PTSD and the Law of Psychiatric Injury in England and Wales: Finally Coming Closer? Marios C. Adamou, MD, MSc, LLM, MRCPsych, and Anthony S. Hale, MB, BS, PhD, FRCPsych With the increase in terrorism in several parts of the world, more people are exposed to traumatic events that could cause psychiatric injury either to them or to members of their families. In Britain, terrorist attacks or other catastrophes are not unknown; indeed, the case law relating to psychiatric injury is vast. However, the intersection between medicine and the law is minimal. The result is a law that lags behind the scientific evidence and, on occasion, may seem unfair. J Am Acad Psychiatry Law 31:327–32, 2003 With the events of September 11 still fresh in our minds, we cannot fail to wonder what the impact might be on the lives of people present at the World Trade Center and the Pentagon, or even on the view- ers of television who witnessed this catastrophe. An early report 1 of a national survey assessing the imme- diate mental health effects of the terrorist attacks has already found 44 percent of adults reporting one or more substantial symptoms of stress. Britain has had its share not only of terrorist at- tacks but of other catastrophes. On some of these occasions, claims were brought forward for compen- sation, resulting in the development of the case law for psychiatric injury, previously called “nervous shock.” We will first discuss how well this case law stands up to criticism when the findings of medical research on post-traumatic stress disorder (PTSD) are applied. Second, we will attempt to bridge the two disciplines of medicine and law in discussing how the current medical research on PTSD can re- form the current case law. Post-traumatic Stress Disorder PTSD is a special case in psychiatric classification. It is the only syndrome, besides the adjustment dis- orders, with an existence that depends on an identi- fiable external event. Classified as an anxiety disor- der, it is typically defined by the coexistence of three clusters of symptoms: re-experiencing, avoidance, and hyperarousal. The core features of PTSD in DSM IV-TR 2 are: (1) a traumatic event that involved actual or threat- ened death or serious injury, or threat to the physical integrity of self and others, resulting in a person’s responding with fear, feelings of helplessness, or hor- ror; (2) the re-experiencing of the trauma in night- mares, intrusive thoughts (flashbacks); (3) the numb- ing of responsiveness, or avoidance of thoughts or acts related to the trauma; and (4) symptoms of dys- phoria and hyperarousal. The diagnosis of PTSD requires the persistence of symptoms for at least one month. It is specified as acute if the duration of symptoms is less than three months and chronic if it lasts longer. It is specified as having delayed onset if the onset of symptoms occurs at least six months after the stressor. PTSD is still described in English law by the ob- solete term “nervous shock.” This term dates back to 1882 when a purely physical syndrome that devel- oped after railway accidents was originally described by Erichsen, a professor of surgery in London. 3 In Dr. Adamou is Lecturer, Kent Institute of Medicine and Health Sci- ences, and Dr. Hale is Professor and Head of the Department of Adult Mental Illness, Kent Institute of Medicine and Health Sciences, Uni- versity of Kent, Canterbury, UK. Address correspondence to: Marios C. Adamou, MD, Kent Institute of Medicine and Health Sciences, Research and Development Center, University of Kent, Canterbury, Kent CT2 7PD, UK. E-mail: mariosadamou@doctors.net.uk 327 Volume 31, Number 3, 2003 REGULAR ARTICLE