Neuropsychiatry

The long historical relationship between neurology and psychiatry impacts the area of transient traumatic head injury. This neuropsychiatric link impacts both the actual brain injury facets as well as the psychological elements. Historically, physicians interested in the central nervous system focused either globally on behavior or more specifically on demonstrated pathology of the central nervous system reflecting such terms as "post-traumatic" and "post-concussional" in the brain injury context and interpretations of etiology that were polarized. Most practitioners in the area have had very little exposure, if any, to neuropsychiatry.

Three specialties have approached the area but from rather diverse origins and conceptual frameworks. Behavioral neurologists define brain behavior relationships often through the single case study with generalizations made about the anatomical basis of the manifested behavior and specific localization of similar types of behavior. Neuropsychiatrists emphasize the phenomenology of behavioral disorders and how these correlate with diseases in neurology and the neurologic aspects of behavioral disorders (Tucker and Neppe, 1988). In head injury, the psyche as well as the brain are both recognized as interplaying with each other. Finally, neuropsychologists employ standardized and objective assessments of intellectual, cognitive and psychological functioning, emphasizing a more actuarial and statistical methodology of evaluating behavior.

While each group appears to look at different aspects of the same animal, each has identified important areas of knowledge that are missing in traditional psychiatric, psychological and neurologic training. We will focus here primarily on the comparison of behavioral neurology and neuropsychiatry and make the case for a time-based neuropsychiatric approach applied to the head injury population.

In the context of head injury, exacerbation of pre-existing conditions commonly occurs. In this context, neuropsychiatrists recognize that marked behavior disturbance may correlate with paroxysmal discharges in the temporal lobe on the electroencephalogram (Tucker and Neppe, 1994). While these patients would not be considered to have a seizure disorder by most behavioral neurologists, many neuropsychiatrists believe these patients represent a form of seizure disorder which we for non-prejudicial reasons have called "Paroxysmal Neurobehavioral Disorder" (Blumer and Neppe, in press). We have characterized the individual events as "atypical spells" (Neppe and Tucker, 1992 and 1994; Tucker and Neppe, 1991). Many of these patients respond to anticonvulsant treatment. Similarly, a patient on neuroleptic medication who develops an atypical movement disorder with neuroleptic medication different biochemically or clinically from extrapyramidal reactions may still be labelled "tardive dyskinesia" with a recommendation that the medication be stopped by the Behavioral Neurologist; the Neuropsychiatrist may be prepared to recognize such atypicality and delineate movement disorders different from those of tardive dyskinesia.

There is a need to incorporate the neuropsychiatric approach to the often misunderstood population of patients with closed head injury (Tucker and Neppe, 1991). A gap exists in the evaluation and management of patients with closed head injury primarily because of the differences in approach between neurology and neuropsychiatry. The neuropsychiatric emphasis can be a practical and helpful adjunct to the primary health care providers (neurologists and neuropsychologists) who are primarily responsible for services provided to the closed head injury population. The purpose of this chapter is to discuss the neuropsychiatric approach and offer some clinical ideas to assist health care providers in providing a more comprehensive and thorough evaluation.

Controversies of mild traumatic brain injury

The experimental and scientific understanding of mild traumatic head injury (MTHI) has evolved over the past twenty years, with a plethora of research being generated and documented within the scientific literature. At the same time, clinical experience across multidisciplinary lines has increased as health care professionals have continued to interact with this population of patients. It has recently been estimated that approximately two million people annually in the United States experience closed head injury (Brown, & Fann, 1994). Closed head injury represents a significant cause of morbidity and mortality, especially within the younger populations. This has resulted in a considerable increase in health problems associated with the residual sequelae of closed head injury.

Epidemiological studies have documented that within the incidence of closed head injury in general, injuries that are classified as mild or minor typically account for the greater percentage of cases evaluated in emergency room and out patient settings (Goodwin, 1989). This is also the case outside the United States, where estimates range as high as eighty percent (Cohadon, Richer, & Castel, 1991).

While the current body of research literature and experience from clinical practice has provided a greater understanding of MTHI, there continues to be controversy with respect to definition and classification (Kibby, & Long, 1996). Any approach for neuropsychiatric and/or neuropsychological evaluation of MTHI must take into account the confusion that exists in understanding this injury as it is differentiated from more severe injuries and from other neuropsychiatric disorders. Earlier attempts at defining the parameters of MTHI have been seen in the research literature (Colohan, Dacey, Alves Rimel, Jane, 1986, Davidoff, Kessler, Laibstain, & Mark, 1988). The Mild Traumatic Brain Injury Committee of the Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine has proposed definitive guidelines, which have been utilized by the research community in more recent studies (Kay, et al, 1993). More current proposals for classification of the spectrum of MTHI have also been suggested (Esselman & Uomoto, 1995).

Despite the clearer definitive guidelines, there continues to be clinical confusion in evaluating and understanding the pathophysiology, symptomatology, and differential diagnosis of MTHI. The use of the terms postconcussive syndrome (PCS)and posttraumatic syndrome (PTS) has been used to describe the pattern of symptom presentation seen in this population of patients. However, this has not led to a clearer understanding of MTHI with respect to evaluation and assessment. In addition, there have been suggestions that mild head injuries should be differentiated from mild brain injuries. Furthermore, there is often the development of secondary psychiatric disorders that may have a physiological and/or psychosocioenvironmental basis, typically referred to among clinicians as psychological overlay, that complicate the clinical presentation of MTHI and make the evaluative process more complex.

Clearly, the greatest scientific and clinical controversy has been associated with the postconcussive nomenclature (Binder, 1986, Lowden, Briggs & Cockin, 1989, Alves, Macciocchi, & Barth, 1993, Kibby & Long, 1996). In general, PCS has been understood to represent the synergistic and interactive effects of physical, cognitive and psychological symptoms seen upon clinical presentation. The assumption is made that there may be physiologic, pharmacologic, psychologic, socioenvironmental, circumstantial, and medicolegal bases underlying the perpetuation of symptomatology. There is also typically a presentation of chronic pain syndrome that may have both physical and psychological factors contributing to the pattern of symptoms and complaints. Neuropsychiatric and neuropsychological evaluation of these patients presents the clinician with a complex task of deciding how to explain the nature of PCS and more importantly what to recommend with respect to treatment.

There is also disagreement among researchers and clinicians as to the duration of PCS and what factors predispose individuals to developing a persistent PCS. Within this context, the issue of premorbid factors such as personality characteristics, past psychiatric history, previous substance abuse, prior incidence of MTHI, and general health problems certainly appears to have an influence on the chronicity of symptoms (Goodwin, 1989).

Because of the confounding issues inherent in the diagnostic assessment of the MTHI patient, a comprehensive time based neuropsychiatric evaluation is proposed to clinically deal with the complexities seen in this patient population. Such a time based evaluation process may not always be necessary, but in cases where there are confusing diagnostic differentials, a time based approach will be helpful in guiding the clinician through the evaluation process. The time based approach will be presented later on in this chapter.

We further propose a neuropsychiatric nomenclature and classification based on the practical aspects of evaluation, which are more meaningful to the clinician in everyday practice. These clinical distinctions should not be considered distinct entities, but rather as clinical aspects of a dynamic post head trauma spectrum that can be useful in guiding the clinician in the evaluation process. We will attempt to integrate current research findings and clinical experience into a methodology for neuropsychiatric evaluation that is first of all useful to the patient and secondly reflects clinical acumen and multiclinical diversity.

A Neuropsychiatric Classification of CHIT: a new terminology

We have chosen to modify the definition proposed by the Interdisciplinary Special Interest Group of the American Congress of Rehabilitative Medicine (Kay, et al, 1993). Proposed instead is the use of the term closed head injury of transient kind (CHIT) to describe a traumatic induced psychophysiologic event that occurs to the head which produces initially little or no unconsciousness, limited retrograde and anterograde amnesia and alteration of consciousness that does not last longer than a day. We feel the term "closed" head injury should be used because injuries involving skull fractures and open exposure of the brain have their own special characteristics such as infection, vascular phenomena and focal disease. We prefer terms like "head" to "brain" because this way psychiatric sequelae are not necessarily implied to have a definite organic base. We understand that there is an observable and diagnosable cluster of physical, cognitive and psychological symptoms that is associated with CHIT and is most usefully defined as posttraumatic CHIT syndrome (PTCHITS). Because injury usually implies "traumatic" we see redundancy in using terms like traumatic (brain or head) injury: injury will suffice. Finally, and most important, we feel it is important to be non-prejudicial at the outset hence the term transient. CHITs are often reported to be of mild severity but the mildness is not invariably so and the trauma may lead to significant sequelae. Conversely, many so-called "mild" injuries are more severe because of the lack of available compensation by the brain. We believe terms like "mild" (or for that matter "minor"), " moderate", "severe" and "profound" should be confined to severity of outcome and not assumed on the basis of initial duration of unconsciousness. Consequently, we do not like the term "brief" preferring "transient. Although the two are similar, brief is more unidimensional in the context of implying some unconsciousness and not commenting on duration of clouding or altered consciousness. "Transient" implies an injury but unconsciousness may not be proven and it takes this into account. On the one hand, such an injury can occur without distinguishable disruption of brain function and yet still be considered as a traumatic event. Some call this post-traumatic syndrome. Alternatively, such an injury can result in a disruption of brain function and thus be considered transient traumatic brain injury - some call this post-concussional syndrome. Additionally, Kurt Goldsteins dichotomy of "pathogenetic" changes based on the actual injury and "pathoplastic" compensations by other areas of the brain or by psychological adaptation introduces a situation of health as opposed to disease into the equation (Neppe and Tucker, 1988A). Consequently, we prefer "transient" in CHIT which we contrast with "prolonged" and the term CHIP - closed head injury of prolonged type in which there is clinically significant retrograde or anterograde amnesia, extended confusion or clouded consciousness over more than a day, or prolonged unconsciousness of more than a day. Transient implies an apparent blow to the head with no, momentary or very short consciousness impairments, with the amnesia and confusion range from momentary to up to a day. In this regard, CHIPs can always be further subdefined descriptively: a CHIP with two days coma as opposed to CHIPs with half hour unconsciousness but two weeks confusion.

Seen within the CHIT syndrome are three subsyndromes which can occur together: postconcussive , posttraumatic and focal residual. Assumed by definition is that with the postconcussive subsyndrome, the brain has been concussed and there is a predominant physiologic basis for primary symptoms and secondary psychologic processes that contribute to the manifestation of symptom patterns. With the posttraumatic subsyndrome, there is a predominant feature of acute or chronic post traumatic stress that represents the primary cluster of symptoms. With both the postconcussive and posttraumatic subsyndromes are typically an overlay of pain syndrome that may have physiologic and/or psychologic factors that affect the pain behavior. The focal residual syndrome involves focal dysfunction such as the development of episodic or paroxysmal atypical spells or seizure type phenomena. These usually impact on the cerebral cortex or manifest as a pain syndrome.

Postconcussive Subsyndrome (PCCHITS) in CHIT

The PCCHITs as described here, refers to physical, cognitive and psychological symptoms that typically occur concurrently following an alleged concussive episode. Within the last five years, the clinical existence of postconcussive syndrome has obtained further verification and has become more widely accepted as a legitimate phenomena (Gouvier, Cubic, Jones, Brantley, & Cutlip, 1992). Brown, Fann, & Grant (1994) more recently have purported that there has been sufficient research generated to establish that postconcussive symptoms do occur and they have a predictable configuration. These are typically acute symptoms of nausea and/or vomiting, dizziness, blurred vision, ringing in the ears, problems thinking clearly and quickly and complaints of cervicocranial pain.

The concussive effect to the brain can occur with or without direct impact to the head and there may be no documented loss of consciousness. There may be a transient change in consciousness with confusion and disorientation. This mild injury to the brain may not be observable on routine neurological examination and typically CT and MRI scanning show no macroscopic findings. The injury underlying the PCCHITs is microscopic in nature and can occur diffusely throughout the brain. There is a high preponderance of involvement in the frontopolar, orbitofrontal and anterior temporal regions of the brain. These areas are more susceptible to the effects of acceleration/deceleration, rotational and coup/contrecoup injury, which is often the underlying pathophysiologic mechanism of the concussive episode. The PCCHITs develops primarily as a result of the disruption of normal brain functioning.

Physiologic Subgroup

Within the PC subsyndrome we distinguish those patients with focal neuropsychiatric signs from those with more generalized symptoms and complaints (Neppe, 1992; Tucker and Neppe, 1994 ). This physiologic subgroup of patients have more physical symptoms which predominate, although there may also be secondary cognitive and psychological features. These patients complain of posttraumatic headaches, myalgias, photophobia, dizziness, ringing in the ears, balance problems, numbness and tingling in the extremities, sleep disturbances and often atypical disorientations or derealizations described as spells (Goodwin, 1989).

Cognitive Subgroup

We also see a cognitive subgroupof PCCHITs patients with primarily intellectual and cognitive changes upon initial presentation. These patients typically exhibit measurable deficits in attentional processes, sustained and focused concentration, memory, problem solving, cognitive flexibility, speed of information processing and cognitive stamina. While there may be concomitant psychological sequelae and physical symptoms along with pain problems, the chief complaints by patients are typically cognitive in nature.

Psychologic Subgroup

We also observe a psychologic sub group of PC subsyndrome with predominantly psychological changes characterized by susceptibility to developing anxiety and depressive disorders, increased irritability, low frustration tolerance, emotional volatility and a reduced ability to cope and deal with everyday life stressors. These patients present with a chief complaint of feeling different since the injury. They are typically aware of this perceived sense of change and the changes are also observed by significant others.

Posttraumatic Subsyndrome in CHIT (PTCHITS)

The post-traumatic subsyndrome represents a spectrum of posttraumatic symptoms commonly referred to within the context of DSM IV as acute stress disorder and post- traumatic stress disorder. This constellation of symptoms is considered functional in nature and represents a psychological reactivity to the traumatic event. It is assumed that when an individual experiences trauma to the head during an event such as assault, moving vehicle accident, slip & fall, or other traumatic circumstances, there is the potential, inherent in these situations, for the development of predictable characteristic symptoms considered to be posttraumatic in nature.

The primary basis for the development of posttraumatic symptoms is a functional response by the individual to the traumatic event. There may be other physical findings associated with the event that may occur as a consequence of the trauma, but these are considered secondary with respect to etiology. It is obviously of clinical importance for the clinician to differentiate post-traumatic subsyndrome from postconcussive subsyndrome. While many patients with postconcussive symptoms also may develop posttraumatic symptoms, clearly there are those patients, who experience trauma to the head, which is not concussive in nature, and present with minimal changes in intellectual and cognitive functioning, but seem to develop posttraumatic symptomatology.

The most appropriate methodology for differentiating this potential diagnostic overlap is to have the patient complete neuropsychological testing, in order to provide a more comprehensive diagnostic assessment of cognitive functioning. Patients with posttraumatic symptoms may have some cognitive difficulties, but not of the same frequency or intensity as patients who have experienced mild to moderate brain injury. Neuropsychological testing is fairly robust in being able to reveal primary cognitive impairment versus cognitive problems that may be associated with a posttraumatic disorder.

Focal residual brain syndromes in CHIT (FRCHITs)

There is a frontal lobe syndrome often seen within this psychologic subgroup of PCCHITs with more dramatic personality changes. This pattern of personality changes often becomes more observable as the acute effects of the PC injury resolve. These patients may lack the ability to be fully aware of how they have changed. They may seem indifferent and apathetic and may even describe themselves as being less bothered by the stresses and strains of life. These patients lack insight and become more passive. Amotivation is often a major problem. Alternatively, the frontal lobe manifestation may be an increase in aggressivity and explosive behavior. These patients exhibit diminished judgmental ability and are often described as impulsive. In both frontal lobe groups there may be measurable deficits in intellectual and cognitive functioning, for which the patient may only be minimally aware. Occasionally these patients exhibit frontal lobe release reflexes (e.g. pout, snout) on examination.

Seizure like disorders and atypical spells fit within the framework of what Neppe and Blumer have called Paroxysmal Neurobehavioral Disorder (Blumer and Neppe, in press). This is dealt with later.

Moreover, the central nervous system has a limited number of ways of responding to stressors and injuries. Consequently, similar behaviors are caused by a number of different etiologies.

Focal brain injury after transient closed head injury

Neuropsychiatric evaluations should pay careful attention for the presence of focal episodic features which may be elicited by such instruments as regular wake - sleep electroencephalograms and ambulatory electroencephalograms but also clinically using such instruments as the INSET, BROCAS SCAN and neurologic examination.

Table A lists focal features that may appear after a CHIT

Mixed Subgroup of CHIT

Finally, there is a subgroup of PCCHITs with more classical postconcussive complaints representing the interactive and synergistic effects of physiologic, cognitive and psychologic changes. This sub group probably represents the greatest percentage of CHIT patients and the group most often encountered in general clinical practice. These patients may have focal residual features as well. We call them MCHITs or Mixed CHIT Syndrom$

This neuropsychiatric classification system provides a practical, clinical based approach for beginning the evaluation process. An understanding of the differentiating features of CHITs can give the health care provider more specific direction when beginning evaluation. The predominant features of MCHITs presented during diagnostic interviewing can be classified and differentiated into more specific sub categories, which can be used to determine the specificity of the neuropsychiatric evaluation.

Most patients with primary psychiatric illness have some seeds of previous psychiatric symptoms in their histories. When the patient presents with a good premorbid social history, a good work history, and a warm and supportive family and changes in behavior particularly abrupt changes in personality, mood, or ability to function, occur after CHIT, the CHIT must be considered a prime etiologic candidate. Similarly, the patient who presents with rapid fluctuations in mental status or rapid variable motor behavior frequently suggests something other than the typical psychiatric disorders - it is unusual for schizophrenics to be hallucinating and delusional in the morning and clear in the afternoon (Neppe , Tucker, 1989).

The Time Based Neuropsychiatric Evaluation

Simply stated, the time based evaluation presupposes that traditional evaluation procedures may not always be sufficient in properly understanding the etiology and manifestations of the CHITS. The traditional neuropsychiatri$ evaluation has routinely consisted of a diagnostic interview process, review of background information, mental status examination and possibly some lab testing. This is often accomplished in a single session or over two sessions with the patient. If predominant cognitive sequelae exist, a referral to a neuropsychologist is often made.

The neuropsychologist or neuropsychiatrist in turn completes another one time clinical interview, administers a battery of neuropsychological tests, reviews available medical and other pertinent records, and forms a clinical impression based on this limited time with the patient. At times, there may be additional collateral information obtained from significant others, usually obtained during a single session.

This traditional process of evaluation gives the clinician a sample of the patients physical, cognitive and psychological behavior that is essentially a snapshot view much like the instant results obtained from the Polaroid picture. The information obtained from this snapshot approach gives the clinician a small slice of how the patient is functioning at a given point in time. This represents a very limited sample of the patients behavior.

Yet as health care providers, we continue to evaluate patients with CHITs in this way and we make inferential leaps and generalizations affecting our conclusions and our recommendations. While this approach may be sufficient in assessing many clinical syndromes, it can lead to many false positives and false negatives within the population of head trauma patients. The current data base of research findings and multidisciplinary clinical experience would suggest that this snapshot approach does not give the evaluator enough information to clearly understand the dynamics presented in many patients with CHIT.

There are obviously many cases of CHIT where the findings derived from a single snapshot approach to evaluation will be sufficient to make appropriate recommendations. However, clinical experience has shown that there is often a need to defer final clinical impression until the clinician has had more time with the patient. This is encountered frequently among clinicians who work with the head injured patient on a daily basis.

When clinicians begin the evaluation process with a patient, we often make underlying assumptions with respect to the patients abilities as a historian. We usually collect our data directly from the patients report. We fail to realize that with patients experiencing head trauma symptoms, there is usually a diminished ability to be aware of ones self and insight is often reduced. Furthermore, there are concurrent deficits in expressive speech that limit the patient in their attempt to completely express the full range of their ideas and recollections about their functioning. These patients almost always complain of difficulty expressing their thoughts and ideas and formulating a self-analysis of their behavior. When the very part of us as human beings that we refer to as "self" is experienced as changed because of underlying pathophysiological disruption, it is difficult to fully appreciate the meaning and effects of this change, let alone try to express this clearly and cogently during the brief time period of diagnostic interviewing. We must always remember that when we refer to head trauma we are also referring to trauma to the mind and its ability to experience and cope with the after effects of the trauma and in turn communicate these after effects to health care providers.

When these patients present their complex constellation of physical, cognitive and psychological changes following head trauma, the clinician needs to give them the time to render a comprehensive self report. Because of diminished awareness and insight, a patient may not be able to fully convey the qualitative aspects of their complaints. They also may not be able to remember everything they need to tell the provider. Memory problems are typically one of the chief complaints in the CHIT syndrome. This makes it difficult for patients to organize and recall their experience of changes in their perception of self.

With a time based approach, we interact with the patient over a number of sessions allowing for the time to obtain a film strip version of the patients experiences, symptoms and complaints. This approach minimizes the tendency to over or under diagnose and increases the validity and reliability of the data collected from the diagnostic interviewing.

The clinician gathers data from a variety of the patients life experiences over time and establishes greater validity to the spectrum of symptomatology. Patterns of symptoms and complaints become clearer as the patient interacts within their familial, social and occupational environment over the course of days and weeks. The health care provider begins to obtain a time based sample from the diverse topography of everyday life. This topographic elicitation of symptom manifestation within the context of the patients personal ecology of life circumstances gives a three dimensional perspective of symptomatology over time, across situations, and within different environments. We refer to this as a time based topographic validity. More simply stated, this validity is based on the presupposition that there is no substitute for time when it comes to case formulation of the dynamics involved in CHIT.

Over the course of time spent with the patient, we advocate utilizing a variety of assessment procedures to attempt to substantiate the patterns of physical, cognitive and psychological problems being presented.

In essence, premorbid and predisposing features are often missed with single evaluations. Undetected problems are regarded as not existing instead of not diagnosed because evaluations are too short. In some instances, particular conditions are especially undiagnosed: in our experience, many have CPSzs which remain undetected and moreover false reassurance by practitioners doing such single or cursory evaluations ultimately may harm the patient: the condition is not diagnosed and the patient regards his/ her symptoms as psychological when there is a good physical base. Moreover, sometimes when symptoms have persisted over months, the patient is investigated neuroradiologically and when no positive findings are found, this is in error could be regarded as proof of the post-traumatic syndrome etiology and the absence of organicity. In actuality, invariably changes which may have been detected neuroradiologically early on in the first month, no longer can be found and this implies not psychological etiology but incorrect timing of the neuroradiologic evaluation.

Finally, we emphasize the real world approach, Neuropsychological testing in a quiet office, with encouragement and one on one testing with one single task at a time may be insensitive to the subtle changes that a bustling office of multitasked demands may bring. Many people require such multitasking in their regular occupation e.g. physicians.

Evaluation

The following is a regular model that we follow for a Comprehensive Complex Neuropsychiatric Evaluation in CHIT. It includes several time based interviews allowing a longitudinal perspective with several cross-sectional views including Detailed History; Physical and Neurologic Examination; Mental status and cerebral cortical examination; Testing including ASH, MMPI, SCL-90, INSET, BROCAS SCAN, FMMSE, NRBRPS; and Electroencephalography and Labs, as required.

The patient is seen on several occasions (usually 4 to 6) for comprehensive consultation.

In general the following order is followed:

On the first meeting, the major focus is the main complaint, focus of referral, a detailed pharmacologic history, history of investigations and of associated features.

On the second meeting more details about medical history are obtained, as well as physical and neurologic examination.

The third evaluation includes integration of test results and provisional diagnosis.

The fourth evaluation stresses recommendations and pharmacologic treatment options and also included feed-back.

Further consultations have a focus on symptom and etiology removal through psychopharmacologic integration and / or responsiveness as well as any further details pertaining to tests or clinical information that have come to light lat$

Mental status is assessed on each occasion.

At the conclusion, an extremely detailed report is produced reflecting historical data, medical evaluation, examination of higher brain functions and investigation information. This allows for a detailed multi-axial neuropsychiatric diagnosis and a road-map for present and future management both pharmacologic and non-pharmacologic. To facilitate the report being properly read, whereas all areas may be important, areas in italics or emboldened as well as table sections on investigations, pharmacology and diagnosis and the recommendations headers allow quicker initial perspective on our findings.

The following order of the report is followed which reflects information obtained, mostly following a solid medical and psychological history and examination model.

Demographic information is listed in as complete a fashion.
Basic medical information is elicited from several sources of information:

Referring physician with date of discussion, report, referral reason and core issues
Detailed notes from other medical colleagues and psychologists are requested and when available examined.
Family members are interviewed as to their perception of the problems and any observations they may have made. In possible seizure disorders, particularly, this is critical because even patients who are excellent historians may not be aware of certain events happening to them.
Information is then obtained directly from the patient.

Main complaints of patient and reason for the consultation are amplified.

This is described in the patients own words as well as then elicited listings and details of the main complaints of patient. This follows with

History of main complaint,
Age of onset of each problem including the CHIT,
History of current and past functionality,
Family history both psychiatric and neurologic, and the
Patients self-perceived positive strengths:

A Special Investigation History follows: Specifically elicited are details on

previous investigations such as EEGs, MRIs Head, CTs Head, SPECTs Head, PETs Head, Spinal tap, Neuroradiological procedures in the neck and back, Electromyography and nerve conduction studies, Electrocardiograms, Polysomnography, MMPI, and Neuropsychological Testing. When available, source material is examined. These tests often suggest that the CHIT was not the first major neuropsychiatric event the patient encountered.

Blood and urine tests are ordered during the course of the evaluation unless they have been done. The following blood tests are the most usual procedures in CHIT, often done to eliminate or diagnose alternative or additional conditions. Erythrocyte sedimentation rate, glucose, serology and HIV status, renal functions, electrolytes, complete blood count, vit B12, folate, electrolytes (sodium, potassium, chloride, magnesium, bicarbonate, calcium, phosphate) hepatic functions, lipid profile (cholesterol, triglycerides, LDL, HDL) and neuroendocrine status including thyroid functions (TSH, thyroxin and T3) and sometimes adrenal status (cortisol), and pituitary and gonadal screens (Prolactin, FSH, testosterone). It is usually sufficient to test the patients urine biochemically at the office level for protein, glucose, ketones, pH, blood and bilirubin. If these are normal, and the patient has no genito-urinary symptoms, one need not progress to sending urine specimens away for cell examination and microscopy, culture and sensitivity.
Pharmacologic history is the next critical area. Current medications are listed and these frequently on first interview have not been prescribed by the evaluating physician complicating interpretations because there is a need to rely on the patient or family as a historian.

This constitutes a record of other medications for baseline and information purposes. The duration of each, onset of prescription, varied dosages, and combinations at varied times in the recent past are elicited. Degree of responsiveness and side-effects are critically detailed and onset and offset of these effects noted. Later interpretations as to whether events were drug related are made . Family history of response and non-response to specific medications as well as allergies and side-effects are also listed. Differentiation of generic and trade preparations is made. The pharmacologic history ultimately leads to the most critical single determining factor for recommendations so that this is done in great detail. A similar process is followed for spontaneously eliciting information pertaining to what the patient previously was taking. From this the patients and also family members opinions are elicited as to what medications the client did best with and did worst with historically.

Thereafter the patient is asked to complete a rather lengthy questionnaire listing all known commonly used psychotropics, pain medications, hormones, anticonvulsants and muscle relaxants and even asking about experimental agents. Known common side-effects are asked about as well as any positive responses to medication. Dosage, duration of treatment and therapeutic effects are also emphasized (Table C).

Again responsiveness and compliance is elicited with regard to each medication as well as general impressions of best responsiveness and improving compliance.

Nonprescription and Recreational Drug Abuse history is then elicited using the same principles as before. Duration, combinations, dosage, effects both good and bad, side-effects, compliance, addictiveness and dependency issues are all asked about. Relevant is the way the patient handled the specific recreational drug and whether this may have predisposed to the CHIT or its consequent severity.
Nonprescription drugs specifically asked about include all the varieties of Marijuana, LSD, amphetamines, mescaline, cocaine, phencyclidine, heroin and narcotics. Additionally, critical to the evaluation is the impacts of alcohol, caffeine, cigars, pipes, cigarettes and other more socially acceptable, legal drugs of abuse.

All the information above is generally elicited on first interview. Later consultations commonly amplify such information.

Neuropsychiatric symptomatology is then evaluated. Originally the measuring instrument used was the Neppe Temporal Lobe Questionnaire derived from researching the symptoms of Temporal Lobe Dysfunction from the literature as most of the major historical organic brain symptoms as opposed to physical signs derive from or impinge upon the temporal lobe. This was later revised to a new instrument which we routinely use on all patients namely, The INVENTORY OF NEPPE OF SYMPTOMS OF EPILEPSY AND THE TEMPORAL LOBE (INSET ). This is a paper and pencil test and amplified by a detailed face-to-face interview. The INSET involves screening for possible temporal lobe, epileptic and organic symptoms and spells. Thereafter the symptoms are categorized into several headers namely nonspecific symptoms, possible and controversial temporal lobe symptoms, seizure related and other focal features. The test is based on the subject and / or his family responding to questions which are thereafter elaborated in greater clinical detail. The INSET is copyrighted instrument.

The INSET plus medical history are major determining factors as to whether to order follow-up specialized electroencephalograms such as an ambulatory EEG in the CHIT patient.

Examples of uncommon paper and pencil neuropsychiatric instruments:

The Narcolepsy Screen and Déjà Vu Questionnaires

We have also developed several less commonly used paper and pencil neuropsychiatric instruments which are applied when appropriate. One is the Neppe narcolepsy screen which has not been well researched. Narcolepsy is a rare condition itself (incidence possibly 1 in several thousand individuals). However, the questionnaire is far more versatile probing sleep disturbance as well as anomalistic experiences and these are common in the CHIT patient. Unfortunately, the questionnaire needs to be scored by paper and pencil at this stage and there are no norms so that although highly relevant history information is obtained at a clinical level, a clinician needs to interpret the results.

The Neppe Déjà vu Questionnaires are other screening history instruments seldom used in clinical practice. However, the major value of this well validated instrument is to demonstrate how we cannot interpret symptoms not elicited in detail as the same. Using a phenomenological analysis, Neppe was able to demonstrate that the symptom of déjà vu, commonly regarded as symptomatic of temporal lobe epilepsy indeed had a very special phenomenologic quality in patients with temporal lobe epilepsy (Neppe, 1983A). This involves its association with post-ictal features such as sleepiness, headache and clouded consciousness and its link in time with these features. This association provides an excellent clue to the existence of temporal lobe epilepsy but déjà vu is a normal phenomenon occurring in 70 percent of the population and unless such phenomenological detail is obtained, patients' symptomatology may be misinterpreted (Neppe, 1983 A). Neppe has similarly done such a study with olfactory hallucinations (Neppe, 1983 B, 1984). A specific type of temporal lobe epilepsy olfactory hallucination could not be demonstrated although there were suggestive features.

A major message, therefore, may be the relevance of adequately assessing in detail the symptomatology of patients presenting with CHIT. If déjà vu occurs, temporal lobe epileptic déjà vu must be specifically sought. Such detail may be as relevant as electroencephalographic monitoring (Neppe, 1983 A ).

Historical Base The next consultation interview series focuses on increasing data bases obtained by questionnaires and computers. This develops the longitudinal perspective of change over time, again essential in head injury patients to understand predisposing features.

Any program involving detailed historical and medical responses should be adequate.

These produce an automated report and significant time is then spent checking data and amplifying all positive information. The automated report has significant limitations, partly due to the way the answers in the ASH program are written, as well as insufficient detail. Particular attention should be paid to clarifying for example current and previous misuse of recreational drugs. Moreover, this cautious interpretation in regard to histories of alcohol and drug use sometimes produce automated interpretations based on group symptoms which can be misconstrued where patterns of behavior unrelated to alcohol or drug use may be misinterpreted as linked.

Results are then combined in general with additional tests and further detailed clarification done thereafter.

The responses should be interpreted with care as the questions asked are broad and the possibility exists of incorrect information particularly as patients may not be computer sophisticated or may make errors in answering paper and pencil forms. This is another reason for checking all positive data.

PSYCHOLOGICAL AND PSYCHIATRIC DIAGNOSTIC EVALUATIONS:

At this stage, the evaluation shifts to more formal standardized evaluations. Routinely at our institute, we evaluate patients using two computerized psychological instruments - The MMPI or its adolescent version - and the Symptom Check List 90. There is strong support to use personality evaluations and some would debate the Millon Clinical Multiaxial Inventory (MMCI) should be used instead of or in addition to the MMPI. We believe it useful to screen current psychological symptoms hence the use of the SCL 90. We do not find this an ideal instrument and recognize its significant limitations both in lack of detail and selectivity of questions. Both these tests are not well standardized in the brain injured populations but with the INSET and other organic screens (e.g. BROCAS SCAN below) we believe they are valuable. We have also considered adding the SCID to our instrumentation. We precede the test discussions with some background.

Assessment of Personality

Within the head trauma population, perhaps the area that is the most difficult to understand for both patient and provider, and often the most complex, is the assessment of personality. Early research in this area (Thomsen, 1974) revealed that families of head trauma patients reported changes in personality to be more of a burden to them than residual physical problems. Goethe and Levin (1984) conclude that family complaints about head injured patients center around personality and behavior changes rather than physical disabilities, and family tensions typically increase as time goes even up to two years following an injury.

Assessing potential changes in personality obviously cannot be accomplished properly within an hour or hour and a half diagnostic interview with the patient. Understanding the subtle yet complex changes that can occur in personality dynamics following head trauma is primarily the basis for advocating a time based evaluation process. Far too often misdiagnosis is made with respect to the presence or absence of personality disorders. As clinicians, we simply need to humble ourselves and not be so quick to make clinical judgments based on limited time with the patient.

From the time period of the 1970s through the 1980s the epidemiological, neurological and neuropsychological evaluation of minor traumatic head injury has produced a greater awareness of the changes that can occur in intellectual and cognitive functioning (OHara, 1988). Within the last five to ten years there has continued to be research generated on the definitions and neuropsychological aspects of minor head trauma (Kibby & Long, 1996, Esselman & Uomoto, 1995, Cohadon, Richer, & Castel, 1991, Alves, Macciocchi & Barth, 1993, Lowdon, Briggs, & Cockin, 1989). There has however, been much less research and clinical literature written on the neuropsychiatric aspects of head trauma. McAllister (1992) discusses neuropsychiatric sequelae of head trauma in terms of pathophysiology, cognitive sequelae, behavior, effects of age, and treatment. Also within the past five years, studies emphasizing personality issues following head trauma have increased our awareness of the need to understand this aspect of the head trauma spectrum (Middleboe, Birket-Smith, Anderson, & Friis, 1992, Miller, 1992). There is a great need within the health profession to appreciate the subtle, yet significant changes in personality that can occur with head trauma, and to get beyond the purely clinical aspects of assessing these changes to recognize the trauma to the self. Clinicians who work day in and day out with head trauma patients will attest to the difficulties these patients experience when their equilibrium of self has been altered by trauma and brain injury.

In addressing this issue, it must be reiterated again that to fully evaluate these changes in personality takes time. Initially, the patient is often preoccupied with problems with pain and they are not yet aware of changes in themselves. As recovery progresses, there is more awareness of the cognitive and psychological problems. When patients begin to feel better physically, they attempt to get back in the swing of things and this is usually the time period when they begin to notice that they do not feel the same. As cognitive sequelae resolve, they return to work and reintegrate into social and leisure activities. However, continued reduction in tolerance, irritability, emotional volatility, and mental and emotional fatigue are experienced on a daily basis.

These subtle residuals are typically difficult to assess in the clinical setting. Yet, time spent with these patients will often reveal the struggle they experience in trying to cope with everyday life. They are constantly reminded by the difficulties they encounter that they have changed and that they feel different. There is often a longing to be like they used to be and get their life back to what it used to be. But the truth of the matter is that many of these patients will never regain the old self and be able to capture the sense of being who they were.

Patients with more dysfunctional personality styles often develop secondary psychiatric problems, which can considerably complicate the clinical picture. This psychological overlay is often misjudged by inexperienced health providers as simply a manifestation of a personality disorder, when in fact it is a manifestation of impaired coping and the expression of futility at being unable to deal with life effectively. There is the constant experience of reduced cognitive stamina even though many frank cognitive symptoms have resolved. This usually takes the form of inability to keep up with the demands of life and inability to enjoy the process of living. There is often an anhedonic experience of going through the motions of living but without the ability to fully enjoy life events. These patients will often feel like they are on the outside looking in and not really participating. They feel detached and surrealistic about living.

Patients with a primary concussive injury and patients with predominant posttraumatic reaction can experience these changes in their sense of self. As a starting point for adequately assessing these issues it is usually helpful to have a psychological consultation incorporating some standardized, objective measures such as the MMPI-2 and the MCMI-III (Millon Clinical Multiaxial Inventory). This is useful in differentiating predominantly posttraumatic symptomatology from postconcussive complaints. The MMPI-2 is helpful in assessing primary features of psychological functioning and can be supplemented with the MCMI-III to gain a more in depth analysis of personality traits and style. This can guide the clinician in how to approach treatment. Patients with more extreme elevations on the MMPI-2 are typically experiencing greater distress and there may be a need for psychopharmacologic intervention. Examining personality style from the MCMI-III can give the clinician valuable information on how the expression of symptomatology will be seen by others and the relative strengths and weaknesses in personality structure.

MINNESOTA MULTIPHASIC PERSONALITY INVENTORY

Adult clinical system interpretive report (based on several authors - we have been using Butchers broad interpretations and modifying from there).

The MMPI-2 interpretation can serve as a useful source of hypotheses about patients. This report is based on objectively derived scale indexes and scale interpretations that have been developed in diverse groups of patients. The personality descriptions, inferences and recommendations still need to be verified by other sources of clinical information since individual patients may not fully match the prototype. Moreover, the interpretations are based on statistically quantified results and every individual is different enough to allow only relative norms. Some of the questions of the MMPI are difficult to answer yes or no to which further complicates individual interpretation. Additionally, diagnostic hypotheses generated by the MMPI are only relevant in the appropriate clinical context.

ADOLESCENT MINNESOTA MULTIPHASIC PERSONALITY INVENTORY

Adolescent clinical system interpretive report (again for example based on Butcher).

The Adolescent MMPI-2 interpretation can serve as a useful source of hypotheses about teenage patients age range 13 through 18. Outside these ranges cautious interpretations should be made with the awareness that the test is technically invalid or of limited validity. This report is again based on objectively derived scale indexes and scale interpretations that have been developed in diverse groups of patients and again need to be verified by other sources of clinical information since individual patients may not fully match the prototype.

SYMPTOM CHECKLIST 90-R (DEROGATIS)

The SCL-90-R is a multi-dimensional self-report inventory developed by Leonard Derogatis. It is designed as a screening instrument for psychopathology in psychiatric, medical, and nonpatient populations. The scoring profile is expressed in percentile rankings across the ninety items and following this is the Derogatis interpretation of scores. For patients below age range 19 years, cautious interpretations should be made with the awareness that the test is technically invalid or of limited validity. Again, the interpretations are based on statistically quantified results and every individual is different enough to allow only relative norms. Some of the questions of the SCL-90 are difficult to answer which further complicates individual interpretation. In our experience, many patients are interpreted as having obsessive- compulsive symptoms on this test probably far more than are warranted. Additionally, diagnostic hypotheses generated by the SCL-90 are only relevant in the appropriate clinical context.

MCMI-III - The Millon

The MCMI-III can be a rich source of information regarding how a given patient may be contributing to the postconcussive or posttraumatic syndrome by the way they may be reacting to their injury and its effects. This clinical data often gives valuable insight into areas of personality vulnerability, which are usually attenuated after head trauma. When used in combination with the MMPI-2, a more comprehensive basis for understanding personality issues can be laid, with hypotheses being made for further evaluation.

It should be pointed out that traditional interpretative approaches for the MMPI-2 and MCMI-III are inadequate and often lead to erroneous conclusions when applied to the head trauma population. Too often, computerized printouts of MMPI-2 and MCMI-III results are misused by clinicians unfamiliar with the dynamics of head trauma, and these patients are assessed inaccurately. Interpretation of these psychological instruments should be made within the context of background information, details of the injury event, symptomatology, and collateral information. Psychological assessment should be considered a starting point and not the only source of evaluation.

Using the MMPI-2 and MCMI-III are also useful in understanding issues of symptom magnification and exaggeration or minimization of symptoms. These issues are usually inherent in medicolegal cases. Both the MMPI-2 and MCMI-III can be helpful in detecting a mind set towards over-reporting or under-reporting symptomatology. Verifying these issues are difficult and a conservative approach should be taken. Clinicians should look to the overall case presentation when making clinical judgment regarding the intentions of a given patient during an evaluation process.

Under-reporting of symptoms can often be related to the denial that is seen in patients with head trauma. These patients are acutely aware of problems in cognitive and psychological functioning, but often minimize these problems, hoping they will just go away. During a cursory initial clinical interview, the clinician can be misled into concluding that the patient is not in any significant distress, when in actuality they are often presenting themselves in a favorable light because it is too difficult for them to admit to the type of symptoms they are experiencing. Patients are often embarrassed to admit to having problems in their cognitive functioning. There is also a tendency to minimize problems with irritability, emotional volatility and reduced tolerance, as these problems may not be consistent with how they would like things to be. When there is consistency between psychological testing and clinical impression, this issue can be the catalyst to initiate a realistic acceptance of these problem areas so that recovery can be further facilitated.

On the other hand, over-reporting of symptomatology is a much debated issue whenever there are potential sources of secondary gain such as the case is in litigation. After ruling out other possible explanations of extreme elevations in clinical profiles from the MMPI-2 and less often the MCMI-III, the clinician can often detect this mind set towards exaggeration and be in a better position to explain the basis of persisting symptoms. This issue is almost always a part of the postconcussive spectrum and should be thoroughly evaluated. More often than not, patients may be magnifying symptoms rather than outright malingering. In addition, many patients magnify symptoms because of their need to convince the clinician that they really are having a legitimate problem. Intentional magnification of symptomatology is far less common than typically thought of among health care professionals and the legal community. Again, it should be pointed out that clarifying these issues takes time and the most valid and reliable assessment of under-reporting or over-reporting, regardless of the results of psychological testing, is to see the patient over a number of sessions to document the consistency of their symptom presentation.

Relevant medical history data: A detailed screening medical history involving specific medical systems such as neurologic, cardiovascular, respiratory, genito-urinary, gastro-intestinal , endocrine and musculoskeletal systems ( including pains ) is then taken. Information in this regard is based on any basic medical textbook and is not further amplified here although, of course, any positive features should be followed through. Allergy history is also elicited as well as injuries including the CHIT that may be the current main complaint. For most patients this should be performed by a medical practitioner although nurses and physicians assistants often obtain this history. The requirement is obvious but worth emphasizing as often psychiatrists particularly ignore taking a detailed medical history and miss critical information.
PHYSICAL EXAMINATION and
including NEUROLOGIC EXAMINATION:

A single physical examination, generally on our second time based examination is then performed. Factors which may vary from time to time, such as labile blood pressure, tachycardic pulse, areas of tenderness and limitations in movement may be repeated on several occasions. The neurological examination is particularly critical and part of the physical examination.

MENTAL STATUS EXAMINATION:

Just as neurologic evaluation is critical to finding subtle deficits, mental status evaluation is the key to a successful psychiatric evaluation and can reflect pathology that may be symptomatic of the CHIT.

This is performed sequentially on several occasions along the time based examination.

There are many different ways of performing the mental status examination in neuropsychiatry. No one technique is necessarily better than another.

We approach mental status by making sure the major aspects are prioritized. The special structure involves mnemonics as a helpful means to recall items otherwise forgotten.

In mental status evaluations, the special skill is to be as flexible as possible. Some mental status headings are ambiguous as you can, for example, describe certain signs under a person's appearance and very often, the same features could equally well relate to the patient's affect - the appearance of the patient may be sad and that same sadness should be picked up with regard to his emotions.

The mental status examination in psychiatry is the equivalent of the physical examination in general medicine. Both logically follow the taking of a medical history. This elicits as much information as possible and prioritizes what needs to be evaluated; then you examine the patient. There is a fundamental difference, however: much of the psychiatric examination is performed by taking a history - this is a special skill itself as the two functions of history and examination are therefore performed simultaneously and sequentially.

Often the mental status examination is confused with history taking. For example, when the patient gives historical information, he may not admit to any hallucinations: this may or may not be true; this is not part of the mental status examination. It is part of the mental status evaluation. It is clearly important to inquire about hallucinatory experiences, but asking about hallucinatory experience may get the response, "No, I never hear voices," when the patient is floridly hallucinating. The patient may or may not tell you about the voices he is hearing. Alternatively, he may describe voices he does not hear to ensure conscious or unconscious gains like admission to hospital (and a warm bed and caring environment) as well as fulfilling dependency needs. In the CHIT patient, where medicolegal facets are often relevant, particular attention should be paid to possible dissimulation or malingering.

We should distinguish between the historical mental status evaluation, which consists of the symptom cluster descriptions relevant to mental status, and the mental status examination, that component of evaluation often relating to the historical data but eliciting physical signs about mental status.

History taking involves probing. This is often facilitated by basic techniques or maneuvers that occur during the interview. Very often, history-taking involves eliciting both symptoms and signs: to do so, the skilled examiner, as required by the demands of the situation, shifts his interaction with the patient. This involves performing frequent probes, and keenly observing the response that results. These have both content and process components:

The single major mnemonic for mental status is ACCLAIMED. In the CHIT we evaluate the nine major subheadings of ACCLAIMED. In these nine major subheadings, which imply the essence of every facet of the mental status examination. The order of this mnemonic was empirically derived from the most logical direction to do the mental status examination; it is not contrived with headings made to fit the mnemonic. ACCLAIMED constitutes a priority system for the larger of the headings of mental status examination.

CEREBRAL CORTICAL AND NEUROPSYCHIATRIC EVALUATION

No adequate screening evaluation of higher brain function appears in the literature. Screening evaluation of the head injured patient using available bedside screening instruments is limited at present. The most widely used test (Naugle, 1989), the Mini Mental Status Examination (FMMSE) (Folstein, 1975), is quickly administered and requires little training, but has little predictive power for diagnosis or classification of coarse neurobehavioral syndromes, and is not designed to detect mild cortical deficits (Naugle, 1989 ). Half of the MMSE s 30 questions emphasize orientation and calculation; focal pathology is not effectively screened. Only 30% of multi-infarct dementia patients (Babikian, 1990) and 68% of Alzheimer's dementia patients scored below the recommended cut-off of 24/30 on the MMSE, raising questions about the test's sensitivity (Galasko, 1990). Even more seriously, 85% were false-positive for the diagnosis of dementia, raising questions about its use in a geriatric community setting (Gagnon, 1990). The MMSE also correlates poorly with basic everyday living skills (Katz ADL Scale)(Ferrell, 1990), education and intelligence level, right hemisphere dysfunction, and mild cognitive dysfunction (Ferrell, 1990) (Gagnon, 1990) (Gurland, 1987).

CHITs, CHIPs, dementia, focal cerebral cortical abnormalities, pseudo-dementia and other coarse neurocognitive brain syndromes are frequently evaluated using neuropsychological batteries such as the Halstead-Reitan and the Luria-Nebraska. Neuropsychological evaluation is often helpful in gathering a comprehensive standardized sample of cognitive and intellectual functioning. When the practical demands of practice make it prohibitive to have a patient complete the often lengthy neuropsychological testing process, there is an alternative that is less formal but clinically quite useful.

The BROCAS SCAN

The most promising such clinical instrument is our bedside screening test, the Screening Cerebral Assessment of Neppe (BROCAS SCAN) which we spent the late 1980s refining and the 1990s developing data on and using. (Neppe, et al, 1992) (scoresheets Appendix 2A and 2B)

This is a test of higher cerebral cortical functions used as a bedside screening instrument.

The BROCAS SCAN permits a quantified behavioral neurologic examination by providing clinical personnel with a focal and global assessment of a patient's mental status. Focal assessments include gnosis, praxis, and sensory-motor-reflex skills, which are not adequately addressed by the MMSE and bedside tests, including the Neurobehavioral Cognitive Status Examination (NCSE) (Schwamm, 1987 ). The BROCAS SCAN is a more valid and more sensitive indicator of pathology than the FMMSE, results which we have seen hundreds of times clinically over numerous neuropsychiatric diagnoses, and also demonstrated in our research (Neppe et al, 1992).

The BROCAS SCAN is readily learned, administered, and scored and has high interrater reliability (Neppe, 1992), even when administered by psychology students. It is versatile -40% of neuropsychiatric patients who had the BROCAS SCAN were considered unable to tolerate longer neuropsychological batteries (Neppe, 1992). A SCAN on patients with CHITs should take 10 to 40 minutes. Screening questions eliminate unnecessary follow-up when the item is answered correctly.

The acronym "BROCAS" spells out the relevant scoring categories. "B" is for behavior rating: a revised form of the Brief Psychiatric Rating Scale (BPRS) of Overall and Gorham (Overall, 1962) (Beller, 1984) - the NEPPE MODIFICATION OF THE BPRS or NMBPRS (Appendix 3).

Despite the frequent use of the BPRS, this is the least quantifiable category and the only one requiring specialized assessment. The remaining 10 categories comprise the "ROCAS" profile: "R" for recall and recognition, "O" for orientation and organization, "C" for concentration and calculation, "A" for apraxia and agnosia, and "S" for speech and sensory-motor-reflex. Each ROCAS category is scored from zero (no impairment) to 10 (gross impairment). The 40 items which compose the 10 ROCAS categories are tabulated on a two-dimensional score sheet (Figures 1a and 1b). The result is expressed as the BROCAS profile (Behavior + ROCAS), which reflects clinical and neuropsychiatric features.

The first half of the test are basic screening items which compose the Core score; the second half are subtle items which compose the Fine score. A Total SCAN score, ranging from zero to 100, is the sum of the Core and Fine scores. Two versions of the BROCAS SCAN, labeled "A" and "B", allow for retesting without contamination. Scoring involves the patient' s performance. A perfect score is zero and the normal intelligence individual without major psychopathology generally scores <15. The maximum score for the very grossly impaired is 100.

Because the BROCAS SCAN test concentrates on physical signs, areas of the cerebral cortex such as the temporal lobe and limbic system involving predominantly symptom profiles are not evaluated in detail - this is done with the INSET evaluation.

Two validity scores are obtained: the first is the raters validity scale (0 = highest level of validity ; 4 = very dubious). The second, the subjective validity scale is the patients ranking of difficulty in such areas as anxiety, concentration and language understanding, and uses the same items as the raters validity scale. This is currently used clinically and helps in that way give insight into the patients perception of his / her illness.

Table E reflects two typical SCANs.

Column A reflects a normal profile and Column B may reflect a patient with a CHIT three months post-injury. Table F reflects the interpretations on these patients.

MINI-MENTAL STATUS EXAMINATION

The subject's mini-mental status examination score based on Folstein and McHugh (1975) (FMMSE: /30) and adding the World score (5) (/30-35) is usually done in our evaluations for comparison only. Because this test is suspect for sensitivity, specificity and reliabilit

The Neuropsychiatric Evaluation of the Closed Head Injury of Transient Type (CHIT)

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