1. Jason M. Bailie, Ph.D. Neuropsychologist
Traumatic Brain Injury: Diagnosis, Malingering, Recovery, and Prognosis for Occupational Functioning
Jason M. Bailie, Ph.D.
Neuropsychologist

2. Objective Overview of TBI Recovery after TBI
Factors that impact recovery
Malingering
Return to work after a TBI

3. Overview of TBI
Prevalence
Definition
Severity
Recovery

4. TBI Overview 1.5 million people sustain a TBI in the US annually
100,000 will experience long-term functional impairment
$17 Billion in healthcare and lost productivity
Over the past decade, hospital emergency department visits have increased by 70%
Increased awareness
NFL/NHL
Youth Sports
Department of Defense

5. TBI Overview What exactly is a TBI?
A structural injury and/or disruption of brain functioning as a result of an external force (e.g., blow to the head)
The force is causes at least one symptom immediately indicating brain dysfunction
Note: Symptoms that emerge weeks or months after the injury are likely caused by something else….

6. TBI Overview Symptoms Immediately with a TBI
Any period of loss of consciousness
Knocked Out
Any alteration in consciousness at the time of the injury (AOC)
“Bell Rung”, “Dazed”
Any loss of memory for events immediately before or after the injury (post-traumatic amnesia [PTA])
Neurological deficits (e.g., weakness, loss of balance, change in vision)

7. Leading Causes of TBI 40.5% of TBIs are from Falls!
15%Being hit by an object
14% Traffic Accidents
11% Assaults
Alcohol related?

8. TBI Severity Mild Traumatic Brain Injury (“Concussion”)
Most TBI are concussions (i.e. mild severity)
Loss of consciousness < 30 minutes
Amnesia < 1 day
Brain Imaging is “normal”
Most (~90%) individuals have a full recovery
Moderate/Severe Traumatic Brain Injury
Likely requires hospitalization and/or medical transport
Typically have abnormal brain imaging
Unconsciousness greater than 30 minutes, and/or loss of memory for more than a day.

9. TBI Severity

10. Difficulty in diagnosing Concussion
The problem….
Many concussions go undiagnosed at the time of injury
Why?
Many patients will not seek treatment for a concussion or go to the doctor days or weeks after the injury
Co-existing physical injuries will take priority in medical triaging (e.g., blood loss) and mild brain injury goes undetected
Result
Medical providers are in a position to diagnose a brain injury based on the patient’s memory
This is inherently flawed, as memory deficits are a cardinal feature of a concussion

11. Repetitive Head Injury
The long-term effects of multiple TBIs is a key issue of debate in the military and in professional contact sports organizations
Since the 1900’s it has been recognized that repetitive head injuries can produce severe and chronic neurological deficits; however, this is rare.
Typically related to MANY of head injuries (i.e., thousands) experienced by football players and boxers
Chronic Traumatic Encephalopathy (CTE) is the pathological signature of repetitive head injury but this something only diagnosed post-mortem and the scientific support is limited

12. Medical Evidence of TBI
Symptoms: Self-report complaints of emotional, sensory, cognitive and/or physical functioning
Limitation: susceptible to bias and unreliable
Signs: Medically demonstrable evidence of impairment in mood, behavior, psychological function etc.
Limitation: often times based primarily on self-report which can be unreliable

13. Medical Evidence of TBI
Laboratory findings
Blood
Presence of TBI related neuroendocrine disorders
Limitation: no well-validated biomarker for TBI
Neuroimaging:
Demonstrate structural abnormality but relationship to functional outcome is indirect.
Limitation: does not show mild structural abnormalities: an individual can have a substantial TBI but have normal neuroimaging
Neuropsychological Testing
Evidence of severity of deficits
Limitation: May be influenced by other factors not related the TBI

14. Assessment of Disability Severity
Understanding, remembering, or applying information
Problems sustaining attention, learning new information, and problems with complex mental operations needed to apply new skills are common in TBI
Interacting with others:
Mood disorders (e.g. anger), impulsivity, poor judgment, and limited social awareness may all impact social functioning.
Concentrating, persisting, or maintaining pace
Poor attention, increased distractibility, and impaired self-monitoring. Further, these are often dependent on both external factors (e.g., environmental distractors) as well as internal states (e.g., stress).
Adapting or managing oneself
Particularly in moderate/severe TBI apathy, depression, poor insight, and substantial cognitive impairment may all impact an individuals resilience and self- management.

15. Recovery After TBI Recovery from Concussion
Recovery from Moderate or Severe TBI

16. Recovery
Recovery is similar across causes (e.g., blast versus car accident)
Outcome varies based on severity, circumstances (i.e., psychological trauma), premorbid conditions, and age
Symptoms are typically:
Cognitive (e.g., attention, memory, impulsivity problems)
Emotional (e.g., depression, anxiety)
Somatic (e.g., pain, numbness)
Physical (e.g., motor and sensory impairment)
Rare of persistent disorganization of motor functioning

17. Concussion Recovery
Symptoms are first seen immediately following the injury (within minutes to hours).
Symptoms are at their worst in the first 1-3 days post- injury.
For most people, symptoms from a concussion only last 1 to 3 months.
Individuals who experience symptoms beyond 6 months post-injury may have developed other health conditions that are causing the same or similar symptoms.
TBI-related symptoms do not worsen over time, they should improve.
Concussion recovery is similar in many ways to recovery from other bodily injuries – e.g., a broken leg.

18. Concussion Recovery
What about individuals with concussion who have symptoms that don’t go away?
5%-38% have persistent symptoms

19. Concussion Recovery Health Issues that Cause Similar Symptoms…
Depression
PTSD
Sleep Disorders (insomnia)
Hormone deficiency (low testosterone)
Metabolic problems (diabetes)
Pain
There are no symptoms that are unique to concussion.

20. Are the problems from a concussion?
Headache
Dizziness
Irritability
Memory Problems
Attention Problems
Concussion
42%
26%
28%
36%
25%
Healthy People
18%
17%
Chronic Pain
80%
67%
49%
33%
63%
Depression
37%
20%
52%
54%
Headache
Dizziness
Irritability
Memory Problems
Attention Problems
Concussion
42%
26%
28%
36%
25%
Healthy People
18%
17%
Chronic Pain
80%
67%
49%
33%
63%
Headache
Dizziness
Irritability
Memory Problems
Attention Problems
Concussion
42%
26%
28%
36%
25%
Headache
Dizziness
Irritability
Memory Problems
Attention Problems
Concussion
42%
26%
28%
36%
25%
Healthy People
18%
17%
Headache
Dizziness
Irritability
Memory Problems
Attention Problems
Concussion
42%
26%
28%
36%
25%
Healthy People
18%
17%
Chronic Pain
80%
67%
49%
33%
63%
Depression
37%
20%
52%
54%
PTSD
90%
89%
56%
92%

21. Concussion Recovery
Factors Related to Persistent Post-Concussive Symptoms:
Coping style (how one experiences stress)
Expectations for recovery
Misattributing symptoms
Social support (or lack of)
Substance abuse
External incentives/rewards for persisting symptoms
Other factors

22. Severe TBI: Recovery Recovery is variable
“no two traumatic brain injuries are alike”
The majority of recovery takes place within six months from injury consistent with recommendations from 11.00(F)
Mortality: 30-40%
Survivors vary from full recovery to persistent vegetative states
Vegetative State: 2%-4%
Severe Disability: 13%-33%
Moderate Disability: 17%-22%
Good Recovery: 19%-46%
Mortality has decreased from over 50% to now 30-40%
When 786 TBI patients were followed up
for 1 year, 35 % achieved a favorable outcome at
6 months and an additional 5 % reached this level at one
year [57].

23. Moderate/Severe TBI: Recovery
Long-term consequences of Severe TBI
Increased mortality: average reduction of 6.6 years
Physical disabilities: sensory/motor impairment, bladder/sphincter dysregulation
Hormonal/Endocrine Impairment: 35%
Cognitive Impairment
Only 30% of individuals with severe TBI have a full recovery in cognition
Psychiatric Disorders Following TBI
behavioral problems, impulsivity,
suicide, motor accidents, etc. are more common in
young survivors, while in cases older than 45 years medical
problems such as pneumonia, sepsis, and neurodegenerative
diseases are associated with early deaths.
Diagnosis
Frequency
Apathy
60%
Depression
10-50%
Agitation
25%
Posttraumatic Stress Disorder
11-18%
Psychosis
7-10%

24. TBI Myths Big hits always result in a TBI
Accidents that seem severe, do not necessarily effect the brain
Physical symptoms (e.g., ear-ringing, nausea) following indicates a TBI
The brain may not be effected even though the person has those symptoms, key indicators are diminished consciousness and memory
If there are severe physical injuries, the brain was also effected
A person may have catastrophic injuries without neurological insult
Traumatic brain injury is permanent
The brain is flexible and recovery in function can occur even years after injury
Problems after a TBI are related to the TBI
Many factors such as coping style and resiliency impact recovery beyond the brain injury itself

25. Factors Impacting Recovery & Assessment

26. Predictors of Poor Outcome
Severity is only a gross indicator and many other factors influence outcome
Genetic factors
Treatment
Adherence to return-to-work standards following TBI

27. Biopsychosocial Factors
Injury Factors
Preinjury Factors
Treatment and Education
Biological Sequelea
Psychiatric Factors
Social Support
Global Functioning
Medical Comorbidities
Biases and Expectations
Assessment Methods
Medication Side Effects
Secondary Gain
Iatrogenesis
From Cole and Bailie (2016) in In: Laskowitz D, Grant G, editors. Translational Research in Traumatic Brain Injury.

28. Assessment Psychological testing Intelligence testing
May provide data pertaining to social functioning, psychiatric symptoms (e.g., depression), and adjustment to disability
Intelligence testing
Assessment of intellectual disability resulting from the neurological insult
Comparisons to pre-morbid intelligence
Personality Assessment
Emergence of personality disorder such as antisocial tendencies or unstable mood
Useful also in assessment of psychiatric symptoms, mood changes, and symptom exaggeration

29. Assessment Assessment Neuropsychological Evaluation 77% Accuracy RTW
Attention/Concentration
Reading
Mental Speed
Distractibility (persistence)
Impulsivity
Planning
Problem Solving
Judgment
Memory
Language
Fine motor functioning
Depression
Anxiety
Personality
Malingering
Neuropsychological Evaluation
Assessment of behavioral and cognitive changes from neurological disorders.
77%
Accuracy RTW
Validity
Reliability
Standardized

30. Malingering

31. Malingering and TBI
The presence of secondary gain such as disability benefits or civil litigation is associated with a poorer outcome
Individuals who are involved in litigation have more severe and persistent symptoms
Malingering vs low incentive to recover
Reviewing records over the last year, only 5%(1/21) people in the NCS database had a TOMM that was statistically below the chance of failure.
VIP Non-Verbal 3/63 = 0.05%
VIP Verbal 2/19 = 11%

32. Malingering
Malingering: To intentionally feign or grossly exaggerate symptoms or illness in order to escape duty/work or gain financial incentive.
Short of a confession, how do we infer intent to malinger?
Statistical probability is a powerful tool in this arena
Below chance performance
If you have a 50% probability of guessing the correct response, and you only get the answer right 10% of the time, the person knew the right answer but intentionally chose an incorrect answer
“the smoking gun of intent”
This is relatively rare in forensic assessments

33. Frequency of Malingering
Many instances the presentation is complicated and obvious malingering is not obvious
Criminal defendants: 12%-54%
Disability Evaluations: 33%-60%
TBI Related Disability Evaluation: 38%
A well-validated scientifically sound approach is needed to identify malingering for the majority of cases
Higher rates of malingering may be associated with higher standards to obtain benefits
TBI patients typically feign:
Memory Problems
Attention/Concentration Issues
Slow Mental Speed

34. Approaches to Detection of Malingering
Performance that is inconsistent with individuals who have a history of TBI (or other neurological disorder)
We give them a task that we know how other individuals with TBI perform
AND
We know how malingers perform
Based on this we can determine:
If they perform normally, we know the probability that is not malingering
If their performance is atypical (i.e., more consistent with malingers) we can provide the probability of they are malingering

35. Malingering Detection
Example: One of the most common measures detects 78% of malingers.
However, 39% legitimate TBI patients are falsely detected.
So if a defendant fails this test there is a 70% probability that the defendant is malingering…..
That also means there is a 30% chance that we are wrong which unacceptably high
The reliance on a single measure to determine malingering can be unreliable.

36. Malingering: Detection
By relying on multiple independent or embedded measures of performance/symptom validity testing a neuropsychologist can have strong confidence (>99%) that a person is malingering their cognitive or emotional symptoms.

37. Return to Work (RTW) Following TBI
Two sections of consideration:
11.18 Traumatic Brain Injury
Disorganization of motor function in two extremities (see 11.00D1), resulting in an extreme limitation (see 11.00D2) in the ability to stand up from a seated position, balance while standing or walking, or use the upper extremities, persisting for at least 3 consecutive months after the injury. OR
Marked limitation (see 11.00G2) in physical functioning (see 11.00G3a), and in one of the following areas of mental functioning, persisting for at least 3 consecutive months after the injury:
Understanding, remembering, or applying information; or
Interacting with others; or
Concentrating, persisting, or maintaining pace; or
Adapting or managing oneself.
12.02 Neurocognitive Disorder
“disturbances in memory, executive functioning, visual-spatial functioning, language and speech, perception, insight, judgment, and insensitivity to social standards.”

38. Return to Work (RTW) Following TBI
Four areas of consideration for mental functioning (12)
Understanding, remembering, or applying information
Interacting with others;
Concentrating, persisting, or maintaining pace
Adapting or managing oneself.
Marked Impairment
Due to the signs and symptoms of the neurological disorder, the person is seriously limited in the ability to function independently, appropriately, effectively, and on a sustained basis in work settings

39. Frequency of RTW Severity Overall RTW Full RTW Modified RTW Mixed
45%-66%
19%
Mild
40%-88%
12%
30%
Mild-Moderate
66%
Severe
25%-31%

40. RTW Factors Related to RTW Pre-Morbid Factors Injury Severity
Post-Injury Impairments
Personal Factors
Environmental Conditions

41. Factors Related to RTW Severity: Employment History
Length of Hospital Stay
Ratings of Disability at Discharge
Employment History
Employed before injury 3-5 more likely than unemployed
Professionals 3 times more likely than manual laborers
Skilled labors 1.5 times more likely than manual laborers

42. Predictors for RTW post-TBI
Age
Education level
Work history
TBI Severity (i.e., S-100B)
Neuropsychological deficits
Severity of other injuries
Physical Capacity
Rates of sick leave
Prior Psychiatric History
Violent Injury
Prior ETOH/drug use
Rehabilitation services
Cognitive Deficits
Inattention
Impaired Memory
Processing Speed
Language

43. RTW after Atypical Concussion
In most concussions, expectation is for full recovery including RTW
After a concussion specific variables predict successful return to work
Age: younger age, associated with improved odds of RTW
Symptoms: the more self-reported symptoms a person reports less likely they are to return to work
Those reporting 6 or more symptoms have lower long-term unemployment

44. Interventions for RTW
Scientific evidence supporting interventions to improve return to work after TBI is insufficient
Cognitive behavioral therapy is useful in improving psychological problems (e.g., depression, anxiety, and anger) during occupational therapy
Supplemental employment is also useful in TBI with job retained greater than 70%
Intensive cognitive rehabilitation has been associated with improved job satisfaction

45. Summary TBI is a complex and heterogeneous disorder
Outcome can vary from full-recovery to persistent vegetative states and death
Recovery can be impacted by a multitude of factors that include both pre-injury psychological characteristics as well as the presence of external financial benefits
Return to work following TBI is complicated by a multitude of factors but length of hospital stay, disability at discharge, and type of employment have greatest predictive power

46. Questions? Jason M. Bailie, Ph.D. jason.bailie@mdofficemail.com