Posttraumatic Stress Disorder and Medical Legal Reports
TASA ID: 2434
On Thursday, December 5, 2013, at 2 p.m. ET, The TASA Group, Inc., in conjunction with forensic phychology expert Dr. David P. Pingitore, presented a free, one-hour, interactive webinar, Posttraumatic Stress Disorder and Medical Legal Reports, for all legal professionals.
During this presentation Dr. Pingitore reviewed how trauma and PTSD were treated in previous centuries and the epidemiology of PTSD in different populations including statistics on remission and recovery. He also discussed the criteria and types of events that are associated with PTSD as well as associated anxiety disorders. Dr. Pingitore defined a traumatic event and provide case studies for question and answer segments that are necessary for an accurate PTSD diagnosis.
About The Presenter:
Dr. David Pingitore holds a PhD in psychology from The Wright Institute in Berkley, CA. He has more than 20 years' experience providing clinical and forensic psychology, neuropsychology services and conducting mental health research. In addition, he has 25 years in graduate education and administration. Dr. Pingitore is a member of the American Psychological Association and the National Academy of Neuropsychology.
Transcription:
Brooke: Good afternoon, and welcome to today's presentation, "Dr. David Pingitore, Post-Traumatic Stress Disorder and Medical Legal Reports." Before we begin our presentation today, I would like to take a few moments to review and highlight some of the necessary CLE tracking environments, as well as some updated information from Webex. If you have logged into the presentation using Mozilla Firefox or Google Chrome, please use the following link on the screen to update your PC for future webinar presentations.
Today, for CLE credit, for those of our attendees who require code words for tracking purposes, the codeword for today is PTSD. During the presentation, we will take short breaks. And during this time, we ask that you enter this code into the chat feature, which is located on the right-hand side of your screen right here for CLE recording purposes. The chat features is located to the right as I pointed out. Dr. Pingitore will also answer your questions. So, please use this same chat feature to submit your questions throughout the presentation. We will take intermittent breaks so that Dr. Pingitore can respond. Tomorrow morning, we will send out an email with a link to an archived report on this webinar. Also, before leaving the presentation today, we ask that you take time to fill out the survey that will appear on your screen after today's program. The survey is also a CLE requirement in some states.
Our presenter today, like I said, is Dr. David Pingitore. He holds a Ph.D. in psychology from The Wright Institute in Berkeley, California. He is licensed in California, Hawaii, and Nevada. He has more than 20 years of experience providing clinical and forensic psychology, neuropsychology services, and conducting mental health research. In addition, he has 25 years in graduate education and administration. Dr. Pingitore is a member of the American Psychological Association and the National Academy of Neuropsychology. At this point, I'm gonna turn the presentation over to Dr. Pingitore. And we hope that you enjoy the presentation. And if you have any technical problems, please feel free to chat us any time during the presentation, and we'll see what we can do. Dr. Pingitore, I'm gonna give the presentation over to you now.
Dr. Pingitore: Thank you very much. As Brooke indicated, there will be time for questions midway through the presentation and at the end. First, I want to acknowledge permission has been granted to me by the American Psychiatric Association. It's providing this presentation information on post-traumatic stress disorder, which is now published in the DSM V. I also want to acknowledge these researchers and clinicians who I've relied upon in the course of preparing this presentation and who have informed my clinical work over the last 20 years. Perhaps, some of them you are familiar with.
Here are some presentation goals. This is what I intend to present this afternoon. Given the topic...it's a daunting task, but I think the subject matter deserves this level of attention. First, I want to briefly review how mental disorders and diagnoses are made by professionals. So, let's start...how post-traumatic disorders seem to be established as a diagnosis. That is, there is a gradual broadening in the criteria of the diagnosis. Provide some shorthand takeaways that attorneys can use in your practice regarding litigation of or defense against PTSD claims. 9/11. No picture illustrates more traumatic events and the human response to the trauma of terror. Perhaps, some of the attendants have experienced trauma themselves or know a family or friend who has done so. If that is the case, I hope this presentation has some personal usefulness.
This picture could represent either of two attorney groups, a group of attorneys who have successfully litigated on a claim, or it is a group of defense counselors who are pleased to hear [inaudible 00:04:56] was selected by the plaintiff because he sees PTSD everywhere. This comment actually is important in the selection of an expert. Plaintiff attorneys, in particular, want an unbiased expert and not an advocate in clients involving PTSD.
The overall scheme of mental disorders in DSM V has not greatly changed. However, we must present an important caveat concerning the forensic use of the DSM V. In particular, the diagnosis does not equal impairment, disability, or [inaudible 00:05:39.207]competency. The role of disability in the DSM does not equal disability in legal terms. Still, in DSM V these following characteristics are presented. There has to be some dysfunction in the person and in the processes that underlie mental functioning. These include physical processes such as sleep functioning, which may be disrupted due to PTSD. The event is not merely an expectable or culturally-sanctioned response to an event such as death.
Let me talk about the epidemiology of PTSD. It is now a professional and scientific growth field with over 15,000 scientific papers having been published on the topic in the last 40 years. It has its own journal, "The Journal of Traumatic Stress." Recent military engagements have resulted in a large number of veterans with traumatic brain injuries, post-traumatic stress disorder, and other conditions. Treatment and disability claims will likely continue well into the future.
Here's a picture of some Oakland Raider fans going to the coliseum to have some fun with likely traumatic results for someone. Research has indicated the prominence of those with post-traumatic stress disorder is more probable from crime rather than non-crime events.
A brief review of the history of stress and post-traumatic stress. From antiquity, certain events were described in dramatic, singular terms in their capacity to alter the lives of humans. Writings from the Greek and Roman Empire have chronicled the powerful effects of war on the individual and their groups. Certain sages illustrated the effect of war on other [inaudible 00:07:42] and on individuals. For example, the phenomenon of soldier's heart in the Civil War era, shell shock in World War I, the image from the film "Patton" when the general berates two soldiers for their unwillingness to go back into combat. Freud coined the term "traumatic neurosis" to illustrate the impact of childhood sexual abuse on adult psychology.
If we fast-forward to World War II, Abram Kardiner published a landmark study, "The Traumatic Neurosis of War," and in it used the term physioneurosis to discuss the adverse effects of war and combat on individuals. In the DSM I, published less than 10 years after World War II, the diagnosis of gross stress reaction is made. However, this diagnosis presumed that the person had a pre-event normal personality and that the stress would resolve over time. Since then, doctors have altered this concept of trauma. Post-stress reaction was dropped from DSM II published in the late 1950s.
In the post-Vietnam war era, researchers and clinicians such as Robert J. Lifton understood the traumatic events led to psychopathology rather than being due to factors such as bad character. A gradual link of events with subsequent trauma was underway. DSM III was crafted in the post-Vietnam era. With its publication in 1980, post-traumatic stress disorder made its appearance as a diagnosis but recognized the lasting pathological effects of traumatic stress. As the researcher and psychiatrist Eric Vermetton has noted, PTSD is a "young disorder" that started to be properly understood only from 1980. It was acknowledged as exposure to traumatic events leading to long-term psychopathology. In short, the mental health establishment has, over the past four decades, altered its definition of PTSD from one of gross stress reaction to traumatic neurosis with a decidedly psychodynamic or Freudian meaning for the PTSD and the DSM III in 1980. With the publication of DSM III in 1980, a discrete event was noted to be the cardinal event. This opened the way for further litigation.
[inaudible 00:10:27.219] takes on subjective criteria that one event was the cause of their distress and the reason for seeking damages. Regarding the course, mention should be made as a gradual introduction of evidence over the last century of nonphysical claims of distress. This training was aided, in part, by the establishment of PTSD, which gave litigants the potential causal link between a presumed negligent event and the subsequent distress. Lastly, the Veterans Administration in 1980 ruled for the delivery of benefits to veterans with a delayed onset of post-traumatic stress disorder. This opened the floodgates of potential claims for benefits.
[inaudible 00:11:12] mind, I'm making a bit of a link between traumatic events and pornography, which in my mind is similar to a $64 question. Simply put, will a jury be able to recognize PTSD in the course of a trial, and what will be their decision? Perhaps more importantly, will an examiner's note, no one may see it. In this case, differential diagnosis is the key.
Now, certain events may be traumatic, but the inference of a PTSD claim is that the event is lasting and has benefits, monetary and otherwise, are due to [inaudible 00:11:53.448] victim. As I'll discuss below, this issue is central to the content of reports delivered by a forensic examiner. The cardinal feature of PTSD is that, unlike all other mental disorders, it alone is based on the patient having experienced a particular event and re-experiencing that stress or [inaudible 00:12:15.643].
This is what's called a conditional probability of PTSD that sets it apart from other diagnoses. The focus on a discreet event is what allows for the establishment of claims based on presumed PTSD. Furthermore, the trauma is defined by the mental health profession, not any other professional organization or institution. The exclusivity of mental health criteria for diagnosis does not necessarily flow through its exclusive role in the court. In the court, there remain the issues of accepted evidence, formative value, assignment of damages, opinion of the examiner.
Let's talk about the epidemiology of PTSD for a few moments. Studies in the last 10 years with both community samples and samples of population of interest have found that trauma is commonplace. Research has offered evidence that traumatic events with lasting symptoms are commonplace with nearly 9% of the U.S. population experiencing a traumatic event before age 75 and about 3% experiencing it in any 12-month period.
Resnick's study of 20 years ago was an example of a study that was conducted over the telephone to assess for the prevalence of crime versus non-crime events. The study noted that the highest rate was found among crime victims. Norris' study found some differences among demographic groups with young persons having even highest rates of PTSD.
Perhaps many of you are familiar with the National Vietnam Veteran Readjustment Survey conducted and published over 20 years ago. Of particular note, it said, "Thirty percent of veterans had PTSD sporadically through a two-decade period." The results that are noteworthy about this study is that it anticipates what may occur in the courts following the wars of the last 10 years. Veterans remain the gold standard clinical population for research and treatment related to PTSD. Yet, I believe that has important limitations regarding models of PTSD symptom presentation and recovery for the civilian population.
Research on who is most likely to experience a traumatic event, not necessarily develop PTSD, but to experience a traumatic event, has found that males with a prior history of no college education, a history of conduct disorder in youth, and a history of family trauma and have the trait of extroversion, that is risk-takers, go on to experience adult traumatic events. That is, prior history is a significant risk factor.
In contrast, some research indicates a link of developing PTSD, that is developing the condition, may be higher in women with a family history of early separation, anti-social behavior, and the personality trait of "neuroticism." This may be due to the development of a particular neurobiological vulnerability where the unfortunate development of limited coping abilities and isolation and poor adaptation to traumatic events. As noted from this particular published study, it's important to note that 50% of women who have been sexual assault victims are nonetheless symptom-free after six months. Both [inaudible 00:16:01] Vietnam veterans and assault victims highlight an important issue for attorneys and their examiners. To what extent do co-morbid conditions for pre-existing conditions contribute to PTSD maintenance?
First responders are also susceptible to conditions. Of note, 5% of the patients will recover. [inaudible 00:16:28.020] have some high [inaudible 00:16:28] to the role of protective factors in eventually recovering from PTSD. I want to point out that this slide notes the concept of remission. And perhaps many of you have read that in medical records or reports and wonder what remission versus recovery means. Well, remission means that the patient no longer meets the full diagnostic criteria of the condition, in this case, PTSD. There may be a reduction in the severity of all symptoms. There may be a slight change in one or more of them. A clinical question for the doctor or the examiner is, "Has the patient improved or not?" Recovery, in contrast, means the patient no longer is in the diagnostic category of interest. Symptoms are present but they no longer warrant the diagnosis. Motor vehicle accidents also have relatively high rates of post-traumatic stress disorder. The rate of individuals who still have the condition six months after the accident is fairly high.
Now, where does post-traumatic stress disorder come from, that is, what is the etiology? There's a genetic contribution. Research among veterans from southeast Asia points to the contributor through all of genetics in developing PTSD found in twin studies, such that both subjects, one of the twins who served in Southeast Asia, and the other did not, developed post-traumatic stress disorder in their lifetime. That is, all post-service events being equal, non-combat experience did not shield the person from eventually developing PTSD. Of course, the rates of PTSD were higher among those who served in combat in Southeast Asia than those who did not. But the important finding was that some percentage of the twins did develop the condition even without being engaged in combat.
Genetic studies have also contributed to an emerging integrated hypothesis. High levels of urban-life trauma lead to a disorder, that is PTSD, due to the interaction of genes, the brain neural circuits that regulate emotions, together [inaudible 00:18:54] resilience in adults. The brain can be transformed as a result of trauma. Research clearly points to how early-life trauma, childhood physical or sexual abuse are predictors of PTSD later in life. Additionally, research has [inaudible 00:19:11] that family and community life factors increase the risk of childhood trauma. Numerous studies have consistently found a relationship between the psychopathology in parents and maladaptive responses in children, including PTSD. In the medical-legal arena, this means that examiners need to "look under the bed" for evidence of early trauma.
Risk factors include the following. Prior trauma. Whether it exists or not, it needs to be reviewed by the examiner. Prior psychiatric history, family psychiatric history. Of particular significance is whether or not there was disassociation during the traumatic event. Of course, an examiner needs to conduct this portion of the assessment in such a manner as to not lead the patient with questions into providing certain data. For example, an examiner doesn't want to ask a question [inaudible 00:20:14] co-worker's injury?
Well, now we come to the centerpiece of the presentation. What are the changes in DSM V regarding post-traumatic stress disorder? With DSM V, you do not have to have witnessed the event to possibly experience PTSD or warrant the diagnosis. The new criteria lists four specific exposure criteria, which are listed in DSM V and include scenarios that involve first responders witnessing human remains or what can be termed bystander disorders or aggrieved parents. The criteria are as follows.
Directly experiencing the traumatic event. Witnessing in person the event as it occurred. Knowing that the event occurred to a close family member. And in that case, it must have been violence or accidental event. Experiencing repeated or extreme exposure to adverse details of the traumatic event such as first responders having to examine and address human remains. But it doesn't mean exposure through the media or television. So, in that regard, playing "Call of Duty" does not warrant a diagnosis of PTSD.
There is also now a separate facilitator termed stressor and trauma-related disorder. DSM V addresses what psychiatric researchers note as the criterion A problem. That is the actual definition of a psychological trauma. The mental health profession has moved from defining PTSD as an event that was once outside the range of human experience to a much broader range of events, such as serious injury, childhood exposure to inappropriate sexual acts, witnessing [inaudible 00:22:13] event, or even being informed of such an event.
The aim of the new criteria is to enable doctors to make a diagnosis that reflects or promotes the research that notes how certain experiences generate trauma and that the trauma results in a constellation of unique symptoms, as I noted earlier. Let's take a moment to review some of the criteria. Exposure criteria, an actual threat of death, serious injury, or sexual violence that involves one or more symptoms. Of particular note in the medical-legal arena is how a serious injury is defined by the doctor. Intrusive symptoms. There has to be one or more from five particular criteria. Of note, intrusive symptoms must be recurrent, involuntary and intrusive. That is, not voluntary as in some suppressive ruminations or obsessive conditions. There is the criteria of avoidance, which is persistent and deliberate avoidance of stimuli associated with the trauma. So, it's called alterations in cognition and mood. A substantial number of symptoms need to be present here, two of seven, in order to warrant the diagnosis. And then marked arousal, two or more symptoms such as irritability. Additional criteria that are present involve if the duration of the disorder is more than one [inaudible 00:23:44].
The diagnosis also provides information on risks or protective factors that need to be taken into consideration. For example, pre-traumatic factors, temperamental, environmental, or genetic. In the environmental realm, what was the extent of stability and safety for the person? Peri-traumatic factors, meaning factors at the time of the trauma, particularly environmental. How serious was the trauma? Did the person disassociate as a result of the trauma? And then, were there what are called post-traumatic factors? Again, temperamental, was the person resilient in the face of this trauma? Were they self-destructive in the face of the trauma? And then, environmental. What level of support and non-support did the person receive?
Forensic experts are required to address in their examination a full and detailed history of the plaintiff. Consider alternate diagnosis and consider the role of secondary gain for what's called malingering. What has been dropped from DSM V is the requirement for diagnosis of the person responding to the event with horror, fear, destructive...subjective distress. This criteria was found to result in a high percentage of false negative cases, meaning individuals who had experienced a traumatic event were then evaluated by clinicians or researchers. They didn't report feeling horrified. And then, they were misdiagnosed as not having PTSD whereupon later examination, they did meet the criteria.
The emphasis is on the behavioral manifestations of the condition. But this doesn't mean that the patent or the examinee should be without emotion following the event. Claimants to an examination discussed witnessing a grotesque event or themselves experiencing a dangerous event without emotion or with only limited evidence of post-event changes in behavior may not be true PTSD patients. The elimination of criteria A1 does not put the claimants or the patient off the record. There must be evidence of some symptoms.
[inaudible 00:26:02.912] childhood criteria for individuals under the age of six years and younger. And perhaps you would agree that that's a telling and distressing comment on our society that children now are experiencing trauma to be diagnosed at such an early age. Fewer symptoms are needed to make the diagnosis. Inclusion of separate criteria for children highlights the role of a developmental perspective for children and adolescents. Among the findings relevant to the diagnosis is the role of attachment [inaudible 00:26:38.875] between child and parent or caregiver for loss of attention. And as this relates to the achievement of the child's safety and increasing self-evidency for the opposite to the traumatic experiences, a sense of fear or a sense of dependent behavior. Now, much more can be discussed on the unique features of PTSD. And the interest of time does not permit that overview.
Point of advice for both plaintiff and defense attorneys on child molestation cases. Both attorneys should realize that examination of very young children may not yield the evidence needed to make a diagnosis, let alone provide evidence for claim of injury. That is often because young children may be hesitant to discuss or reveal their encounters with a strange doctor, even if he is supposed to be the expert. It's better to have the young victim begin psychotherapy and have the psychotherapist serve as a source of evidence to the child's mental health condition.
Now, I'm gonna move to the biological framework of PTSD. And we have here on this slide, this is of the brain. Hopefully, it's similar to everyone's brain here that's in attendance. Three particular structures that I'm gonna talk about. This is a lateral view. It's the frontal lobe on the right-hand side of the slide. The brain stem, as you can see, extending down into the lower left-hand corner. You have the occipital lobe in the far left corner. Substantial evidence from animal studies and populations exposed to chronic stress, the brain structure, circuitry, and neurochemistry changes as a result of these events.
The neuroscientists have provided evidence of how the human brain responds to stressors in a manner different from that of nonstressor situations. However, attorneys should keep in mind that much of the research and clinical findings are based on either animal studies that look at basic brain functions, of populations that are not often focused on civil litigation. That is, the published research has mostly been based on studies of combat veterans, women who are survivors of lengthy child abuse, or concentration camp survivors.
I am not familiar with research that has given evidence of significant changes in brain functioning as a result of a single traumatic event. But I'll briefly introduce the neurobiological model of fear processing as it relates to all conditions that might generate fear. First, information related to a threatening stimulus so being attacked by two men with knives in a dark alley [inaudible 00:29:22.669] the primary senses, sight, smell, touch, hearing. This potentially traumatic event is then integrated with coherent images, in our brains, in our minds, and that are grounded, that is, they're imprinted in time and space.
This information is integrated in brain areas in the amygdala, which you see in the lower central portion of the slide so the frontal cortex. This event then activates neural traces of similar previous experiences with appropriate emotional valence necessary in order to evaluate [inaudible 00:29:58.048] potential of the stimulus. Taken together, these subsequently trigger an appropriate motor response in the person, that is, fright, fight, or freeze.
Specific brain circuits that mediate a person's responses make up the neurocircuitry of anxiety and fear. What occurs is the following. The critical brain structures that are impacted in the neural processing are the hippocampus, the amygdala [inaudible 00:30:30.281] frontal cortex. You can note from the slide where these brain structures are located. Particularly, the region known as the amygdala is the area that generates emotional experience. The hippocampus is where much of memory is located. And the frontal cortex is the judgment or reasoning center of the brain.
Let's take a moment to understand the developmental trajectory of human fear and anxiety. Sensory information enters through our eyes and ears. For example, a car coming towards you at high speed with the person in the car screaming in front of you. This information is related to the areas of the brain that are designed to process such information, the visual or auditory cortex. These brain areas can project that information to multiple other areas of the brain that are involved in mediating memory and emotions. For example, olfactory information has been found to project to the amygdala. Recall that the amygdala governs emotional experience? That's why certain people have adverse reactions to the smell of blood. The sensation is linked to the earlier emotive memory.
[inaudible 00:31:45] the potential for the [inaudible 00:31:43] important aspect of the threat response. That is, replace the threatening object or person or place in time that involved the individual traumatic event from memory and then make a decision about the stimuli in front of us. For example, entering [inaudible 00:32:02.249] crowded room may trigger prior memories of being assaulted with disassociated negative emotions and physical arousal.
I will briefly review the three brain structures that I've noted that are involved in processing fear and arousal. The hippocampus has an important role in memory. And research has found that chronic stress can actually generate damage in its structure. The amygdala is involved in the memory for the emotional significance and intensity of events. It is also involved in generating the condition of fear and emotional responding. Remember, it's peripheral stress responses that is, increased heart rate and sweating. The frontal cortex, which region is involved in the regulation of emotional responsiveness. You're inhibiting the amygdala. Thus, failure in this region makes claim the emotional responses of persons with PTSD and anxiety disorder. Fear and trauma also involve neural hormonal regulation. Among hormones, norepinephrine released to the brain represents an important part of the stress response. And for some reason, my slides are not... Here we go. Oh, yeah, now, we're moving. Excuse me.
To understand the biological basis of PTSD, we must first appreciate the underlying neurobiology of fear [inaudible 00:33:28.570] processes that involve all fear responses, not just those associated with trauma. In particular, as norepinephrine is noted, a long continuation of biological responses following sweat, increased heart rate, the release of hormones and opiates activating [inaudible 00:33:47.928] pairing of the traumatic memories with the stress. Cars coming toward you. They may then generate a cascade of secondary biological alterations.
It's first important to understand that the brain is the key organ of regulation. The psychobiology of fear involves 20 particular characteristics. Stress sensitization. Alterations in brain function as a result of stress, that is, persons become wired for responses. Fear conditioning. Immediate, unregulated, unwanted response to events with fear. Failure in extinction. Difficulties in stopping or extinguishing the fear related to behaviors, and memory function. Pairing the events in the present with what are seen or interpreted as similar events in the past.
Let me conclude this section with two brief comments. There are two things that acute trauma responses that represent unique pathways to chronic stress-related type of pathology. One is primarily intrusive and hyper-aroused, increased heart rate, short of breath, and can be seen as a form of emotional under-modulation. That is, the [inaudible 00:35:10.550] type of person. The other type is primarily dissociative with no real increase in autonomic nervous system. It is a form of emotional over-modulation. That is, the guy who sits out in the [inaudible 00:35:24]. A person may exhibit both types and may alternate between the two. This can serve as a useful overview in how to understand the results of chronic stress and trauma. Now, I believe we're at the section of the presentation where I do take some questions.
Brooke: Okay. Great. We do have quite a few questions for you. We have a particular attendee who is representing a 15-year-old autistic boy who was involved in a pedestrian accident with his grandmother. His grandmother sustained significant physical injury. The boy's physical injuries were not as significant. But since the accident, he's refused to have a physical exam. He was functional before the accident with some limitations. And since the accident, his paranoia has intensified. How can an autistic young adult be diagnosed with PTSD? And how can he be treated?
Dr. Pingitore: Well, let's focus on the treatment first. It sounds like this young boy, unfortunately, had symptoms of paranoia prior to the accident. I'm assuming that they were treated with medication. If they were not, then the first step would be for...this young boy should be seen by a psychiatrist and either be prescribed medication for the first time or have the current medication revised. With respect to the physical exam, perhaps with the introduction of more or different medication, his agitation might decrease.
It may also be beneficial for him to be present during the exam with a family member, if the grandmother is able or another family member to have him examined. That might reduce his anxiety. Certainly, in a case like this, there's a complex combination of symptoms related to the autism and potentially symptoms related to post-traumatic stress disorder. But an examiner should be able to distinguish between the social withdrawal, the problems with social reasoning, the lack of assets in a person with autism versus the avoidance and the fear that might be related to post-traumatic stress.
Brooke: Okay. Before we continue on with the next questions, at this time we do ask our participants to put in the CLE code that we asked for at the beginning of the presentation. So, if you could do that in the chat feature at this time, that would be greatly appreciated. Thank you, everybody. Dr. Pingitore, related to that question before we go on to the next one, apparently, the young boy he refuses to take medicine, he thinks he's gonna be poisoned. Just so you know, they added that at the end of the question.
Dr. Pingitore: Okay. oh, that makes it a little more difficult. Certainly, the most direct and vigorous route would be to provide the medication [inaudible 00:38:51.767] injection if the boy refused to take it orally himself. I would think that this young boy should be seen first in some form of intensive treatment [inaudible 00:39:14.058] perhaps with the family members together to try to reduce his paranoia first in order for him to be receiving the treatment and evaluation that he needs.
Brooke: Okay. Moving on to our next question. In personal injury litigation in which the plaintiff claims to exhibit symptoms characteristic of PTSD, is it possible to obtain a reliable independent medical examination for diagnostic tests to determine the actual cause of these symptoms? Is a psychologist or counselor qualified to make such a diagnosis?
Dr. Pingitore: Yes, psychologist, in particular. A counselor may or may not be. I think it's based, in part, on the regulations in the state in which they practice. But certainly, as I'll talk in the second half of this presentation, I'll write out the ingredients of a forensic assessment for filing such a claim.
Brooke: Okay. I have another question here. Are there any general observations that could be made regarding the trauma experienced by victims of human rights violations such as massacres, genocides, ethnic cleansing, etc.?
Dr. Pingitore: Yes, there are some general characteristics. And I know indirectly of many psychologists in the area that I work in who have evaluated such individuals, particularly from Latin America. And they would be a particular resource to serve in that regard. But certainly, there would be a constellation of symptoms perhaps consistent for people who have experienced that type of trauma, particularly of avoidance, hyper-vigilance, perhaps nightmares, secondary symptoms such as depression or anxiety. But I've not seen in great detail in the literature... I would be fairly confident that there's been quite a bit of research published on the unique profiles of the people who have suffered those kind of things.
Brooke: Okay. [inaudible 00:41:31.162] question before we continue on. What is the intersection between PTSD and involuntary intoxication due to drug interaction to form a complete defense to charge?
Dr. Pingitore: Involuntary... Repeat the question again. Involuntary intoxication?
Brooke: Correct.
Dr. Pingitore: Well, I guess I'm not certain what is meant by involuntary intoxication unless that means that somebody was unbeknownst injected with drugs or [crosstalk 00:41:52] alcohol to drink when they were not conscious. I'm not certain about that relationship. Certainly, there's a high degree of co-morbidity in part based on the severity of the post-traumatic stress disorder. But certainly, problems with alcohol and drugs can, with some frequency, occur with individuals who have PTSD.
Brooke: Okay. And part of that question was, "Does PTSD form a [inaudible 00:42:36.365] to unintended drug interaction?"
Dr. Pingitore: I'm not familiar with any research that indicates that the condition of post-traumatic stress leads to hyper-sensitivity with drugs. I'm assuming that the questioner means illicit drugs as opposed to prescribed drugs. I'm not quite familiar with that.
Brooke: Okay. That's all we have right now. So, we'll continue on with the presentation.
Dr. Pingitore: Okay. So, moving right along here...slide from the previous portion of the presentation, talking about differential diagnosis. There is more coincidence that in DSM IV PTSD appears in the anxiety disorders section. That is because the condition shows a number of the same symptoms have many anxiety disorders. Post-traumatic disorder also shares some instances of personality disorders. Listed here are six probable alternate conditions or diagnoses. Five...yes six. Excuse me, that may account for the patient's condition. As you can see from this table, many conditions share the same symptoms. Five of the particular symptoms are illustrated as seen in post-traumatic stress disorder.
Similarly, individuals with panic disorder have four of the five symptoms. Individuals who have personality disorders, which I'll talk about in a moment, also share [inaudible 00:44:10.421] three of the five symptoms. Hence, given this complexity in similar areas between disorders, the examiner needs to establish for all parties that a count [inaudible 00:44:26.118] diagnosis is conducted. There should be "no rush to judgment" about the diagnosis.
The examiner must determine the following alternate findings. The plaintiff suffers from another non-post-traumatic stress disorder diagnosis such as panic disorder or depression. The plaintiff suffers from PTSD and another disorder, alcohol abuse, [inaudible 00:44:50.184] disorder. Differential diagnosis is aided by the following characteristics which should be evident in the examiner's report. PTSD patients may avoid situations out of fear for safety or a return of an event while paranoid patients avoid persons and situations out of delusional beliefs of harm. Suppressed patients are overcome by guilt and present with psychomotor retardation while post-traumatic stress disorder patients present with arousal.
Patients with phobias, a condition that's listed here in the table, have fear for a particular object that symbolizes something from their life, snakes, airplanes. If that's not the case, it presents as post-traumatic stress disorder. Those with a panic disorder are fearful of an event, situation or a person in the here and now. This is distinguished from the person with post-traumatic stress disorder who is reacting to an event in the past versus the flashback [inaudible 00:45:47.115] PTSD may experience the "voices" of their [inaudible 00:45:53.983] soldiers or the fallen family member, which are different from hallucinations.
With the personality disorders, one key element is that the person's disorder, that is their chronic, maladaptive way of relating to self and others, may be the key driver in the litigation. Persons with this condition fall into one of three descriptive types. First is what's called the dramatic erratic person. Very, very emotional. They're vague in presentation. They have multiple [inaudible 00:46:28.067] complaints. They have little insight into their condition. What's called odd or peculiar type of individuals. They have very few relationships, little emotional experience. And they have unusual beliefs about the world and other people. [inaudible 00:46:42.919] called manipulative or [inaudible 00:46:45]. They're anti-social, psychopathic. They have little empathy for others. Careful review of their social history on examination can lead to an opinion [inaudible 00:46:58] regarding different diagnoses.
The doctor's summary and the report should include an explanation of how the diagnosis was arrived at, how alternate diagnosis was considered, [inaudible 00:47:10.521] chosen. Some other characteristics of post-traumatic stress disorder relevant to litigation. What I'll call doctor delay and patient delay. Delay by doctors [inaudible 00:47:25.871] understand from a fact-finding perspective. The patient came in very infrequently over the course of the year to see their physician. And this suggests the medical records may not be sufficient as evidence.
Patients may be very, very reluctant to discuss the matter with primary care doctors. This is also what I'll call the counter-transfer from the doctor, that is, the unconscious motivations within doctors, for example, primary care doctors, not to want to talk about things that appear to be overly emotional and very complex. They're not trained to do such an evaluation. They're not specialists in psychotherapy or psychological examinations. They shy away from the condition.
Delay by patients. Now, this may be less relevant to [inaudible 00:48:11.328] cases since the patient becomes the plaintiff. But on some occasions, delay can be due to the person sinking themselves into work or [inaudible 00:48:20] for a period of time. There is also what's called [inaudible 00:48:24.663] PTSD. It's not an official diagnosis but reflects multiple overlapping and difficult symptoms, including somatic complaints, asphyxiation, vulnerable to repeated traumas, and in some unfortunate circumstances, even attachment to the perpetrator.
Psychological assessment of the condition in litigation, a brief overview of types of litigation that happens. Now, I'm not gonna direct the forensic issues related to the diagnosis of PTSD as a defense in diminished capacity. Self-defense cases are syndrome evidence. For the remainder of the presentation, I'll examine issues regarding workers' compensation claims and, in particular, personal injury claims.
Statutes regarding causation in workers' compensation claims vary across states. In California where I conduct the majority but not all of my practice, the statute is highly restrictive. In fact, the passage [inaudible 00:49:30.351] in January of this year instituted an elimination of awards for permanent disability for physical/mental claims, except under certain limited circumstances. Claims of post-traumatic stress disorder in the workers' compensation setting often involve a claim of "sudden extraordinary employment events" [inaudible 00:49:48.794] condition and associated impairments.
For a physical-mental claim, a physical injury leads to some sort of mental distress. There is suppression or anxiety following [inaudible 00:50:01] or post-traumatic stress disorder secondary to a traumatic brain injury. Physicalmental claims appear to be the most straightforward. The physical component refers to incidents where there is an injury, an occupational disease, which is found compensable. As a consequence of the initial disabling condition, the employee develops a mental condition that is [inaudible 00:50:22].
For a claimant to warrant a diagnosis of PTSD, the physical injury, by definition, would have to involved serious injury, threat [inaudible 00:50:34.919]. A mental-mental claim means, of course, that mental stress has resulted in a mental problem. These claims could warrant the diagnosis of PTSD as a result of [inaudible 00:50:44.396]. As a transit worker [inaudible 00:50:49]. In mental-physical cases, the key problem is lost in the causality issue. These claims can be problematic because of the need to prove that the condition, the physical condition, arose out of and in the course of employment. For example, cardiovascular disease as a result of stress on the job.
This is a particular case that both examiners and attorneys who are involved in workers' compensation probably encounter. Someone who is the department head in a public service agency is threatened and files a claim for post-traumatic stress. You can take a moment to read the vignette. A number of questions can be raised and need to be answered in a case like this. What was the nature of the harm? How serious was the event? [inaudible 00:51:44.960] how does the plaintiff react or the claimant in this case, how does the claimant react in discussion with the examiner?
What's the symptom presentation? Issue differential diagnosis. Is it really PTSD or perhaps one of the other conditions that I noted earlier? Is there secondary gain on the part of this claimant? That is, is he or she avoiding work conflicts that may not be resolved and has latched onto the issue of post-traumatic stress disorder? Can the person return to work after treatment? In that regard, what prevents them from sustaining the hardiness, given their long history on the job? Does the person have a genuine presentation or are they feigning the symptoms?
Now, I'm gonna talk about post-traumatic stress disorder in personal injury suits. What I like to think of, at least for examiners, as many chapters and many verses. As many of you are well familiar, there's entire monographs and books that have been published on this subject. I assume that the audience is well familiar with reports from forensic psychiatrists and psychologists regarding PTSD claims in personal injury cases. But very basically, those principles still cover PTSD claims. [inaudible 00:53:06.029] as chapters with many verses. Causation in these cases can clearly be understood as divided into two parts. There's the factual cause related to the plaintiff. Were it not for the disastrous motor vehicle accident, PTSD would not have occurred in Ms. Torez. On the other hand, there's much [inaudible 00:53:25] to suggest that a PTSD claim or a misdiagnosis becomes an organizing fact in the person's life. It becomes a convenient [inaudible 00:53:34.668] to be worn as a way to avoid other personal issues.
Then, there's the proximate cause or legal cause [inaudible 00:53:44.443] legal duty to care. Liabiilty for damages is due to fact that [inaudible 00:53:29] was not prepared as scheduled and Ms. Torez was seriously injured. In this regard, even if Ms. Torez had a prior injury of domestic abuse, some portion of her current condition may still be liable for damages. First, and this is chapter two regarding council, the defense has at its disposal the argument that the plaintiff was a super sensitive person. In other words, demonstrate that other [inaudible 00:54:16.004] exist to account for her condition. In that regard, Ms. Torez jumps whenever [inaudible 00:54:21.384] enters the room. The third chapter involves the expert. Through a court of law, the experts report [inaudible 00:54:27.964] to be entered as evidence. As I will discuss below that the report made it a minimum standard for a forensic examination and it addressed all of the new criteria for post-traumatic stress.
For the defense attorney, the most effective method to attack a PTSD claim is not to challenge the symptoms but to suggest and ultimately prove or plant the question in the factfinder's mind that the defendant's actions did not bring about the symptoms. For instance, if the symptoms are valid, they pre-existed the traumatic incident or were caused by something other than the defendant's [inaudible 00:55:08.307] negligence. For plaintiffs' attorneys, [inaudible 00:55:12] effective method should include attaining an early assessment from the expert as to whether the case justifies the expenses of retaining them in the first place. Can the expert produce a report that [inaudible 00:55:23.287] evidence that some injury amenable to damages even if it is not post-traumatic stress disorder?
Here for your review is a list of essential ingredients of a forensic examination. And I'll try to tailor it with respect to post-traumatic stress disorder. With respect to reports involving PTSD, the key ingredient linking them is the focus on evidence of pre-incident trauma or the absence of it. Post-incident symptoms or the absence of them and other post-event traumas, are they present or not? In some cases, neuropsychological evaluations may need to be conducted for prominent sensory, motor, and memory complaints. I like to encourage applicant attorneys to inform their clients that the [inaudible 00:56:12.059] pre-event history be examined. It's more than likely it's gonna be brought out at some point in the case.
With respect to mental sanity examination and the substance protocol, many examiners recommend that the only way to conduct a sound differential diagnosis is to use the SCID, which is the Structured Clinical Interview for the DSM system. It's a careful, comprehensive fashion to establish a sound differential diagnosis. This is a gold standard assessment that allows the differential diagnosis.
Assessment can also include a specific structured interview, which is used to determine the presence of PTSD. For sex conditions, the examination should be focused on whether the plaintiff meets the full criteria for PTSD or another condition. With respect to the assessment protocol, it should cover a range of measures. It can include the MMPIII or some other measure to assess validity in general personality functioning. It's also a means to measure how the person is coping with the condition. The MMP [inaudible 00:57:24.295] in particular gives information on the symptoms and the person's adaptation or lack of adaptation to the symptoms.
There are some specific incidents that allow for compensation of the person's complaints with known PTSD groups. Among them are the clinician-administered PTSD scales, the 25-item questionnaire given directly to the plaintiff. Prior trauma events may have been successfully coped with by the plaintiff but the current event was different and perhaps more serious. All of those questions are routine, particularly for children where information from teachers and coaches would be valuable to reinforce the clinical presentation.
Interviews of persons who claim PTSD then have more than one date to obtain evidence of behavior in more than one instance. Then, at the end of the report, there should be a case formulation. It should establish if the diagnosis is relevant to the case or not. It should offer an opinion as to the relationship of the diagnosis to the events at hand. How was the person changed by the event? How does the behavior fit the diagnosis? There should be an opinion as to causation and damages [inaudible 00:58:34.287] patient. At best, the report should offer an opinion as to how the diagnosis of PTSD is related to the facts of the case and to make a link between the plaintiff's behavior and what is known about the scientific condition. For example, if the plaintiff is so traumatized by the assault that they avoid it at all costs and return to work [inaudible 00:58:54] or any similar environment and that such behavior is consistent with the condition.
It should include the trauma history, detailed history, of whether there was any pre-existing traumatic events. There should be an assessment of the plaintiff's behavior, specifically the plaintiff's narrative, on examination. A person who historically describes a particularly harrowing or grotesque event or accident but their presentation seems matter-of-fact, almost casual. The interview should be nondirected, it shouldn't be leading questions.
Let me just briefly talk about some common errors in forensic examinations that fit particular occasions. The most important one I think is the advocacy or bias. The [inaudible 00:59:52.977] examiner should not present themselves in an advocacy manner. They need to be an objective examiner. There should not be any bias one way or the other. I can truthfully say that I issued a report in a civil trial some years ago that was called into question by the defense as not being sufficiently objective and having taken the time to [inaudible 01:00:17.755]. And that was a lesson hard-learned.
[inaudible 01:00:27.452] second case, in a civil trial. Now, this is a typical case example where the issues of pre-event trauma may be central to the issue of causation. So, take a moment to just read the case example. As noted, there may be two plaintiffs involved, the driver of the truck... More than one expert [inaudible 01:00:53] in such a case if damages are being sought from multiple parties in the case of gross negligence on the part of the trucking company. That's an example of obtaining the medical service records and employment records would be crucial to establishing the extent of possible trauma, if any, previously suffered by the driver. Of course, looking at whether there's any premarital issues or marital complaints that might be contributing to the person's condition.
Here is one of my heroes, Galileo. And he has been quoted to say something of relevance to examinations of PTSD claims, and the assessment of malingering. Galileo has said that "All truths are easy to understand once they're discovered." But the point is to discover them. We talk about the phenomenon of malingering in examinations, particularly with respect to PTSD claims. Malingering is a difficult and treacherous diagnosis to make by the experts. It requires fool-proof evidence that the person was not incredible for reasons of secondary gain.
Often, my approach is to indicate to the examinees that I'm going to be measuring effort and validity of their symptoms during the course of a lengthy exam. I say to them, "Do not try to exaggerate the extent of your challenges such as not being able to add two plus two." In cases of suspected performance, I may indicate that there's not sufficient evidence to make the diagnosis but indicate that one is out there, as well. Perhaps this is due to poor effort, inconsistent performance on the part of the plaintiff. But there are some common examples of what needs to be conducted in a monitoring assessment, particularly PTSD claims.
[inaudible 01:02:54.880] suicidal ideation dramatically in the interview. But the event doesn't fit the behavior or the suicidal ideation [inaudible 01:03:01.158] that quality. There's the self-reported memory problems but memory assessment is adequate or memory assessment results are highly exaggerated, and that's consistent with the condition. There's self-reported sleep disturbance. They haven't slept in weeks yet their office presentation is vital with a lot of energy. They don't yawn at all in a six-hour exam. They give textbook definitions of the symptoms or ultimately they give very vague reporting of the symptoms. And then, of course, assessment or testing results might show [inaudible 01:03:37.154].
I'm gonna test your knowledge here. Since you have to get CLE credits, this is the test portion of the presentation, testing your knowledge. The first question. The MMPI-2 can diagnose the presence of PTSD in a claimant. True or false? And put in your answer now. False. MMPI clinical scale, in particular, the PK or the post-traumatic stress scale, measures anxiety or PTSD-ness related to a stressful event. [inaudible 01:04:13.482] consistent predictability around PTSD. The scale...
Brooke: Hello? It appears we're having some sound issues here so just bear with us. Hold on one moment.
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Again, we apologize for the technical difficulty. We seem to have lost our phone connection with Dr. Pingitore. I'll be getting back on the line with him. Just please be patient. We'll be right back. Thank you.
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Dr. Pingitore, if you can hear us, we lost your phone call. We need you to call back in. And we apologize, again, to our participants for the inconvenience. Please stand by.
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[inaudible 01:09:00] we have Dr. Pingitore back on the line. We'll finish up the presentation. Thank you for your patience today.
Dr. Pingitore: So, hopefully, everybody can hear me. This is an indication that I'm somewhat [inaudible 01:09:12], meaning that I persistently and obsessively was reading my notes and didn't even look at the slide presentation when the [inaudible 01:09:23.126] told me that I was cut off. But at any rate, we're coming back up to the end of the test your knowledge. Self-report measures and reviews of the medical records can provide a diagnosis of post-traumatic stress disorder. True or false. Again, provide your answer. False. As I indicated earlier, there's a number of assessment instruments and then the structure of clinical interviews which are really [inaudible 01:09:50] in managing a differential diagnosis.
Psychotropic medications are the first line of treatment for post-traumatic stress disorder. This is not a leading question bearing the fact that I'm a psychologist. True or false. False. The Institute of Medicine in 2007 and the Department of Defense in their working guidelines a few years ago indicated that psychological therapies aren't the select line of treatment for post-traumatic stress disorder.
Let's talk about treatment. Besides considerable research in psychiatry and the neurosciences and the biological factors that generate PTSD symptoms, the consensus professional opinion appears to remain that psychological therapies are the number one choice for treatment. Regarding pharmacological treatment, a recent review of the research conducted in 2012 suggests the treatment with [inaudible 01:10:43.689] medication is small. The effect that has been found is with the SSRIs [inaudible 01:10:50.062] medication [inaudible 01:10:50.490] side effects.
On that note, The Conley Group, an independent research evaluation organization, issued a review in 2007 of the literature. It involved a META analysis of randomized controlled trials. It considered well-defined psychological treatments to review these symptoms. In comparison with the placebo, other control groups [inaudible 01:11:19] medical doctor or a waitlist to study their effect of remission [inaudible 01:11:21.440] psychological treatment conditions. Thirty-three different trials [inaudible 01:11:27.390] criteria and were part of the META analysis. The results confirmed that particular and specific psychological treatments can more effectively reduce traumatic stress in individuals with PTSD than other treatments, usual medical care, or no healthcare at all.
In particular, what's called trauma [inaudible 01:11:47] behavioral therapy and what some of you may be familiar with as high movement desensitization in responsiveness that is MPR had the best evidence for advocacy at present. And these should be made available to PTSD sufferers. Nonspecific treatments for individuals who have [inaudible 01:12:05] post-traumatic stress disorder conditions should be referred to, not some form of open-ended psychotherapy with a counselor that is merely supportive. That's not the treatment of choice.
There is also limited evidence that stress management such as regressive muscle relaxation is effective. These treatments are short in duration, often less than a year in length. An examiner should consider making that referral in their report if there is a question of subsequent treatments. So, that concludes my presentation. I'll probably take a few more questions [inaudible 01:12:46.839].
Brooke: We do have a question. Is it possible for a traumatic or stressful event to aggravate or trigger a pre-existing PTSD in remission caused by other previous events or life circumstances?
Dr. Pingitore: Yes.
Brooke: Okay. And is it possible to differentiate between these possible underlying causes?
Dr. Pingitore: Well, it may be possible to differentiate between the underlying cause if in the initial event there's documentation of the discreet set of symptoms. And then, there's evidence following the subsequent event that there's new and additional symptoms. But, again, in those instances, they have to meet the diagnostic criteria and so there has to be symptoms that meet all of the four criteria for DSM V at present. There may be additional ones that have, unfortunately, been generated as a result of a recent event.
Brooke: Okay. And we do have one more question but in the interim, could the attendees please put in the code for the CLE that we asked for at the beginning of the presentation at this time. Thank you.
Dr. Pingitore: Here's my identifying information and my website for those who are interested.
Brooke: Thank you. All right. We have one more question, Dr. Pingitore. If a plaintiff has a positive psychiatric history before a traumatic event, can a forensic expert offer an opinion to demonstrate a distinction between the pre-injury history and the current trauma?
Dr. Pingitore: Yes. I think that the presentation has outlined the general approach that an examiner would need to take. For example, if the pre-incident history was of the question for a person who is not eating, has suicidal ideation, that worked sporadically, then they got treatment, their life improves, they went on for a number of years, and then they had the supposed or recorded traumatic event with another set of symptoms. It could take clinical examination, some of it might be reports, a careful review of the records perhaps collateral interviews. But certainly, I believe the case may be made.
Brooke: Okay. I have one last question. Is it appropriate for a treater to also serve as a forensic expert at trial?
Dr. Pingitore: No. I hate to be so blunt, but no.
Brooke: Okay. And we have somebody that...
Dr. Pingitore: [crosstalk 01:15:31] would want to put themselves in that position.
Brooke: Okay. I do have one more question from Mr. [inaudible 01:15:40] who said he asked a question earlier, and we must have missed it. I'm just going back to look for it for him to get an answer from you. Hold on one moment... Mr. [inaudible 01:15:57], if you could just type in the question that you'd like answered to the chat feature at this time, I'll be more than happy to ask Dr. Pingitore for you. And Mr. Cohen[SP], I didn't get your question as well. We do have a question, "Were there increases in PTSD claims as a result of the mass shootings at the various schools over the past recent years?"
Dr. Pingitore: I don't know of any published information on those. Again, I don't know which mass shootings you're talking about, [inaudible 01:16:32.416] Connecticut. But, you know, they take a while to generate as their intent to claim.
Brooke: Okay. Mr. [inaudible 01:16:43] asks, will PTSD victims be more likely to use marijuana?
Dr. Pingitore: More likely in comparison to whom? There is evidence to suggest that they certainly use marijuana as a form of treatment to reduce anxiety. Then, there's the... And if that's the case and they've been suffering from the condition for many years and have been using the marijuana heavily, then there's an alternate and secondary impact on their working memory because then you have an additional problem potentially. If they've got intermittent or possible working memory deficits as a result of the eventual and lasting effects of marijuana use.
Brooke: Okay. And we have one last question. Can prolonged daily emotional abuse lead to a diagnosis of PTSD?
Dr. Pingitore: Well, I would want to operationalize emotional abuse. Unlikely, unless it's chained with threats, physical harm, or something worse. But such a condition such as chronic emotional abuse could certainly lead to any of a number of other painful problems particularly if it's a child who then, you know, would actually develop into an adolescent or an adult suffering depression or anxiety or substance abuse. But, you know, chronic verbal abuse, in and of itself, unless it involved threats wouldn't potentially create a diagnosis or a condition of PTSD.
Brooke: Okay. Those are all the questions that we have for today. I'm gonna take the presentation back over to TASA as the host.
Man: Thank you very much for attending. I hope that you found the information useful in all aspects of your life and work. Thank you.
Brooke: Okay. Thank you, Dr. Pingitore.
Dr. Pingitore: You're welcome.
Brooke: We thank everybody again for attending today, and especially Dr. Pingitore. We'd like to remind you about the CLE information as well...the webinar is eligible for CLE credit in California, Illinois, Minnesota, Missouri, New Jersey, Pennsylvania, and Texas. And to ensure you receive your CLE credit, please make sure you complete the survey that comes up at the end of the presentation.
The TASA Group, in addition to being your best source for testifying and consulting experts, we also offer e-discovery and document management, free interactive webinars, and research reports on expert witnesses. Tomorrow, we will send out a link to an archived recording of this webinar. And the archived recording will also be posted in the Knowledge Center on TASA's website. If you have any follow-up questions or comments, please feel free to email Carol Kowalewski at her email address below.
I want to take this opportunity, again, to thank everyone for attending this, especially Dr. Pingitore. We apologize for our technical difficulty today, and we appreciate your patience. If you would like to speak to Dr. Pingitore, or if you'd like to speak with a TASA representative regarding an expert witness for a case that you're working on, please be sure to call TASA at 1-800-523-2319. Thank you again, and have a good day.
Dr. Pingitore: Bye-bye.
Brooke: Bye-bye.