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