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.