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

Mrs Jones
6 June 1969
The Rookery
High Street
Midloe
Cambridgeshire
Not as yet known
Not as yet known
Clay More
123456789/jones
Pailess Insurance
987654321
25/JONES/CP
25 October 2003

(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 seven 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 3 November 2002 in which the claimant allegedly
suffered personal injury. I have been jointly instructed by Clay More Solicitors and Pailess
Insurance 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.

(2) INVESTIGATION
(2.1) INTERVIEW
DATE OF INTERVIEW: 6 October 2003
ALSO INTERVIEWED: Mr Jones (Husband)
(2.1.1) ON EXAMINATION

Mrs Jones presented entirely appropriately and gave a clear and consistent account of the
accident and its impact upon her. She was clearly distressed by her level of anxiety in
relation to the driving situation.
(2.1.2) THE INCIDENT AND SUBSEQUENT DEVELOPMENTS
On the 3 November 2002 Mrs Jones was returning home from work and travelling through
the village of Mulsoe. She described how a car in front suddenly braked to turn into a
driveway and as she came to a halt she was hit from behind by a lorry. Her immediate
reaction was, Oh no, I cant cope with this. She disintegrated into tears and was
surprised by the extent of her reaction.
Feelings of distress persisted in the aftermath of the accident and a woman from a nearby
house came to her assistance. She remained in the car and contacted her husband on her
mobile phone, to inform him of the accident. At the scene she recalled feeling totally
pathetic, and unable to control her emotions. The police were called and dealt with the
aftermath of the accident and she later returned home with her husband.
She remained very tearful when she arrived home and went to bed saying, I felt I wanted
to be out of it. Generally felt that she was unable to cope with the extent of her reaction.
She was aware of an overwhelming sense of vulnerability in that accidents could occur at
any time. She did not want to talk about the accident but described vivid intrusive images of
the accident that would repeatedly come into her mind.
The following day Mrs Jones awoke in great pain from her neck and made an appointment to
see her doctor. He diagnosed a whiplash injury and recommended that she rest for a few
days. Mrs Jones was off work for a week or so, during which time the pain was severe.
However, she noted that this has improved since and the pain generally recovered within a
period of several months. On interview she did not report any ongoing pain related
problems.
Mrs Jones gained a replacement vehicle from her insurance, which she needed to attend
work. She reflected that she lives in a rural area and was dependent upon a car for
transportation. However, when the car arrived she described feeling terrified of driving and
that the trip to work became a horrendous experience. This has persisted until the present
day and has dominated her life and caused her significant difficulty.
Mrs Jones has not been able to avoid driving, but generally endures this situation with
dread. She lives in an isolated rural location, has to travel some ten miles to work, and
there is no public transport for her to use. Consequently, she has no option but to drive and
experiences severe and disabling anxiety when she does so. The intensity of her reaction
tends to fluctuate depending on her experiences on the day. Sometimes she is able to make
the journey in one go but more often than not she will have to stop and compose herself, for
example if someone is driving too close behind her, suddenly pulls into her pathway, or if
there are lorries in close proximity. She is unable to drive in the dark or if the weather
conditions are poor. Her employers have been sympathetic toward her difficulties and have

provided her with a computer at home with e-mail, so if she is unable to drive she can
continue to work from home.
Other than avoiding driving in the dark, she also avoids driving on motorways. She will
avoid any non-essential journey and will not even go out shopping, now buying goods over
the Internet. She acknowledged that short local journeys are not too distressing although
she endeavours to limit the time that she spends in the car.
As a result of her driving anxiety her social life has been considerably curtailed. Whereas
she used to drive to see friends, she now no longer does so. She generally prefers to remain
at home and whilst she will occasionally go out to town if necessary, she will avoid doing so
if at all possible. She is exceedingly wary of other vehicles on the road, particularly those
travelling behind her. She feels that she is constantly looking in her mirror and as a result is
aware that she is driving unsafely.
She is also very anxious as a passenger, reflecting that at times she will scream out, and on
one occasion even tried to get out of the car. She will make the driver, usually her husband,
pull over at times given the extent of her distress. She does not feel in control and feels that
the driver tends to go too fast for her. If they do have to go anywhere socially then she
prefers to travel by train.
She feels very despondent about the extent of her anxiety as she is aware how limited her
life has become as a result. For example, she and her husband no longer go for days out in
the ca for pleasure and neither does she go on shopping trips in town which she used to
enjoy.
She has endeavoured to seek help for her difficulties. She underwent a course of driving
lessons but was told that there was nothing wrong with her driving and that it was in her
head. She was referred by her doctor to a counsellor but did not find this of any help in
managing her anxieties.
Mrs Jones did not describe dwelling on the accident and neither did she note spontaneous
intrusive imagery of such. However, she is reminded of the accident whilst travelling in a car
and is always conscious of vehicles travelling behind. The main psychological impact of the
accident would appear to be her shattered belief in her sense of safety whilst travelling in a
car and that there is nothing she can do to protect herself. This is in marked contrast to her
former confidence driving, where she was able to undertake long distances in the car and
had even driven on her own to Scotland and abroad.
Whilst she did not describe having recurrent dreams of the accident she did describe anxiety
type dreams in relation to the driving situation where she will be trying to drive from the
back seat of the car and unable to reach the pedals.
In general her sleep has not been markedly affected by the accident. However, she will wake
up worrying in the middle of the night if she has a particular journey to undertake the
following day.

She did not describe being anxious in other situations other than in relation to car travel.
However, even news of accidents on the television will cause her to worry and feel anxious,
as she fears that she will be involved in a similar incident.
There was no indication of symptoms of emotional numbing. She reflected that life goes
on and is generally happy whilst at home. She did not describe any loss of interest in her
previous hobbies of knitting and sewing, but does feel frustrated that her social life has been
affected on account of her driving anxiety.
Her relationship with her partner has not been effected as she remains close and loving
toward him and, indeed, he would appear to be very patient and sympathetic over her
difficulties. She is not generally more irritable, although does get uptight in the car and rows
can sometimes ensue.
She did not describe any significant concentration difficulties reflecting that she has been
able to cope with her work. However, she does worry that, whilst her employers have been
sympathetic in the past, they would appear to be increasingly frustration about her situation
in respect to her driving anxiety and avoidance.
There is no sense of a foreshortened future.
Her husband, who attended part of the interview, noted a number of changes in Mrs Jones.
These included:
1. The main change has been in respect to driving and car travel and whereas she used to
enjoy going out at weekends, they no longer do so.
2. They no longer have the same social life as they used to and holidays have been curtailed
as these usually involve driving.
3. If scenes of accidents occur on the television, then he has to change channels straight
away.
4. It is difficult to accompany her in the car now given the extent of her anxiety.
5. She is more cautious when she is driving herself.
6. As a passenger, she insists that he pulls over if anything comes up from behind.
7. Her sleep is disturbed prior to any notable journeys.

(2.2) PREVIOUS PERSONAL HISTORY

Mrs Jones was born in South Yorkshire and grew up in Lincoln. She has one sister. She has
good memories of her childhood although her mother suffered from poor health and died
when she was in her twenties. She has remained close to her father whom she continues to
visit on a regular basis. He is now retired and in his eighties.
Mrs Jones enjoyed school and left at the age of sixteen after her GCSE examinations. She
went on to study business and administration at college and has worked with the same

company since then in administration. She is happy in her job and did not describe any
other concurrent stressors.
She has been married since 1995 and she and her husband generally have a good
relationship together. They do not have any children.

(2.3) PREVIOUS MEDICAL HISTORY

Mrs Jones described her medical history noting that she had generally been fit and well. She
did not note any previous psychological problems and history of such in her family. She
recalled a previous road traffic accident several years before that in question, although this
had not affected her confidence driving. She has never taken any psychotropic medication
and neither has she undergone any psychological therapy prior to the accident. Since the
accident, she has seen a counsellor, but did not find this of any help, reflecting that
generally the counsellor just let her talk about her feelings and thoughts associated with the
accident.
(2.3.1) MEDICAL RECORDS
The claimants general practice records from 1970 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
15/12/1996 RTA, hit from the side, low speed, some neck pain. Nil else.
10/3/1998 Some stress at work, not sleeping. Doesnt want medication.
6/4/1998 Feels better now.
(b) SUBSEQUENT TO THE INCIDENT
4/11/2002 Had accident yesterday, some neck pain. Tearful, not depressed. ?PTS. Advise
rest.
03/01/2003 Accident 2/12 ago, terrified of travelling in car. Probs getting to work. Requests
counselling refer M Lewis. Not depressed at present.
29/1/2003 ..fear of driving ? for psychotherapy
05/02/2003 Letter of referral to M Lewis regarding fear of driving which is clearly interfering
with her quality of life

16/04/2003 Letter M Lewis, Counsellor, noting referral and that an appointment had been
offered.
10/08/2003 Still troubled by driving +++

(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 NO
(2) Experience of intense fear, helplessness or horror ?
Symptom Symptom present
Current post accident but not
necessarily current
B RE-EXPERIENCE PHENOMENA
(1)
(2)
(3)
(4)
(5)

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

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

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

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

Sleep difficulties NO NO
Irritability/angry outbursts NO NO
Concentration difficulties NO NO
Hypervigilance YES 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

(3) DISCUSSION AND OPINION

Following a road traffic accident in November 2003 Mrs Jones has suffered a marked
psychological reaction.
She would not at any time have qualified for a diagnosis of Post Traumatic Stress Disorder.
She described no significant symptoms of traumatisation. However, the accident appeared
to shatter her belief that she could travel safely in a car and left her with a marked sense of
vulnerability which underlies her anxiety in relation to car travel.
Mrs Jones clearly suffers from a Specific Phobia in relation to driving/ car travel. Whilst she
has continued to drive she experiences great distress when she does so and generally
endures this situation with dread. The extent of her anxiety has had a marked impact upon
the quality of her life, as she, at times, has to work from home and her social life and
interests have been restricted. Despite counselling there has been no improvement in the
intensity of her psychological reaction over time.
Prior to the accident Mrs Jones will be noted to have experienced some stress at work,
although this was short lived and did not persist for any length of time. There is no
indication of a continuation of a pre-existing condition, and anxiety related to car travel has
never been part of her clinical picture beforehand. Whilst she had had a previous road traffic
accident in 1996 this had not affected her psychologically. Consequently, her symptoms of
anxiety related to driving and car travel can be entirely attributed to the accident in
question.

(4) CONCLUSIONS
(4.1) SUMMARY OF DIAGNOSIS
Mrs Jones has suffered a Specific Phobia to driving/car travel of moderate intensity, which
has persisted without improvement over the past year.

(4.2) CAUSATION

Her symptoms of anxiety related to driving and car travel can be entirely attributed to the
accident in question
(4.3) PROGNOSIS
There has been little improvement to date in Mrs Joness symptomatology despite being
referred for counselling. However, this form of therapy is rarely appropriate in such anxiety
cases and can conversely make the situation worse. She requires cognitive behavioural
therapy and with appropriate intervention there should be good recovery within some six to
nine months from the commencement of such.
(4.4) TREATMENT REQUIRED
Mrs Jones currently requires cognitive behavioural therapy with a therapist such as a
chartered clinical psychologist or cognitive behavioural therapist. This should be sought
privately given the long waiting lists within the NHS and the cost of therapy should be
budgeted at between 90 to 120 per session. Some eight sessions should suffice.
(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