Mental Findings in Trauma Victims

Abstract

Introduction

In medico-legal evaluation of trauma patients, the bio-psychological effects of the trauma and the severity of the injuries require to be evaluated. In this study, assuming the fact that psychiatric assessment is not taken into consideration in physical trauma cases, we planned to show the presence of psychological trauma in our medico-legally evaluated patients who presented with different types of traumas and to review the mental findings and diagnoses in trauma victims.

Method

We retrospectively analyzed the hospital records of 1975 patients aged 18 years or older who presented to the Department of Forensic Medicine at Dokuz Eylül University School of Medicine for medico-legal evaluation between 1999 and 2009. Psychiatric assessment was performed in 142 patients by the Department of Psychiatry. The data contained in medico-legal reports and patient records were then examined with respect to patients’ age, gender, nature of traumatic events, psychiatric diagnoses, descriptive characteristics of the patients, severity of trauma and past history of mental disorder and trauma experience. Results of the medicolegal evaluations were also analyzed.

Result

Of the 142 patients, 80 (56.3%) were female and their average age was 40.30±17.17 years. The most frequent traumatic events were traffic accidents (29.6%) and violence-related blunt force trauma (28.9%). When the distribution of the most common psychiatric diagnoses was examined, it was found that anxiety disorders were found in 69 cases (48.6%), adjustment disorders were found in 16 cases (11.3%) and mood disorders were found in 12 cases (8.5%). Among anxiety disorders, acute stress disorder (n=39) and post-traumatic stress disorder (PTSD) (n=27) were the most common ones. In 27 cases of the 142, it was determined that, psychiatric symptoms and findings did not meet the diagnostic criteria of any psychiatric disorder. Diagnosis of psychiatric disorder was not significantly related with traumatic experiences, comorbidity, marriage status, education level or lack of health insurance.

Conclusion

We assume elucidating the presence of a psychological trauma is crucial not only for the health benefit but also for legal rights of the patient. The necessity of considering merely the international diagnostic criteria in determining the existence of psychiatric trauma and its severity level can bring forth some difficulties in medico-legal evaluation.

Introduction

Trauma-related psychiatric disorders have been demonstrated in many studies (1,2,3,4,5). These studies have been mostly conducted with war veterans and natural disaster victims and fewer studies have been conducted with the victims of other physical traumas (6,7,8,9,10,11,12).

In victims of trauma, various psychiatric disorders including peritraumatic dissociation, anxiety disorders and depression may develop (12,13,14). However, when studies are examined, it is observed that the most commonly investigated trauma-related psychiatric disorder is post-traumatic stress disorder (PTSD) (12,13,14,15,16).

In an epidemiological study performed in six European countries, it was reported that the lifelong prevalence of PTSD in the general population was 1.9% (17). In another study in which 1824 randomly selected individuals were included, PTSD was reported to have a prevalence of 5.6% and to be observed with a 2-fold higher rate in women compared to men (18). In another study, in which Priebe et al. examined adults exposed to the Balkan war in 1990’s, anxiety disorder was found in 15.5%–41.8% of the subjects, mood disorder was found in 12.1–47.6% and substance abuse was found in 0.6%–9% (19).

In our country, the majority of studies conducted with trauma victims have included victims of natural disasters. There is a limited number of studies related with psychiatric disorders observed in victims of physical trauma especially originating from deliberate action (2,15,16,20). In the study performed by Eşsizog̃lu et al., it was reported that a disruption in psychological state was observed in 12.5% of the individuals who witnessed a terrorist attack one month after the event and physical injury was a risk factor in development of PTSD (20). Özaltın et al. reported that acute stress disorder developed in 20% of the patients who were injured as a result of motor vehicle accident in the first one month and PTSD developed in 17% in the 6th month (15).

Evaluation of psychiatric problems occurring in trauma victims in terms of forensic medicine is important in terms of demonstrating the damage related with trauma and the severity of this damage (1). Currently, it is expected that psychosocial effects of physical traumas are assessed in addition to the level of injury caused by these traumas in criminal suits and civil suits (1,2,3,4).

In our country, the 86th item under the title of intentional injury found in the second part of the Turkish Criminal Code (TCC) (TCC with the date 09.26.2004 and number 5237) which became effective in 2005 defines the harms which occur in individuals with effective action (21,22). One of the new concepts included in this item which shows some differences compared to the older law is the concept of “disruption in the ability of perception”. When the definition of “injury which gives pain to someone else’s body/causes to disruption in health or the ability of perception” in TCC is examined, it is observed that the severity of physical and psychological harm arising from the trauma or action is aimed to be determined (21,22,23). The definition of “injury such as to cause to disruption in the health or ability of perception in the individual” also covers the psychological effects of trauma.

Although the psychological effects of physical trauma are considered objective proofs of trauma, it is observed that physical findings are emphasized mostly both by the judicial office and physician in forensic evaluation of the trauma cases in dispute in our country. This study was planned to show the presence and frequency of trauma-related psychiatric disorders based on the observation that psychological findings are omitted in forensic assessment of individuals who are victims of forensic trauma reflected to forensic processes. At the same time, the effect of the new arrangement made in TCC in 2005 on psychiatric consultations of patients who were victims of trauma and who were evaluated in terms of forensic medicine was examined.

Method

The files of 1975 patients in the adulthood age group who were evaluated in terms of forensic medicine by Dokuz Eylül University, Medical Faculty, Department of Forensic Medicine between 1999 and 2009 with the request of legal authorities found in our archive were examined. Among these patients, 186 patients who were victims of trauma and who were examined in the Department of Forensic Medicine and referred to the Department of Psychiatry for consultation in the process of forensic medicine evaluation were included in the study. Forty-four patients in whom we observed psychological trauma findings during the examination in the Department of Forensic Medicine but who did not accept psychiatric consultation or who accepted psychiatric consultation but did not present to the outpatient clinic of psychiatry were not included in the study. Legal authorities including the law court and prosecution office had requested medicolegal evaluation of all patients included in the study. In consultations requested from the Department of Psychiatry, it was questioned if any psychological pathology was present as a result of the trauma experienced and the cause-effect relation was interrogated.

The reports and files including psychiatric evaluation of 142 patients whose psychiatric evaluation was performed in terms of forensic medicine after trauma in the Dokuz Eylül University, Medical Faculty, Department of Psychiatry were examined in detail. Age, gender, violence type which caused to injury, occupation, education level, marital status, traumatic experiences before the event, presence of chronic disease and the outcomes of trauma in these patients were recorded. The point of views in the reports prepared as a result of medico-legal evaluation were also considered. These reports also included the points of views of the physicians who made the medico-legal assessment about the cause-effect relation between the signs and symptoms they found and the trauma experienced by the patients. The psychiatric assessments of the patients were made by a resident of psychiatry and a responsible academic member according to Diagnostic and Statistical Manual of Mental Disorders-TR (DSM-IV-TR) (24). The reports were prepared after the first evaluation. Psychiatric therapies of some patients continued, but the evaluations performed later were not included in the study. The data obtained were assessed using SPSS 15.0 program by Fisher Exact and Pearson Chi-Square tests. Approval was obtained from the Clinical and Laboratory Investigations Ethics Committee of Dokuz Eylül University, Medical Faculty for the study.

Results

While psychiatric consultation was requested in only 15 (1.6%) of 916 adult patients who were victims of trauma evaluated in our outpatient clinic of Forensic Medicine before June 2005 when the Turkish Criminal Code became effective, psychiatric evaluation was made in 127 (12%) of 1059 adult patients who were victims of trauma evaluated after the law became effective. This difference was found to be statistically significant (p<0.001).

States of diagnosis of psychiatric disorder in patients evaluated before and after June 2005 by types of events are shown in (Table 1).

Table 1.

Diagnosis of psychiatric disorder by event type in victims of trauma

	Patients diagnosed with psychiatric disorder		Patients who were not diagnosed with psychiatric disorder, since the diagnostic criteria were not met
	Before 2005	After 2005	Before 2005	After 2005
Traffic accidents (motor vehicle/wayfarer)	6	29	.	7
Lunt trauma	3	30	.	8
Sexual assault	2	13	.	5
Intra-familial violence	.	13	.	6
Sharp object injury	1	10	.	1
Firearm injury	.	3	.	.
Dog bite	1	2	.	.
Persecution	2	.	.	.
Total	15/916	100/1059	0/916	27/1059

In a 10-year period, the most commonly observed events included traffic accidents (n=42, 29.6%), blunt traumas as a result of interpersonal violence (n=41, 28.9%), sexual assaults (n=20, 14.1%), intra-familial violence (n=19, 13.4%) and sharp object injuries (n=12, 18.5%).

The descriptive properties of the patients who were victims of trauma for whom consultation was requested from the department of Psychiatry by the Department of Forensic Medicine and who were evaluated psychologically are presented in (Table 2).

Table 2.

Descriptive properties of the patients who were victims of trauma

	Patients diagnosed with psychiatric disorder	Patients not diagnosed with psychiatric disorder, since the diagnostic criteria were not met
Number of patients	115	27
Gender
Female	62	18
Male	53	9
Marital status
Married	39	9
Single	76	18
Post graduate/Graduate of university	33	6
Graduate of primary school and high school	46	12
Absence of social security	15	4
Having a profession	82	18
Immigration	48	10
Deliberate actions (traumas caused by other people)	77	20
Unintentional events (Traffic accidents, animal attacks)	38	7
Presence of chronic disease before traumatic event	14	5
Experience of traumatic event before the traumatic event or history of major invasive/surgical intervention	32	5
History of psychiatric disease	1	.
Severity of trauma Sequela	31	7
Hospitalization	22	5
Fracture	24	6
Life-threatening condition	11	2
Clinical condition which cannot be eliminated by simple medical intervention*	115	13

^*Severity of the clinical condition determined as a result of the forensic medicine point of view (χ²=66.152, p<0.01)

The man age of 142 patients whose psychiatric evaluation was made in the last 10 years was found to be 40.30±17.17 years and 80 patients were female (56.3%). 19% of the patients had no social security (public/private health insurance). Although 86% of the patients reported that they lived in İzmir, it was observed that 38% were born in İzmir. Approximately 1/3 of the patient had an education level of post graduate/university. While the married patients constituted 34% of the subjects (n=48), the others were single, widowed or divorced. When the patients were examined in terms of occupation groups, housewives and retirees constituted the majority of our patient group.

No significant relation could be found between a diagnosis of psychiatric disorder and previous traumatic experiences, presence of chronic disease, marital status, education level and presence of health insurance.

It was observed that drug treatment was also started in 48.6% (n=69) of the patients who were made a diagnosis in psychiatric evaluation.

There was a history of traumatic experience or major surgical intervention before the event in 20 of 69 patients who were diagnosed with anxiety disorder. It was observed that the diagnostic criteria of a psychiatric disorder were met in 82.8% of the patients who were found to have stayed far from the birth places reported on the identity cards and resided in another place. No significant difference was found between the patients in whom a diagnosis of psychiatric disorder was made and was not made in terms of living far from the birth place for a long time.

The distribution of the diagnoses of psychiatric disorder by the type of event leading to trauma is shown in (Table 3).

Table 3.

Distribution of the most common psychiatric diagnoses by type of event

Type of trauma Anxiety Mood Other diagnoses Adaptation disorders
	n	%	n	%	n	%	n	%	n	%	n	%
Traffic accidents (motor vehicle/wayfarer)	25	59,5	-	-	4	9,5	6	14,3	7	16,7	42	100
Blunt trauma	23	57.5	1	2.5	7	17.5	2	5	8	17.5	41	100
Sexual assault	5	25.0	3	15.0	1	5.0	6	30.0	5	25.0	20	100
Intra-familial violence	3	15.8	4	21.1	2	10.5	4	21.1	6	31.5	19	100
Sharp object injury	8	66.7	2	16.7	1	8.3	-	-	1	8.3	12	100
Firearm injury	1	33.3	1	33.3	1	33.3	-	-	-	-	3	100
Dog bite	2	66.7	1	33.3	-		-	-	-	-	3	100
Persecution	2	100	-		-	-		-	-	-	2	100

It was observed that the most common psychiatric diagnoses in victims of trauma included anxiety disorders (48.6%), adaptation disorders (11.3%) and mood disorders (8.5%). Acute stress disorder (n=39) and PTSD (n=27) were the most common diagnoses among anxiety disorders. Eleven of the mood disorder group (n=12) met the diagnostic criteria of major depression. Twenty-seven victims of trauma did not meet the diagnostic criteria of any psychiatric disorder, although they had psychological symptoms and signs (Table 2). A statistically significant relation was not observed between gender and psychiatric diagnoses.

The mean time from the traumatic event to the first psychiatric evaluation was 43.22±61.34 days (minimum 1-maximum 222 days). It was observed that almost all of the patients (96%) in whom no diagnosis was made but psychological findings were observed were evaluated medico-legally and underwent psychiatric examination in the first month after the traumatic event.

In traumas caused by other people, psychiatric signs and symptoms were found in 79.4% of the victims (n=77) exposed to deliberate action, while this rate was found to be 84.4% (n=38) in unintentional actions including traffic accidents and dog bite. A diagnosis was not made in 15.6% of the victims exposed to trauma caused by other people, although psychiatric signs and symptoms were observed, while this rate was found to be 20.6% in the other patients. This difference was not found to be statistically significant. It was found that 15 of 27 patients who were diagnosed with posttraumatic stress disorder and 24 of 39 patients who were diagnosed with acute stress disorder were injured as a result of a deliberate action. It was found that deliberate actions did not lead to a significant difference between the state of having a diagnosis of psychiatric disorder and psychiatric diagnoses.

When anxiety disorders and other psychiatric diagnoses were compared, it was found that event types and conditions including fracture due to traumatic events and loss of function and traumatic experiences reported in the history did not cause to a significant difference.

Anxiety disorders among psychiatric disorders were observed most frequently in victims of blunt trauma due to violence (57.5%) and victims of traffic accidents (59.5%). 1/4 of the patients who were victims of sexual assault did not meet the diagnostic criteria of any psychiatric disorder, though they had psychological findings.

The severity of the lesions and clinical condition resulting from the traumatic injury (bone fracture, hospitalization, life-threatening conditions, elimination by simple medical intervention and loss of function) was evaluated according to the psychiatric findings and diagnoses. When the patients who had signs and symptoms meeting the diagnostic criteria of psychiatric disorders and the patients in whom no diagnosis was made were compared, no significant difference was found between the levels of traumatic lesions to cause to hospitalization, fracture or loss of function (sequela).

A life-threatening condition was found in 6 of 69 patients who had anxiety disorder and in 5 of 41 patients in the other diagnostic groups. There was no significant difference between the patients in whom a psychiatric diagnosis was made and not made in terms of the frequency of causing to a life-threatening condition stated in the medico-legal report. When the relation of the severity of traumatic lesions according to the guide used in our country in the area of forensic medicine with the state of having a diagnosis of psychiatric diagnosis was examined, all patients who were diagnosed with a psychiatric disorder were found to meet the criterion of “condition which cannot be eliminated with simple medical intervention” (χ2=66.152, p<0.01).

Discussion

In evaluations made to report point of view in terms of forensic medicine, it has been reported that psychiatric symptoms may be much more prominent in some cases and these symptoms may persist for a long time in contrast to physical involvement (2,3). Physical and psychological trauma does not lead to psychiatric effects in everyone with the same severity. However, some symptom groups are observed rather frequently in special cases (including persecution). It has been emphasized that psychiatric evaluation and interpretation should be performed in the cultural, political and social context and with awareness of the interview-evaluation conditions (1,2,3,4).

Medico-legal psychiatric evaluations are frequently performed during forensic examination of victims of sexual abuse, intra-familial violence and persecution (11,25,26,27,28,29). However, it is observed that psychiatric evaluation is omitted in many traumatic events including other violence actions or traffic accidents (8,9,17). The increase in the rates of psychiatric consultations required for victims of trauma after the operation of the new TCC in 2005 is notable. In our study, the rate of psychiatric consultations required during medico-legal examination increased11-fold compared to the period before 2005.

Sociodemographic and Clinical Properties

The majority of the subjects in whom medico-legal evaluation was made in our clinic presented after traffic accidents. One of the important psychiatric diagnoses which occur in relation with traffic accidents is PTSD (10). It has been reported that the rate of PTSD ranges between 10% and 46% and the rate of acute stress disorder ranges between 18% and 42% in patients who experience motor vehicle accidents (13,15,18,30). It has been reported that this difference in the rates may be related with the difference in the diagnostic tools used in the studies (15). In a longitudinal study performed by Ursano et al. in victims of motor vehicle accidents, it was shown that 1/3 of the patients met the diagnostic criteria of PTSD 1 month after the accident and 1/4 met the diagnostic criteria 18 months after the accident. Female gender, presence of a history of PTSD and presence of personality disorder increases the risk of development of PTSD (30). In addition, depression develops with a rate of 5%–20% and pervasive anxiety disorder develops with a rate of 15%–20% in victims of motor vehicle accidents (30). In our study, 3/4 of the victims of traffic accidents met the diagnostic criteria of a psychiatric disorder. 59.5% of these patients were diagnosed with anxiety disorder. 31.6% of the wayfarers met the diagnostic criteria of acute stress disorder and 21.1% met the diagnostic criteria of PTSD. It was observed that 28.6% of the patients (n012) in whom psychiatric evaluation was made at least 6 months after the accident met the diagnostic criteria of PTSD.

Gender and Age Properties

Although the lifelong frequency of exposure to traumatic events is higher in men and the rate of development of PTSD is higher in women, the characteristic of trauma should also be considered (13). Sexual assault and intra-familial violence are related with a higher rate of development of PTSD in women, while military conflict causes to PTSD with a higher rate in men (31,32). In our study, 62 of 80 female victims of trauma (77.5%) and 53 of 62 male victims of trauma (88.5%) met the diagnostic criteria of a psychiatric disorder. The rate of acute stress disorder was found to be higher in male and the rate of PTSD was found to be higher in women. This difference in our findings may be thought to be related with the fact that our study included only the patients who were referred during the medico-legal process. It is known that the patients who are reported to legal authorities and investigated are mostly males in medico-legal processes. It can be thought that female victims of trauma are reported with a lower rate as forensic cases and are not reflected in the process of investigation.

Post-Traumatic Stress Disorder

In a cohort study performed by Bryant et al. in 1084 victims of trauma, it was reported that a psychiatric disorder was found in 31% of the patients 12 months after the event and depression and anxiety disorders were observed with the highest rate (8). PTSD is considered as a psychiatric disorder which is observed frequently after trauma (10). In development of PTSD, especially traumas caused by other people including assault and sexual assault are more determinative compared to natural disasters (12). In our study, acute stress disorder and PTSD were found to be the most common psychiatric disorders occurring after trauma which was compatible with the literature. In addition, anxiety disorders were found with a higher rate in victims of traffic accidents and inter-personal violence and mood disorders were found with a higher rate in victims of intra-familial violence and sexual assault. The patients who were diagnosed with PTSD were the ones who were referred by legal authorities in the late period after trauma (at the earliest one month).

It is thought-provoking that psychological complaints were questioned during examinations in the Department of Forensic Medicine, but the majority of patients did not describe any complaint. It was understood that psychological trauma was more severe compared to physical trauma in many patients and lasted for a long time. The distribution of the diagnoses of psychiatric disorders seems to be compatible with the literature (1,2,12).

Presence of psychiatric disease before trauma and physical injury arising from trauma are considered risk factors for PTSD (33). However, it has been reported that risk factors may change in the follow-up of victims of trauma (1th mont, 3rd month and 6th month) (20). Presence of psychiatric disorder before trauma increases the risk of PTSD. Özaltın et al. reported presence of psychiatric disorder before trauma in more than half of the patients who were diagnosed with PTSD (15). It has been proposed that especially a history of PTSD increases the risk of development of acute and chronic PTSD after trauma (30). In our study, further discussion could not be made on this subject, since a history of psychiatric disorder before trauma was found only in one patient.

It has been proposed that a strong relation is present between a history of exposure to trauma before the event and a diagnosis of PTSD in deliberate traumas caused by other people (12). However, it has been emphasized that this should be not interpreted as that a traumatic experience causes to a high prevalence of PTSD. It has been reported that the risk of development of PTSD is high in conditions including sexual assault, presence of life-threatening conditions and severe physical injuries (12,19). Our findings are not compatible with this information. Presence of psychiatric disorder before the event, a familial history of psychiatric disorder and traumatic experiences in the childhood are considered risk factors for PTSD (34). In our study, no finding supporting this was found.

In one study, it was shown that patients who developed PTSD tended to be unemployed with a higher rate (9). In our study, most of the patients were unemployed (retiree, housewife). It has been reported that lack of social support increases the psychological effect of trauma on the individual (12). In a study conducted with victims of war, it was emphasized that old age, female gender and unemployment were closely related with mood disorders and anxiety disorders. However, the risk related with post-traumatic psychiatric disorders cannot be determined exactly in conditions of intensive economical problems and in presence of chronic diseases (12). The relation of mood disorders with low education level has been demonstrated (19). Conclusively, our findings do not support the above-mentioned statements. However, the fact that limited information related with risk factors could be reached in the data obtained from medical records of our patients was a limitation of our study and further studies are needed in this area.

Although it has been accepted that patients who do not have social security carry a higher risk in terms of psychological findings and psychiatric diagnoses, there was no such finding in the patients who stated that they had no social security in our study. Since all patients included in our study were referred during forensic process with the request of legal authorities, the social security of these patients were provided by the government, though temporarily under the title of “red-handed allowance” during the process of forensic evaluation. This data may explain the absence of a relation between lack of social security and psychiatric disorders reported in the literature.

In this study, it was shown that psychiatric evaluation was necessary in all trauma patients during medico-legal evaluation including mild physical injuries. In our study, 1/5 of the patients had psychiatric symptoms, though they did not meet the diagnostic criteria of any psychiatric disorder. It has been found that the effect of physical injury on development of PTSD shows substantial variance. It has been shown that the severity and level of threat do not predict and affect the risk of PTSD (12,15). However, a relation with the severity of physical injury was found in a study which included 138 subjects exposed to physical assault (14). The relation between physical injury and PTSD should be investigated in future studies (15).

Medico-Legal Evaluation

The necessity of evaluation of the psychiatric state in individuals in medico-legal approach in claims of sexual abuse, intra-familial violence and persecution has been stated for a long time in national and international protocols (2,6,35). Especially as stated in Istanbul protocol, post-traumatic psychiatric disorders are considered objective proofs of trauma (2,35).

In these cases, psychiatric evaluation is required frequently in the process of medico-legal evaluation. However, it is observed that evaluation of the psychological status is omitted in patients injured as a result of inter-personal relations and traffic accidents. Patients injured as a result of inter-personal relations and traffic accidents constitute the majority of the clinical cases of our department. It is noted that these patients frequently describe psychological complaints during examination.

The diversity of psychiatric scales has increased with the advances in psychiatric neurology. Basically, the judgement based on the psychiatric interview of the clinician is essential for medico-legal examination and psychological tests are only assistive tools for the diagnosis (25,36,37). During medico-legal examination, the behavioral, cognitive and emotional properties of the patient and all signs found in verbal and non-verbal communication should be described in detail (37,38,39). In addition, in the phase of establishing medico-legal point of view, the diagnosis of the patient exposed to trauma should be stated including the DSM-IV diagnostic criteria as much as possible (18).

In the Turkish penal Code “disruption of perception” is the only description indicating psychological disorder resulting from trauma or accident. However, “disruption of perception” can be defined only as a symptom in the literature of psychiatry; it does not describe a psychiatric disorder as indicated in the law (2,5,8,9). The fact that psychological trauma and the severity of trauma are not described in detail in the Turkish Penal Code can lead to difficulties in medico-legal examinations (2,21,22,28,40).

In our country, it is a priority to state if the lesion can be eliminated with simple medical intervention in determination of the severity in medico-legal evaluation of forensic cases according to the Turkish Penal Code. Trauma score systems are used frequently to determine the severity of lesions and clinical condition in medico-legal evaluation. A “Guide for Forensic Reports” including these score systems has been prepared with the contribution of the Association of Specialists of Forensic Medicine. In this guide, conditions which disrupt the ability of perception are considered as transient psychiatric disorders which meet the criteria of a psychiatric diagnosis in evaluation of the psychological status of victims of trauma (excluding psychotic disorders and severe and chronic clinical conditions like dementia) (2,5,22,28). Disorders which can be eliminated by simple medical intervention are specified as any transient neuropsychiatric complaints which would not meet the criteria of a certain picture of any psychiatric disorder (according to international classification and definition criteria). The fact that psychological trauma and its severity are not described in detail in the penal code can lead to difficulties in medico-legal evaluations.

Both physical and psychological findings are substantially important in the process of trial. After 2005 the rate of requests for psychiatric consultation has increased for the objective of evaluating the psychological effects of trauma in patients who are victims of trauma included in forensic processes. We think that demonstration of presence of psychological trauma is not only significant in terms of the health of the patient, but also for his/her legal rights, all medical proofs are valuable in trial and punishment of the people who are responsible of disruption of the health status of individuals and legal arrangements related with description of presence and severity of psychological trauma should be seriously put on the agenda and discussed.