PTSD, the Permanent Life Altering Injury

Post Traumatic Stress Disorder (PTSD) is showing up more and more in litigation. The information and tips that we offer in this Litigare Journal article are courtroom and settlement proven strategies for the plaintiff and the defense. This article will cover PTSD symptomology, the effects it has on the human brain, and the subsequent social and emotional functioning issues that arise from a diagnosis of Chronic Post Traumatic Stress Disorder. We have listed a few current research studies and articles that have been effective for trial and settlement.  

PTSD is characterized by hyper and hypo activations in brain functioning resulting from experiencing a traumatic event. The DSM lists examples of possible traumatic events that may lead to PTSD (i.e. war, death, massive explosion, etc…). Those listings are only guides and the DSM does not claim that the events listed are the only causes or reasons for developing PTSD. We must be very clear in this area; many factors can lead to an acute or chronic diagnosis of PTSD. It can be a low speed MVA, witnessing violence (simulated or real), experiencing a suppressed memory (real or implanted), a slip and fall, a traumatic brain injury (mild, moderate, or severe), and the list goes on and on. With the growing knowledge in the general public about PTSD arguing that PTSD can only be caused by of the highest level of intensity is a poor strategic choice. Sound evidence based research has clearly disproven that argument.

Throughout my decades of clinical experience, perception is a cornerstone to a PTSD diagnosis; it is how each individual perceives the experienced threat that is the key to developing PTSD. So two people who view the same incident will have diverging responses; one will develop PTSD and the other will not. A low speed MVA can easily cause PTSD and a no physical injury accident can certainly lead to chronic PTSD and will absolutely severely alter life course. In its simplest terms it all comes down to how the brain responds to the perception of threat. The limbic system is where it all gets processed. This system is hard wired for threat response evaluation for self-preservation. The limbic system is designed to hold onto and repeat (in the form of flashbacks or emotions) any life threatening experience into hard memory. It is a cold-hard fact that this system is designed to ensure our survival, nothing more and nothing less. The limbic system is not a place of reasoning. The prefrontal cortex holds that job.

Modern science has reached a point where we can reliably chart and pinpoint permanent changes in brain functioning resulting in hyper and hypo activation of brain centers using magnetic resonance imaging (MRI). The areas of the brain that are affected by PTSD include: (a) inferior occipital gyrus, (b) ventromedial prefrontal cortex, (c) rostral and dorsal anterior cingulate cortex, (d) parahippocampal gyrus, (e) Ingual gyrus, (f) Dorsal amygdala, (g) anterior hippocampus, (h) orbitofrontal cortex, (g) putamen, (h) middle occipital gyrus, (i) dorsamedial prefrintal cortex, (j) thalamus, (k) ventromedial prefrontal cortex and (l) mid-cingulate cortex. Most of these structures lay in the limbic system or deal with reasoning like the ventromedial prefrontal cortex. Pinpointing these structures helps us locate where PTSD symptomology occurs in the brain and helps to identify how it is different than other mental health disorders.

PTSD symptomology includes: (a) hyperviligance, (b) emotional shut down example by an inability to feel joy or a lust for life, (c) sleep issues (d) easily overwhelmed which can result in learning difficulties, memory deficits, and task completion issues, (e) not feeling safe or connected, (f) altered decision making ability, (g) and avoidance. Avoidance is an essential and important issue because many PTSD victims will avoid treatment. They do this because the act of seeking treatment is a reminder of traumatic event and part of the preservation response (limbic response) is to avoid the perceived life threat. This avoidance can become irrational and there is no reasoning when it comes to survival. All of this information means that PTSD patients can see a life long struggle with having to modulate emotional responses much more than you and me. Chronic PTSD is a permanent life altering injury.

There are numerous research studies that clearly document this description and a competent PTSD expert will be able to determine the most sound research studies to utilize. As stated previously, we have listed a series of studies and articles below for your review and use.

Current evidence based research indicates that chronic PTSD creates permanent changes in brain structure. Contrary to what others may argue, these changes are not reversible. Psychological treatments do exist that are highly effective in teaching the PTSD patient how to cope with their symptoms and help improve their lives, but it does not negate or change the permanent brain damage that occurs from chronic PTSD. So what does this damage look like? The answer lies in our previous description that PTSD causes hyper and hypo activation in certain areas of the brain. Individuals with chronic PTSD have some areas of the brain that work faster and harder and less and slower than individuals without PTSD; once chronic the hyper and hypo activation will not change and we experience the common life altering issues resulting from this disorder.

The following describes the type of issues we see with chronic PTSD. This includes but is not limited to: (a) emotional modulation deficits, (b) inaccurate perceptions of self and others, (c) decreased ability for self-control, and (d) altered perceptions of what is safe and dangerous. These issues point towards serious life-long ramifications in social and emotional functioning altering a person’s life course. When the victims are children then we are looking at real limitations to their life trajectory. One of the more problematic issues with PTSD victims is how they view social and emotional interactions through a threat versus safety view point. From a Maslovian view when the individual exists in a threat versus safety view point the majority of psychological energy is directed towards self-preservation leaving the individual living at the most base psychological level. They have no psychological energy for higher levels of functioning; social relationships, the ability to love and be loved become retarded or even shut down completely. So we are left with a person who ends up focusing solely on how to survive. This poses serious ramifications for how this person will interact with their spouse, significant other, children, family, friends, and work. Imagine living with an underlying fear that death or severe harm is always lurking somewhere nearby. Imagine living with the feelings and confusion of wanting to be close to someone while always fearing that they will harm you. This is the cost of PTSD because one can never truly settle down, relax, or trust their own decision making process.

The PTSD victim has been thrust into a world where they doubt if they are welcomed by others. They are acutely aware that their life has become constantly rattled by panic and irritability. Tragically many PTSD patients I treated witnessed themselves transform into a person who reacts from a volatile emotional place leaving them coping with excessive shame and self-blame. The tragic irony is that they witness their own self decay and feel powerless to change course. 

Evidenced based research indicates that PTSD can be classified as late onset. For example, a child sexually abused at age 6 may not recall the event until later in life; in this scenario we usually see late onset of PTSD during puberty. The then sudden horror of re-experiencing the event is enough to cause an acute PTSD reaction and if the symptoms continue for more than 3 months it is classified as chronic. 

Lastly, individuals with Chronic PTSD are susceptible to a multitude of other psychological disorders including: (a) Panic Disorder, (b) Agroaphobia, (c) Obsessive-Compulsive Disorder, (d) Social Phobia, (e) Major Depressive Disorder, (f) Somatization Disorder, and (g) Substance related disorders. A competent expert, previous mental health records (if they exist), and a high quality psychological evaluation can determine if any of these psychological issues existed prior to the traumatic event. That information is extremely valuable for strategic development.

Tips to remember when dealing with PTSD in Trial:

1.      Chronic PTSD is a permanent life altering injury because it causes changes in the brain (brain damage);

2.      The PTSD victim has impairments in the following areas:

a.      Poor decision making

b.      Impaired social and emotional functioning

c.      Partial to complete emotional shut down

d.      Perception Deficits

3.      New trauma or re-traumatization creates further brain damage

Articles for Use and Review:

Etkin, A., & Wager, T. D. (2007). Functional neuroimaging of anxiety: A meta-analysis of emotional processing in PTSD, social anxiety disorder, and specific phobia. The American Journal of Psychiatry, 164(10), 1476-88. Retrieved from 

Etkin and Wager (2007) conducted a meta-analysis exploring a variety of mental disorders including PTSD. This is a good research source because of their sound research and ability to scientifically show effects on the brain that are unique to PTSD and clearly shows brain structures that cause the emotional dysreulation symptoms of PTSD. In their research they show the areas of the brain that are hyper and hypoactive indicating changes in brain functioning and structure.

Silove, D. (1998). Is posttraumatic stress disorder an overlearned survival response? an evolutionary-learning hypothesis. Psychiatry, 61(2), 181-90. Retrieved from 

Silove (1998) provides a very interesting theoretical analysis of PTSD and the survival response. This is a must read when developing strategies for no physical injury PTSD and PTSD with physical injuries.

van der Kolk, B. A., (2001) The psychobiological and psychopharmacology of PTSD. Hum Psychopharmacol Clin Exp; 16 S49-S64. 

Bessel A. van der Kolk is a name to know with PTSD and has been a major contributor to the PTSD body of knowledge. This article covers PTSD symptomology, changes in brain structure and possible medicinal treatments to help PTSD patients.