When my father’s generation came home from World War II, many of them carried psychological scars about which they kept quiet. My parents married young, at 21 and 18, the week he returned from combat in 1945. My mother said that dad fought the air war over Europe every night in his sleep for at least a decade. The longer-term ramifications of that played out in many ways throughout his life. As he lay dying over six decades later, he began to tell me for the first time the war experiences that had haunted him most through his life.
Recently, I was with a nurse practitioner and a community mental health counselor during their impromptu discussion of the ramifications of PTSD that they see regularly in dealing with people on the front lines of medicine and mental health. They rattled off numerous examples of what they almost daily among veterans of Vietnam, Iraq and Afghanistan, and survivors of a variety non-combat traumas.
When dad came home from WW2, there was no widely accepted medical name for this condition. The terms “shell shock” and “battle fatigue” were used, but were generally limited to debilitating short term reactions to battle in wartime rather than the chronic reactions that can stretch out over decades.
The term PTSD was not given a standard psychiatric definition until 1980 when the American Psychiatric Association (APA) added PTSD to the third edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-III) classification scheme. Although controversial when first introduced, the PTSD diagnosis has filled an important gap in psychiatric theory and practice.
PTSD through history
From cave men attacked by saber tooth tigers to victims of twenty-first century terrorists, humans have always suffered similar psychological outcomes of violence. Over 400 years ago, Shakespeare in “Henry IV” presaged the modern diagnostic criteria for Posttraumatic Stress Disorder (PTSD), describing the post-battle condition of a character:
Tell me, sweet lord, what is ‘t that takes from thee
Thy stomach, pleasure, and thy golden sleep?
Why dost thou bend thine eyes upon the earth,
And start so often when thou sit’st alone?
Why hast thou lost the fresh blood in thy cheeks
And given my treasures and my rights of thee
To thick-eyed musing and curst melancholy?
In thy faint slumbers I by thee have watched,
And heard thee murmur tales of iron wars,
Speak terms of manage to thy bounding steed,
Cry “Courage! To the field!” And thou hast talk’d
Of sallies and retires, of trenches, tents,
Of palisadoes, frontiers, parapets,
Of basilisks, of cannon, culverin,
Of prisoners’ ransom and of soldiers slain,
And all the currents of a heady fight.
Thy spirit within thee hath been so at war
And thus hath so bestirred thee in thy sleep,
That beads of sweat have stood upon thy brow
Like bubbles in a late-disturbèd stream;
And in thy face strange motions have appeared,
Such as we see when men restrain their breath
On some great sudden hest. O, what portents are these?
Some heavy business hath my lord in hand,
And I must know it, else he loves me not.”
—Henry IV, Part 1 (2.3.39-67)
As a lawyer accustomed to dealing with clients who have been seriously injured or lost a loved one killed in a crash with a car or tractor trailer, the tendency is often to focus on the physical injuries – broken bones, back injuries, neck injuries, chronic pain, etc. It is easy to overlook the silent injury of Posttraumatic Stress Disorder (PTSD), or to confuse it with a traumatic brain injury.
What is PTSD?
PTSD is officially recognized as a mental health condition that some people develop after experiencing or witnessing a life-threatening event. The diagnostic criteria are outlined in the Diagnostic and Statistical Manual of Mental Disorders, currently in the Fifth Edition, known as the DSM-5©.
In 2013, the American Psychiatric Association revised the PTSD diagnostic criteria and included PTSD in a new category Trauma- and Stressor-Related Conditions. The diagnostic criterion for all of the conditions included in this new classification require exposure to a traumatic or stressful event.
The DSM-5 criteria for PTSD, ICD-9 309.81 or ICD-10 F43.10, for adults, adolescents and children over 6 years old are as follows (the DSM-5 has separate criteria for children 6 years and younger) 2:
Criterion A (one required) – the person was exposed to death or actual serious injury in the following way(s):
- Directly experiencing the traumatic event
- Witnessing the event as it occurred to others
- Learning the traumatic event occurred to a relative or close friend
- Indirect exposure to aversive details of the trauma
Criterion B (one required) – the traumatic event is persistently re-experienced in the following way(s):
- Unwanted upsetting memories
- Emotional distress after exposure to traumatic reminders
- Physical reactivity after exposure to traumatic reminders
Criterion C (one required) – avoidance of trauma-related stimuli after the trauma in the following way(s):
- Trauma-related thoughts or feelings
- Trauma-related reminders
Criterion D (two required) – negative thoughts or feelings that began or worsened after the trauma in the following ways:
- Inability to recall key features of the trauma
- Overly negative thoughts and assumptions about oneself or the world
- Exaggerated blame of self or others for causing the trauma
- Negative affect
- Decreased interest in activities
- Feeling isolated
- Difficulty experiencing positive affect
Criterion E (two required) – trauma-related arousal and reactivity that began or worsened after the trauma in the following ways:
- Irritability or aggression
- Risky or destructive behavior
- Heightened startled reaction
- Difficulty concentrating
- Difficulty sleeping
Criterion F (required) – symptoms last for more than 1 month
Criterion G (required) – symptoms create distress or functional impairment
Criterion H (required) – symptoms are not due to medication, substance abuse or other illness
When can PTSD appear after trauma?
Symptoms of PTSD usually begin within the first three months after the trauma, although there may be a delay of months, or even years, before criteria for the diagnosis are met. The DSM-5 refers to this as “delayed expression” with the recognition that while some symptoms typically appear immediately, others are often delayed.
Often a person’s reaction to trauma initially meets criteria for Acute Stress Disorder immediately after experiencing a traumatic event, but Acute Stress Disorder is distinguished from PTSD because the symptoms are restricted to a duration of three days to one month. The duration of PTSD symptoms varies with complete recovery within three months occurring in approximately 50% of adults. I had some of this after I was hurt in an explosion. For months, I looked away whenever there was an explosion on TV and was timid about lighting a gas grill. But that reaction passed.
However, some individuals remain symptomatic for more than 12 months and some for more than 50 years. There were times when an elderly neighbor stood in his driveway and openly wept about things he had experienced over sixty years earlier as a Marine on Peleliu and Iwo Jima.
Research indicates that PTSD is more prevalent in females and they experience PTSD for a longer duration on average than do males. PTSD is associated with high levels of social, occupational and physical disability as well as considerable economic costs and high levels of medical utilization.
What are risk factors for PTSD in some people but not others?
Risk factors may increase a person’s chances of getting post-traumatic stress disorder (PTSD) compared to others who seem mentally unscarred by similar experiences Some of those risk factors include experiences of:
- Long-lasting, never-ending trauma
- Intense, severe trauma
- Situations that put one at greater risk for harm, such as first responders or those in the military
- History of substance, alcohol, or drug abuse
- A loss earlier in childhood, such as abuse or neglect.
- History of other mental health concerns or mental illness
- Few friends or close family members they can rely on for emotional support
- A history of mental illness within their family
How is PTSD involved after motor vehicle collisions?
Most people who are hurt in routine car and truck wrecks do not have PTSD. They may have some short term anxiety but nothing that rises to the level of PTSD. We have all had stressful conditions that we endured, sucked it up, and went on. When I was an insurance defense lawyer, I routinely sliced and diced psychologists who testified for exaggerated claims of PTSD that stretched beyond the diagnostic criteria.
However, there are vehicles crashes in which PTSD is a realistic issue. One study found that about 9% of motor vehicle crash survivors have symptoms of PTSD. Examples can include:
- A crash survivor who witnesses the death and sees the mangled corpse of a parent, spouse or child in the wreckage.
- A guy who was spun out of the line of impact when a tractor trailer ran over stopped traffic, so that he had minor physical injuries while everyone in the vehicle behind and in front of him was killed.
- A person trapped wide awake with the lifeless corpse of a family member until they are discovered, and as first responders labored to extract them.
- People who survived crashes in which they feared the immediate death of themselves or family members.
Any such experience in a car or truck crash is frightening, and it’s very common to experience a number of symptoms associated with PTSD, including:
- Feelings of anxiety and increased heart rate when you’re faced with reminders of the event.
- Hearing a horn honk or brakes screeching may automatically activate a fear response.
- Because of the anxiety that often follows an MVA, it’s natural that you may want to avoid some situations or experience hesitation at times, such as driving on the highway.
- Nervousness when driving or riding as a passenger, startling easily in traffic.
- Being more watchful. You’re more likely to scan your environment for potential sources of threats (for example, people driving too fast).
While we are careful to avoid exaggeration of on minor degrees of PTSD symptoms in auto and truck crash cases, we are alert to the need to have clients evaluated when appropriate for more serious and long-term PTSD symptoms. Whether mild or severe, credible PTSD symptoms can be presented as part of mental pain and suffering in car and truck crash cases.
If you have questions about a serious injury or wrongful death case in Georgia, contact us at 404-253-7862.
Ken Shigley is a past president of the State Bar of Georgia, past chair of the State Bar’s Tort & Insurance Practice Section, past chair of the Georgia Insurance Law Institute, past chair of the American Association for Justice Motor Vehicle Collision, Highway & Premises Liability Section, and a member of the board of governors of the Academy of Truck Accident Attorneys. He is lead author of Georgia Law of Torts: Trial Preparation & Practice (Thomson Reuters West, 2010-2018). His law practice is focused on catastrophic injury and wrongful death including those arising from commercial trucking accidents and those involving brain, neck, back, spinal cord, amputation and burn injuries. He is licensed to practice law in Georgia. Representation of clients in others states, which possible, can be undertaken only in strict compliance with the multijurisdictional practice and pro hac vice rules of the other state.