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.     

Impact of Common Mental Health Disorders on Cognition: Depression and Posttraumatic Stress Disorder in Forensic Neuropsychology Context

The assessment and diagnosis of posttraumatic stress disorder (PTSD) and depression in forensic evaluations may lack an acknowledgement of the neurocognitive impact of these disorders and how they interact with other causative factors, such as traumatic brain injury (TBI), pain or fatigue. Both PTSD and depression have a complex, growing and consolidating neuroscientific and neuropsychological evidence base, and both can affect neuropsychological test results. In forensic neuropsychological assessments, they are often considered to be confounding factors in evaluating TBI and neurodegenerative disorders but not a source of cognitive impairment in their own right. Yet, an accurate neuropsychological assessment of both cognition and affect is vital to causality determination, prognosis and treatment planning. To complicate matters, selective brain injuries, contingent on the location of injury, can produce symptoms of depression that also affect the neurocognitive profile. Therefore, behavior can overlap not only due to overlapping or comorbid diagnoses, but also due to similar neuroanatomical correlates of both conditions. This paper focuses on reviewing and integrating the available empirical evidence from neuroscience and neuropsychology regarding the cognitive impact of PTSD and depression. Our critical review will emphasize the implications of the more recent evidence for forensic assessment determinations regarding causality, diagnosis, and the impact on function, prognosis and treatment. Hence, electronic search engines, PubMed, PsycINFO, and Google Scholar (up to January 2018) were screened and reviewed both for the neuroscience and neuropsychological literature related to depression and PTSD.     

PTSD,Endophenotypes, the RDoC,and the DSM-5

The search for endophenotypes that stand between genetics and disease has been applied to the diagnostic entity of Posttraumatic Stress Disorder (PTSD). Advances are being made in understanding the pathway to disorder in PTSD in terms of brain regions, neuronal networks, stress-related systems (e.g., the hypothalamic–pituitary–adrenal (HPA) axis), and their underlying genetic and neurogenetic bases. The latter are affected by gene–environmental interactions and epigenetic effects, and the environment and context reciprocally interrelate with them, as well. Therefore, a primary focus on (neuro)pathophysiological intermediates in the disease pathway, as appears emphasized in the research domain criteria (RDoC) approach to etiology of psychiatric disorder, and to which the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5) subscribes, might detract from a more inclusive biopsychosocial approach that would be more applicable in the case of PTSD. The paper undertakes a comprehensive review of the recent literature in the areas of endophenotypes, neurogenetics, epigenetics, neural networks, HPA axis, neuronal networks, pathways, the PTSD five-factor model, allostasis, and the RDoC criteria for psychiatric diagnosis, and then returns to the topic of endophenotypes. Neuronal networks constitute one integrating area that could help in arriving at an appropriate model of PTSD endophenotype. Pathway analysis provides a rich field for discerning individual differences in PTSD development, more so than the static approach of using DSM-5 symptom criteria. A model of endophenotypes is presented, which considers these factors in relation to PTSD. The paper concludes with implications for the DSM-5, for practice and for court, especially that it would be premature to seek individual biomarkers of PTSD given the current state of knowledge, even if it is burgeoning.     

Impact of Tinnitus on Cognitive Function in Forensic Neuropsychology Context

Tinnitus, a common hearing condition encountered in medicolegal evaluations, often but not always in association with traumatic brain injuries, can adversely impact both cognitive and affective functioning and neuropsychological test results. Although it has been traditionally conceptualized as primarily related to cochlear pathology, tinnitus has been seen more recently as a condition involving brain plasticity. Its persistent clinical effect on cognition and affect is compounded by comorbid psychiatric syndromes such as depression. Understanding the impact of tinnitus, a factor often difficult to capture and neglected in forensic neuropsychology, is essential for determination of causality, diagnosis, prognosis, functional outcomes, and treatment in medicolegal neuropsychological assessment. This paper aims to critically review and integrate the available empirical evidence from neuroscience and neuropsychology regarding the cognitive and affective impact of tinnitus. Our research review will emphasize the implications of the new evidence for the forensic assessment determinations. To this end, electronic search engines, including PubMed, PsycINFO, and Google Scholar (up to January 2018), have been screened and reviewed for the neuroscience and neuropsychological literature related to tinnitus.     

Cognitive-behavioral skills,social supports,and child abuse potential among mothers of handicapped children

This study examined the relationship among cognitive functioning, social support networks, and risk for child abuse in a sample of 92 mothers of developmentally disabled children. Mothers found to be at highest risk for child abuse potential tended to score low on cognitive skills, social support networks, and life satisfaction. Beck Depression Inventory scores were found to explain 57% of the variance in the Child Abuse Potential Scores. Single mothers differed significantly from married mothers on child abuse potential, relationship satisfaction, community involvement, and loneliness. The authors discuss implications of the study and the need for future research with families of handicapped children.     

Executive functioning profiles of adult and juvenile male sexual offenders: A systematic review

Evidence regarding biological correlates of sexual offending, which might enhance the understanding, research, and treatment of these offenders, is rather emerging or in the embryonic stage. In this study, our main objective is to identify specific executive functioning (EF) processes that are commonly impaired in sexual offenders, and to further determine whether these differ as a function of offender subtypes. A search is conducted in ProQuest, Criminal Justice Abstract, EBSCOhost, and Social Science Citation Index electronic journal databases for studies published spanning the period 1990–2015. Google Scholar and Google search engines were also searched and the reference lists of the retrieved papers were searched for additional papers. A total of 1303 papers were retained for consideration. After removing duplicates, and subjecting the retrieved papers to inclusion and exclusion criteria, 24 papers (19 published and 5 unpublished) were deemed appropriate for the review. While several EF processes have been investigated, the available evidence implicates deficits in cognitive flexibility and inhibition of interference as commonly reported among adult male sexual offenders. This finding may be due to the sensitivity of tests of cognitive flexibility (e.g. the Wisconsin Card Sorting Test) and inhibition of interference (e.g. the Stroop Test) to frontal lobe lesions, and also because these tests are among the most frequently administered EF tests as revealed by this study. Juvenile sexual offenders, however, exhibit no distinct EF profiles. The findings of the study, implications for treatment, and recommendations for future studies are succinctly discussed.     

Underlying Dimensions of DSM-5 Posttraumatic Stress Disorder and Major Depressive Disorder Symptoms

This study examined the relationship between the underlying latent factors of major depression symptoms and DSM-5 posttraumatic stress disorder (PTSD) symptoms (American Psychiatric Association, 2013). A nonclinical sample of 266 participants with a trauma history participated in the study. Confirmatory factor analyses were conducted to evaluate the fit of the DSM-5 PTSD model and dysphoria model, as well as a depression model comprised of somatic and nonsomatic factors. The DSM-5 PTSD model demonstrated somewhat better fit over the dysphoria model. Wald tests indicated that PTSD’s negative alterations in cognitions and mood factor was more strongly related to depression’s nonsomatic factor than its somatic factor. This study furthers a nascent line of research examining the relationship between PTSD and depression factors in order to better understand the nature of the high comorbidity rates between the two disorders. Moreover, this study provides an initial analysis of the new DSM-5 diagnostic criteria for PTSD.     

Investigating Differences in Truthful and Fabricated Symptoms of Traumatic Stress over Time

False allegations of victimization typically are accompanied by malingered emotional symptomology to corroborate claims. This analog study was designed to compare truthful and fabricated symptom profiles on measures of post-traumatic stress (i.e., Revised Impact of Event Scale, Post-Traumatic Stress Disorder (PTSD) Checklist, Trauma Symptom Inventory) and levels of symptom consistency over time. Participants (undergraduate students) described their mental health symptoms for both traumas at time 1 (N?=?291), time 2 (N?=?252, 3 month), and time 3 (N?=?181, 6 months). Results indicated that fabricated traumas were associated with inflated symptom profiles. Validity scales were not effective at discerning symptom veracity, although reports could be discriminated somewhat by atypical responding and clinical scales. PTSD symptoms in malingerers also were reported more consistently over time. This research offers applicable information for identifying feigned traumatic stress.     

Symptom Validity Testing in Claimants with Alleged Posttraumatic Stress Disorder: Comparing the Morel Emotional Numbing Test, the Structured Inventory of Malingered Symptomatology, and the Word Memory Test

In independent medical examinations, unjustified claims of posttraumatic stress disorder (PTSD) are to be expected at an increased rate. In a prospective study, consecutive cases of patients claiming PTSD who underwent independent neuropsychiatric evaluation were analyzed. For 61 adult patients, results of three symptom validity tests (Morel Emotional Numbing Test, Structured Inventory of Malingered Symptomatology, and Word Memory Test) were available. Seventy percent of all claimants showed probable negative response bias in at least one of the three tests, 25% in all three tests. High probability of negative response bias was associated with symptom overreporting and demonstration of cognitive deficits in performance tests. The results indicate that high rates of uncooperativeness must be expected in civil forensic patients with claimed PTSD. A multi-method approach to the assessment of response distortion in PTSD claimants is indicated.     

The Impact of Anger on the Intimate Partner Violence Decision-Making Process

McFall’s (1982, 1989) Social Information Processing (SIP) model outlines different stages in cognitive processing and decision-making that may be deficient in men who engage in interpersonal violence (IPV). A decision-making task was developed to assess the utility of abusive and nonabusive behaviors among 32 men who engage in mild IPV, 32 maritally distressed men, and 32 nondistressed men. Because anger impacts appraisal and decision-making (e.g., Lerner and Tiedens in Journal of Behavioral Decision Making, 19, 115-137, 2006), all participants were randomly assigned to an anger induction or neutral induction condition. As hypothesized, the perceived utility for abusive behavior was greater for angry abusive men and the perceived utility of control appeared to significantly contribute to this difference. Specific deficits in the IPV group were found, supporting a SIP model of IPV, aiding in understanding the function of violent behavior. Despite study limitations, these findings have implications for enhancing specific skill training components of treatment for abusive men.     

Trauma Characteristics and Posttraumatic Stress Disorder among Adolescent Survivors of Childhood Sexual Abuse

This study examined the relationship between the characteristics of childhood sexual abuse (CSA) and the severity of consequent posttraumatic stress disorder (PTSD), depression, suicidal ideation, and substance use in a sample of 83 female adolescents aged 13–18 years seeking treatment for PTSD. Nearly two-thirds of the sample (60.7 %, n?=?51) reported the perpetrator of the CSA was a relative. A large portion (40.5 %, n?=?34) of the sample reported being victimized once, while almost a quarter of the sample reported chronic victimization (23.8 %, n?=?20). PTSD and depression scores were in the clinical range, whereas reported levels of suicidal ideation and substance use were low. The frequency of victimizations was associated with suicidal ideation. Contrary to expectation, CSA characteristics including trauma type, perpetrator relationship, and duration of abuse were unrelated to PTSD severity, depressive symptoms, or substance abuse.     

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.     

Impact of Pain on Cognitive Function in Forensic Neuropsychology Context

Chronic pain is a biopsychosocial condition with a complex neuroscientific and neuropsychological literature. Common types of pain that are seen in the medicolegal context include headaches and musculoskeletal and neuropathic pain, all of which are known to affect neuropsychological test results. Differentiating between the cognitive impact of pain and the effects of traumatic brain injury and other factors, such as emotional distress or fatigue, is often challenging, especially in forensic determinations. Cutting through the polarization of forensic examiners’ opinions on the significance and nature of chronic pain impact on neuropsychological function with research evidence can make neuropsychological assessments more objective and defensible in court. This review focuses on surveying and integrating the available vast empirical evidence from neuroscience and neuropsychology regarding the cognitive impact of chronic pain. Our critical review will emphasize the implications of the new evidence for the forensic assessment determinations regarding causality, diagnosis, impact on function, and prognosis and treatment. To this end, electronic search engines, including PubMed, PsycINFO, and Google Scholar (up to January 2018), have been screened and reviewed both for the neuroscience and neuropsychological literature related to chronic pain, and subsequently updated for content and referencing.     

Effectiveness of cognitive remediation for female inmates: a pilot study

There is considerable evidence that neurocognitive deficits are frequent among incarcerated offenders. However, current correctional programming does not directly seek to remediate deficits in offenders’ neurocognitive deficits. In this pilot project, we sought to treat neurocognitive deficits in incarcerated Portuguese adult women offenders (n?=?28) using cognitive remediation to target cognitive flexibility, memory, and planning. Statistically significant positive changes, with medium to large effect sizes, were discovered across several neurocognitive domains, including attention, speed of processing, verbal learning and memory, cognitive flexibility, and planning. We also found a decrease in the negative emotional states of depression, anxiety, tension/stress, and on disturbed behavior in prison. Cognitive remediation has the potential to enhance the neurocognitive functioning of incarcerated women. Controlled research is needed to establish cognitive remediation fully as an intervention for the treatment of neurocognitive deficits of incarcerated women.     

Legal liability and research ethics boards: the case of neuroimaging and incidental findings

Neuroimaging research covers a wide range of intriguing issues from revealing brain structures to investigating what happens in our brain when we lie. The field appears to be thriving, but skepticism and alertness to the various ethical, scientific, policy and philosophical challenges associated with it also appear to be on the rise. One particularly complex issue concerns what to do with incidental findings that emerge during the course of neuroimaging research. Research ethics boards (REBs) play a central role in research oversight. In this paper, we will consider some of the potential issues associated with REB liability in negligence in the context of incidental findings in neuroimaging research.     

The Prevalence of Mental Health Problems in Men Arrested for Domestic Violence

The problem of male perpetrated intimate partner violence (IPV) is widespread. In an effort to identify risk factors for perpetrating IPV, researchers have examined mental health problems among perpetrators. However, the majority of research in this area has examined personality psychopathology and/or limited their investigation to posttraumatic stress disorder (PTSD) or depression. Thus, the present study examined self-reported Axis I psychopathology among men arrested for domestic violence (N?=?308). Results replicated past research showing high rates of PTSD and depression. In addition, the prevalence of generalized anxiety disorder (GAD), panic disorder, social phobia, and alcohol and drug disorders were very high. All types of mental health problems were positively associated with aggression perpetration. Males meeting probable diagnostic classification reported significantly more frequent aggression than males not meeting diagnostic classification, even after controlling for social desirability. Directions for future research and implications of these findings are discussed.     

Malingered Posttraumatic Stress Disorder (PTSD) and the Effect of Direct Versus Indirect Trauma Exposure on Symptom Profiles and Detectability

Posttraumatic stress disorder (PTSD) is arguably prone to malingering due to its subjective and heterogeneous nature. Various factors can influence PTSD symptom profiles including trauma type and trauma exposure. However, it is unknown whether trauma exposure influences malingered PTSD symptom profiles. We used a malingering simulation design with trauma type controlled to compare (1) PTSD symptom profiles (Posttraumatic Stress Checliklist-5; PCL-5) at the syndrome, symptom cluster, and individual symptom levels and (2) symptom validity profiles (Structured Inventory of Malingered Symptomatology; SIMS) at the overall and subscale level, as a function of direct and indirect trauma exposure. Seventy-three participants were randomly assigned to either the direct (“witnessed” trauma) or indirect (“learned about” trauma) condition. Participants were coached about symptoms and instructed to simulate PTSD. PCL-5 profile analyses revealed that simulators in the direct exposure group reported greater overall PTSD severity. Significant differences were found on cluster D (changes in cognition and mood) and individual symptoms including intrusive thoughts, amnesia, difficulty experiencing positive emotions, and risk-taking. No differences were identified for any other symptom scores nor for the symptom validity profile, except for the SIMS total score (direct: M?=?33.0, SD?=?12.8, indirect: M?=?26.5, SD?=?13.9, t(71)?=?2.06, p?=?.043, d?=?.48). These findings indicate that trauma exposure can influence malingered PTSD profiles at the syndrome, symptom cluster, and individual symptom levels (small effects), but, with one exception for a summary score, it does not produce a detectable difference on symptom validity testing. This study may provide insight for clinicians into the how malingered PTSD profiles can manifest as a result of direct and indirect trauma exposure; however, further research is strongly indicated.     

Examining the effects of the TASER on cognitive functioning: findings from a pilot study with police recruits

Objectives

Despite its widespread adoption by more than two-thirds of police departments in the US, there has not been a single study examining the effects of the TASER on cognitive functioning. This inquiry is important for two reasons. First, research has consistently documented cognitive deficits following exposure to electricity (the TASER is an electrical device). Second, questions have emerged regarding whether TASER exposure impairs suspects’ ability to understand and waive their Miranda rights.

Methods

To explore this issue, the authors carried out a pilot study with 21 police recruits who received a TASER exposure as part of their training at the San Bernardino County (CA) Training Center. Each recruit was given a battery of cognitive tests 3–4 h before TASER exposure, within 5 min after exposure, and again 24 h after exposure.

Results

Recruits experienced statistically significant reductions in several measures of cognitive functioning following TASER exposure. However, all recruits had returned to their baseline levels of functioning within 24 h. Learning effects were documented in several of the cognitive tests.

Conclusions

The questions driving this study involve serious issues including constitutionally protected rights of the accused, use of force by police, and previously unexamined effects of the TASER on the human body. The pilot study represents a critical first step in exploring the effects of the TASER on cognitive functioning. Moreover, the results provided the authors with important information that will guide their larger study, a randomized controlled trial where healthy human volunteers will be randomly assigned to four groups, two of which receive a TASER exposure.     

The Rigor of Research Design and “Forensic” Publications in Neuropsychological Research

Seven neuropsychology journals that publish on topics relevant to clinical neuropsychology were examined for their experimental rigor according to the standards of the American Academy of Neurology (AAN) in their Clinical Practice Guidelines. By using a keyword approach on topics relevant to forensic neuropsychology, all articles that reported empirical findings from 2003 through 2008 were identified. Each study was rated by AAN classification criteria that ranged from a level I classification (prospective, most rigorous, and independent) to level IV (least rigorous). The typical forensic neuropsychological study averaged a class III ranking. Few studies were based on large sample sizes or utilized a reported masking or blind technique with regards to subject selection and how diagnostic criteria were met and/or data analyzed. While the authors for the average study reported a university affiliation, few reported explicit Institutional Review Board statements. Considerable variability across these seven journals with regards to conflict of interest (COI) disclosure policies was observed and only a few studies reported explicit statements about funding or COI issues. These observations suggest that neuropsychological research on forensic topics currently has many limitations and that future research needs to address these issues.     

Assessing Latent Level Associations Between PTSD and Dissociative Factors: Is Depersonalization and Derealization Related to PTSD Factors More So than Alternative Dissociative Factors?

Posttraumatic stress disorder (PTSD) criteria in DSM-5 included a dissociative diagnostic subtype characterized by a depersonalization item and a derealization item. Researchers have queried whether this was too restrictive, as alternative dissociative symptomatology may also be characteristic of the subtype. The current study utilized data from 318 Northern Irish students, of which 165 were trauma exposed. Participants were assessed for PTSD symptomatology based on DSM-5 criteria via a modified version of the PTSD Symptom Scale-Self-Report (PSS-5) and dissociative experiences via the Dissociative Experiences Scale (DES). Confirmatory factor analysis of PTSD and DES models revealed an optimal four-factor DSM-5 PTSD model including reexperiencing, avoidance, negative alterations in mood and cognitions, and alterations in hyperarousal and reactivity factors, and an optimal three-factor DES model including absorption, amnesia, and depersonalization/derealization factors. When comparing the correlations between depersonalization/derealization and the four PTSD factors, significant Wald tests of parameter constraints revealed that depersonalization/derealization is more related to alterations in arousal and reactivity (r?=?.432) compared to avoidance (r?=?.289), χ ² (1, N?=?165)?=?8.352, p?=?.004. We discuss whether the mechanism for comorbid PTSD and dissociation may be related to PTSD’s arousal factor.