Forensic Neuropsychological Assessments in the Assessment of Traumatic Events: A Multi-Factorial Approach to Neuropsychological Assessments

One is frequently presented with an individual who presents for evaluation as a result of traumatic events such as sexual harassment, sexual abuse in the school and workplace, electrical injury, and Traumatic Brain Injury.

These events present for evaluation by a forensic psychologist and require a multi-tiered approach. Credibility is best addressed by a multi-modal approach, viz, collateral interviews of third parties, and testing for effort and malingering. Psychological tests can shed useful light on a tendency to minimize or exaggerate complaints. Medical records and academic transcripts often prove illuminating.

Brain Trauma

Neuropsychological assessment is invaluable in assessment of brain trauma. However, it is critical to have proper brain imaging methodology. Otherwise, significant areas of injury are missed. CT Scans sacrifice precision due to volume averaging and the technique also suffers from false positives and false negatives. However, a relatively new Magnetic Resonance Imaging (MRI) technique called multi-echo gradient recalled echo (GRE) T2* weighted imaging (T2*WI) (Tang et al., 2014) can detect cerebral microbleeds in remote areas. Single-photon Emission Computed Tomography (SPECT) is a nuclear medicine tomographic procedure evaluating microscopic blood flow and brain metabolism. Some practitioners, viz, Daniel Amen profess that SPECT can assess how well treatment is working. However, the American Psychiatric Association in a 2012 review found that neuroimaging studies "have yet to impact significantly the diagnosis or treatment of neurological patients."

It is essential to incorporate treatment in a neurocognitive program for individuals suffering from cognitive deficits due to brain trauma. This writer has seen significant benefits to individual's cognitive functioning with individuals being treated in these programs.

Course of Trauma (PTSD)

PTSD is in essence a neurobiological disorder affecting brain function. The noradrenergic operating system is adversely affected by PTSD, resulting in an elevated level of arousal. Neuroanamotical studies have implicated alterations in the amygdala and hippocampus in individuals with PTSD. (Rauch et al., 2000). fMRI and PET have demonstrated increased reactivity of the anterior cingulate and of the frontal areas (Shin et al., 1999). These biological alterations suggest that there may be a neuroanatomical basis for PTSD symptomatology (Schnuff et al., 2001).

In terms of evaluating extent and cause of damage in individuals impacted by traumatic events (witnessing violence, sexual and physical assault, sexual harassment), immediately following traumatic exposure, a high percentage of individuals develop a mixed symptom picture (paranoia, dissociation). Approximately 50% of individuals with PTSD develop a persistent chronic form of the illness (First and Tasman, 2004). (Kessler et al., 1995) demonstrated that one-third of those diagnosed with PTSD fail to recover for many years.

Limitation of Current Methodology

Currently, the FDA has given approval to a blood test for concussion which utilizes protein biomarkers. However, concussions are best diagnosed by neurologists, neuropsychologists, and neuropsychological testing. Moreover, this methodology does not capture the effects of cumulative subconcussive blows to the head.

Electrical Injury and Severe Trauma

Severe forms of trauma significantly upend individual's lives disrupting marriages, families, and an individual's ability to earn a living. This, in turn, adversely impacts self-esteem and self worth. Ability to parent children is also affected. Electrical injury is significant due to its course which may not fully impact individuals until years later. There is psychological and neuropsychological damage from such injuries. Frequently, these individuals suffer from chronic pain which escalates anxiety and depression.

Concluding Comments

Traumatic events impact individuals for many years post-injury. A comprehensive psychological test battery of personality tests, instruments to assess trauma and its sequelae, and neuropsychological screening tests are necessary to accurately assess damage in victims of such injuries.The new, experimental "Blood Test" for concussions cannot capture data or assess cognitive function, spatial, memory, and frontal lobe dysfunction, which can be assessed by neuropsychological testing. While the FDA uses the rationale for "Blood Tests" as decreased use of CT scans due to concerns about radiation, substantial progress is being made in reducing radiation exposure in CT scan, such as at UCLA. The Court also needs to be advised of the need for multiple therapies to address the injuries and take steps towards restoring quality of life for these individuals. Frequently needed treatments are:

Cognitive Behavioral Therapy (CBT) - Restructure and modify maladaptive thought process

Prolonged Exposure Therapy - Assists in confronting avoidance of traumatic events

Eye Movement Revisitation and Reprocessing (EMDR) - Goal is to think about positive events while thinking about trauma

Relocation and Guided Visual Images - Individuals are taught to establish a hierarchy of anxiety provoking events and visualize pleasant scenes, along with sensory relaxation while thinking about anxiety-laden events

Psychiatric Medicines - SSRI's are useful in treating depression for 80% of the patients with PTSD; anti-anxiety agents such as Buspirone have been found useful in alleviation of screen memories of traumatic events

Conjugal Therapy - Frequently, this writer has found spouses frequently affected by their partner's traumatization. Conjugal therapy assists with stabilization of the marital relationship and assists with enlisting support from the spouse of the injured party.