Interview with Neuropsychologist Dr. Alexandra Stone on PTSD and Litigation

Each state has its own approach to PTSD, particularly the threshold for recovering this element of damages in a tort case. It may depend on the severity of the experience and whether the claim is based on an intentional tort or some lesser level of culpability.

I had the opportunity to work with neuropsychologist Alexandra Stone, Ph.D., in a case involving PTSD as a significant component of claimed damages. We have since done CLEs on the subject. Dr. Stone was kind enough to let me interview her for TortSource. The following focuses on the neurological and psychological aspects of PTSD so that one can scientifically consider such a diagnosis in the context of one’s own legal framework.

PTSD and the Brain

Q. Are there specific parts of the brain associated with PTSD?

Yes. They are:

• Amygdala (emotions and fear response)
• Hippocampus (memory and learning)
• Prefrontal cortex (self-regulation, decision-making)

The amygdala is a primitive/animalistic part of our brain that is wired to ensure survival and releases cortisol to the brain to prepare us for survival (fight, flight, or freeze) while other systems are simultaneously being shut down (accessing language/information, reasoning/problem-solving) – this is a primitive in that brain cannot decipher what is a real or benign threat. After a stressful event, the hippocampus works to remember the event accurately and make sense of it. The prefrontal cortex helps us think through decisions, regulate emotional responses, and slam on the ‘brakes’ when we realize something we first feared isn’t actually a threat after all.

Q. How does trauma create PTSD?

Traumatic events cause changes in brain chemistry and structure:

• Hippocampus. Trauma may be so overwhelming that memories of the traumatic event are fragmented and stored separately (i.e., sounds, visual images, olfactory/smells, sensory sensations) and are not integrated into our higher-level thinking and conscious mind.
• Amygdala. The emotional system in our brain is now over-reactive to the environment and being unnecessarily activated (triggered) by benign stimuli associated with the original trauma, which results in a heightened fear response (flashbacks, panic).
• Prefrontal cortex. The largest part of our brain that helps us think rationally is now under-reactive and unable to regulate the emotions triggered by the amygdala when we need it the most.

Prognosis of PTSD

Q. Does physical injury correlate with PTSD?

Current studies suggest the prevalence of PTSD is higher in patients who sustain injuries to the musculoskeletal system (between 13 percent and 51 percent) as a result of an accident or trauma to the body. See Warren AM, Jones AL, Bennett M, et al., Prospective evaluation of posttraumatic stress disorder in injured patients with and without orthopaedic injury. J. Orthop Trauma, 2016;30: e305–e311.

Q. Are some people more predisposed to PTSD?

Yes. People who are subject to childhood stress or violence, lack the security of a positive relationship, and lack social support are at greater risk. See Laura Palmer, Sam Norton, Roberto J. Rona, Nicola T. Fear, Sharon A.M. Stevelink, The evolution of PTSD symptoms in serving and ex-serving personnel of the UK armed forces from 2004 to 16: A longitudinal examination, J. Psychiatric Rsch., Vol. 157 (2023).

Q. How can we assess PTSD? And what are some of the specific tools?

The assessment of PTSD should include cognitive/intellectual assessment, tests of executive functions and attentional control, psychological assessment, personality testing, and tests or scales ruling out malingering.

The following measures to assess for or rule out PTSD are recommended:

• Wechsler Adult Intelligence Scale - Fourth Edition (WAIS-IV) (ages 16.0 – 90.11) and Wechsler Intelligence Scale for Children-Fifth Edition (WISC-V) (ages 6.0 - 16.11):A person’s neurological ‘wiring’ and inherent strengths and challenges should generalize into their natural environment (outside of a traumatic brain injury).
• Delis-Kaplan Executive Function System (D-KEFS): Executive functions can assess attentional shifting, which moderates the effect of rumination on PTSD symptoms, in addition to helping to delineate if impulsivity is inherent to the individual or driven by high levels of anxiety (cortisol).
• Continuous Performance Test-Third Edition (CPT-3): The CPT-3 assesses areas of inattentiveness, impulsivity, sustained attention (attentional control), and vigilance.
• Personality Assessment Inventory (PAI) and Personality Assessment Inventory-Adolescent (PAI-A): Both measures assess psychopathology and contain validity scales designed to assess factors that could distort the results of testing.
• Millon Clinical Multiaxial Inventory-Fourth Edition (MCMI-IV) and Millon Adolescent Clinical Inventory-Second Edition (MACI-II): Both measures provide an in-depth analysis of personality functioning/personality disorders and clinical symptoms and contain validity scales designed to assess factors that could distort the testing results.
• Minnesota Multiphasic Personality Inventory-3: The MMPI-3 (revised in 2020) is one of the most common psychometric measures devised to assess personality traits and psychopathology and includes validity scales for detecting overreporting and underreporting.
• Trauma Symptom Inventory-Second Edition (TSI-2): The latest version of the TSI-2 (published in 2011) was developed “in light of the fact that the first version of the TSI was unable to detect instances when PTSD symptoms were over-reported, grossly exaggerated” (feigning -Individuals who are attempting to feign (or fabricate/pretend) psychopathology by endorsing a wide range of symptoms to an extreme degree.) “…or fully fabricated” (malingering - independent of psychopathology and tend to be observed in persons that are attempting to simulate a mental disorder (particularly severe mental disorders) due to external incentives.) (Palermo, C. A., & Brand, B. L. (2019). Can the Trauma Symptom Inventory-2 distinguish coached simulators from dissociative disorder patients? Psychological Trauma: Theory, Research, Practice, and Policy, 11(5), 477–485.)
• Structured Interview of Reported Symptoms-Second Edition (SIRS-2): The SIRS-2 (revised in 2010) has been developed to assess deliberate distortions in self-reporting symptoms.

Q. Are psychologists bound by ethical standards?

Yes. Psychologists and neuropsychologists are expected to follow “best practice” and are ethically bound to perform objective testing following the American Psychological Association (APA) Guidelines for Psychological Assessment and Evaluation (PAE). American Psychological Association, APA Task Force on Psychological Assessment and Evaluation Guidelines (2020); APA Guidelines for Psychological Assessment and Evaluation.

Q. Can we police malingering?

Yes. Using assessment measures containing validity scales is critical and measures designed to rule out malingering. A competent expert can spot biased testing and the avoidance of using objective testing.

Q. Do all evaluators adhere to these standards?

No. I have encountered biased evaluators/experts who promote results that lack sophistication and arrive at stark conclusions that are not supported by the data or are inconsistent with the history of the case and the overall functioning of the individual.

The most common sources of bias affecting the interpretation of psychological assessment data include distortions by an evaluator who is resorting to subjectivity (rather than objectivity) based on preconceived beliefs and, favoring data from one source over another and selectively giving too much weight to certain data to suit the needs of a particular case.

Q. What is the risk of these biased findings?

Skewed findings in favor of positive outcomes for an attorney’s client are likely to backfire. It is easy for a seasoned clinician to spot test data inconsistencies, the use of outdated and unsophisticated testing measures, the avoidance of using assessments that contain validity scales, a failure to rule out malingering, embellishment of test findings, and incorporating statements that lack in impartiality.

Q. How would you describe “best practices” for assessing PTSD claims in litigation for either side?

Psychologists and neuropsychologists are expected to be able to appropriately select and accurately interpret the tests they administer, maintain an appropriate degree of responsibility in understanding the strengths and weaknesses of all assessment procedures, and use the latest versions or forms of all tests and procedures.

Accurate interpretation depends on the psychologist’s ability to integrate multiple sources of data points and to reflect accuracy in their interpretation of assessment results while carefully considering and discussing any factors that may have confounded or biased the results. See Hopwood, C. J., & Bornstein, R. F. (Eds.), Multimethod clinical assessment (2014).

In Closing

From this interviewer’s perspective, having the right objective expert in a PTSD case is critical. As Dr. Stone notes, there are specific and exhaustive assessments to utilize in evaluating a PTSD claim. A plaintiff should make good use of these measures to assess PTSD and bring such a claim only when it is scientifically supported (I would suggest robustly supported). A weak PTSD claim that adversely impacts a plaintiff’s credibility may well undermine stronger elements of the case. And we all know the falsus in uno instruction.

From the defense perspective, have your expert review the plaintiff’s data first. A sloppy, incomplete, or dated analysis may be enough to persuade opposing counsel that this claim is not worth the effort. In my own experience, and perhaps stating the obvious, be wary of cases in which the level of PTSD seems disproportionate to the initiating trauma. Have your expert utilize the various measures Dr. Stone references above to drill down to the clinical support for these claims and, hopefully, flag potential bias, exaggeration, and malingering.