Masquerades of Brain Injury: A 4-part Series


The Journal Of Controversial Medical Claims

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Martelli, M.F., Zasler, N.D., Nicholson, K. and Hart, R.P. (2001). Masquerades of Brain Injury. Part I: Chronic pain and traumatic brain injury. The Journal of Controversial Medical Claims, 8, 2, 1-8.

Three reviews are presented which support the conclusion that pain and pain related symptomatology can and often do produce impaired performances on neuropsychological tests, especially measures assessing attentional capacity, processing speed, psychomotor speed, and executive functions. Consistent neurophysiologic findings support these conclusions derived from several lines of experimental and clinical research in humans and animals. Notably, chronic pain often does not cause cognitive impairments; when present, cognitive changes are likely reactive and reversible and symptoms associated with chronic pain, such as sleep disturbance, depression, medication use and premorbid coping vulnerabilities, likely play a predominant role in mediating the impact of chronic pain on cognitive functioning. Nonetheless, available findings indicate that chronic pain and its concomitants represent a source of performance variance and that caution is warranted in interpreting decrements in neuropsychological test scores as signs of neurologic sequelae of brain disease or injury in patients with chronic pain. Recommendations are offered which might help minimize the confounding effects of chronic pain on neuropsychological test performance.

Martelli, M.F., Zasler, N.D., Hart, R.P., Nicholson, K., and Heilbronner, R.L. (2001). Masquerades of Brain Injury. Part II: Response Bias in Medicolegal Examinees and Examiners. The Journal of Controversial Medical Claims, 8, 3, 13-23.

Neuropsychological and neuromedical assessments frequently provide the primary evidence of neurologic impairment following mild and moderate brain injury. The validity of these assessments, however, depends on the cooperation and motivation of the client. Unfortunately, litigation and adversarial insurance situations introduce a situation in which financial and other incentives often influence performance, and not just the behavior of examinees. This paper reviews neuropsychological and neuromedical procedures for assessing response bias during acquired brain injury (ABI) evaluations. In order to minimize limitations of these instruments and their use, a multiaxial model for conceptualizing and assessing motivation and response bias which incorporates a wide array of findings involving integration of interview, history, behavioral observation, and commonly employed instruments and procedures that are derived from neuropsychology, physiatric medicine, psychology, psychiatry, and neurology, is suggested. Recommendations for enhancing motivation, assessing response bias, and increasing efficiency, utility, and ecological validity of ABI assessments are offered.

Martelli, M.F., Zasler, N.D., Nicholson, K., Hart, R.P. and Heilbronner, R.L. (2002). Masquerades of Brain Injury. Part III: Critical Examination of Symptom Validity Testing and Diagnostic Realities in Assessment. The Journal of Controversial Medical Claims, 9, 2, 19-21.

Especially in medicolegal evaluations, assessment of response bias is critical to ensuring accurate determination of symptom source or diagnosis and thereby appropriate decisions on treatment and compensation, and the prevention of iatrogenic complications. Unfortunately, the recent increase in attention to response bias assessment has too often been accompanied by overzealous application of poorly validated detection procedures and questionably strong opinions regarding malingering. Although these instruments and procedures vary in terms of empirical support, all have identifiable limitations. This paper reviews these limitations, concludes that response bias detection methodology is still developing. The review of shortcomings underscores the need for caution in interpretation, the importance of integrating multiple data sources, including behavioral observations, interview data, test results, medical workups, historical and collateral sources of information, as well as specific measures of effort and response bias, a motivational assessment model that conceptualizes effort on a continuum and is dependent on multiple strategies and measures that are not easily conveyed, and the need for further research.

Heilbronner, R.L., Martelli, M.F., Nicholson, K. & Zasler, N.D. (2002). Masquerades of Brain Injury. Part IV: Functional Disorders. The Journal of Controversial Medical Claims, 9, 3, 1-7.

Patients presenting with significant functional disabilities after seemingly mild injuries represent complex assessment challenges for physiatrists, neuropsychologists, and other rehabilitation professionals. At a minimum, clinicians must have an understanding of the pathophysiology and neurobehavioral sequelae associated with MTBI. They must also have a familiarity with other more 'traditional' psychiatric disorders to assist in differential diagnosis, as well as admixtures. Data from neuropsychological testing, in combination with other objective and subjective psychological data (e.g., a thorough history, clinical interview, review of school records, reports of collaterals, etc.) and information from other medical disciplines, promises the greatest method for differentiating between premorbid factors and post morbid residua secondary to an accident/injury. Many cases of mild head trauma are not simple or clear-cut, but consideration of some of the other functional disorders mentioned in this paper may lead to a greater understanding of some of the complexities involved in differential diagnosis and provide a better foundation for rendering opinions about the causes, needed treatment, and eventual prognosis of symptoms following an accident that purportedly involves MTBI.

Martelli, M. F., Bender, M. C., Nicholson, K., & Zasler, N. D. (2002). Masquerades of brain injury Part V: Pre-injury factors affecting disability following traumatic brain injury. Journal of Controversial Medical Claims, 9(4), 1-7.

Variability in outcome following TBI is more often the rule than the exception, and this phenomenon has not been well understood. There is increasing appreciation, however, that such premorbid vulnerability factors such as psychiatric status, substance abuse, and sexual abuse histories can exert a very strong influence on neuropsychological functioning and ability to cope with and adapt to demands and challenges associated with TBI. Increasingly, researchers and clinicians are recognizing the importance of evaluating the collective influence and interaction of psychological, social and cultural factors with biological factors in explaining disease and its variable expression in terms of health care outcomes. A biopsychosocial model, and empirical support are described which represent a more integrated and through understanding of the effects of brain injury and reveals better pathways for explaining causality and apportionment than ones describing simpler trauma dose response relationships.