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Traumatic Brain Injury and other Dementias

Stephen M. Raffle, M.D.

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Curriculum Vitae

By Stephen M. Raffle, M.D.

Traumatic Brain Injury (TBI) is sometimes manifested in mental injuries, changes in behavior, changes in mental functioning, impairments in judgment including the ability to change or make a Will or Trust, enter into a contract or practice a profession. It is interesting to note that Board-Certification in Psychiatry is by the American Board of Psychiatry and Neurology. The two disciplines are sometimes closely intertwined.

My qualifications result from early in my medical training: in my residency and continuing thereafter, I have been interested in learning about neurological disorders which cause psychopathology. From 1971-1975 I was the neuropsychiatric consultant to the neurological rehabilitation unit at Herrick Hospital in Berkeley, California, and thereafter I treated mental disorders of patients who had neurological diseases. Years later, as part of my practice I was a neuropsychiatrist at Kentfield Rehabilitation Hospital, a facility which mainly treats neurologically impaired patients. (Dementias may not always be the result of a traumatic neurological injury; take the case of dementia associated with aging, a common concern in assessing testamentary capacity.)

Assessment of the impact of traumatic brain injury (TBI) on an individual’s functioning, for forensic purposes, usually requires a multidisciplinary team which would include a psychiatrist who is experienced with the evaluation and treatment of TBI, a neurologist with similar experience, and a neuropsychologist who also is clinically involved in the evaluation and treatment of TBI. No one of the three disciplines is, in my opinion, sufficient to perform a comprehensive workup of this complicated malady. TBIs and other dementias virtually always have an emotional component. The component either has to do with the question of secondary gain if there is a litigated situation or the emotional impact of the injury, usually a life-changing injury, on the individual.

By the time the person with the TBI comes to the attention of the forensic team, the individual usually has had a thorough medical workup with various opinions given about causation and prognosis. Occasionally, the workup is incomplete and the forensic team is able to add important dimensions to understanding the individual’s problems, their causes, and the prognosis, as well as to the need for treatment.

A word about neuropsychological assessment, I believe, is in order here. Different neuropsychologists have different opinions as to the reliability and meaning of the results obtained on various neuropsychological tests. For example, one of the most popular neuropsychological batteries, the Halstead-Reitan battery, includes the Tactual Performance Test (TPT). One scholar of neuropsychological assessment, Muriel Lezak, considers the TPT to have several drawbacks, which are so substantial that she only uses the test under special circumstances (such as needing to assess tactile learning in a blind or near-blind person). She believes that the test consumes too much time and that it is usually administered by a technician rather than by the clinician responsible for deciding which test to give. Administration of the test creates psychological distress and the results are, in fact, obtainable from other tests.

Neuropsychological testing is helpful in providing some understanding regarding a person’s ability to perform standardized testing and can give some idea of how the person is functioning when compared to a statistically normative population. Also, because neuropsychological testing so frequently is given to TBI patients and patients with other dementias, psychiatrists and neurologists must have more than a passing familiarity with the tests to be able to understand the raw data as well as the neuropsychologist’s opinions and conclusions.  A psychiatrist who is conversant with neuropsychological tests is able to provide a better explanation of his findings to a jury as to the basis of his opinions.

Ultimately, a diagnosis of TBI or other dementias, and the emotional impact, need for treatment, and prognosis, is a clinical one and cannot be made solely on the basis of a testing protocol.

Predicting prognosis on the basis of the original insult to the brain is difficult. I have examined many patients with traumatic brain injury and other dementias and have found their progress to be quite substantial even when the original physical insult was significant, for instance,when the patient was comatose for 72 hours before awakening. The rate of improvement is an important predictor of outcome as well as the severity of injury. Although most clinicians use 18 months post-injury as the beginning of the recovery plateau, a federally funded study found modest, though measurable, improvement in brain injured people years later.

The impact of TBI and other dementias on a person’s competency is always an issue in such an assessment. This should be borne in mind by the evaluators. Also impacting the assessment of the case is the historical reliability of the affected person. It is well known that individuals with these disorders confabulate, or make up, a history explaining why they are acting in a particular way. This is done because the person does not remember, not because he is intentionally trying to deceive an examiner. The confabulation is a construct invented to fill a void in their memory, is common in such patients, and in my opinion does not constitute malingering. On other occasions, however, I have examined an individual who has suffered a TBI and at a later time tried to appear as if the symptoms persisted when in fact they did not. Awareness of this possibility is an essential part of this evaluation.

You might find it interesting to read the Case Study: “Head Injury or Schizophrenia?”

DISCLAIMER: The information provided on this website does not constitute legal or medical advice. Readers should consult with their own legal counsel or physician for the most current information and to obtain professional legal advice or medical advice before acting on any of the information presented.

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