborations (pp.231248). New York: Springer.

References

105

Miller, L. (2012c). Criminal psychology: Nature, nurture, culture. Springfield: Charles C Thomas.
Miller, L. (2013a). Psychological evaluations in the criminal justice system: Basic principles and
best practices. Aggression and Violent Behavior, 18, 8391.
Miller, L. (2013b). Stress, traumatic stress, and posttraumatic stress syndromes. In L. Territo & J.
D. Sewell (Eds.), Stress management in law enforcement (3rdedn., pp.936). Durham: Carolina Academic Press.
Miller, L. (2013c). Military and law enforcement psychology: Cross-contributions to extreme
stress management. In L. Territo & J. D. Sewell (Eds.), Stress management in law enforcement
(3rdedn., pp.455486). Durham: Carolina Academic Press.
Miller, L. (2013d). Stress and resilience in law enforcement training and practice. In L. Territo &
J. D. Sewell (Eds.), Stress management in law enforcement (3rdedn., pp.523550). Durham:
Carolina Academic Press.
Miller, L. (in press-a). Law enforcement stress: Risk, resilience, and strategies for success. In S.
Freeman, B. Moore, L. Miller, & A. Freeman (Eds.). Behind the badge: A psychological treatment handbook for working with law enforcement officers. New York: Guilford.
Miller, L. (in press-b). The police officer, the forensic expert, and legal proceedings. In S. Freeman, B. Moore, L. Miller, & A. Freeman (Eds.). Behind the badge: A psychological treatment
handbook for working with law enforcement officers. New York: Guilford.
Miller, H. B., Miller, L., & Bjorklund, D. (2010). Helping military parents cope with parental
deployment: Role of attachment theory and recommendations for mental health clinicians and
counselors. International Journal of Emergency Mental Health, 12, 231235.
Mitchell, J. T., & Everly, G. S. (1996). Critical incident stress debriefing: Operations manual. (rev.
ed.). Ellicott City: Chevron.
Mitchell, J., & Levenson, R. L. (2006). Some thoughts on providing effective mental health critical care for police departments after line-of-duty deaths. International Journal of Emergency
Mental Health, 8, 14.
Modestin, J., Hug, A., & Ammann, R. (1997). Criminal behaviors in males with affective disorders. Journal of Affective Disorders, 42, 2938.
Modlin, H. C. (1983). Traumatic neurosis and other injuries. Psychiatric Clinics of North America,
6, 661682.
Modlin, H. C. (1990). Posttraumatic stress disorder: Differential diagnosis. In C. L. Meek (Ed.),
Posttraumatic stress disorder: Assessment, differential diagnosis, and forensic evaluation
(pp.6389). Sarasota: Professional Resource Exchange.
Mogil, M. (1989). Maximizing your courtroom testimony. FBI Law Enforcement Bulletin, May,
pp.79.
Monahan, J. (2001). Major mental disorder and violence: Epidemiology and risk assessment. In
G.-F. Pinard & L. Pagani (Eds.), Clinical assessment of dangerousness: Empirical contributions (pp.89102). New York: Cambridge University Press.
Monahan, J. (2002). The scientific status of research on clinical and actuarial predictions of violence. In D. Faigman, D. Kaye, M. Saks, & J. Sanders (Eds.), Modern scientific evidence: The
law and science of expert testimony (pp.423445). St.Paul: West Publishing.
Monahan, J., Steadman, H. J., Silver, E., Appelbaum, P. S., Robbins, P. C., & Mulvery, E. P.
(2001). Rethinking risk assessment: The MacArthur study of mental disorder and violence.
New York: Oxford University Press.
Moore, B. A. (Ed.). (2011). Treating PTSD in military personnel: A clinical handbook. New York:
Guilford Press.
Moore, B. A., & Krakow, B. (2009). Characteristics, effects, and treatment of sleep disorders in
service members. In S. M. Freeman, B. A. Moore & A. Freeman (Eds.), Living and surviving
in harms way: A psychological treatment handbook for pre- and post-deployment of military
personnel (pp.281306). New York: Routledge.
Moore, B. A., Hopewell, C. A., & Grossman, D. (2009). After the battle: Violence and the warrior. In S. M. Freeman, B. A. Moore & A. Freeman (Eds.), Living and surviving in harms
way: A psychological treatment handbook for pre- and post-deployment of military personnel
(pp.307328). New York: Routledge.

106

References

Morrison, A. P., Frame, L., & Larkin, W. (2003). Relationships between trauma and psychosis: A
review and integration. British Journal of Clinical Psychology, 42, 331353.
Morrow, L. A., Ryan, C. M., Goldstein, G., & Hodgson, M. J. (1989). A distinct pattern of personality disturbance following exposure to mixtures of organic solvents. Journal of Occupational
Medicine, 32, 743746.
Morrow, L. A., Ryan, C. M., Hodgson, M. J., & Robin, N. (1991). Risk factors associated with
persistence of neuropsychological deficits in persons with organic solvent exposure. Journal
of Nervous and Mental Disease, 179, 540545.
Moskowitz, A. (2004). Dissociation and violence: A review of the literature. Trauma, Violence,
and Abuse: A Review Journal, 5(1), 2146.
Moss, H. B. (1989). Psychopathy, aggression, and family history in male veteran substance abuse
patients: A factor analytic study. Addictive Behaviors, 14, 565570.
Mossman, D. (1994). At the VA, it pays to be sick. Public Interest, 114, 3547.
Mossman, D. (1996). Veterans Affairs disability compensation: A case study in countertherapeutic
jurisprudence. Bulletin of the American Academy of Psychiatry and the Law, 24, 2744.
Mueller, J. (2005). Simplicity and spook: Terrorism and the dynamics of threat exaggeration. International Studies Perspectives, 6, 208234.
Nash, W. P. (2007). Combat/operational stress adaptations and injuries. In C. R. Figley & W. P.
Nash (Eds.), Combat stress injury: Theory, research, and management (pp.1131). New York:
Routledge.
National Center for PTSD. (2010). Criminal behavior and PTSD: An analysis. Washington, DC:
National Center for PTSD.
Nesca, M., & Dalby, J. T. (2013). Forensic interviewing in criminal court matters: A guide for
clinicians. Springfield: Charles C Thomas.
Neustein, A. (Ed.). (2009). Tempest in the temple: Jewish communities and child sex scandals.
Waltham: Brandeis University Press.
Newman, K. S., Fox, C., Harding, D. J., Mehta, J., & Roth, W. (2004). Rampage: The social roots
of school shootings. New York: Basic Books.
Nichols, B. L., & Czirr, D. K. (1986). Posttraumatic stress disorder: Hidden syndrome in elders.
Clinical Gerontologist, 5, 417433.
Nielsen, E. (1991). Traumatic incident corps: Lessons learned. In J. Reese, J. Horn, & C. Dunning
(Eds.), Critical incidents in policing (pp.221226). Washington DC: US Government Printing
Office.
Nies, K. J., & Sweet, J. J. (1994). Neuropsycholological assessment and malingering: A critical
review of past and present strategies. Archives of Clinical Neuropsychology, 9, 501552.
Nims, D. R. (2000). Violence in the schools: A national crisis. In D. S. Sandhu & C. B. Aspy
(Eds.), Violence in American schools: A practical guide for counselors (pp.320). Alexandria:
American Counseling Association.
Novaco, R. W. (1994). Anger as a risk factor for violence among the mentally disordered. In J.
Monahan & H. J. Steadman (Eds.), Violence and mental disorder: Developments in risk assessment (pp.2159). Chicago: University of Chicago Press.
Nutt, D., & Malizia, A. (2004). Structural and functional brain changes in posttraumatic stress
disorder. Journal of Clinical Psychiatry, 65, 1117.
OBrien, L. S. (1998). Medicolegal aspects of post-traumatic illness. In L. S. OBrien (Ed.), Traumatic events and mental health (pp.242261). Cambridge: Cambridge University Press.
Oppenheim, H. (1890). Tatsachliches und hypthothetisches uber das wesen der hysterie. Berlin
Klinik Wschr, 27, 553.
Packer, I. K. (1983). Post-traumatic stress disorder and the insanity defense: A critical analysis.
Journal of Psychiatry and Law, 11, 125136.
Papanastassiou, M., Waldron, G., Boyle, J., & Chesterman, L. P. (2004). Posttraumatic stress disorder in mentally ill perpetrators of homicide. Journal of Forensic Psychiatry, 15, 6675.
Pardeck, J. T., & Nolden, W. L. (1983). Aggression levels in college students after exposure or
non-exposure to an aggressive life experience. Adolescence, 18, 845850.
Paris, J. (2000). Predispositions, personality traits, and posttraumatic stress disorder. Harvard Review of Psychiatry, 8, 175183.

References

107

Parker, R. S. (1990). Traumatic brain injury and neuropsychological impairment: Sensorimotor,


cognitive, emotional, and adaptive problems in children and adults. New York: Springer-Verlag.
Parker, R. S. (1996). The spectrum of emotional distress and personality changes after minor head
injury incurred in a motor vehicle accident. Brain Injury, 10, 287302.
Pasternack, S. A. (1971). Evaluation of dangerous behavior of active duty servicemen. Military
Medicine, 136, 110113.
Paton, D., & Smith, L. (1999). Assessment, conceptual and methodological issues in researching
traumatic stress in police officers. In J. M. Violanti & D. Paton (Eds.), Police Trauma: Psychological Aftermath of Civilian Combat (pp.1324). Springfield: Charles C Thomas.
Pentland, B., & Rothman, G. (1982). The incarcerated Vietnam-service veteran: stereotypes and
realities. Journal of Correctional Education, 33, 1014.
People v. Danielly, 33 Cal.2d 362, 1949.
People v. Gilberg, 240P. 1000 (Cal. 1925).
Perrou, B., & Farrell, B. (2004). Officer-involved shootings: Case management and psychosocial investigations. In V. Lord (Ed.), Suicide by cop: Inducing officers to shoot (pp.239242).
Flushing: Looseleaf Law Publications.
Perry, B. (2002). Childhood experience and the expression of genetic potential: What childhood
neglect tells us about nature and nurture. Brain and Mind, 3, 7910.
Pillar, G., Malhotra, A., & Lavie, P. (2000). Posttraumatic stress disorder and sleepwhat a nightmare! Sleep Medicine Review, 4, 183200.
Pinizzotto, A. J., Davis, E. F., & Miller, C. E. (2005). Suicide by cop: Defining a devastating dilemma. FBI Law Enforcement Bulletin, February, pp.820.
Pitman, R. K., Orr, S. P., Forgue, D. F., de Jong, J. B., & Claiborn, J. M. (1989). Prevalence of
posttraumatic stress disorder in wounded Vietnam veterans. American Journal of Psychiatry,
146, 667669.
Pitman, R., Sparr, L., & Saunders, L. (1996). Legal issues in posttraumatic stress disorder. In A.
McFarlane (Ed.), Traumatic stress: The effects of overwhelming experience on mind, body, and
society (pp.378397). New York: Guilford.
Pizarro, J., Silver, R. C., & Prouse, J. (2006). Physical and mental health costs of traumatic experiences among Civil War veterans. Archives of General Psychiatry, 63, 193200.
Plante, T. G. (2004). Sin against the innocents: Sexual abuse by priests and the role of the Catholic
Church. Westport: Greenwood.
Pliszka, S. R., Sherman, J. O., Barrow, M. V., & Irick, S. (2000). Affective disorder in juvenile
offenders: A preliminary study. American Journal of Psychiatry, 157, 130132.
Pollock, P. H. (1999). When the killer suffers: Post-traumatic stress reactions following homicide.
Legal and Criminological Psychology, 4, 185202.
Pontius, A. A. (1981). Stimuli triggering violence in psychoses. Journal of Forensic Sciences, 26,
123128.
Pontius, A. A. (1984). Specific stimulus-evoked violent action in psychotic trigger reaction: A
seizure-like imbalance between frontal lobe and limbic systems? Perceptual and Motor Skills,
59, 299333.
Pontius, A. A. (1987). Psychotic trigger reaction: Neuro-psychiatric and neuro-biological (limbic?)
aspects of homicide, reflecting on normal action. Integrative Psychiatry, 5, 116139.
Pontius, A. A. (1996). Forensic significance of the limbic psychotic trigger reaction. Bulletin of the
American Academy of Psychiatry and the Law, 24, 125134.
Pontius, A. A. (1997). Homicide linked to moderate repetitive stresses kindling limbic seizures in
14 cases of limbic psychotic trigger reaction. Aggression and Violent Behaviour, 2, 125141.
Porter v. McCollum, 558 U.S. 130 S. Ct. 447 (2009).
Posey, A. J., & Wrightsman, L. S. (2005). Trial consulting. New York: Oxford University Press.
Potts, M. K. (1994). Long-term effects of trauma: Posttraumatic stress among civilian internees of
the Japanese during World War II. Journal of Clinical Psychiatry, 50, 681698.
Pressman, M. R. (2007). Disorders of arousal from sleep and violent behavior: The role of physical
contact and proximity. Sleep, 30, 10391047.
Pynoos, R. S., Frederick, C., Nader, K., Arroyo, W., Steinberg, A., & Eth, S. (1987). Life threat and
posttraumatic stress in school-age children. Archives of General Psychiatry, 44, 10571063.

108

References

Quanbeck, C. D., Stone, D. C., Scott, C. L., McDermott, B. E., Altshuler, L. L., & Frye, M. A.
(2004). Clincal and legal correlates of inmates with bipolar disorder at time of criminal arrest.
Journal of Clinical Psychiatry, 65, 198203.
Quanbeck, C. D., McDermott, B. E., & Frye, M. A. (2005). Clinical and legal characteristics of
inmates with bipolar disorder. Current Psychiatry Reports, 7, 478484.
Quanbeck, C. D., Stone, D. C., & McDermott, B. E. (2005). Relationship among criminal arrest
and and community treatment history among patients with bipolar disorder. Psychiatric Services, 56, 847852.
R. v. Bosch. (2006). Manitoba Judgments No. 221.
Raphael, B. (1986). When disaster strikes: How individuals and communities cope with catastrophe. New York: Basic Books.
Raskin, S. A., & Mateer, C. A. (Eds.). (2000). Neuropsychological management of mild traumatic
brain injury. New York: Oxford University Press.
Reese, J. T. (1987). Coping with stress: Its your job. In J. T. Reese (Ed.), Behavioral Science in
Law Enforcement (pp.7579). Washington DC: FBI.
Reijneveld, S. A., Crone, M. R., Verhulst, F. C., & Verloove-Vanhorick, S. P. (2003). The effect of
a severe disaster on the mental health of adolescents: A controlled study. Lancet, 362, 691696.
Resnick, P. J. (1995). Guidelines for the evaluation of malingering in posttraumatic stress disorder.
In R. I. Simon (Ed.), Posttraumatic stress disorder in litigation: Guidelines for forensic assessment (pp.117134). Washington, DC: American Psychiatric Press.
Resnick, P. J. (1997). Malingering of posttraumatic stress disorders. In R. Rogers (Ed.), Clinical
assessment of malingering and deception (2ndedn., pp.130152). New York: Guilford.
Resnick, P. J. (1999). The detection of malingered psychosis. Psychiatric Clinics of North America, 22, 159172.
Roca, V., & Freeman, T. W. (2002). Psychosensory symptoms in combat veterans with posttraumatic stress disorder. Journal of Neuropsychiatry and Clinical Neurosciences., 14, 185189.
Roccia, F., DellAcqua, A., Angelini, G., & Berrone, S. (2005). Maxillofacial trauma and psychiatric sequelae: Post-traumatic stress disorder. Journal of Craniofacial Surgery, 16, 355360.
Roemer, L., Litz, B. T., & Orsillo, S. M. (1998). Increases in retrospective accounts of war-zone
exposure over time: The role of PTSD symptom severity. Journal of Traumatic Stress, 11,
595605.
Rosen, G. (1975). Nostalgia: A forgotten psychological disorder. Psychosomatic Medicine, 5,
342347.
Rosen, G. M., & Lilienfeld, S. O. (2008). Posttraumatic stress disorder: An empirical evaluation of
core assumptions. Clinical Psychology Review, 28, 837868.
Ross, C., Joshi, S., & Currie, R. (1991). Dissociative experiences in the general population: A
facror analysis. Hospital and Community Psychiatry, 42, 297301.
Ross, R., Ball, W., Sullivan, K., & Caroff, S. (1989). Sleep disturbance as the hallmark of posttraumatic stress disorder. American Journal of Psychiatry, 146, 697707.
Roszell, D., McFall, M., & Malas, K. (1991). Frequency of symptoms and recurrent psychiatric
disorder in Vietnam veterans with chronic PTSD. Hospital and Community Psychiatry, 42,
293296.
Roth, M. L. (2008). Tips for persuasive defense of your client suffering from posttraumatic stress
disorder. http://fd.org/docs/select-topicsmental-health/tips-for-persuasive-criminal-defense-ofyour-client-suffering-from-posttraumatic-stress-disorder.pdf?sfvrsn=4. Accessed 15 June 2012.
Roth, T. L., & Frances, A. C. (2012). Epigenetic pathways and the consequences of adversity and
trauma. In C. S. Widom (Ed.), Trauma, psychopathology, and violence: Causes, consequences,
or correlates? (pp.2348). New York: Oxford University Press.
Rothbaum, B., & Mellman, T. (2001). Dreams and exposure therapy in PTSD. Journal of Traumatic Stress, 14, 481490.
Rothbaum, B. O., Foa, E. B., Riggs, D. S., Murdock, T., & Walsh, W. (1992). A prospective examination of posttraumatic stress disorder in rape victims. Journal of Traumatic Stress, 5,
455475.
Rubenstein, J. L., Heeren, T., Houseman, D., Rubin, C., & Stechler, G. (1989). Suicidal behavior
in normal adolescents: Risk and protective factors. American Journal of Orthopsychiatry,
59, 5971.

References

109

Rudofossi, D. (2007). Working with traumatized police officer-patients: A clinicians guide to complex PTSD syndromes in public safety personnel. Amityville: Baywood.
Russell, R. T. (2009). Veterans treatment court: A proactive approach. New England Journal on
Criminal and Civil Confinement, 35, 357372.
Russell, H. E., & Beigel, A. (1990). Understanding human behavior for effective police work (3rd
ed.). New York: Basic Books.
Rutter, M. (1985). Resilience in the face of adversity: Protective factors and resistance to psychiatric disorder. British Journal of Psychiatry, 147, 598611.
Rutter, M. (1987). Psychosocial resilience and protective mechanisms. American Journal of
Orthopsychiatry, 57, 316331.
Rutter, M., Tizard, J., Yule, W., Graham, P., & Whitmore, K. (1976). Research report: Isle of Wight
studies, 1964-1974. Psychological Medicine, 6, 313332.
Sapolsky, R. M. (1996). Why stress is bad for your brain. Science, 273, 749750.
Sapolsky, R. M., Krey, L. C., & McEwen, B. S. (1984). Glucocorticoid-sensitive hippocampal
neurons are involved in terminating the adrenocortical stress response. Proceedings of the National Academy of Sciences, 81, 61746177.
Sapolsky, R. M., Uno, H., Rebert, C. S., & Finch, C. E. (1990). Hippocampal damage associated
with prolonged glucocorticoid exposure. Journal of Neuroscience, 10, 28972902.
Savitch, H. V. (2003). Does 911 portend a new paradigm for cities? Urban Affairs Review, 39,
103127.
Schenck, C. H., & Mahowald, M. W. (1995). A polysomnographically documented case of adult
somnambulism with long-distance automobile driving and frequent nocturnal violence: Parasomnia with continuing danger as a noninsane automatism? Sleep, 18, 765772.
Schenck, C. H., Bundlie, S. R., Eitinger, M. G., & Mahowald, M. W. (1986). Chronic behavioral
disorders of human REM sleep: A new category of parasomnia. Sleep, 9, 293308.
Schenck, C. H., Lee, S. A., Bornemann, M. A. C., & Mahowald, M. W. (2009). Potentially lethal
behaviors associated with rapid eye movement sleep behavior disorder: Review of the literature and forensic implications. Journal of Forensic Sciences, 54, 14751484.
Schnurr, P. P., Lunney, C. A., Sengupta, A., & Spiro, A. (2005). A longitudinal study of retirement
in older male veterans. Journal of Consulting and Clinical Psychology, 73, 561566.
Schottenfield, R. S., & Cullen, M. R. (1985). Occupation-induced posttraumatic stress disorders.
American Journal of Psychiatry, 142, 198202.
Schouten, R. (1994). Distorting posttraumatic stress disorder for court. Harvard Review of Psychiatry, 2, 171173.
Schreiber, S., & Galai-Gat, T. (1993). Uncontrolled pain following physical injury as the core
trauma in post-traumatic stress disorder. Pain, 54, 107110.
Schretlen, D. J. (1988). The use of psychological tests to identify malingered symptoms of mental
disorder. Clinical Psychology Review, 8, 451476.
Schreuder, B., Kleijn, W., & Rooijmans, H. (2000). Nocturnal re-experiencing more than forty
years after war trauma. Journal of Traumatic Stress, 13, 453463.
Shalev, A. Y., Schreiber, S., Galai, T., & Melmed, R. N. (1993). Post-traumatic stress disorder following medical events. British Journal of Clinical Psychology, 32, 247253.
Sheehan, D. C., Everly, G. S., & Langlieb, A. (2004). Current best practices: Coping with major
critical incidents. FBI Law Enforcement Bulletin, September, pp.113.
Sherman, N. (2005). Stoic warriors: The ancient philosophy behind the military mind. New York:
Oxford University Press.
Shin, L., Rauch, S., & Pitman, R. (2006). Amygdala, medial prefrontal cortex, and hippocampal
function in PTSD. Annals of the New York Academy of Sciences, 1071, 219243.
Silke, A. (Ed.). (2003). Terrorists, victims, and society: Psychological perspectives on terrorism
and its consequences. Hoboken: Wiley.
Silva, M. N. (1991). The delivery of mental health services to law enforcement officers. In J. T.
Reese, J. M. Horn, & C. Dunning (Eds.), Critical incidents in policing (rev ed., pp.335341).
Silva, J. A., Leong, G. B., Harry, B. E., Ronan, J., & Weinstock, R. (1998). Dangerous misidentification of people due to flashback phenomena is posttraumatic stress disorder. Journal of
Forensic Science, 43, 11071111.

110

References

Silva, J. A., Derecho, D. V., Leong, G. B., Weinstock, R., & Ferrari, M. M. (2001). A classification
of psychological factors leading to violent behavior in posttraumatic stress disorder. Journal of
Forensic Science, 46, 309316.
Simon, R. I. (1995). Toward the development of guidelines in the forensic evaluation of posttraumatic stress disorder claims. In R. I. Simon (Ed.), Posttraumatic stress disorder in litigation:
Guidelines for forensic assessment (pp.3184). Washington, DC: American Psychiatric Press.
Simon, R. I. (2003). Posttraumatic stress disorder in litigation: Guidelines for forensic assessment
(2nd ed.). Washington, DC: American Psychiatric Publishing.
Skeem, J. L., Miller, J., Mulvey, J., Tiemann, J., & Monahan, J. (2005). Personality traits and violence among psychiatric patients: Using a five-factor lens to explore the relationship. Journal
of Consulting and Clinicial Psychology, 73, 454465.
Slagle, D. A. (1990). Psychiatric disorders following closed head injury: An overview of biopsychosocial factors in their etiology and management. International Journal of Psychiatry in
Medicine, 20, 135.
Slobogin, C. (2006). Proving the unprovable: The role of law, science, and speculation in adjudicating culpability and dangerousness. New York: Oxford University Press.
Slobogin, C. (2010). Psychological syndromes and criminal responsibility. Annual Review of Law
and Social Science, 6, 109127.
Slovenko, R. (1994). Legal aspects of posttraumatic stress disorder. Psychiatric Clinics of North
America, 17, 439446.
Slovenko, R. (1995). Psychiatry and criminal culpability. New York: Wiley.
Slovenko, R. (2004). The watering down of PTSD in criminal law. Journal of Psychiatry and Law,
32, 411438.
Small, L. (1980). Neuropsychodiagnosis in psychotherapy (rev. ed.). New York: Brunner/Mazel.
Smith, D., & Resnick, P. (2007). Amnesia and competence to stand trial. Journal of the American
Academy of Psychiatry and the Law, 35, 541543.
Smith, E. M., North, C. S., McCool, R. E., & Shea, J. M. (1990). Acute postdisaster psychiatric
disorders: Identification of persons at risk. American Journal of Psychiatry, 147, 202206.
Sneirson, J. F. (1995). Black Rage and the criminal law: A principled approach to a polarized debate. University of Pennsylvania Law Review, 143, 22512288.
Solomon, R. M. (1995). Critical incident stress management in law enforcement. In G. S. Everly
(Ed.), Innovations in disaster and trauma psychology: Applications in emergency services and
disaster response (pp.123157). Ellicott City: Chevron.
Solomon, P., & Draine, J. (1999). Explaining lifetime criminal arrests among clients of a psychiatric probation and parole service. Journal of the American Academy of Psychiatry and the Law,
27, 239251.
Solursh, L. P., Meyer, C. A., & Nolan, W. P. (1991). Addiction to violence in the United States
Vietnam combat veteran. Medical Law, 10, 375379.
Sparr, L. F. (1990). Legal aspects of posttraumatic stress disorder: Uses and abuses. In M. E. Wolf
& A. D. Mosnaim (Eds.), Posttraumatic stress disorder: Etiology, phenomenology, and treatment (pp.238264). Washington, DC: American Psychiatric Press.
Sparr, L. F. (1996). Mental defenses and posttraumatic stress disorder: Assessment of criminal
intent. Journal of Traumatic Stress, 9, 375379.
Sparr, L. F., & Atkinson, R. M. (1986). Posttraumatic stress disorder as an insanity defense: Medicolegal quicksand. American Journal of Psychiatry, 143, 608612.
Sparr, L. F., & Pankratz, L. D. (1983). Factitious posttraumatic stress disorder. British Journal of
Psychiatry, 140, 10161019.
Sparr, L. F., & Pittman, R. K. (2007). PTSD and the law. In M. J. Friedman, T. M. Keane, & P. A.
Resnick (Eds.), Handbook of PTSD: Science and practice (pp.449468). New York: Guilford.
Sparr, L. F., Reaves, M. E., & Atkinson, R. M. (1987). Military combat, posttraumatic stress disorder, and criminal behavior in Vietnam veterans. Bulletin of the American Academy of Psychiatry and the Law, 15, 141162.
Sperry, L. (1995). Handbook of the diagnosis and treatment of the DSM-IV personality disorders.
New York: Brunner/Mazel.
Spungen, D. (1998). Homicide: The hidden victims. A guide for professionals. Thousand Oaks: Sage.

References

111

State v. Heads, No. 106, 126 (lst Jud. Dist. Ct. Caddo Parish, Oct. 10, 1981).
State v. Bratcher, 223 P.3d 1087 (2009).
Steadman, H. J., Mulvey, E. P., Monahan, J., Robbins, P. C., Appelbaum, P. S., & Grisson, T.
(1998). Violence by people discharged from acute psychiatric inpatient facilities and by others
in the same neighborhoods. Archives of General Psychiatry, 55, 393401.
Stebnicki, M. A. (2001). The psychosocial impact on survivors of extraordinary, stressful, and
traumatic events: Principles and practices in critical incident response for rehabilitation counselors. Directions in Rehabilitation Counseling, 12, 5772.
Stein, M. B., Walker, J. R., Hazen, A. L., & Forde, D. R. (1997). Full and partial posttraumatic
stress disorder: Findings from a community survey. American Journal of Psychiatry, 154,
11141119.
Stolle, D. P., Wexler, D. B., Winick, B. J., & Dauer, E. A. (2000). Integrating preventive law and
therapeutic jurisprudence: A law and psychology based approach to lawyering. In D. P. Stolle,
D. B. Wexler, & B. J. Winick (Eds.), Practicing therapeutic jurisprudence: Law as a helping
profession (pp.544). Durham: Carolina Academic Press.
Stone, 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, 2332.
Stone, D. C., & Boone, K. B. (2007). Feigning of physical, psychiatric, and cognitive symptoms:
Examples from history, the arts, and animal behavior. In K. Boone (Ed.), Assessment of feigned
cognitive impairment: A neuropsychological perspective (pp.312). New York: Guilford Press.
Strauss, I., & Savitsky, N. (1934). Head injury: Neurologic and psychiatric aspects. Archives of
Neurology and Psychiatry, 31, 893955.
Stuss, D. T., & Benson, D. F. (1984). Neuropsychological studies of the frontal lobes. Psychological Bulletin, 95, 328.
Swanson, J. W., Holzer, C. E., Ganju, V. K., & Jono, R. T. (1990). Violence and psychiatric disorder in the community: Evidence from the epidemiologic catchment area surveys. Hospital and
Community Psychiatry, 41, 761770.
Swanson, J. W., Borum, R., Swartz, M., & Monahan, J. (1996). Psychotic symptoms and disorders
and the risk of violent behavior in the community. Criminal Behavior and Mental Health, 6,
317332.
Swanson, J. W., Swartz, M. S., Van Dorn, R. A., Ellenbogen, E. B., Wagner, H. R., & Rosenheck,
R. A. (2006). A national study of violent behavior in persons with schizophrenia. Archives of
General Psychiatry, 63, 490499.
Sweet, J. J. (2009). Posttraumatic stress disorder and neuropsychological malingering: A complicated scenario. In J. E. Morgan & J. J. Sweet (Eds.), Neuropsychology of malingering casebook
(pp.155169). New York: Psychology Press.
Taft, C. T., Street, A. E., Marshall, A. D., Dowdall, D. J., & Riggs, D. S. (2007). Posttraumatic
stress disorder, anger, and partner abuse among Vietnam combat veterans. Journal of Family
Psychology, 21, 270277.
Taft, C., Weatherill, R. P., Woodward, H. E., Pinto, L. A., Watkins, L. E., Miller, M., & Dekel,
R. (2009). Intimate partner and general aggression perpetration among combat veterans presenting to a posttraumatic stress disorder clinic. American Journal of Orthopsychiatry, 79,
461468.
Taylor, J. S. (1997). Neurolaw: Brain and spinal cord. Washington DC: ATLA Press.
Taylor, A. J. W. (2001). Traumatic stress and differential diagnosis of malingering. Traumatology,
9, 197215.
Taylor, S. (2006). Clinicians guide to PTSD: A cognitive-behavioral approach. New York: Guilford.
Teten, A. L., Schumacher, J. A., Bailey, S. D., & Kent, T. A. (2009). Male-to-female sexual aggression among Iraq, Afghanistan, and Vietnam veterans: Co-occurring substance abuse and
intimate partner aggression. Journal of Traumatic Stress., 22, 307311.
Toch, H. (2002). Stress in Policing. Washington DC: American Psychological Association.
Travin, S., & Potter, B. (1984). Malingering and malingering-like behavior: Some clinical and
conceptual issues. Psychiatric Quarterly, 56, 189197.
Treadwell, J. (2010). Counterblast: More than casualties of war? Ex-military personnel in the
criminal justice system. Howard Journal of Criminal Justice, 49, 7377.

112

References

Trimble, M. R. (1981). Post-traumatic neurosis: From railway spine to whiplash. New York: Wiley.
Trimble, M. R. (2004). Somatoform disorders: A medicolegal guide. New York: Cambridge University Press.
Ursano, R. J., Fullerton, C. S., & Norwood, A. E. (1995). Psychiatric dimensions of disaster: Patient care, community consultation, and preventive medicine. Harvard Review of Psychiatry,
3, 196209.
U.S. v. John Brownfield, 08-cr-00452-JLK. (2009).
van der Kolk, B. A. (1994). The body keeps the score: Memory and the evolving psychobiology of
posttraumatic stress. Harvard Review of Psychiatry, 1, 253265.
van der Kolk, B. A. (2003). Posttraumatic stress disorder and the nature of trauma. In M. Solomon
& D. Siegel (Eds.), Healing trauma (pp.168195). New York: Norton.
van der Kolk, B., Blitz, R., Burr, W., Sherry, S., & Hartmann, E. (1984). Nightmares andtrauma: A
comparison of nightmares after combat with lifelong nightmares in veterans. American Journal
of Psychiatry, 141, 187190.
Varney, N. R., & Roberts, R. J. (Eds.). (1999). The evaluation and treatment of mild traumatic
brain injury. Mahwah: Erlbaum.
Vasterling, J. J., MacDonald, H. Z., Ulloa, E. W., & Rodier, N. (2010). Neuropsychological correlates of PTSD: A military perspective. In C. H. Kennedy & J. L. Moore (Eds.), Military
neuropsychology (pp.321360). New York: Springer.
Vasterling, J. J., Bryant, R. A., & Keane, T. M. (2012). Understanding the interface of traumatic
stress and mild traumatic brain injury: Background and conceptual framework. In J. J. Vasterling, R. A. Bryant, & T. Keane (Eds.), PTSD and mild traumatic brain injury (pp.311). New
York: Guilford.
Vermetten, E., & Bremner, J. D. (2002a). Circuits and systems in stress: Preclinical studies. Depression and Anxiety, 15, 126147.
Vermetten, E., & Bremner, J. D. (2002b). Circuits and systems in stress: Applications to neurobiology and treatment in posttraumatic stress disorder. Depression and Anxiety, 16, 1438.
Vesper, J. H., & Cohen, L. J. (1999). Litigating posttraumatic stress disorder: Effects on the family.
Behavioral Sciences and the Law, 17, 235251.
Vinson, D. E., & Davis, D. S. (1993). Jury persuasion: Psychological strategies and trial techniques. Little Falls: Glasser Legalworks.
Violanti, J. M. (1999). Police trauma: Psychological impact of civilian combat. In J. M. Violanti &
D. Paton (Eds.), Police trauma: Psychological aftermath of civilian combat (pp.59). Springfield: Charles C Thomas.
Violanti, J., Paton, D., & Dunning, C. (Eds.). (2000). Posttraumatic stress intervention: Challenges, issues, and perspectives. Springfield: Charles C Thomas.
Walker, L. E. (1984). The battered woman syndrome. New York: Springer.
Watson, I. (2004). Flashbacks in war veterans. British Journal of Psychiatry, 184, 185.
Webster, C. D., & Jackson, M. A. (Eds.). (1997). Impulsivity: Theory, assessment, and treatment.
New York: Guilford.
Weiner, H. (1992). Perturbing the organism: The biology of stressful experience. Chicago: University of Chicago Press.
Weiss, S. J. (2007). Neurobiological alterations associated with traumatic stress. Perspectives in
Psychiatric Care, 43, 114122.
Weissman, H. N. (1990). Distortions and deceptions in self presentation: Effects of protracted
litigation in personal injury cases. Behavioral Sciences and the Law, 8, 6774.
Werner, E. E. (1989). High-risk children in young adulthood: A longitudinal study from birth to 32
years. American Journal of Orthopsychiatry, 59, 7281.
Werner, E. E., & Smith, R. S. (1982). Vulnerable but invincible: A study of resilient children. New
York: McGraw-Hill.
Wessely, S., Unwin, C., & Hotopf, M. (2003). Stability of recall of military hazards over time:
Evidence from the Persian Gulf War of 1991. British Journal of Psychiatry, 183, 314322.
Williams, T. (1991). Counseling disabled law enforcement officers. In J. T. Reese, J. M. Horn,
& C. Dunning (Eds.), Critical incidents in policing (pp.377386). Washington DC: Federal
Bureau of Investigation.

References

113

Williams, M. B. (1999). Impact of duty-related death on officers children: Concepts of death,


trauma reactions, and treatment. In J. M. Violanti & D. Paton (Eds.), Police trauma: Psychological aftermath of civilian combat (pp.159174). Springfield: Charles C Thomas.
Wilson, J. P. (1994). The historical evolution of PTSD diagnostic criteria: From Freud to DSM-IV.
Journal of Traumatic Stress, 7, 681698.
Wilson, J. P., & Keane, T. M. (Eds.). (2004). Assessing psychological trauma and PTSD. New
York: Guilford Press.
Wilson, J. P., & Zigelbaum, S. D. (1983). The Vietnam veteran on trial: The relationship of posttraumatic stress disorder to criminal behavior. Behavioral Sciences and the Law, 1, 6983.
Wilson, J. K., Brodsky, S. L., Neal, T. M. S., & Cramer, R. J. (2011). Prosecutor pretrial attitudes
and plea-bargaining behavior toward veterans with posttraumatic stress disorder. Psychological Services, 8, 319331.
Windle, R. C., & Windle, M. (1995). Longitudinal patterns of physical aggression: Associations
with adult social, psychiatric, and personality functioning and testosterone levels. Development and Psychopathology., 7, 563585.
Winick, B. J. (2000). Therapeutic jurisprudence and the role of counsel in litigation. In D. P. Stolle,
D. B. Wexler, & B. J. Winick (Eds.), Practicing therapeutic jurisprudence: Law as a helping
profession (pp.309324). Durham: Carolina Academic Press.
Wolff, N. L., & Shi, J. (2010). Trauma and incarcerated persons. In C. L. Scott (Ed.), Handbook
of correctional mental health (2nd ed.; pp.277320). Washington, DC: American Psychiatric
Publishing.
Wong, E. C., Marshall, G. N., Shetty, V., Zhou, A., Belzberg, H., & Yamashita, D. D. R. (2007).
Survivors of violence-related facial injury: Psychiatric needs and barriers to mental health care.
General Hospital Psychiatry, 29, 117122.
Wortzel, H. S., & Arciniegas, D. B. (2010). Combat veterans and the death penalty: A forensic
neuropsychiatric perspective. Journal of the American Academy of Psychiatry and the Law,
38, 407414.
Yang, P., Wu, M., Hsu, C., & Ker, J. (2004). Evidence of early neurobiological alterations in
adolescents with posttraumatic stress disorder: A functional MRI study. Neuroscience Letters,
370, 1318.
Yehuda, R. (1998). Psychoneuroendocrinology of post-traumatic stress disorder. Psychiatric Clinics of North America, 21, 359379.
Yehuda, R. (1999). Biological factors associated with susceptibility to posttraumatic stress disorder. Canadian Journal of Psychiatry, 44, 3439.
Yehuda, R. (2002). Clinical relevance of biological findings in PTSD. Psychiatric Quarterly, 73,
123133.
Yesavage, J. A. (1983). Differential effects of Vietnam combat experiences vs. criminality on
dangerous behavior by Vietnam veterans with schizophrenia. Journal of Nervous and Mental
Disease, 171, 382384.
Yesavage, J. A. (1984). Correlates of dangerous behavior by schizophrenics in hospital. Journal of
Psychiatric Research, 18, 225231.
Young, G., & Yehuda, R. (2006). Understanding PTSD: Implications for court. In G. Young, A.
W. Kane, & K. Nicholson (Eds.), Psychological knowledge in court: PTSD, pain, and TBI
(pp.5569). New York: Springer.
Zatzick, D. F., Marmar, C. R., Weiss, D. S., Browner, W. S., Metzler, T. J., & Golding, J. M. (1997).
Posttraumatic stress disorder and functioning and quality of life outcomes in a nationally representative sample of male Vietnam veterans. American Journal of Psychiatry, 154, 16901695.
Zervas, I., & Soldatos, C. (2005). Nightmares: Personality dimensions and psychopathological
attributes. International Review of Psychiatry, 17, 271276.
Zimrin, H. (1986). A profile of survival. Child Abuse and Neglect, 10, 339349.
Zuckerman, M., & Kuhlman, D. M. (2000). Personality and risk-taking: Common biosocial factors. Journal of Personality, 68, 9991029.

Index

A
Acute stress disorder, 13
Anxiety disorders, 2628, 31
Automatism defense, 75
Avoidance/numbing, 1113, 16, 25, 29, 31,
35, 41, 58

F
Factitious disorder, 26, 3436, 42
Flashbacks, 11, 12, 17, 38, 39, 41, 61, 72, 75
Forensic psychological evaluation
components of, 85
report of, 84

B
Battle fatigue, 2, 3
Bipolar disorder, 25, 26, 2931, 69, 73, 76

G
Generalized anxiety disorder, 26, 28
Guilty but mentally ill, 7375, 81
Gulf war syndrome, 2, 5

C
Civil justice system, 45
Civil War, American, 3
Cognitive impairment, 16, 25, 27, 32, 49
Crime victim trauma, 18
Criminal justice system, 4, 6, 7, 31, 39, 4345,
49, 5566, 69, 70, 72, 74, 76, 78, 80, 81
D
Deposition testimony, 86, 87
Designer defenses, 80, 81
Diminished capacity, PTSD and, 73, 75
Disasters, 5, 7, 18, 56, 66
Dissociative disorders, 32
Dreams, 3, 11, 12, 17, 39, 61, 64
DSM-5, 11, 27
DSM-III, 5
E
Evolution of trauma response, 1315
Expert witness, 7, 44, 76, 83, 8790
Expert witness testimony, testifying tips,
87, 89

H
Hyperarousal, 13, 52, 56, 59, 72
I
Insanity defense standards, 70
Insanity defense, PTSD and, 7075
L
Law Enforcement Trauma, 60
Limbic psychotic trigger reaction, 6062
M
Major depressive disorder, 10, 25, 26, 28,
29, 49
Malingering, 26, 30, 3442, 72, 77, 86
Memory impairment, 27, 34
Military disability claims, 31, 52
Military veterans
PTSD as criminal defense for, 78, 79
PTSD in, 55, 56
Mood disorders, 26, 28, 29, 31, 60
Motor vehicle accidents, 10, 17

The Author 2015


L. Miller, PTSD and Forensic Psychology, SpringerBriefs in Psychology,
DOI 10.1007/978-3-319-09081-8

115

116
P
Pain, 16, 34
Panic disorder, 28, 30, 31
Personality disorders, 9, 25, 26, 30, 31, 38
Personal injury claims, 4446, 5153
Postconcussion syndrome, 16, 17, 27
Posttraumatic Stress Disorder (PTSD)
active shooter, 66, 67
civilian, 1520, 39
demographics of, 9, 10
diagnostic criteria for, 23, 73
differential diagnosis of, 2541
history of, 17
military, 5, 6, 15, 39, 40, 73, 79
neurobiology of, 20, 21
resiliency factors in, 21, 22
risk factors in, 21, 56, 57
treatment of, 22
PTSD and civil litigation, 4352
PTSD and criminal prosecution, 43
PTSD and insanity defense, 7075
PTSD and violence, 18, 19, 61, 64, 66
combat addiction, 60, 62, 63
dissociative flashback, 60, 69
limbic psychotic trigger reaction, 6062
mood disorder, 26, 28, 29, 60, 63
risk factors for, 21, 56, 57
sleep disorders, 60
PTSD and violent crime
patterns of, 6067
PTSD and war, 5, 9, 15, 37, 55, 62, 74
PTSD as criminal defense, 78
PTSD as criminal defense in military veterans,
78, 79

Index
R
Re-experiencing, 62
S
School violence, 19
Self-defense, 74, 75, 80
Shell shock, 24
Sleep disorders, 60, 75
Somatoform disorders, 26, 3135, 38
Stressor criterion, 5, 49, 78
T
Terrorism, 19, 20, 48
Torts, 26, 4547, 49
Tort claims, legal criteria, 46
Toxic trauma, 17
Traumatic brain injury, 6, 12, 16, 2527, 34,
59, 73
Trial testimony, 87
V
Vietnam War, 2, 4, 9, 15, 55, 62
W
Workers Compensation, 7, 44, 45, 48, 50,
51, 53
Workplace violence, 18, 19, 48
World War I, 24
World War II, 24

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