Psychological and cognitive effects of mild traumatic brain injury from motor vehicle accident

¶ … Gender: Female

Birthdate: 01/16/1985

Age: 30 years, 11 months

Dates of Evaluation: 10/25/15 -10/30/2015

Reason for Referral

This is a 30-year-old right-handed woman referred by Dr. Smith for a psychological evaluation to determine any lingering psychological and cognitive effects as a result of a mild head injury that she suffered on October 15, 2015 as a result of an automobile accident. The client has complained of severe memory problems, being disoriented at times, feeling depressed and anxious, and having nightmares the accident. Her physical complaints consist of headaches, back aches, poor sleep, nausea, and vomiting.

Identifying Information

The client is a 30-year-old, divorced, Hispanic woman who lives with her children in a home that she rents in XXX (client please insert city). She has been married three times and has three children from two of the marriages.

Developmental History

The client grew up in XXXX (insert). She reported that her mother had no issues with her pregnancy and that she was born at full term. She is the third child in a sibship of seven. All developmental milestones were met at appropriate times and did experience any developmental delays or issues with motor tasks, language acquisition, or toilet training. Her primary language was Spanish and she told me that she learned English when she went to formal school.

Medical History and Psychiatric History

According to her self-report and to medical records, the client was a restrained driver who was driving after stopping at a four-way stop when her car was struck on the driver's side front quarter panel by another car. Her airbag deployed. The other driver fled the scene and has not been found. She reported that she experienced a brief loss of consciousness of unknown duration and she was taken to Fredrciks Hospital Emergency Department (referred to as ED in this report) where she obtained a Glascow Coma Scale score (GCS) of 14. She was able to vividly recall the accident, her ride in the ambulance, and speaking with medical personal. Her orientation was reportedly intact for person and place, but temporal her orientation was slightly off according to time of day according to the medical record. Reports also indicate that she was anxious and had a very mild left scalp abrasion; however, CT scan of the brain was negative for acute changes and a CT scan of the spine was also negative. She was admitted to the hospital where she claims she remained for three days; however, the records provided to me indicated that she was discharged the next day on 10-16-2015. She was discharged home.

The client has complaints of pain, confusion, depersonalization (feeling that her legs were not part of her body), and other vague ailments. There are reports of six ED visits before her MVA and three shortly after the accident. Her complaints before the MVA that led to her ED visits consisted of anxiety related to financial concerns, difficulties with ulcerative colitis, stroke-like symptoms which were thought to be related to her anxiety, and paralysis related to deep vein thrombosis (DVT) in her right arm. The patient discussed these admissions and was offended that there was an insinuation in the reports that she was medication seeking. Nonetheless, three subsequent CT scans of the brain obtained in response to the patient's complaints of cognitive problems and headaches failed to reveal any evolving acute cerebral changes. I also note mention of two EEG's (10/18/2015; 10/20/2015) ordered by her physician. Results of these tests have also been reported as unremarkable. Her physical complaints at these visits consisted of her having headaches, back aches, poor sleep, nausea, and problems with memory.

Psychiatric History

The client's psychiatric history is remarkable for depressive symptoms during an admission in January of 2014 for treatment of her DVT. She also reported being physically and sexually abused by her three ex-husbands, but denied significant emotional distress as a result of that experience. I am not able to find mention of this prior abuse in any other of the medical reports provided to me by her case manager. The patient was diagnosed with an adjustment disorder and a history of post-traumatic stress syndrome (which is equivocal given the information in the reports).

According to the information presented in medical records the patient received significant assistance and supervision from her family following her accident, but over time this has apparently decreased. She received PT, OT, Speech Therapy, as well as psychiatric support following her discharge from the hospital. According to the records I have been provided with she made good progress in her therapies; however, based on the results of her most recent evaluations her insurance has stopped funding further rehabilitation. She was not driving, going to school, or working at the time of this evaluation.

The client's current medications are reviewed based on a list of medications provided by her. The client's current active medical regimen according to this list consists of Tylenol, Lunesta, Ultram, Cymbalta, Xanax, and Ambien. She does not smoke and denied a history of drug or alcohol abuse.

Academic and Employment History

The client he reported that she graduated from high school on her history form, but records indicated she obtained a GED. When confronted with this discrepancy she admitted that she dropped out of high school as a junior in order to work full-time and obtained a GED. She reported that her grades in high school were "above average" even though she was held back in the tenth grade. She was never identified as having a learning disability or was involved in special education classes.

The client reported that she was preparing to go to school to be a nursing assistant at the time of her accident. She has completed one year of college and just began classes again shortly before her accident. She did not return to school following her accident and reported that she does not retain material that she reads now, whereas this was not a problem for her prior to her accident. She discussed trying to read and recall information from an anatomy book she was reading and how this was very difficult for her. As a result the patient is concerned about returning to school in the future. Regarding her grades, the patient reported her college GPA as a 3.40 on the history intake form she completed during her lunch break during the first evaluation which is somewhat lower than her previous report to me during the initial interview of a grade point average of 2.20.

With respect to her employment, the client was an interviewer for a research project at a local university. She apparently took a leave from her position following her accident, as would be expected. According to her self-report she attempted to return to work "too soon" after her accident leading to some difficulties interviewing clients and she subsequently was let go. She has also worked as a waitress at several restaurants. She was not working at the time of this evaluation.

Tests Administered

Mini Mental Status Examination

Wechsler Adult Intelligence Scale-III (WAIS-III)

Minnesota Multiphasic Personality Inventory-II (MMPI-II)

Millon Clinical Multiaxial Inventory-III (MCMI-III)

Cognitive Functioning

The client was administered the Wechsler Adult Intelligence Scale --Third Edition (WAIS-III) to assess her intellectual functioning. The WAIS-III produces three major IQ indices, a Full Scale IQ index (an estimate of overall intellectual functioning), a Verbal IQ scale (overall verbal performance skills), and a Performance IQ index (overall nonverbal skills; Groth-Marnat, 2009). In addition for additional composite indices are calculated: Verbal Comprehension, Perceptual Processing, Working Memory, and Processing Speed that make up the Full Scale IQ score (Tulsky, 2003). The client's performance on these four indices ranged from the Borderline range to Average range.

WAIS-III Results (Mean = 100; Standard Deviation = 15)

Index

IQ

Percentile Rank

Classification

Verbal IQ

50

Average

Performance IQ

92

27

Low Average

Verbal Comprehension

63

Average

Perceptual Organization

97

42

Average

Working Memory

79

8

Borderline

Processing Speed

76

5

Borderline

Full Scale

97

42

Average

WAIS-III Subtest Scores (Mean = 10; Standard Deviation = 3)

Subtest

Scaled Score

Percentile Rank

Classification

Verbal Comprehension

63

Average

Vocabulary

13

86

High Average

Similarities

11

66

Average

Information

15

93

Superior

Comprehension

10

50

Average

Perceptual Organization

97

42

Average

Picture Completion

8

16

Low Average

Block Design

9

37

Average

Matrix Reasoning

10

50

Average

Picture Arrangement

8

Low Average

Working Memory

79

8

Borderline

Arithmetic

5

2

Mildly Deficient

Digit Span

6

5

Borderline

Letter Number Sequencing

5

2

Mildly Deficient

Processing Speed

76

5

Borderline

Digit Symbol

6

5

Mildly Deficient

Symbol Search

5

2

Mildly Deficient

Significant discrepancies (Black, Wallace, Sokoloff, & Kenworthy, 2009) were observed between the client's Working Memory (Standard Score = 79) and Processing Speed (Standard Score = 76) indices and her Verbal Comprehension (Standard Score = 105) and Perceptual Organization ((Standard Score = 97). There is a 26 point difference between her Verbal Comprehension and Working Memory indices; a 29 point difference between her Verbal Comprehension and Processing Speed indices; an 18 point difference between her Verbal Comprehension and Processing Speed indices; and a 15 point difference between her Perceptual Organization and Processing Speed indices. Therefore the client's Full Scale IQ does not accurately represent the variability in her overall functioning and the differences in her index scores need to be taken into consideration (Hogan, 2015).

The client's Verbal Comprehension Index, a measure of general her verbal skills including verbal fluency, her ability to understand and use verbal reasoning skills, and general verbally mediated knowledge abilities was in Average Range (Verbal Comprehension = 105). She demonstrated a relative strength regarding her overall fund of general information (Information subtest 93rd percentile). However, her ability to attend to new information, hold new information in short-term memory and mentally manipulate this material was significantly poorer than one would predict given her overall verbal reasoning skills (Working Memory = 79). Moreover, her ability to focus her attention, quickly scan and discriminate or sequentially order visual information was also significantly poorer than expected given her verbal reasoning ability (Processing Speed = 76). Thus, while the client has an adequate fund of stored general information and adequate verbal reasoning abilities she may be easily overwhelmed when challenged to process new information quickly or when there is a significant amount of new material or unfamiliar material to process (Baddeley, 1992).

In addition, the client's non-verbal reasoning abilities such her ability to examine a visually mediated problems, recruit her visual-motor and/or visual-spatial skills, and then create solutions to the problem at hand (Lange, 2011) was in the Average Range (Perceptual Organization = 95) and significantly better expressed than her Working Memory and Processing Speed indices (Working Memory = 79; Processing Speed = 76 respectively). Thus, while the client expresses adequate non-verbal reasoning potential there may be a serious restriction on this ability when she is challenged to work with and manipulate visually-mediated information quickly or when there is a significant amount of material presented to her at once.

The results of intellectual testing suggest overall adequate verbal and non-verbal intellectual abilities; however, the client may exhibit limitations in her ability to process and use information if she is required to work quickly or perceives that there is too much information for her to handle.

Socio-Emotional Functioning

The client was administered two measures to assess her level of socio-emotional functioning: the MMPI-2 (a self-report true-false questionnaire that assesses emotional functioning and potential psychopathology) and the MMCI-III (a self-report true-false questionnaire that assess personality style and socio-emotional functioning).

MMPI-II Results

Scale

T-Score

L (Lie)-Scale

45

F (Infrequency)-Scale

K (Correction)-Scale

33

Hysteria Scale

90

Depression Scale

93

Hypochondriasis Scale

92

Psychopathic Deviant Scale

80

Masculine-Feminine Scale

70

Paranoia Scale

Psychasthenia Scale

89

Schizophrenia Scale

Mania Scale

60

Social Introversion

88

The client produced a classic "fake bad" profile on the validity scales of the MMPI-II. People who produce similar validity scale profiles may be attempting to illicit assistance for severe perceived psychological stress as opposed to attempting to overtly presently themselves as being impaired in an effort to achieve some form of secondary gain. The client's validity scale profile suggest that she may indeed be producing a "cry for help" regarding her overall perceived psychological distress (Walters & Clopton, 2000). As the profile is deemed invalid the clinical scales cannot be interpreted.

MMCI-II Results

X Disclosure

Y Desirability

Z Debasement

V Validity

1 Schizoid

2A Avoidant

2B Depressive

3 Dependent

4 Histrionic

5 Narcissistic

6A Antisocial (Aggressive)

6B Sadistic

7 Compulsive

8A Negativistic (Passive-Aggressive)

8B Masochistic (Self-Defeating)

S Schizotypal

C Borderline

P Paranoid

A Anxiety

H Somatoform

N Bipolar: Manic

D Dysthymia

B Alcohol Dependence

T Drug Dependence

R PTSD

SS Thought Disorder

CC Major Depression

PP Delusional Disorder

42

60

40

63

62

59

80

60

60

50

52

41

44

71

50

44

56

44

76

67

52

66

50

45

63

55

72

44

The client produced a valid profile with no evidence to present herself in an overly positive manner or to portray herself as extremely or excessively distressed or defensive in her approach to answering questions. There was no evidence that she suffers from a severe characterological disorder. Her responses suggest she is pessimistic, overly serious, gloomy, passive, and preoccupied with negative events (Millon, Millon, Meagher, Grossman, & Ramnath, 2012).

Individuals with similar profiles are also so concerned with the negative aspects of their experiences and may concentrate on these. They may present as gloomy and depressed and may be dependent on the opinions of others to provide them with acceptance. People like this can be passive/aggressive, irritable, and critical (Millon et al., 2012).

Diagnostic Impressions

Axis I: 309.28 Adjustment Disorder with Mixed Features (Provisional)

850.2 Mild Concussion with Brief Loss of Consciousness; Resolved

Axis II: 799.9 Deferred

Axis III: Ulcerative colitis deep vein thrombosis in right arm.

Axis IV: Divorced, unemployed, no longer in school, single parent with some support.

Axis V: 55

Summary

This client is a 30-year-old woman who was involved in a car accident on 10**. Her initial presentation in the ED was consistent with a mild concussion as a result of her accident. She suffered a brief loss of consciousness and concussion following this accident, but there have were no positive findings over numerous neuroimaging results and the patient had a GCS of 14 on the ED indicating no serious cognitive effects.

Current findings indicate that she demonstrates poor working memory and processing speed than would be expected given her nonverbal and verbal intellectual abilities on the WAIS-III, consistent with her complaints of issues with memory and overall functioning. There was no evidence of significant difficulties with expressive or receptive language abilities, visuoperception, or conceptualization on the WAIS-III. Problem solving abilities appear to be within expectation. Thus her presentation may reflect psychological overlay given her performances on measures of social-emotional functioning (MMPI-II and MMCI-III.

Her inconsistencies on the WAIS-III with regard to working memory and processing speed when taken in context with her history and performance on measures of social-emotional functioning suggest the potential for difficulties with adjustment and a tendency to recruit others to assist her (this was also noted in behavioral observations). However, the current evaluation did was not a full neuropsychological evaluation and therefore the findings of this evaluation suggest a need for more intensive testing. In order for the current diagnosis impressions to be accepted a more thorough evaluation of her cognitive functions including memory, motor functioning, and executive functions should be considered.

Recommendations

1.) The client should undergo a full neuropsychological evaluation to determine the extent of any issues with her memory, executive functions, and motor functioning related to her mild head injury.

2.) The client does have issues with adjustment and continues to believe that she has been irreparably damaged as a result of her accident. Efforts should be made to move the patient back to her previous level of independence even if she is found to have a post-concussive syndrome.

3.) The patient would be a good candidate for cognitive-behavioral therapy to assist her with her adjustment issues, restructure her self-image, and to return to her previous levels of activities. The therapist will need to provide empathy but at the same time be firm and therapy should be goal-oriented. She may require strong emotional support when returning to school and work. Practical strategies for learning could also be introduced to this patient.

4.) Reviewing and adjusting the patient's medications as medication effects can affect cognitive functioning. The patient currently does take some medications know to produce untoward cognitive effects (e.g., Xanax and Ambien).