I. Posttraumatic Stress Disorder Posttraumatic Stress Disorder (PTSD), once called shell shock or battle fatigue, is a mental health problem that can occur following the direct experience or witnessing of life- threatening events such as military combat, natural disasters, terrorist attacks, serious accidents, or violent personal assaults. PTSD is a medically recognized anxiety disorder that occurs in normal individuals under extremely stressful conditions. Most people who experience a traumatic event will have reactions that may include shock, anger, nervousness, fear, and even guilt. These reactions are common and for most people go away over time. People who suffer from PTSD often relive the experience over and over again through a range of symptoms (e.g., nightmares and uncontrollable thoughts, difficulty sleeping, and feeling detached or estranged from other people), and these symptoms can be severe enough and can last long enough to significantly affect the person’s quality of life and ability to function (Veterans Healthcare Administration, 2011; United States Department of Veteran Affairs, n.d.). For individuals suffering from PTSD, the area of the brain that processes emotions is also more likely to be triggered by stimuli, regardless of whether the stimulus has anything to do with the original trauma. These biologically based body-changes that occur with PTSD help explain why a veteran might react to noises differently, such as fireworks or a helicopter flying overhead or certain odors, textures, climates, and situations. As a result of these PTSD-related biological changes, the ability to tell the difference between a real threat and a perceived threat can be impaired (National Alliance of Mental Illness [NAMI], 2011). Signs and Symptoms Signs and symptoms of PTSD occur most frequently within 3 months of the traumatic experience but can often be delayed for years. The severity and duration of PTSD can vary greatly among people but the symptoms can usually fit into three main categories including: Reliving (Re-experiencing): • Reliving the ordeal through thoughts and memories of the trauma. • Flashbacks, hallucinations, and nightmares. • Physical reactions to triggers that symbolize or resemble the event (NAMI, 2011). Avoiding (Feeling numb, Hypoarousal): • Avoiding people, places, thoughts, or situations that may remind him/her of the trauma. • Feelings of detachment and isolation from friends and family, as well as a loss of interest in things the person once enjoyed. • Difficulty thinking about the long-term future. Sometimes this is expressed in an inability to plan for the future or risk-taking because the individual may not see themselves living a full lifespan (NAMI, 2011). Increased Arousal (Hyperarousal): • Includes excessive emotions; problems relating to others, including feeling or showing affection; difficulty falling or staying asleep; irritability; outbursts of anger; difficulty concentrating; and being “jumpy” or easily startled. • The person may also suffer physical symptoms, such as increased blood pressure and heart rate, rapid breathing, muscle tension, nausea, and diarrhea (WebMD, 2012). Katrine sackett32463 info: internet article ___________________________________________________________________________________________________________________ I. Introduction Post Traumatic Stress Syndrome Post Traumatic Stress Disorder (PTSD) is a stress and anxiety condition that results from exposure to an overwhelming traumatic event combined with feelings of utter helplessness ( self-hatred.) .1 At the most general level, PTSD exists when the trauma resurfaces over time in intrusive ways causing disruption in a person’s thoughts and behaviors. (A response to a triggering event causes a physiological response in which “adrenaline . . . becomes a neurotransmitter which overrides the decision making and executive processes of [the] cerebral cortex, or smart brain.”122 While it is possible to decrease a response in the beginning stages using relaxation techniques, the lack of effective and early intervention usually leads to a period of heightened arousal that lasts between three-and-a-half to four days.123 In such a state, concentration and communication become impaired and intrusive thoughts increase.1249(2009] ATTORNEY AS PTSD FIRST-RESPONDER 169)) (In the most general terms, “Triggers can come through any of the senses and include sounds, sights, tastes, and smells.” Id.) (An anniversary date of a traumatic event can also bring back thoughts, feelings, and physical reactions related to the trauma. For instance, a veteran may experience an “anniversary reaction” or an increase in posttraumatic stress symptoms at Thanksgiving, as she recalls a mortar blast that happened on Thanksgiving Day, killing one of her buddies. Anniversary reactions can cause intense peaks in anxiety or depression and may occur even before [the Soldier] consciously remembers that a particular traumatic event even happened on that date.) (Whether an undiagnosed client’s condition resulted from Delayed Onset PTSD, which was dormant for months before its symptoms surfaced,14 or the client’s intentional efforts to mask her symptoms in an effort to appear strong or loyal (uncommon access to the client’s decision processes, personal history, and behavior, a combination of which can easily reveal PTSD symptoms) (Many attorneys may not desire PTSD first responder status because the title implies a responsibility to “respond” to matters normally in the domain of licensed clinicians.18 Even for those few attorneys who do litigate matters facially related to PTSD, such as in the defense to a criminal charge or efforts to obtain disability benefits, 19 the condition is normally addressed solely through expert witnesses with the responsibility of diagnosis falling exclusively on the shoulders of the trained clinician) (The resulting lack of concern for or knowledge of the effects of this disorder create a substantial risk that the attorney will be misled into believing that a client with PTSD either does not have the disorder or is not impaired by it.27 Through this limited frame, even a well-meaning attorney can unknowingly contribute to the aggravation of a client’s condition while believing she has fully satisfied her professional responsibilities.28 In fact, attorneys who fail to acknowledge their clients’ PTSD symptoms or counter the effects of stress responses can cause harm beyond their clients’ legal cause. Chief among other potential harms, the compounded stress of litigation alone can increase the risk of suicidal behavior.29) (Even a civilian who has never deployed to combat will face harmful stress responses to litigation, which can sometimes last for months, causing lack of sleep, depression, and other undesirable symptoms.34 For a population already susceptible to taking their own lives due to PTSD, clients who suffer from PTSD will face heightened stress and anxiety.) (Posttraumatic Stress Disorder is a condition caused by an over whelming traumatic event that “distressingly recurs” in various manifestations leading to impairment lasting more than a month.38 Although the Text Revision of the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV-TR) recognizes PTSD as a “stress disorder,” the condition “contains the components of both stress and anxiety.”39 Anxiety is most apparent in the “chronic feeling of dread, apprehension, and hypervigilance” experienced by victims of PTSD.40) (43 While “the symptoms of PTSD are part of the normal reaction to trauma,”44 the symptoms translate into Acute Stress Disorder when experienced for four weeks, Acute PTSD when they last beyond four weeks, and Chronic PTSD when they persist beyond three months.45) (When left untreated, PTSD can lead veterans to behave irresponsibly, impulsively, violently, and self-destructively, which has created significant concern for their own well-being and the well-being of others.) (The link between PTSD and criminal activity is also well documented.64 Commonly, veterans with the disorder knowingly participate in dangerous behavior in attempts to recreate the rush of combat.65 This could include anything from driving at extremely fast speeds,66 to provoking road rage,67 and starting fist-fights.68 While the use of illegal narcotics can also supply a desired adrenaline rush that simulates combat, drug abuse is also common among those who desire to escape feelings of guilt or shame over losses they suffered in combat.69 Ultimately, criminal activity can result from (1) Overreaction to danger cues; (2) Behavioral re-experiencing while in a dissociative state; (3) Stimulation-seeking behavior to overcome numbness and emotional nonreactivity; and (4) Engaging in dangerous behavior to alleviate survivor guilt.70 The above “flashback” scenario in number two, which is commonly cited in legal publications, is quite possible71 but hardly demonstrates all possible criminal manifestations of PTSD. For many of these reasons, “military trial practitioners are likely to encounter PTSD in some fashion in future trials involving combat veterans.”) (Victims experiencing PTSD may have extreme difficulty concentrating, feel constantly on guard or jumpy, and experience unpredictable outbursts of rage.”). (“Forensic stress disorder” (FSD), which contains many of the same diagnostic criteria as PTSD,99 manifests symptoms that include obsessive thinking, panic attacks, fear, and “intrusive thoughts of the legal case [that] can invade daily activities and disrupt evening dreams.”100 However, the symptoms of FSD normally persist six months or less following the conclusion of the legal action.101 Importantly, the client who is already suffering from PTSD prior to litigation is far more likely to experience acute stress reactions to litigation, which can “lead to an inability to manage the uncertainty and frustration of the legal process.”102) (The avoidance of the triggers by the defendant who has self-inflicted PTSD) (Additionally, the accused is forced throughout the pretrial and trial stages of a criminal prosecution to relive, often as a passive spectator, the traumatic experience of the crime through the testimony of witnesses, photographs, exhibits, and legal arguments. All of these circumstances, routine to the criminal trial process, have the potential to stimulate and aggravate the accused’s PTSD.104) (“Criminal and similar kinds of legal proceedings are intensely stressful and can create feelings of fear, anxiety, and depression.”). (101 Cohen & Vesper, supra note 34, at 4 (“Although litigants may suffer symptoms found in individuals diagnosed with acute or posttraumatic stress disorder, the psychological disturbance for litigants usually abates within six months after the legal case has concluded.”). (102 Id. at 14 (“[I]ndividuals who witnessed violent or life threatening-events as well as those people who were involved in traumatic accidents prior to litigation experience acute stress reactions.”). (Among immigrants applying for asylum or victims of domestic violence, for example, it is valuable to assist clients in regaining a sense of lost control) (Lack of trust of others and self-destructive tendencies, which are common characteristics of PTSD,) (Since self-abuse is common among trauma victims, you may see it acted out in the form of settlement suggestions that are self-defeating or self-destructive behaviors such as not showing up for court appearances.”113 Attorneys must be prepared to explore aspects of the client’s legal decision-making process— objectives, prioritization of issues, and the weighing and balancing of decisions—to identify the presence of otherwise unseen distorting forces. In the strategic vernacular, the attorney must endeavor to get inside the client’s defective OODA loop, and counter it with in a way that permits effective evaluation of legal options.114 Too often, combat veterans who experience a traumatic event suffer from shattered beliefs about the world around them.11) (recognizing that traumatic stress has the ability to “shatter necessary and deeply held beliefs”); Decker, supra note 65, at 31 (observing that “[t]he very nature of trauma is such that it attacks our basic beliefs and challenges our processes of accommodation and assimilation” and that “most trauma survivors’ beliefs (including combat veterans’) are deconstructed and set into disarray”). 1. Exposure Therapy is based on the theory that a patient with PTSD will benefit from re-experiencing trauma in a controlled environment where his or her fears can be explored with the guidance of a nonthreatening clinician.129 In a very real way, lawyers engage in exposure therapy when they take reluctant clients or witnesses to visit a courtroom and sit in the witness chair to aid in easing the anxiety of providing live testimony. Some clinicians have hailed exposure therapy as the most effective among the treatment choices.130 Prolonged Exposure (PE) is a popular and effective method in which patients “vividly imagine” traumatic events, by speaking or writing about them, often in the first-person, present tense format, with a focus on “the most distressing aspects.”131 Patients then revisit their accounts, which are either written or recorded, and observe subtle differences in the way the event is recounted over time.132 By revisiting the event with the guidance of the clinician, the patient is able to develop more accurate statements or images over time. Studies reveal that PE can have as much as a 70% success rate in reducing PTSD symptoms after nine sessions of treatment.133 Attorneys should seek to learn whether a client is receiving exposure therapy treatment at the time of legal counseling. By synchronizing calendars with the clinician, the attorney can avoid scheduling meetings close in time to the days when the client will revisit vivid traumatic experiences. Another form of clinician-supervised exposure therapy includes: Virtual Reality (VR) Therapy, which exposes veterans to computersimulated images that resemble their own traumatic experience.134 Virtual environments commonly depict streets, homes, and scenes encountered in Iraq.135 In some pilot programs, clinicians can reproduce smells common to combat environments and other effects that make the experience extremely realistic.136 Virtual Reality programs are not yet mainstream, but attorneys in the near future may represent clients undergoing PE or VR clinical trials during the course of the representation. 2. Cognitive Behavior Therapy (CBT) involves clinical exploration of the link between the client’s distorted thoughts and his maladaptive behavior.137 During CBT, a therapist helps the client explore these links by making the client complete charts and other written assignments.138 133 E. The goal is to assist the client in challenging faulty assumptions or beliefs and to permit the client to adopt corrected beliefs.139 Scholars describe a “feedback loop” that explains how unchecked thoughts can result in ongoing impairments: In the case of painful feelings, a negative feedback loop becomes an “event,” the subject of further thoughts, which produce more painful feelings, which become a larger event inspiring more negative thoughts, and so on. The loop continues until you work yourself into a rage, an anxiety attack, or a deep depression.140 Cognitive Behavior Therapy practitioners use a common three column “A-B-C Worksheet” to identify the interrelationship of thoughts, situations, and feelings.141 (PTSD victems often experience emotions first, without seriously considering their thoughts,143 ) Specialist Melvin’s thought above (“These kids have an IED or this is an ambush,”) can represent three of eight types of distorted thinking— “overgeneralization,” “catastrophizing,” or “magnifying”—which are defined in Figure 2, below.146 Fig. 2. Eight Forms of Distorted Thinking Distorted thoughts commonly associated with PTSD, and which could influence legal representation, include the following: 1. Filtering: You focus on the negative details while ignoring all the positive aspects of a situation. 2. Polarized Thinking: Things are black or white, good or bad. You have to be perfect or you’re a failure. There’s no middle ground, no room for mistakes. 3. Overgeneralization: You reach a general conclusion based on a single incident or piece of evidence. You exaggerate the frequency of problems and use negative global labels. 4. Mind Reading: Without their saying so, you know what people are feeling and why they act the way they do. In particular, you have certain knowledge of how people think and feel about you. 5. Catastrophizing: You expect, even visualize, disaster. You notice or hear about a problem and start asking, “What if?” What if tragedy strikes? What if it happens to you? 6. Magnifying: You exaggerate the degree or intensity of a problem. You turn up the volume on anything bad, making it loud, large, and overwhelming. 7. Personalization: You assume that everything people do or say is some kind of reaction to you. You also compare yourself to others, trying to determine who is smarter, more competent, better looking, and so on. 8. Shoulds: You have a list of ironclad rules about how you and other people should act. People who break the rules anger you, and you feel guilty when you violate the rules. Distorted thoughts commonly associated with PTSD, and which could influence legal representation, include the following: • “It’s not worth my time and energy to plan for the future because I may be redeployed”147 • “I never think beyond today, much less tomorrow or the next day. I won’t live much longer.”148 • “Grieving means I’m weak.”149 • “If I move on with my life, I will stop thinking about those I lost.” 150 With knowledge of such limitations, the client can conduct further self analysis, acting as a personal scientist, to substitute dysfunctional thoughts with more productive ones. 151 The process can work equally well in permitting the client to evaluate errors in the interpretation of legal advice 146 MCKAY ET AL., supra note 140, at 32 (“Summary”). These eight patterns represent most of the dysfunctional thoughts exhibited by patients, although they might go by different names. Elsewhere, ATTORNEYS AS FIRST-RESPONDERS: RECOGNIZING THE DESTRUCTIVE NATURE OF POSTTRAUMATIC STRESS DISORDER ON THE COMBAT VETERAN’S* LEGAL DECISION-MAKING PROCESS† Captain Evan R. Seamone‡ * From Katrine Elizabeth Sackett32463 whitelady (5’3)(5’21/2) page 1 of 4 Information found in article named above Look and find easily under google Feb 2019 Loss of military benefits and medical coverage and care and other (veterans benefits) Consider, for example, the trial defense counsel who advises an active duty servicemember regarding nonjudicial punishment. The attorney may believe that the issue is isolated, and fail to detect a pattern of conduct related to symptoms of PTSD. If the client continues to engage in risky behavior related to symptoms of the untreated condition, the recidivism could lead to a discharge under other than honorable conditions that eliminates or substantially limits his ability to receive necessary medical treatment upon separation, even if he is diagnosed with PTSD at the time. E.g., 38 C.F.R. § 3.12(b) (2009) (barring eligibility for veterans’ benefits under several circumstances related to misconduct or characterization of discharge unless the veteran was “insane at the time of committing the offense”); Brittany Cvetanovich & Larkin Reynolds, Note, Joshua Omvig Veterans Suicide Prevention Act of 2007, 45 HARV. J. ON LEGIS. 619, 634 (2008) (“Receiving a less-than-honorable discharge, even for offenses linked to PTSD (such as drug abuse, being absent without leave, and assault), renders a veteran ineligible to receive medical benefits.”); Amy N. Fairweather, Compromised Care: The Limited Availability and Questionable Quality of Health Care for Recent Veterans, 35 HUM. RTS. 2, 24 (2008) (observing the “limited eligibility for federal benefits” and a “particularly cruel outcome for many veterans who suffer from PTSD and are kicked out of the military for behavior stemming from their combat injury”). All the while, the attorney, who had no knowledge of PTSD symptoms, could go on thinking that she did everything within her power and responsibility to assist the client when she counseled him on the legal issues related to the initial minor infraction. 29 Savitsky, supra note 12, at 333 (“When mental health issues are not addressed, the results may be deadly.”); id. (“Without treatment and support, PTSD-related stress may lead to divorce, substance abuse, family violence, unemployment . . . and other related issues that can have a lasting, detrimental effect on family life and society.”). See generally Cvetanovich & Reynolds, supra note 28, at 620 (“Numerous studies have linked suicide to PTSD and other mental illnesses.”). 30 E.g., Chuck Crumbo, Military Moms Meet on Somber Occasion; Gold Star Mother Chapter Opens in Columbia, HERALD (Rock Hill, S.C.), Aug. 2, 2009, at 28 (observing that, in 2008, “[t]hrough mid-July, 129 soldiers had died from suicide, exceeding the combat death toll”). 31 Compare Grace Vuoto, Wounds of War; Army Suicides at Record Pace, WASH. TIMES, July 2, 2009, at B02 (predicting a suicide rate in which “the tally for 2009 will likely eclipse last year’s total of 140 suicides, the highest rate since the Pentagon began recording suicide rates 28 years ago”), with Mark Mueller & Tomãis Dinges, The Wounds Within: Suicide in the Military, STAR LEDGER (Newark, N.J.), Nov. 22, 2009, at 1 (noting that by October 2009, the Marine Corps matched its prior year’s suicide record of forty-two and by 16 November 2009, the Army had matched its own record of 140 cases); see also Elizabeth A. Stanley & Amishi P. Jha, Mind Fitness: Improving Operational Effectiveness and Building Warrior Resilience, 8 JOINT FORCE Q. 144, 144 (2009) (noting “the growing number of suicides, with the Marine Corps experiencing 1 page of 1 ___________________________________________________________________________________________________________________ Psychiatry (Edgmont). 2005 Oct; 2(10): 21–24. Published online 2005 Oct. PMCID: PMC2993515 PMID: 21120087 Posttraumatic Stress Disorder Within the Forensic Arena Charles A. Morgan, MD, MA, Seth Feuerstein, MD, JD, Frank Fortunati, MD, JD, Vladimir Coric, MD, Humberto Temporini, MD, and Steven Southwick, MD Author information Copyright and License information Disclaimer In this piece, we discuss the diagnosis of posttraumatic stress disorder (PTSD) within the forensic context of civil and criminal litigation. Although most psychiatrists are familiar with PTSD and with making a diagnosis of PTSD in a clinical setting, many are unaware that their typical clinical approach, when used in the context of legal proceedings, can lead to problems. The main source of difficulty lies in the clinician's failure to recognize that there are significant differences between clinical and forensic concerns. In the clinical setting, the primary concern is one of providing relief and care. The clinical doctor-patient relationship is a supportive one wherein the doctor generally assumes the patient is honest, forthcoming when providing the history of illness or symptoms, and interested in treatment. By contrast, most clients who are evaluated for PTSD by forensic examiners are participating in the evaluation because it has been requested by an attorney or by the court. The primary goal of most people being evaluated for PTSD in this context is to persuade the examiner that they [the plaintiffs] have suffered serious psychological injury and, as a result, are deserving of compensation. In the case of criminal defendants, the primary goal is usually to convince the examiner that they are not culpable for their actions due to their PTSD [an insanity defense] or that they are, due to their condition of PTSD, eligible for a more lenient view in the eyes of the court [a less serious sentence; this is often referred to as ‘mitigation' or ‘downward departure']. Thus, the relationship in this context is quite different: The person is not interviewed as a patient, and there is no assumption on the part of the physician that the interviewee is entirely honest or forthcoming when providing information. Further, the explicit purpose of the evaluation is not treatment; it is to establish whether the person does indeed suffer from PTSD, and if so, to describe for the court, the degree of impairment (past or present) that is caused by the condition. So what do we do differently in a forensic evaluation? Go to: Establish Whether or not There are Verifiable Traumatic Events Current diagnostic criteria (DSM-IV-TR) require that in order for a person to meet criteria for a diagnosis of PTSD, he or she first must have been exposed to a traumatic event. This is referred to as Criterion A. Specifically, this means that a person must have been exposed to an event during which 1) there was a serious, imminent threat to his or her life, his or her physical integrity, or to that of others; and 2) he or she experienced a sense of fear, helplessness, or horror. If an event does not meet these criteria, a person is NOT evaluated for PTSD in relationship to the event. [NOTE: The large number of ‘recovered memory' cases reported in the 1990s provided robust evidence that it is both unwise and dangerous for professionals to work ‘backward' by using symptoms reported by the client as evidence for a traumatic event.] Go to: Not Everything Bad that Happens is a Trauma Although it may seem obvious that there is an identifiable traumatic event to which the person was exposed, this is not always the case. Numerous events [such as loss of one's job or one's home or being diagnosed with a serious or incurable medical condition] can be highly distressing but do not meet criteria as traumatic events in that there was no imminent risk to a person's physical integrity or life. The only way to sort out this issue is by obtaining as much data as possible. If you are asked to evaluate a civil PTSD claim, you should ask for as much documentation about the traumatic event as you can, such as accident reports, photographs, police accounts, and medical documents from that time. In addition, you should ask the plaintiff or the attorney for the names of individuals with whom you might be able to speak who may have witnessed the event or who interacted with the person shortly after the event. These sources of information can be very helpful when making a judgment about whether or not the event qualifies as a traumatic event. In criminal PTSD cases, it can be more difficult to obtain data about reported traumatic events owing to the fact that the index trauma [i.e., the event that caused PTSD] often predates the criminal event by a number of years. Nevertheless we believe that a serious attempt to verify the existence of the traumatic event is warranted. If you are asked to assess a defendant who claims to suffer from a condition of combat-related PTSD, you and the defendant's attorney should make contact with the Department of Veterans Affairs in order to verify that the veteran was actually in combat. Similarly, if a defendant claims PTSD from sexual abuse or assault, an effort should be made to seek out objective evidence for the traumatic event. If none is available, it is wise to be explicit about this when rendering an expert opinion. Go to: Use Structured Interviewing Techniques At present, the gold standard in PTSD assessment is the Clinician Assessed PTSD Scale (CAPS) (DSM-IV version). Indeed, a CAPS evaluation is currently the normative basis for diagnosis or treatment response in most scientific studies of PTSD. The CAPS is a semistructured interview that is extremely useful in documenting the intensity and frequency of PTSD symptoms. It is performed for each traumatic event in a person's history that meets Criterion A (DSM-IV) requirements. Some training on the instrument is required, but we believe most experts will find that the time required is worth the effort. The CAPS structures the interview so that the expert is able to obtain the greatest amount of detail about each of the symptom categories of PTSD. In addition it can be great help in making an assessment about the degree of severity and functional impairment caused by the illness. In our experience, individuals who genuinely suffer from PTSD have little difficulty generating numerous examples of their symptoms whereas individuals who are feigning or exaggerating their symptoms provide a narrow range of stereotypical responses. Semistructured interviewing has been around for more than two decades. The CAPS, like the SCID, has proven to be reliable and valid. The use of highly rigorous assessment instruments in the forensic setting reduces the likelihood of false positive and false negative findings. This is, in part, due to the fact that the detailed information obtained during the CAPS interview can be compared with the information obtained from work records, school records, and interviews with people who know the examinee in various contexts. In addition to the use of the CAPS, other semistructured assessments, such as the Structured Clinical Interview for DSM-IV [SCID]) can be very valuable when performing a forensic PTSD evaluation. It is extremely common for people with PTSD to suffer from additional psychiatric disorders (such as affective disorders, anxiety disorders, substance abuse, and alcohol-related disorders). The SCID can be extremely helpful in rendering an opinion that is based on data and not on clinical guesswork. Similarly, although many experts do not request standardized psychological testing, such as the MMPI-2, Millon, or IQ, it often can be very helpful to the expert who is performing a PTSD evaluation for the court. Such testing can be helpful to the expert when he or she is making judgments about the examinee's style of coping, degree of effort, or degree of impairment. Go to: Traumatic Memories: Not Indelible and Not Reliable Many professionals have assumed that because people who suffer from PTSD experience intrusive thoughts, nightmares, or flashbacks about their traumatic events,that memory for trauma is relatively indelible and stable over time. Indeed, a large number of mental health professionals often believe that the ‘gist' of one's memory is true, which results in the conclusion that what the patient or client remembers must in fact be true. Over the past 10 years, a number of studies have provided evidence that memories for traumatic events are not indelible, but subject to substantial change over time. Further, we now know that high levels of stress may disrupt human memory. The bottom line about memory is this: While the veracity of a memory for traumatic events may not matter within the clinical context, it may matter a great deal in the forensic context. At the present time, forensic experts do not have an objective test that would let us know which memories are likely to be accurate and which are not. We know, based on good science, that neither a person's level of confidence in his or her memory nor the level of detail he or she provides when reporting such memories are reliable indicators of truth or accuracy. Thus, at present we recommend mental health professionals and experts refrain from commenting on the ‘accuracy' of memory and refrain from using memories as evidence for objective facts. Unless the reported memories can be paired with valid, corroborative, objective evidence, it is unwise to consider traumatic memories as reliable or valid indicators of external events. Go to: Causality and Responsibility In civil cases, it is often the case that plaintiffs who are claiming to suffer PTSD from the event before the court have also suffered from previous traumatic events. When this occurs, the expert is faced with the challenge of separating out the degree of impairment caused by previous traumas from that caused by the event before the court. When performing a psychiatric evaluation, it is vital that one assess a traumatic event's history prior to performing the CAPS. The CAPS is then conducted for each event that meets the Criterion A definition for a traumatic event. The CAPS scoring system permits a rating of PTSD severity for each traumatic event. Coupled with the information obtained from interviews with people who knew the plaintiff prior to and after the traumatic event before the court, this data can assist the expert in rendering an opinion of severity to the court. In criminal cases, a defendant may put forward a PTSD-related Not Guilty by Reason of Insanity (NGRI) defense. In putting forward this defense, the defendant acknowledges having committed the act, but is not criminally responsible due to his or her condition of PTSD. The symptom of PTSD that is most commonly invoked to explain why a person may lack responsibility for his or her actions is the “flashback.” Flashbacks are dissociative states brought on by a high degree of arousal or alarm during which a person may be completely or partially unaware of his or her immediate circumstances—a distortion of perception and thinking that may rob that person of the ability to accurately appreciate the nature of his or her actions with regard to the law. A trier of fact is more likely to be persuaded by an expert's psychiatric opinion if the expert can establish that the defendant has a well documented history (via medical records or third party observations) of flashbacks and the circumstances of the alleged crime are similar to the contexts in which such symptoms most often occur. The expert may inform the court if it is within a reasonable degree of medical certainty that the defendant suffered from PTSD at the time of the alleged crime. The expert may also inform the court that PTSD symptoms, such as flashbacks, may impair a person's capacity to accurately assess his or her situation and circumstances. However—and it is important to emphasize this—it is the role of the judge or the jury (not the psychiatric expert) to decide whether, at the time of the alleged crime, but for the presence of a PTSD-related flashback, the defendant would not have committed the crime. The most common reason for which a PTSD evaluation may be requested in a criminal case is for mitigation. When deciding on the sentence a person receives, judges may often take into consideration mitigating factors, such as the presence of psychiatric illness. Judges want to know, among other things, whether the person suffers from a psychiatric condition, the severity of the condition, the degree of impairment caused by the condition, and whether or not treatment is necessary for the condition. By providing this type of psychiatric information to the court, the expert may have a significant impact on the sentence a person will receive. Go to: In Closing In this article we only have addressed some of the issues related to assessing and diagnosing PTSD in the forensic context of civil and criminal proceedings. In future articles, we hope to address non-PTSD related psychiatric problems that may arise in victims of trauma.________________________________________Articles from Psychiatry (Edgmont) are provided here courtesy of Matrix Medical Communications NOTE: this is not always the case ----in some cases being sent to a mental hospital can be more of a sentence already because legal system (jails/police/sheriff/courts) sent you there when what you have done or charged with don’t meet the written form of the law like the manuels or other legal books legal system have themselves written up for police/courts/jails to try to follow when deciding on guilt or not guilty of the accused and when you don’t meet those written form of laws then you get sent to a mental hospital and that can be a worse sentence from the legal system then a sentence of going to jail as a sentence and some people see that as a worse sentence being sent to a mental hospital due to varies reasons and because of the fact their medicines have been known to cause medical conditions and staff have had accidents being careless as employee’s at work to include holding patients down which have caused patients deaths In other cases ------being sent to a mental hospital (like others besides me meaning not me) the mental health staff as a group of staff have gotten others off a real crime a person did commit or got them a lower sentence and maybe a lower sentence then deserved to the them) From Katrine Elizabeth sackett32463 whitelady (5’3)(5’21/2) 7101 n ih 35 austin tx 214 spring terrace apts Date feb 28 2019 Information can be the fastest and easiest found under google
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1. Paresthesia definition medical Answer from 5 sources medical Definition of paresthesia. : a sensation of pricking, tingling, or creeping on the skin having no objective cause and usually associated with injury or irritation of a sensory nerve or nerve root. Paresthesia | Definition of Paresthesia by Merriam-Webster merriam-webster.com Medical Definition of Paresthesia. Paresthesia: An abnormal sensation of the body, such as numbness, tingling, or burning. Medical Definition of Paresthesia - MedicineNet medicinenet.com glutamate hypothesis of schizophrenia delusional parasites latent inhibition dopamine hypothesis of schizophrenia successive irritation of nerve fibrils in the skin. At times patients who suffer from it will scarcely be persuaded that it is not due to insects. These symptoms usually arise from nerve damage (neuropathy). Continued nerve damage can lead to numbness (lost of sensation) or paralysis (loss of movement and sensation). Paresthesia is one of the symptoms of Hypervitaminosis-D. ... Peripheral neuropathy is a general term indicating disturbances in the peripheral nerves. Numbness (paresthesia and neuropathy) (MPKB)https://mpkb.org/home/symptoms/neurological/paresthesia What is paresthesia and what causes it? Chronic paresthesia is often a symptom of an underlying neurological disease or traumatic nerve damage. Paresthesia can be caused by disorders affecting the central nervous system, such as stroke and transient ischemic attacks (mini-strokes), multiple sclerosis, transverse myelitis, and encephalitis.Jun 14, 2018 Is there a difference between neuropathy and peripheral neuropathy? Peripheral neuropathy refers to nerve damage involving the peripheral nervous system, which is those nerves outside the brain and spinal cord. The damaged peripheral nerves malfunction and provoke abnormal sensations, pain, and numbness. These sensory abnormalities most commonly affect the feet, lower legs, and hands.Oct 19, 2018 Can paresthesia be treated? Treatment of Paresthesia. Treatment of paresthesia depends on an accurate diagnosis of the underlying cause. ... If the paresthesia is due to a chronic disease, such as diabetes, or occurs as a complication of treatments like chemotherapy, the majority of treatments are aimed at relief of the person's symptoms. Dysesthesia should not be confused with anesthesia or hypoesthesia, which refer to a loss of sensation, or paresthesia which refers to a distorted sensation. Dysesthesia is distinct in that it can, but not necessarily, refer to spontaneous sensations in the absence of stimuli. Term called myelopathy term -------------- Term called pallesthesia vibratory sensation Term diabetic neuropathy (type of nerve damage and other ) Peripheral neuropathy motor neuropathyautonomic neuropathyaxillary nerve palsy Direct injury to a nerve, interruption of its blood supply resulting in (ischemia), or inflammation also may cause mononeuropathy "Polyneuropathy" is a pattern of nerve damage that is quite different from mononeuropathy, often more serious and affecting more areas of the body. The term "peripheral neuropathy" sometimes is used loosely to refer to polyneuropathy. In cases of polyneuropathy, many nerve cells in various parts of the body are affected, without regard to the nerve through which they pass; not all nerve cells are affected in any particular case. In distal axonopathy, one common pattern is that the cell bodies of neurons remain intact, but the axons are affected in proportion to their length; the longest axons are the most affected. Diabetic neuropathy is the most common cause of this pattern. In demyelinating polyneuropathies, the myelin sheath around axons is damaged, which affects the ability of the axons to conduct electrical impulses. The third and least common pattern affects the cell bodies of neurons directly. This usually picks out either the motor neurons (known as motor neuron disease) or the sensory neurons (known as sensory neuronopathy or dorsal root ganglionopathy). small fiber peripheral neuropathy with typical symptoms of tingling, pain, and loss of sensation in the feet and hands Mononeuritis multiplex also may cause pain, which is characterized as deep, aching pain that is worse at night and frequently in the lower back, hip, or leg. In people with diabetes mellitus, mononeuritis multiplex typically is encountered as acute, unilateral, and severe thigh pain followed by anterior muscle weakness and loss of knee reflex.[medical citation needed] The signs and symptoms of autonomic neuropathy include the following: • Urinary bladder conditions: bladder incontinence or urine retention • Gastrointestinal tract: dysphagia, abdominal pain, nausea, vomiting, malabsorption, fecal incontinence, gastroparesis, diarrhoea, constipation • Cardiovascular system: disturbances of heart rate (tachycardia, bradycardia), orthostatic hypotension, inadequate increase of heart rate on exertion • Respiratory system: impairments in the signals associated with regulation of breathing and gas exchange (central sleep apnea, hypopnea, bradypnea).[21] • Other areas: hypoglycemia unawareness, genital impotence, sweat disturbances • Toxic causes: drugs (vincristine, metronidazole, phenytoin, nitrofurantoin, isoniazid, ethyl alcohol, statins),[medical citation needed] organic herbicides TCDD dioxin, organic metals, heavy metals, excess intake of vitamin B6 (pyridoxine). Peripheral neuropathies also may result from long term (more than 21 days) treatment with Linezolid (Zyvox).[medical citation needed] • Adverse effects of fluoroquinolones: irreversible neuropathy is a serious adverse reaction of fluoroquinolone drugs[medical citation needed] Neuritis[edit] Neuritis is a general term for inflammation of a nerve[22] or the general inflammation of the peripheral nervous system. Symptoms depend on the nerves involved, but may include pain, paresthesia (pins-and-needles), paresis (weakness), hypoesthesia (numbness), anesthesia, paralysis, wasting, and disappearance of the reflexes. Causes of neuritis include: 1. Pallesthesia Pallesthesia refers to the sensation of mechanical vibration on or near the body. Vibration sense may be lost as a result of a number of lesions to the nervous system, often in conjunction with other deficits. The word "pallesthesia" is derived from the Greek pallein, meaning "to shake." Pallesthesia - Wikipedia Morgellons dysesthesia myriads eszema raphania pruritus From Katrine elizabeeth sackett32463 whitelady (5’3)(5’21/2) Spring terrace apts 7101 n ih 35 austin tx apt 214 Date May 9, 2019 Information found in internet articles and books The easiest and fastest way to find probabily would be to go under google first reply
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EDUCATIONAL HAND-OUT ON FORMICATION FROM KATRINE SACKETT 32463 INFO: INTERNET AND BOOKS Formication Formication (also known as speed bumps, meth sores, crank bugs): A common symptom in diseases of the spinal cord and peripheral nerves involving the illusion or hallucination (also called delusions of parasitosis –DP for short) that ants, snakes or other insects are creeping on or under the skin causing itching. Formication is associated with psychotic states, drug and alcohol abuse (crystal meth, cocaine, amphetamines, heroine, alcohol), certain prescription medication (Ritalin, Adderall and Lunesta), menopause, allergies, diabetic neuropathy, skin cancer and with herpes zoster (shingles). Heavy stimulant use causes a rise in body temperature and increased blood flow to the skin (to counteract the hyperthermia). Sweat is produced that contains an enzyme which further increases blood flow. As the sweat evaporates, it removes the protective oils on the skin. This scenario, combined with the toxins released from the skin, also dehydrates the dermal layer creating an itchy sensation on the nerve endings. ________________________________________ ________________________________________ Other term for formication Formication Meth mites, crank sores, speed bumps or bugs are common symptoms Medically known as formication, this condition occurs due to the severe dehydration and chemical imbalance the drug has caused in their body hallucinations of bugs crawling inside of them.. ……... These chemicals can cause toxic reactions in the body and many other serious side effects. known to cause a rise in body temperature and increased sweating. The sweat that is produced contains an enzyme that increases blood flow to the skin. Additionally, the excess substance in the body is expelled through normal processes such urine and through the skin. When the sweat evaporates, it is acidic from the enzyme. This acidic sweat removes the protective oils which coat the skin. This combined with dehydration cause a crawling sensation on the nerve endings on the skin, leading users to believe that bugs are crawling on them.( prickling, tingling sensation known as "pins and needles".)(burning,wetness,itching,electric shock, and pins and needles) drug-induced formication ________________________________________ UNDER FORMICATION addition,--------polypharmacy (simultaneous use of multiple medications) with concomitant side effects and potential drug interactions---------neuropathy, leading to paresthesia, which may be misinterpreted as bites or stings------ , the antidepressant --phenelzine produced both widespread pruritus and the perception of being infested with parasites (Ritalin or Adderall.) EXTRA----. Since stimulants rapidly accelerate the heart rate while simultaneously constricting blood vessels, making them work harder, they can weaken the cardiovascular system. From katrine sackett 32463 info: books and internet reply

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