Hugh Koch1, Paul Elson2, Richard Cosway3, Sophie Mayhew4
1Hugh Koch, Chartered Psychologist, Hugh Koch Associates, Cheltenham, U.K., visiting Professor to Stockholm University, Sweden.
2Paul Elson, Chartered Psychologist, Cheltenham & Cardiff.
3Richard Cosway, Chartered Psychologist, Cheltenham & Edinburgh.
4Sophie Mayhew, Chartered Psychologist, Cheltenham & Truro.
Corresponding Author: Hugh Koch, Chartered Psychologist, Hugh Koch Associates, Cheltenham, U.K., visiting Professor to Stockholm University, Sweden. Tel: 01242 263 715; E-Mail: Hugh@hughkochassociates.co.uk
Received Date: 14 Mar 2016
Accepted Date: 15 Jun 2017
Published Date: 19 Jun 2017
Copyright © 2017 Koch H
Citation: Koch H, Elson P, Cosway R and Mayhew S. (2017). Specific Phobia Following Road Traffic Collision: MedicoLegal Issues of Causation, Diagnosis, and Prognosis in Single Case Study. Mathews J Case Rep 2(2): 029.
The multi-faceted assessment process involved in providing evidence of psychological injuries to the courts is illustrated with particular reference to a case study of a road traffic collision claimant diagnosed with a specific travel phobia. The need for reliable medico-legal processes is emphasized.
Road Traffic Collision (RTC); Medico-legal postulates; Diagnosis.
Assessing trauma in personal injury compensation cases in the civil courts is complex. It involves consideration of many overlapping clinical and medico-legal issues . Experts providing evidence need experience in assessing reliability and truthfulness [2, 3]. This publication addresses these issues in the context of a road traffic collision (RTC) and a common cluster of psychological symptoms, diagnosed as a specific phobia (travel), classified as DSM-V 300.29 . The case study individual presented here who was seen by the first author is anonymised, and an aggregation of salient features seen across several cases are discussed here.
BACKGROUND OF RTC CASE
Mr. Smith (21 years of age) was a rear seat passenger in a 4x4 vehicle travelling on a dual carriageway outside London. The vehicle was hit by an oncoming vehicle - both vehicles were travelling at approximately 60 mph. The claimant's vehicle was knocked into a ditch and rolled over partially. The claimant attended a nearby hospital with physical injuries to his neck, shoulders and back, however he was not admitted to hospital. He sought help and advice from his general practitioner (GP). He had previously been learning to drive prior to the index accident.
The claimant was interviewed approximately 9 months postaccident. He described a mixture of post-traumatic stress symptoms, mood disturbance, social withdrawal, and, predominantly, travel anxiety as both a passenger and a 'learner' driver. This was supported by history of GP attendance. Although the stress and mood disturbance had largely subsided, his main difficulty with travelling remained. The interviewer considered a range of diagnoses as illustrated in the amended road map/decision tree, for anxiety,  in (Figure. 1) below.
Figure 1: Amended Decision Tree for Anxiety.
To obtain a differential diagnosis for a specific phobia, this cluster of symptoms must be differentiated from other anxietybased disorders as illustrated in (Figure 2) below .
Figure 2: Differential Diagnosis for Specific Phobia.
|Specific Phobia must be Differentiated from...||In contrast to the specific phobia, the other condition...|
|Panic Disorder with Agoraphobia||Is characterized by recurrent unexpected Panic Attacks and avoidance of typically many different situations|
|Social Phobia||Is characterized by fear and avoidence of social situations.|
|Avoidance in Posttraumatic Stress Disorder||Is related to stimuli that remind the individual of a previously experienced life-threatening event.|
|Avoidance in Obsessive-Compulsive Disorder||Is associated with the content of the obsessions (e.g. dirt, contamination)|
|Avoidance in Separation Anxiety Disorder||Is associated with fear of separation from parents or caretakers.|
|Avoidance in Psychotic Disorders||Is in response to a delusion (without the recognition that the fear is excessive or unreasonable)|
|Non-pathological avoidance of circumscribed objects or situations||Lacks clinically significant impairment or distress (e.g. person who fears snakes but lives in Manhattan.|
Having decided the 'best fit' diagnosis for Mr. Smith was a Specific Phobia (Travel), the expert assessed that the claimant's ongoing phobia of travelling was unlikely to resolve spontaneously and he therefore recommended 8 - 10 sessions of cognitive-behavioural therapy (CBT), focusing on a gradual re-exposure model in line with prevailing research . Psychometric test data using the GAD-7 & PHQ-9 indicated a high level of low mood and anxiety which acted as a base line measure of his general psychological state/difficulties. [7, 8].
12 months later, the expert was re-instructed to review Mr. Smith's psychological status, following receipt of 10 sessions of CBT which had focused on gradual re-exposure to travel situations of increasing complexity. He reported significant improvement in his travel anxiety and avoidance with no current disruption. Repeated psychometric testing was consistent with a lowered level of mood disturbance and generalised anxiety, as shown in (Figure 3).
Figure 3: Psychometric Scores On Two Occasions.
Raw scores and ranges are shown above.
MEDICO-LEGAL ISSUES IN MR. SMITH'S CASE
The two assessments of Mr. Smith's psychological status and the opinions given to the Court were consistent with commonly held medico-legal postulates (9) shown in (Figure 4) below.
Figure 4: Koch's Medico-legal Postulates.
In particular, Mr. Smith's history included the following
One previous road accident
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Pre-existing vulnerability to anxiety
High frequency of driving prior to accident
Post accident bereavement
Feelings of injustice
Pre-existing vulnerability to anxiety
Use of 'but for' theorem to assess attribution (10)
Evidence-based 'default' model for post trauma recovery
Credibility of Claimant
Given the complex area of claimant reliability in personal injuries previously described (3), a list of credibility variables were addressed by the interviewer which included verbal and nonverbal behavioral cues and content analysis of self-report, witness statement and pre-interview questionnaire. An overall aggregated score was consistent with Mr. Smith being a highly credible/reliable historian.
This case study and description of clinical and medico-legal aspects of assessing and treating a trauma reaction diagnosed as a specific phobia illustrates the many facets of this type of evidence collection in civil cases including the essential proof of causation . It has shown the need for concise and reliable assessment followed by rapid formulation of treatment requirements in line with recommended guidelines . It is essential that experts and lawyers are fully aware of diagnostic factors such as range of opinion and decision-making analysis as well as the medico-legal postulates underpinning the whole assessment process.