Download Neuropsychological Assessment of Effort and Motivation

Wounds of War:
Traumatic Brain Injury
Rex M. Swanda, Ph.D., ABPP-CN
Neuropsychology Program
New Mexico VA Healthcare System
Traumatic Brain Injury (TBI)
Brain injury caused by an external
mechanical force such as a blow to the head,
concussive forces, acceleration-deceleration
forces, or projectile missile (e.g., bullet).
CONCLUSIONS





TBI does not typically occur in isolation
 Emotional and psychosocial stressors
Reported TBI most frequently involves mild TBI
Credible research indicates that full cognitive
recovery is the norm in mild TBI (e.g., LOC < 30
minutes)
Important to identify TREATABLE symptoms
 No direct treatments for TBI
Associated psychological symptoms are associated
with subjectively reported TBI symptoms that
ARE highly treatable
 Depression, PTSD, Substance Abuse
Incidence of TBI
500,000 to 2,000,000 per year
(civilian)
Poorly defined
Poorly documented
Risk Factors Associated with TBI

Age
 15 to 24 years of age
 First 5 years of life
 Elderly

Males outnumber Females 2:1
 Except over age 75
Risk Factors Associated with TBI
Lower Socio-Economic Status
 Unemployment
 Lower Education
 Prior History of a Medical Condition
Affecting the Central Nervous System
 Alcoholism or Substance Abuse
 History of Prior Head Injury

Frequent Causes of TBI

Falls

Motor Vehicle Accidents

Interpersonal Violence
Classification of TBI
Closed Head Injury
 Skull intact, Brain tissue not exposed
 90% of civilian head injury
 Diffuse effects are common
• Attention / Executive
Penetrating Head Injury (Open Head Injury)
 Skull and dura are penetrated
 Focal injury is more common

High Risk Areas for Contusion
Long-Term Consequences of TBI
Cognitive consequences
 Emotional consequences
 Social consequences

Indicators of Severity for all
types of head injury
Loss of Consciousness (Loss of Awareness)
 Coma
 (operationalized by Dikmen, et al. as
Time to Follow Commands)
 Post Traumatic Amnesia (PTA)
 Signs of Intracranial Injury

Glasgow Coma Scale
15 point scale measures presence, degree,
and duration of coma
 Based on
 Eyes Opening response (1 – 5 pts)
 Best Verbal response (1 – 5 pts)
 Best Motor response (1 – 6 pts)

Post-traumatic Amnesia
A period of anterograde amnesia in which new memories
cannot be consistently made and recalled that follows
recovery of consciousness in head injury or other
neurological trauma.
The duration of PTA is often used as a
predictor of the degree of recovery.
Classification of Head Injury



Mild Head Injury
 Glasgow Coma Scale 13 – 15
 PTA 5 – 60 minutes
Moderate Head Injury
 Glasgow Coma Scale 9 – 12
 PTA up to 24 hours
Moderate to Severe Head Injury
 Glasgow Coma Scale 3 – 8
 PTA 1 to 7 days or longer
What does empirical research tell us
about the consequences of Traumatic
Brain Injury

Dikmen, S.S., Machamer, J.E., Winn, R., &
Temkin, N.R. (1995). Neuropsychological
outcome at 1-year post head injury.
Neuropsychology, 9, 80-90.
Dikmen, S., Machamer, J., & Temkin, N. (2001).
Mild Head Injury: Facts and Artifacts. Journal
of Clinical and Experimental Neuropsychology,
23, 729-738.
What does empirical research tell us
about the consequences of Traumatic
Brain Injury

Hoge, C.W., McGurk, D., Thomas, J.L.,
et al (2008) Mild traumatic brain injury
in U.S. soldiers returning from Iraq. New
England Journal of Medicine. 358, no. 5,
453-463.
Outcome Research: Mild TBI
Appropriately designed research studies
indicate that virtually 100% mild head
injured subjects show no cognitive
impairment within about 3 months to a year
(outside) post-injury
 EXCELLENT Prognosis for Mild Head
Injury

TBI Outcome Research:
Surreya Dikmen, Ph.D.
Studies date from 1986
 Follow patients and controls over time
 Prospective Design
 Consecutive hospital admissions of welldefined Head Injury patients
 Harborview Medical Center (Seattle,
WA), a Level I Trauma Center

TBI Outcome Research: Dikmen
Study minimized selection bias
 Large demographically representative group
 English-speaking only (for testing criteria)
 Did NOT screen out preexisting conditions
 Unusually high rates of follow-up
 85% followed up after one year

Outcome Research: Dikmen

Pre-existing conditions included:
 Prior significant head injury
 Alcoholism receiving treatment
 History of cerebral disease
 Psychiatric disorder (schizophrenia,
bipolar disorder)
Outcome Research: Dikmen




Broad spectrum of head injury severity
Minimum injury criteria include:
 Any period of loss of consciousness
 Post-traumatic amnesia of at least 1 hour
 Other objective evidence of head trauma (e.g.,
hematoma)
Injury severe enough to hospitalize
Survival to complete at least 1 month follow-up
for neuropsychological assessment baseline
Outcome Research: Dikmen

Trauma Control Subjects
 recruited from ER after trauma to parts of
body, other than head
 Controls matched head-injured on
 age
 sex
 education
Outcomes Following TBI

Dose-Response Relationship
 Dikmen, et al. (1995) found a significant
relationship between length of coma
(Time to Follow Commands) and level of
performance on sensitive
neuropsychological measures at 1 year
post-injury
 Greater cognitive impairment is
associated with longer periods of coma
Outcomes Following TBI

Mild head injured patients (TFC < 1 hour)
were indistinguishable from trauma controls
at one year post-injury on sensitive
measures of cognitive functioning
Outcomes Following TBI
Although there were no significant
differences on cognitive testing, premorbid
characteristics and risk factors were more
powerful than head injury in explaining
persistent psychosocial symptoms at one
year post-injury (Dikmen, et al. 2001)
Contributing Risk Factors Account
for Persistent Symptoms in cases of
Mild Closed Head Injury



Age
Education
Pre-existing conditions
 Treatment for alcohol or substance abuse
 CNS disorder (prior head injury)
 Psychiatric condition (including PTSD)
 Somatoform-Spectrum diagnoses
Dikmen’s Conclusion
“It is equally unusual for mild head injury
to produce deficits after 1 year as it is for
severe head injury to produce no deficits
after 1 year.”
(Dikmen, et al., 1995)
Recent Study of Soldiers
Returning from Iraq

Hoge, et al (2008, in NEJM) studied 2525 U.S.
soldiers returning from Iraq.
 124 (4.9%) reported injuries with LOC
 43% of these met criteria for PTSD
 260 (10.3%) reported altered Mental Status
 27.3% of these met criteria for PTSD
 435 (17.2%) reported other injuries
 16.2% of these met criteria for PTSD
 1760 reported no injury
 9.1% of these met criteria for PTSD
Recent Study of Soldiers
Returning from Iraq
Although the relationship is associative and
not necessarily causal……
 …“after adjustment for PTSD and
depression, mild traumatic brain injury
was no longer significantly associated
with these physical health outcomes or
symptoms, except for headaches.”
 Consistent with Dikmen’s research

So, how do we account for
subjective complaints of lasting
symptoms following TBI ?
Postconcussion Syndrome
ICD-10 Diagnostic Criteria

A. History of head trauma with loss of
consciousness precedes symptoms onset by
maximum of four weeks
Postconcussion Syndrome
ICD-10 Diagnostic Criteria

B. Symptoms in 3 or more of the following categories:
 Headache, dizziness, malaise, fatigue, noise tolerance
 Irritability, depression, anxiety, emotional lability
 Subjective concentration, memory, or intellectual
difficulties without neuropsychological evidence of
marked impairment
 Insomnia
 Reduced alcohol tolerance
 Preoccupation with above symptoms and fear of
brain damage with hypochondriacal concern and
adoption of sick role.
Misattribution of Symptoms

Why do patients, families – even providers
– “misattribute” symptoms, such as memory
problems, “loss” of cognitive abilities, or
declining cognitive performance – to brain
injury?
Psychological Theories for
Understanding
Postconcussion Syndrome and
“Misattribution of Symptoms”
“Good Old Days” Hypothesis
 “Nocebo” Effect
 Diathesis-Stress Model
 Expectation as Etiology

“Good Old Days” Hypothesis

Gunstad & Suhr (2001)

Tendency of people to recall past symptoms
and functioning more favorably than was
actually the case

Suggests that, following any negative event,
people tend to attribute all symptoms to that
negative event, regardless of a preexisting
history of that very problem or any other
factors that may be influencing that problem.
Nocebo Effect



Hahn (1997)
The notion that expectations of sickness
and associated emotional distress cause
the sickness in question
Suggests that response expectations are
“anticipations of automatic reactions to
particular situational cues” and are outside
both volition and conscious thought.
Diathesis-Stress Model



Wood (2004)
Examines the interaction between physiologic and
psychological factors that generate and maintain
postconcussional symptoms.
Suggests that iatrogenic forces can influence a
patient’s recovery after MTBI, especially if health
care providers inadvertently reinforce
misperceptions of symptoms or insecurities about
recovery
Diathesis-Stress Model



In McCrea (2008, p. 176)
“an unfortunate scenario unfolds when a patient
with vague symptom complaints and no clear
indication of significant head trauma is told he has
“brain damage” and will never make a complete
neurologic, symptom, or functional recovery.”
“The long-term damage of creating that perception
for a patient is most difficult to undo.”
Expectation as Etiology



Mittenberg et al (1992)
Suggests that the incidence and
persistence of PCS may be explained by
the degree to which an individual
misattributes common complaints to a
prior head injury
Examine in detail as an example of
“normal” tendencies to misattribute
symptoms
Misattribution of Symptoms
Poor understanding that many common
symptoms represent a “final common
endpoint” of many overlapping diagnoses
and disorders
 Poor understanding of mechanisms of
brain processing, injury, and recovery
 Poor understanding of base rates of
symptoms among “normal” individuals

Symptoms Overlap Across
Diagnoses
From: McCrea (2007) Mild Traumatic Brain Injury and Postconcussion
Syndrome p. 160, Table 161
Headache
Dizziness
Irritability Memory
Problems
Attention
Problems
College
Students
36 %
18%
36%
17%
42%
Chronic Pain
80%
67%
49%
33%
63%
Depressed
37%
20%
52%
25%
54%
Non-TBI
Personal Inj
77%
41%
63%
46%
71%
Mild TBI
42%
26%
28%
36%
25%
Poor Understanding of Brain
Mechanisms Involved in Memory
“Memory” complaints are among most
common symptoms associated with
postconcussion syndrome
 Information Processing Model of Memory
helps clarify the role that “psychological
factors” can play in memory complaints
 Example of the important role that basic
education plays as a therapeutic intervention

Information Processing Model of
Memory
Base Rates and Misattribution of
Symptoms

Base Rates: The frequency with which
abnormal neuropsychological findings are
observed among “normal” individuals.

It is “normal” to perform in the impaired range on
some cognitive measures
Heaton, Grant, and Matthews norms indicate that
very few healthy individuals complete a
neuropsychological protocol without any impaired
scores, while as many as 38% of “normals”
perform in the impaired range on 6 or more
discrete scores in a 40-score battery.

Percent of “normal” individuals who score in the
impaired range on 0 to 6 or more measures in a
battery of 40 measures
Expectation as Etiology




Mittenberg, et al. (1992)
223 volunteers
100 pts with closed head injuries
 Average 1.7 years after injury
 Average reported LOC = 23 minutes
30-symptom checklist of items
 Affective
 Somatic
 Memory
Examples of symptom checklist
Forgets where car is parked
 Forgets why they entered a room
 Loses items around the house
 Sensitivity to bright light
 Blurry or double vision
 Concentration difficulty
 Depression

Control Subjects


Which symptoms do you (healthy
volunteers) currently experience?
….Now imagine an MVA-related head
injury 6 months before, in which you were
knocked out, hospitalized for a week or
two. Respond to the symptoms that you
think you would have after an accident
like this.
Patients with head injuries

Identify the symptoms you think you would
have had before the accident (how you used
to be)

Then identify symptoms that you notice
now, after the accident (how you are now)
No difference between the
incidence of Post-concussion
Symptoms expected by controls
and those reported by head injury
patients.
Control Group M = 14.8
s.d. = 7.6
Head Injured M = 13.8
s.d. = 8.3
Incidence of Expected and Actual
Postconcussion Symptoms
% controls
% patients
Headache
80.0
59.1
Anxiety
68.1
58.3
Concentration difficulty
66.8
70.5
Irritability
50.0
65.9
Forgets why entered room 34.8
50.6
Loses items around house 28.5
28.1
However, Head Injury patients
significantly underestimated
symptoms prior to injury,
compared to normal base rates

Head injury patients underestimated
premorbid frequency of 21 specific
symptoms compared to base rates of normal
controls
Normal Base Rates of normal
controls compared to head injury
patient’s premorbid estimates of
symptoms
% controls
% patients
Forgets where car parked 32.0
7.0
Loses car keys
31.0
6.0
Forgets groceries
28.3
9.0
Concentration difficulty
13.5
5.0
Forgets appointment dates 20.2
7.0
Loses items around house 17.0
4.0
“Results suggest a tendency for
patients with head injuries to
attribute [normally occurring]
premorbid symptoms to head
trauma.”
Neuropsychological Assessment
of Effort and Motivation
Malingering (DSM-IV)

…the intentional production of false or
grossly exaggerated physical or
psychological symptoms, motivated by
external incentives such as avoiding
military duty, avoiding work, obtaining
financial compensation, evading criminal
prosecution, or obtaining drugs.
Diagnoses Involving Symptom
Exaggeration or Unfounded
Physical or Psychological
Symptoms
Malingering – intentional feigning or
exaggerating symptoms of illness or
injury for external gain.
Intentional
Production
of Symptoms
Absent
Symptoms Satisfy
Obvious
Psychological Needs
External
Incentives
Not Obvious Likely
Somatoform
Disorder
Absent
Not Obvious Likely
Conversion
Disorder
Absent
Not Obvious Symptoms worsened
by stress and conflict
Somatization
Disorder
Hypochondriasis Absent
Not Obvious Misinterpretation of
Physical Symptoms
Factitious
Disorder
Present
Not Obvious Need to Maintain the
“Sick” Role
Malingering
Present
Present
Not Obvious
Base Rates of Malingering and
Symptom Exaggeration



Mittenberg, Patton, Canyock, & Condit (2002)
Surveyed ABCN diplomates
Rates of cases involving “probable malingering”
and “symptom exaggeration”
 19% personal injury
 30% disability
 19% criminal
 8% general criminal cases
Base Rates of Malingering and
Symptom Exaggeration
Larrabee, G. (2003)
 Reviewed 11 studies
 1363 consecutively evaluated mild
traumatic brain-injury litigants.
 Found a rate of about 40% symptom
exaggeration or malingering among the
sample

Base Rates of Malingering and
Symptom Exaggeration
Chafetz & Abrahams (2005)
 Adults seeking Social Security disability
 13.8% met criteria for definite malingering
 58.6% met criteria for probable malingering
(two or more failed validity indicators)
 Combined definite/probable base rate of
malingering of 72.4%

Base Rates of Malingering and
Symptom Exaggeration


Bush, et al (2005)
Likely rates of malingering or symptom
exaggeration – and potential costs to the system
(SSD, VA, personal injury litigation) – are
significant enough that National Academy of
Neuropsychology recommends that symptom
validity testing be included as part of
comprehensive neuropsychological test battery.
What Makes Sense
“Neuropsychologically”
in a Specific Case?
Circumstances of the Alleged Injury
 Reported Changes in Functioning Over
Time
 Consideration of Brain – Behavior
Relationships
 Pattern of Neuropsychological Performance

Documented Evidence of Injury
versus
Patient’s Account of the Injury


Consider subjective reports of
 LOC
 Force of Collision
 Level of toxic exposure
In light of documentation
 Ambulance / Police Reports
 Medical Records
 Laboratory Reports
Reported Changes Over Time
versus
Natural Course of Recovery
Mild head injury symptoms should improve
over time – not worsen
 “It is equally unusual for mild head injury
to produce deficits after one year as it is for
severe head injury to produce no deficits
after one year.” Dikmen, et al., 1995

The pattern of
neuropsychological performance
should be consistent with the
reported symptoms and
circumstances of the
alleged injury
“Odd” complaints for mild head
injury without signs of focal
neuroanatomical injury





Stuttering
Loss of vocabulary
Severe self-neglect
with preserved ability to drive
Loss of autobiographical memory
Loss of developmentally overlearned skills
 Tying one’s shoes
 Spelling
Two Main Approaches to Detect
Poor Effort or Malingering
Identification of motivationally-impaired
patterns of performance on traditional
neuropsychological tests
 Use of specific measures of effort

Deviations from Expected
Patterns of Functioning




VIQ vs. PIQ differences on WAIS testing
Strengths on “Hold” vs. “Don’t Hold” Measures
Unexpected pattern of Index Scores
 Verbal Comprehension Index
 Perceptual Organization Index
 Working Memory Index
 Processing Speed Index
Worse performance on easier vs harder items
Specific Measures of Effort and
Validity

MMPI-2 Personality Self-Report
 “F” family (F, Fb, Fp, F – K)
 FBS
 VRIN Variable Response indicators
 TRIN True Response Set
Forced Choice Recognition
Techniques
Many types of Stimuli
 Pictures, Faces, Words, Numbers,
Textures
 Expectation for high levels of Success, even
among significantly impaired individuals
 Chance rules

15-Item Memory
1
2
3
A
B
C
1
2
3
a
b
c
Outright “Malingering” is Rare

Malingering is only one point on a
diagnostic continuum of poor effort and
symptom exaggeration
Outright “Malingering” is Rare

Poor effort and symptom exaggeration are
most frequently associated with:
 Chronic illness behavior
 Significant emotional symptoms
• Depression
• Anxiety
• PTSD
 Poor expectations for one’s own
performance (Nocebo effect)
Effort and Motivation are best
assessed in light of:
Objective Records and Documentation
 Known brain-behavior relationships
 Natural history of recovery from injury
 Unusual pattern of performance on standard
materials

CONCLUSIONS

TBI does not typically occur in isolation
 Emotional and psychosocial stressors are
typically significant
CONCLUSIONS

Reported TBI most frequently involves mild TBI
CONCLUSIONS

Credible research indicates that full cognitive
recovery is the norm in mild TBI
 Duration of documented Loss Of
Consciousness is most frequently subtle, or less
than 30 minutes
CONCLUSIONS

Important to identify TREATABLE symptoms
 No direct treatments for TBI, BUT
 Highly successful treatment programs for
 Depression
 PTSD
 Substance Abuse
 Family/Couples Therapy
CONCLUSIONS





TBI does not typically occur in isolation
 Emotional and psychosocial stressors
Reported TBI most frequently involves mild TBI
Credible research indicates that full cognitive
recovery is the norm in mild TBI (e.g., LOC < 30
minutes)
Important to identify TREATABLE symptoms
 No direct treatments for TBI
Associated psychological symptoms are associated
with subjectively reported TBI symptoms that
ARE highly treatable
 Depression, PTSD, Substance Abuse