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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.



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