Vignette. A new patient enters the burn center. Deep burns to 50% of the body surface. The next few weeks are a trip through Hell. Two years pass. The patient has survived but with disfiguring scars. A lawsuit is underway, which includes a claim for "psychological damage." Because of my experience in trauma psychiatry, I have been retained as an expert witness for the defense. (It could just as well have been for the plaintiff.) I must keep in mind the conflicting interests of the contending attorneys. I want my testimony to be useful, even-handed, and to the point. Let this vignette serve as our paradigm.

To know burns is to know trauma. Newly burned patients progress through a standard trauma sequence: shock>acute trauma response>repair>stable state, in an orderly fashion. Other traumas follow the same sequence, though internally the various stages will differ. In this article, I use the burn model to sketch the natural history of trauma as I have come to understand it. My emphasis is on mental stress and psychological  residuals, from the perspective of an expert witness. Plaintiffs’ attorneys in personal injury cases should find this outline helpful in clarifying their clients’ of psychological damage. Defense attorneys, for their part, might use it to contest claims that run counter to medical knowledge or biological principles.

A preliminary note: Brain scans and other sophisticated technologies offer the promise that many of my assertions will eventually become accessible to the tools of hard science. When that day comes, expert witnesses will be able to support their testimony with precise definitions and objective data. We’re not there yet. We all know that trauma can give rise to psychological disorders. Posttraumatic stress disorder (PTSD) and major depression are most common, each with its own diagnostic criteria. Yet, in any given case, some symptoms may portend disaster while others remain inconsequential—a distinction that expert witnesses need to keep in mind.

Shock is characterized by circulatory collapse and other emergency shutdowns—always alarming and often dangerous. Think of it as a serious, but time-limited physiological disturbance: emotionally distressing to be sure, but unless associated with brain damage, unlikely to cause long-term mental problems.

• For the plaintiff: Traumatic shock’s "emergency room" flavor heightens the emotional impact of the victim’s testimony.
• For the defense: Shock may be likened to the stress of childbirth. When it’s over it’s over.
• The expert witness: Be ready to clarify how a "shocking experience" (e.g., viewing a disaster on television) differs in kind from traumatic shock.

Think of the acute trauma response as a call to arms. At first, internal organs behave autonomously, using their own built-in programs. Before long they come under the influence of Brain, the body’s chief executive organ. The time for making has then arrived, and with it, inevitable, anxiety. Anxiety energizes the very symptoms which, if unchecked, segue into posttraumatic stress disorder (PTSD): hypermetabolism, sleep disturbance, flashbacks, intrusive imagery, avoidance, denial. As if to balance these destabilizing effects, nature has wisely included regression in her trauma response. Regression means that one reverts to a more childlike state which is considered to be a stabilizing, back-to-basics strategy.

Forward-looking counselors view regression as providing a window of opportunity, rich with possibilities for emotional growth.

• For the plaintiff: The acute trauma response represents an incubation period for psychological complications. The victim’s testimony, supported by that of percipient witnesses, can be cited as evidence of mental decompensation. Marital discord, loss of consortium, and social conflict, when they occur, broaden the base of the claim. Persistent, unremitting stress opens the door to major depression; interpersonal complications open the door to PTSD. Both are chronic, often disabling, disorders.
• For the defense: the acute trauma response has its benefits. For example, regression encourages emotional bonding between victim and caregivers. Bonding heals. While pain and suffering tend to favor the plaintiff’s claim, the fact that many trauma victims find their lives changing for the better may work to the defense’s advantage. A witness who ignores or minimizes these positive effects can properly be challenged. Furthermore, acute trauma by its very nature lends itself to dramatic and sensational exploitation. PTSD may, in fact, sometimes represent little more than a passing dislocation in an otherwise stable life. The criteria for PTSD include more subjective elements that invite deliberate exaggeration and distortion. PTSD symptoms are not necessarily destructive. For skilled psychotherapists, flashbacks, intrusive images and trauma-related dreams are viewed as Nature’s attempt to revisit and undo a destabilizing event—an opportunity for caregivers to intervene and help the victim "tame" the memories.
• The expert witness: During training, psychiatrists and other mental health professionals learn to recognize and treat damage inflicted by remote traumas, especially those of infancy and childhood. Traditionally, less attention has been given to the immediate effects of acute trauma. In no way does expertise in the former area guarantee competence in the latter. For that reason, attorneys on either side of a personal injury claim might take issue with testimony that relies heavily on psychological interpretations rooted in the remote past. An expert witness should be able to specify what techniques were used to rule out spurious claims and malingering. The witness should be prepared to describe whether the issue of secondary gain was addressed with the patient and caregivers, and if so, how.

Think of psychological repair as a file in the patient’s recovery folder. It contains information on how to avoid interpersonal complications. ("Reduce social contacts", "Don’t antagonize caregivers"). There are formulas for self-evaluation ("Look to your priorities—at what’s important in life—and who’s important in life"). There are instructions for maintaining the dependency state throughout the active bonding process. However, while dependency is useful during active repair, prolonged dependency can impede recovery. A pre-existing neurosis tends to perpetuate the condition but, apart from a major mental illness, does not relieve the patient of responsibility for engaging in productive activity sooner, rather than later.

• For the plaintiff: As a rule, the longer the repair process, the greater the risk of lasting psychological damage. Also, if another trauma occurs during this time, the new trauma may re-ignite the earlier one. The patient may then revisit the acute stress response, compounding the problem.
• For the defense: Back to the benefits. During repair, interpersonal gains achieved during the acute stress response are secured. This is a time when one "occupies the territory". Barring serious complications, friendships deepen and marriages improve during the repair process.
• The expert witness: Keep in mind that no one emerges from major trauma unchanged. Sometimes the net change is for the worse, sometimes for the better. To remain credible, a witness must always be prepared to admit this simple fact.

"Stable state" corresponds to the expression "permanent and stationary" and, as such, speaks for itself. Issues of compensation (How much? For how long?) go beyond the scope of this article.

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