Explaining persistent symptoms from mild head injuries

A road traffic accident or other traumatic event which involves a head injury may cause a brain injury, which can cause cognitive, emotional and physical symptoms. The severity of the brain injury is usually graded as mild, moderate or severe and this can help provide accurate information to the individual affected and their families, as well implement the correct rehabilitation intervention.

Only a minority of individuals experience cognitive and emotional symptoms a year after a mild brain injury. To date, there are disagreements about the conceptual framework in which persistent symptoms after mild head injury should be considered, and consequently treated.

Some experts regard these symptoms as due to the neuronal and pathogenic process associated with a traumatic brain injury; others regard these symptoms as merely co-occurring after a brain injury, triggered by the same event, but produced by different mechanisms. To complicate matters there are also cases in which a very minor blow to the head can cause persistent cognitive and emotional symptoms, although arguably any brain injury is very unlikely. Given the secondary gains involved in a compensation claim it is always necessary to also consider symptom magnification and or cognitive underperformance.

Case study

A hypothetical example could be a young man who, following a mild traumatic brain injury during a car accident, does not receive any formal cognitive assessment or any guidance on recovery by NHS services. The NHS treatment focuses on his other injuries, but he experiences cognitive problems.

He goes online and reads about brain injury symptoms. During his rehabilitation funded by the claim, cognitive symptoms are attributed to emotional disturbances and he does not receive any expert formal assessment of his cognitive functioning. He is referred to a charity for people with head injuries where he shares his difficulties with other attendees. He starts feeling his life is ruined and feels resentful with the driver of the car in which he travelled. Eventually he receives an expert clinical neuropsychological assessment as part of his compensation claim. Twelve months post-accident he has not yet returned to work due to his self-perceived cognitive problems. He still suffers from anxiety and depression and his activities of everyday living are very limited.

At a formal assessment his cognitive test results indicate intact cognitive skills and treatment recommendations are made. He then goes on to receive cognitive-behavioural therapy (CBT) by a treating clinical neuropsychologist, including guidance on recovery following a mild brain injury and symptom misattribution. The aim is for the young man to feel again satisfied with his abilities, to feel able to cope, for him to gradually return to work, for his mood to improve and for his activities to return to normal levels.

This example highlights the importance of considering the whole clinical picture, both also relying on validated and standardised tools, both for the purpose of establishing diagnosis, causation and prognosis.

Clinical neuropsychologists

It therefore appears of paramount importance that a clinical neuropsychologist is involved in assessing someone's cognitive and emotional functioning and also be given access to any hospital records as well as GP's records. In most cases this is essential to be able to correctly identify the severity of a known or suspected brain injury as well as any pre-existing vulnerabilities, which in turn informs on recovery and provision of the most effective rehabilitation treatment, as well as impacting on the potential financial value of a case. As Professor Jane Ireland's review has found, some individuals appear to offer medico-legal services but lack the required professional qualifications.

Disregarding the complexities of psychosocial variables, some practitioners may otherwise be led to erroneously conclude someone intentionally feigns their symptoms when this is not the case.

This is why it is important that only qualified clinical neuropsychologists are involved in carrying out medico-legal evaluations of cognitive functioning. For those of you who are outside the field, being a chartered psychologist with the British Psychological Society (BPS) does not necessarily indicate that the psychologist is registered with the health and care profession council (HCPC), which would be statutorily required to be employed in the NHS.

Recent BPS professional guidelines (2013) stated that although the title of clinical neuropsychologist is at present not a legally protected title:

"To refer to oneself as a clinical neuropsychologist, consultant clinical neuropsychologist or to offer clinical neuropsychology services while not listed on the Specialist Register in Clinical Neuropsychology (SRCN) is acting against this professional and ethical guidance.

Professionals undertaking their Qualification in Clinical Neuropsychology training should always have their clinical neuropsychological work supervised by a member of the SRCN".

Dr Linda Monaci

Consultant Clinical Neuropsychologist

www.monaciconsultancy.com

Practitioner Psychologist (HPCP), Registered as a Chartered Psychologist (BPS). Full Practitioner of the Division of Clinical Neuropsychology.
Member of Expert Witness Institute.