Misdiagnosis of PTSD
Diagnoses of PTSD are commonly made inaccurately in litigation contexts.
Clinicians treating trauma survivors or retained as experts by such individuals
when they become plaintiffs tend to overdiagnose PTSD
(Rosen, 1995). Defense experts in civil litigation and experts retained by the
prosecution may tend to underdiagnose the disorder.
Misdiagnosis may occur for reasons other than misunderstanding the nature of
the disorder or misapplication of diagnostic criteria. Adversarial bias, that
is, conscious or unconscious pressure to formulate an opinion favorable to the
retaining party, may exert a profound influence in some cases. At times, a
misapplied diagnosis of PTSD can represent a vehicle for promoting the forensic
psychiatrist's values of support for victims' rights (Stone, 1993). Conversely,
antipathy toward the diagnosis and its implications may result in the
misinterpretation or overlooking of genuine posttraumatic symptomatology
(Briere, 1997; Pitman et al., 1996).
Indirect Assessments
Attorneys frequently attempt to use psychiatric testimony to make indirect
statements regarding a plaintiff's credibility. As a rule, expert evidence on
the credibility of a witness is not permitted. Nevertheless, attorneys may try
to use psychiatric terminology and diagnoses to introduce indirect credibility
assessments through expert testimony.
Certain diagnoses lend themselves to this type of misuse. A diagnosis of
PTSD in a plaintiff carries implications that the plaintiff's allegations are
true. Certain personality disorder diagnoses, such as borderline or histrionic
personality disorder, carry the implication that the plaintiff's allegations
are not credible. The use of psychiatric diagnoses to indirectly establish the
credibility of a legal claim should be viewed as a misuse of psychiatric
expertise (Halleck et al., 1992).
Use of Syndrome Evidence
In recent years, attorneys have also increasingly sought expert testimony
about various trauma-related syndromes, such as battered woman syndrome, rape
trauma syndrome or battered child syndrome. Syndrome diagnoses are based on the
presence of constellations of certain symptoms and have been offered in both
civil and criminal cases. In civil cases, the presence of a syndrome may be
used in attempts to establish that a particular stressor actually occurred,
thus establishing witness credibility (Simon and Gutheil,
1997). In criminal cases, arguments for the presence of a syndrome in the
defendant may serve as justifications for criminal acts or mitigation of
sentence.
Although they may have some relation to the diagnosis of PTSD, syndromes are
not formal DSM diagnoses. The
description of certain syndromes may serve a variety of clinical and
sociopolitical purposes, but their utilization in litigation requires careful
consideration. The use of a claimant's psychological symptoms in the form of
syndrome evidence (or even an established DSM
diagnosis) to establish the occurrence of a traumatic event generally has not
found favor with the courts (Boeschen et al., 1998; Slovenko, 1995). However, by offering such testimony that a
complainant is or is not suffering rape trauma syndrome, battered woman
syndrome or some other type of psychological syndrome, the expert's testimony
may arguably be characterized or construed as testifying to the truthfulness of
the complainant or the presence of mitigating circumstances for a crime. Almost
all states refuse to admit this level of testimony (Boeschen
et al., 1998).
These and other concerns have resulted in courts taking a purpose-specific,
qualified approach to syndrome testimony. Courts most often accept syndrome
evidence by experts where the defense argues that the woman did not act the way
a "real" survivor of rape would, or where the defense argues that if her
domestic situation had really been that bad, she would have left. Courts are
more divided on whether to allow syndrome evidence where there is no overt need
to rebut the defense's reliance on myths about women (Orenstein, 1999).
Courts have been most sympathetic to syndrome testimony when the expert
spoke generally about typical responses to sexual assault rather than offering
an opinion regarding whether the particular woman suffered from a specific
posttraumatic syndrome. Most are also receptive to syndrome evidence when it is
offered to dispel myths about behaviors associated with sexual assault,
domestic violence or child abuse (Massaro, 1999;
Melton et al., 1997).
Conclusion
Although imperfect and subject to continuous updating and refinement, the DSM is regarded by mental health
professionals and the courts alike as a generally valid and reliable diagnostic
system (Shuman, 1989). The diagnostic criteria and research supporting a
diagnosis of PTSD is extensive. However, the tactical legal exploitation of the
diagnosis of PTSD most often arises from the use of DSM diagnoses for nonclinical purposes.
Psychiatrists who enter the legal arena are well advised to provide reliable,
credible testimony if the diagnosis of PTSD is raised as a legal defense or
claim.
Pages
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