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Psychiatric Disorders Following Physical Trauma - A guide for the Non-Specialist
- Jun 16, 2026
- Latest Journal
Psychiatric Disorders Following Physical Trauma - A guide for the Non-Specialist
by Dr Stephen Davies, Consultant Psychiatrist (General Adult & Liaison).
Dr Davies is a General Adult and Liaison Psychiatrist from Wales with an interest in the interface of Physical and Psychiatric disorders.
Summary
There is a strong association between physical injury and Psychiatric disorders, and this goes beyond Post-Traumatic Stress Disorder to include mood disorders, substance misuse, Somatoform/ Dissociative Disorder and anxiety disorders. If an expert witness practising outside of the field of mental health is asked to make recommendations about need for a psychiatric evaluation they might consider asking some key questions or make use of rating scales. As ever, experts should not stray outside of their own field of expertise.
The expert witness who sees a claimant about their physical injuries often does so many months before an appointment with a mental health expert takes place. It can be helpful at this stage if the presence or absence of a few key Psychiatric symptoms is recorded. Experts in medical and surgical specialities are not expected to have detailed knowledge of mental health conditions, nor should they give opinions outside their expertise. But an understanding that is more than basic may be needed to say why a Psychiatry or Psychology report is required. Psychiatric symptoms can alter the course and manner of presentation of physical injuries or disease in a number of ways. Clinical Depression, Anxiety Disorders or Post Traumatic Stress Disorder may manifest as physical symptoms such as tiredness, pain, palpitations or weakness. Patients with depression or anxiety disorders may be reluctant to participate in rehabilitation (including physiotherapy) or resume work or exercise because of reduced motivation or fear of further injury. Patients with substance misuse may be more vulnerable to developing dependence on prescribed painkillers after an injury, and this in turn can contribute expression of pain or to impaired function for longer than expected. Unexplained physical symptoms or prolonged recoveries may be due to a variety of psychiatric disorders including somatoform disorders.
An association between injury and Psychological symptoms does not demonstrate causation, of course. There can be good reasons why individuals with existing psychiatric disorders are more prone to physical injury, aside from attempted suicide or self-injury. For example, cognitive impairment, sedative medication or excessive alcohol may all predispose to falls, road traffic accidents (RTAs), or burns. People with ADHD (with or without associated Neurodevelopmental Incoordination Disorder) are more prone to sustaining accidental injuries and road traffic accidents.
Psychiatric diagnoses are standardised in ICD-11 (World Health Organisation) introduced in 2022) and DSM5 (American Psychiatric Association, Text Revision, 2022). The former is more widely used in UK and is freely available online. Table 1 lists some disorders that a reporting Orthopaedic, Neurology or Pain Medicine Expert may want know a little about. It is worth these experts checking they understand some of the more commonly used terminology.
Table 1 – Psychiatric Disorders Relevant to Physical Injury
- Post Traumatic Stress Disorder
- Depression
- Anxiety Disorders
- Somatoform Disorders
- Functional Neurological Symptom Disorder
- Alcohol and Opiate Use Disorders
- Factitious Disorder and Malingering
Post-Traumatic Stress Disorder (PTSD) is perhaps the condition which clinicians will first think of as a psychiatric complication of physical trauma. Possibly it is unique among psychiatric disorders due to a specified requirement for a distressing event in order for the diagnosis to be made. The threshold is set fairly high, and a minor trip injury or low impact RTA would not be expected to lead to PTSD. ICD-11 requires “event(s) of an extremely threatening or horrific nature” eg natural or human-made disasters, serious accidents, torture, sexual violence, terrorism, assault or acute life-threatening illness, witnessing the threatened or actual injury or death of others in a sudden, unexpected, or violent manner; and learning about the sudden, unexpected or violent death of a loved one. Among the requirements in DSM5 is “Exposure to actual or threatened death, serious injury”. What is “serious” in terms of injury or accident is not defined. Clearly, how threatening a particular injury is to a person will depend on its context and their psychiatric vulnerability or robustness. But only a minority of people experiencing an incident meeting the required threshold will go on to develop PTSD. A further requirement is that Psychological symptoms have a significant impact in terms of distress or altered activities. Of the two classifications of PTSD, ICD-11 is probably the more straightforward in terms of symptom profile. It requires all three of the following:
- Re-experiencing. This could be in the form of frequent distressing dreams, intrusive distressing thoughts, or flashbacks. In psychiatric jargon, the term flashbacks has a specific meaning, denoting that the traumatic event is being experienced again, in the here and now. It entails a dissociative element and is different in that sense to a memory. In this context, a “flashback”is different to the way the term is used about a film or movie, denoting simply an insertion of past events into the narrative, and it is worth obtaining a description of what a claimant experiences if this term is used.
- Hypervigilance/hyperarousal. Hypervigilance is not simply being careful. Anyone who has had a significant njury will be more careful next time, and all drivers are expected to remain vigilant. ICD-11 says that people who are hypervigilant “constantly guard themselves against danger and feel themselves or others close to them to be under immediate threat either in specific situations or more generally. They may adopt new behaviours designed to ensure safety (e.g., not sitting with ones’ back to the door, repeated checking in vehicles’ rear-view mirrors)”.
- Avoidance. In DSM-5, for PTSD, avoidance has to be persistent. It can be avoidance of internal reminders (thoughts, memories, feelings) or external reminders (people, places, activities, discussion). However, in ICD-11, the requirement is for avoidance not merely of reminders, but of situations or activity likely to lead to re-experiencing (eg flashbacks).
To screen for PTSD, a rating scale such as the PCL- 5 (based on the DSM-5 criteria) could be used. Alternatively, consider a few questions about key symptoms such as: Do you get dreams or nightmares about the incident? Is there anything that you will not do because it reminds you of the incident in a way that is too upsetting? In what ways are you more on your guard than before the incident? Was there a time where you would not go to the place where the incident happened or do what you were doing at the time, e.g. driving, sport?
Depression
Depression is used as an everyday synonym for feeling sad, miserable or fed up. For example, “This weather makes me feel so depressed”. It is worth reminding ourselves that the definition of clinical depression is different. Symptoms are more persistent and are present for most or all of the time over at least two weeks (usually longer). ICD-11 requires that during this period, depressed mood or diminished interest must be present most of the day, nearly every day, accompanied by other symptoms, such as difficulty concentrating, feelings of worthlessness or excessive or inappropriate guilt, hopelessness, recurrent thoughts of death or suicide, changes in appetite or sleep, psychomotor agitation or retardation, and reduced energy or fatigue. Importantly therefore, an episode consisting of low mood that has been present less than most of the time, with maintained interest in activities rules out a depressive episode. Likewise, DSM 5 specifies similar core symptoms (with the addition of loss of capacity for enjoyment) and the additional and core symptoms must make up a minimum of 5. There is also a requirement that symptoms are not better explained by another physiological process or substance.
Various rating or screening scales are sometimes used. The Beck Depression Inventory and Hospital Anxiety and Depression Rating Scale (HADS) have their merits but do not correspond well to the definition of Depression given above. NHS Psychological Services which operates in England has adopted the PHQ-9 which is also commonly used in primary care. The PHQ9 corresponds well to the DSM5 criteria for Major Depression and unlike HADS, is copywright free. If the medicolegal expert is going to use one of these scales, they might choose the PHQ9 in order that scores may be directly compared with those used by others. However, as with all such scales, they should not be regarded by the Courts as substitutes for a clinical assessment and nor should scores be interpreted very literally like blood test results or thermometer readings.
Anxiety Disorders
These might include Generalised Anxiety Disorder, Panic Disorder and specific phobia. It is helpful to think of both physical symptoms (eg palpitations, dry mouth) and psychological symptoms (worry, feelings of impending doom, wish to escape) when considering anxiety. Identical symptoms can occur as appropriate responses to fear, but also during drug or alcohol withdrawal, or as side effects of stimulants. Generalised Anxiety Disorder denotes free floating anxiety as well as problems with concentration, sleep, worries and restlessness. A panic attack is a severe paroxysm of anxiety unrelated to specific triggers or situations. It does not simply denote “panic” as used in an everyday sense, “I am in a panic because I am late for my appointment”. The term “specific phobia” may conjure images of spiders or needles, and may seem irrelevant to physical injury. But this diagnosis might apply to someone unable to resume travel by car due to severe anxiety following a RTA (assuming the other features of PTSD are not present). Also, in the elderly, after injuries to the lower limbs, fear of falling is fairly common and can itself impair mobility. This can also occur following other fall injuries and in younger adults. Psychiatrists and Psychologists rarely see patients with phobic presentations in the clinical settings, and often they will be managed by pragmatic way eg by Physiotherapists. Specific phobia presentations often resolve with simple measures or with time, but are amenable to formal psychological treatment if symptoms persist. Sometimes care is needed to differentiate this situation from one in which somebody has taken a rational decision to not longer participate in a particular activity, e.g. motorcycling, hang-gliding, following an injury. It is helpful to ask whether the person misses the activity again, or if they are glad not to have to do so.
TABLE 2 - Psychologist or Psychiatrist? Which to recommend?
There is a lot of overlap. Both usually use a bio- Psycho-social approach. A Psychiatrist will usually have more expertise in Bio-medical matters and will be able to make recommendation about medication as well as Psychological therapy. Psychologists will often have more expertise in Psychological therapy and Psychometric testing. But expertise varries between individuals and solicitors will have particular experts they work with. So suggest a report by a “Psychiatrist or Psychologist with relevant expertise”
Alcohol Use Disorder
Features can include physical tolerance, craving, wanting to reduce or stop drinking but being unable to, continuing consumption despite physical harm or impact on work/relationships, and repeatedly consuming more than intended. For mild Alcohol Use Disorder (AUD) just 2 or 3 symptoms are required, and the threshold is lower than concepts confined to physical dependence and withdrawal. Criteria for other substances eg opiates are similar. AUD can develop anew following a physical injury. Sometimes claimants will say that following an incapacitating accident or injury, they found they had more time on their hands and their drinking crept up. Or that they began drinking to help with impaired sleep, due to pain or anxiety. Sometimes there is a pre-existing or previous pattern of heavy or dependent drinking which becomes worse following a physical injury. For the non-specialist, often it is sufficient to obtain an account of the current pattern of drinking and comparing it to the pre-injury account or recommended limits. Rating scales such as the Audit-10 can be useful.
Somatoform Disorders
The psychiatric classification of these conditions has changed in recent years, with new terminology of Somatic Symptom Disorder (DSM5) or Bodily Distress Disorder (ICD-11). They are no longer thought of as psychological or social factors “causing” pain, nor is it required to invoke unconscious mechanisms. It is best to think of these as conditions defined by disproportionate levels of concern, behaviour or thinking about a physical symptom eg pain. There is not a requirement that there be a total absence of any physical disease process, but rather that thinking, actions or worries are disproportionate or excessive. It is helpful if the physical health specialist can say whether, based on their experience the person’s level of concern or behaviour is within the range of what is typically expected following an injury of this type, at this stage. If it is outside the expected range, then this is very helpful to the Psychiatrist or Psychologist considering a diagnosis of a somatoform disorder. In many cases, there will have been a similar patterns of thinking, behaving or worrying in relation to health concerns (not necessarily the same health concerns) prior to the injury. The aetiology of the condition mainly involves factors present in early life, including family/genetics, personality traits, early experience of illness, abusive experiences. Scales such as the PHQ15 and SSD12 (Somatic Symptom Disorder-B Criteria Scale) are sometimes used to screen for or quantify symptoms. Three published meta-analysis indicate the treatment is amenable to Cognitive Behavioural Therapy.
Table 3 Somatic Symptom Disorder in DSM 5 - requires A,B and C
A. One or more somatic symptoms that are distressing or result in significant disruption of daily life.
B. Excessive thoughts, feelings, or behaviours related to the somatic symptoms or associated health concerns as manifested by at least one of the following:
- Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
- Persistently high level of anxiety about health or symptoms.
- Excessive time and energy devoted to these symptoms or health concerns.
C. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).
Functional Neurological Symptom Disorder
This requires one or more alterations in voluntary motor or sensory function,but that clinical findings are incompatible with neurological or physical disease. Presentations include seizure-like activity, tremor, dystonia, visual symptoms etc. In DSM-5, the term Functional Neurological Symptom Disorder (FNSD) has replaced the term Conversion Disorder. There is no assumption of Psychological causation and no requirement for underlieing stress. There have been several publications by an Edinburgh group using a slightly different term, Functional Neurological Disorder (FND not FNSD). This term emphasises that this is not a diagnosis of exclusion, but rather that there are specific “rule in” signs and symptoms. The ICD-11 uses a different term again - “Dissociative neurological symptom disorder” and does not require rule-in signs or symptoms to be present. It should be added that the Psychiatric classifications make a make a distinction between FNSD/DNSD on the one hand and Factitious Disorder / Malingering on the other. The concept used by neurologists of “FND” does not make this distinction explicitly and many of the published “rule in” signs for FND and symptoms can also be features of malingering / factitious disorder. It will be appreciated that with this rather confusing terminology, there is scope for cross-examiners to have a field day. Some experts, sensibly perhaps, stick to the descriptive term “Functional”, but should define what they mean. Finally, while DSM5 recognises that Functional Neurological Symptom Disorder may arise anew after even minor physical trauma, the aetiology of the condition involves mainly factors present from early life.
According to ICD-11, “Factitious disorders are characterised by intentionally feigning, falsifying, inducing, or aggravating medical, psychological, or behavioural signs and symptoms or injury in oneself or in another person associated with identified deception”. Sometimes a person deliberately induces additional symptoms or signs with an established illness, injury or wound. A distinction is made between Factitious disorder and deliberate feigning of symptoms for material gain (ie Malingering, which is not considered a Psychiatric disorder). But in a medicolegal context, a person’s motives will often be difficult to determine and as always, reliability of a person’s account is a matter for the court. Tread carefully here!