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.
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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 reliability, it is listed here only
because of its common use. The scores alone should
not be used to base any clinical decision.
NEPPE MODIFICATION OF THE REVISED
BRIEF PSYCHIATRIC RATING SCALE:
NMBPRS
This test generally uses a 0-6 (occasionally
7) ordinal ranking scale of each of 18 basic items,
plus 3 cognitive (COP) items and an additional frustration
score). The original Overall and Gorham test has
been subject to numerous variations and used a great
deal in evaluating change in psychopathology scores
over time, although inter-rater reliability may
be questioned. In this instance, the frustration
score is an additional item not found in the usual
BPRS, and in addition to orientation, a score of
on the COP items - concentration, orientation, perplexity
- is developed for higher cerebral function. To
ensure greater scoring consistency than in the original
BPRS, the essence of each item is summarized on
a score-sheet and the criteria in the PANSS of Kay
and Fiszbein are used. Also, a "validity score"
based on whether particular items could be ranked
accurately is used as well as an Overall Clinical
Impression Score.
The NMBPRS as recorded involves several
assessments over each interview and observation
period during testing. The NMBPRS score may be more
exaggerated at times of evaluating distinct psychopathology
and in a non-structured environment, hence, our
tendency is to evaluate at a time based level and
put in several scores. A subtest interpretative
report is then prepared. Table G reflects the NMBPRS
results of the CHIT patient in Table E above.
From the data of the ROCAS and B
items (i.e. the BROCAS SCAN and NMBPRS scores) a
provisional attempt is made to analyze scores by
combining these profiles. Conclusions pertain to
evidence of organic brain dysfunction reflecting
frontal, parietal or temporal lobe disease, current
marked dynamic or psychopathologic elements, any
direct evidence for possible psychotic preoccupation
although this is not specifically focussed on, and
evidence of a generalized organic brain syndrome.
Finally, a global perspective of range of normal
limits or mildly, moderately and severely impaired
are made.
-
Movement disorder evaluation: The
STRAW
Movement disorders are not generally
of great significance in CHIT or CHIP but may be
so depending on impacts on different parts of the
brain. Moreover, many of these patients may be receiving
major tranquilizer (i.e. neuroleptic - also called
antipsychotic) medication, sometimes in small doses.
Organicity may predispose to tardive dyskinesia
and thus it would then be mandatory to do such an
evaluation for abnormal involuntary movements.
STRAW is an acronym for a new technique
of evaluating involuntary movements, particularly
tardive dyskinesia. Neppe developed the STRAW in
the early 1990s because of the non-availability
of adequate measures which would reliably differentiate
subtle differences in tardive dyskinesia, and which
could be easily scored within a 10% range by several
different raters.
The STRAW has two components, a timing
component and a severity component. The STRAW timing
system involves equal scores of 50 for activation
and rest. The key to the STRAW is the timed component.
The timing component is scored out of 100 based
on a time period using the criterion of presence.
Tremor and epileptic seizure are not included as
involuntary movements.
Half the time is at rest is the "S"
for sitting at rest while relaxed, not under stress
and standing - the score is a rest score. The five
evaluations during activity are each out of 10 making
up 50 for activity (the TRAW) loaded equally with
the 50 for rest (the S of the STRAW).
Three body sections are measured
for severity: the head, the axial skeleton, and
the limbs. Each body section is rated between 0
and 10 in severity . In practice, the most severe
of these three rankings is the one that is most
closely followed over a period of time for tardive
dyskinesia.
The STRAW timing system is multiplied
by the STRAW severity, giving a total score out
of 1000. It is thereafter divided by 10 to score
out of 100. This gives an index of both severity
and duration of particular physical signs. Table
H reflects a typical scoresheet of a CHIT patient.
i.e. no movements.
-
The PBRS:
The Problem Behaviors Rating Scale
of Neppe and Loebel (PBRS)
is only useful in the context of inpatients. Thus
it may have more relevance acutely in a CHIP or
in a situation of permanent sequelae. We have found
it particularly useful to monitor change closely
over time in that it is unambiguous and usable even
by nurse aids. It is still being researched, however.
The PBRS is a 33 item rating scale
developed for nurses and related professionals in
a nursing geriatric, neuropsychiatric or other inpatient
environment. This ranks patients behavioral changes
over a defined period of time (a day or a week).
Each scale scores range from a normal of 0 to an
extreme of 3 producing a total of 99 making a range
from 0 to 99 (or 100 with 1 more for inpatients).
These criteria are based on unambiguous clinical
mental status features using the mental status mnemonic
ACCLAIMED covering areas broadly translated under
appearance, consciousness and concentration, cognitive
function, localization of cortical pathology, affect,
insight and judgement, motivation and motoric elements,
ego environment interaction, and dangerousness and
disability. A copy is listed in FIGURE C.
-
Routine Electroencephalogram
(EEG) (both sleep and wake with activating
procedures such as hyperventilation and photic
stimulation in th$ absence of medical conditions
contra-indicating these) is a reasonable proc$
in CHIT given any possible temporolimbic features,
episodic nature of sympt$ and history of atypical
spells . Sleep records have been well demonstrated
$ likely find focal pathology than waking EEGs.
However, waking EEGs have a h$ up rate and sleep
EEGs cannot be interpreted without the wake EEG.
It is interesting that prior to the
development of the EEG (by the neuropsychiatrist,
Dr. Hans Berger in the 1930's) all seizure disorders
were classified with mental disorders (Neppe, Tucker,
1988A, 1988B, 1992). EEG technology remains rather
primitive and reflections of brain waves from the
perspective of analysis of psychopathology somewhat
limited. Nevertheless, the only definitive way of
demonstrating that a symptom or physical sign such
as, for example, an olfactory hallucination is definitely
epileptic, is the demonstration of correlates of
seizure phenomena on EEG, such as spike-wave paroxysms,
while the person is having that experience. This
is unusual unless the seizure phenomena are relatively
uncontrolled. Even in the event of them having such
an experience, the EEG correlate may not necessarily
be of a spike kind but depending on location, it
could be normal or show a marked slowing, with a
nonspecific theta rhythm generally of limited help
unless focal or a delta rhythm, which is frankly
abnormal unless the patient is asleep (theta is
4 to 7 cycles per second, delta is less than 4).
It is occasionally extremely difficult to localize
such features on scalp EEG even when firing is occurring
because symptoms may occur from the mesial temporal
or deep structures within the brain which do not
easily manifest on surface EEGs (Tucker, Neppe,
1984, 1988).
Special electrode placements
Special techniques have been used
to overcome the problem. One commonly used technique
was nasopharyngeal electrodes but the increased
yield with nasopharyngeal electrodes is insubstantial.
A second placement is sphenoidal electrodes which
unfortunately, requires time, expertise and discomfort
limiting availability. A recent new suggestion has
been the placement of electrodes on the buccal skin
surface in the area of the submandibular notch -
possibly as effective in picking up foci as sphenoidal
placements. Finally, cerebral cortical placements
during neurosurgery procedures may show firing,
for example, in patients with temporal lobe epilepsy
and psychosis, in the region of the hippocampus.
The direct placement of intracranial electrodes
shows how commonly spike firing may be occurring
in this area with no correlate of any kind on surface
EEGs (Neppe, Tucker, 1988A, 1988B, 1992).
Sleep EEG records
There are several methods that are
used for evoking electroencephalographic abnormalities.
Sleep records increase the potential delineation
of focal abnormality such as a temporal lobe focus
by approximately fourfold. The administration of
chloral hydrate, 1 to 3 grams as premedication prior
to the sleep record is useful as this induces little
change of significance in the electroencephalogram
and does not prevent the demonstration of focal
abnormalities. Certain medications should be particularly
avoided in this regard. The first is the benzodiazepine
group which may have by virtue of their very strong
anti-epileptic effects profound effects in normalizing
the EEG. Such effects at a receptor level may last
weeks even with the apparent short acting benzodiazepines
so that the yield of demonstrating epilepsy after
the patient has had benzodiazepines administered
apparently decreases substantially, although adequate
data in this regard is not easily available (Neppe,
1984). Photic stimulation and hyperventilation are
also important evokers of abnormality in EEGs.
-
Home Ambulatory Electroencephalogram
(EEG)
Developments in this regard have
been rapid over the past few years.EEG Telemetry
involves prolonged monitoring over periods of time
varying from 12 hours to 2 weeks while the patient
is generally confined to a particular room. Cable
telemetry, is most commonly used. This involves,
for example, a 25 foot cable connected to the EEG
montage on the patient's head. Very often no seizure
manifestations are picked up for prolonged periods
of time because seizures only occur paroxysmally.
Moreover, those patients evaluated in a specialized
center with EEG telemetry are invariably so atypical
that the hypothesized seizure originates deep within
the brain. The apparatus costs over $100,000 and
the costs involved in monitoring patients are thousands
per day at times for two weeks. Instead, home ambulatory
electroencephalograms are easily available (Neppe,
Tucker, 1988A, 1988B, 1992), (Neppe, Tucker, 1988A,
1988B, 1992).
Ambulatory Electroencephalogram
(EEG) with the patient not modifying medication
is a valuable test when the patient's symptomatology
needs to be monitored day and night in a natural
environment of home using computerized filtering
of artefact. The advantage of this technique is
to establish if any scalp electrode can detect events
such as atypical spells alerted to by pushbuttons
reflecting deep brain electrical activity. It has
limited availability at this point, however, but
our pick up rate for atypical spells and seizures
is high.
Recent advances in EEG technology
may ultimately change the whole perspective in its
use in psychiatry. Computerized EEG monitoring
allows breakdown of wave forms and allows correlation
with evoked potentials including cognitive evoked
potentials. It also facilitates demonstrations of
changes in particular areas of the brain which can
be easily delineated at a visual level. This should
prove to be a useful psychophysiological correlate
of psychopathology. Indeed, this may be the beginning
of an important new era. However, at this point
in time it is still experimental.
-
Other investigations: Structural
lesion investigations are sometimes necessary
during the acute phase to ensure that secondary
bleeding has not occurred. Usually, this is clear
based on neurologic deficits or deterioration
of some kind. However, if neuroradiologic anatomic
tests are not done in the first month, the likelihood
that abnormalities will be picked up are considerably
diminished. Thus depending on symptomatology,
neuroradiologic investigations such as Magnetic
Resonance Imaging (MRI) of the head may be a useful
consideration. The balance is one of cost versus
Computerized (CT) SCAN but the yield may be more
with MRI. Additionally, CT is accessible and indicated
when magnetic clips make MRI contra-indicated
and bony lesions or acute blood extraversations
exist. This should be done with contrast material
unless allergy contra-indicates. However, it cannot
as well demonstrate tiny lesions, lesions of the
pituitary (where gadolinium contrasting on MRI
should be performed), small vessel vascular disease
and white matter lesions such as demyelinating
and degenerative disease.
Functional lesions which are
not necessarily structural and detected on MRI or
CT may be found on Single photon emission computerized
tomography (SPECT). This will demonstrate differences
in regional cerebral blood flow and hot and cold
areas of hyperflow and hypoflow. The differences
in laterality and particular areas of the brain
may have great clinical significance but the interpretations
are limited by lack of adequate diagnostic base.
Tests such as Positron emission tomography
(PET) are still experimental, very expensive and
not easily available in humans.
Similarly, measures such as Computerized
EEG like BEAM or Spectrum measures involve technology
which has outstripped research which means clinical
meaning may be difficult to interpret.
-
SYMPTOM MONITORING
- The patient and family should monitor episodes
of symptoms of anger/ aggression/ irritability/
anxiety / depression / memory / distress level.
This will be based on a daily grade evaluation.
Patient -ranking and / or family
ranking is listed in a table under the headings
date, time, approximate duration, with severity
at a nil 0, mild 1, moderate 2, severe 3, profound
4 level.
Rank irritability, concentration,
memory
-
Overall ranking for the day:
Mark out of 10 every day (This is individualized
by the patient depending on impairments: one
patient chose the following: 10 excellent, 0
very poor. with: 10 going to the store - walking;
8 still little trouble; 1 very impaired but
can make coffee
-
A sleep chart may facilitate
sleep monitoring so as to establish progress.
The patient or family should list total amount
of sleep for a 24 hour period, ending in morning
on waking.
-
The patient should list time
of day when feeling worst eliciting diurnal
variations in depression and fatigue.
-
Collateral Information
We have stated previously that the
patient with head injury symptoms is likely to have
difficulty expressing their thoughts and ideas.
This may be due to expressive deficits, a reduction
In self awareness, or secondary to memory problems.
Many patients with postconcussive symptoms experience
a reduction in spontaneous word production and are
unable to communicate the full extent of the changes
in cognitive and psychological functioning. Patients
with expressive problems often come up short in
trying to explain the daily problems they are encountering.
There may be dysnomia, poverty of thought content,
and loss of their train of thought. This can result
in inadequate clinical information being given to
the health care provider, who in turn may under
diagnose due to the appearance of minimal symptom
presentation.
Concurrently, there may be an inability
to fully appreciate the extent of cognitive problems
or psychological changes. This can be due to denial
and/or loss of ability to be aware of self and to
engage in insightful introspection or self analysis.
This is often seen with the frontal dysexecutive
syndrome. These patients do not fully appreciate
the changes in cognitive and psychological functioning
that significant others are keenly aware of.
On the other hand, many patients
go through a phase of denial, where they minimize
their postconcussive problems and may present themselves
in the most favorable light. This is often the case
where patients have been inappropriately reassured
by medical personnel that they will be back to normal
within a relatively short period of time, or that
there is nothing to worry about, or that their symptoms
will gradually diminish with time and there is very
little that can be done to treat them. When they
continue to experience difficulty in cognitive functioning,
continue to have problems with pain, and are unable
to cope effectively, they experience cognitive dissonance
because of their belief that they should be improving.
They may deny or try to hide or minimize their difficulties
with the hope that it will just go away. There may
be embarrassment with regards to their cognitive
problems, irritability and emotional volatility.
These problems may often be obscured by the patient
telling others that they just dont feel well.
Most patients with head trauma symptomatology
experience memory problems. Impairments in memory
processing may be due to concussive injury or as
part of the spectrum of posttraumatic disorder or
depression. These patients simply forget how they
are doing from day to day. They may be experiencing
a multiplicity of problems, but are unable to retrieve
this information during the time spent with the
health care provider. This may lead to the impression
that a given patient is not experiencing any significant
problems because they have not been able to adequately
remember the instances of cognitive dysfunctioning
or emotional overreactivity on a day to day basis.
It is for these reasons that it is
crucial to interview significant others or acquaintances
who have known the patient for some time before
the injury and have been in regular contact with
the patient following the injury. Where possible,
these friends and family members should have had
routine contact with the patient before the injury
and be able to describe their premorbid behavior.
These individuals will be able to document any changes
that have taken place by way of their regular interactions
with the patient. This collateral information is
often more accurate than information given by the
patient. The clinician should be careful to ask
about physical, cognitive and psychological functioning.
The most important issue to establish is whether
or not the significant other or acquaintance has
observed changes in the patients behavior following
the traumatic event.
A review of the patients physical
functioning from someone who is around the patient
on a daily basis can provide valuable information
regarding the frequency, intensity, and duration
of complaints. It is important to ask about changes
in the patients sense of smell and taste, since
there is often a loss or partial loss of olfactory
processes. This is often an overlooked symptom in
the mild to moderate head injury population. Information
should be gathered as to any complaints the patient
may be making regarding more subtle changes in functioning
such as sensitivity to bright light (sunlight or
night driving), the sensation of obscurity to their
visual acuity, ringing in the ears, intolerance
to noise or distractions during active concentration,
problems with coordination and tactile dexterity,
poor proprioception, and sensation. Review of the
patients pain behavior is essential in understanding
the factors that may be influencing the experience
of pain.
During a review of the patients cognitive
functioning, the clinician should ask about situational
manifestations of cognitive problems. The clinician
needs to know how the patient is functioning across
different situations and within a variety of environments.
It is important to know if the patients cognitive
changes are obvious to others and whether or not
the patient is relying on others to compensate for
his cognitive difficulties.
Primary care group members should
be asked about the patients flow of thinking including
speed of information processing, attention and concentration.
The clinician should try to ascertain whether the
patient is able to maintain and sustain attention
and concentration and if there is distractibility.
Memory processing should be thoroughly evaluated
to establish a pattern of memory problems that is
specific to that patient. It is not enough to just
document the presence or absence of memory problems.
It is also important to review the patients problem
solving abilities, organizational skills, reasoning,
the ability to perform sequential activities and
make schedules and plan ahead. Mental arithmetic
reasoning should be asked about regarding the patients
ability to keep up with finances, make change, and
estimate necessary everyday calculations. The clinician
should ask about the patients ability to express
themselves, word finding difficulties, losing their
train of thought and the style of speech. The patients
comprehension and receptive language abilities should
also be reviewed including reading comprehension,
the ability to follow TV programs, and how well
the patient understands and responds to others.
Perhaps the most important reason
for obtaining collateral information is to document
and describe the changes in psychological functioning.
Head trauma patients typically are better historians
with respect to their physical functioning, but
have more difficulty describing changes in themselves.
Individuals who know the patient well are often
able to notice changes in mood and affect more readily
than the patient. It is important to know how the
patient is responding to stress. The clinician should
determine whether the patient is more irritable,
is less patient with others, has low frustration
tolerance and whether there have been episodes of
emotional volatility. Questions should also be asked
about frontal lobe behavior, especially increased
passivity or aggressivity. Routine questions should
also be included to asses other areas of psychological
functioning in consideration of secondary psychological
problems such as anxiety or depression.
DIAGNOSTIC EVALUATION
Based on the above findings, provisional
ideas begin to develop. In the course of the time
based evaluation these may change. We have found that
a multi-axial schema is critical taking into account
an amplification of DSM 4 psychiatrically and an equivalent
schema neurologically. These are reflected below under
two major sections - neurologic neuropsychiatric.
This example is of a prototype patient with CHIT.
The complexity of all these elements in this way can
be perceived.
DIAGNOSIS
Evaluation Based on the above findings,
the following provisional ideas seem appropriate.
|
PREDOMINANT DIAGNOSIS |
Closed head injury of transient kind
(CHIT)
Mixed elements:
Post traumatic syndrome, Post concussional syndrome
Possible contrecoup injury with frontal lobe features
(residual focal)
Secondary sexual dysfunction BR> Secondary Pain syndrome predominantly hips
Tinnitus chronically
Abnormal EEG with right lateral temporal structural
abnormality
Headache and dizziness both improving
Obesity |
|
NEUROLOGIC LABEL: |
|
1n |
Neurologic overview |
CHIT with PTS, PCS, Focal syndrome |
1s |
Seizure Classification |
possible minor temporal lobe features:
structural on EEG and clinically correlates with
tinnitus? and headache? |
1m |
Movement disorder |
no evidence at this time |
1s |
Dyssomnia |
intermittent initial insomnia (mild,
secondary to psychological elements) |
1h |
Higher cortical elements |
high functioning individual previously;
now Significant organizational - integration impairment
with frontal lobe elements |
1p |
Perceptual distortions |
tinnitus - chronic persistent since
accident. |
1h |
Pain syndrome |
headaches when tired |
1 g |
General neurologic |
CHIT |
1pn |
RELEVANT MEDICAL CONDITIONS |
no evidence at this time |
1fn |
Family history |
No neurologic family history |
2 l |
Learning style |
No evidence of pre-existing learning
disability |
2n |
Premorbid Intelligence: |
Normal range. |
3p |
Physical condition |
As per examination, main complaints,
social history |
3n |
Links of Neurologic events to presentation |
Probably significant. Dynamically
different coping styles exist. Organically different
compensations for deficits occur. |
3 c |
Cerebral Localization |
Temporolimbic phenomena not triggered
or mobilized by hallucinogen or stimulant use |
4 |
Special investigations |
as listed above |
4e |
Electroencephalographic |
sleep and wake EEG 1993 slightly
abnormal with bitemporal spiking ambulatory EEG
right lateral temporal |
4n |
Neuroradiologic |
tests as above MRI 1995 apparently
normal |
|
Other test features: |
apparently normal blood tests |
5n |
Course: |
|
|
Deteriorating or not |
Non-deteriorating |
|
Chronicity degree |
Not chronic |
6n |
Neuropharmacologic Response |
Carbamazepine has helped the explosive
anger but not assisted with the amotivation and
dysexecutive phenomena |
|
Compliance |
By history, expected to be reasonable |
7n |
Neurologic onset age |
since head injury on 4/7/97 |
Prototype example of CHIT patient diagnostically
(neuropsychiatric)
|
NEUROPSYCHIATRIC FRAMEWORK: |
|
|
Descriptive Psychopathology: |
atypical depression and anxiety confusional
episodes |
1 fp |
Family history |
family history negative except for
one aunt |
2 a |
Addictive disorder |
no evidence of alcoholism or drug
dependency or abuse |
2p |
Personality Elements: |
No relevant characterologic deficits.
Anankastic personality features accentuated post-injury
possibly as coping mechanism |
3p |
Relevant Physical disorders: |
conditions above are major components
to current psychopathologic manifestations |
|
Symptomatic relevance: |
major components to current psychopathologic
manifestations$ |
|
Relatedness to illness: |
significant |
4p |
Psychosocial components: |
&&&&& &&&&&&&&&
|
|
Family support |
reasonable |
|
Patient Strengths |
self-perceived: "trying to get
better" |
|
Predisposing factors: |
Constitutional diathesis. Environmental
experience. Aggravating cerebral trauma |
|
Precipitating stressors: |
No significant new stressors. Chronic
difficulties linked with impaired function |
|
Perpetuating factors: |
Predisposing elements |
|
Problem areas |
listed above |
5p |
Functionality: |
&&&& &&&&&&&&&& |
|
Maximum expected in future: |
limited |
|
Highest functionality before insult: |
reasonable: normal days work |
|
Functionality currently: |
limited by deficits and unable to
work though does daily chor$ |
6p |
Psychopharmacologic: |
|
|
Psychopharmacologic Responsiveness: |
as listed above: buspirone has helped
irritability and concentration |
|
Psychopharmacologic Compliance: |
historically reasonable |
7p |
Age of onset of major psychopathology: |
since head injury on 4/7/97 |
Conclusions:
Evaluations of the closed head injuries
of transient kind are therefore areas for fertile
research as what was previously regarded as irrelevant
are now realized to be significant. Many patients
with CHITs have not been regarded as ill when, in
actuality, they were so impaired that their day to
day functioning was that interfered with. Only by
detailed, time-based, cross-sectional evaluations
can one develop enough longitudinal perspective to
be able to manage the patient appropriately and to
appreciate better their strengths and their limitations.
Certain pointers on management are dealt with in a
later chapter (Neppe, Goodwin, 1998 in press).
References
Alves, W., Macciocchi, S.N., &
Barth, J.T. (1993). Postconcussive symptoms after
uncomplicated mild head injury. Journal of Head
Trauma Rehabilitation, 8 (3), 48-59.
Babikian VL, Wolfe, N, Linn, R, Knoefel,
JE , Albert, ML. (1990 ). Cognitive changes in patients
with multiple cerebral infarcts. Stroke; 21
(7): 1013-8
Binder, L.M. (1986). Persisting Symptoms
After Mild Head Injury: A Review of the Postconcussive
Syndrome. Journal of Clinical and Experimental
Neuropsychology, 8 (4), 323-345.
Blumer D, Neppe, VM (In press) Atypical
spells in the non-epileptic and psychopathology: a
classification, In: Blumer D, eds. Psychiatric
Aspects of Epilepsy. Washington, DC: APA Press.
Brown, S.J., Fann, J.R., & Grant,
I. (1994). Postconcussional disorder: time to acknowledge
a common source of neurobehavioral morbidity. Journal
of Neuropsychiatry and Clinical Neuroscience,
6 (1), 15-22.
Cohadon, F., Richer, E., & Castel,
J.P. (1991). Head Injuries: incidence and outcome.
Journal of the Neurological Sciences, 103,
27-31.
Colohan, A.R.T., Dacey, R.G., Alves,
W.M., Rimel, R.W., Jane, J.A. (1986). Neurologic and
neurosurgical implications of mild head injury. Journal
of Head Trauma Rehabilitation, 1 (2), 13-21.
Davidoff, D.A., Kessler, H.R., Laibstain,
D.F., & Mark, V.H. (1988). Neurobehavioral Sequelae
of Minor Head Injury: A Consideration of Post-Concussive
Syndrome Versus Post-Traumatic Stress. Cognitive
Rehabilitation, March/April, 8-13.
Esselman, P.C., & Uomoto, J.M.
(1995). Classification of the spectrum of mild traumatic
brain injury. Brain Injury, 9 (4), 417-424.
Ferrell BA, Ferrell, BR, Osterweil,
D. (1990). Pain in the nursing home. J Am Geriatr
Soc. 1990; 38 (4): 409-14
Folstein MF, Folstein, SE , McHugh,
PR (1975). "Mini-mental state: A practical method
for grading the cognitive state of patients for the
clinician. J Psychiatr Res 12 (3): 189-98
Gagnon M, Letenneur, L, Dartigues,
JF, Commenges, D, Orgogozo, JM, Barberger, GP, Alperovitch,
A, Decamps, A, Salamon, R. (1990). Validity of the
Mini-Mental State examination as a screening instrument
for cognitive impairment and dementia in French elderly
community residents. Neuroepidemiology; 9 (3):
143-50
Galasko D, Klauber, MR, Hofstetter,
CR, Salmon, DP, Lasker, B, Thal, LJ (1990). The Mini-Mental
State Examination in the early diagnosis of Alzheimer's
disease. Arch Neurol; 47 (1): 49-52
Goethe, K.E., & Levin, H.S. (1984).
Behavioral Manifestations During the Early and Long-Term
Stages of Recovery After Closed Head Injury. Psychiatric
Annals, 14 (7), 540-546.
Goodwin, G.T. (1989, 3rd
Quarter). Minor Head Injury: Are there persisting
symptoms after recovery?. The Institute Review,
p. 1.
Gouvier, W.D., Cubic, B., Jones, G.,
Brantley, P., & Cutlip, Q. (1992). Postconcussion
Symptoms and Daily Stress in Normal and Head Injury
College Populations. Archives of Clinical Neuropsychology,
7, 193-211.
Gurland BJ, Cote, LJ, Cross, PS, Toner,
JA (1987). The assessment of cognitive function in
the elderly. Clinics in Geriatric Medicine;
3 (1 ): 53-63
Kay, T., Harrington, D.E., Adams. R.,
Anderson, T., Berrol, S., Cicerone, K., Dahlberg,
C., Gerber, D., Goka, R., Harley, P., Hilt, J., Horn,
L., Lehmkuhl, D., Malec, J. (1993). Definition of
mild traumatic brain injury. Journal of Head Trauma
Rehabilitation, 8 (3), 86-87.
Kibby, M.Y., & Long, C.J. (1996).
Minor Head Injury: attempts at clarifying the confusion.
Brain Injury, 10 (3), 159-186.
Lowdon, I.M.R., Briggs, M., & Cockin,
J. (1989). Post-concussional symptoms following minor
head injury. Injury, 20, 193-194
McAllister, T.W. (1992). Neuropsychiatric
sequelae of head injuries. Psychiatric Clinics
of North America, 15 (2), 395-415.
Middleboe, T., Birket-Smith, M., Anderson,
H., & Friis, M.L. (1992). Personality traits inpatients
with postconcussional sequelae. Journal of Personality
Disorders, 6(3), 246-255.
Miller, L. (1992). Neuropsychology,
personality, and substance abuse in the head injury
case: Clinical and forensic issues. International
Journal of Law & Psychiatry, 15 (3), 303-316.
Naugle RI , Kawczak, K (1989). Limitations
of the Mini-Mental State Examination. Cleve Clin
J Med; 56 (3): 277-81.
Neppe VM. (1982). Olfactory hallucinations
in the subjective paranormal experient. Proceedings,
Centenary SPR/Jubilee PA Convention, Cambridge, England;
2 1-17.
Neppe VM (1983 A) The Psychology
of Déjà Vu: Have I been Here Before?
. Johannesburg: Witwatersrand University Press.
1-277 & I-XLV
Neppe VM: (1983 B). The olfactory hallucination
in the psychic, In: Roll WG, Beloff, J, White, RA,
eds. Research in Parapsychology 1982. Metuchen,
NJ.: Scarecrow Press;: 234-237
Neppe VM: (1984A). The management of
psychoses associated with complex partial seizures,
In: Carlile JB, eds. Update on Psychiatric Management.
Durban: MASA;: 122-127.
Neppe VM: (1984B). Phenomenology and
the temporal lobe, In: Roll WG, Beloff, J, White,
RA, eds. Research in Parapsychology 1983. Metuchen,
NJ.: Scarecrow Press; 1984B
Neppe VM: (1984C). The relevance of
the temporal lobe to anomalous subjective experience,
In: White RA, Broughton, RS, eds. Research in Parapsychology
1983. Metuchen, NJ.: Scarecrow Press;: 7-10
Neppe V, Chen, A, Davis, JT, Sawchuk,
K, Geist, M. (1992) The application of the Screening
Cerebral Assessment of Neppe (BROCAS SCAN) to a neuropsychiatric
population. J Neuropsychiatry Clin Neurosci.;
4 (1): 85-94.
Neppe VM, Goodwin G, (1998, in press)
Integration of the evaluation and management of the
transient closed head injury patient - some directions.
Neppe VM, Tucker, GJ. (1988 A). Modern
perspectives on epilepsy in relation to psychiatry:
classification and evaluation. Hosp Community Psychiatry.
39 (3): 263-71
Neppe VM, Tucker, GJ. (1988 B). Modern
perspectives on epilepsy in relation to psychiatry:
behavioral disturbances of epilepsy. Hosp Community
Psychiatry.; 39 (4): 389-396.
Neppe VM, Tucker, GJ: (1989). Atypical,
unusual and cultural psychoses, In: Kaplan HI, Sadock,
BJ, eds. Comprehensive Textbook of Psychiatry,
Fifth Edition. Baltimore: Williams and Wilkins;:
842-852, Ch 10.
Neppe VM, Tucker, GJ. (1992).: Neuropsychiatric
aspects of seizure disorders, In: Yudofsky SC, Hales
, RE, eds. Textbook of Neuropsychiatry. Washington,
D.C.: American Psychiatric Press; : 397-426.
Neppe VM, Tucker, GJ. (1994). Neuropsychiatric
aspects of epilepsy and atypical spells, In: Yudofsky
SC, Hales, RE, eds. Synopsis of Textbook of Neuropsychiatry.
Washington, D.C.: American Psychiatric Press;: 397-426.
O Hara, C. (1988). Emotional Adjustment
Following Minor Head Injury. Cognitive Rehabilitation,
March/April, 26-33.
Overall JC, Gorham, DP. (1962). The
Brief Psychiatric Rating Scale. Psychol Rep;
(10 ): 799-802.
Overall JE, Beller, SA. (1984). The
Brief Psychiatric Rating Scale (BPRS) in geropsychiatric
research: I. Factor structure on an inpatient unit.
J Gerontol; 39 (2): 187-93.
Schwamm LH, Van Dyke, C, Kiernan, RJ,
Merrin, EL, Mueller, J (1987). The Neurobehavioral
Cognitive Status Examination: comparison with the
Cognitive Capacity Screening Examination and the Mini-Mental
State Examination in a neurosurgical population. Ann
Intern Med. 107 (4): 486-91.
Thomsen, I.V. (1974). The patient with
severe head injury and his family. Scandinavian
Journal of Rehabilitative Medicine, 6, 180-183.
Tucker GJ, Neppe, VM. (1988). Neurology
and psychiatry. Gen Hosp Psychiatry. 10 (1):
24-33.
Tucker GJ, Neppe, VM: (1991) Neurologic
and neuropsychiatric assessment of brain injury, In:
Doerr HO, Carlin, AS, eds. Forensic Neuropsychology:
Legal and scientific basis. New York: Guilford;:
70-85.
Tucker GJ, Neppe, VM: (1994). Seizures,
1. In: Silver JM, Yudofsky, SC, Hales, RE, eds. Neuropsychiatry
of Traumatic Brain Injury. Washington , D.C.:
American Psychiatric Press;: Ch 16, 513-532.
TABLE A
Examples of scoring of BROCAS SCAN
scores in normals (Nl) and closed head injured patients
(HI).
PATIENT |
Nl |
HI |
Comments on the
HI patient |
CORE SCORE |
4 |
17 |
commonly outside
normal range but not invariably |
FINE SCORE |
1 |
3 |
focality may change
fine score markedly |
TOTAL SCORE |
7 |
20 |
usually falls in
the mild cognitively impaired range |
MBPRS SCORE 18 |
2 |
6 |
usually mild psychopathology |
MBPRS SCORE COP
|
0 |
2 |
some concentration
difficulty |
MBPRS FRUSTRATION
Score |
0 |
2 |
some frustration
common |
MBPRS SCORE TOTAL |
2 |
10 |
Sum of above |
RATERS VALIDITY
SCORE |
0 |
0 |
Usually valid |
SUBJECTIVE VALIDITY
Score |
0 |
1 |
Concentration noted
defective |
MBPRS VALIDITY
SCORE |
0 |
0 |
Invariably no rater
dilemmas |
|
SCAN ITEMS |
N |
CHIT |
|
r |
Spontaneous recall
|
1 |
3 |
( usually 0-2) |
r |
Cued recognition
|
0 |
1 |
( usually 0) |
o |
Orientation |
0 |
0 |
( usually 0-1) |
o |
Organization |
1 |
2 |
( usually 0-2) |
c |
Concentration |
1 |
3 |
( usually 0-2) |
c |
Calculation |
1 |
2 |
( usually 0-2) |
a |
Apraxia |
2 |
4 |
( usually 0-4) |
a |
Agnosia |
0 |
1 |
( usually 0-2) |
s |
Speech |
1 |
1 |
( usually 0) |
s |
Sensory Motor Reflex.
|
0 |
0 |
( usually 0) |
TABLE B
Examples of interpretation of scoring
of BROCAS SCAN scores in normals (Nl) and closed head
injured patients (HI).
Memory as reflected by recall and
retention:
The patient did not perseverate.
Mild verbal but no obvious visual difficulties
were present on spontaneous recall or cued recognition.
Recall and recognition are inappropriate
for age and intelligence
Normal recall / recognition implies
adequate eventual registration (measured, in part,
more acutely by concentration) and retention of information.
In this instance, impaired recall with
reasonable recognition may imply difficulty with organizing
retained information.
Orientation for time, space and passage
of time was within normal limits.
(Passage of time is selectively impaired
in certain psychoses; spatial impairment may imply
organicity)
Organization as reflected by abstraction
of proverbs and ability to coherently put elements
together appears within normal limits taking cultural
elements into account.
The measure in this instance unfortunately
has more cultural elements than any other part of
this test.
Communication skills were unimpaired.
Concentration: The patient was able
to concentrate but only poorly and outside normal
limits.
Calculation: Simple calculation skills
as measured by subtraction appear appropriate for
the overall profile. (Calculation difficulties may
reflect specific impairments including pre-existing
learning difficulties and focal impairments of either
parietal or frontal lobe or generalized concentration
disturbance)
Praxic skills pertaining, inter alia,
to copying, construction and sequential movements
scored at the upper limits of normal. (Many normal
people have significant difficulties with tests of
complex sequences. Separation of the motor impairment
from the perceptual gnosic difficulties is at times
very difficult clinically.)
Gnosic elements testing both perceptual
modality (auditory, visual, tactile) and organization
of information is within normal limits. (The test
involves relatively simple tasks so abnormality reflects
significant pathology or limited attention to detail.)
Speech pronunciation was normal
Comprehension of complex English phrases
was appropriate.
Naming of body parts, colors and objects
appear within normal limits.
Speech generation as reflected by spontaneous
word generation using stipulated criteria was normal.
(Tests broadly cover the spectrum of receptive and
expressive speech.)
Sensory-motor-reflex elements: No evidence
for impaired gait or posturing,
The patient has no obvious motor weakness
in the upper limbs with nor arm sway and no flexor-extensor
weakness and the lower limb strength appears adequate.
Motor tone appears adequate.
No tremor occurs on either side either
at rest or on writing.
No obvious sensory loss exists.
No primitive reflexes were demonstrated
by this test.
Because broad elements only are
tested this is no substitute for a detailed neurologic
examination.
TABLE C
Patient performance on the NMBPRS scoring
(based on the HI example of Table E)
The patient scored 6 on the first 18
items averaging 0.3 reflecting mild distress throughout.
Particular loading occurred on anxiety items.
The single item frustration score is
2.
The score is 2 on the three COP items
(concentration, orientation, perplexity) for higher
cerebral function.
The total score on the MBPRS is 10;
this is a composite of the above 22 items.
The raters validity score is 0 (0 is
the highest level of validity) and subjectively 1
(concentration)
The Overall Clinical Impression Score
is 1 (this item is the raters overall impression of
psychopathology)
Table D
STRAW EXAMINATION FOR INVOLUNTARY MOVEMENTS
This is a timed and severity neurologic
evaluation for involuntary movements.
AT REST
S - SITTING AND STANDING - out of 50
; SCORED 0
ACTIVATION PROCEDURES; SCORED
T - TAPPING WITH RIGHT AND LEFT HAND
- out of 10; SCORED 0
R - READING - out of 10; SCORED 0
A - ARMS OUTSTRETCHED - out of 10; SCORED
0
W - WRITING - out of 10; SCORED 0
W - WALKING - out of 10; SCORED 0
STRAW TIMING SCORE TOTAL IS 0
SEVERITY score is 0
COMBINED SEVERITY TIMING STRAW SCORE
= TIMING * SEVERITY / 10 = 0
When scores increase above zero movements
may be voluntary and related to anxiety.