Psychiatric Annals

Psychological Assessment and Psycho-Legal Formulations in Psychiatric Traumatology

Herbert N Weissman, PhD

Abstract

Personal injury includes the negative consequences of accidents (traumatic) or exposures (cumulative) which significantly compromise the injured party's physical, mental, or emotional well-being. Mental and emotional elements may be entered as causes of action in the tort liability system ?t under workers' compensation, and expert evaluation and testimony may be sought.

A wide range and sizable number of such injuries, occurring both with and without physical impact, have come to be represented in case law, being viewed as constituting potentially compensable causes of action. Addressed herein are concepts and methods of evaluating such conditions, and ascertaining whether and if so the extent of the impairments and defects are in fact "causally" related to the claimed injury or exposure. Emphasis will be on the role of clinical examination and psychodiagnostic assessment in circumstances of traumatic injury (impact and non-impact, functional and organic) with focus on psycho-legal considerations and formulations. Legal standards, which serve as criteria against which such conditions can be assessed, derive from lines of legal reasoning and from case law precedents; hence these will be delineated because knowledge of legal bases is essential to the examiner when serving as an expert in matters of legal relevance.

There are three broad classes of disorders which are evident. These include: 1) disorders that are physical, such as vehicular head trauma, spinal injury, toxic conditions; 2) disorders reflecting psychophysiological impairments, where emotional, physiological and somatic factors are involved; and 3) disorders that are said to be entirely functional in nature, with no somatic accompaniments. The first two classes of disorders, where physical and/or psychophysiological symptoms are present, have a long history of legal acceptance as compensable causes of action both in tort law and workers' compensation.

Prosser points out that it has long been settled that in an action for a personal injury the plaintiff may recover damages for physical pain and suffering and for mental suffering or disturbances resulting from it.1 It was not until the 1930s, however, that the third class of disorders, where there is emotional distress without accompanying physical injury, began to attain independent status. The courts had previously held that emotional pain and anguish were too vague for legal redress.2 Prosser contributed to principles of compensation for emotional distress (negligent or intentional) by elevating such factors to an established doctrine of tort law, asserting that mental suffering constituted as real an injury as physical pain.3 An increased interest in behavioral science understandings as well as growing appreciation of the presence and potentially serious effects of emotional distress led to increased efforts in the courts to seek redress against its infliction.

LEGAL STANDARDS

Opinions have historically diverged relative to society's proper response through the courts to causes of action in tort, relative to establishing civil liability and compensation for personal injury. The courts have sought, as they must, to balance social responsibility with the concerns of the individual. Resistance by the courts to unleashing a frighteningly limitless number and range of plaintiff actions has resulted over the years in arduous efforts to set boundaries. These efforts, in the form of legal decisions and rulings, have served to establish thresholds above which and parameters outside of which, certain claimed wrongs would not be considered legally cognizable.

A brief review of the history of such boundary setting rulings4 will serve to provide a context for the current state of affairs, which considers functional psychological factors (producing and resulting in emotional and mental disorders) as potentially constituting a complete claim, and thus deserving of compensation. A frequentiy cited precedential analysis of the view of emotional stress in the legal system is…

Personal injury includes the negative consequences of accidents (traumatic) or exposures (cumulative) which significantly compromise the injured party's physical, mental, or emotional well-being. Mental and emotional elements may be entered as causes of action in the tort liability system ?t under workers' compensation, and expert evaluation and testimony may be sought.

A wide range and sizable number of such injuries, occurring both with and without physical impact, have come to be represented in case law, being viewed as constituting potentially compensable causes of action. Addressed herein are concepts and methods of evaluating such conditions, and ascertaining whether and if so the extent of the impairments and defects are in fact "causally" related to the claimed injury or exposure. Emphasis will be on the role of clinical examination and psychodiagnostic assessment in circumstances of traumatic injury (impact and non-impact, functional and organic) with focus on psycho-legal considerations and formulations. Legal standards, which serve as criteria against which such conditions can be assessed, derive from lines of legal reasoning and from case law precedents; hence these will be delineated because knowledge of legal bases is essential to the examiner when serving as an expert in matters of legal relevance.

There are three broad classes of disorders which are evident. These include: 1) disorders that are physical, such as vehicular head trauma, spinal injury, toxic conditions; 2) disorders reflecting psychophysiological impairments, where emotional, physiological and somatic factors are involved; and 3) disorders that are said to be entirely functional in nature, with no somatic accompaniments. The first two classes of disorders, where physical and/or psychophysiological symptoms are present, have a long history of legal acceptance as compensable causes of action both in tort law and workers' compensation.

Prosser points out that it has long been settled that in an action for a personal injury the plaintiff may recover damages for physical pain and suffering and for mental suffering or disturbances resulting from it.1 It was not until the 1930s, however, that the third class of disorders, where there is emotional distress without accompanying physical injury, began to attain independent status. The courts had previously held that emotional pain and anguish were too vague for legal redress.2 Prosser contributed to principles of compensation for emotional distress (negligent or intentional) by elevating such factors to an established doctrine of tort law, asserting that mental suffering constituted as real an injury as physical pain.3 An increased interest in behavioral science understandings as well as growing appreciation of the presence and potentially serious effects of emotional distress led to increased efforts in the courts to seek redress against its infliction.

LEGAL STANDARDS

Opinions have historically diverged relative to society's proper response through the courts to causes of action in tort, relative to establishing civil liability and compensation for personal injury. The courts have sought, as they must, to balance social responsibility with the concerns of the individual. Resistance by the courts to unleashing a frighteningly limitless number and range of plaintiff actions has resulted over the years in arduous efforts to set boundaries. These efforts, in the form of legal decisions and rulings, have served to establish thresholds above which and parameters outside of which, certain claimed wrongs would not be considered legally cognizable.

A brief review of the history of such boundary setting rulings4 will serve to provide a context for the current state of affairs, which considers functional psychological factors (producing and resulting in emotional and mental disorders) as potentially constituting a complete claim, and thus deserving of compensation. A frequentiy cited precedential analysis of the view of emotional stress in the legal system is the decree of the English Court in Lynch ? Knight5 which states that "... Mental pain or anxiety the law cannot value, and does not pretend to redress, when the unlawful act complained of causes that alone." In Sloane ? Southern CaI. Ry. Co.,6 the court recognized that mental suffering "... constitutes an aggravation of damages when it naturally ensues from the act complained of," but that suffering alone would not support an action. The court ruled that "... if the primal cause of an injury is tortious, it is immaterial whether it is direct, as by a blow, or indirect through some action of the mind." While in Sloane there is recognition of emotional injury, recovery was only allowable for that portion of the complaint representing physical symptoms. Two frequently reiterated beliefs were thus set in motion, first that "recovery for emotional distress must be relegated to the status of parasitic damages," and second, that "mental disturbances can be distinctly classified as either psychological or physical injury."7 In Palsgraf ? Long Island R. R.,8 the notion of a "zone of risk" was first proposed, which sought to define the duty to the plaintiff. Two components were required for a plaintiff to recover, the first being that the plaintiff be within the zone of physical danger, the second that the defendant's negligence result in physical injury to some third person.

The next significant departure from Sloane occurred in 1952 in the case of State Rubbish etc. Assn. v Siliznoff,9 where the court held for the plaintiff in ruling on his mental suffering:

Cause of action is established when it is shown that one, in the absence of privilege, intentionally subjects another to mental suffering incident to serious threats to his physical well-being, whether or not threats are made under such circumstances as to constitute a technical assault.

Previously it had been held that only those mental traumas resulting in physical injury were actionable. Dillon ? Legg10 yielded wider changes, providing compensation for mental suffering to the plaintiff absent physical impact to the plaintiff, and absent physical zone of risk, but within an "emotional zone of risk." A mother had witnessed an automobile strike and kill one of her two daughters (from a physically safe distance) as they stood in a crosswalk. The court did utilize an element from Palsgraf pertaining to duty being imposed where physical injury is a foreseeable risk. The court retained an attachment to the clear manifestation of physical harm by stating that the Dillon recovery was allowable because of the plaintiffs "great emotional disturbance and shock and injury to the nervous system." A three-pronged test of foreseeability emerged:

1. Whether the plaintiff was located near the scene of the accident as contrasted with one who was a distance away from it.

2. Whether the shock resulted from a direct emotional impact upon plaintiff from the sensory and contemporaneous observance Of the accident, as contrasted with learning of the accident from others after its occurrence.

3. Whether plaintiff and the victim were closely related as contrasted with an absence of any relationship or presence of only a distant relationship.

In Rodriguez v State11 the court discarded the traditional rule that there can be no recovery for the negligent infliction of emotional distress alone. It recognized that "... the interest in freedom from negligent infliction of serious mental distress is entitled to independent legal protection."

In Johnson v State12 the court further held that "... recovery for emotional harm to one subjected directly to the tortious act may not be disallowed so long as the evidence is sufficient to show causation and substantiality of the harm suffered, together with a 'guarantee of genuineness'."

In Molien v Kaiser7 a landmark decision was made which fully recognized the concept of negligent infliction of emotional distress as an independent tort. In this action, a husband brought suit against a hospital and a doctor, alleging loss of consortium and emotional distress resulting from the defendant's negligence in incorrectly diagnosing and treating the plaintiffs wife for syphilis. Suspicion, tension and hostility followed which led to initiation of dissolution proceedings. The Court, in its opinion, sought to justify its move away from the physical impact and injury requirements, by asserting that these requirements had long been in place as screening devices to minimize a presumed risk of feigned injuries and false claims. The court in Molien held that "Such harm is believed to be susceptible of objective ascertainment and hence to corroborate the authenticity of the claim."

The California Supreme Court in Molien further opined that whether a plaintiff has suffered a serious and compensable injury is a matter of proof to be presented to the trier of fact, and that the distinction between physical injury and emotional distress was no longer defensible. In so holding, it drew upon reasoning of the Massachusetts Supreme Court,'3 In Agis, the court recognized a cause of action for loss of consortium arising out of severe emotional distress intentionally inflicted on the plaintiffs spouse "... the underlying purpose of such an action is to compensate for the loss of companionship, affection and sexual enjoyment of one's spouse, and it is clear that these can be lost as a result of psychological or emotional injury as well as from actual physical harm."

In Molien then, previously adopted safeguards against spurious claims for negligently inflicted emotional distress were abandoned. New legal standards were adopted to limit recoveries under the new, independent tort. The standards permit recovery". . . where proof of mental distress is of a medically significant nature," or the claim of mental distress is supported by ". . . some guarantee of genuineness in the circumstances of the case." In applying these standards, jurors were viewed as "... best situated to determine whether and to what extent the defendant's conduct caused emotional distress." However, jurors were viewed as far less capable of determining the traumatic effects that are consequences of "outrageous conduct." Expert testimony is often needed to assist the court in assessing traumatic effects and making determinations concerning them.

The expansion and liberalization has thus resulted in affirming the role of mental and emotional factors as independent and potentially compensable causes of action. The probative standard to be met in this area of civil law is preponderance of evidence. To meet this burden of proof, the plaintiff must demonstrate that it is more likely than not that the traumatic effects being claimed were proximately caused by legally relevant incidents.' Not just any incidents or determinants are relevant, but rather only those that are proximately related. Thus, co-existing and pre-existing factors, secondary gain motivations, as well as factors associated with malingering and with factitious disorders must be parcelled out or ruled out, in the examiner's ascertainment of substantiality of the traumatic effects of a claimed injury.

External (legal) constraints (ie, rules requiring physical injury, direct impact and so on) having been removed, it becomes incumbent upon the behavioral sciences to utilize disciplined internal (professionally self-imposed) standards, with wellformulated conceptual distinctions to fulfill the requirements of these newly expanded definitional boundaries. Criterial attributes attached to respective diagnostic categories in DSM-Hl·4 provide a reliably organized and conceptually based set of (psychological) standards against which clinical findings may be compared for the purpose of ascertaining substantiality of the claimed traumatic effects. Distinctions between organic and functional disorders and their reciprocal interactive effects can be formulated in ways congruent with concepts associated with organic brain syndromes, somatoform conditions, and psychophysiological reactions. Similarly, state-level (eg, circumstantial and reactive) from trait-level (eg, enduring and pervasive) disorders can be distinguished using multiaxial formulations, as can physical disorders and conditions, severity of psychosocial stressors, and levels of adaptive functioning.

Multiaxial considerations are central to efforts seeking to distinguish proximate factors from those which are co-existing and pre-existing. Compensation for damages is bifurcated into special and general damages. The former pertain to wage loss and direct costs to health-care providers for treatment of injuries generated by the accident. General damages are nonpecuniary and compensate for what is commonly referred to as pain and suffering, resulting from the injury.

THE ROLE OF PSYCHOLOGY: SUBSTANTIVE CONSIDERATIONS

The following issues derive from the foregoing, and are pivotal concerns of the examiner whose role it is to clarify the contribution of proximate and other factors, along with motivational factors in the causal nexus of impairment. This is accomplished through comprehensive and detailed clinical interviewing, review of records, and psychological assessment. These concerns include identification of:

* The extent to which the accident or exposure constituted a "substantial factor" in causing a new disorder, or in aggravating or accelerating a preexisting disorder.

* Whether a disorder would have occurred at all "but for" the instant event(s), traumatic or cumulative.

* The relative contributions to the presented disorder of proximate, pre-existing, and co-existing factors.

* The extent to which a pre-existing disorder in its natural progression or evolutionary course would have resulted in the observed impairments, in the absence of the instant event.

* Whether motivational factors associated with malingering are present, where plaintiff voluntarily produces and presents false or grossly exaggerated physical or psychological symptoms to obtain financial compensation.

* Whether a factitious disorder is present, where psychological symptoms are being voluntarily produced and presented (as in malingering), but where the goal is to assume the "patient" role.

* Whether presented complaints constitute a convenient focus, psychologically enabling the claimant to abdicate stage-appropriate responsibilities, which had perhaps long been viewed as onerous, through convenient albeit unconscious displacement of anxieties, affects, and ungratified need states onto physical and/or psychological symptoms.

The dynamics of secondary gain are operative in the latter three categories, which range on a continuum from being governed by mostly conscious to mostly unconscious motivations. Somatoform disorders (DSM-IH) reflect the more deeply submerged unconscious motivations.

PROXIMATE VS. OTHER CAUSES

Assessment of proximate cause requires detailed inquiry into a complex array of determinants. The areas to be explored and investigated obviously depend on the nature of the particular ease, but the process of analysis remains the same. Whenever mental and emotional factors are claimed as legally relevant in an action, the origins (ie, the product, the ambient environment, or other physically or psychologically traumatic events) notwithstanding, a comparison of pre/post conditions must be undertaken. The goal is to determine whether similar mental and emotional states and traits present post-accident/injury had been present prior to the injury, but which are being attributed to the injury. Understanding the role of pre-existing factors requires comprehensive clinical examination as well as psyehodiagnostic assessment with empirically based and appropriately standardized measurement instruments. Of critical importance in this analytic assessment process is to acquire a full understanding, from the vantage point of the plaintiff, his/her understanding of the instant event, the circumstances surrounding it, his/her perception of the legal relevance of it, in terms of the claimed injury for which compensation for damages is being sought, a description of the injury in the form of subjective complaints, and a statement reflecting the plaintiffs view of his/her medical and/or psychological symptoms as acquired from health service providers and attorneys. Of equal importance is an understanding of longerstanding, enduring patterns of functioning, acquired through the vehicle of bio-historical interviewing. Developmental, early childhood, psychosocial, interpersonal, educational, marital, vocational, medical and psychological themes are traced therein. Apart from plaintiff's own version and retrospective reconstruction, information derived from independent sources is essential. Independent sources include all medical records (pre- and post-), vocational performance evaluations, educational and psychological records, and other casespecific pertinent documents. Additionally, independent sources include persons known to the plaintiff prior to the instant event. This is particularly important where children are involved; teacher observation and school records may be the single most important category of information concerning pre-incident functioning.

Where subjective complaints exceed objective findings (medical and/or psychological), a common occurrence once circumstances have become litigious, the psychological examiner must address this discrepancy. The goal becomes One of analyzing and articulating the dimensions of this purported discrepancy in the interest of rendering objective and understandable what has hitherto been defined as subjective and confusing. Further, it is to assess the degree of veracity of the complaints along with the motivations that prompted them and the purposes that they have come to serve. Data derived from appropriately administered, psychometrically sound general and specialized psychodiagnostic assessment instruments constitute objective findings. Detailed clinical and bio-historical interviewing yields the qualitative information that is highly useful relative to identifying conscious and unconscious motivational factors that may be promoting and exaggerating the identified discrepancy. Appropriate utilization of findings disentangle inconsistencies by factoring out what is objectively and proximately related, and separating these influences from other sources. Its goal is to define whether and if so the extent to which functional and/or organic factors are present in the form of dysfunctions and defects, and the extent to which they are proximately related to the cause of action.

COEXISTING FACTORS

In addition to the potentially determinate role of pre-existing factors is the role of co-existing factors. These pertain to circumstantial features in an individual's life (ie, stressful events) which serve to promote, maintain and protract the mental and emotional condition being claimed. Either preexisting or co-existing factors may severally or in combination account for the claimed disorder. These pertain to various aspects of the individual's current life circumstances, including quality of personal relationships with significant others and psychosocial stress factors generally. A significant number of stressful events, such as death of a relative, financial loss, marital dysfunction, and crises with children often serve to cause and/or aggravate, and thus maintain and protract, clinical complaints and disorders quite apart from proximate factors of the instant event.4

PSYCHODIAGNOSTIC ASSESSMENT

In planning one's assessment strategy, a set of clinical procedures is identified whose aim it is to yield information that will accurately and representatively portray the individual being examined, and in so doing address the clearly articulated referral questions in ways which bring data to bear upon the psycho-legal issues. In matters of personal injury litigation, the primary question to be ultimately answered is whether the accident or exposure (traumatic or cumulative) was causally (proximately) related to the plaintiffs claimed psychological impairments and disorders. If present, specificity regarding the nature and the extent of the impairments is required with sound documentation of their effects on emotional, cognitive, and behavioral functioning. Questions that require equal attention concern whether co-existing and pre-existing factors may have been responsible, wholly or in part, in relationship to the claimant's condition, such as malingering, secondary gain, and predisposing functional and/or organic disorders, which would have in their course or natural progression resulted in the condition now present in the plaintiff, independent of, (or in the absence of) the causes of action that are being alleged.

TEST BATTERIES

In response to clearly articulated referral questions, the selective utilization of psychological testing procedures yields findings which serve to further the understanding of the patient/client in the interest of making informed decisions. They can be useful in providing baseline information, in evaluating the patient's status after treatment, in differential diagnosis, in planning and guiding therapeutic and rehabilitative interventions, and in rendering contingent predictions regarding future behavior. The value of psychological tests lies in their permitting focused observation and under standard conditions in ways that reduce subjective bias, so that different individuals can be compared in more quantitative ways along relevant dimensions of psychological functioning.15 Diagnostic assessment of children's play serves a similar purpose. Baseline data are particularly useful with persons whose conditions are viewed at the time of the evaluation as temporary. Repeat assessment (including psychological testing) in protracted situations, provides data which can then be relatively objectively compared to hitherto established baselines, along relevant dimensions in a given case. Efforts to determine current status are benefited by assessing changes that may have occurred as a consequence of medical and psychological interventions and as a result of restorative and rehabilitative services generally. Assessment (testing) data rests on case specific determinations and may include findings derived from measures of personality, intelligence, memory, and cognition generally. It may also include findings from neuropsychological batteries, vocational interest and aptitude batteries, and from self-report inventories of varying descriptions. All psychodiagnostic measures have as a primary goal the understanding and prediction of meaningful nontest behavior.

Diagnostic, prognostic, dispositional, and treatment considerations are addressed in all comprehensive evaluations. In some cases, actuarial predictions will be called for relative to establishing damages, to determine long-term occupational limitations and preclusions as well as future financial restrictions and losses resulting, for instance, from traumatic amputation of a limb in a 16-year-old female adolescent due to a motorboat accident, loss of vision of an 11-year-old male child due to a vehicular injury, organic and cerebral impairment resulting from a fall in a 21 -year-old male laborer, emotional distress allegedly due to harassment in a 43-year-old female schoolteacher. In such cases, a full-range vocational evaluation, where vocational interests, values, intelligence, aptitudes, as well as personality and neuropsychological factors must be considered in the larger context of occupations, job market considerations, and restricted entry potential, due to handicaps and/or social stigma. Prognostic, dispositional, and treatment considerations pertain also to establishing damages and protecting the injured party's welfare. Through accurate appraisal of strengths and limitations and apprising the relevant parties of therapeutic, rehabilitative, special educational and other continuing needs, a more fair and equitable settlement or verdict will likely follow.

Clinical procedures of proven psychometric value, such as the Minnesota Multiphasic Personality Inventory16 are likely to promote understanding in the area of personality functioning. Validity scales detect dissimulation, prevarication, and whether the person is responding to items in a defensively overly self-favorable way in the interest of minimizing psychological problems, or in an overly unfavorable way for the purpose of exaggerating psychological impairments. Configurai interpretation of clinical scales reflects psychological disorders and is relevant in analysis of somatic focus and psychophysiologic involvement. Another well-referenced, self-administered, objective measure of personality functioning is the Millón Clinical Multiaxial Inventory17 whose 20 scales organize into four categories relating to basic personality styles, pathological personality syndromes, and symptom disorders. More transient clinical disorders (Axis 1, DSM-UI) are specifically differentiated by this inventory from the more pervasive and enduring personality disorders and character patterns (Axis II, DSM-III). This and other psychodiagnostic measures assist the clinician in separating state-(reactive and circumstantial) from trait-(chronic and pervasive) level disorders.

A relatively new, but well-standardized and documented personality inventory for assessing children, is the Personality Inventory for Children.'8 It is an empirically and rationally constructed instrument of 600 items in a True-False format, to be answered by a respondent who is significant in the child's life. The Inventory provides comprehensive and clinically relevant personality description of individuals ranging from six to sixteen years of age, based on responses concerning a child's behavior, attitudes and family relationships.

Of the projective and semi-projective personality measures, the Rorschach Psychodiagnostic19 and the Thematic Apperception Test20 are among the most highly recognized and utilized. Both are significant and valuable in providing the clinician with findings whose interpretation clarifies structural and dynamic dimensions of personality functioning, and which assist in the detection of disorders of thought and perception. How individuals perceive, cope or fail to cope with stressful events, and the impact of stress on mental and emotional functioning is clarified. The comprehensive system of Rorschach interpretation, developed by Exner21 has played a major role in advancing the value of the Rorschach procedure through providing empirically based standardized data on both adult and child populations. A full complement of projective measures is available for assessing children, many of which are well-standardized, highly regarded, and available to the clinical psychologist.

The Wechsler series of intelligence scales are of primary importance in any assessment battery. They sample a broad range of intellectual functions in children22 and adults23 and yield reliable and valid estimates of general intelligence. The interpretive significance of qualitative features of test responses exceeds what is learned from quantitative scores. The behavior of the patient in testing, characteristics of test responses, and indications of stylistic and pathology-based impediments to functioning all enter prominently, and correspond with nontest behaviors in everyday life situations.15 In assessing characteristic and unique patterns of ego processes, the examiner acquires understanding of how an individual integrates and adapts to reality demands.24 The particular ways in which affective reactions to stressful events compromise and otherwise intrude negatively upon cognitive functioning thereby may be clarified.

A variety of clinical instruments exists which provide a useful screening function relative to neuropsychological dysfunction in adults and children. In addition, there are formalized and comprehensive procedures in this domain. These most notably include the Halstead-Reitan25 and LuriaNebraska.26,27 Neuropsychological Batteries are highly sensitive measures utilized to detect the presence and localization of impairments in brainbehavior relationships. Neuropsychological assessment is indicated in cases where impairments are associated with, or are a consequence of brain trauma and/or when a history of cerebral dysfunction is present. Assessment measures which are sensitive to impairments in brain-behavior relationships facilitate understanding of the potential impact of such deficits on an individual's personal and vocational life and assist in the formulation of appropriate rehabilitation plans.

Vocational patterns are frequently assessed by such instruments as the Strong-Campbell Interest28 and the Career Assessment Inventory29 in combination with evaluation of intellectual and aptitude factors. Interviews, directed at previous occupational activity and performance, along with self-report measures, such as the Forer Structured Sentence Completion Test,3U provide information which may then be applied in retraining the injured worker toward gainful reemployment, consistent with capacities, limitations, and preclusions.

Specialized self-administered instruments for assessing the relative contribution of functional and somatic factors in chronic pain and pain tolerance include the Wahler Physical Symptoms Inventory,51 the Millón Behavioral Health Inventory,32 and the Minnesota Multiphasic Personality Inventory. The Millón provides data on "Basic Coping Styles," "Psychogenic Attitudes," and "Psychosomatic Correlates." Assessment devices, sensitive to the involvement of functional factors in the production, promotion, and protraction of somatic factors and of chronic pain complaints, assist the examiner in distinguishing subjective complaints from objective medical and psychological findings. They also provide useful information of a predictive nature, relative to whether a patient is likely to benefit from surgical and other medical interventions, or conversely to seek repeated medical contacts and interventions and to demonstrate a protracted pattern of pain and fear in the context of multiple regressions and retarded recovery.

Regarding measurement of the coronary-prone (Type A) behavior pattern,33 the principal instrument currently utilized is the self-administered Jenkins Activity Survey.34 The Type A pattern has been formally acknowledged as a risk factor in developing coronary heart disease, therein further acknowledging the contributing role of psychosocial stress factors in symptom formation and disorder.35 Pattern A refers to a set of overt behaviors that occur in susceptible individuals given appropriately eliciting conditions. It is an action-emotion complex, characterized by competitive, ambitious, achievement-striving, time-urgent, and hostile behaviors.33

An approach toward assessing level of psychosocial stressors as contributing factors in the formation of medical and psychological impairments is reflected in the life change index method, codified by Holmes and Rahe in their self-administered Social Readjustment Rating Scale.36 A significant research literature substantiates the value of this approach in assessing vulnerability to symptom formation as a consequence of stress factors.37-41 Identifying the role of psychosocial stressors serves additionally to fulfill DSM-HVs multiaxial diagnostic requirements relative to coding the overall "Severity of Psychosocial Stressors" (Axis IV) and "Highest Level of Adaptive Functioning Past Year" (Axis V). Evaluation of these factors provides information as to the degree to which various kinds of stressful events in a person's life have contributed to the development or exacerbation of the current disorder. This information additionally is significant to prognostic and dispositional considerations.

In sum, it is the pain and suffering component of the tort liability system and workers' compensation programs to which psychological expertise is directed, and where its most significant contribution can be made. As described, there are many difficulties attendant upon defining what is meant by pain and suffering, distinguishing what is real from what is artifactual or factitious in such claims, and assisting the trier of fact in establishing just compensation for injuries proximately related to traumatic events. Systematic psychological study yields approaches toward the resolution of these difficulties through providing the trier of fact with sound concepts and with well-documented data.

Conceptually integrated and empirically grounded formulations, thus derived, provide the basis for testimony. Once qualified through the voir dire process, the expert witness on direct examination responds to detailed questions regarding the formative and procedural aspects of his/her role and the substantive findings, formulations, and opinions that have resulted from the case study. Cross-examination provides the occasion for searching and challenging inquiry by opposing counsel. The expert's obligation is to present material objectively and accurately, consistent with the bounds of knowledge in the given area, and to share fully with the trier of fact all that has been relied upon in the derivation of opinions, including the reasoning process upon which opinions are founded.

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10.3928/0048-5713-19840701-09

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