as yet known
as yet known
as yet known
Mr Brown. I am a Chartered Clinical Psychologist. My specialist
field is psychological trauma an area within which I have worked
over the past twelve years. Full details of my qualifications entitling
me to give expert opinion and evidence are set out at the end of
case concerns an accident dated 31 May 2002 in which the claimant
allegedly suffered personal injury. I have been instructed by Clay
More Solicitors, to investigate for the court whether the claimant
has suffered a formal psychological/psychiatric condition as a result,
and the effects and prognosis of this if appropriate. I have been
provided with the claimant’s general practice notes and records.
In addition I have also been provided with a medical report by Mr
R Bones, Consultant Orthopaedic Surgeon, dated 28 April 2003.
OF INTERVIEW: 10 December 2003
Jones gave a clear and consistent account of the accident and his
subsequent reactions. He was distressed and somewhat tearful throughout
much of the interview.
THE INCIDENT AND SUBSEQUENT DEVELOPMENTS
31 May 2002 Brian Jones was on his way to Cambridge, riding his
motorbike with his friends. He recalled that it was approximately
7.00 pm and had started to rain. Consequently, a friend, Peter,
decided that they should take a back route although Mr Jones had
not wished to go that way, preferring their normal route, which
was “fun for bikes”. Mr Jones recalled that as they
negotiated a corner they were suddenly confronted with a vehicle
spinning out of control in front of them. His friend, Peter, was
leading the group of motorcyclists on the inside and he said “He
hadn’t a chance, he hit straight into the side of car and
flew off his bike”. Mr Jones himself was also knocked off
and, at the time of the accident, there was “no time for thoughts
before Mr Jones had come to a halt he was up on his feet and ran
back to check upon his friend. He described the physical state of
his friend noting “a hole where his eye was, the visor had
completely gone.” To his surprise there was no blood, and
that remained in his mind after. He was immediately aware that the
situation was hopeless and that there was nothing that could be
done for his friend. He felt a mixture of feelings of anger toward
the driver but also horror at what he had seen. He recalled not
wishing to go near his friend again as he did not want to see the
image of the devastation to his face once more. He described how
he was “running around like a headless chicken”, trying
to organise the situation, stopping other people approaching Mark
and to telephone for the emergency services.
was some twenty minutes or so before the ambulance arrived and,
even though Mr Jones knew that his friend’s situation was
hopeless, he felt “so mad that it had taken them so long.”
At one point in the aftermath he recalled taking himself off and
crying, reflecting that he was in a state too and full of despairing
thoughts for his friend’s mother. During the interview he
cried as he relayed this emotion. His partner was called to the
scene and he returned home with her, feeling numb and confused,
not wanting to talk about the accident.
at the time of the accident Mr Jones had been unaware of any particular
pain, he reflected that the day after his knee was very swollen
“like a football” and his neck and back ached. He went
to hospital where no bony injuries were noted but he was advised
him to rest. He was off work for a period of some six weeks or so,
noting that pain was acute for several weeks after the accident.
Although he endeavoured to return to work beforehand he reflected
that back pain was severe and he was in “agony”. However,
he was desperate to get on with his normal life at the earliest
possibility and did not like being at home on his own. Over time,
there has been much improvement in his physical condition although
he continues to have some pain if he undertakes certain activities.
Jones described feeling very low and irritable during the first
few months after the accident. This frequently played on his mind
and he had thoughts such as “Why did we go that way? Why did
we let Peter lead?” Intense ruminations and imagery was apparent
during this period of time and frequently evoked feelings of irritability.
He was withdrawn and described how he would push his partner away.
He did not want her to hug him and, in bed, would roll away from
her. As a result the relationship suffered. Likewise, he was also
lacking in any motivation or interest in his life generally and
reflected how “I couldn’t enjoy myself. I didn’t
feel up to anything. I just wanted a rest.”
Jones described strong ruminations and imagery during the first
few months. He would frequently recall the accident scene and the
image of his friend’s injured face Mr Jones described some
feelings of survivor guilt that he had not done anything for his
friend and also felt angry with himself for “not even trying”.
His feelings about the accident are also combined with those of
grief. He greatly misses his friend, having worked and socialised
together in the past.
Jones described marked intrusive imagery in which he would re-experience
the image of his friend’s face evoking feelings of marked
distress. This would occur frequently during the first few months
after, particularly at night time when trying to go to sleep. Even
now, the image continues to wake him up on occasions and is apparent
when he talks about the accident.
has felt and continues to feel at times intense distress on reminders
of the accident. This reflects both the loss of his friend but also
the guilt and anger that he has felt about the way his friend died
and the fact that he did not do anything at the time. Again during
the interview he was tearful describing this emotion. Consequently,
he has endeavoured to avoid thoughts or feelings of the accident.
He said, “I wanted to talk about it but I didn’t. I
wanted to get away from it all. For the first couple of weeks I
lost it for a while, I’d just jabber on about all sorts.”
He reflected that he was drinking more than usual, particularly
at night time when thoughts of the accident would come back intensely.
During the day he would endeavour to distract himself whilst at
home off sick, by watching films, videos or reading books.
the first few months he had frequent distressing dreams of the accident,
noting that he would “wake up coming round that corner or
looking at Mark’s face”. These were so frequent initially
that he was fearful to close his eyes or go to sleep. They have
improved in frequency over time although continue to occur on a
once a month basis.
his sleep was greatly disturbed on account of both intrusive thoughts
and imagery of the accident and also through recurrent dreams. Consequently,
he tended to drink more alcohol than usual which would help him
get off to sleep but then he would wake through the night. Sleep
disturbances gradually began to improve and after he returned to
work his sleep began to settle into a more normal pattern.
Mr Jones described how after the accident he did not wish to resume
motorbike riding. However, he described forcing himself to ride
a bike whilst a friend followed in his car. He uncharacteristically
went at forty miles per hour all the way and by the time he arrived
at his destination he felt sick, dizzy and was shaking. He has still
not acquired a replacement motorbike although more recently he has
felt that he would like to do so. He has occasionally ridden friend’s
bikes but continues to experience notable anxiety.
When driving he did not describe any significant difficulties. However,
he hates travelling as a passenger and avoids it where possible.
When driving he tends to be slower and less aggressive, tending
to question the situation more. He is much more aware now of what
could happen and constantly looks out for vehicles, particularly
when approaching corners, for fear of a similar accident occurring.
He is also exceedingly wary of motorbikes in general.
Jones did not describe anxiety in other situations and neither did
he describe an exaggerated startle reaction.
to the accident motorbikes were Mr Jones’s main interest.
He had always loved this activity and would go out regularly each
week for a ride, simply because he enjoyed the situation so much.
In addition, he described other interest such as riding a bicycle,
fishing and golf. Initially, during the first few months, Mr Jones
described marked diminished interest in his previous activities.
He had no motivation to do anything and even when he went out socially
with friends he would “be there but I wasn’t”.
During this time he was drinking more than usual and would often
become aggressive in his conversation, particularly if the accident
or his friend was discussed. As a result he often avoided social
situations. Even now, he no longer sees his friends as much, reflecting
that he feels different from them and no longer has the same interest
of detachment and estrangement were apparent in respect to his close
family and his partner. During the interview he became tearful as
he described how initially he would push his partner away and was
unable to cope with any physical contact. Even now, he finds it
difficult to get close to her but reflected that “I don’t
want to lose her”. He has also been more detached from his
family and, whereas in the past he would join them watching television
in the evening, he now spends more time alone in his bedroom. Likewise,
at work he tends to keep himself busy rather than spending time
with his fellow colleagues.
was an indication of constricted affect during the first few months
and also of low libido notably in respect to his emotions towards
his partner and his inability to cope with intimacy. During this
period he did not have the same loving feelings toward her.
and angry outbursts were marked during the first few months. This
was in respect to his feelings about the accident and his distress
that his friend had been killed. He described how when he went out
socially he would “always want to be hitting someone”.
Even with his partner he described how he would “be so nasty
that I’d make her cry so many times”. As a result their
relationship was very tenuous during this initial period of time.
The extent of his irritability has improved over time although it
remains apparent on occasions, particularly when he is tired.
Jones found it difficult to concentrate initially, reflecting that
even if he went fishing it took him ages to put the line with the
hook given his distraction. Likewise, when watching television he
would be constantly “channel flicking”. If reading a
book or magazine he would flick through the pages rather than read
any particular article. Even when he returned to work he found that
his mind would wander and he would “disappear into my own
world”. As a result he had “a few tellings off”.
Concentration has again improved although reoccurs on occasions
when he is tired.
was indication of a sense of foreshortened future as Mr Jones reflected
that whilst he had considered settling down with his partner and
having children he subsequently felt that he could be involved in
a further similar accident again and that he too could be killed.
Consequently, he felt that there was no point in making plans. This
has improved to some extent over time.
partner, who attended part of the interview, noted some changes
in Mr Jones. These were:
He was very nasty and short tempered at first and was “stressed
out a lot of the time. It would always get back to the accident.”
This situation has improved to some extent over time.
2. He was initially reluctant to talk about the accident as he felt
weak in himself.
3. He was less interested in sex and was not as close emotionally.
4. He did not have the same interest or enjoyment in activities.
5. He would talk about the accident and ‘what he saw”.
It appeared that he wanted to go into detail of the image of Mark’s
face, “needing to get it out”.
6. He had many nightmares and would wake up in the morning feeling
very tired. Again, nightmares were always of what he saw that night.
7. He was waking up a lot during the night and his sleep was poor.
This has improved to some extent over time.
8. He can still be very nasty and short tempered on occasions.
(2.2) PREVIOUS PERSONAL HISTORY
to the accident Mr Jones was described by his partner as being a
“joker, laid back, we had lots of fun, we used to laugh all
was born and brought up in Cambridge and has one sister and large
extended family who all live nearby. He described his childhood
as “fun”, reflecting that he was the eldest and therefore
spoilt. His father is a builder whilst his mother is a housewife.
did not particularly enjoy his education and he described some problems
coping with the academic work. He described having many friendships
and was “Mr Popular”. He left school at the age of sixteen
years and has worked as a painter and decorator until the present
did not describe any previous serious relationships. However, he
has been with his current partner for two years and he described
the relationship as very good and said that they are close.
(2.3) PREVIOUS MEDICAL HISTORY
Jones noted his previous medical history and described a number
of minor falls from his motorbike without any significant physical
or psychological impact. He has also had minor car accidents. He
did not describe any psychiatric history in either himself or his
family. After the accident he noted how his doctor suggested that
he saw a stress counsellor but Mr Jones refused, feeling that talking
about the accident would make it worse.
claimant’s general practice records from 1978 have been obtained
and studied in respect of references to psychological or psychiatric
symptoms/conditions which predate the matter under litigation, or
occur subsequent to it, and which may be relevant to the current
PRIOR TO THE INCIDENT
1994 a previous motor bike accident was noted. There were no references
to any associated psychological symptoms.
SUBSEQUENT TO THE INCIDENT
Involved in RTA (physical injuries described)
Bad headaches and nose bleed. Not sleeping discussed accident and
death of friend. Flashbacks, nightmares, more aggressive and been
involved in fights. Relationship probs with gf. ? PTSD ?Counselling
Back to work – coping OK. Main problem now – persisting
neck and back pain, aggravated by extension. Advised. PTSD probs
Bones, Consultant Orthopaedic Surgeon, dated 28/4/03. Physical symptoms
reported. In respect to psychological symptoms nightmares and flashbacks
were noted during the initial months after.
(2.4) TEST RESULTS
DSM-IV POST TRAUMATIC STRESS DISORDER SYMPTOM CHECKLIST
compiled by the writer from the above interview)
(1) Event involving actual/threatened death, serious injury
or threat to physical integrity YES
Experience of intense fear, helplessness or horror YES
Current post accident but not
Recurrent/intrusive recollection ? YES
(2) Recurrent dreams NO YES
(3) Acting/feeling “As If” event recurring NO NO
(4) Distress on exposure YES YES
(5) Physiological reactivity on exposure NO YES
Avoidance of thoughts/feelings NO YES
(2) Avoidance of activities/situations NO YES
(3) Inability to recall NO NO
(4) Diminished Interest NO YES
(5) Estrangement/detachment NO YES
(6) Constricted affect NO YES
(7) Sense of foreshortened future NO YES
Sleep difficulties ? YES
(2) Irritability/angry outbursts ? YES
(3) Concentration difficulties NO YES
(4) Hypervigilance NO YES
(5) Exaggerated startle NO NO
a DSM-IV diagnosis of PTSD, positive answers are required from (A)
1 and 2, a minimum of one symptom from (B), three symptoms from
(C) and two symptoms from (D). In addition, there must be clinically
significant impairment of functioning.
Symptom present but not necessarily related to PTSD
symptomatology present but does not fulfil criteria
IMPACT OF EVENT SCALE
self-rating scale, which measures the degree of psychological impact
of a traumatic event, has two subscales. INTRUSION corresponds to
the first axis of PTSD, RE-EXPERIENCE PHENOMENA; and AVOIDANCE,
which corresponds to the avoidance of thought/feelings or reminders
in the second axis, AVOIDANCE/NUMBING. This questionnaire is not
used as a diagnostic tool.
Client Score Average score of patients
attending a trauma stress clinic
(Zilberg et al, 1982)
Intrusion 27 21.2 (SD=7.9)
Avoidance 32 20.8 (SD=10.2)
GENERAL HEALTH QUESTIONNAIRE (28 QUESTION VERSION)
GHQ is a self-rating scale for screening for psychological disorder
in the general population. The threshold score for identifying “Caseness”
is 4/5, ie above which there is an increasing likelihood that the
person would be classified as suffering from significant psychological/psychiatric
symptoms. The range is 0 to 28. This questionnaire is not used as
a diagnostic tool.
Social Dysfunction 3
Severe Depression 0
BECK DEPRESSION INVENTORY (Revised)
self-rating scale is divided into two subscales. The Cognitive-Affective
subscale measures the severity of depressive thought and feelings,
and the Somatic-Performance subscale measures the severity of the
physical and social aspects of depression. This questionnaire is
not used as a diagnostic tool.
Total Score 15
score from 0 to 9 is within the normal range
from 10 to 18 indicates mild to moderate depression
from 19 to 29 indicates moderate to severe depression
from 30 to 63 indicates extremely severe depression
DISCUSSION AND OPINION
May 2002 Mr Jones was involved in a serious road traffic accident
in which his friend was fatally inured and Mr Jones himself suffered
he would not currently qualify for a DSM-IV diagnosis of Post Traumatic
Stress Disorder there is a full range of symptomatology during the
first three months or so which would warrant as diagnosis of such.
During this period of time he was markedly distressed by reminders
and frequently suffered from Re-experience Phenomena, notably in
respect to the fatal injuries of his friend including significant
recurrent nightmares. He was emotionally withdrawn, had little interest
in his former lifestyle and tended to be more irritable, pushing
away his partner which resulted in arguments and points of near
separation. Over time, the situation has markedly improved although
symptoms of Re-experience Phenomena remain apparent on occasions.
the Impact of Event Scale, used as a measure of the psychological
impact of a traumatic event, his scores are well above the average
scores for patients attending a trauma stress clinic. This gives
further support for Mr Jones’s traumatic response to the accident.
the General Health Questionnaire, a screening tool for identifying
psychological disorder in the general population, his score is just
above the threshold for identifying “Caseness”. This
is loaded upon the subscale of Anxiety/Insomnia reflecting Mr Jones’s
feelings of raised anxiety in respect to his diagnosis of Post Traumatic
Stress Disorder. On the Severe Depression subscale his score is
zero and on the Beck Depression Inventory his score lies just within
the range indicating mild to moderate depression. Whilst he has
suffered from some low mood he would not at any time have qualified
for a diagnosis of clinical depression.
Jones has suffered from situational anxiety with phobic avoidance
in respect to riding motorbikes and also in the car as a passenger.
He has not as yet replaced his motorbike although has on occasions
ridden motorbikes since. He is hopefully that he may regain this
former hobby in due course.
The main psychological impact of the accident has, therefore, been
in respect to his Post Traumatic Stress Disorder. Indeed, his distress
was obvious both to his family and his doctor who suggested counselling
during the early stages. However, Mr Jones did not feel that he
was ready to accept such an option. Over time, there has been marked
improvement in his condition and he is now endeavouring to get on
with his life.
to the accident Mr Jones was of good personality and of no vulnerability
to the development of a psychological reaction. His symptoms of
Post Traumatic Stress Disorder are entirely consequent upon it.
SUMMARY OF DIAGNOSIS
Jones suffered from a DSM-IV diagnosis of Post Traumatic Stress
Disorder during the first three or four months after the accident.
Symptoms of traumatisation have persisted over time although at
a subclinical level. He is now endeavouring to get on with his normal
of Post Traumatic Stress Disorder are entirely consequent upon the
has been much improvement in Mr Jones’s psychological reaction
over time. Further spontaneous improvement should occur over the
next six to nine months although it must be stated that he will
never be able to forget the accident and the distressing image of
his friend’s fatal injuries may remain with him for some time
currently. Should Mr Jones find that his recovery does not continue
as expected then psychological therapy may be helpful to address
residual symptoms, notably those of re-experience phenomena. EMDR
may be useful in this respect and some six sessions may be required
Whilst this form of therapy may be available within the NHS, it
is a very specialised treatment and, consequently, is likely to
need to be sought privately. In such circumstances therapy should
be budgeted at approximately £150 per session.
that my duty as an expert witness is to the court. I have complied
with that duty. This report includes all matters relevant to the
issues on which my expert evidence is given. I have given details
in this report of matters which might affect the validity of this
report. I have addressed this report to the court.
that I have not entered into any arrangement where the amount or
payment of my fees is in any way dependent on the outcome of the
that insofar as the facts stated in my report are within my own
knowledge I have made clear which they are and I believe them to
be true, and that the opinions I have expressed represent my true
and complete professional opinion.
Brown BSc. MSc. CPsychol
Chartered Clinical Psychologist
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D.P. & Hillier, V.F. (1979) A Scaled Version of the General
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