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Wounds of War:Traumatic Brain Injury
Rex M. Swanda, Ph.D., ABPP-CNRex M. Swanda, Ph.D., ABPP-CN
Neuropsychology ProgramNeuropsychology Program
New Mexico VA Healthcare SystemNew Mexico VA Healthcare System
Traumatic Brain Injury (TBI)
Brain injury caused by an Brain injury caused by an external mechanical force external mechanical force
such as a blow to the head, such as a blow to the head, concussive forces, concussive forces,
acceleration-deceleration acceleration-deceleration forces, or projectile missile forces, or projectile missile
(e.g., bullet). (e.g., bullet).
CONCLUSIONS TBI does not typically occur in isolationTBI does not typically occur in isolation
Emotional and psychosocial stressors Emotional and psychosocial stressors Reported TBI most frequently involves mild TBI Reported TBI most frequently involves mild TBI Credible research indicates that full cognitive Credible research indicates that full cognitive
recovery is the norm in mild TBI (e.g., LOC < 30 recovery is the norm in mild TBI (e.g., LOC < 30 minutes)minutes)
Important to identify TREATABLE symptomsImportant to identify TREATABLE symptoms No direct treatments for TBINo direct treatments for TBI
Associated psychological symptoms are associated Associated psychological symptoms are associated with subjectively reported TBI symptoms that with subjectively reported TBI symptoms that ARE highly treatableARE highly treatable Depression, PTSD, Substance AbuseDepression, PTSD, Substance Abuse
Incidence of TBI
500,000 to 2,000,000 per year500,000 to 2,000,000 per year(civilian)(civilian)
Poorly definedPoorly definedPoorly documentedPoorly documented
Risk Factors Associated with TBI
AgeAge 15 to 24 years of age15 to 24 years of age First 5 years of lifeFirst 5 years of life ElderlyElderly
Males outnumber Females 2:1Males outnumber Females 2:1 Except over age 75 Except over age 75
Risk Factors Associated with TBI
Lower Socio-Economic StatusLower Socio-Economic Status UnemploymentUnemployment Lower EducationLower Education
Prior History of a Medical Condition Prior History of a Medical Condition Affecting the Central Nervous SystemAffecting the Central Nervous System Alcoholism or Substance AbuseAlcoholism or Substance Abuse History of Prior Head InjuryHistory of Prior Head Injury
Frequent Causes of TBI
FallsFalls
Motor Vehicle AccidentsMotor Vehicle Accidents
Interpersonal ViolenceInterpersonal Violence
Classification of TBI Closed Head InjuryClosed Head Injury
Skull intact, Brain tissue not exposedSkull intact, Brain tissue not exposed90% of civilian head injury90% of civilian head injuryDiffuse effects are commonDiffuse effects are common
• Attention / ExecutiveAttention / ExecutivePenetrating Head Injury (Open Head Injury)Penetrating Head Injury (Open Head Injury)
Skull and dura are penetratedSkull and dura are penetratedFocal injury is more commonFocal injury is more common
High Risk Areas for Contusion
Long-Term Consequences of TBI
Cognitive consequencesCognitive consequences Emotional consequencesEmotional consequences Social consequencesSocial consequences
Indicators of Severity for all types of head injury
Loss of Consciousness (Loss of Awareness)Loss of Consciousness (Loss of Awareness) Coma Coma
(operationalized by Dikmen, et al. as (operationalized by Dikmen, et al. as Time to Follow Commands)Time to Follow Commands)
Post Traumatic Amnesia (PTA)Post Traumatic Amnesia (PTA) Signs of Intracranial InjurySigns of Intracranial Injury
Glasgow Coma Scale
15 point scale measures presence, degree, 15 point scale measures presence, degree, and duration of comaand duration of coma
Based on Based on Eyes Opening response (1 – 5 pts)Eyes Opening response (1 – 5 pts) Best Verbal response (1 – 5 pts)Best Verbal response (1 – 5 pts) Best Motor response (1 – 6 pts)Best Motor response (1 – 6 pts)
Post-traumatic Amnesia
A period of anterograde amnesia in A period of anterograde amnesia in which new memories cannot be which new memories cannot be
consistently made and recalled that consistently made and recalled that follows recovery of consciousness in follows recovery of consciousness in
head injury or other neurological head injury or other neurological trauma. trauma.
The duration of PTA is often used The duration of PTA is often used as a predictor of the degree of as a predictor of the degree of
recovery.recovery.
Classification of Head Injury
Mild Head InjuryMild Head InjuryGlasgow Coma Scale 13 – 15Glasgow Coma Scale 13 – 15PTA 5 – 60 minutesPTA 5 – 60 minutes
Moderate Head InjuryModerate Head InjuryGlasgow Coma Scale 9 – 12 Glasgow Coma Scale 9 – 12 PTA up to 24 hoursPTA up to 24 hours
Moderate to Severe Head InjuryModerate to Severe Head InjuryGlasgow Coma Scale 3 – 8Glasgow Coma Scale 3 – 8PTA 1 to 7 days or longerPTA 1 to 7 days or longer
What does empirical research tell us about the consequences of Traumatic Brain Injury Dikmen, S.S., Machamer, J.E., Winn, R., & Dikmen, S.S., Machamer, J.E., Winn, R., &
Temkin, N.R. (1995). Neuropsychological Temkin, N.R. (1995). Neuropsychological outcome at 1-year post head injury. outcome at 1-year post head injury. NeuropsychologyNeuropsychology, , 99, 80-90., 80-90.
Dikmen, S., Machamer, J., & Temkin, N. (2001). Dikmen, S., Machamer, J., & Temkin, N. (2001). Mild Head Injury: Facts and Artifacts. Mild Head Injury: Facts and Artifacts. Journal of Clinical and Experimental Journal of Clinical and Experimental Neuropsychology, 23Neuropsychology, 23, 729-738., 729-738.
What does empirical research tell us about the consequences of Traumatic Brain Injury
Hoge, C.W., McGurk, D., Thomas, J.L., Hoge, C.W., McGurk, D., Thomas, J.L., et al (2008) Mild traumatic brain injury et al (2008) Mild traumatic brain injury in U.S. soldiers returning from Iraq. in U.S. soldiers returning from Iraq. New England Journal of Medicine.New England Journal of Medicine. 358, 358, no. 5no. 5, 453-463. , 453-463.
Outcome Research: Mild TBI
Appropriately designed research studies Appropriately designed research studies indicate that virtually 100% mild head indicate that virtually 100% mild head injured subjects show no cognitive injured subjects show no cognitive impairment within about 3 months to a year impairment within about 3 months to a year (outside) post-injury(outside) post-injury
EXCELLENT Prognosis for Mild Head EXCELLENT Prognosis for Mild Head InjuryInjury
TBI Outcome Research: Surreya Dikmen, Ph.D.
Studies date from 1986Studies date from 1986 Follow patients and controls over timeFollow patients and controls over time Prospective DesignProspective Design
Consecutive hospital admissions of well-Consecutive hospital admissions of well-defined Head Injury patientsdefined Head Injury patients
Harborview Medical Center (Seattle, Harborview Medical Center (Seattle, WA), a Level I Trauma CenterWA), a Level I Trauma Center
TBI Outcome Research: Dikmen
Study minimized selection biasStudy minimized selection bias Large demographically representative groupLarge demographically representative group English-speaking only (for testing criteria)English-speaking only (for testing criteria) Did Did NOT NOT screen out preexisting conditionsscreen out preexisting conditions Unusually high rates of follow-upUnusually high rates of follow-up
85% followed up after one year85% followed up after one year
Outcome Research: Dikmen
Pre-existing conditions included:Pre-existing conditions included: Prior significant head injuryPrior significant head injury Alcoholism receiving treatmentAlcoholism receiving treatment History of cerebral diseaseHistory of cerebral disease Psychiatric disorder (schizophrenia, Psychiatric disorder (schizophrenia,
bipolar disorder)bipolar disorder)
Outcome Research: Dikmen
Broad spectrum of head injury severityBroad spectrum of head injury severity Minimum injury criteria include:Minimum injury criteria include:
Any period of loss of consciousnessAny period of loss of consciousness Post-traumatic amnesia of at least 1 hourPost-traumatic amnesia of at least 1 hour Other objective evidence of head trauma (e.g., Other objective evidence of head trauma (e.g.,
hematoma)hematoma) Injury severe enough to hospitalizeInjury severe enough to hospitalize Survival to complete at least 1 month follow-up Survival to complete at least 1 month follow-up
for neuropsychological assessment baselinefor neuropsychological assessment baseline
Outcome Research: Dikmen
Trauma Control SubjectsTrauma Control Subjects recruited from ER after trauma to parts of recruited from ER after trauma to parts of
body, other than headbody, other than head Controls matched head-injured on Controls matched head-injured on
age age sex sex educationeducation
Outcomes Following TBI
Dose-Response RelationshipDose-Response Relationship Dikmen, et al. (1995) found a significant Dikmen, et al. (1995) found a significant
relationship between length of coma relationship between length of coma (Time to Follow Commands) and level of (Time to Follow Commands) and level of performance on sensitive performance on sensitive neuropsychological measures at 1 year neuropsychological measures at 1 year post-injurypost-injury
Greater cognitive impairment is Greater cognitive impairment is associated with longer periods of comaassociated with longer periods of coma
Outcomes Following TBI
Mild head injured patients (TFC < 1 hour) Mild head injured patients (TFC < 1 hour) were indistinguishable from trauma controls were indistinguishable from trauma controls at one year post-injury on sensitive at one year post-injury on sensitive measures of cognitive functioning measures of cognitive functioning
Outcomes Following TBI
Although there were no significant Although there were no significant differences on cognitive testing, premorbid differences on cognitive testing, premorbid characteristics and risk factors were more characteristics and risk factors were more powerful than head injury in explaining powerful than head injury in explaining persistent psychosocial symptoms at one persistent psychosocial symptoms at one year post-injury (Dikmen, et al. 2001)year post-injury (Dikmen, et al. 2001)
Contributing Risk Factors Account for Persistent Symptoms in cases of Mild Closed Head Injury
AgeAge Education Education Pre-existing conditionsPre-existing conditions
Treatment for alcohol or substance abuseTreatment for alcohol or substance abuse CNS disorder (prior head injury)CNS disorder (prior head injury) Psychiatric condition (including PTSD)Psychiatric condition (including PTSD) Somatoform-Spectrum diagnosesSomatoform-Spectrum diagnoses
Dikmen’s Conclusion
““It is equally unusual for mild head injury It is equally unusual for mild head injury to produce deficits after 1 year as it is for to produce deficits after 1 year as it is for severe head injury to produce no deficits severe head injury to produce no deficits after 1 year.”after 1 year.”
(Dikmen, et al., 1995) (Dikmen, et al., 1995)
Recent Study of Soldiers Returning from Iraq
Hoge, et al (2008, in NEJM) studied 2525 U.S. Hoge, et al (2008, in NEJM) studied 2525 U.S. soldiers returning from Iraq.soldiers returning from Iraq. 124 (4.9%) reported injuries with LOC124 (4.9%) reported injuries with LOC
43% of these met criteria for PTSD43% of these met criteria for PTSD 260 (10.3%) reported altered Mental Status260 (10.3%) reported altered Mental Status
27.3% of these met criteria for PTSD27.3% of these met criteria for PTSD 435 (17.2%) reported other injuries435 (17.2%) reported other injuries
16.2% of these met criteria for PTSD16.2% of these met criteria for PTSD 1760 reported no injury1760 reported no injury
9.1% of these met criteria for PTSD9.1% of these met criteria for PTSD
Recent Study of Soldiers Returning from Iraq
Although the relationship is associative and Although the relationship is associative and not necessarily causal……not necessarily causal……
…“…“after adjustment for PTSD and after adjustment for PTSD and depression, mild traumatic brain injury depression, mild traumatic brain injury was no longer significantly associated was no longer significantly associated with these physical health outcomes or with these physical health outcomes or symptoms, except for headaches.”symptoms, except for headaches.”
Consistent with Dikmen’s researchConsistent with Dikmen’s research
So, how do we account for subjective complaints of lasting
symptoms following TBI ?
Postconcussion SyndromeICD-10 Diagnostic Criteria
A. History of head trauma with loss of A. History of head trauma with loss of consciousness precedes symptoms onset by consciousness precedes symptoms onset by maximum of four weeksmaximum of four weeks
Postconcussion SyndromeICD-10 Diagnostic Criteria
B. Symptoms in 3 or more of the following categories:B. Symptoms in 3 or more of the following categories: Headache, dizziness, malaise, fatigue, noise toleranceHeadache, dizziness, malaise, fatigue, noise tolerance Irritability, depression, anxiety, emotional labilityIrritability, depression, anxiety, emotional lability SubjectiveSubjective concentration, memory, or intellectual concentration, memory, or intellectual
difficulties difficulties without neuropsychological evidence of without neuropsychological evidence of marked impairmentmarked impairment
InsomniaInsomnia Reduced alcohol toleranceReduced alcohol tolerance Preoccupation with above symptoms and fear of Preoccupation with above symptoms and fear of
brain damage with hypochondriacal concern and brain damage with hypochondriacal concern and adoption of sick role.adoption of sick role.
Misattribution of Symptoms
Why do patients, families – even providers Why do patients, families – even providers – “misattribute” symptoms, such as – “misattribute” symptoms, such as memory problems, “loss” of cognitive memory problems, “loss” of cognitive abilities, or declining cognitive performance abilities, or declining cognitive performance – to brain injury?– to brain injury?
Psychological Theories for Understanding
Postconcussion Syndrome and “Misattribution of Symptoms”
““Good Old Days” HypothesisGood Old Days” Hypothesis ““Nocebo” EffectNocebo” Effect Diathesis-Stress ModelDiathesis-Stress Model Expectation as EtiologyExpectation as Etiology
“Good Old Days” Hypothesis
Gunstad & Suhr (2001)Gunstad & Suhr (2001) Tendency of people to recall past symptoms Tendency of people to recall past symptoms
and functioning more favorably than was and functioning more favorably than was actually the caseactually the case
Suggests that, following any negative event, Suggests that, following any negative event, people tend to attribute all symptoms to that people tend to attribute all symptoms to that negative event, regardless of a preexisting negative event, regardless of a preexisting history of that very problem or any other history of that very problem or any other factors that may be influencing that problem.factors that may be influencing that problem.
Nocebo Effect
Hahn (1997)Hahn (1997) The notion that expectations of sickness The notion that expectations of sickness
and associated emotional distress cause and associated emotional distress cause the sickness in questionthe sickness in question
Suggests that response expectations are Suggests that response expectations are “anticipations of automatic reactions to “anticipations of automatic reactions to particular situational cues” and are outside particular situational cues” and are outside both volition and conscious thought.both volition and conscious thought.
Diathesis-Stress Model
Wood (2004)Wood (2004) Examines the interaction between physiologic and Examines the interaction between physiologic and
psychological factors that generate and maintain psychological factors that generate and maintain postconcussional symptoms.postconcussional symptoms.
Suggests that iatrogenic forces can influence a Suggests that iatrogenic forces can influence a patient’s recovery after MTBI, especially if health patient’s recovery after MTBI, especially if health care providers inadvertently reinforce care providers inadvertently reinforce misperceptions of symptoms or insecurities about misperceptions of symptoms or insecurities about recoveryrecovery
Diathesis-Stress Model
In McCrea (2008, p. 176)In McCrea (2008, p. 176) ““an unfortunate scenario unfolds when a patient an unfortunate scenario unfolds when a patient
with vague symptom complaints and no clear with vague symptom complaints and no clear indication of significant head trauma is told he has indication of significant head trauma is told he has “brain damage” and will never make a complete “brain damage” and will never make a complete neurologic, symptom, or functional recovery.” neurologic, symptom, or functional recovery.”
““The long-term damage of creating that perception The long-term damage of creating that perception for a patient is most difficult to undo.”for a patient is most difficult to undo.”
Expectation as Etiology
Mittenberg et al (1992)Mittenberg et al (1992) Suggests that the incidence and Suggests that the incidence and
persistence of PCS may be explained by persistence of PCS may be explained by the degree to which an individual the degree to which an individual misattributes common complaints to a misattributes common complaints to a prior head injuryprior head injury
Examine in detail as an example of Examine in detail as an example of “normal” tendencies to misattribute “normal” tendencies to misattribute symptomssymptoms
Misattribution of Symptoms
Poor understanding that many common Poor understanding that many common symptoms represent a “final common symptoms represent a “final common endpoint” of many overlapping diagnoses endpoint” of many overlapping diagnoses and disordersand disorders
Poor understanding of mechanisms of Poor understanding of mechanisms of brain processing, injury, and recoverybrain processing, injury, and recovery
Poor understanding of base rates of Poor understanding of base rates of symptoms among “normal” individualssymptoms among “normal” individuals
Symptoms Overlap Across Diagnoses
From: McCrea (2007) Mild Traumatic Brain Injury and Postconcussion Syndrome p. 160, Table 161
HeadacheHeadache DizzinessDizziness IrritabilityIrritability Memory Memory ProblemsProblems
Attention Attention ProblemsProblems
CollegeCollege
StudentsStudents36 %36 % 18%18% 36%36% 17%17% 42%42%
Chronic PainChronic Pain 80%80% 67%67% 49%49% 33%33% 63%63%
DepressedDepressed 37%37% 20%20% 52%52% 25%25% 54%54%
Non-TBI Non-TBI Personal Inj Personal Inj
77%77% 41%41% 63%63% 46%46% 71%71%
Mild TBIMild TBI 42%42% 26%26% 28%28% 36%36% 25%25%
Poor Understanding of Brain Mechanisms Involved in Memory ““Memory” complaints are among most Memory” complaints are among most
common symptoms associated with common symptoms associated with postconcussion syndromepostconcussion syndrome
Information Processing Model of Memory Information Processing Model of Memory helps clarify the role that “psychological helps clarify the role that “psychological factors” can play in memory complaintsfactors” can play in memory complaints
Example of the important role that basic Example of the important role that basic education plays as a therapeutic education plays as a therapeutic interventionintervention
Information Processing Model of Memory
Base Rates: The frequency with which Base Rates: The frequency with which abnormal neuropsychological findings are abnormal neuropsychological findings are observed among “normal” individuals. observed among “normal” individuals.
It is “normal” to perform in the impaired range on It is “normal” to perform in the impaired range on some cognitive measuressome cognitive measures
Heaton, Grant, and Matthews norms indicate that Heaton, Grant, and Matthews norms indicate that very few healthy individuals complete a very few healthy individuals complete a neuropsychological protocol without any impaired neuropsychological protocol without any impaired scores, while as many as 38% of “normals” scores, while as many as 38% of “normals” perform in the impaired range on 6 or more perform in the impaired range on 6 or more discrete scores in a 40-score battery. discrete scores in a 40-score battery.
Base Rates and Misattribution of Symptoms
Percent of “normal” individuals who score in the impaired range on 0 to 6 or more measures in a
battery of 40 measures
Mittenberg, et al. (1992)Mittenberg, et al. (1992) 223 volunteers 223 volunteers 100 pts with closed head injuries100 pts with closed head injuries
Average 1.7 years after injuryAverage 1.7 years after injury Average reported LOC = 23 minutesAverage reported LOC = 23 minutes
30-symptom checklist of items30-symptom checklist of items AffectiveAffective SomaticSomatic MemoryMemory
Expectation as Etiology
Examples of symptom checklist
Forgets where car is parkedForgets where car is parked Forgets why they entered a roomForgets why they entered a room Loses items around the houseLoses items around the house Sensitivity to bright lightSensitivity to bright light Blurry or double visionBlurry or double vision Concentration difficultyConcentration difficulty DepressionDepression
Control Subjects
Which symptoms do you (healthy Which symptoms do you (healthy volunteers) currently experience?volunteers) currently experience?
…….Now imagine an MVA-related head .Now imagine an MVA-related head injury 6 months before, in which you were injury 6 months before, in which you were knocked out, hospitalized for a week or knocked out, hospitalized for a week or two. Respond to the symptoms that you two. Respond to the symptoms that you think you would have think you would have afterafter an accident an accident like this.like this.
Patients with head injuries
Identify the symptoms you think you would Identify the symptoms you think you would have had have had beforebefore the accident (how you used the accident (how you used to be)to be)
Then identify symptoms that you notice Then identify symptoms that you notice now, now, afterafter the accident (how you are now) the accident (how you are now)
No difference between the incidence of Post-concussion Symptoms expected by controls and those reported by head injury patients.
Control Group M = 14.8 s.d. = 7.6
Head Injured M = 13.8s.d. = 8.3
Incidence of Expected and Actual Postconcussion Symptoms
% controls% controls % patients% patients
HeadacheHeadache 80.080.0 59.159.1
AnxietyAnxiety 68.168.1 58.358.3
Concentration difficultyConcentration difficulty 66.866.8 70.570.5
IrritabilityIrritability 50.050.0 65.965.9
Forgets why entered roomForgets why entered room 34.834.8 50.650.6
Loses items around houseLoses items around house 28.528.5 28.128.1
However, Head Injury patients significantly underestimated symptoms prior to injury, compared to normal base rates
Head injury patients underestimated Head injury patients underestimated premorbid frequency of 21 specific premorbid frequency of 21 specific symptoms compared to base rates of normal symptoms compared to base rates of normal controlscontrols
Normal Base Rates of normal controls compared to head injury patient’s premorbid estimates of symptoms
% controls% controls % patients% patients
Forgets where car parkedForgets where car parked 32.032.0 7.07.0
Loses car keysLoses car keys 31.031.0 6.06.0
Forgets groceriesForgets groceries 28.328.3 9.09.0
Concentration difficultyConcentration difficulty 13.513.5 5.05.0
Forgets appointment datesForgets appointment dates 20.220.2 7.07.0
Loses items around houseLoses items around house 17.017.0 4.04.0
“Results suggest a tendency for patients with head injuries to attribute [normally occurring] premorbid symptoms to head trauma.”
Neuropsychological Assessment of Effort and Motivation
Malingering (DSM-IV)
……the intentional production of false or the intentional production of false or grossly exaggerated physical or grossly exaggerated physical or psychological symptoms, motivated by psychological symptoms, motivated by external incentives such as avoiding external incentives such as avoiding military duty, avoiding work, obtaining military duty, avoiding work, obtaining financial compensation, evading criminal financial compensation, evading criminal prosecution, or obtaining drugs. prosecution, or obtaining drugs.
Diagnoses Involving Symptom Exaggeration or Unfounded Physical
or Psychological Symptoms
Malingering – intentional feigning or Malingering – intentional feigning or exaggerating symptoms of illness or exaggerating symptoms of illness or injury for external gain.injury for external gain.
Intentional Intentional Production Production of Symptomsof Symptoms
Obvious Obvious External External IncentivesIncentives
Symptoms Satisfy Symptoms Satisfy Psychological NeedsPsychological Needs
Somatization Somatization DisorderDisorder
AbsentAbsent Not ObviousNot Obvious LikelyLikely
Somatoform Somatoform DisorderDisorder
AbsentAbsent Not ObviousNot Obvious LikelyLikely
Conversion Conversion DisorderDisorder
AbsentAbsent Not ObviousNot Obvious Symptoms worsened Symptoms worsened by stress and conflict by stress and conflict
HypochondriasisHypochondriasis AbsentAbsent Not ObviousNot Obvious Misinterpretation of Misinterpretation of Physical SymptomsPhysical Symptoms
Factitious Factitious DisorderDisorder
PresentPresent Not ObviousNot Obvious Need to Maintain the Need to Maintain the “Sick” Role“Sick” Role
MalingeringMalingering PresentPresent PresentPresent Not ObviousNot Obvious
Base Rates of Malingering and Symptom Exaggeration
Mittenberg, Patton, Canyock, & Condit (2002)Mittenberg, Patton, Canyock, & Condit (2002) Surveyed ABCN diplomatesSurveyed ABCN diplomates Rates of cases involving “probable malingering” Rates of cases involving “probable malingering”
and “symptom exaggeration”and “symptom exaggeration” 19% personal injury19% personal injury 30% disability30% disability 19% criminal19% criminal 8% general criminal cases8% general criminal cases
Base Rates of Malingering and Symptom Exaggeration Larrabee, G. (2003)Larrabee, G. (2003) Reviewed 11 studiesReviewed 11 studies
1363 consecutively evaluated mild 1363 consecutively evaluated mild traumatic brain-injury litigants.traumatic brain-injury litigants.
Found a rate of about 40% symptom Found a rate of about 40% symptom exaggeration or malingering among the exaggeration or malingering among the samplesample
Base Rates of Malingering and Symptom Exaggeration Chafetz & Abrahams (2005)Chafetz & Abrahams (2005) Adults seeking Social Security disabilityAdults seeking Social Security disability 13.8% met criteria for definite malingering13.8% met criteria for definite malingering 58.6% met criteria for probable malingering 58.6% met criteria for probable malingering
(two or more failed validity indicators)(two or more failed validity indicators) Combined definite/probable base rate of Combined definite/probable base rate of
malingering of 72.4%malingering of 72.4%
Base Rates of Malingering and Symptom Exaggeration
Bush, et al (2005)Bush, et al (2005) Likely rates of malingering or symptom Likely rates of malingering or symptom
exaggeration – and potential costs to the system exaggeration – and potential costs to the system (SSD, VA, personal injury litigation) – are (SSD, VA, personal injury litigation) – are significant enough that National Academy of significant enough that National Academy of Neuropsychology recommends that symptom Neuropsychology recommends that symptom validity testing be included as part of validity testing be included as part of comprehensive neuropsychological test battery.comprehensive neuropsychological test battery.
What Makes Sense “Neuropsychologically”
in a Specific Case? Circumstances of the Alleged InjuryCircumstances of the Alleged Injury Reported Changes in Functioning Over Reported Changes in Functioning Over
TimeTime Consideration of Brain – Behavior Consideration of Brain – Behavior
RelationshipsRelationships Pattern of Neuropsychological PerformancePattern of Neuropsychological Performance
Documented Evidence of Injuryversus
Patient’s Account of the Injury Consider subjective reports ofConsider subjective reports of
LOC LOC Force of Collision Force of Collision Level of toxic exposureLevel of toxic exposure
In light of documentationIn light of documentationAmbulance / Police ReportsAmbulance / Police ReportsMedical RecordsMedical RecordsLaboratory ReportsLaboratory Reports
Reported Changes Over Timeversus
Natural Course of Recovery
Mild head injury symptoms should improve Mild head injury symptoms should improve over time – not worsenover time – not worsen
““It is equally unusual for mild head injury It is equally unusual for mild head injury to produce deficits after one year as it is for to produce deficits after one year as it is for severe head injury to produce no deficits severe head injury to produce no deficits after one year.” Dikmen, et al., 1995after one year.” Dikmen, et al., 1995
The pattern of neuropsychological performance
should be consistent with the reported symptoms and circumstances of the
alleged injury
“Odd” complaints for mild head injury without signs of focal neuroanatomical injury
StutteringStuttering Loss of vocabularyLoss of vocabulary Severe self-neglect Severe self-neglect
with preserved ability to drivewith preserved ability to drive Loss of autobiographical memoryLoss of autobiographical memory Loss of developmentally overlearned skillsLoss of developmentally overlearned skills
Tying one’s shoesTying one’s shoes SpellingSpelling
Two Main Approaches to Detect Poor Effort or Malingering
Identification of motivationally-impaired Identification of motivationally-impaired patterns of performance on traditional patterns of performance on traditional neuropsychological testsneuropsychological tests
Use of specific measures of effortUse of specific measures of effort
Deviations from Expected Patterns of Functioning
VIQ vs. PIQ differences on WAIS testingVIQ vs. PIQ differences on WAIS testing Strengths on “Hold” vs. “Don’t Hold” Measures Strengths on “Hold” vs. “Don’t Hold” Measures Unexpected pattern of Index ScoresUnexpected pattern of Index Scores
Verbal Comprehension IndexVerbal Comprehension Index Perceptual Organization IndexPerceptual Organization Index Working Memory IndexWorking Memory Index Processing Speed IndexProcessing Speed Index
Worse performance on easier vs harder itemsWorse performance on easier vs harder items
Specific Measures of Effort and Validity
MMPI-2 Personality Self-ReportMMPI-2 Personality Self-Report ““F” family (F, Fb, Fp, F – K) F” family (F, Fb, Fp, F – K) FBSFBS VRIN Variable Response indicatorsVRIN Variable Response indicators TRIN True Response SetTRIN True Response Set
Forced Choice Recognition Techniques Many types of StimuliMany types of Stimuli
Pictures, Faces, Words, Numbers, Pictures, Faces, Words, Numbers, TexturesTextures
Expectation for high levels of Success, even Expectation for high levels of Success, even among significantly impaired individualsamong significantly impaired individuals
Chance rulesChance rules
15-Item Memory
11 22 33
AA BB CC
1 1 22 33
aa bb cc
Outright “Malingering” is Rare
Malingering is only one point on a Malingering is only one point on a diagnostic continuum of poor effort and diagnostic continuum of poor effort and symptom exaggeration symptom exaggeration
Outright “Malingering” is Rare
Poor effort and symptom exaggeration are Poor effort and symptom exaggeration are most frequently associated with:most frequently associated with: Chronic illness behaviorChronic illness behavior Significant emotional symptomsSignificant emotional symptoms
• DepressionDepression• AnxietyAnxiety• PTSDPTSD
Poor expectations for one’s own Poor expectations for one’s own performance (Nocebo effect)performance (Nocebo effect)
Effort and Motivation are best assessed in light of:
Objective Records and DocumentationObjective Records and Documentation Known brain-behavior relationshipsKnown brain-behavior relationships Natural history of recovery from injuryNatural history of recovery from injury Unusual pattern of performance on standard Unusual pattern of performance on standard
materialsmaterials
CONCLUSIONS
TBI does not typically occur in isolationTBI does not typically occur in isolation Emotional and psychosocial stressors are Emotional and psychosocial stressors are
typically significanttypically significant
CONCLUSIONS
Reported TBI most frequently involves mild TBI Reported TBI most frequently involves mild TBI
CONCLUSIONS
Credible research indicates that full cognitive Credible research indicates that full cognitive recovery is the norm in mild TBI recovery is the norm in mild TBI Duration of documented Loss Of Duration of documented Loss Of
Consciousness is most frequently subtle, or less Consciousness is most frequently subtle, or less than 30 minutesthan 30 minutes
CONCLUSIONS
Important to identify TREATABLE symptomsImportant to identify TREATABLE symptoms No direct treatments for TBI, BUTNo direct treatments for TBI, BUT Highly successful treatment programs forHighly successful treatment programs for
DepressionDepressionPTSDPTSDSubstance AbuseSubstance AbuseFamily/Couples TherapyFamily/Couples Therapy
CONCLUSIONS TBI does not typically occur in isolationTBI does not typically occur in isolation
Emotional and psychosocial stressors Emotional and psychosocial stressors Reported TBI most frequently involves mild TBI Reported TBI most frequently involves mild TBI Credible research indicates that full cognitive Credible research indicates that full cognitive
recovery is the norm in mild TBI (e.g., LOC < 30 recovery is the norm in mild TBI (e.g., LOC < 30 minutes)minutes)
Important to identify TREATABLE symptomsImportant to identify TREATABLE symptoms No direct treatments for TBINo direct treatments for TBI
Associated psychological symptoms are associated Associated psychological symptoms are associated with subjectively reported TBI symptoms that with subjectively reported TBI symptoms that ARE highly treatableARE highly treatable Depression, PTSD, Substance AbuseDepression, PTSD, Substance Abuse
Recommended