Psychiatric traumatology is a term used to cover all symptoms claimed to be causally connected to trauma of the body, mind or emotions. Obviously, any trauma to the human organism, impact or non-impact, may be reflected in the subject's psyche: in this context, such reflection becomes the preoccupation of forensic psychiatrists who are asked to evaluate the part played by the trauma per se in the resulting dysfunction. Moreover, the expert is asked to measure the intensity of the disability and pain and to estimate probable duration. Psychiatric traumatology then should encompass all objective and subjective complaints as well as non-medical elements not ordinarily credited in a neuropsychiatrie report. Non-medical means: a) the diagnosis itself and its influence on the examining physician's attitudes; b) the patient's biases and attitudes toward his disabilities; c) cultural and economic factors influencing the symptoms and; d) intangible social pressures exerted on all parties concerned. This clinical presentation is based on the study of 1,000 cases studied over 30 years where a legal tribunal and/or third party agent was involved.
Symptoms following injury to the head and spine involve objective and subjective elements. Thus pain, muscular disability, headache, photophobia, blurred vision, hearing impairment, hyperaccusis, fatigue, dizziness or vertigo, memory loss, restlessness or apathy may be observed or demonstrated. In addition, symptoms such as tinnitus, depression, tension, anxiety, catastrophic dreams, phobias, impaired memory, feelings of humiliation and depression, sexual disinterest and impotence, anhedonia, startle reaction, irritability, restlessness, seclusiveness, "psychic numbness," lack of concentration and a wide range of complaints subsumed under the heading "personality change" are reported. The latter, being subjective, are not readily demonstrable. Hence, the examiner's interpretation must be used in describing the clinical picture in a judicial setting. This description should include stresses external to the original injury (non-medical factors).
THE DIAGNOSIS AND ITS INFLUENCE
Although neurologic sequelae from cranial fracture, brain concussion and/or spinal injury have been recognized for centuries, specifically "nervous" symptoms were relatively neglected until John Erichsen, originator of the term "railroad spine," in 1875 published a book with the self-explanatory title On Concussion of the Spine, Nervous Shock and Other Obscure Injuries of the Nervous System in Their Clinical and Medico-legal Aspects.' Recognizing the "nervous" symptoms ("emotional") as part of the clinical picture, Erichsen assumed that the condition depended on molecular changes in shocked nerve tissue. Considered at the time to be one aspect of neurasthenia, the plausible term traumatic neurosis was introduced by Oppenheim, a German neurologic authority (1889), to cover the varied symptoms in cases where no organic damage could be found. The "molecular change" theory gradually lost credence following World War I experiences with "shell shock" casualties.
Pooling their experiences after the war, English, German and American neuropsychiatrists agreed with the conclusion reached by German military psychiatrists in 1931. 2 They concluded, "traumatic neurosis (induced) by accidents meant . . . mental elaboration based on alleged injury . . . The greatest number of war neuroses resulted from wishdetermined mental elaboration ... a smaller number constituted Organic sequelae of brain concussions.'" As civilian and industrial injuries increased during the pre- World War Il years, the term neurosis after trauma was favored; coincidentally the pre-morbid personality of the victim loomed larger in importance in evaluating the wide panorama of mental symptoms after injury. World War Il brought another change in diagnosis when the term combat fatigue was used to designate nonimpact cases (shelling, explosions, etc.). By the 1940s the phrase post-traumatic syndrome came into use while traumatic neurosis was still invoked after World War II. In the 1950s and 1960s, the concept of post-traumatic neurosis, including psychologic stresses, was extended to catastrophic events (eg, concentration camp experiences, earthquakes, bomb destruction, etc.), which modified the thinking about the effect on hitherto healthy persons of non-impact trauma. However, the organic aspect of head injuries was not neglected. Neurosurgeons in 1973 viewed post-traumatic syndrome as the effect of "complex causal chains powered by neurophysiological, psychophysiological, psychiatric and probably some unknown factor."5
The 1960s witnessed renewed criticism of traumatic neurosis because of the disturbing presence of prior "neurotic" elements in traumatic neurotics and a general uneasiness with the term. The issue surrounded the question of whether an accident "triggered off" a pre-existing neurosis or developed de novo from the accident became important. It was acknowledged that "definite functional or psychoneurotic symptoms . . . which affect the prognosis"4 must be considered and Tuerk,5 writing in the American Handbook of Psychiatry stated "the patient's predisposition to disease and his reaction to injury. . . [are] . . . intangible factors . . . [that] . . . may be as important as the injury itself." It was established practice during these decades that examiners should be aware of the categories established by Robitscher6 in 1966; "I) traumatic neurosis in mentally healthy persons overcome by stress, 2) compensation neurosis, whose latent illness . . . [is] triggered by the trauma and held onto ... for largely unconscious reasons and 3) malingering . . . [with] conscious deception."
Recognition of a neurotic predisposition of illness-proneness brought a new accent into traumatic situations due to negligence. As early as 1932 Huddleston,7 in a discussion of traumatic neurosis wrote .... "Many symptom complexes are so superficial as scarcely to merit the designation of neurosis, particularly when monetary compensation is involved."
In time, broadening the concept of stress led to a yielding of the concept traumatic neurosis to that of post-traumatic stress disorder.8 However, there has been a recent revival of the original term. Van Putten, among others working with Vietnam veterans, finds a place for traumatic neurosis nosological^.9 Atkinson et al point out that those examiners with a "professional bias" against the diagnosis post-traumatic stress disorder among Vietnam veterans tend to diagnose these conditions as psychosis, neurosis, depressive or anxiety disorders, since the delayed type of stress disorders are being found more consistently since the Veterans Administration has been empowered to honor such claims in Vietnam veterans.10
As in all medicine, a diagnosis and prognosis of nervous system injury is made from "hard data," plus an interpretation of the history, symptoms and findings. The net result is that the patient is expected to behave as projected by good medical experience. What the patient should feel may, in medical decisions, replace what the patient actually feels. Whatever exceeds the "normal" recovery time is laid to "functionalism," an inexact term, which is, as an English neurologist put it, "hallowed through common usage."11 Functionalism as a concept alters our perception of traumatic clinical pictures: in a way functionalism is a "black hole" to cover our lack of knowledge of stress reactions. Interpretations, themselves guided by changing conceptualizations in medicine modify evaluations offered to a medico-legal tribunal.
PATIENTS' ATTITUDES TOWARD DISABILITIES
A vital aspect of the patient's complaints rest on his/her perception of body-image distortion in the affected part. This is significant in nervous system injuries. The brain generally represents the site of "self," the ego, and any distortion of bodily parts is reflected in behavior, feelings, even the patient's lifestyle. This intensity is evident in anxiety the patient expresses as concern about "paralysis," the "wheelchair life," permanent handicaps, oncoming insanity and mental deterioration.
An injury, especially to the head Or back, evokes a momentary distortion in the body-image which Schilder defined as the "tridimensional image everybody has about themselves."12 Ordinarily it contributes to feelings of well-being, the sense of mastery of the environment and a nucleus of accepted narcissism. In injuries meaningful to the victim, the disturbed body-image is forced to the surface of consciousness, stimulating increased perception of pain and disability, a sense of loss of body parts and "body boundaries,"15 amounting to anxiety and pain. To put the situation in Freudian terms, the "libido" flows to the traumatized area. Of these psychological phenomena, the patient is vaguely, if at all, aware. When the condition is prolonged, continued pain and disability exert a subtle effect on the patient's symptoms. As Sternback saw it, "pain is both a function of and a stimulus to abnormal behavior."14 The total effect, as seen by the observer, is of complaints extending beyond normal expectations as judged by consensual medical experience.
Reaction to body-image distortion following impact can be specific or symbolic. The former is illustrated in a case of a muscular, 50-year-old workman who stepped on a bare wire at work with a resultant shock that threw him several yards, producing unconsciousness and a burn on the plantar surface of one foot. Careful medical studies over the three years demonstrated no surgical, neurologic or cardiac sequelae. However, the patient was disabled from work, complained of depression, "electrical shocks" passing through his chest muscles, pain at the site of the electrical burn, and anxiety lest he "die any time" in a delayed electrocution. More then three years post-accident he remained extremely anxious, unable to bear weight on the burned foot, depressed, and non-ambulatory requiring a wheelchair.
A symbolic body-image distortion occurred in a well-developed truck driver in his 50s who fell 12 feet from his truck, suffering a brain concussion with momentary unconsciousness and confusion, followed by a classical post-concussion syndrome. Within a day or two of his injury, he became aware of a compulsion to grind his teeth during sleep and waking hours (bruxism). During the two years after his accident, he had ground an intact, normal set of teeth to the gum line. A thorough and prolonged medical work-up during this period for a possible cancerous lung lesion proved to be negative. Being shunted from one specialist to another, the possibility of having cancer contributed to fears of early death and physical deterioration increased his anxiety. The bruxism was interpreted as a defense against fears of physical disintegration.
Injuries to the lumbar and cervical area also carry the weight of body-image distortion, especially among men. The spinal column functions as the axis of the body, the coordinating center of all movements. Pain and disability are reflected immediately in the muscles and ligaments of the back and neck. Besides this palpable effect, the back is invested with special psychologic sensitivity. There is a sense of unfairness, of not meeting one's attacker "face-to-face," of an invasion of privacy when one is slapped playfully or is injured unexpectedly in the back. Unanticipated trauma to the spinal area can easily grow to a paranoid feeling, as has been observed in victims of rear-end collisions. On a deeper unconscious level, such assaults may be equated to anal attacks. The frequency of car phobias, especially among women, after car accidents, may represent increased anxiety occasioned by a symbolic dorsal attack. In illustration, a 30-yearold woman struck while seated in her car at a traffic light, developed a cranio-cervical syndrome (whiplash) which slowly but incompletely yielded to treatment. Several years later her car phobia persisted. She was unable to sit in the passenger's seat without facing the driver and looking backward, alternately watching the traffic in both directions. When forced to look only forward, her anxiety escalated markedly.
The sense of injustice experienced by victims of accidents where they are blameless often contributes to prolongation of post-traumatic symptoms. Ordinarily not reckoned as an element of illness, or misread as a conscious decision to prolong the illness, it is in fact an attitude invoked by a feeling of humiliation and denigration. Whether the accident is regarded as "fate" - being in the wrong place at the wrong time - or fancied maliciousness, the victim comes to view the negligent party as an "enemy." Cases where aggressive, even homicidal impulses explode toward the "miscreant" are not uncommon. Often guilt reactions arise in reaction to such hostile feelings which then intensify subsequent depressions. Cases have been seen where depersonalization enters the clinical picture, representing a further blocking of rage against the perpetrator. This situation has occurred even in nonimpact accidents where the trauma was essentially psychologic: A middle-aged woman who worked in an executive position in a large commercial organization for 1 3 years was suddenly discharged with only a few minutes notice. She was shocked, bewildered and depressed. Where she had been active socially and on the job, rated as a competent worker, she became withdrawn, unable to cry, markedly anorexic and blunted. All examiners agreed the depression was "extreme." Her anger at her summary dismissal was overpowering. Examination two years after the original trauma found her to be emotionally flat, blocked, withdrawn and depersonalized.
Of the symptoms following head injury, especially in industrial accidents, that of "personality change" often outlasts acute complaints by years. The continued pain and disability without relief seems to superimpose certain attitudes - constriction of interests, heightened irritability, reduction of social amenities, intolerance toward associates or friends - resulting in a totally different constellation of personality characteristics. Whether this behavioral change is secondary to miscroscopic brain tissue modification or chemical milieu alteration is unknown. One interpretation points toward an extension of resentment as a basic cause. Factors such as the lengthy legal process of settlement or court trials, the tedium of interrogatories, depositions where the patient may feel on trial, dilatory tactics of third parties, the strangeness of legal tribunals in contrast to medical settings, repeated examinations by specialists all stimulate the uneasy feeling that justice will be denied. Trauma patients may become irritable and belligerent even toward their physicians, particularly when it becomes evident that doctors appear less than objective in their reports to third parties.
To a person negligently injured, the entire social - legal system can be viewed as their malefactor. An example is the case of a 42-year-old warehouseman struck on the head by a heavy metal garage door with resulting brain concussion. Classic symptoms of post-concussive syndrome persisted for several years. Three years after the accident, the patient's relatives noted irritability, poor grooming, loss of self-respect, perpetual anger; as described by his wife, "as full of hatred as a criminal." He had previously been an effective worker, a loving father and husband, a social being within his circle. His sons now described the patient as "selfish, uncaring, depressed, miserable, without responsibility ..." Four years after the accident he was disinterested in rehabilitation, morose at home, "battling each day about trifles" even though the concussive symptoms had faded. Five years after trauma the patient declared, "I am sick of my illness." He was particularly incensed over the numerous psychiatric examinations and the protracted legal delays in arriving at a settlement of his compensation case.
In assessing attitudes toward injury symptoms, cultural and ethnic differences must be considered. The stoical illness attitude of many, especially male, members of the host country (US) diverges from that of other areas of the world - Asiatic, Latin American, European, Mexican-American. As Corinne Nydegger pointed out in a recent study of differences between Western medicine and that of other (non-scientific) cultures, the underlying premise of causes, hence of diagnosis, differ.15 When the "cause of an illness is that of sinning, being the victim of an evil spirit or of anger in an outraged neighbor, the so-called scientific paradigm has little meaning." Although this author was speaking of tribes who use curanderos or shamans, one can see traces of this cultural difference among unsophisticated foreign-bred workers injured in industrial situations. I have seen this peculiar attitude toward pain and disability among illiterate or partly illiterate Mexican-American victims of industrial accidents. Here there is no interest in psychotherapy in the sense of analyzing, comparing or trying to reduce the intensity of pain by reasoning or through natural explanations; it cannot be suppressed through action of the will. A hurt or disability is endowed with a finality that only a diety can cure. It is as if to say, "There is something wrong with my bones, joints or muscles. Unless it goes away I consider myself sick." I have called this attitude, for want of a better term and with no disrespect toward Mexican-Americans, the Aztec Syndrome. It is evident in the failure of therapy, rehabilitative efforts and in symptom prolongation. A case in point was a woman of 51, born in Mexico, living and working in a Spanish-speaking enclave in California. While riding in a company van to work in the fields she hurt her head when the van jolted her on a rough road. Her complaints of neck, shoulder pain and headache persisted for several years. Careful and repeated examinations revealed no organic changes beyond the original musculoligamentous sprain. Three years after the accident, an orthopedic specialist considered her to be "highly suggestible and her illness feigned."
The patient was illiterate in Spanish and English having been born in a rural area in Mexico. Married with seven children, her narrow range of interests included her home and seasonal farmwork. Proud of her capacity for hard field labor, she wanted only to be delivered of her headache. One received the impression that continued neck muscle and head pain represented an immutable fact of life for her.
A similar reaction in an accident victim from a different, Asiatic, culture illustrates this sense of finality. He suffered a muscular sprain, complicated by hysterical anesthesia. The final clinical picture five years post-accident indicated a mixture of resentment, body-image distortion and unacceptable resignation to a less desirable social and economic status, ie, a laborer, the patient a Vietnamese man of 44, in the US for three years was injured when a heavy box fell on his left shoulder and neck. A diagnosis of muscular sprain and radiculopathy at C4-7 on the left was made. Two years later he consistently complained of severe pain at the acromioclavicular joint on the left and limitation of movement and marked tenderness of the shoulder girdle muscles on the left and complete hemi-analgesia and hemi-anesthesia on the left from the face to the foot. Numerous examiners, including this one. concluded he suffered from hysteria and/or malingering, especially after viewing a film, surreptitiously taken, showing full mobility of all extremities.
The patient had been a teacher in Vietnam, a Lieutenant in the ARVN Army (South Vietnam) but a laborer in this country. Five years after the accident, the patient displayed immobility of the left arm, sensory deficiency on the left side and complete disability for work. Again, a moving picture demonstrated good movement when not observed. The possibility of a reflex dystrophy was suggested but functional overlay remained a main element in the evaluation.
Economic problems in accident victims necessarily play an important role in estimating prognosis. Usually placed under the heading of "secondary gain," these problems can be real, ie, halfformulated plans for retirement occurring at the time of the accident; welcomed relief from a boring or monotonous job; loss of status in the labor market; the shock of forced retirement; dethronement of the male worker from his position of wageearner and by implication, the titular head of the household; impairment as an independent, effective member of society; fear of sexual inadequacy ("macho"); loss of ego satisfaction from both "work mastery" and recreational satisfaction. Similarly, the female victim is affected by feelings of helplessness and being displaced as an effective homemaker and pivotal figure in the family constellation.
It is often emphasized that secondary gain can be essentially psychologic in nature, ie, the help and sympathy the patient receives from relatives. The older literature distinguishes this from "primary gain." Thus, Feniche! in discussing the dynamics of traumatic neurosis stated "primary gain from an accidental injury can be interpreted as the advantage conferred by simulation and malingering, whereas secondary gain . . . ihas] the meaning of love and protecting security. ",b Except in the most flagrant malingering, in the current author's experience, there is no primary gain from motor car. motorcycle or various industrial accidents unless one postulates a masochistic need for injury for which one may be compensated. If this rare situation is encountered, it is invariably mixed with other psychologic elements as demonstrated in the following case.
A 55-year-old iron worker, active for years, reinjured an old laminectomy site while lifting heavy objects. Aside from back pain, he developed tinnitus which was "driving him crazy." Careful otologic examinations revealed only "high frequency loss . . . not ratable . . . resulting from noise exposure and aging." He also suffered from hyperacusis and irritability because of the intolerable tinnitus.
Two years after the accident he complained of increased tinnitus, although he was neurological Iy negative, and the otologist found no "auditory disability or labyrinthine impairment" other than the common high frequency losses. He claimed inability to do any kind of work; the patient wished only to "retire to a few acres in some quiet place."
Neuropsychiatries working with forensic material function somewhat apart from the formalism of main-line medical diagnosticians. They are required to estimate the award-value of injured individuals in terms of prognosis with due regard to history, findings, pre-existing neurotic and "extramedical" factors discussed above. How can these tangible and intangible findings be clinically evaluated?
In an earlier paper17 the author described a grathent of defensive, ego-saving mechanisms as: simulation, malingering, exaggeration, over-valuation, functional overlay and hysteria. These stages merge into each other, but they do present enough specificity to justify clinical evaluation. Simulation is the assumption of pain and disability in the form of a feigned illness. Malingering also feigns illness but may, in accident cases, have a basis in actual or presumed trauma. Exaggeration magnifies pain and disability of an extant medical condition. Overvaluation represents increased importance of the condition to the injured person in terms of his or her lifestyle, social or economic situation. Functional overlay is the superimposition on the original injury of emotional elements unknown to the patient. Hysteria (conversion hysteria) expresses physical or physiological symptoms of an unconscious emotional conflict.
Of these, functional overlay can be difficult to establish. Some deny its existence or consider it "ambiguous." In Weinberger's critical terms, "... [it isl no more than an off-hand notation of physicians . . . unacquainted with the perplexities of psychiatry ... or with the true motives of their patients . . . "'* This commentator feels functional overlay is "inconsistent with long clinical observation and unnecessarily complicating."
The puzzling state of affairs among post-injury patients where the disability claimed outlives minimal physical impairment has been noted for decades. Shands and Meltzer recall an old phrase, "disproportionate disability;"19 the "Freud-Charcot Syndrome," established by Freud in 1886 when he described hysteria in males following work trauma.20 These investigators, examining 120 workers' compensation cases in 1975, found 88 to show "cognitive limitation" on psychological testing, which left the patients "vulnerable to severe . . . disorganization following change in self-definition." Their observation that "cognitive" impairment made psychotherapy impossible and was accompanied by a "confusing array of nonspecific symptoms . . . without apparent physical impairment" coincides with the concept of functional Overlay.
Functional overlay then is a mental set, or constellation of attitudes, largely unknown to the patient (ie, unconscious), that combines reaction to body-image distortion, a belief that the injury is difficult to repair, a final conviction of permanence. In such a patient, no medical Or scientific proof of the absence of physical or neurologic impairment can convince the patient. Hence, therapy of any kind, including psychotherapy, is valueless.
This is admittedly a gray area but a real problem in considering the part played by trauma in the resulting clinical picture. In previous communication the writer intimated that functional overlay is not currently legitimately considered a diagnosis.17 We now ask whether in this era of heightened selfperception on the public's part, it may not really be a valid psychiatric entity resulting from trauma, negligently caused.
Prolongation of symptoms following past-traumatic stresses beyond the "normal" time anticipated by medical experience is a real problem for neuropsychiatrists working in a legal environment. Such conditions as exaggeration of symptoms and functional overlay lie upon attitudinal and emotional factors other than those Of recognized psychiatric entities. In addition to prior neurotic predisposition, unstable personalities, hypochondriac tendencies, accident proneness, etc. in victims of injury, there are "non-medical" factors tending to delay recovery. These are the diagnosis itself; medical biases consequent on diagnosis and changes; patient's biases secondary to body-image distortion; social-economic-cultural reactions; resentments at the legal system with its frustrations and frequent development of faint paranoid feelings. Although all these factors are often dismissed as malingering or evidences of secondary gain, such reactions must be included in the field of psychiatric traumatology.
1. Erichsen IEt On Concussion of the Spina, Nervous Shock and Other Obscure Injuries of the Nervous System in Their Clinical und Medico-legni Aspects. New York. Wm Wood Co. 1975.
2. Symposium, Die Unfall Kreigs Neurose tfrom German translation). Archives of Neurology and Psvchiatrv 1931: 29:25.
3. McLauTJn RL. Titchener IO: Posttraumatic syndrome. Vn Woumans |(ed): Neurological Surgery. Philadelphia. WB Saunders Co. 1973, ? 1023.
4. Merritt HH: A Textbook of Neurology, ed 6. Philadelphia. Lea and Febiger, 1979. ? 354.
5. Tuerk K. et al: Head injury, in Arieta S(ed): American Handbook of Psychiatric Education, ed 2. New York, Basic Books, 1975, pp 166-181.
6. Robitscher |B: Pursuit of Agreement. Psychiatry and the Law: Philadelphia. JB Lippincott Co, 1966. pp 93-1 17.
7. Huddleson IH: Accidents. Neuroses and Compensation. Baltimore. Williams & Wilkins, 1932.
8. DSM-UI. Washington, DC, American Psychiatric Association, 1980.
9. Van Putten T: Traumatic neurosis in Viet Nam returnees: A forgotten diagnosis? Arch Gen Psychiatry 1973: 29:695-698.
10. Atkinson RM, Henderson RG, Sparr LF. et al: Assessment of Viet-Nam veterans for post-traumatic stress disorder in Viet Nam administration disability claims. Am / Psychiatry 1982; 139:1118-1121.
11. Walton JN: Essentials of Neurology, ed 2. Philadelphia, [B Lippincott, 1965, p 3.
12. Schilder P: The Image and Appearance of the Human Body. New York, International University Press, 1950.
13. Steiner H, Clark WR |r: Psychiatric complications of burned adults: A classification. J Trauma 1977; 17:134-143.
14. Sterrtback RA: Treatment of the chronic pain patient. J Human Stress 1978:4:11-15.
15. Nydegger N: Multiple causality: Consequences for medical practice. West I Med Vol. 1 38. No. 3. pp 430-436.
16. Fenichel O; The Psychoanalytic Theory of the Neurosis. New York, WW Norton Co, 1945, p 127.
17. Bromberg W: Functional overlay: An illegitimate diagnosis? West J Med 1979; 130:561-565.
18. Weinberger LM : Another view of functional overlay. West J Med 1979; 131:251-252.
19. Shands HC, Meltzer D: Disproportionate disability: The FreudrCharcot syndrome rediscovered. The Journal of Psychiatry and Law, spedai reprint. Spring 1975.