Recently, we saw two patients in our office who were involved in separate automobile accidents, one fairly minor and one more serious. In each case, however, neither patient complained of experiencing any cognitive problems of any degree for over two years following their accidents, despite having been seen by numerous medical specialists, including neurologists. In fact, they both consistently denied experiencing cognitive problems when frequently asked about their symptoms. Nevertheless, both patients were subsequently referred by their attorney to a local neuropsychologist who purportedly specializes in mild brain injury cases. That doctor diagnosed each of them with having suffered a significant traumatic brain injury and referred them both for a comprehensive treatment program! That same doctor has also recently reported that of all patients referred to his practice, he diagnoses a traumatic brain injury 85% of the time!
This report, as well as what happened to these patients, is profoundly disturbing. For patients who only begin to complain of thinking problems after an extended period of time following their accident, a careful review of the pre and post accident medical and vocational records, and academic transcripts, is imperative. While the onset of cognitive problems following trauma can be delayed, or masked by other problems, it is extremely unusual that more than 12 months would elapse without any cognitive symptoms emerging. In such cases as above, other factors, including motivation, must be considered before concluding a patient has a brain injury.
The diagnosis of MTBI is especially complex and should only be made when all other potential causative factors have been ruled out. In addition to pain, sleep problems, and stress, other factors include: age related dementia, vascular conditions, pulmonary difficulty, and secondary gain, to name just a few.
Research has found that persistent cognitive complaints following an MTBI only occur between 20 – 40% of the time. Numerous other studies have documented that many conditions associated with automobile accidents (chronic pain, emotional distress, PTSD, TMJ, and sleep disturbance) can all cause profound changes in cognitive functioning. In the presence of one or any combination of those conditions, a patient may easily experience symptoms of reduced attention and concentration, memory difficulties, speech difficulties, and slowed information processing speed which can be misdiagnosed as brain damage. Inappropriately diagnosing a patient as brain injured, without taking into account other factors which can have an effect on cognition, can lead to adverse complications, including symptom magnification, the development of a more serious and chronic disability profile, and the carrying of a label of “brain injured” for the rest of the patient’s life.
The most prudent course of treatment for a patient complaining of cognitive difficulties during the acute stage (1 to 3 months) following involvement in an automobile accident is to aggressively treat the physical, emotional, and sleep difficulties until they are either stabilized or become absent. If the patient is continuing to complain of cognitive difficulties after the stabilization of their physical and emotional problems they may then undergo comprehensive neuropsychological testing to document the presence or absence of any acquired organic brain injury and to offer any recommendations for further treatment procedures or strategies, if necessary.
Utilizing this model, the confounding factors impacting cognition are identified and treated. Oftentimes, after those factors are resolved, the patient’s thinking complaints disappear. In fact, between 1997 and 1999, 66% of all patients seen through our Post Concussion Syndrome Clinic experienced an almost complete resolution of their cognitive problems once their physical, emotional, and sleep complaints were treated.
Some patients, of course, have actually sustained a brain injury as a result of a traumatic accident. When cognitive symptoms do not resolve, a comprehensive test battery is administered. With the confounding physical and emotional variables treated and stabilized, the neuropsychological test results may then be considered diagnostically definitive.
It is easy to mislabel a patient complaining of cognitive difficulties following a trauma as “brain damaged”. But many other contributory factors must be considered before such an impactful diagnosis is made. Be sure to refer your patient or client to a competent and well trained clinical neuropsychologist to make such a diagnosis.