Motor Vehicle Collisions and Their Consequences—Part 1: Common Physical,Psychosocial, and Cognitive Outcomes

Motor vehicle collisions (MVCs) have a significant impact on injured persons and society. MVCs generally result in property damage, but more serious MVCs often result in physical injuries that have significant physical, psychosocial, and cognitive consequences, all of which may result in long-standing functional impairment and disability as well as marked changes in quality of life. This article represents the first part of a two-part review of MVCs; the complex and interactive array of physical, psychosocial, and cognitive changes that occur consequent to injury-causing MVCs; and the person and environmental factors that best predict functional impairment and disability following an MVC. The current article provides an overview of the scope and significance of MVCs and summarizes the literature related to the physical injuries and the physical, psychosocial, and cognitive impairments that are most commonly experienced consequent to MVCs. Physical injuries reviewed in the current article include fractures, whiplash-associated disorders (WADs), traumatic brain injury (TBI), multiple traumatic injuries or polytrauma, and chronic pain conditions. These injuries and conditions are reviewed because of the relative quantity and quality of existing research related to these injuries and conditions. This article also provides a review of those psychological disorders that more commonly begin, recur, or are exacerbated in the aftermath of an MVC. The following psychological disorders are reviewed: posttraumatic stress disorder, complex posttraumatic stress disorder, major depressive disorder, somatic symptom disorder, and major neurocognitive disorder and mild neurocognitive disorder. Finally, this article ends with a brief discussion of changes in quality of life that can occur in relation to the physical injuries and psychological and neurocognitive disorders that are common consequences of MVCs. The final section of this article will serve to introduce part II of this review of MVCs and their consequences, in which predictors of MVC-related impairment and disability are discussed.     

Motor Vehicle Collisions and Their Consequences—Part II: Predictors of Impairment and Disability

A significant number of persons involved in motor vehicle collisions (MVCs) evidence persistent changes in physical, psychosocial, and cognitive functioning consequent to physical injury. While post-injury impairment and disability can sometimes be predicted with knowledge of injury type and injury severity, post-injury experiences of pain, psychological distress, cognitive dysfunction, and role disruption have been determined to contribute to injury-related impairment and disability. This article represents the second part of a two-part review of MVCs and their consequences. In part I of the review, research findings related to physical, psychosocial, and cognitive changes that occur consequent to injury-causing MVCs are described. In this article, measures used to document the severity of physical injuries are reviewed, along with the most widely accepted definitions of impairment and disability. Models that have been proposed to explain the progression from injury to impairment and disability are reviewed, including a more recently proposed model created specifically to guide the assessment and management of MVC-related outcomes. The greater part of this article is devoted to the review of findings related to physical, psychological, and cognitive predictors of post-MVC impairment and disability. The relation of these predictors to post-MVC impairment and disability is described across three specific injury contexts: (1) whiplash-associated disorders, (2) traumatic brain injury, and (3) polytrauma. In each context, findings related to recovery of function in the form of return to work are summarized, along with findings related to the contribution of compensation to injury-related symptoms and impairments. Although not characterized as a physical injury, chronic pain serves frequently as the post-injury symptom that persists beyond all injury management and rehabilitation efforts and that contributes significantly to MVC-related functional impairment, disability, and emotional distress. It is appropriate, therefore, to include in this review a discussion of those MVC studies that specifically address impairment and disability occurring in relation to chronic pain. The article ends with the identification of ongoing research challenges and future directions for both the study of MVCs and their associated sequelae and clinical practice with persons who are experiencing the consequences of MVC-related injuries.     

脑外伤认知障碍者神经心理学评价研究

目的探讨神经心理学检测指标在脑外伤者认知功能障碍评定中的应用价值。方法对脑外伤后认知障碍者进行中国修订韦氏成人智力量表、韦氏记忆量表及计算机化神经行为评价系统部分项目等神经心理学检测,按照原发性损伤程度和专家鉴定结论分别编组,对检测结果进行分析。结果损伤程度组填图、长时记忆、瞬时记忆、视觉保留及视简单反应时项目得分,轻型组高于中、重型组(P<0.05),其余项目(木块图、知识、相似、曲线吻合及数字筛选)组间差异无统计学意义。专家鉴定组中长时记忆、瞬时记忆、视觉保留、视简单反应时、曲线吻合及数字筛选得分值随认知功能障碍程度加重而逐渐降低,其中前4项组间差异具有统计学意义(P<0.05)。而韦氏智力测验4个项目较轻组与较重组得分接近,且均低于中度组,其中3项得分比较具有统计学差异(P<0.05)。结论原发性脑外伤与认知障碍严重程度有一定相关性,但相关检测项目显示不完全平行,在进行鉴定中应选择更为可靠的检测项目。     

Navigating the Legal System After a Motor Vehicle Collision

More often than not, individuals involved in motor vehicle collisions (MVCs) do not sustain physical injuries. When individuals are involved in serious, injury-causing MVCs, the consequences may be devastating. Injured persons sometimes elect to pursue legal action to address the medical costs incurred and earning losses experienced in association with their injuries and the resulting impairments in function. This article presents a comprehensive review of the requirements of MVC-related litigation and the laws that govern this process, with emphasis placed on Ontario law in effect at the time of writing. Information considered germane to the decision to pursue legal action is reviewed, including the likely settlement amount, length of the legal process, costs associated with legal services and fee agreements that govern remuneration paid to the lawyer. Also described are no-fault regime and civil lawsuit, the two avenues of compensation that injured persons can pursue in an effort to recover losses and obtain the assistance they need to recover from their MVC-related injuries.     

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.     

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.     

实验性脑挫伤后caspase-3表达的免疫组织化学研究

目的 观察大鼠在不同程度及不同时间脑挫伤后caspase-3表达的变化。方法 对48例实验性脑挫伤大鼠的脑组织进行检验,同时以10例非脑挫伤的脑组织做对照。结果 伤后1h,caspase-3即有表达;24～48h达高峰,2周时仍有阳性细胞存在。阳性细胞多集中于挫伤区及周围带皮质和脑实质内海马区;不同程度脑挫伤组之间于伤后1h,12h,24h,72h,1周和2周caspase-3表达有差异。结论 不同程度脑损伤后caspase-3表达量不同;在脑损伤后caspase-3的表达有时间变化规律,对探讨脑挫伤后二次损害原因和研究脑挫伤程度有一定意义。     

Posttraumatic Stress Disorder: Protective and Risk Factors in 18 Survivors of a Plane Crash

The aim of this study is to identify protective and risk factors related to the development of posttraumatic stress disorder (PTSD) on a sample of survivors from a single plane crash. Eighteen survivors were examined 6 months following the event. The subjects all underwent psychiatric interviews, Clinician‐Administered PTSD Scale structured interviews, personality and cognitive tests. Only 38.9% of them presented with all of the symptoms of PTSD; 22.2% showed no symptoms for PTSD; remaining survivors exhibited emotional/affective symptoms related to the event. In addition to the severity of the traumatic event itself, other risk factors identified were the loss of a relative, the manifestation of depressive symptoms, and the severity of physical injuries sustained. Low levels of hostility and high levels of self‐efficacy represented protective factors against developing PTSD.     

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.     

Modification of the Marmarou and Foda model of diffuse axonal injury (DAI) improves percentage survival of rats at 24 h and increases the amount of DAI identified

More than two decades ago, Marmarou published a valid model for producing diffuse axonal injury (DAI) in rats. Since then, both mild and severe injuries have been obtained by researchers using the original method and a weight of 450 g. However, the diffuse brain injuries produced in rats were only similar to those seen in humans when the rats sustained severe brain injuries. In these cases, rat mortality in the original article was around 50%, and the cause of death was prolonged apnea post-impact. Rat survival after impact is critical for studying the progression of DAI. In order to explain the cause of death in human victims with cranial trauma who do not show gross brain injury, testing for the presence of DAI is essential. Thus, in order to minimize local and cervical injuries to increase rat survival, attention should be paid to the following aspects: a wider head protector disc should be used, the head of the rat should be elevated at the time of impact, and the foam bed should be soft enough to allow the movement caused by acceleration. With our modified method, rat survival increased by 30% compared to the original model (80% versus 50%). Moreover, 85.7% of rats demonstrated DAI after 24 h of survival. With these modifications, injuries appear in the same locations as in humans; thus, the method is suitable for the study of traumatic DAI in humans.     

Severity of neurocognitive impairment in women who have experienced intimate partner violence in Spain

This study examines neuropsychological impairment in women who have experienced intimate partner violence using DSM 5 criteria for mild and severe cognitive impairment. A total of 108 females in Spain were included in one of three groups: psychological abuse (n = 24), physical and psychological abuse (n = 45), and no-abuse (n = 39). There were differences between the control and IPV groups in attention and executive functioning. Furthermore, approximately 25% of women experiencing IPV suffer mild neuropsychological alterations and 5% severe, mostly in memory and executive function domains. This evidence supports the growth in research that suggests psychological violence on its own to be as strongly related to poor health outcomes as physical violence in intimate partner relationships.     

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.     

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.     

Homogenous Base Rates for Malingering in Neuropsychological Examination of Litigants

Base rates for malingering are often obtained and averaged across multiple clinicians who apply heterogeneous methods for detection (Mittenberg et al., J Clin Exp Neuropsychol 24: 1094?1102, 2002; Young, Psychol Inj Law 8: 200–218, 2015). Our aims of obtaining homogenous base rates included the following: (a) evaluation of all our legal cases in accordance with the guidelines set forth in the position papers by both the National Academy of Neuropsychology and the Association for Psychological Advancement in Psychological Injury and Law, (b) minimal variation between our comprehensive neuropsychological examinations, and (c) determination of base rates of failed effort in 150 consecutively examined legal cases in one medical setting. To assess the various levels of volitional exaggeration, we introduced four gradations of poor effort definitions, which relied on performance validity tests (PVTs). A comparison between two consecutive samples of 75 litigants indicated less frequent poor effort with increasingly more conservative criteria. In our analysis of a subset of litigants who sustained traumatic brain injuries (N?=?115), the four base rates for mild versus moderate-severe TBI groups were equivalent for the two more lenient malingering definitions but varied for the two more conservative definitions. Specifically, for the mild TBI cases investigated, the percentage of three PVT failures (or one PVT failure significantly below chance) arrived at 3.4 %. Our final aim was to compare the base rates of poor effort that were obtained with PVTs to the base rates of emotional and physical symptom endorsement, which were obtained with symptom validity tests (SVTs). No significant correlations emerged in this analysis. The discussion emphasizes the relatively lower base rates of poor effort found in the convenience sample studied in neuropsychological evaluations relative to the higher estimates in the literature (40 +/? 10 %, Larrabee et al., Clin Neuropsychol 23: 841–849, 2009) but not others based on comprehensive review (Young, Psychol Inj Law 8: 200–218, 2015).     

Parents’ Potential for Child Abuse: An Intergenerational Perspective

This study examined predictors for parents’ potential for abusing their children. Two hundred and thirteen Jewish and Arab parents of children up to 6 years of age completed six questionnaires assessing child-abuse potential, childhood history of abuse/neglect, attachment style, emotional control, perceived stress, and cognitive appraisal of parenthood. Results indicated that parents who experienced childhood abuse and neglect scored significantly higher in child-abuse potential than parents without a history of abuse or neglect. A Structural Equation Model indicated that anxious and avoidant attachment mediated the experiences of abuse and neglect in childhood and emotional control; whereas emotional control deficits mediated the relationship between insecure attachment and parenthood as challenge vs. threat, leading to greater child-abuse potential. Clinical implications were discussed.     

Patterns of injuries in domestic violence in a romanian population

In Romania, the quantification of traumatic injuries is achieved in medical- legal services; therefore, each domestic violence (DV) victim needs a medical-legal certificate to prove in a court of law the presence of traumatic injuries. In this study, we aimed to determine the pattern of traumatic injuries in DV. A total of 219 consecutive DV cases were included. For each victim, a detailed medical-legal examination was performed, including specialized consults, if needed. Results were analyzed statistically using the SPSS software. Traumatic injuries in DV cases were usually located in the head, face, and neck areas and had a low severity index. Severe lesions were found in less than 10% and no sexual aggression was found. The severity increases with age and is higher for males than females. The pattern of DV-associated injuries we have encountered is similar to the one found in other similar studies. Knowing this pattern may be useful in clinical practice to detect cases of DV.     

脑外伤所致精神障碍司法鉴定400例分析

目的探讨精神疾病司法鉴定中颅脑损伤所致精神障碍的临床特征及相关因素。方法收集脑外伤后司法鉴定案例资料,按照神经外科GCS评分把脑损伤所致精神障碍鉴定案例分为重型(A组)、中型(B组)及轻型(C组)颅脑损伤;对案例的临床症状进行分析,根据中国精神障碍分类与诊断标准(第三版)(CCMD-3)进行精神障碍诊断,并探索临床症状与脑外伤程度之间的关系。结果轻、中度颅脑损伤所致精神障碍以器质性神经症样综合征最多见。重度颅脑损伤所致精神障碍中以智能损害综合征为多。三组间有显著性差异(P≤0.01)。结论在精神疾病司法鉴定中,不同严重程度的颅脑损伤所致的精神障碍有不同的临床特征。     

Neuroscience and Neurolaw

At the intersection of neuroscience and psychological science stands neuropsychology, providing patients, triers of fact, and other parties a quantifiable, evidence-based method for understanding cognitive, emotional, and behavioral changes that occur in the context of injury or disease. The purposes of this special issue of Psychological Injury and Law are to (1) illustrate the ways in which neuroscience, psychological practice, professional ethics, and laws are intertwined in the evaluation and treatment of persons who have been injured or are experiencing a neurological disease, (2) demonstrate the ways in which neuropsychological practice is applied to forensic questions, and (3) promote quality neuropsychological practice and services to patients, courts, and other consumers of neuropsychological services. This special issue provides a sample of the types of ways that practitioners integrate neuroscience and clinical psychology, informed by and consistent with relevant laws and professional ethics, to understand people who have cognitive, emotional, and/or behavioral problems stemming from neurological injuries or other disorders.     

Neuropsychological Tests are Poor at Assessing the Frontal Lobes, Executive Functions, and Neurobehavioral Symptoms of Traumatically Brain-Injured Patients

The frontal lobes play a major role in the regulation of our emotions and behavior, planning, decision making, social conduct, actions, and executive functions. They are quite vulnerable to damage when an individual sustains a moderate or severe traumatic brain injury. Patients who sustain damage to their frontal lobes may not complain of any cognitive or neurobehavioral symptoms. They often do not show any abnormalities on standardized neuropsychological tests, particularly when the anterior and ventral areas of their frontal lobes are damaged. When these patients are observed in unstructured, novel, or complex real-world settings, they frequently exhibit cognitive difficulties, neurobehavioral symptoms, and problems with their executive functions. Since standardized neuropsychological tests are generally poor at assessing these problems and symptoms, neuropsychologists may not be aware of these problems if they have never observed these patients function in real-world settings or have never interviewed the significant others of these patients. As a consequence, neuropsychologists should not rely solely on the quantitative test data of these patients since it may provide inaccurate and misleading information.     

Optimism as a Mediator Between the Experience of Child Abuse,Other Traumatic Events,and Distress

In this study, we examined the role of dispositional optimism in mediating distress among students who experienced traumatic events, including child physical abuse, emotional abuse, and sexual abuse. Participants included 199 undergraduate and graduate students (aged 18–63 years) from a private university in Oregon. In this study, dispositional optimism partially mediated distress among individuals who had experienced child physical abuse and child emotional abuse; participants with higher levels of optimism had lower levels of distress. In addition, dispositional optimism fully mediated distress among individuals who had experienced traumatic events such as rape, assault, and fire; participants with higher levels of optimism had lower levels of distress. Contrary to prediction, the experience of child sexual abuse was not associated with distress. Clinical implications of these results are addressed.