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Personal Injury Division

Personal Injury Division  Sample Psychological Report

NAME: Mr Brian Jones
DATE OF BIRTH: 22 February 1964
ADDRESS: The Rookery
High Street
Midloe
Cambridgeshire
COUNTY COURT: Not as yet known
CASE NO Not as yet known
CLAIMANT SOLICITOR Clay More
REFERENCE: 123456789/jones
DEFENDANT INSURERS: Pailess Insurance
REFERENCE: Not as yet known
THE PSYCHOLOGY
SERVICE REFERENCE
141/J/CP
REPORT DATED: 1 January 2004

(1) INTRODUCTION

(1.1) THE WRITER

I am 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 this report.

(1.2) INSTRUCTIONS

The 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.

(2) INVESTIGATION

(2.1) INTERVIEW

DATE OF INTERVIEW: 10 December 2003

ALSO INTERVIEWED: Girlfriend

(2.1.1) ON EXAMINATION

Brian 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.

(2.1.2) THE INCIDENT AND SUBSEQUENT DEVELOPMENTS

On 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 or feelings”.

Almost 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.

It 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.

Although 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.

Mr 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.”

Mr 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.

Mr 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.

He 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.

During 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.

Initially, 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.

Mr Jones did not describe anxiety in other situations and neither did he describe an exaggerated startle reaction.

Prior 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 in motorbikes.

Feelings 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.

There 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.

Irritability 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.

Mr 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.

There 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.

His partner, who attended part of the interview, noted some changes in Mr Jones. These were:

1. 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

Prior 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 the time.”

He 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.

He 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 day.

He 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

Mr 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.

(2.3.1) MEDICAL RECORDS

The 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 investigation.

(a) PRIOR TO THE INCIDENT

In 1994 a previous motor bike accident was noted. There were no references to any associated psychological symptoms.

(b) SUBSEQUENT TO THE INCIDENT

01/06/02 Involved in RTA (physical injuries described)

20/07/02 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

26/11/02 Back to work – coping OK. Main problem now – persisting neck and back pain, aggravated by extension. Advised. PTSD probs slowly improving.

(2.3.2) MEDICAL REPORTS

Mr 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

(2.4.1) DSM-IV POST TRAUMATIC STRESS DISORDER SYMPTOM CHECKLIST

(As compiled by the writer from the above interview)

A (1) Event involving actual/threatened death, serious injury
or threat to physical integrity YES

(2) Experience of intense fear, helplessness or horror YES

Symptom Symptom present
Current post accident but not
necessarily current

B RE-EXPERIENCE PHENOMENA

(1) 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

C AVOIDANCE/NUMBING

(1) 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

D INCREASED AROUSAL

(1) Sleep difficulties ? YES
(2) Irritability/angry outbursts ? YES
(3) Concentration difficulties NO YES
(4) Hypervigilance NO YES
(5) Exaggerated startle NO NO

For 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.

(YES) Symptom present but not necessarily related to PTSD

? Some symptomatology present but does not fulfil criteria

(2.4.2) IMPACT OF EVENT SCALE

This 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.

Sub-scale 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)

(2.4.3) GENERAL HEALTH QUESTIONNAIRE (28 QUESTION VERSION)

The 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.
Client Score

Somatic Symptoms 1
Anxiety/Insomnia 5
Social Dysfunction 3
Severe Depression 0

TOTAL 9

(2.4.4) BECK DEPRESSION INVENTORY (Revised)

This 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.

Client Score
Total Score 15
Cognitive-Affective 8
Somatic-Performance 7

Total 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

(3) DISCUSSION AND OPINION

In May 2002 Mr Jones was involved in a serious road traffic accident in which his friend was fatally inured and Mr Jones himself suffered significant injuries

Whilst 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.

On 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.

On 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.

Mr 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.

Prior 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.

(4) CONCLUSIONS

(4.1) SUMMARY OF DIAGNOSIS

Mr 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 life.

(4.2) CAUSATION

Symptoms of Post Traumatic Stress Disorder are entirely consequent upon the accident.

(4.3) PROGNOSIS

There 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 to come.

(4.4) TREATMENT REQUIRED

None 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.

(5) DECLARATION

I understand 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.

I confirm 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 case.

I confirm 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.

Mr Brown BSc. MSc. CPsychol
Chartered Clinical Psychologist

(6) APPENDIX

Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) – 4th ed. (1994)
Published by the American Psychiatric Association

The ICD-10 Classification of Mental and Behavioural Disorders (1993)
By the World Health Organisation

Zilberg, N.J., Weiss, D.S., *Horowitz, M.J. (1982) Impact of Events Scale: A Cross Validation Study and some Empirical Evidence Supporting a Conceptual Model of Stress Response Syndromes. J Consulting and Clinical Psychology, 50, 407-414.

Golberg, D.P. & Hillier, V.F. (1979) A Scaled Version of the General Health Questionnaire. Psychological Medicine, 19, 139-145.

Oliver, J.M. & Simmons, M.E. (1984) Depression as measured by DSM-III and the BDI in an Unselected Adult Population. J Consulting and Clinical Psychology, 52.892-898.

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