Catastrophic injury may be
more than physical

by Dale Panzer, M.D.

Introduction

Each year, hundreds of thousands of Americans’ lives are changed by injuries that leave them with lasting disability. The circumstances that lead to these injuries may be attributable to unsafe conditions resulting from carelessness, risky practices (willful misconduct), or neglect. And while the physical trauma often dominates the clinical and medical-legal discourse, the associated emotional distress may be just as disabling and cannot be overlooked. Assessing emotional damages from a catastrophic injury is a complex calculation that requires the expertise of a forensic psychiatric evaluator with vast experience in the clinical treatment of individuals with such injuries.

What is a Catastrophic Injury?

Catastrophic injuries occur suddenly and most often result from an accident that leads to severe bodily damage. Most catastrophic injuries can be partially accommodated with sophisticated high-quality medical care and rehabilitation, but they are permanent, meaning full recovery is not possible.

The consequences of this type of injury can be life-changing.  In the short term, catastrophic injuries are associated with significant emotional distress, whereas long-term consequences are more variable. As a psychiatrist with over 20 years of experience providing clinical care to thousands of patients with catastrophic injuries, I’ve observed the wide range of individual emotional responses to catastrophic injuries.

Types of Catastrophic Injury

Traumatic Brain Injury (TBI) & Traumatic Spinal Cord Injury account for the majority of catastrophic injuries sustained by Americans each year, with  223,000 TBI-related hospitalizations recorded in 2019 [cdc.gov/TraumaticBrainInjury] and approximately 18,000 spinal cord injuries annually [themiamiproject.org]. The two may result from serious motor vehicle accidents, falls from heights, sports-related injuries, and interpersonal violence, among other causes.

Traumatic amputations comprise 45% of the 185,000 amputations that occur each year [https://www.amputee-coalition.org]. Shockingly, over 1500 military traumatic amputations were performed during the Iraq and Afghanistan wars.

Injuries due to burns (flame, scald, chemical, or electrical) may result in severe disfigurement as well as cause lasting physical damage [The American Burn Association (ABA) National Burn Repository 2019]. Of the estimated 410,000 burns per year in the U.S., approximately 10% (40,000 cases) required hospitalization [WHO website].

Listed below are the more frequently occurring catastrophic injuries, along with a conservative estimate of how many such patients I’ve treated since 1992:

  • TBI (over 500)
  • Spinal Cord Injury resulting in paralysis (over 500)
  • Nerve damage/Nerve injury (over 500)
  • Amputations (over 500)
  • Severe orthopedic injury (over 500)
  • Severe organ damage (over 250)
  • Severe burns (over 150)
  • Facial injury with associated deformity (over 100)

Causes of Catastrophic Injury

Here are the most common reasons why catastrophic injuries occur, and a conservative estimate of how many such patients I’ve treated since 1992:

  • Motor vehicle accidents including car accidents, truck accidents, motorcycle collisions, bike accidents, and pedestrian crashes (over 500)
  • Workplace accidents (over 500)
  • Falls (over 500)
  • Burns, electrical and chemical injuries (over 150)
  • Sports accidents (over 150)
  • Medical malpractice  (over 25)
  • Product defects (over 100)

Emotional & Physical Consequences of Catastrophic Injury

Catastrophic injuries cause more pain and suffering in the short term. The pain and suffering are not only due to the physical trauma. Such injuries are more likely to affect relationships and lead to a loss of consortium.  Quality of life is more likely to be impacted; previously enjoyed recreational activities may no longer be possible to pursue. The capacity to travel outside the home may be restricted, and the ability to perform activities of daily living such as cooking, cleaning, bathing, or grocery shopping independently may be severely limited.  Those with severe physical injuries may lose the capacity to transfer in and out of bed or ambulate without assistance, whereas severely brain-injured people may not be able to think or communicate coherently. Therefore, catastrophic injuries are associated with more emotional distress and often lead to mental health disorders meeting Diagnostic and Statistical Manual of Mental Disorders – 5th edition (DSM-5) criteria.

Common DSM-5 psychiatric diagnoses associated with catastrophic injuries:

A knowledgeable and experienced mental health professional is needed to ensure that DSM-5 criteria are met.

Post-Traumatic Stress Disorder (PTSD):

The serious bodily harm that occurs with catastrophic injuries increases the potential for PTSD. The diagnosis requires patients to meet multiple explicitly identified DSM-5 criteria such as directly experiencing or observing death or life-threatening trauma injury oneself or in a close relative or friend, reliving the traumatic event in flashbacks or nightmares, and avoiding any situations that evoke memories of the event. In forensic settings, PTSD is commonly misdiagnosed.

Adjustment Disorder:

This diagnosis requires a serious precipitant stressor (the catastrophic injury) that directly leads to anxiety and/or depression or behavioral change.  The condition often resolves when the stressor remits, but it may persist with a permanent injury.

Major Despression:

Individuals overwhelmed by catastrophic injuries may develop severe depression immediately, with 5 or more symptoms for a period of two weeks or longer, as required by the DSM-5. This diagnosis is applicable when the intensity and severity of depression exceed the expected response to a specific injury and circumstance.

Panic Disorder:

Individuals often develop panic attacks in the initial stages of catastrophic injury due to a newfound sense of vulnerability and helplessness, and feelings of loss of control.   As the individual accommodates the injury, the panic attacks commonly remit.

Trauma and Stressor-Related Disorder:

This new DSM-5 diagnosis requires severe trauma and identifying that the individual meets some, but not all, DSM-5 criteria for PTSD.

Generalized Anxiety Disorder:

This diagnosis is more appropriate for individuals with baseline anxiety that persists over time but is less directly associated with their injury than is the case for an adjustment disorder. Individuals must meet at least 3 DSM-5 criteria for a timeframe of six months or longer.

Despression Due To Chronic Pain:

Some individuals accommodate well to their physical limitations but their persistent chronic pain leads to personality changes such as secondary depression.

Personality Change Due To A General Medical Condition:

When compared to the injured’s pre-morbid condition, personality change can be significant. For example, some individuals with catastrophic physical injuries who were active, physical, industrious, and empathic become inhibited, dependent, and self-involved as a coping mechanism.

No Diagnoses:

Not all individuals with a catastrophic injury meet DSM-5 criteria for a mental health disorder. It is important to distinguish individuals with persistent emotional distress from those who learn to accommodate their injuries and lead satisfying lives. As a psychiatrist with extensive experience working with patients in a rehabilitation medicine setting, I have seen the full spectrum of such responses.

The Role of the Psychiatric Expert in Determining Emotional Distress:

Lost quality of life, severed previous relationships, pain and suffering, and emotional distress as a result of catastrophic injury must be established through the plaintiff’s own testimony and that of medical experts, including doctors and mental health care providers. Catastrophic injury litigations are often high-stakes and high-value; the typical treating provider may not have adequate expertise to testify with clarity about the emotional response to such injuries.  Oftentimes, expert psychiatry witnesses lack the adequate clinical experience to author authoritative reports.  

As a forensic expert evaluator and expert witness who has treated thousands of patients with catastrophic injuries, I write and speak with conviction and clarity about how and where an individual’s emotional response falls within a range of expected responses.  My deep understanding of the range of responses to catastrophic injury allows me to raise reasonable suspicion for exaggeration when a plaintiff’s complaints fall outside such a spectrum. I’ve demonstrated how plaintiffs’ inconsistent reports reflect malingering for secondary financial gain. My encounters with patients years out from their injury inform the forensic prognosis. In short, my extensive experience in diagnosing and treating patients with catastrophic injuries enables me to fully appreciate the subjective nature of complaints of emotional distress, and more effectively rebut the forensic reports from psychiatrists lacking such clinical expertise.

Not all Catastrophic Injuries Lead to Significant Long-Term Emotional Distress

Recently, I made rounds at Bryn Mawr Rehabilitation Hospital and saw two middle-aged males with similar catastrophic injuries but very different emotional responses. Both had suffered lower thoracic spinal cord injuries in motor vehicle accidents several years earlier, and both were paralyzed from the waist down and had bowel and bladder incontinence.

Mr. A

Mr. A felt his life was “destroyed” by his injury.  He had been athletic and worked as a construction foreman.  Early on, he completed a six-week in-patient rehabilitation program and complied with all treatment recommendations. Six months after his injury, he tried returning to work with modified duties, but he felt overwhelmed. He sensed other men were looking down on him due to his “weakness.” Within a year of his injury, he had reached the point of maximal medical improvement. As time went on, he became more depressed. The permanent nature of his injury led him to feel like “less of a man.” He was convinced his wife thought less of him despite her reassurances. He often felt like life wasn’t worth living.

He took antidepressant medication and met with a therapist after his injury but did not find it helpful. His family encouraged him to learn to drive using adaptive equipment, but he declined, saying “he had nowhere to go.” He lost interest in socializing with old friends because it “could never be the same.” Nothing felt satisfying, and the future seemed bleak.  He “wouldn’t mind” if he died but insisted that he would not try to hurt himself. With time, he stopped following his bladder program, which led to frequent urinary tract infections and occasional hospitalizations. Essentially bedbound, he rapidly became deconditioned and developed significant skin breakdown, landing him back in the rehabilitation hospital. I diagnosed Mr. A with a persistent Adjustment Disorder with Depression due to the chronic stressor of his spinal cord injury. Given his significant emotional distress, I recommended that he increase his antidepressant dose and pursue psychotherapy.

Mr. B

Mr. B had been injured after hitting a tree while driving intoxicated. He had a longstanding history of alcohol abuse and blamed himself for his injuries. Soon after sustaining his spinal cord injury, he became acutely depressed and suicidal. He often refused to participate in his rehabilitation therapies until he was treated with medication for his acute depression. Thereafter, he complied with all treatment recommendations, committed to complete sobriety, and attended Alcoholics Anonymous (AA) meetings.  Life was different for him as a sober man. He began to enjoy time with family and friends and soon married a woman he met through AA.  He worked with a vocational specialist and eventually became an insurance agent, a job that required him to learn to interact with people while sober.  He was proud of his accomplishments and acknowledged the irony of his accident changing his life for the better. Yet, his inability to walk or participate in athletics often frustrated him.  He also lamented the dependence of being wheelchair-bound but adapted his car with hand controls that enabled him to drive independently. On balance, the positive changes in his life far outweighed the frustration and loss connected with his injury. As such, I did not find Mr. B had a diagnosable DSM-5 condition or significant emotional distress. We agreed at his annual outpatient visit he could stop his antidepressant.

Dr. Panzer’s personal injury cases are evenly divided between plaintiff and defense work.