IMPACTOS DEL PROYECTO

Post-traumatic stress disorder (PTSD) was only recognised as a diagnosis after the Vietnam War, where it was commonly diagnosed in military

personnel. It continues to be diagnosed in a military setting, a setting where the diagnosis is associated with entitlement for compensation. In the US, the incidence of PTSD in military veterans is rising. The number of veterans awarded compensation for PTSD increased from 120,000 in 1999 to 216,000 in 2004. Costs for PTSD rose from US$1.7 billion to US$4.3 billion over the same period.184

Within the Veteran’s Affairs organisation in the US, research has been done to determine any effect of compensation on the diagnosis or reporting of

symptoms (which, in turn, influences the diagnosis). As with other conditions, reports of symptom exaggeration in those seeking compensation185 are mixed with reports concluding that there is no difference in symptom reporting.186 Like the conditions discussed above, difficulties with classification exist within studies of PTSD because the diagnosis is dependent on symptom reporting, and the compensation system is complex, and all veterans are potentially eligible for compensation so any distinction between those currently seeking compensation and those not seeking compensation may not be meaningful.

The increase in incidence over the years may not be due to changes in symptom reporting, but rather due to changes in the diagnostic criteria for PTSD. Concern has been raised regarding the change in diagnostic criteria

for PTSD in the latest (fourth) edition of the DSM as it has become more subjective.6 Whereas previously the definition of PTSD relied on a traumatic event which is “out of the ordinary” and would be “markedly distressing to almost everyone” (i.e. referenced to the population norm), the current

definition requires exposure to a stressor which elicits a response of “intense fear, helplessness or horror” from the subject (i.e. referenced to the patient, or subjective).5

The diagnosis of PTSD has been questioned by Summerfield7 who argues that it is an entity that has been constructed as much from sociopolitical ideas than psychiatric ones, and that PTSD may be another example of the medical community labelling (or medicalising) normal human distress and suffering.

The subjectivity of PTSD is also demonstrated in the way physician

expectations influence the outcome in PTSD patients seeking compensation. In a study by Sayer and Thuras,187 clinicians treating veterans for PTSD were found to have a more negative view of the likely treatment outcome for

patients who were seeking compensation. This difference, however, may be based on valid experience, or may be part of a self-fulfilling prophecy

regarding the poor outcomes for compensation-seeking patients. They also found that the negative perceptions towards the compensation-seeking group increased with increased exposure to the patients. Interestingly, the treating physicians in this study also had more negative perceptions towards

compensation-seeking patients, compared to patients who were already receiving permanent compensation, even though the latter group were more

severely affected, indicating that the pursuit of compensation is seen as the negative factor, not receipt of compensation.

In the general community, PTSD is one of the most prevalent categories of mental illness188 and motor vehicle accidents are the single largest civilian cause of PTSD.189 190

The role of compensation in PTSD following motor vehicle accidents has been studied, with varying results. Mayou et al, in a prospective study of over one thousand consecutive patients presenting to an Oxford Emergency

Department after a motor vehicle accident, found that chronic PTSD at one year191 and 3 years192 was associated with pursuit of litigation when allowing for other variables. This supported previous smaller studies by Blanchard et al, which showed that litigation was an independent predictor of PTSD at 4 months193 and 1 year190 after presenting for treatment after a motor vehicle accident.

In a study from New South Wales that argues against the influence of litigation on PTSD, Bryant and Harvey base their conclusion on their finding that

settlement of compensation did not influence PTSD symptoms.194 This reasoning is common in the literature: that if litigation or compensation influences illness, then settlement (of the litigation or compensation) should have the opposite effect on the illness. This implies that the illness is a conscious process and is a false logic: removal of a stimulus does not

reverse lung cancer. This fallacy is shown in Bryant and Harvey’s results, which showed that patients involved in compensation (whether settled or not) had a significantly higher incidence of PTSD than those who were not so involved.

A more recent study from New South Wales, however, showed that PTSD at 18 months was not influenced by compensation status in a similar cohort of patients presenting to hospital after a motor vehicle accident.188

The methodological inadequacies of studies of psychiatric morbidity following motor vehicle trauma have been highlighted in a review by Blaszczynski et al,195 citing factors such as selection bias, absence of a clear definition of PTSD, reliance on clinical judgement and failure to incorporate ratings of injury severity. Interestingly, they cite issues of compensation as being the main concern.

The literature regarding the relationship between road trauma and PTSD has also been reviewed by Matthews196 who found evidence of the legal process contributing to the diagnosis but that the literature regarding compensation was mixed. Matthews concludes that “compensation neurosis” only occurs in a minority of patients after road trauma but bases this conclusion on the findings that malingering is not more frequent in compensated patients, and that symptoms do not appear to improve after settlement of a claim.

Matthews, like Bryant and Harvey, seems to imply that the effect of

that PTSD in compensated patients is not due to malingering and does not improve after case settlement does not discount the possibility that

compensation is associated with the development of (genuine) PTSD, a finding that is supported by the literature.