Myths and Mild Traumatic Brain Injury

Despite the fact that patients with mild traumatic brain injuries (TBI) are commonly encountered in clinical practice, there are numerous myths surrounding their diagnosis, assessment, and outcome. The purpose of this paper is to review some of the more common myths related to mild TBI including: (a) there is no Miserable Minority; (b) meta-analytic studies have proven that patients with mild TBI do not experience persistent deficits; (c) personality tests can reliably capture psychological problems in patients with a mild TBI; (d) findings from the sports concussion literature can be directly applied to clinical patients; and (e) in the absence of loss of consciousness, the diagnosis of a mild TBI is uncertain.     

Neuroimaging in Mild Traumatic Brain Injury

Neuroimaging in mild traumatic brain injury (mTBI) is reviewed. While computed tomography remains the acute standard for neuroimaging of mTBI, it is only sensitive to gross abnormalities and is typically performed as a measure to rule out more serious and life-threatening injury. Magnetic resonance imaging (MRI), especially at field strength of 3.0 T, is the follow-up neuroimaging standard for assessing potential underlying structural injury to the brain. Several MRI sequences are particularly sensitive to subtle hemorrhagic lesions and signal abnormalities in white matter, sensitive enough to detect pathology when present in mTBI. Clinical correlation of neuropsychological outcome with neuroimaging findings is discussed along with the future potential for functional neuroimaging in evaluating the mTBI patient.     

Forensic Neuropsychology and Mild Traumatic Brain Injury

Over the last 20 years, the Courts and the legal community have increasingly relied on neuropsychologists to provide opinions, guidance, and expertise in the area of brain–behavior relationships. The purpose of this article is to review issues neuropsychologists commonly face when asked to evaluate cases with suspected mild traumatic brain injuries (TBI) in the civil or criminal legal context. In particular, we will discuss: (a) the neuropsychologist’s role in TBI forensic cases, (b) the attorney’s role in forensic TBI cases, (c) a neuropsychological framework to approach forensic mild TBI cases, (d) establishing working relationships with attorneys, (e) the Daubert and Frye standards, (f) symptom validity, (g) ethical issues, and (h) recommendations to improve the ecological validity of our tests and encourage test developers to provide alternate forms of tests.     

Nocebo Effects and Mild Traumatic Brain Injury: Legal Implications

Expectations may play a large role in health-related outcomes, but they may not be fully addressed or considered in medical–legal contexts. Contextual factors can influence a patient’s expectations for recovery following a concussion, including explicit or implicit messages from the media, healthcare providers and systems of care, and the forensic arena. This article discusses these factors as nocebo effects, that is, various inherently “inert” factors may create negative expectancies for recovery and therefore impede a given patient’s progress and recovery. It is argued that the negligence theory upon which the legal system is based tends to compound these nocebo effects. In accident-related concussions, both the accident itself and subsequent nocebo effects including potential healthcare and medical–legal provider negligence can create legal liability.     

轻度创伤性脑损伤脑脊液及血液生物标记物研究进展

轻度创伤性脑损伤(mild traumatic brain injury,MTBI)被认为是轻度脑损伤导致的短暂意识丧失和精神改变,但有时也会导致持久性、进行性的临床症状。MTBI可引起神经系统结构损伤及相应的体液生物标记物改变,但有关其严重程度及个体易感性与意识障碍持续时间的关联程度研究不足,同时,一次打击后脑损伤程度也缺乏可靠的评估方法。本文综述了与TBI有关的脑脊液及血液生物标记物,探讨这些标记物在MTBI诊断中的应用现状及研究前景,为法医学及临床医学中脑损伤的诊断及评估提供参考依据。     

Beyond Traumatic Brain Injury: Advancing Forensic Neuropsychological Assessment

As research on the cognitive impact of medical conditions and mental health disorders advances, it is imperative for forensic neuropsychologists to stay abreast of rapidly accumulating new empirical evidence from neuroscience and neuropsychology to disentangle multiple determinants of cognitive impairment. Although medicolegal neuropsychological assessments traditionally focused on traumatic brain injury (TBI) sequelae, it is equally important to consider the potential impact of any other acquired, or secondarily induced brain impairments, regardless of their source. Such injuries or conditions are at times assumed to cause a lesser cognitive impact than TBIs; however, their effects depend entirely on the factor in question. Injuries and illnesses implicated in civil litigation—and eventually affecting competency—can indeed involve TBI, but also anoxic/hypoxic injuries, pain, depression, posttraumatic stress disorder (PTSD), sensory deficits (e.g., tinnitus), and fatigue, and all, in turn, can affect an individual’s cognitive function and quality of life. Impairments caused by these conditions can be disabling and resistant to treatment, particularly, when the treatment is based on incorrect diagnostic, prognostic, and causality assumptions.     

Predictive Validity of the Neuropsychological Assessment Battery-Screening Module for Assessing Real-World Disability in Patients with Mild Traumatic Brain Injury

The present study set out to examine the ecological validity of the Neuropsychological Assessment Battery-Screening Module (NAB-S) and to examine more specifically, whether performance on this test battery is related to real-world disability status in patients who have sustained a mild traumatic brain injury (mTBI) as a consequence of a motor vehicle collision (MVC). Seventy-nine patients were recruited from a random sample of litigating patients who incurred an mTBI and were referred for a neuropsychological examination due to subjective complaints of cognitive function. Of the total sample, 54 patients were categorized into the non-disabled group and 25 patients were categorized into the disabled group using the 4th edition of the American Medical Association (AMA) Guides to the Evaluation of Permanent Impairment (AMA; 1993). A multivariate analysis of variance revealed that performance on the NAB-S significantly differed between the two groups, and that memory and attention domains provided a more discriminative index of disability than general neuropsychological functions. In addition, discriminant function analyses revealed that the NAB-S correctly classified 73% of patients according to their group membership. The current findings provide evidence for the ecological validity of the NAB-S as a reliable index of real-world disability status as defined by the AMA Guides.     

Traumatic Brain Injury Across the Lifespan: A Neuropsychological Tutorial for Attorneys

Traumatic brain injuries (TBIs) are prevalent across the lifespan and occur from multiple sources (e.g., motor vehicle accidents, falls, sports injuries, assaults, abuse). Because many of these injuries are compensable, plaintiff and defense counsel often rely on the expertise of a forensic neuropsychologist to help establish or refute the claim of the presence of TBI, or the degree of severity claimed. In this paper, we offer a tutorial in which we provide information that attorneys need to know in handling of TBI cases: We address definitions, epidemiology, pathophysiology, guidelines for grading TBI severity, and treatment. Also, we cover moderating variables that affect TBI outcome and recovery and specific forensic issues that may arise in the neuropsychological evaluation (e.g., symptom magnification, malingering). Although the focus is on mild TBI in adults, we also cover the more serious variants of moderate and severe adult TBI and include a separate all-severity section on pediatric populations. We consider the special challenges the attorney faces, for example, in establishing causality.     

The Intersection of Intimate Partner Violence and Traumatic Brain Injury: A Call for Interdisciplinary Research

An emerging body of research suggests that survivors of intimate partner violence (IPV) are at a high risk for sustaining traumatic brain injury (TBI). However, most scholars and practitioners working on the problem of IPV have not examined how TBI could be related to their familiar subject of study. Concomitantly, little work in the brain injury field has been done to examine TBI in the context of IPV. In this paper, we encourage cross-collaboration among these fields. To that end, we consider the relationship between IPV and TBI; the difficulty in detecting and measuring the IPV-related TBI and ethical concerns that may arise when addressing this issue. Our work emphasizes the need to recognize the complex interplay among psycho-physiological health and socio-cultural contexts. As such, we present a socio-ecological perspective of IPV-related TBI to provide a contextual framework to guide future interdisciplinary research. Finally, we outline directions for future research.     

Correlative Factors for Organic Psychotic Symptoms in Patients Following Traumatic Brain Injury

Objective To investigate the correlative factors for organic psychotic symptoms following trau matic brain injury （TBI）. Methods In the current study, 391 subjects who had undergone forensic iden tification of the organic mental disorders due to TBI were included, both the demographic and posttrau matic information collected. The relevant data were statistically analyzed in those confirmed as organic psychotic syndrome according to Chinese Classification of Mental Disorders 3rd version （CCMD3）. Re suits Fiftytwo subjects （13.3%） were identified as organic psychotic symptoms. The chisquare test showed that the detectable organic psychotic symptoms were associated with the marriage status, damage nature, injury severity and treatment, and the multivariate logistic regression analysis revealed good fitness of treatment and injury severity with the regression model （OR=0.044, 95% CI： 0.0170.114; OR=2.145, 95% CI： 1.201-3.832, respectively）. Conclusion The risks of organic psychotic symptoms following TBI can be involved in the alternative of craniotomy for the cases with trauma and moderate brain injury.     

颅脑损伤部位及程度与日常生活活动能力的相关性

目的：研究颅脑损伤部位及程度与日常生活活动能力的相关性,为提高鉴定意见的准确性提供理论依据。方法选取颅脑损伤被鉴定人501例,详细记录其伤前情况、损伤部位及程度、治疗方式、教育程度,应用日常生活活动能力量表（Barthel指数）对被鉴定人进行测验,统计损伤部位及程度与Barthel指数的相关性。结果轻度颅脑损伤组各损伤部位Barthel指数差异无统计学意义（P〉0.05）;中度颅脑损伤组蛛网膜下腔出血与其他脑叶损伤,顶、枕叶损伤与额叶损伤,顶、枕叶损伤与颞叶损伤间Barthel指数差异均具有统计学意义（P〈0.05）,额叶损伤与颞叶损伤Barthel指数差异无统计学意义（P〉0.05）;重度颅脑损伤不论手术与否,各颅脑损伤部位的Barthel指数两两之间差异均有统计学意义（P〈0.05）。结论颅脑损伤部位与Barthel指数存在一定相关性,对分析判断颅脑损伤后日常生活活动能力具有重要的参考价值。     

Re-examination of the Controversial Coexistence of Traumatic Brain Injury and Posttraumatic Stress Disorder: Misdiagnosis and Self-Report Measures

The coexistence of traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD) remains a controversial issue in the literature. To address this controversy, we focused primarily on the civilian-related literature of TBI and PTSD. Some investigators have argued that individuals who had been rendered unconscious or suffered amnesia due to a TBI are unable to develop PTSD because they would be unable to consciously experience the symptoms of fear, helplessness, and horror associated with the development of PTSD. Other investigators have reported that individuals who sustain TBI, regardless of its severity, can develop PTSD even in the context of prolonged unconsciousness. A careful review of the methodologies employed in these studies reveals that investigators who relied on clinical interviews of TBI patients to diagnose PTSD found little or no evidence of PTSD. In contrast, investigators who relied on PTSD questionnaires to diagnose PTSD found considerable evidence of PTSD. Further analysis revealed that many of the TBI patients who were initially diagnosed with PTSD according to self-report questionnaires did not meet the diagnostic criteria for PTSD upon completion of a clinical interview. In particular, patients with severe TBI were often misdiagnosed with PTSD. A number of investigators found that many of the severe TBI patients failed to follow the questionnaire instructions and erroneously endorsed PTSD symptoms because of their cognitive difficulties. Because PTSD questionnaires are not designed to discriminate between PTSD and TBI symptoms or determine whether a patient's responses are accurate or exaggerated, studies that rely on self-report questionnaires to evaluate PTSD in TBI patients are at risk of misdiagnosing PTSD. Further research should evaluate the degree to which misdiagnosis of PTSD occurs in individuals who have sustained mild TBI.     

颅脑外伤致运动和感觉障碍的评残时机

目的研究颅脑外伤致运动、感觉障碍相对合理准确的最佳鉴定时机。方法分别收集108例交通事故颅脑外伤患者伤后不同时间段（3、6、9、12、15、18月）的病史、影像学及电生理检查资料,并对患者家属进行随访调查,进行法医学检验,据此做出诊断并进行伤残等级评定;同时分别应用脑卒中残损评价表（Stroke Impairment Assessment Set,SIAS）、日常生活能力量表（Activity of Daily Living Scale,ADL）和Fugl-Meyer评定表（Fugl-Meyer assessment,FMA）对患者进行测验。结果SIAS、ADL、FMA对不同等级伤残及不同时间段区分良好,整体样本显示患者SIAS、ADL、FMA平均值9月至18月变化无差别,轻度伤残SIAS、ADL、FMA平均值6月至18月变化无差别,中度伤残SIAS、ADL、FMA平均值9月至18月变化无差别,重度伤残SIAS、ADL、FMA平均值12月至18月变化无差别。结论颅脑外伤所致运动、感觉障碍评残时机应在医疗终结以后,轻度伤残（7～10级）最佳评残时机为颅脑外伤后6个月,中度伤残（4～6级）评残时机以颅脑外伤后9个月为宜,重度伤残（1～3级）评残时机不应短于伤后12个月,视具体情况可以适当延后评残。     

Traumatic Brain Injury with Personality Change: a Challenge to Mental Capacity Law in England and Wales

Psychological Injury and Law - It is well documented that people with moderate-to-severe traumatic brain injury (TBI) can undergo personality changes, including becoming more impulsive in terms of...     

Traumatic Brain Injury Among Mothers Identified as Having a High Risk of Child Maltreatment: A Pilot Study

Traumatic brain injury (TBI) occurs frequently and may result in deficits in concentration, fatigue, attention, aggression and emotion regulation; significantly impacting an individual’s ability to function. This study examined reports of TBI among mothers identified as having high risk for child abuse/maltreatment. Participants were 206 Mothers referred to a child abuse prevention programme (The Family Help Trust, Christchurch, New Zealand) between 2003 and 2010 (n?=?206); TBI prevalence of 36.4 % (n?=?75). One-third had experienced multiple TBI (n?=?24), and 58.7 % (n?=?44) of those reporting TBI had experienced their first injury prior to age 16. TBI in at-risk mothers was more than three times the TBI found in community samples, with many injuries occurring in childhood. Given the increased prevalence of TBI among mothers at high risk of child abuse, there is a need for greater information regarding the long-term outcomes of TBI, particularly for vulnerable groups requiring assistance to manage life roles.     

颅脑损伤后昏迷与社会活动、生活功能的相关性探讨

目的研究颅脑损伤后格拉斯哥昏迷指数（GCS）评分、昏迷时间与社会功能缺陷筛选量表（SDSS）值、日常生活活动能力评价表（ADL）值的相关性。方法选取常州市德安医院司法鉴定所及苏州大学司法鉴定所颅脑损伤被鉴定人281例,详细记录损伤部位、损伤程度、昏迷时间、GCS评分,是否手术治疗、是否为多发伤;同时应用SDSS量表及ADL量表评分,并进行统计分析。结果 GCS评分与颅脑损伤6个月后SDSS值低度相关,与ADL值中度相关;昏迷时间与颅脑损伤6个月后SDSS值低度相关,与ADL高度相关。结论 GCS评分及昏迷时间与颅脑损伤后ADL值、SDSS值具有一定的相关性,对颅脑损伤司法鉴定具有一定的参考价值。     

Assessing the Behavior and Needs of Veterans with Traumatic Brain Injury in Washington State Prisons: Establishing a Foundation for Policy,Practice, and Education

Abstract

A growing awareness of justice-involved veterans is revealing how little is known about this population, to what extent they have experienced a traumatic brain injury (TBI), and how this may relate to institutional behavior, participation in programs, and use of institutional resources. The current study identifies the prevalence of incarcerated veterans in Washington State who have experienced a TBI and how a TBI history may affect their prison experience and use of prison resources. The results of our study show that incarcerated veterans in Washington State with a moderate-to-severe TBI are more likely to use medical services, commit violent infractions, be placed in maximum custody (solitary confinement), and less likely to complete vocational and job skills programs. The importance of these findings to policy and practice is discussed.     

Traumatic Brain Injury Alters Word Memory Test Performance by Slowing Response Time and Increasing Cortical Activation: An fMRI Study of a Symptom Validity Test

The Word Memory Test (WMT) is an established symptom validity test that relies on verbal memory performance to make inferences about “effort.” Previous studies, using a functional MRI (fMRI) adaptation of the WMT with healthy controls, have shown that successful completion of the WMT relies on a widespread network of neural systems associated with high cognitive effort. Additional studies using the same fMRI paradigm with patients with severe traumatic brain injury (TBI) suggest that increased activation of cortical regions associated with cognitive load are recruited to meet the cognitive challenges that the WMT places on a compromised neural system. This study builds on previous findings as a result of highly uncommon circumstances in which fMRI data on the WMT task were made available from the very same individual both 1 year before and 1 year after sustaining a TBI. Interestingly, the effect of TBI did not appear to impair performance on the WMT in terms of standard accuracy measurements, though response times were notably slower. The main fMRI finding was a significantly stronger and more widespread pattern of activation post-injury, particularly in the frontal and parietal brain regions, suggesting that stronger engagement of these networks was necessary to sustain accurate WMT performance compared to pre-injury testing. This unique source of data, together with previous findings, suggests a more complex relationship between effort and performance levels on the WMT than what is commonly assumed.