Rejoining Joy

Ways of living

Psychological Injury

Is There Real Trauma, Pain, or Brain Damage?

Karen felt so depressed and traumatized. "Oh my, I do not know where to turn. I can't smile anymore. My co-workers are concerned. My daughter worries and tries to cheer me up. I cry for no reason. I wasn't this way before the accident. Why did that kid run in front of my car? I keep dreaming about it, how they tried to save him. In my nightmares, its my own daughter." Karen exhibits all the major symptoms of Posttraumatic Stress Disorder (PTSD), including the feeling that she is reliving the accident (flashbacks), nightmares, jumpiness, reacting to reminders, fear of driving, hypervigilance when driving, poor sleep, and relationship numbness. Her family doctor sends her to a psychiatrist.

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Jimmy could not stand the pain. "I used to be on all the school teams. Rugby was my favorite. I was team captain. I was looking forward to playing on the university team. Now I am in a wheelchair with a crushed leg, and my dreams are crushed. Why did the driver drink and drive? He gets away with a ticket. I lose my life." Jimmy has developed chronic pain and depression because of his accident and the serious changes in his quality of life and activities of daily living. He is not motivated in his rehabilitation. A psychiatrist is called in.

Frank had part of his skull sheared off and received a facial smash as well as multiple injuries. His friend took him on a joy ride on a country road, and lost control. They hit a tree. His friend died. Frank was in a coma for 2 months, and ended up with serious brain, sensory, and bodily injuries. His mother never accepted the doctors' prognosis that if he survived he would be in a vegetative state in a group home. She remained by his side day and night for years, coaxing him on. He is now completing his high school diploma through the home study program that she organized with the school board, although he needs 24 hour care. She indicated that she would not have succeeded without the help of the psychologist who the case manager had contacted.

Paul found me by looking in the telephone directory. He claimed that he had a serious car accident, and hurt his back and leg. He limped and used a cane. I listened to his complaints but was doubtful because of his extremely exaggerated pain behavior and inconsistencies in his story. He failed a psychological screening test of whether he was "faking" it. I declined to see him further. I had read that week in the newspaper about criminal elements starting up rehabilitation clinics and staging fake accidents.

These stories are based on true cases that I see in my practice. They have been changed in detail to protect the privacy of the individuals involved.

People who are hurt in accidents suffer physical and psychological injuries, and after comprehensive assessments I might diagnose PTSD, Major Depression, chronic Pain Disorder, or refer to a neuropsychologist to evaluate for possible Traumatic Brain Injury. It is harder when the patients suffer polytrauma, or two or more of these conditions together.  They might also manifest an Adjustment Disorder, which is less serious, or other anxiety disorders, such as a Phobia of driving vehicles.

The cases are complex when there are pre-existing factors, such as a personality disorder that has not been treated, a pre-existing psychopathology such as Bipolar Disorder, or ongoing stressors that predate the accident at issue (e.g., a divorce that has been conflictual). In addition, psychologists might have to deal with patients who grossly exaggerate their symptoms or even are lying or malingering for financial gain.

Fortunately, psychologists can use tests that help in determining not only clinical problems but also when malingering or related behavior might be taking place. These tests include the MMPI-2 and the MMPI 2 RF (Minnesota Multiphasic Personality Inventory, second edition, Restructured Form; chief author, Dr. Yossi Ben-Porath). However, the tests are not infallible.

Moreover, psychologists might have to give testimony in these cases, and the need to remain impartial is required. (Note: when psychologists evaluate these patients for court purposes, without preparing reports for treatment purposes, they are called forensic psychologists.) However, the pressures of the legal system might influence their approach to the testimony (these pressures are called "the adversarial divide").

Generally, psychologists are empathic to patients in rehabilitation and treat them effectively. Moreover, forensic psychologists, in particular, evaluate them comprehensively and impartially. However, both types of psychologists face difficulties when a patient is dishonest or when they face pressures from insurers and attorneys.

The best remedy for psychologists and other mental health professionals in dealing with these stresses is:

  • to be educated and trained to an excellent level,
  • to practice the profession with integrity (as per their professional regulations and guidelines, such as the Specialty Guidelines for Forensic Psychology (Committee on the Revision of the Specialty Guidelines for Forensic Psychology, 2010; chief author, Dr. Randy Otto), and
  • to be up to date on the scientific literature on which their practice is based (e.g., the journal Psychological Injury and Law). Their professional and governing bodies and their patients expect nothing less.

Today, I was asked if it is depressing to hear these stories from patients. To the contrary, it is uplifting when I hear how they are improving with therapy and can take the small steps (and sometimes great leaps) in their recovery that I try to help them bring out. The task of treating them might appear overwhelming, but psychology is a scientific profession that has developed finely-tuned treatment approaches and specific procedures that can be tailored effectively to meet individual needs.

The best way of helping patients with these injuries is to give them scientifically-informed treatment, but only after verifying as best as one can that their psychological injuries are genuine and not grossly exaggerated or the result of lying or malingering. Fortunately, a majority of patients are honest. They might be crying out for help, and psychologists are well-trained to offer the help that they need. 

Gerald Young, Ph.D., is a professor of psychology at York University.

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