The Forensic Evaluation of Traumatic Brain Injury: A Handbook for Clinicians and Attorneys, Second Edition

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s e cond e di t ion

The

Forensic evaluation of Tr aum atic Br ain Injury A H A NDBOOK for C linici a ns a nd At tor neys

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s e cond e di t ion

The

Forensic evaluation of Tr aum atic Br ain Injury A H A NDBOOK for C linici a ns a nd At tor neys Edited by

Gregory J. Murrey Donald Starzinski

Boca Raton London New York

CRC Press is an imprint of the Taylor & Francis Group, an informa business

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CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487‑2742 © 2008 by Taylor & Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, an Informa business No claim to original U.S. Government works Printed in the United States of America on acid‑free paper 10 9 8 7 6 5 4 3 2 1 International Standard Book Number‑13: 978‑0‑8493‑9075‑3 (Hardcover) This book contains information obtained from authentic and highly regarded sources. Reprinted material is quoted with permission, and sources are indicated. A wide variety of references are listed. Reasonable efforts have been made to publish reliable data and information, but the author and the publisher cannot assume responsibility for the validity of all materials or for the conse‑ quences of their use. No part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers. For permission to photocopy or use material electronically from this work, please access www. copyright.com (http://www.copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC) 222 Rosewood Drive, Danvers, MA 01923, 978‑750‑8400. CCC is a not‑for‑profit organization that provides licenses and registration for a variety of users. For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged. Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Library of Congress Cataloging‑in‑Publication Data The forensic evaluation of traumatic brain injury : a handbook for clinicians and attorneys / Gregory J. Murrey and Donald Starzinski, editors. ‑‑ 2nd ed. p. ; cm. “A CRC title.” Includes bibliographical references and index. ISBN 978‑0‑8493‑9075‑3 (hardcover : alk. paper) 1. Brain damage‑‑Diagnosis. 2. Forensic neuropsychology. 3. Forensic psychology. 4. Neurologic examination. 5. Mental status examination. I. Murrey, Gregory J. (Gregory Jay), 1960‑ II. Starzinski, Donald. [DNLM: 1. Brain Injuries‑‑diagnosis‑‑Handbooks. 2. Expert Testimony‑‑Handbooks. 3. Forensic Medicine‑‑methods‑‑Handbooks. 4. Neuropsychological Tests‑‑Handbooks. WL 39 F711 2008] RC387.5.F66 2008 614’.1‑‑dc22

2007024064

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Contents List of Tables and Figures..........................................................................................ix Preface.......................................................................................................................xi Acknowledgments................................................................................................... xiii About the Editors...................................................................................................... xv Contributors............................................................................................................xvii Chapter 1

Overview of Traumatic Brain Injury: Issues in the Forensic Assessment..........................................................................................1 Gregory J. Murrey

Chapter 2

The Forensic Neurological Assessment of Traumatic Brain Injury.......................................................................................25 Donald T. Starzinski

Chapter 3

The Forensic Neuropsychiatric Assessment of Traumatic Brain Injury....................................................................................... 43 Robert Granacher

Chapter 4

The Forensic Neuropsychological Evaluation and Report................ 67 Henry V. Soper and Arthur MacNeill Horton, Jr.

Chapter 5

Neuropsychological and Psychological Rehabilitation after TBI.................................................................................................... 91 Fofi Constantinidou

Chapter 6

Legal Issues in Expert Testimony................................................... 119 Daniel A. Bronstein

Chapter 7

The Forensic Examiner as an Expert Witness: What You Need to Know to Be a Credible Witness in an Adversarial Setting........ 141 Joseph A. Davis, Gregory J. Murrey, and Daniel A. Bronstein



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Appendix A Model Outline for the Assessment of Mild Traumatic Brain Injury............................................................................................... 157 Appendix B Select Issues in the Forensic Assessment of Traumatic Brain Injury with Key References from the Research Literature............. 163 Appendix C Listing of State Courts Using Federal Rule 702 or the Daubert Standard........................................................................... 167 Index....................................................................................................................... 169

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Dedication This book is dedicated to Martha, Hope, and the boys.

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List of Tables and Figures Tables Table 1.1 Table 1.2 Table 1.3 Table 1.4 Table 1.5 Table 1.6 Table 2.1 Table 2.2 Table 2.3 Table 2.4 Table 3.1 Table 3.2 Table 3.3 Table 3.4 Table 3.5 Table 3.6 Table 3.7 Table 4.1 Table 7.1 Table 7.2 Table 7.3

Glasgow Coma Scale.............................................................................3 Definition of Mild TBI — Head Injury Special Interest Group of the American Congress of Rehabilitation Medicine.........................4 Galveston Orientation and Amnesia Test (GOAT)...............................4 DSM-IV Research Criteria for Postconcussional Disorder...................7 DSM-IV Diagnoses and Criteria Commonly Used in TBI Cases...........8 Complaints and Symptoms in Mild TBI by Category........................ 18 Elements of Neurologic Diagnosis......................................................26 Elements of the Medical/Neurological History..................................26 Elements of the Neurologic Examination........................................... 27 Diagnostic Studies by Type.................................................................28 General Elements of the Neuropsychiatric History Following Brain Trauma.......................................................................................46 Common Elements of Neuropsychiatric Mental Status Examination........................................................................................ 48 Neurological Examination.................................................................. 50 Structural and Functional Brain Imaging during Neuropsychiatric Assessment............................................................. 52 Common Uses of Structural Brain Imaging....................................... 55 Common Uses of Functional Brain Imaging...................................... 58 Important Records to Review.............................................................. 61 Sample Outline of Sections for the Forensic Neuropsychological Report.................................................................84 Survey Results of Forensic Experts................................................... 143 Average Responses of Forensic Examiners to Specific Survey Questions........................................................................................... 144 Standard Background, Training, and Qualifications of a Forensic Neuropsychologist............................................................................. 147

Figures Figure 4.1 Figure 6.1 Figure 6.2 Figure 6.3 Figure 6.4

Behavior Observation Form................................................................84 Standard Format Template................................................................ 121 Old-Fashioned Courtroom................................................................ 132 Modern Courtroom........................................................................... 132 Ranking Measurement Tool.............................................................. 134

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Preface Over the past two decades, I have seen a drastic increase in the number of traumatic brain injury (TBI) cases that have ended up in the courtroom. As a clinical neuropsychologist who conducts evaluations of persons with suspected brain injuries, I have all too often found myself sitting in a courtroom trying to defend my professional opinion and decisions. I have discovered, along with my colleagues, that to be comfortable or at least confident in such an adversarial system, it is important to be knowledgeable in the entire assessment of TBI and the forensic process involved. Although there have been a myriad of publications on TBI and forensic neuropsychology, I could not find a text available to provide a medical and legal professional with a concise overview of the forensic assessment process and the issues in TBI. Finding such a need, I felt compelled to draw together a group of experts in the medical, neuropsychological, and legal professions to develop such a text. However, the text was not designed as a comprehensive work on forensic neuropsychology, neuropsychiatry, or even TBI, as there are many excellent authoritative texts available on these subjects. Instead, my colleagues and I have designed this test to provide both the clinician involved in forensic examinations and the legal professional involved in personal injury litigation or legal proceedings with a general overview of the issues and assessment process in TBI cases. Accordingly, the text begins with an overview of the key issues involved in the forensic assessment of TBI, including definitions and select medical diagnostic terminology that should be of particular interest to the forensic examiner and legal professional. Subsequent chapters provide an overview of the neurologic, neuropsychiatric, neuropsychological, and psychological forensic assessment process specific to brain injury cases. As part of the revisions to this text, additional chapters have been added, including a chapter on the neuropsychiatric evaluation performed by a clinical or forensic neuropsychiatrist. Although there is a clear overlap between the forensic neurological and neuropsychiatric assessments, there are distinct differences in focus and areas addressed between these two medical specialties and evaluations. Additional chapters expand on the topic of forensic testimony, and on the forensic examiner as an expert witness. Additionally, in the chapters on the forensic examiner as expert witness and expert witness testimony, such issues as qualifications and credibility of the forensic expert and admissibility of expert testimony in TBI cases are reviewed. These chapters will, of course, be of particular interest and concern to the forensic examiner in light of new court rulings and possible modifications to the admissibility of a given forensic examiner’s testimony. Finally, a chapter on neuropsychological rehabilitation issues after traumatic brain injury has been added. Although this chapter does not necessarily address the traumatic brain injury evaluation, it provides critical information for the forensic examiners and other professionals within the forensic setting with regard to rehabilitation treatments or services that may be beneficial to or required for persons xi

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who have suffered traumatic brain injuries. Such information may be critical in TBI litigation as the type of treatment (possibly ongoing) and duration thereof are often essential information within such cases. The contributors of this book have also attempted to provide clinically useful and practical tables and reference pages that can be used by forensic examiners and legal professionals involved in TBI cases. It is my hope as editor that this text will be a useful resource and overview for clinicians and legal professionals alike. Gregory J. Murrey Brainerd, Minnesota

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Acknowledgments This text would not have been possible without the dedication and diligence of Amanda Gangl and Arlene Jones, whose excellent organizational, technical writing, and proofreading skills were critical in its development.

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About the Editors Gregory J. Murrey, Ph.D., A.B.P.N., received his doctorate in clinical psychology from Washington State University and completed his specialty training in neuropsychology at Duke University Medical Center. He has been named Diplomate in Clinical Neuropsychology from the American Board of Professional Neuropsychology and also holds a Diplomate from the American Board of Forensic Examiners. He is currently on the faculty in the Graduate School of Psychology, Fielding Graduate School, and has served as the director of Neuropsychology and Neurobehavioral Services at the Minnesota Neurorehabilitation Hospital in Brainerd, Minnesota. He is also a consulting neuropsychologist at the Polinsky Medical Rehabilitation Center in Duluth, Minnesota, and at St. Josephs Medical Center in Brainerd, Minnesota. Dr. Murrey has published and presented widely in the area of traumatic brain injury and has served as an expert witness in forensic neuropsychology in a myriad of civil and criminal cases related to traumatic brain injury. Donald T. Starzinski, M.D., Ph.D., has had the privilege of extensive training in both Western and Eastern Medicine. After completing a baccalaureate degree summa cum laude, he earned a doctorate in psychopharmacology; receiving his Ph.D. from the University of Minnesota before pursuing further medical studies. After completing work for his M.D. degree, also at the University of Minnesota, Dr. Starzinski completed a neurology residency and received certification from the American Board of Neurology and Psychiatry. Continuing Western medical education includes educational offerings through the American Academy of Neurology, to which Dr. Starzinski has belonged since 1982. Study of traditional Chinese medicine was made possible by a Bush Medical Fellowship, prominently involving training directed by Dr. Tsun-Nin Lee in San Francisco. Through affiliations, including the Academy of Pain Research, the University of California, and St. Luke’s hospital in San Francisco, Dr. Starzinski has studied traditional Chinese medicine involving work in acupuncture, herbal medicine, and Qigong. Dr. Starzinski’s career has included private practice in neurology at the Mankato Clinic as well as work as the clinical director of the Minnesota Neurorehabilitation Hospital. More recently, Dr. Starzinski has integrated his practice of medicine to combine knowledge of both Eastern and Western Medicine. Current clinical interests most prominently include neurological and psychiatric conditions and wellness.

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Contributors Daniel A. Bronstein, J.D. Professor, College of Agriculture & Natural Resources Michigan State University East Lansing, Michigan

Robert Granacher Jr., M.D., D.F.A.P.A. President and Executive Director Lexington Forensic Institute Lexington, Kentucky

Fofi Constantinidou, Ph.D. Professor and Director NeuroCognitive Disorders Laboratory Department of Speech Pathology and Audiology Miami University Oxford, Ohio and Associate Professor University of Cyprus Nicosia, Cyprus

Arthur MacNeill Horton, Jr. Psych Associates of Maryland Towson, Maryland

Joseph A. Davis Center for Applied Forensic Behavioral Sciences San Diego, California

Gregory J. Murrey Minnesota Neurorehabilitation Hospital Brainerd, Minnesota Henry V. Soper Faculty, School of Psychology Fielding Graduate University Santa Barbara, California and Developmental Neuropsychology Laboratory Ventura, California

Donald T. Starzinski Minnesota Neurorehabilitation Hospital Brainerd, Minnesota

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1

Overview of Traumatic Brain Injury Issues in the Forensic Assessment Gregory J. Murrey

Contents 1.1

Definitions and Criteria for TBI.......................................................................1 1.1.1 Level of Consciousness.........................................................................2 1.1.2 Posttraumatic Amnesia.........................................................................3 1.1.3 Alteration in Mental Status................................................................... 5 1.2 Diffuse Axonal Injury Due to Traumatic Brain Injury....................................7 1.3 Estimation of Premorbid Intelligence and Functioning................................. 10 1.4 Postinjury Emotional Functioning and Personality Assessment Issues........ 12 1.5 Assessment of Executive Control Dysfunctions and Impaired Awareness Following Brain Injury................................................................ 15 1.6 Special Assessment Considerations in Mild TBI Cases................................ 17 References................................................................................................................. 19

1.1  Definitions and Criteria for TBI The incidence of brain injury in the U.S. has been estimated to be in excess of 10 million new cases each year (Hartlage, 1990). Approximately 1.5 million Americans sustain head injuries requiring medical attention each year, with roughly half of these requiring hospitalization as a result (Davis, 1990). The incidence of traumatic brain injury (TBI) in the U.S. continues to grow despite many state and national prevention initiatives. Both the medical professional community and the lay population have become increasingly aware of the prevalence of traumatic brain injury and, to some degree, its clinical sequelae. Even more relevant to the readers of this text is the fact that a number of lawsuits and forensic cases related to traumatic brain injury have increased exponentially over the past decade. Certainly the TBI caseload percentage of neuropsychologists and select neurologists has also increased dramatically. The purpose of this chapter is thus to provide a general overview of the forensic assessment issues in cases of traumatic brain injury. The etiologies of TBI are quite varied, but include motor vehicle accidents, falls, on-the-job injuries, and assault. In the forensic evaluation, it is critical for clinical and legal professionals to 

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have a clear set of criteria for and definition of TBI. In the medical, neuropsychological, and legal literature, there are a variety of definitions and criteria set forth on the matter of TBI; however, existence and severity of a TBI are usually established by the following (Evans, 1992; Esselman and Uomoto, 1995):

1. The occurrence and period of loss of consciousness 2. The degree of loss of memory for events immediately before or after the accident 3. The degree and duration of alteration in mental state at the time of the accident 4. The degree of focal neurological deficits (which may or may not be transient)

It needs to be emphasized that in both the research and clinical settings, various definitions and criteria continue to be used for specific diagnosis and classification of traumatic brain injury. Both standardized and less formalized methods are used as part of the classification and identification of such. Some of the more commonly used assessment tools and clinical terminology in the diagnosis and classification of traumatic brain injury are discussed in later sections of this chapter. It should also be remembered that, depending on the setting and clinician making the diagnosis, other terms may be used in lieu of traumatic brain injury. Other terms or diagnoses equivalent to traumatic brain injury may include closed head injury (CHI), concussion, head trauma, or brain trauma. Finally, a variety of factors may help to predict prognosis of recovery following traumatic brain injury. The most common psychosocial factors affecting the prognosis and recovery outcome after TBI include the following:

1. Age at TBI onset (older clients tend to show poorer recovery prognosis) 2. History of previous brain injury or neurological impairments 3. Premorbid intellectual, academic, and vocational functioning 4. History of chemical abuse 5. Premorbid history of psychiatric disorder 6. Premorbid history of cognitive dysfunction

1.1.1  Level of Consciousness Level of consciousness is most commonly assessed by medical or emergency personnel using the Glasgow Coma Scale (GCS) soon after the injury (Teasdale and Jennett, 1974; see Table 1.1). The GCS formally and objectively assesses eye, motor, and verbal responses to various external stimuli. Total GCS scores range from 3 (no response to stimuli) to 15 (normal response to stimuli), and GCS scores of 13 to 15 are considered to be within the normal range of functioning. The definition and criteria for mild TBI, as established by the American Congress of Rehabilitation Medicine (1993; see Table 1.2), do not require a loss of consciousness. However, loss of or change in level of consciousness postinjury does provide the medical professional or other clinician with important information that is helpful in determining the existence and severity of a brain injury.

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Table 1.1 Glasgow Coma Scale (Recommended for Ages 4 to Adult) Eyes Score Open Spontaneously To verbal command To pain No response

4 3 2 1

Best Motor Response To Verbal Command Obeys

6

To Painful Stimulus Localizes pain Flexion — withdrawal Flexion — abnormal Extension No response

5 4 3 2 1

Best Verbal Response Oriented and converses Disoriented and converses Inappropriate words Incomprehensible sounds No response

5 4 3 2 1

GCS Total

3–15

Source: Adapted from Teasdale, G. and Jennett, B., Lancet, 2, 81–84, 1974. With permission.

1.1.2  Posttraumatic Amnesia Another important criterion to be considered in the assessment of TBI is the level of posttraumatic amnesia (PTA), which refers to the loss of memory for events immediately before or after the accident, and typically includes an inability or reduced ability to effectively process information or stimuli (visual or otherwise) postinjury. The level and duration of PTA can certainly correlate with the degree of loss of consciousness; however, the existence and duration of PTA can be difficult to determine. A formal, semi-standardized method of assessing PTA is the Galveston Orientation and Amnesia Test (GOAT) (Levin et al., 1979; see Table 1.3). The GOAT quickly screens a patient’s orientation to self, place, and time as well as assesses the existence and degree of anterograde (postinjury) and retrograde (prior to the injury) amnesia (memory loss or memory processing deficit). Scores on the GOAT range from 0 to 100, with 76 to 100 within the normal range and 65 or lower in the impaired range. Although the GOAT is a commonly known and utilized instrument

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Table 1.2 Definition of Mild TBI — Head Injury Special Interest Group of the American Congress of Rehabilitation Medicine A patient with mild brain injury is a person who has had a traumatically induced physiological disruption of brain function as manifested by at least one of the following:   • Any period of loss of consciousness   • A loss of memory for events immediately before or after the accident   • Any alteration in mental status at the time of the accident (e.g., feeling dazed, disoriented, or confused)   • Focal neurological deficit(s) that may or may not be transient, but where the severity of the injury does not exceed the following: (a) Loss of consciousness of approximately 30 minutes or less (b) After 30 minutes and initial Glasgow Coma Scale of 13 to 15 (c) Posttraumatic amnesia not greater than 24 hours Source: Adapted from American Congress of Rehabilitation Medicine, J. Head Trauma Rehabilitation, 8, 86–87, 1993. With permission.

Table 1.3 Galveston Orientation and Amnesia Test (GOAT) 1. What is your name? Where do you live? 2. Where are you now? City ____________ Hospital ____________ (unnecessary to state name of hospital) 3. On what date were you admitted to this hospital? How did you get here? 4. What is the first event you remember after the injury? Can you describe in detail (i.e., date, time, companions) the first event you can recall after the injury? 5. Can you describe the last event you recall before the accident? Can you describe in detail (i.e., date, time, companions) the first event you can recall before the injury? 6. What time is it now? 7. What day of the week is it? 8. What day of the month is it? 9. What is the month? 10. What is the year? Source: Adapted from Levin, H.S. et al., J. Nervous Mental Disorders, 167, 675–684, 1979. With permission

among ­neuropsychologists who work in acute rehabilitation settings, it is not commonly used by medical professionals. Thus, the forensic examiner must often rely on somewhat subjective reports (after the fact) of family members and observers or even the injured person. When it is used, the GOAT is typically administered in the emergency room or other acute medical setting to individuals suspected of having suffered a brain injury. It is important for the examiner to determine if there was any indication of PTA and to arrive at a gross estimate of the period of PTA. It is not so

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Overview of Traumatic Brain Injury



critical or typically possible to determine the exact number of minutes or hours of PTA. Rather, it is important for the examiner to determine if (1) there was a period of PTA and (2) if the duration was less or more than 24 hours.

1.1.3  Alteration in Mental Status Alteration in mental status, often described by the injured party as feeling dazed, disoriented, or confused at the time of the accident, can at times be formally observed and documented by emergency or medical personnel at the scene of the accident or in the emergency room. Assessment of alteration in mental status is particularly important in mild TBI cases. Yet, such alterations are most commonly reported only by the patient/injured person after the fact. Even though an alteration in mental status has not been formally documented by an outside observer, the forensic examiner should not and cannot conclude that it did not occur. The alteration or transient change in mental status could be momentary and may have resolved (at least to some degree) before the arrival of a reliable observer or examiner (e.g., law enforcement or emergency medical personnel). However, the duration and extent of alteration in a person’s mental state postinjury certainly should be considered by the forensic examiner and typically correlates with the severity of the injury. Focal neurological deficits, typically assessed by technical neuroimaging studies such as magnetic resonance (MR) images, computed tomography (CT) scans, electroencephalogram (EEG) studies, and, on rare occasions, positron emission tomography (PET) scans (see Chapters 2 and 3 for further discussion on these technologies), need to be considered in determining the existence and severity of a TBI. Medically documented neurological deficits are not required criteria for the existence or occurrence of TBI, although such technologies as MRI and CT scans are invaluable in its assessment. However, both of these technologies are limited and may be insensitive to abnormalities or functional deficits after brain injury (Wilson and Wyper, 1992). In fact, it is not uncommon for persons who have suffered a mild brain injury to have normal CT and MRI scans, which argues for the importance of the functional (neuropsychological) assessment in such cases. A prime example of the limitations of CT and MRI scans as well as the often lack of correlation between such neuroimaging studies and neuropsychological results is the research data in the area of persons with Alzheimer’s disease. The majority of persons diagnosed with mild to moderate Alzheimer’s disease who present with clear neurobehavioral and neuropsychological dysfunctions and deficits often have normal CT or MRI scans, whereas many “normal” functioning (neuropsychologically and neurobehaviorally speaking) elderly persons have abnormal CT or MRI scans (Thatcher et al., 1997; Gonzales et al., 1978; Eslinger et al., 1984; Hatazawa et al., 1981; De Leon, 1997; Bird et al., 1986). Newer and more sophisticated technologies and procedures such as PETs and functional MRIs (fMRIs) are proving to be more sensitive to neuropsychological changes following TBI and are more highly correlated with neuropsychological findings (Ruff et al., 1989; Gale et al., 1995). In fact, it was once commonly believed and accepted within the medical field that once a TBI person is out of the acute recovery stage, there should be no further decline in cognitive functioning or adverse change

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in neuroanatomical or neurophysiological systems; however, more recent research using PET studies has actually demonstrated that cerebral atrophy (shrinkage) may occur as a result of cellular damage, but may not be able to be observed clinically until at least 6 to 9 months postinjury. Newer research also suggests that mildly brain injured persons with evidence of neurological deficits or documented focal lesions (e.g., more complicated mild head injuries) may actually have poorer functional outcomes (Williams et al., 1990) than those without such deficits or lesions. The term concussion is commonly used by medical professionals and often corresponds with the diagnosis of mild or moderate brain injury. According to the International Classification of Disease, 9th revision (ICD-9; Medicode, Inc., 1998), a concussion is a “transient impairment of function as a result of a blow to the brain,” which can include brief, moderate, or prolonged loss of consciousness, “with or without return to pre-existing conscious level.” Another term important for the legal and medical professional to understand is postconcussional syndrome or disorder. This term is commonly used by treating and consulting physicians and is typically seen in the medical documentation of persons who have suffered or are suspected of having suffered a mild TBI. The term infers the existence of chronic or ongoing cognitive, physical, and social/functional impairment as a result of a TBI (or more specifically, a significant cerebral concussion). Table 1.4 outlines the research criteria found in Appendix B of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV; American Psychiatric Association, 1994). Note that this is labeled as “research criteria,” as the task force reviewing these specific criteria at that time determined that “there was insufficient information to warrant inclusion [of the proposals] as official categories or axes in the DSM-IV.” DSM-IV diagnoses that can be used for persons presenting with postinjury cognitive or emotional impairment (transient or permanent) include dementia due to head trauma, amnestic disorder, cognitive disorder not otherwise specified, delirium due to a general medical condition (TBI), personality change due to TBI, mood disorder due to a general medical disorder, and anxiety disorder due to a general medical disorder. (See also Table 1.5 for a listing of the DSM-IV diagnostic criteria for each of these diagnoses.) A final term that should be reviewed here is closed head injury (CHI), and how it is similar to and different from the term traumatic brain injury. According to the International Classification of Disease, 9th revision (ICD9; Medicode, Inc., 1998), Section 907, a closed head injury is defined as the “late effects of inter-cranial injury without mention of skull fracture.” Thus, the terms closed head injury and TBI are standardly used interchangeably in the field of neuropsychology. It would also be important for the medical and legal professional to be aware of any definitions of TBI within his or her respective state statutes that may be applicable to a given case. For example, Minnesota has a statutory definition of mild TBI (see Minnesota Statute 144.661). In summary, it is important for a professional conducting the forensic assessment to be knowledgeable in the varied and often conflicting definitions and criteria applied to a TBI (particularly mild TBI). The examiner should also be clear on the definition or criteria that he or she is applying to determine the existence or severity of a TBI, and should be able to defend the decision to use that particular definition.

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Table 1.4 DSM-IV Research Criteria for Postconcussional Disorder A. The history of head trauma that has caused significant cerebral concussion. Note: The manifestations of concussion include loss of consciousness, posttraumatic amnesia, and, less commonly, posttraumatic onset of seizures. The specific method of defining this criterion needs to be established by further research. B. Evidence from neuropsychological testing or quantified cognitive assessment of difficulty in attention (concentrating, shifting focus of attention, performing simultaneous cognitive tasks) or memory (learning or recalling information). C. Three or more of the following occur shortly after the trauma and last at least 3 months: 1. Becoming fatigued easily 2. Disordered sleep 3. Headache 4. Vertigo or dizziness 5. Irritability or aggression on little or no provocation 6. Anxiety, depression, or affective lability 7. Changes in personality (e.g., social or sexual inappropriateness) 8. Apathy or lack of spontaneity D. The symptoms in criteria B and C have their onset following head trauma, or else represent a substantial worsening of preexisting symptoms. E. The disturbance causes significant impairment in social or occupational functioning and represents a significant decline from a previous level of functioning. In school-aged children, the impairment may be manifested by a significant worsening in school or academic performance dating from the trauma. F. The symptoms do not meet criteria for dementia due to head trauma and are not better accounted for by another mental disorder (e.g., amnesic disorder due to head trauma, personality change due to head trauma). Source: American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th ed., American Psychiatric Association, Washington, DC, 1994. With permission.

It is also necessary for the examiner to address the definition and criteria applied by other medical professionals involved in a particular brain injury case.

1.2  Diffuse Axonal Injury Due to Traumatic Brain Injury Over the past 5 to 7 years, a newer and very important area of research related to traumatic brain injury has surfaced on diffuse axonal injury (DAI) (Wallesch et al., 2001a; Meythaler et al., 2001). Research on DAI is still somewhat in its infancy, and definitions of DAI still very widely; however, per the literature, DAI is most typically referred to as widespread (vs. a clear focal lesion) axonal damage in the brain resulting in microbleeds in slight neuroanatomical areas of the brain with corresponding cognitive and functional impairment (Meythaler et al., 2001; Scheid et al., 2006; Fork et al., 2005). Only recently has DAI begun to be clinically assessed after traumatic brain injury, and only within select medical settings such as in regional trauma centers or specialized clinics and hospitals. DAI is not yet a specific ­diagnosis or

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The Forensic Evaluation of Traumatic Brain Injury

Table 1.5 DSM-IV Diagnoses and Criteria Commonly Used in TBI Cases DSM-IV Criteria for Dementia Due to Head Trauma A. Disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention. B. A change in cognition (such as memory deficit, disorientation, or language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia. C. The disturbance develops over a short period (usually hours to days) and tends to fluctuate during the course of the day. D. There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition (TBI). DSM-IV Criteria for Dementia Due to Other General Medical Conditions A. The development of multiple cognitive deficits manifested by both (1) memory impairment (impaired ability to learn new information or to recall previously learned information) and (2) one (or more) of the following cognitive disturbances: (1) Aphasia (language disturbance) (2) Apraxia (impaired ability to carry out motor activities despite intact motor function) (3) Agnosia (failure to recognize reality or identify objects despite intact sensory function) (4) Disturbance in executive functioning (e.g., planning, organizing, sequencing, and abstracting) B. The cognitive deficits in criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning. C. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of one of these general medical conditions: dementia due to HIV disease, head trauma, Parkinson’s disease, Huntington’s disease, Pick’s disease, Creutzfeldt– Jakob disease, or TBI. D. The deficits do not occur exclusively during the course of a delirium. DSM-IV Criteria for Amnestic Disorder Due to (Indicate General Medical Condition) A. The development of memory impairment is manifested by impairment in the ability to learn new information or the inability to recall previously learned information. B. The memory disturbance causes significant impairment in social or occupational functioning and represents a significant decline from a previous level of functioning. C. The memory disturbance does not occur exclusively during the course of a delirium or a dementia. D. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition (including physical trauma). DSM-IV Criteria for Cognitive Disorder Not Otherwise Specified This category is for disorders that are characterized by cognitive dysfunction presumed to be due to the direct physiological effect of a general medical condition that does not meet criteria for any of the specific deliriums, dementia, or amnestic disorders listed in this section that are not better classified as delirium not otherwise specified, dementia not otherwise specified, or amnestic disorder not otherwise specified. For cognitive dysfunction due to a specific or unknown substance, the specific substance-related disorder not otherwise specified category should be used. Examples include: (1) Mild neurocognitive disorder: Impairment in cognitive functioning as evidenced by neuropsychological testing or quantified clinical assessment, accompanied by objective evidence or a systemic general medical condition or central nervous system dysfunction. (2) Postconcussional disorder: Following a head trauma, impairment in memory, or attention with associated symptoms.

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Overview of Traumatic Brain Injury



Table 1.5 (continued) DSM-IV Diagnoses and Criteria Commonly Used in TBI Cases DSM-IV Criteria for Personality Change Due to TBI A. A persistent personality disturbance that represents a change from the individual’s previous characteristic personality pattern. (In children, the disturbance involves a marked deviation from normal development or a significant change in the child’s usual behavior patterns lasting at least 1 year.) B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition. C. The disturbance is not better accounted for by another mental disorder (including mental disorders due to a general medical condition). D. The disturbance does not occur exclusively during the course of a delirium and does not meet criteria for a dementia. E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. DSM-IV Criteria for Mood Disorder Due to TBI A. A prominent and persistent disturbance in mood predominates in the clinical picture and is characterized by either or both of the following: (1) Depressed mood or markedly diminished interest or pleasure in all, or almost all, activities (2) Elevated, expansive, or irritable mood B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition. C. The disturbance is not better accounted for by another mental disorder (e.g., adjustment disorder with depressed mood in response to the stress of having a general medical condition). D. The disturbance does not occur exclusively during the course of a delirium. E. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Source: American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th ed., American Psychiatric Association, Washington, DC, 1994.

commonly used term, and thus is not typically used in local hospitals or clinics (even by many neurologists in smaller geographic regions). Although much more research is needed in this area, DAI is now being diagnosed through CT and MRI scans in select clinical settings (Fork et al., 2005; Wallesch et al., 2001; Cook, 2001a; Anderson et al., 1996). However, some researchers argue that DAI is “still extremely difficult to detect noninvasively and is poorly defined as a clinical syndrome” (Smith et al., 2003). The still somewhat limited research suggests that DAI affects areas of the frontal and temporal lobes, resulting in corresponding executive and memory dysfunction (Wallesch et al., 2001b; Scheid et al., 2006). Specific cognitive deficits resulting from DAI reported in the research include impairments in information processing speed, attention and concentration, psychomotor speed, short-term memory, abstract reasoning, working memory, mental selection ability, and problem solving (Felmingham et al., 2004; Wallesch et al., 2001b; Fork et al., 2005). Because DAI causes “diffuse” injury as opposed to a prominent focal lesion or injury, such cognitive deficits may be more mild or subtle in nature and more varied by individual.

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The Forensic Evaluation of Traumatic Brain Injury

Although there is still a fair amount of debate on the subject, many researchers do believe that DAI can result even in mild traumatic brain injury (Wallesch et al., 2001b). The following is a list of neuroimaging and neuropsychological indicators of possible DAI after traumatic brain injury:

1. CT diagnostic criteria of DAI a. Single or multiple small hemorrhages in the cerebral hemispheres (