them, you can be really impressed with yourself as a clinician. You will surely not win every case, as some patients’ beliefs about their condition are so ingrained that it may not be possible to assist them out of a situation in which they are malingering or exaggerating their symptoms. However, there are some tools we can employ to help determine the validity of the patient’s reporting and our findings on clinical assessment. The following tools are helpful in this situation:
Table # 7 – Establishing validity in patient reporting
| Consistency on neurocognitive and neurological exam; perform tests of malingering that can be useful | The field of neuroscience utilizes testing tools that are generally consistent across patient population and disease conditions based on our classification of diseases. Any significant variation on what is expected often introduces concerns of legitimacy that should not be ignored. It takes a knowledgeable and experienced clinician to be able to administer and interpret these exams/tests. |
| Evaluation of the incentive and drivers of playing the sick role, if any | This can be driven by a parent, spouse, family members, friends and issues of obligation, fear of a particular outcome or a reward. |
| Purging yourself from biases as a clinician | Assuming that the patient is guilty until proven otherwise is not the best approach to the patient’s situation. |
| Listening to all sides before drawing conclusions | Information provided by all parties can be misleading. A smart clinician knows the right questions to ask to get the information needed and utilizes such information to analyze a patient’s situation. |
| Clinicians’ knowledge of what they treat | Before attempting treatment, a clinician must be certain as to what they are treating. As a rule of thumb, it is not a good idea to treat something you do not know or understand. |
In the USA, the entire system of jurisprudence is strictly polarized down the middle; physicians and neuropsychologists are defined as either supporting the plaintiff or the defense side. We must realize that at times money/economics are the major drivers at play here.
Beyond workers’ compensations and personal injury, the US has been through one of the largest settlements seen between the National Football League and the retired players only to be matched by the tobacco settlement. Irrespective of where you find yourself, perplexing questions central to this issue of compensation for the retired injured player are as follows: Who is injured and who is not? Who is healed and who is not? The National Football League (NFL) world has been rocked by controversy on this question when an injury occurs, defining the post-concussion sequelae of such injury and finally determining if the symptoms persist. Even after a billion-dollar settlement with the former players, setting up a way of objectively making those determinations with the former players has been challenging. While there have been consorted efforts by all parties, professional biases by specialty physician groups, neuropsychologists, and the legal community and pressure from the players, their advocates, and NFL representation can limit clinicians’ ability to objectively answer the fundamental question as to who should qualify for the settlements.
For soldiers returning from recent military conflicts, the question as to who is injured and who remains with symptoms and signs have been at the forefront. During my training years, I spent time in a Veterans Hospital and had the opportunity to see and evaluate veterans of war from the Vietnam War. Sure enough, I was looking at brain injuries and concussions that went untreated. For all practical purposes, this is a generation of persons with TBI/concussion, who have been lost in the community with little attention from the medical system. Returning soldiers and their families, as in the case of football players, have been living in the shadow, as they have largely gone undiagnosed and untreated.
Another issue where there is a clash of cultures is that of post-traumatic stress disorder, otherwise known as PTSD. PTSD is commonly seen in soldiers and following traumatic events, such as accidents (Morissette 2011). Most persons with this condition have knowledge of the accident and often re-live the experience in many ways. In PTSD, the key feature of the condition is heralded by what is known as “anniversary reaction.” Individuals are often reminded of the experience (anniversary) consciously and unconsciously where they re-live the experience of the accident when they are exposed to days that seem like the day of the event, anniversary periods such as the time and circumstance of the accident, or in seeing others with similar fate. These experiences can be anxiety-producing and can create fear and apprehension. For years, soldiers were not taken seriously about having this condition until the military realized that these individuals became highly dependent due to crippling symptoms. Today, the US military has developed an entire system to deal with patients who have witnessed horrifying experiences, including trauma from blast incidents and direct blow to the head (Morissette 2011).
A group of patients who develop PTSD that we often forget are patients in intensive care units (ICUs), who experience the terror of certain procedures and experiences. They may vividly recollect those experiences and feel trapped. Nurses and doctors are often insensitive about the issue of pain-producing procedures carried out without enough anesthesia or sedation or the terrifying hallucinations or nightmares that patients may experience in the ICU. Sideris (2019) presented a paper on the case of a patient who developed PTSD due to terrifying hallucinations and nightmares in the ICU. Like the cases seen in the returning soldiers, these cases of PTSD in trauma and ICU settings may be more common than we previously recognized.
The Walking Wounded – Missing the diagnosis
WE HAVE LOOSELY used terms such as “the walking wounded” and “missed TBI/concussions” in the brain injury world. In many cases, these conditions go unrecognized and can cause pain and suffering that last a lifetime. My practice is filled with patients who present with major depression, anxiety, OCD, panic attacks, headaches, dizziness, vertigo, memory disturbances, and anger management disorders, and who for reasons not of their own doing have suffered from a TBI or a concussion that went unrecognized. In many cases, these injuries were only discovered as a major contributing cause to the patient’s problems much later.
Robert Laskowski calls this condition (TBI in general) a “silent epidemic” because “many of the acute and enduring alterations in cognitive, motor, and somatosensory functions may not be readily apparent to external observers” (Laskowski 2015). A study by JS Delaney showed that as much of 88% of concussions may go unrecognized (Delaney 2005). According to a national public radio poll, one in four Americans reported having suffered a concussion. (NPR 2016).
This late discovery of the existence of a TBI/concussion is not only true of many in the prison population and the military but can also be true for people who are functioning in the society and are otherwise experiencing limited fulfillment from their lives because of challenges with interpersonal relationships, trouble advancing in their company, or in the case of a person’s inability to achieve what they believe to be their life goals or reach their fullest potential.
(Case # 5)
I was presenting a lecture in the Caribbean on the clinical features of concussion and TBI when a young lady (we shall name Jill to protect her identity) came up to me and said, “I have what you described in your lecture and I want help.” She was 25 years old at the time and, for all practical purpose, felt lost because she could not achieve her life goals. Jill saw her brothers, sisters, and colleagues of her age excelling but could not figure out why she could not.
Her getting a visa to come to the US, find out what was truly going on, and finally receive treatment was next to impossible. Gathering enough funds to buy the ticket and pay for care in the US was also challenging.
Somehow, she managed to overcome both hurdles, and two whole years after meeting her, I was able to evaluate and treat her at my clinic in Miami. The unique part
