1. Wounds of War: Traumatic Brain Injury
Rex M. Swanda, Ph.D., ABPP-CN
Neuropsychology Program
New Mexico VA Healthcare System

2. 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).

3. 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

4. Incidence of TBI 500,000 to 2,000,000 per year (civilian)
Poorly defined
Poorly documented

5. 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

6. 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

7. Frequent Causes of TBI Falls Motor Vehicle Accidents
Interpersonal Violence

8. 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

9. High Risk Areas for Contusion

10. Long-Term Consequences of TBI
Cognitive consequences
Emotional consequences
Social consequences

11. 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

12. 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)

13. 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.

14. 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

15. 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,
Dikmen, S., Machamer, J., & Temkin, N. (2001). Mild Head Injury: Facts and Artifacts. Journal of Clinical and Experimental Neuropsychology, 23,

16. 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,

17. 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

18. TBI Outcome Research: Surreya Dikmen, Ph.D.
Studies date from 1986
Follow patients and controls over time
Prospective Design
Consecutive hospital admissions of well-defined Head Injury patients
Harborview Medical Center (Seattle, WA), a Level I Trauma Center

19. 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

20. Outcome Research: Dikmen
Pre-existing conditions included:
Prior significant head injury
Alcoholism receiving treatment
History of cerebral disease
Psychiatric disorder (schizophrenia, bipolar disorder)

21. 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

22. 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

23. 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

24. 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

25. 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)

26. 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

27. 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)

28. 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

29. 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

30. So, how do we account for subjective complaints of lasting symptoms following TBI ?

31. Postconcussion Syndrome ICD-10 Diagnostic Criteria
A. History of head trauma with loss of consciousness precedes symptoms onset by maximum of four weeks

32. 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.

33. 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?

34. Psychological Theories for Understanding Postconcussion Syndrome and “Misattribution of Symptoms”
“Good Old Days” Hypothesis
“Nocebo” Effect
Diathesis-Stress Model
Expectation as Etiology

35. “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.

36. 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.

37. 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

38. 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.”

39. 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

40. 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

41. 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%
46%
71%
Mild TBI
26%
28%

42. 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

43. Information Processing Model of Memory

44. 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.

45. Percent of “normal” individuals who score in the impaired range on 0 to 6 or more measures in a battery of 40 measures

46. 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

47. 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

48. 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.

49. 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)

50. No difference between the incidence of Post-concussion Symptoms expected by controls and those reported by head injury patients. Control Group M = s.d. = Head Injured M = s.d. = 8.3

51. 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

52. 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

53. 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
Loses items around house
17.0
4.0

54. “Results suggest a tendency for patients with head injuries to attribute [normally occurring] premorbid symptoms to head trauma.”

55. Neuropsychological Assessment of Effort and Motivation

56. 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.

57. Diagnoses Involving Symptom Exaggeration or Unfounded Physical or Psychological Symptoms
Malingering – intentional feigning or exaggerating symptoms of illness or injury for external gain.

58. Intentional Production of Symptoms Obvious External Incentives
Symptoms Satisfy Psychological Needs
Somatization Disorder
Absent
Not Obvious
Likely
Somatoform Disorder
Conversion Disorder
Symptoms worsened by stress and conflict
Hypochondriasis
Misinterpretation of Physical Symptoms
Factitious Disorder
Present
Need to Maintain the “Sick” Role
Malingering

59. 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

60. 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

61. 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%

62. 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.

63. 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

64. 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

65. 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

66. The pattern of neuropsychological performance should be consistent with the reported symptoms and circumstances of the alleged injury

67. “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

68. 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

69. 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

70. 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

71. 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

72. 15-Item Memory
A B C
a b c

73. Outright “Malingering” is Rare
Malingering is only one point on a diagnostic continuum of poor effort and symptom exaggeration

74. 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)

75. 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

76. CONCLUSIONS TBI does not typically occur in isolation
Emotional and psychosocial stressors are typically significant

77. CONCLUSIONS
Reported TBI most frequently involves mild TBI

78. 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

79. CONCLUSIONS Important to identify TREATABLE symptoms
No direct treatments for TBI, BUT
Highly successful treatment programs for
Depression
PTSD
Substance Abuse
Family/Couples Therapy

80. 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