1: PTSD
Lecture
Forensic mental health assessment
- Goal → examination and presentation of professional opinion with the highest possible
psychological certainty
- Legal questions
- Competency to stand trial
- CR
- Personal injury
- Child custody
- Sources of information → multiple sources: FMHA results and corroborate information
- Main domains to be covered:
(1) Cognitive functioning (WAIS-IV, etc-always stays at 100) → crucial for competency to
stand trial
(2) Neuropsychological screening (neurologist or neuropsychologist)
(3) Personality → personality tests (personality structure, pathology). Most famous =
MMPI-2 (the most famous), and also have PAI.
(4) Trauma testing - the most famous: PTSD checklist (PCL-5), Trauma Symptom Inventory
(TSI-2)
(5) Projective techniques (no consensus in field - Rorschach
(6) Specific forensic test:
(a) Violence (Risk Assessment)
(b) Malingering (SIMS, MENT, TOMM)
(c) CR (RCRAS)
→ This is the part where you as a forensic psychologist have the most impact on assessments, the above
numbers overlap with clinical psychologists
The purpose
Clinical context Forensic context
Diagnoses for purpose of treatment Diagnoses for purpose of legal decision and
rehabilitation
Differential diagnosis
- Prior to making a diagnostic decision
- Specific for each disorder (see DSM-5)
(1) First rule out malingering/factitious disorder
(2) Then rule out that it isn't a substance aetiology (just high on drugs)
(3) Rule out a disorder due to general medical condition (conditions apart from mental, eg seizures)
(4) Determine the primary diagnosis
(5) Differentiating adjustment disorders from the residual unspecified disorder (eg: under high
impact - wait it out first to see if they might temporarily have this
(6) Establish a boundary with no mental disorder
PTSD criteria
(a) Exposure to traumatic event (actual or threatneed death, serious injury, or sexual violence in >1
of the following ways - may by multiple events)
, - Can be directly experiencing, witnessing the event in person as it occurs to others, learning it
happened to close person, someone recurrently exposed (eg: police officer)
(b) Intrusion symptoms
(c) Avoidance
(d) Altered mood
(e) Altered reactivity (this symptom is related to why people might commit a crime)
(f) Duration of disturbance > 1 month
* if its less than 1 month its acute PTSD
Specify if:
- With dissociative symptoms (depersonalization/derealization) - freud: people forget trauma
because they dissociative and later on it will pop up because it fell apart
- With delayed expression (not after 1 month but later)
Diagnostics
- Prevalence is higher in forensic population than general public (17% up to 50%)
- Gender difference: females higher
- Existing relationship between PTSD and violence
- Plays a role in determining outcomes legal
- Potential source for personal injury claim
- Financial benefit compensation
- Admission to forensic hospital etc.
Risk and protective factors
- Pretrauamtic: temperamental, environment; genetic and physiological
- Peritraumatic : environmental (severity of trauma)
- Posttraumatic: temperamental and environmental
*also consider culture (cross cultural findings: eg eastern european) and gender (women more prone)
→ some studies suggest brain changes in PTSD patients
Consequences PTSD
- Other mental health effects
- Sexual dysfunction etc.
Psychopathology & violence
- Rarely a direct relationship: usually SA moderates relationship, if you control this, then its anger
control that creates the link between PTSD & violence
- Combat population - most often used in research → Increase in violence, higher (self-reported)
aggression and more frequently carrying weapon
- More likely to be violent if you're already in combat and have PTSD diagnosis
PTSD in court
- Use of PTSD in criminal law: either as a defense or as a mitigating factors
, - Main issues: within criminal context (competency to stand trial, diminished criminal
responsibility), and within civil context (personal injury claims, disability claims/pension)
PTSD in court: insanity defenses
- Guilty but mentally ill/not guilty by reason of insanity
- M’Naghten rule - At time of committing offense you had such defects of reasoning that you
couldn’t understand what you were doing, ad neven if you did know what you were doing you
couldn’t reason it wasn’t okay.
- Automatism (no mens rea)
- Insane (internal cause)
- Sane (external cause) - results from believing trauma is external and hence you are san if
you suffer as a result of external
- Diminished criminal responsibility → more often applicable than insanity defense (more often
applicable than insanity defense
Assessment of PTSD
- Interview (SCID)
- Clinical rating scales (CAPS-5)
- Self report (PTSD Checklist DSM-5)
→ Purpose is the verify PTSD claims- but that's not enough; also need to falsify
Assessment
PCL-R
- 0 (not at all) - 4(extremely)
- Total severity score 0-80 (sum 20 items), cutoff from 31 - 33 (gen population)
- 94% naive participants successfully fulfilled criteria for PTSD when instructed to malinger
- PTSD moved from anxiety disorders (DSM-4) to trauma and or stress related disorder disorders
(DSM-5)
- Only diagnosis that has a cause specified: TRAUMA
- Most people develop: “shit happens”, however, whilst >70% face trauma, only 10% develop
PTSD
→ its not just about resilience, also about WHICH trauma you’ve developed (eg: sexual abuse (80% , may
be the worst), wat veterans (58% full blown PTSD), general public (up to 15%).
→ these numbers change, don’t rely too much
Symptom validity tests
- MMPI-2
- Stand alone
→ but that's not enough. Also need characteristics of a malingerer: (irregular employment,
contradictions, ASPD traits, lack of cooperation etc…) If there is a lack of evidence then malingerer
classification shouldn't be made.
Article: DSM - PTSD
PTSD 6 years old and up
a) Criterion A: Exposure to Traumatic Event(s)
, i) Directly witnessing event happening to oneself.
ii) Directly witnessing event occurring to others.
iii) Learning about the event happening to a close person.
iv) Repeated/extreme exposure, not in media (e.g., work-related exposure for police
officers).
b) Criterion B: Intrusion Symptoms (1+)
i) Recurrent, involuntary play of memories.
ii) Recurrent distressing dreams.
iii) Flashbacks.
iv) Intense psychological distress and cues symbolizing trauma.
v) Marked physiological reactions to cues symbolizing trauma.
c) Criterion C: Avoidance of Stimuli Associated with Traumatic Event (1+)
i) Internal avoidance (thoughts, feelings).
ii) External avoidance (people, places, activities).
d) Criterion D: Negative Alterations in Cognitions and Mood Associated with Trauma (2+)
i) Inability to remember important aspects due to dissociative amnesia.
ii) Persistent exaggerated negative beliefs about oneself (e.g., "I am bad").
iii) Distorted cognitions about the cause or consequences of traumatic events.
iv) Persistent negative emotional state.
v) Diminished interest in significant activities.
vi) Feelings of detachment from others.
vii) Inability to experience positive emotions.
e) Criterion E: Marked Alterations in Arousal and Reactivity Associated with Trauma (2+)
i) Irritable behavior and angry outbursts.
ii) Self-destructive behavior.
iii) Hypervigilance.
iv) Exaggerated startle response.
v) Problems with concentration.
vi) Sleep disturbances.
f) Criterion F: Duration of Symptoms → Duration of symptoms B, C, D, E, lasting more than 1
month.
g) Criterion G: Clinical Significance → Disturbance causes clinically significant distress or
impaired functioning.
h) Criterion H: Exclusion Criteria → Disturbance not attributable to the effects of substances.
Specifiers:
1. With dissociative symptoms (depersonalization or derealization).
2. With delayed expression (if symptoms not met until at least 6 months after event)
Criteria for Posttraumatic Stress Disorder (PTSD) in Children 0-6 Years:
a) Criterion A: Exposure to Trauma
i) Directly witnessing the traumatic event happening to oneself.
ii) Directly witnessing the traumatic event occurring to others.
iii) Learning about the traumatic event happening to a close person.
b) Criterion B: Intrusion Symptoms (1+)
i) Distressing memories.
ii) Distressing dreams.
iii) Flashbacks.
iv) Intense psychological distress at cues.
v) Marked physiological reactions to reminders of traumatic events.
c) Criterion C: Avoidance or Negative Alterations
Lecture
Forensic mental health assessment
- Goal → examination and presentation of professional opinion with the highest possible
psychological certainty
- Legal questions
- Competency to stand trial
- CR
- Personal injury
- Child custody
- Sources of information → multiple sources: FMHA results and corroborate information
- Main domains to be covered:
(1) Cognitive functioning (WAIS-IV, etc-always stays at 100) → crucial for competency to
stand trial
(2) Neuropsychological screening (neurologist or neuropsychologist)
(3) Personality → personality tests (personality structure, pathology). Most famous =
MMPI-2 (the most famous), and also have PAI.
(4) Trauma testing - the most famous: PTSD checklist (PCL-5), Trauma Symptom Inventory
(TSI-2)
(5) Projective techniques (no consensus in field - Rorschach
(6) Specific forensic test:
(a) Violence (Risk Assessment)
(b) Malingering (SIMS, MENT, TOMM)
(c) CR (RCRAS)
→ This is the part where you as a forensic psychologist have the most impact on assessments, the above
numbers overlap with clinical psychologists
The purpose
Clinical context Forensic context
Diagnoses for purpose of treatment Diagnoses for purpose of legal decision and
rehabilitation
Differential diagnosis
- Prior to making a diagnostic decision
- Specific for each disorder (see DSM-5)
(1) First rule out malingering/factitious disorder
(2) Then rule out that it isn't a substance aetiology (just high on drugs)
(3) Rule out a disorder due to general medical condition (conditions apart from mental, eg seizures)
(4) Determine the primary diagnosis
(5) Differentiating adjustment disorders from the residual unspecified disorder (eg: under high
impact - wait it out first to see if they might temporarily have this
(6) Establish a boundary with no mental disorder
PTSD criteria
(a) Exposure to traumatic event (actual or threatneed death, serious injury, or sexual violence in >1
of the following ways - may by multiple events)
, - Can be directly experiencing, witnessing the event in person as it occurs to others, learning it
happened to close person, someone recurrently exposed (eg: police officer)
(b) Intrusion symptoms
(c) Avoidance
(d) Altered mood
(e) Altered reactivity (this symptom is related to why people might commit a crime)
(f) Duration of disturbance > 1 month
* if its less than 1 month its acute PTSD
Specify if:
- With dissociative symptoms (depersonalization/derealization) - freud: people forget trauma
because they dissociative and later on it will pop up because it fell apart
- With delayed expression (not after 1 month but later)
Diagnostics
- Prevalence is higher in forensic population than general public (17% up to 50%)
- Gender difference: females higher
- Existing relationship between PTSD and violence
- Plays a role in determining outcomes legal
- Potential source for personal injury claim
- Financial benefit compensation
- Admission to forensic hospital etc.
Risk and protective factors
- Pretrauamtic: temperamental, environment; genetic and physiological
- Peritraumatic : environmental (severity of trauma)
- Posttraumatic: temperamental and environmental
*also consider culture (cross cultural findings: eg eastern european) and gender (women more prone)
→ some studies suggest brain changes in PTSD patients
Consequences PTSD
- Other mental health effects
- Sexual dysfunction etc.
Psychopathology & violence
- Rarely a direct relationship: usually SA moderates relationship, if you control this, then its anger
control that creates the link between PTSD & violence
- Combat population - most often used in research → Increase in violence, higher (self-reported)
aggression and more frequently carrying weapon
- More likely to be violent if you're already in combat and have PTSD diagnosis
PTSD in court
- Use of PTSD in criminal law: either as a defense or as a mitigating factors
, - Main issues: within criminal context (competency to stand trial, diminished criminal
responsibility), and within civil context (personal injury claims, disability claims/pension)
PTSD in court: insanity defenses
- Guilty but mentally ill/not guilty by reason of insanity
- M’Naghten rule - At time of committing offense you had such defects of reasoning that you
couldn’t understand what you were doing, ad neven if you did know what you were doing you
couldn’t reason it wasn’t okay.
- Automatism (no mens rea)
- Insane (internal cause)
- Sane (external cause) - results from believing trauma is external and hence you are san if
you suffer as a result of external
- Diminished criminal responsibility → more often applicable than insanity defense (more often
applicable than insanity defense
Assessment of PTSD
- Interview (SCID)
- Clinical rating scales (CAPS-5)
- Self report (PTSD Checklist DSM-5)
→ Purpose is the verify PTSD claims- but that's not enough; also need to falsify
Assessment
PCL-R
- 0 (not at all) - 4(extremely)
- Total severity score 0-80 (sum 20 items), cutoff from 31 - 33 (gen population)
- 94% naive participants successfully fulfilled criteria for PTSD when instructed to malinger
- PTSD moved from anxiety disorders (DSM-4) to trauma and or stress related disorder disorders
(DSM-5)
- Only diagnosis that has a cause specified: TRAUMA
- Most people develop: “shit happens”, however, whilst >70% face trauma, only 10% develop
PTSD
→ its not just about resilience, also about WHICH trauma you’ve developed (eg: sexual abuse (80% , may
be the worst), wat veterans (58% full blown PTSD), general public (up to 15%).
→ these numbers change, don’t rely too much
Symptom validity tests
- MMPI-2
- Stand alone
→ but that's not enough. Also need characteristics of a malingerer: (irregular employment,
contradictions, ASPD traits, lack of cooperation etc…) If there is a lack of evidence then malingerer
classification shouldn't be made.
Article: DSM - PTSD
PTSD 6 years old and up
a) Criterion A: Exposure to Traumatic Event(s)
, i) Directly witnessing event happening to oneself.
ii) Directly witnessing event occurring to others.
iii) Learning about the event happening to a close person.
iv) Repeated/extreme exposure, not in media (e.g., work-related exposure for police
officers).
b) Criterion B: Intrusion Symptoms (1+)
i) Recurrent, involuntary play of memories.
ii) Recurrent distressing dreams.
iii) Flashbacks.
iv) Intense psychological distress and cues symbolizing trauma.
v) Marked physiological reactions to cues symbolizing trauma.
c) Criterion C: Avoidance of Stimuli Associated with Traumatic Event (1+)
i) Internal avoidance (thoughts, feelings).
ii) External avoidance (people, places, activities).
d) Criterion D: Negative Alterations in Cognitions and Mood Associated with Trauma (2+)
i) Inability to remember important aspects due to dissociative amnesia.
ii) Persistent exaggerated negative beliefs about oneself (e.g., "I am bad").
iii) Distorted cognitions about the cause or consequences of traumatic events.
iv) Persistent negative emotional state.
v) Diminished interest in significant activities.
vi) Feelings of detachment from others.
vii) Inability to experience positive emotions.
e) Criterion E: Marked Alterations in Arousal and Reactivity Associated with Trauma (2+)
i) Irritable behavior and angry outbursts.
ii) Self-destructive behavior.
iii) Hypervigilance.
iv) Exaggerated startle response.
v) Problems with concentration.
vi) Sleep disturbances.
f) Criterion F: Duration of Symptoms → Duration of symptoms B, C, D, E, lasting more than 1
month.
g) Criterion G: Clinical Significance → Disturbance causes clinically significant distress or
impaired functioning.
h) Criterion H: Exclusion Criteria → Disturbance not attributable to the effects of substances.
Specifiers:
1. With dissociative symptoms (depersonalization or derealization).
2. With delayed expression (if symptoms not met until at least 6 months after event)
Criteria for Posttraumatic Stress Disorder (PTSD) in Children 0-6 Years:
a) Criterion A: Exposure to Trauma
i) Directly witnessing the traumatic event happening to oneself.
ii) Directly witnessing the traumatic event occurring to others.
iii) Learning about the traumatic event happening to a close person.
b) Criterion B: Intrusion Symptoms (1+)
i) Distressing memories.
ii) Distressing dreams.
iii) Flashbacks.
iv) Intense psychological distress at cues.
v) Marked physiological reactions to reminders of traumatic events.
c) Criterion C: Avoidance or Negative Alterations
