Psychiatric Annals

Introduction

Walter Bromberg, MD

Abstract

Injuries to the central nervous system, including the sensorium, have been a part of life since a caveman clubbed his colleague in a disagreement over the spoils of the hunt. Of course, the matter of compensation for injury - mental and physical - did not enter into that transaction, nor was the question of blame, ie, negligence for the injury a concern. However, in our society with its alarming and escalating number of industrial and personal injuries, questions of the acute and chronic effects of head and spinal injury are important. The primary physicians who see accident cases, emergency room physicians and neurosurgeons are concerned with the acute problems in their patients. To the neuropsychiatrist, psychiatrist, clinical psychologist and rehabilitation worker falls the task of dealing with remote or chronic effects of trauma In emotional, cognitive and personality areas.

With the universal coverage of workers' rights by Workers' Compensation Boards throughout this country and the growth of third party indemnification in civil accidents, these emotional and intellectual deficits cannot be neglected and require careful analysis and interpretation. What was rejected as evidences of "malingering" or "hysteria" in times gone by, now requires the attention of the neuropsychiatrist, psychiatrist and clinical psychologist. As insurance coverage has broadened, lawsuits for damages and disabilities, as well as awards for onthe-job injuries have demanded more meaningful opinions from mental specialists in courts of law.

As a result, the field of head injury with its sequelae and complications has extended to form what can be called Psychiatric Traumatology. This field was slow to develop during the past four or five decades. The law did not accept mental and emotional changes secondary to trauma as being compensatory. In fact, in a railway accident in 1888, an English judge stated that "normal persons do not suffer injury from fright" (Coultas j/ Victorian Railways), meaning any "nervous condition" resulting from an injury. This statement reflected the legal and public attitude until the 1930s. Dr. Walter Alvarez, a widely respected physician and publicist wrote in 1951 ". . . [traumatic neurosis cases] . . . develop from unwise suggestions by interns, doctors, nurses, physiotherapists, lawyers . . . land in whom] recovery usually occurs only after a remuneration has been satisfied." Our English colleagues have similar problems. Reginald Kelly, writing in the journal of the Royal Society of Medicine (April 1981) notes that "Textbooks [of neurology] dismiss Post-Traumatic Syndrome in five lines" and the celebrated text by Brain and Walton (1977 edition) "allots three sentences to the condition."

In the meantime, a more realistic and humane attitude has been evolving in our judicial system regarding the neuropsychologic aspects of trauma. In a 1937 Michigan case (Schneyder ? Cadillac Motors) an Appellate Court judge ruled that "mental disabilities arising out of an accident are compensable" and in 1960 the landmark case of Carter v General Motors approved an award for a worker who developed a disabling schizophrenia brought on by "the pressure" of a repetitive job on the assembly line. Although there was dissent by some judges because the worker had shown a predisposition toward mental illness previously, the general principle of social responsibility for mental consequences of industrial accidents was laid down. Similarly, our Social Disability Program considers mental illnesses and neurological defects, however incurred, worthy of compensation, or more accurately, of support.

The slow growth of forensic psychiatry and psychology in evaluating mental and physical disturbances following injury and presenting its conclusions in law courts had reasons other than judicial discomfort with what has been called "abstruse" concepts. Many physicians, including psychiatrists, are disinclined to appear in courts…

Injuries to the central nervous system, including the sensorium, have been a part of life since a caveman clubbed his colleague in a disagreement over the spoils of the hunt. Of course, the matter of compensation for injury - mental and physical - did not enter into that transaction, nor was the question of blame, ie, negligence for the injury a concern. However, in our society with its alarming and escalating number of industrial and personal injuries, questions of the acute and chronic effects of head and spinal injury are important. The primary physicians who see accident cases, emergency room physicians and neurosurgeons are concerned with the acute problems in their patients. To the neuropsychiatrist, psychiatrist, clinical psychologist and rehabilitation worker falls the task of dealing with remote or chronic effects of trauma In emotional, cognitive and personality areas.

With the universal coverage of workers' rights by Workers' Compensation Boards throughout this country and the growth of third party indemnification in civil accidents, these emotional and intellectual deficits cannot be neglected and require careful analysis and interpretation. What was rejected as evidences of "malingering" or "hysteria" in times gone by, now requires the attention of the neuropsychiatrist, psychiatrist and clinical psychologist. As insurance coverage has broadened, lawsuits for damages and disabilities, as well as awards for onthe-job injuries have demanded more meaningful opinions from mental specialists in courts of law.

As a result, the field of head injury with its sequelae and complications has extended to form what can be called Psychiatric Traumatology. This field was slow to develop during the past four or five decades. The law did not accept mental and emotional changes secondary to trauma as being compensatory. In fact, in a railway accident in 1888, an English judge stated that "normal persons do not suffer injury from fright" (Coultas j/ Victorian Railways), meaning any "nervous condition" resulting from an injury. This statement reflected the legal and public attitude until the 1930s. Dr. Walter Alvarez, a widely respected physician and publicist wrote in 1951 ". . . [traumatic neurosis cases] . . . develop from unwise suggestions by interns, doctors, nurses, physiotherapists, lawyers . . . land in whom] recovery usually occurs only after a remuneration has been satisfied." Our English colleagues have similar problems. Reginald Kelly, writing in the journal of the Royal Society of Medicine (April 1981) notes that "Textbooks [of neurology] dismiss Post-Traumatic Syndrome in five lines" and the celebrated text by Brain and Walton (1977 edition) "allots three sentences to the condition."

In the meantime, a more realistic and humane attitude has been evolving in our judicial system regarding the neuropsychologic aspects of trauma. In a 1937 Michigan case (Schneyder ? Cadillac Motors) an Appellate Court judge ruled that "mental disabilities arising out of an accident are compensable" and in 1960 the landmark case of Carter v General Motors approved an award for a worker who developed a disabling schizophrenia brought on by "the pressure" of a repetitive job on the assembly line. Although there was dissent by some judges because the worker had shown a predisposition toward mental illness previously, the general principle of social responsibility for mental consequences of industrial accidents was laid down. Similarly, our Social Disability Program considers mental illnesses and neurological defects, however incurred, worthy of compensation, or more accurately, of support.

The slow growth of forensic psychiatry and psychology in evaluating mental and physical disturbances following injury and presenting its conclusions in law courts had reasons other than judicial discomfort with what has been called "abstruse" concepts. Many physicians, including psychiatrists, are disinclined to appear in courts for fear of becoming enmeshed in legal technicalities: The inordinate time consumed in trials and crossexamination further belabor the expert. Indeed, many medical people regard the word "legal" as an impolite "five letter word." They shun the legal forum in disgust and anger. The development of the American Board of Forensic Psychiatry (1976), a certifying board, and the American Board of Forensic Psychology (1978) is aimed at removing the stigma that testifying in court evoked. The differing opinions of experts in criminal and civil cases, the public clamor for removal of such experts from the courtroom has been partly due to lack of inadequately trained specialists. For this reason, the Boards are striving to unify the fields involved by certifying competence of the candidates.

This issue contains a contribution by two eminent neurosurgeons, Dr. Robert B. Aird and Dr. Bill Garoutte of the University of California, San Francisco on the pathology of brain injury as reflected in behavior, cognitive functions, including memory, aphasia, etc. This article follows a discussion on psychiatric symptomatology by the undersigned, pointed toward its interpretation within the medico-legal context.

It is a curious twist in the neuropsychiatry of trauma that problems of "proximate cause" call for a detailed examination of the trauma patient with respect to predisposing emotional factors, prior neurotic reactions and accident proneness, stimulated by legal decisions as to negligence, awards, etc. In this regard recent work in neuropsychology has been helpful in delineating the exact degree of brain dysfunction (as close as can be obtained) in head injuries. Hence this issue includes articles by psychologists, Dr. Herbert Weissman of the University of California, Davis (currently the President of the American Board of Forensic Psychology) and Dr. Charles Golden, University of Nebraska, who has adapted the Luria-Nebraska test designed to elicit organic brain defects. Dr. Harvey Levin and Dr. Katherine Goethe of the University of Texas, Galveston have contributed a paper adding to the thrust of neuropsychological testing which supplies more precise data for court testimony.

Since clinical judgment and evaluation has become subject to public scrutiny via the courts and the legal process, the psychiatric-psychologicaleconomic-behavioral-social aspects of trauma cases require close examination. It is hoped this issue of Psychiatric Annals will stimulate interest in this increasingly common condition.

10.3928/0048-5713-19840701-06

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