Encyclopedia of Psychology and Law

even inaccurate bad news from a doctor, learning that

one’s child has a chronic disease such as diabetes, and

completing work duties as a policeman or fireman. Of

particular relevance to forensic psychologists is the

determination that PTSD can also occur as a result of

automobile accidents or workplace injuries and even

in response to hearing sexual jokes or experiencing

verbal harassment. Compensation for traumatic symp-

toms resulting from these types of events is now rou-

tinely being sought through legal channels.

The symptom criteria for PTSD in DSM-IV-TR

were also changed. To receive the diagnosis, the trau-

matized person is now required to report at least one

reexperiencing symptom, three or more avoidant/

numbing symptoms, and two or more symptoms of

hyperarousal as a response to the traumatizing event.

Moreover, according to the DSM-IV-TR, the trauma-

tized individual has to experience these symptoms for

at least 1 month, which is considerably less than the 6

months required for the PTSD diagnosis as specified

in the DSM-III.

Another noteworthy addition is that PTSD is one of

the few DSM-IV-TRdiagnoses in which malingering

is specifically identified as a necessary component of

the differential diagnosis. Malingering has been

defined as the intentional production of false or

grossly exaggerated symptoms, as a result of external

incentives. Therefore, clinicians assessing PTSD need

to be able to rule out malingering as a diagnosis when

financial remuneration and/or benefit eligibility are a

part of their patient’s clinical picture. For example,

more than 90% of veterans experiencing PTSD symp-

toms seek financial compensation for their emotional

distress. Determining which, if any, of these patients

are malingering is difficult because most PTSD symp-

toms are obtained by self-report measures and easily

feigned clinical interviews. Therefore, one of the

major problems with the diagnosis is that many PTSD

symptoms are nonspecific and subjective.

It is now recommended that symptom validity tests

be routinely included in PTSD assessment proce-

dures. Clinicians also need to be able to detect when a

patient has been coached to report particular symp-

toms (i.e., by his or her attorney or by a family mem-

ber), as malingering has been considered a threat to

the therapeutic alliance and has been shown to have a

significant negative economic impact. Detecting

malingering may require clinicians to collect accurate

historical records related to the trauma and to interview

other family members about the patient and his or her

symptoms. Clinicians may also need to ask for spe-

cific examples of reported symptoms, look for incon-

sistencies in the self-report, and obtain physiological

measures of responses to trauma-related versus neu-

tral stimuli, if possible. Efforts should also be made to

determine how to best manage and/or treat patients

who have, or are thought to have, exaggerated or

feigned their PTSD symptoms, as this may be a rela-

tively common event in some settings.

Prevalence of PTSD

The DSM-IV-TRindicates that the lifetime prevalence

for PTSD is approximately 8% in the population of

U.S. adults. Women are at significantly greater risk of

developing PTSD than are men. However, estimates

of the rates of the disorder in at-risk or high-risk pop-

ulations have varied substantially. For example,

among the survivors of the Oklahoma City bombing,

only about 35% developed PTSD. There is also evi-

dence that the prevalence of PTSD has been increas-

ing across cultures, perhaps as a consequence of the

broadened criteria for what constitutes a significant

trauma. Since only a small number of individuals

who experience trauma go on to develop PTSD,

researchers have concentrated on delineating risk fac-

tors for developing the disorder. These include lower

intelligence, experiences of childhood trauma and

interpersonal violence, having a psychiatric diagnosis

prior to experiencing the trauma, dissociation in the

weeks following the event, use of avoidance rather

than problem-focused coping strategies, a poor social

support network, and perhaps having a genetic vulner-

ability to strong physiological reactions to stress. The

national comorbidity study also identified a number of

consequences associated with a diagnosis of PTSD.

These included increased risk of developing other

psychiatric disorders, committing suicide, failing

school, experiencing a teenage pregnancy or marital

difficulties, and having an unstable work history.

Issues Related to Diagnosing PTSD in

Children and Other Special Populations

Diagnosing PTSD is especially difficult in children

because they may not have experienced significant

distress at the time of the event (i.e., in some cases of

childhood sexual abuse). They may also have limited

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