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.

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:


1. 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.

2. 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.
3. 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.

4. 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.
5. 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.

6. 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.

7. 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 ).

8. 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.

9. 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.

10. 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.
11. PHYSICAL EXAMINATION and
12. 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.

13. 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.

14. 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.

15. 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.

16. 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.

17. 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.

18. 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.

19. 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.

20. SYMPTOM MONITORING
1. 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

1. 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
2. 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.
3. The patient should list time of day when feeling worst eliciting diurnal variations in depression and fatigue.
21. 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.