Neuropsychological,Psychological, and Vocational Assessment of High Achievers in a Medicolegal Context

High achievers are a unique subset of persons referred for neuropsychological and psychological assessments in medicolegal contexts, including personal injury, disability, and workers’ compensation cases. Literature in this area is limited and poorly integrated, and neither a conceptual model nor best evidence-informed practices for the assessment of high achievers in the medicolegal context have yet emerged. Construct and methodological issues also hamper the ability of assessors to accurately and fairly assess this specialist group, which is particularly troubling in high-stakes forensic assessments. This paper reviews the current methodological issues involved in the assessment of high achievers and proposes an integrated, multimethod assessment model based on a particular vocational group, namely that of business leaders and entrepreneurs, that draws from available empirical research in different fields of psychological inquiry.     

Neurocognitive Disorders in DSM-V: Forensic Perspective

Although determination of diagnosis of cognitive impairments constitutes one of the core objectives of forensic neuropsychological assessment, the diagnostic criteria for cognitive disorders provided by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR, American Psychiatric Association 2000) have been of low internal and external validity and limited utility. This paper reviews the evolution of diagnosis of cognitive disorders from current DSM-IV-TR to the proposed DSM-V (American Psychiatric Association 2010). The conceptual framework is tracked, along with the body of literature associated with the DSM-V proposal on Minor and Major Neurocognitive Disorders. The quality of evidence for internal and external validity is reviewed, as well as the fairness and utility of newly proposed diagnoses from both clinical and forensic perspectives. Significant conceptual, evidentiary, psychometric, assessment, and practical questions are raised related to the new classification, and recommendations are offered for improvement to the proposal of the DSM-V Work Group on Neurocognitive Disorders.     

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.     

Anoxia-Hypoxia in Forensic Neuropsychological Assessment: Cognitive Impact of Pulmonary Injuries,Respiratory Distress,Cerebral Blood Hypoperfusion,and Major Surgeries

Pulmonary injuries, respiratory distress, blood loss-related cerebral blood perfusion, and major surgeries are common features of medical histories in forensic neuropsychological assessments. Unless the explicit reason for referral is determination of the cognitive impact of one of these adverse medical conditions, their contribution to neuropsychological causality determination can be overlooked, minimized, or misattributed to other causes. Given the underlying common denominator among these conditions, that is, sub-optimal oxygen delivery to the brain, transient or long-term debilitating injuries causing neuropsychological change of various degrees can result. A thorough understanding of the impact of these medical events is paramount in forensic neuropsychological assessment for diagnosis, causality, and functional impact determination, prognosis, rehabilitation, and recommendations. In this paper, we critically review the available empirical evidence regarding anoxia and hypoxia arising from pulmonary injuries and respiratory distress, cerebral blood hypoperfusion, and major surgeries, together with evidence of their impact on cognitive functioning. Medical and psychological electronic search engines [PubMed, PsycINFO, and Google Scholar (up to January 2018)] have been screened for neuroscience-related and neuropsychological literature pertaining to pulmonary injuries and respiratory distress, cerebral blood perfusion, and major surgeries, and subsequently optimized for the issue under review.     

DSM-5 Neurocognitive Disorders: Validity, Reliability, Fairness, and Utility in Forensic Applications

A previously published paper (Schultz Psychological Injury and Law 3: 271–288, 2010) on forensic considerations regarding neurocognitive disorders within the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5; American Psychiatric Association, 2013) reviewed evidence for internal and external validity, as well as the fairness and utility of the proposed classification. Given recent publication of the DSM-5, in May 2013, the current paper provides an update on this review. It focuses on changes in the final version of the neurocognitive disorders section of the DSM-5 as compared with the earlier proposal in 2010 and raises a range of new conceptual, methodological, and clinical practice issues related to this classification. An examination of forensic neuropsychologists’ diagnostic choices and their associated pitfalls follows. Discussion extends to the unresolved issue of disorder threshold, associated risks of overdiagnosis of mild neurocognitive disorder and underdiagnosis of major neurocognitive disorder, and the absence of a moderately severe disorder classification. Methodological concerns in diagnostic determinations, especially with DSM-5 Criteria A and B, issues associated with subtypes and specifiers, as well as functional assessments of activities of daily living, now embedded in the diagnosis, follow. Subtype omissions and methodological inconsistencies are highlighted.The vulnerability of neuropsychologists and psychiatrists during courtroom testimony on neurocognitive disorders-particularly with conceptual, methodological, and practical issues-will be addressed through clinical and forensic practice recommendations.     

Early Intervention with Compensated Lower Back-Injured Workers at Risk for Work Disability: Fixed versus Flexible Approach

Low back pain (LBP), a leading cause of disability, has been linked with profound economic, personal, and social costs (Hills 2006; World Health Organization 2003). This significant effect propels research in identifying modifiable risk factors that protract LBP; these factors can be targeted in early intervention (EI) (Pransky, Journal of Occupational & Environmental Medicine, 49(3):249–251, 2007; Schultz et al., Journal of Occupational Rehabilitation, 17:327–352, 2007, Journal of Occupational Rehabilitation, 18(2), 140–151, 2008; White et al. 2013). This randomized controlled study evaluated the effectiveness of two approaches, fixed versus flexible, in delivering proactive, interdisciplinary EI with 63 workers within a workers' compensation interdisciplinary case management setting (i.e., WorkSafeBC, Canada). Off-work 4 to 10 weeks post-back injury, the workers were also at risk of protracted work disability (N?=?24 at high risk; N?=?39 at moderate risk). Fixed, protocol-driven, interdisciplinary, multimodal, clinical, occupational, and case management-based EI was compared with a flexible, individual need-driven EI with the same modalities as the fixed approach. Results showed a significant narrowing of the outcome gap between the two interventions. High-risk injured workers tended to benefit more from a fixed, protocol-driven approach, as shown in the pilot study (Schultz et al. Journal of Occupational Rehabilitation, 18(2), 140–151, 2008). The results indicated that moderate-risk workers benefitted from a more flexible, need-based, individual, and low-intensity approach as compared with a fixed approach. The flexible approach for moderate-risk workers was also less costly and consumed fewer rehabilitation and health care resources. Recommendations for future research and practice included larger sample sizes, controllability of research interventions, risk for disability-EI matching, and conditions under which a flexible delivery of multimodal EI is more efficacious than a fixed approach, and vice versa.     

Sequential monitoring of burials containing small pig cadavers using ground penetrating radar

Ground-penetrating radar (GPR) was used to monitor 12 pig burials in Florida, each of which contained a small pig cadaver. Six of the cadavers were buried in sand at a depth of 0.50-0.60 m, and the other six were buried in sand at a depth of 1.00-1.10 m to represent deep and shallow burials that are generally encountered in forensic scenarios. Four control excavations with no pig interment were also constructed as blank graves and monitored with GPR. The burials were monitored for durations of either 13 or 21 months, and were then excavated to correlate the decomposition state of the cadaver with the GPR imagery. Overall, this study demonstrated that it may be difficult to detect small cadavers buried in sand soon after they are skeletonized because the area surrounding the body, or the grave, may not provide a strong enough contrasting area to be detected by GPR when compared to that of the surrounding undisturbed soil. Also, depth of burial appears to influence grave detection because bodies that are buried at deeper depths may be detected for a longer period of time due to reduced decomposition rates.     

Coronary artery aneurysms in a young adult

Coronary artery aneurysms are an extremely rare cause of death at any age, but particularly so in young adults. A case is described of a young and previously fit man who died suddenly following thrombosis within one of multiple coronary artery aneurysms. He had had a childhood illness with symptoms consistent with an episode of unrecognized infantile polyarteritis nodosa. It is suggested that many cases of aneurysm of the coronary arteries in young adults, where atherosclerosis has been excluded, may in fact be due to previous polyarteritis, rather than of congenital origin as is usually claimed.