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Sample Psychological Report

NAME:
DATE OF BIRTH:
ADDRESS:

COUNTY COURT:
CASE NO
CLAIMANT SOLICITOR
REFERENCE:
DEFENDANT INSURERS:
REFERENCE:
THE PSYCHOLOGY
SERVICE REFERENCE
REPORT DATED:
(1) INTRODUCTION

Mr Brian Jones
22 February 1964
The Rookery
High Street
Midloe
Cambridgeshire
Not as yet known
Not as yet known
Clay More
123456789/jones
Pailess Insurance
Not as yet known
141/J/CP
1 January 2004

(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 claimants
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 hadnt 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 friends 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 friends 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 couldnt enjoy
myself. I didnt 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 friends 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 friends 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 didnt. I
wanted to get away from it all. For the first couple of weeks I lost it for a while, Id 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 Marks 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 friends 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 Joness 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 wasnt. 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 dont 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 Id 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 Marks 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 claimants 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)
(2)
(3)
(4)
(5)

Recurrent/intrusive recollection ? YES


Recurrent dreams NO YES
Acting/feeling As If event recurring NO NO
Distress on exposure YES YES
Physiological reactivity on exposure NO YES

C AVOIDANCE/NUMBING
(1)
(2)
(3)
(4)
(5)
(6)
(7)

Avoidance of thoughts/feelings NO YES


Avoidance of activities/situations NO YES
Inability to recall NO NO
Diminished Interest NO YES
Estrangement/detachment NO YES
Constricted affect NO YES
Sense of foreshortened future NO YES

D INCREASED AROUSAL
(1)
(2)
(3)
(4)
(5)

Sleep difficulties ? YES


Irritability/angry outbursts ? YES
Concentration difficulties NO YES
Hypervigilance NO YES
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
from
from
from

score from 0 to 9 is within the normal range


10 to 18 indicates mild to moderate depression
19 to 29 indicates moderate to severe depression
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 Joness 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 Joness 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 Joness 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
friends 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 reexperience 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.