Supporting Evidence from the DSM and ICD Classifications to Better Understand Traumatic Experiences, PTSD in Law

  •  Yega Muthu    


This paper will discuss the recognition of Post-Traumatic Stress Disorder (PTSD) in legal cases based on the historical development of the Diagnostic Statistical Manual for Mental Disorders (DSM). Further the discussion will draw on the diagnostic relationship between the DSM and the International Classification of Diseases (ICD). It is important to understand how the courts received evidence in relation to a person’s traumatic experience and to define the limits of liability for psychiatric illness cases. In tort law, the courts had been cautious to permit recovery to underserving litigants. Interpreting traumatic experiences from psychiatry to law, at times, do not succeed in a claim for compensation.  Belanger-Hardy opined ‘Tort Law has always viewed mental harm with caution, not to say scepticism’.  Historically, compensation for PTSD claims have always been awarded on ad hoc basis in tort law for fear of opening the floodgates.  In Saadati v Moorhead , Brown J acknowledged the requirement of a psychiatrist to diagnose a psychiatric disorder by referring to DSM and ICD classifications.  The diagnostic manual is a guide book and should be used with caution.  The DSM Manual also explains the concept of malingering and practitioners should be cautious when preparing an expert report to assist the court.
It is argued the courts are trying to play catch up with psychiatry, however, in its deliberations pronouncing inappropriate policy decisions, hampering recovery for a deserving claimant in tort law.  Ultimately, Judges control the goal posts for awarding damages in trauma related cases. 
Historically, PTSD was defined as railway spine, shell shock, traumatic neurosis, accident neurosis and fright neurosis. Medical science established there is a relationship between the mind and body and the mind can only function in the body. Therefore, if the mind is affected by an external factor, the psyche may become muddled to develop post traumatic symptoms.
This paper will examine the method adopted by practitioners and judges in interpreting the manual. This is seen from a methodological assessment of diagnostic concordance in the light of inherent problems of psychiatric classifications and malingering. This assessment will ultimately relate to psychiatric classification of individual patients who are subjected to an intense trauma resulting in fear and helplessness. Hence, unable to relate to what had taken place and subsequently not able to realize that the psyche is muddled or disorganized. In the absence of an actual physical lesion, the courts have become sceptical and wary of extending the defendant’s liability to cover alleged damage such as psychiatric illness. The inherent fears are that evidence can be confabulated and based on false premise. Hence, the courts make a linguistic interpretation in view of the struggle between the law and psychiatric illness.
Furthermore, the discussion will capture the essence of PTSD which was introduced in the 1970’s and adopted in DSM-III in 1980 by the American Psychiatric Association (APA). In 1992, PTSD was recognised as a diagnosis in the International Classifications of Diseases (ICD-10) in Europe under the rubric of Neurotic, Stress-related and Somatoform Disorders by the World Health Organization (WHO).  The DSM is a guidebook for mental health practitioners.  However the origins of PTSD lie further back than the twentieth century. The history can be traced through the experience of the American Civil War, First World War, Second World War and the Vietnam War where veterans who returned home suffered trauma because of devastating exposure to war. Their traumatic experiences were documented and translated as symptoms which were eventually associated with PTSD, as described in DSM-III. These traumatic experiences were observed in the civil and forensic setting. 
Moreover, this paper will contain a summary of the historical development of the ICD and DSM classifications depicting war associated syndromes as they played a dominant role in shaping the early diagnostic thinking of WHO and APA. From 1840 to 1921, in the United States, data was collected by gathering statistical information across mental hospitals in order to produce a nationally acceptable psychiatric nomenclature.  In particular, a notable physician called Da Costa in the American Civil War gave the name ‘irritable heart’ to the symptoms suffered by some soldiers.
Consequently, the statistical information was broadened to take account of and incorporate outpatient presentations from World Wars I and II veterans. This was known as ‘shell shock’ and ‘war neurosis’. War neurosis was further refined following World War II and the Vietnam War in terms of ‘trauma’. Contemporaneously in 1948, WHO adopted the Armed Forces categorisation based on Army, Navy and Veteran experiences in World War I and II, when it integrated mental disorders into the sixth revision of the ICD depicting an European model. Mental disorders were not introduced into the ICD until its sixth edition, published by WHO in 1948,  and therefore it is not pertinent to discuss ICD classifications from 1 to 5 editions for the purposes of mental illness. 
Besides, this paper will explore the development of trauma as defined in the current understanding of PTSD. This development is necessary to show how the term ‘trauma’ was transformed into PTSD. Evidence is also drawn from the courts as to how PTSD is used in a legal setting. As was the case for DSM-I where a category called ‘gross stress reaction’  was recognized in 1952 and a diagnosis called ‘transient situational disturbance’ or ‘anxiety neurosis’  was declared in DSM-II in 1968. The development of DSM-III was coordinated with the ninth revision of ICD.  In 1980, DSM-III introduced PTSD for the first time. DSM-III made major changes in which the diagnosis of PTSD was formally introduced. DSM-III did not prescribe duration of the symptoms. 
Similarly, ICD-9 did not include diagnostic criteria to specify mental categories and facilitate the collection of basic health statistics. In view of the incompatibility between ICD-9 and DSM-III, APA suggested that modifications to be made to ICD-9 for its use in the United States. The result was ICD-9-CM. 
In 1987, DSM-III-R was introduced to refine the duration of symptoms.
In 1992, WHO introduced the diagnosis of PTSD in ICD-10 and consequently the APA formed a task force to develop the DSM-IV in 1994. At the time, WHO was ready to publish ICD-10. The U.S. was under a treaty to maintain systems consistent with WHO and there was a desire to build a better empirical foundation, using 13 groups of researchers in field trials. Research in natural environment diagnoses in the United States and Canada used DSM-IV, whilst most countries officially use ICD-10 and now ICD-11adopted in 2019. In DSM-IV-TR of 2002, there was still doubt by psychiatrists as to whether PTSD is an anxiety disorder or a disorder in its own category. Refinement of DSM-IV-TR was undertaken in the current DSM-5 following research.
In addition, issues related to malingering and methodology for the detection of malingering are explored. Such methodology will confirm evidence as to whether an individual malingers or not.
In conclusion, this paper will look at the latest developments in the DSM Manual and by discussing how such a manual should be utilised effectively by the courts and psychiatrists.

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