the assessment of post-traumatic stress disorder for workers' compensation in emergency service...

ORIGINAL ARTICLE

The Assessment of Post-traumatic Stress Disorder for Workers’Compensation in Emergency Service PersonnelDelphine Bostock Matusko,1 Richard I Kemp,1 Helen M Paterson,2 and Richard A Bryant1

1School of Psychology, University of New South Wales and 2School of Psychology, University of Sydney

There is considerable debate concerning the diagnosis of post-traumatic stress disorder (PTSD) in compensation claims. This study reviewed thequality of the assessment reports prepared by clinicians who evaluated 31 emergency service workers making PTSD-related compensationclaims. Assessments were conducted by 4-year trained psychologists (39%), psychologists holding a masters degree (36%), and psychiatrists(19%). The assessment reports were evaluated relative to the diagnostic criteria for PTSD in the Diagnostic and Statistical Manual of MentalDisorders 4th edition (2000). In the majority of cases (81%), the assessor determined that the emergency service worker had PTSD, but only onereport met the minimum standard for that diagnosis. In the majority (65%) of cases the clinician failed to address the possibility of malingering.These data suggest that clinical assessment reports for PTSD frequently fail to meet minimum assessment standards.

Key words: assessment; compensation; emergency service; psychological assessment; PTSD; trauma

What is already known on this topic

1 The diagnosis of PTSD can be problematic because of the sub-jective nature of many of the symptoms.

2 Emergency personnel, such as firefighters, police officers, andparamedics, are at increased risk of developing PTSD.

3 Given the health risks and costs associated with PTSD, it isessential that assessment and reporting procedures are bothvalid and reliable.

What this article adds1 The researchers were given a rare opportunity to review the

assessment reports prepared by clinicians who evaluated emer-gency service workers making PTSD-related compensation claims.

2 Only one of the assessment reports met the minimum standardfor the diagnosis of PTSD, but despite this in most cases theassessor determined the emergency service worker had PTSD.

3 The reports suggest that most of the clinicians failed toadequately assess for malingering.

Research indicates that as many as half of the population haveexperienced a significant traumatic event in their lifetime (Kessler,Sonnega, Bromet, Hughes, & Nelson, 1995). Although post-traumatic stress disorder (PTSD) is not the only type of psycho-logical injury that can result from such trauma, it is the mostcommonly diagnosed (Green & Kaltman, 2003). The diagnosis ofPTSD is complicated by the fact that some of the symptoms arealso found in other mental disorders; for example, recurrent intru-sive thoughts, sleep disturbance, avoidance, and withdrawal arefrequently observed across a range of mood and anxiety disorders(Brewin, 1998; Day, Holmes, & Hackmann, 2004; Hackmann,Clark, & McManus, 2000; Kessler, Chiu, Demler, & Walters,2005). However, unlike most other disorders, listed in the Diag-nostic and Statistical Manual of Mental Disorders 4th edition (DSM-IV-TR; American Psychiatric Association, 2000), PTSD is defined by aprecipitating stressor. This causal relationship between the identi-

fied trauma and the resulting disorder may have contributed toPTSD being the favoured diagnosis in the medico-legal arena, andclaims for psychological injury following trauma have increasedsubstantially in recent years (Neal, 1994).

Using the DSM-IV-TR (2000) criteria, estimates of the preva-lence of PTSD in the general community range from 1% to 14%(DSM-IV-TR, 2000). About one quarter of people who experi-ence a traumatic event will go on to develop PTSD (Green &Kaltman, 2003), with the probability of developing PTSD beinginfluenced by the severity, duration, and proximity of exposureto the stressor (Brewin, Andrews, & Valentine, 2000). Further-more, the subjective emotional experience of trauma as out-lined in criterion A2 (fear, helplessness, and horror) alsoinfluences the likelihood of developing PTSD (Bedard-Gilligan& Zoellner, 2008). Evidence is also increasing to suggest thatprior exposure to traumatic experiences increases the risk ofdeveloping PTSD on subsequent exposure (Green, 1994);however, emerging evidence interprets this not as a conse-quence of a sensitisation process, but rather a susceptibilitybased on the previous development of PTSD in response to atraumatic experience (Breslau, Peterson, & Schultz, 2008).

Given the growing evidence that exposure to multiple trau-matic experiences is related to both the likelihood of developing

Correspondence: Richard I Kemp, School of Psychology, University ofNew South Wales, Sydney, NSW 2052, Australia. Fax: +61 29385 3641;email: [email protected]

Accepted for publication 18 December 2012

doi:10.1111/ap.12009

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Australian Psychologist 48 (2013) 420–427© 2013 The Australian Psychological Society

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PTSD and the severity of trauma symptoms (e.g., Green, 1994;Scott, 2007), it is no surprise that emergency personnel, such asfirefighters, police officers, and paramedics are at increased riskof developing PTSD (e.g., Carlier, Lamberts, & Gersons, 1997;Carlier, Lamberts, Fouwel, & Gersons, 1996; McFarlane, 1989;Wagner, Heinrichs, & Ehlert, 1998). For example, rates of PTSDin serving police officers have been noted between 9% and 26%(Martin, McKean, & Veltkamp, 1986; Robinson, Sigman, &Wilson, 1997).

Employers have a duty of care to their employees, and inAustralia and many other countries employers are required tobe adequately insured to cover claims for compensation madeby employees who are injured in the course of their work. Thereis some evidence that the numbers of claims for psychologicalinjury, including PTSD, among emergency service workers hasrisen in recent years. For example, a 2008 report by the NewSouth Wales Auditor General into the management of injury inNSW Police found that claims for psychological injuries wereincreasing and were rated as the third most common cause ofinjury (The Audit Office of New South Wales, 2008).

The Diagnosis of PTSD

Given the substantial health risks and costs associated withPTSD, it is essential that the psychological assessment of theimpact of trauma is both valid and reliable. The forensic assess-ment of PTSD must establish the existence or absence of PTSD,describe the temporal/functional relationship of PTSD to thetraumatic stressor, advise as to the likelihood of remission with/without treatment, and establish the extent of functional dis-ability associated with the PTSD (Koch, O’Neill, & Douglas,2005). Several factors obscure the psychological assessment ofPTSD. Some of these relate to the inherent features of PTSD. Forexample, avoidance may hinder help seeking as the person fearsa worsening of symptoms by talking about the traumatic event(Simon, 2003). The diagnosis of PTSD in a forensic contextraises particular concerns primarily because the symptoms ofPTSD are largely subjective and being incident specific, create apresumption of cause. One of the most common errors made byclinicians assessing PTSD is assuming that it is the only or mostprobable consequence of trauma exposure (Keane, Buckley, &Miller, 2003). This is problematic because it should not beassumed that a qualifying stressor will necessarily cause PTSD(Simon, 2003). Not all people who experience a traumatic eventwill develop PTSD (Green & Kaltman, 2003). The lack of objec-tive clinical signs and symptoms for PTSD has led to an overre-liance on the self-report of subjective symptoms with little or noobjective measurement or verification (Bryant, 2003).

Exposure to stress or trauma is generally presumed to increasethe risk of physical and mental pathology. Therefore, assessmentof PTSD may be hindered by comorbid conditions. PTSD is rarelyfound alone, with as many as 88% of men and 79% of womenwith PTSD meeting criteria for another DSM disorder (Kessleret al., 1995). Comorbid diagnoses include substance abuse ordependence and major depression (Kessler et al., 1995). The moti-vational factors associated with compensation rewards also raisethe possibility of malingering PTSD symptoms. The DSM makes aspecial note that malingering “should be ruled out in those situ-ations in which financial remuneration, benefit eligibility, and

forensic determinations play a role” (2000, p. 427). The growingawareness of PTSD symptoms among the general populationunderpins suspicion that PTSD may be falsely claimed for somesecondary gain (Regehr, Goldberg, Glancy, & Knott, 2002). Kochet al. (2005) question whether forensic health professionals arereliably diagnosing PTSD. Although there are a range of reliableand valid diagnostic measures for the assessment of PTSD (e.g., theClinician-Administered PTSD Scale; Blake et al., 1998), these toolscommonly fail to screen for compensation seeking or factors asso-ciated with litigation (Koch et al., 2005). Furthermore, a study oftest utilisation by personal injury assessors indicated that none ofthe most reliable and valid PTSD assessment tools were being usedin that context (Boccaccini & Brodsky, 1999).

In their review of common problems in the forensic assess-ment of PTSD, Keane et al. (2003) identified exclusive relianceon the claimant as the sole source of information and failure toconsult external corroborative sources of information as a majorproblem. External sources of information might include verifi-cation of the trauma, examination of work records, perform-ance evaluations, and information relating to the deteriorationof general social or other important areas of functioning. Ideally,multiple methods of gathering information (e.g., psychometrictesting, using structured interviews, and possibly psychophysi-ological assessment) should be used (Keane et al., 2003). Keaneet al. also commonly noted a failure to apply the specific diag-nostic criteria of PTSD to the claimant, or to provide examples ofhow the claimant meets a particular symptom criterion. DSM-IVis the most reliable diagnostic tool for PTSD (Simon, 2003), andadherence to the DSM-IV criteria is a crucial foundation of acredible forensic diagnosis of PTSD.

However, it has been suggested that, because lists of the majorsymptoms of PTSD are publicly available, the assessing clinicianshould insist on detailed illustrations of PTSD symptoms(Resnick, 2003) and use open-ended questions that do not cuedesired responses (Bryant, 2003). It has also been noted that theclinician assessing PTSD may find it difficult to remain objectivein the face of apparent distress; personal accounts of traumaticexperiences may be highly emotive for the attentive clinician,and feelings of sympathy may threaten impartiality (Keaneet al., 2003). It has also been suggested that when trauma expo-sure may be a result of negligence or wrongdoing, the clinicianmay be tempted to fill a role of advocacy rather than scientificobjectivity (Keane et al., 2003). The clinician may also be politi-cally motivated to endorse a diagnosis of PTSD; for example, inthe case of war veterans (Resnick, 2003).

The Current Study

Given the clinical need for accurate diagnosis for members ofat-risk populations and also the substantial costs paid to PTSDclaimants by employers, it is essential to assess the quality of thepsychological assessments of claimants undertaken by psycholo-gists and medical practitioners. Despite the common concerns thatexist about the quality of PTSD assessments in forensic settings,there is a dearth of evidence regarding the standard that is met innaturalistic settings. This study explores the extent to which psy-chological assessment reports used for the determination ofworkers compensation on the basis of PTSD in emergency serviceworkers address issues of diagnostic and forensic importance.

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Method

Participants

Claimants were 31 employees of a particular Australian emer-gency service organisation, whose records were consecutivelyretrieved from the insurers’ records from a pool of recordswhere a claim for PTSD had been lodged since July 2005 untilJune 2009. Each of these employees had been assessed by aclinician (psychologist or psychiatrist) in order to screen forpossible PTSD as part of their assessment for workers’ compen-sation, and the researchers were given access to these assess-ment reports.

Claimants’ ages at the time of assessment ranged from 34 to60 years (M = 49.03, standard deviation [SD] = 6.47), and all butone were male. At the time of assessment, 77% were married orin de facto relationships and 13% were divorced. The averagelength of employment with the emergency service at the time ofassessment was 25 years (SD = 9.50), with a range from 4 to 40years of service.

With regard to the qualifications of the assessor, 39% were4-year qualified psychologists, 36% held a master’s degree inpsychology, 19% were psychiatrists, and 6% were generalpractitioners.

Procedure

After receiving ethics approval and support from the employerand employee union, the files were accessed at the offices ofthe insurer. Identifying information such as claimant namewas not recorded. The assessment report within each file wasreviewed and evaluated relative to a predetermined set ofassessment criteria derived from the DSM-IV-TR (2000) diag-nostic criteria for PTSD, including the symptom clusters A–F.For each symptom, the assessor’s report was evaluated todetermine whether the symptom was (a) assessed (i.e., did theassessor make note of asking the claimant whether or not theyhad experienced the particular symptom); (b) justified (i.e.,did the assessment report include examples provided by theclaimant demonstrating how the particular symptom mani-fested); and (c) endorsed (i.e., did the assessor’s report indi-cate that the claimant stated that they experienced the par-ticular symptom). Other data extracted and coded includedwhether or not malingering had been assessed and if so how;whether the claimant was currently receiving treatment; if theassessor had recommended treatment; and stressor andtrauma type.

Results

Type of Trauma

In the majority of cases (84%), the claimant cited a traumaticevent as the stressor, with many claimants citing more than onetraumatic incident. The remaining 16% cited organisationalstressors (e.g., conflict at work) to be the source of their PTSD.The categories employed for the A1 stressor for this study werederived from the Clinician-Administered PTSD Scale (Blakeet al., 1998), which classifies the traumatic stressor into one of17 categories including organisational stressors. “Conflict at

work,” “bullying,” and “harassment” were considered organisa-tional stressors, and the file review indicated that the incidentsinvolved systematic and targeted abusive behaviour that per-sisted at high threshold levels both inside and outside of theworkplace. In these cases the claimants experienced events thatthreatened death or serious injury and threat to physical integ-rity of self.

The most commonly reported type of traumatic event was atransportation accident (40%; including car, train, and motor-cycle), and this included the emergency service worker eitherbeing directly involved in an accident, or attending the after-math. Other traumatic stressors included fire or explosion(23%), natural disaster (3%), serious accident (6%), life-threatening illness or injury (3%), severe human suffering(6%), and sudden violent death (3%). A further 16% of caseswere coded as “any other very stressful event or experience,”which included cases coded as organisational stress. On average,the time lag between the cited date of trauma and date ofassessment was 7.3 years (SD = 8.60).

Overall Assessment of Symptoms

In the majority of cases (81%), the assessor concluded that theemergency service worker had PTSD. The assessor did not diag-nose PTSD in 16% of cases and in one case did not make adecision regarding the diagnosis of PTSD.

Criterion A1 (precipitating stressor) was assessed in 100% ofcases because all emergency service workers discussed with theclinician the traumatic experience that had brought them to aclaim for workers’ compensation. Trauma symptoms werelinked to a specific event (not just a general history of traumaticexperiences) in 81% of cases (n = 25). It was less common forthe assessor to establish a temporal link between stressor andsymptoms (i.e., to make note that the symptom had begun afterthe index trauma), with this being established for 55% of thecases (n = 17).

The extent to which each symptom of PTSD was investigatedby the assessors is presented in Table 1. For each symptom thereare three criteria detailing whether the symptom was assessed(i.e., did the assessor ask the claimant about a particularsymptom), justified (i.e., was a specific example of how a par-ticular symptom manifests provided by the claimant), andendorsed (i.e., did the claimant subsequently endorse thesymptom in question). Table 1 shows considerable variation inthe percentage of reports which showed evidence of the assess-ment, justification, and endorsement of each symptom listed inthe DSM-IV-TR (2000) criteria. For example, while symptom E(duration of disturbance) was assessed, justified, and endorsedby 93% of assessors, none (0%) fully investigated symptom C7(sense of foreshortened future).

The DSM-IV-TR (2000) lists a total of 21 symptoms of PTSD,but not all of these must be present to qualify for diagnosis.Although all symptoms must be present for criteria A, E, and F,only one of the five symptoms need be present to satisfy crite-rion B, only three of the seven symptoms need be observed forcriterion D, and there must be at least two of the five symptomspresent for criterion D. Thus, in the case of criteria B, C, and D,it is possible that assessors chose not to assess some symptoms ifthe claimant had already met the minimum diagnostic standard

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for that criterion. To clarify whether this explanation accountedfor the low frequency of assessment of some symptoms, wedetermined the number of reports which met at least theminimum diagnostic threshold for each criterion (see Table 2).Results indicated that for criterion B, 70% of assessors askedabout, sought examples of, and subsequently endorsed at leastone of the five symptoms necessary for diagnosis, therebymeeting the minimum standard. For criterion C, only 10% ofassessors fully investigated whether the claimant experiencedthe minimum of three of the seven symptoms. In the case ofcriterion D, only 26% of assessors fully investigated at least

two of the five symptoms. Only one assessor (6%) met theminimum diagnostic standard for all six criteria.

Effects of Assessor Qualification onAssessment Reports

The number of symptoms assessed, justified, and endorsed by4-year trained psychologists, psychologists with master’sdegrees, and psychiatrists are shown in Table 3. Given thatpsychologists holding a master’s degree receive specialised train-ing in assessment, it might be expected that this group would bemore comprehensive in their assessment of PTSD symptomatol-ogy. To test this hypothesis, we compared the number of symp-toms evaluated (irrespective of whether the claimant hadexperienced the symptom) by these three groups of profession-als using a one-way between-groups analysis of variance. Therewere no significant differences found between the groups onnumber of symptoms assessed, the number justified, thenumber endorsed, and total number of symptoms that wereassessed, justified, and endorsed (all p-values > .05). These non-significant differences may be attributable to low power due tosmall sample size. Means and standard deviations for the threegroups of professionals are shown in Table 3.

We also investigated whether the assessor’s qualification wasassociated with likelihood that they would decline a diagnosis ofPTSD. There was no significant association between professionalqualification (psychologist/MPsych/psychiatrist) and whetheror not diagnosis was confirmed (PTSD/Not PTSD) (c2[2,N = 30] = 0.19, ns). Results indicated that overall, 80% of theassessors diagnosed PTSD. While the psychiatrists endorsed adiagnosis of PTSD in all (100%) of the cases they saw, 80% of

Table 1 Percentage (of the Total of 31) of Reports Which Showed Evidence of Symptom Assessment, Symptom Justification, and Symptom Endorsement, and

the Percentage Showing Evidence of All Three of These, for Each Diagnostic Criterion

DSM-IV-TR criterion Assessed

(%)

Justified

(%)

Endorsed

(%)

Assessed, justified,

and endorsed (%)

A1—Precipitating stressor 100 90 100 90

A2—Emotional reaction 36 23 29 23

B1—Intrusive, distressing recollections 77 26 74 23

B2—Recurrent distressing dreams 77 29 71 29

B3—Acting or feeling as though event reoccurring 55 10 45 10

B4—Psychological distress at reminders 55 39 52 39

B5—Physiological reactivity at reminders 55 48 55 48

C1—Avoid thoughts and feelings associated with trauma 32 6 26 6

C2—Avoid activities, places, and people 61 39 55 39

C3—Inability to recall 6 6 6 6

C4—Diminished interest/participation in activities 68 29 42 29

C5—Detachment/estrangement from others 32 13 19 10

C6—Restricted affect 26 6 19 6

C7—Sense of foreshortened future 23 0 13 0

D1—Sleep difficulty 97 48 90 48

D2—Irritability/anger 68 23 55 23

D3—Difficulty concentrating 81 32 77 29

D4—Hypervigilance 36 10 32 10

D5—Startle response 36 16 32 13

E—Duration of disturbance 97 93 97 93

F—Clinically significant distress or impairment 97 77 84 74

Note. DSM-IV-TR = Diagnostic and Statistical Manual of Mental Disorders 4th edition.

Table 2 Percentage (and Number) of the 31 Reports Which Showed Evi-

dence of Assessment, Justification, and Endorsement of at Least the

Minimum Number of Symptoms Necessary to Meet Each of the Diagnostic

and Statistical Manual of Mental Disorders 4th Edition (DSM-IV-TR) Criterion

DSM-IV-TR criterion (and

number of symptoms

in criterion)

Minimum number

of symptoms

necessary

to meet criterion

Percentage (and

number) of reports

meeting this

minimum standard

A: Stressor (2) 2 19 (6)

B: Intrusive recollection (5) 1 71 (22)

C: Avoidant/numbing (7) 3 10 (3)

D: Hyperarousal (5) 2 23 (7)

E: Duration (1) 1 94 (29)

F: Functional significance (1) 1 55 (17)

Number meeting minimum

for all diagnostic criteria

3 (1)



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MPsychs endorsed a PTSD diagnosis. In contrast, psychologistswere the least likely to endorse a diagnosis of PTSD (67%).

Assessment of Malingering

Overall, it was relatively uncommon for assessors to address thepossibility of malingering with only 35% (n = 11) of the sampledoing so. Of all the professions, psychiatrists were the mostlikely to check for malingering, with 50% of their cases showingevidence that they had made some reference to the possibility ofmalingering, such as noting inconsistencies in client self-report.Psychologists were the second most likely of the assessors toaddress potential malingering (42%), and MPsychs were theleast likely to do so (10% of cases); however, the relationshipbetween profession and the assessment of malingering was notsignificant (c2[2, N = 30] = 0.15, ns).

In the 11 cases in which malingering had been considered,most commonly determination was based on the assessor’s ownclinical judgment (64% of these cases). The use of standardisedmeasures to assess malingering (such as the Personality Assess-ment Inventory [PAI]; Morey, 1991) occurred in only two cases.In two additional cases, malingering was assessed through theassessor’s clinical judgment in conjunction with either a stand-ardised measure or another’s professional opinion.

The majority of the sample (90%, n = 28) were receivingtreatment at the time of the assessment. In 23% (n = 7) of cases,the assessor was the treatment provider. In only one case did anassessor who was also the treatment provider consider the pos-sibility of malingering.

It might be expected that an assessor who was considering thepossibility of malingering would undertake a more comprehen-sive assessment for PTSD; however, there was no difference inthe number of symptoms assessed (t[29] = -.41, p = .68;h2 = 0.00), or the number of symptoms assessed, justified, andendorsed (t[29] = .71, p = .48; h2 = 0.02) by those who did anddid not consider malingering.

Effects of Time between Trauma and Assessment

On average, there was a lag of 7 years between the reported dateof trauma and the date of assessment. To investigate whetherlonger time lags were associated with more comprehensiveassessments, the correlation between comprehensiveness scoreand time lag was computed. The correlation was positive but notsignificant (r = 0.3, n = 28, ns).

Discussion

The aim of this study was to investigate the quality of thepsychological assessments of emergency service workers seeking

compensation for PTSD. Regardless of professional qualificationof the assessor, almost all the reports failed to address the com-plete DSM-IV-TR (2000) diagnostic criteria for PTSD. There wasalso a notable lack of empirical support for the methods used toconduct the assessment and the inferences drawn. These find-ings were consistent with previous research suggesting thatforensic professionals are not reliably diagnosing PTSD (Kochet al., 2005) because they are failing to apply the specific diag-nostic criteria of PTSD to the claimant (Andrews, Brewin, Phil-pott, & Stewart, 2007), failing to seek examples of how theparticular symptom manifests (Keane et al., 2003), and failingto use valid and reliable PTSD assessment tools (Boccaccini &Brodsky, 1999).

Assessment of Symptoms

Our analysis revealed that criterion A2 was not consistentlyaddressed by the assessors, with only about one third makingmention of this in their report. Criterion A2 requires the clini-cian to assess the emotional response to the trauma and deter-mine whether or not an event was traumatic, and to distinguishthis from ordinary stress experiences (Bedard-Gilligan & Zoell-ner, 2008). Criterion A2 has been challenged in recent timesbecause it does not improve the accuracy of identifying cases ofPTSD (Brewin, Andrews, & Rose, 2000; O’Donnell, Creamer,McFarlane, Silove, & Bryant, 2010; Rizvi, Kaysen, Gutner,Griffen, & Resick, 2008) as well as confounding the responsewith the stimulus (McNally, 2009). For this reason it is beingdeleted in DSM-5, in part also because of some evidence thatthe subjective response to a traumatic event is often notreported in military or emergency response personnel, as aresult of their absorption in their missions, which can maskimmediate responses of fear (Friedman, Resick, Bryant, &Brewin, 2011). Accordingly, the failure to assess A2 is probablynot critical in these assessments. However, waiving the require-ment for the assessment of A2 has little effect on the number ofassessors in our study who met the minimum standard fordiagnosis of PTSD, with only one additional assessor meetingthis reduced standard.

Of the A, B, C, and D symptom clusters, assessors were morelikely to ask about the B cluster that assesses re-experiencingsymptoms including flashbacks, nightmares, psychological dis-tress, and physiological reactivity on exposure to reminder cues.The majority of the assessors described how they assessed thesesymptoms. It is possible that criterion B symptoms were moreoften addressed in reports than other symptom clusters becausethey appear more salient to clinicians who are assessingwhether the emergency service worker can return to work orwhether the workplace will trigger reminders of the traumatic

Table 3 Mean (and Standard Deviation) of the Number of Symptoms Assessed, Justified, and Endorsed (and Total Number of Symptoms That were Assessed,

Justified, and Endorsed) by Different Professional Groups

Assessed Justified Endorsed Assessed, justified,

and endorsed

Psychologists (4-year trained) 11.42 (2.64) 5.83 (2.00) 11.00 (3.36) 5.50 (1.98)

Psychologists with a masters qualification 12.90 (2.42) 6.8 (3.97) 12.40 (3.95) 6.30 (3.94)

Psychiatrists 12.50 (2.39) 9.00 (3.85) 11.75 (2.12) 8.75 (3.65)



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experience. This may also explain why the majority of assessorsnote whether the emergency service worker avoided activities,places, or people that reminded them of the trauma (symptomC2) despite neglecting other avoidance symptoms. Assessorswere less likely to ask whether the emergency service workermade effort to avoid thoughts, feelings, or conversations asso-ciated with the trauma (C1), or to investigate the other negativesymptoms of PTSD that make up cluster C. Among the symp-toms most infrequently assessed were inability to recall animportant aspect of the trauma, restricted range of affect, senseof foreshortened future, and feelings of detachment or estrange-ment from others. This may be because these negative symp-toms are not commonly associated with PTSD and run counterto the public portrayal of the disorder as an active reliving oftrauma. Further, commentaries have noted that the passivesymptoms of PTSD are often not recognised by individuals asbeing related to their trauma and accordingly may not reportthem in a clinical assessment (Solomon & Canino, 1990). Thispossibility makes it particularly important to assess these symp-toms during a forensic assessment. Consistent with this expla-nation, we note that the more generic symptoms, such as sleepdifficulties (D1), irritability (D2), and problems with concentra-tion (D3) were among the most likely to be assessed. However,these frequently assessed symptoms are also characteristics ofother disorders such as major depression (DSM-IV-TR, 2000).Conversely, only a third of assessors made note of arousal symp-toms, including hypervigilance (D4) and exaggerated startleresponse (D5), which are more specific to PTSD. On the whole,assessors did ensure that the symptoms had been present for atleast 1 month, with all but one establishing the duration of thedisturbance and making note of the distress or impairment thiscaused.

We addressed the possibility that assessors failed to assess thefull range of symptoms for each diagnostic category because theclaimant had already met the minimum diagnostic standard forthat criterion. Results indicated that this was not the case andthat the minimum number of symptoms was assessed in the Cand D clusters less than half the time. The consistent failure toassess even the minimum number of symptoms necessary pre-vents the assessing clinician from making a thorough diagnosisthat meets the standards of forensic assessment integrity. Fur-thermore, this failure to adequately assess the client may alsoundermine the ability to formulate appropriate treatmenttargets.

Recent evidence based on the use of a clinical inter-view and psychometric measures that included a validityindex, and a measure of dissociative symptoms related toPTSD, compared the symptom levels of compensation-seekingand non-compensation-seeking claimants, and found thatcompensation-seeking claimants tend to exaggerate symptoms(Frueh, Smith, & Barker, 1996). For this reason it is important toask the claimant to provide an example of the symptom. Thisalso helps to ensure that the claimant is not simply endorsing allsymptoms suggested by the assessor. It is unclear why the asses-sors involved in the cases reviewed here failed to follow thisrecommended approach, particularly when there are valid andreliable PTSD assessment tools that prompt the assessor toobtain examples from the claimant (such as the Clinician-Administered PTSD Scale, Blake et al., 1998). It is possible that

the assessor may have asked for and received examples of symp-toms but then failed to indicate this in their report. However,this is still problematic as it is essential both that the assessmentis comprehensive and valid, and that the report provided by theclinician demonstrates this. We also note that use of directivequestions in the absence of prior open-ended interviewing isfraught with problems because it can cue the claimant toprovide the desired responses (Bryant, 2003).

Assessment of Malingering

The question of malingering is important in any assessmentwhere there is the potential for the claimant’s financial gain.This is particularly so in the assessment of PTSD given thereliance on self-report. The nature of PTSD is such that therewill always be a reliance on self report. There are some sugges-tions that have been shown to increase the reliability of theself-report, as well as suggestions to use a multidimensionalassessment approach. In terms of the clinical interview, self-report that includes: descriptions of unvarying and repetitivedreams; overidealised functioning prior to the traumatic expe-rience; evasiveness; reporting of rare symptoms; overendorse-ment of obvious symptoms; atypical combination of symptoms;and/or excessive severity of reported symptoms (Resnick, 2003;Rogers, 1997) may suggest malingering. Open-ended interviewsthat do not cue the desired responses from the interviewee butthen proceeds to more direct questioning has empirical supportbased on the finding that people feigning PTSD symptoms willtend to under-report symptoms in open questioning and over-report in cued questioning (McBride & Bryant, 2006).

Furthermore, supplementing the clinical interview with psy-chometric data, physiological measures, historical records, andcollateral informants can be used to discriminate real frommalingered symptoms (Litz, Penk, Gerardi, & Keane, 1991).Psychometric measures that have demonstrated reliability indetecting malingering include the Millon Clinical MultiaxialInventory, the Minnesota Multiphasic Personality Inventory,and the PAI (Bryant, 2003). Although the multidimensionalapproach to assessment is recommended, we recognise that itmay not always be possible for the practicing clinician to haveaccess to instruments that measure physiological reactivityrelated to PTSD (e.g., heart rate, skin conductance, and eyeblink startle). Finally, the possibility of gathering informationfrom a range of sources may be somewhat determined by thetraumatised population (e.g., historical records and collateralinformants may be more readily available in veteranpopulations).

Although there is evidence that people can fake PTSD symp-toms in both clinical interviews and written measures (Bryant &Harvey, 1998) and DSM-IV-TR includes a guideline regardingmalingering, Rosen and Taylor (2007) note that in practice theissue remains largely ignored. Only a third of the reports weexamined mention the assessment of malingering, and thesemostly relied on clinical judgement which has been shown to bean unreliable method of detecting malingering in claimants(Lees-Hayley & Dunn, 1994; Rosen & Phillips, 2004).

While general trauma measures lack the ability to detectmalingering, other non-trauma measures such as the MorelEmotional Numbing Test, the Million Clinical Multiaxial



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Inventory, and the Minnesota Multiphasic Personality Inven-tory can assist in the detection of those feigning PTSD (Bryant,2003). Two of the cases we reviewed employed such a measure,the PAI (Morey, 1991). However, although the PAI can help inthe detection of PTSD malingering (Bowen & Bryant, 2006), thereport content suggests it was deployed in these cases to assessclinical disturbance (such as substance misuse) rather thanmalingering.

Certain symptoms of PTSD, such as emotional numbing andsense of foreshortened future, are relatively unlikely to bereported by people feigning PTSD (McBride & Bryant, 2006).Worryingly, these were among the symptoms least likely to beconsidered by the assessors in our study.

Diagnosis of PTSD

The evidence earlier suggests that most of the assessments werenot comprehensive, yet 80% resulted in the diagnosis of PTSD.This suggests that the assessors may have regarded a history oftrauma as sufficient to justify a diagnosis of PTSD. This approachis flawed because most people who experience a traumaticevent will not develop PTSD (Green & Kaltman, 2003), and thedevelopment of PTSD may be influenced by multiple traumas orpre-existing illness. It is critical therefore to establish a temporallink between stressor and symptoms in the determination ofcausality. While most of the assessors linked the onset of symp-toms to a specific event, only about half established a temporallink between stressor and symptoms. Without ensuring thatsymptom onset was post-trauma, the assessor may falselyattribute current symptoms to the index trauma, or fail toappropriately apportion causation (Gold, 2003). Although thereremains a possibility of delayed-onset PTSD, when the symp-toms exacerbate over time to the point when the claimant meetsdiagnostic threshold after a delay since the trauma, these casesshould also be justified by demonstrating the causal linkbetween the traumatic exposure and the subsequent symptoms(Andrews et al., 2007). We also note that the average timebetween the identified trauma and the assessment was 7 years.This increases the difficulty of the assessment because of thegreater number of intervening events that may weaken thecausal link between trauma and symptom, and the problemsassociated with accurate recall for a long past event and itsconsequences (Andrews et al., 2007; Bryant, 2003). Thesefactors further emphasise the need for careful assessment inthese cases.

Our analysis involved an evaluation of assessment reportsrelative to the published standards for such reports. Nothing inthis work should be taken to suggest that we disagree with thediagnosis made by the assessing clinician in any particular case.Our concern is not that the diagnoses were wrong, but thatinadequate reports make it difficult for the clinicians to justifythese diagnoses.

Two principal limitations need to be noted. First, the smallnumber of reports examined restricts our capacity to makebroad generalisations, and second, it is possible that reports didnot accurately reflect the assessment, perhaps because of thedesire for brevity. Nonetheless, this study suggests that currentpractice falls short of expected standards in conducting andreporting forensic assessments of PTSD.

Conclusions

The increased frequency and cost of PTSD claims for workerscompensation and the need to identify those in need of treat-ment requires the careful application of valid assessments ofPTSD. The use of open-ended questions followed by validatedtools can assist in assessing both the full range of PTSD symp-toms and the potential for malingering. One way forward wouldbe to develop a standard template for assessment reports and toensure that assessors, regardless of discipline, were adequatelytrained in this form of assessment. A credible forensic assess-ment will assist genuine claims of PTSD and is vital for thedetermination of appropriate treatment for the claimant. It willalso provide decision-makers, such as insurers and employers,with protection from unwarranted claims.

Acknowledgements

This research was supported by the ARC Linkage grant(LP0989719) awarded to the second, third, and fourth authors.

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