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.     

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.     

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.     

Traumatic Brain Injury among Indiana State Prisoners

Research on traumatic brain injury among inmates has focused on comparing the rate of traumatic brain injury among offenders to the general population, but also how best to screen for traumatic brain injury among this population. This study administered the short version of the Ohio State University Traumatic Brain Injury Identification Method to all male inmates admitted into Indiana state prisons were screened for a month (N = 831). Results indicate that 35.7% of the inmates reported experiencing a traumatic brain injury during their lifetime and that these inmates were more likely to have a psychiatric disorder and a prior period of incarceration than those without. Logistic regression analysis finds that a traumatic brain injury predicts the likelihood of prior incarceration net of age, race, education, and psychiatric disorder. This study suggests that brief instruments can be successfully implemented into prison screenings to help divert inmates into needed treatment.     

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.     

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.     

脑损伤患者听觉P300电位特点

目的探讨听觉P300电位对脑损伤患者认知功能障碍程度法医学评价的应用价值。方法对正常人和脑损伤患者,分别在主动（踩踏板）与被动任务状态下进行听觉P300测试。结果正常人主动任务状态P300电位中的N2、P3波波幅较被动状态高,潜伏期无明显延长,N1、P2波幅Cz点高于Pz点。脑损伤组被动任务状态下N2、P3波波幅较正常人被动状态下高．且潜伏期延长。脑损伤组主动任务状态P300电位中的N2、P3波波幅较被动状态高,且潜伏期延长。注意障碍患者P3波潜伏期改变最明显。结论任务类型主要影响N2、P3波幅。被动反应中的N2、P3潜伏期可作为评价脑损伤患者认知功能的指标。     

Functional Neuroimaging of Symptom Validity Testing in Traumatic Brain Injury

The Word Memory Test (WMT) is a commonly used symptom validity test (SVT) that assesses recognition verbal memory. The task has been adapted for use within a functional magnetic resonance imaging (fMRI) paradigm so the neural correlates of WMT activation patterns can be studied. In the current investigation, performance on the delayed recognition subtest of the WMT was examined in two patients who sustained severe TBI and compared to ten healthy controls. The patients underwent comprehensive neuropsychological evaluations and structural MRI. All participants completed two versions of the WMT: full-effort and simulated poor effort conditions. Despite extensive structural brain damage, the fMRI activation patterns during full-effort WMT performance were somewhat similar in the two TBI patients and likewise, somewhat similar to controls. The fMRI activation pattern in both patients demonstrated intact activation of the basic neural structures necessary to perform the WMT. Dissimilar patterns of activation were obtained during the simulated poor effort condition of WMT performance suggesting that fMRI techniques may be sensitive in demonstrating non-credible cognitive performance. The results of our study represent the first fMRI investigation of normal and simulated poor effort SVT performance in individuals with documented brain damage. The implications of fMRI techniques in SVT research and their clinical application are discussed.     

Chronic Traumatic Encephalopathy Pathology After Shotgun Injury to the Brain

Chronic traumatic encephalopathy (CTE) was initially conceptualized in boxers, but has extended to other athletes in recent years, albeit with limited clinical correlations. It is often asserted that CTE pathology represents the substrate for progressive neurodegenerative disease. We report the case of a shotgun injury to the brain with 42‐year survival and no neurological disease progression until shortly before death. The decedent had no other traumatic brain injury (TBI) exposure and did not play football or other high energy collision sport. Neuropathological examination confirmed tissue damage, but additionally demonstrated localized patterns of phosphorylated tau (p‐tau) meeting criteria for CTE pathology. P‐tau and TDP‐43 deposits within marginal tissue of damaged brain were also present focally. No amyloid‐β (Aβ) deposits were present. These findings indicate that CTE pathology may occur following a single, severe TBI.     

Chapter 14: Encephalitis

Encephalitis is infectious inflammation of the brain. The following types may be provisionally distinguished: (a) primary encephalitis with direct infection of the brain, and (b) secondary encephalitis, caused by various general infections.     

Chapter 11: Epilepsy

Epilepsy is a disease whose chief symptoms are seizures and other convulsive disorders of neuropsychopathic activity, predominantly in the form of disorders of consciousness. In an adversely progressing illness, changes in the personality and intellect arise, forming the peculiar picture of epileptic dementia.     

外伤性癫痫法医学评定100例分析

目的探讨颅脑外伤后癫痫的法医学评定要点,提出外伤性癫痫的法医学评定依据。方法对100例颅脑损伤后癫痫患者门诊及住院病历,结合临床脑电图（EEG）结果、CT片、MRI片等影像学资料,进行了回顾性分析。结果依据GBl8667-2002《道路交通事故受伤人员伤残评定》标准有关颅脑损伤后癫痫发作类型、发作频率的相关条款规定,Ⅲ级伤残8人,Ⅴ级伤残10人,Ⅶ级伤残22人,Ⅸ级伤残40人,Ⅹ级伤残20人。误工期限、营养期限和护理期限评定结论时间长短差异较大,具有个体化特征。结论外伤后癫痫常继发于严重的颅脑损伤,其发作特点决定于颅脑外伤的部位和程度,外伤性癫痫法医学鉴定必须以外伤史及既往史为基础,结合电生理及影像学检查,综合癫痫发作类型、频率及药物控制情况作出正确的伤残等级及误工期限、护理期限、营养期限的鉴定结论。     

Chapter 1: Introduction

This chapter provides an overview of the statutes that are the subject of this book-the Uniform Child Custody Jurisdiction Act (UCCJA), the Parental Kidnapping Prevention Act (PKPA), the Hague Convention on the Civil Aspects of International Child Abduction (Hague Convention) and the International Child Abduction Remedies Act (ICARA).     

Chapter 21: Psychopathy

Psychopathy is a pathologic state characterized by a disharmony primarily in the emotional and volitional aspects of the personality in which the intellect remains relatively intact.     

Chapter 10: Schizophrenia

Schizophrenia is a mental disease often encountered by both general and forensic psychiatrists.