NAN 2000 Poster Presentations (including References for Abstracts)

  1. Martelli, M.F., Zasler, N.D. & Pickett, T. (2000). Awareness Isnít Always Necessary for Rehabilitation. Archives of Clinical Neuropsychology, 15, 8, 659-660.
  2. Martelli, M.F., Zasler, N.D. & Pickett, T.C. & Hart, R.P. (2000). Advances in Cognitive Behavioral Rehabilitation in Acquired Brain Injury (ABI). Archives of Clinical Neuropsychology, 15, 8, 660.
  3. Martelli, M.F. and Zasler, N.D. & Pickett, T. (2000). Integrated Neuropsychologic and Neuromedical Assessment of Response Bias Following ABI. Archives of Clinical Neuropsychology, 15, 8, 661.
  4. Martelli, M.F. and Zasler, N.D. & Pickett, T. (2000). A Habit Retraining Model for Neurobehavioral Rehabilitation. Archives of Clinical Neuropsychology, 15, 8, 662.
  5. Martelli, M.F. and Zasler, N.D. & Pickett, T. (2000). Utility / Can EEG Biofeedback Help With Remediation of Post Concussive Disorders. Archives of Clinical Neuropsychology, 15, 8, 671.
  6. Martelli, M.F. and Zasler, N.D. & Pickett, T. (2000). Protocol for Management of Emotional Reactions Associated with Temporal Lobe Epilepsy. Archives of Clinical Neuropsychology, 15, 8, 670.

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Martelli, M.F., Zasler, N.D. & Pickett, T. (2000). Awareness Isnít Always Necessary for Rehabilitation. Archives of Clinical Neuropsychology, 15, 8, 659-660. Poster presentation at the National Academy of Neuropsychology Annual Meeting, Orlando, FL 2000.

Isnít Awareness Always Necessary for Rehabilitation Following Acquired Brain Injury (ABI)

Michael F. Martelli1,2, Treven C. Pickett1 and Nathan D. Zasler1

2Concussion Care Centre of Virginia, Ltd. and Tree of Life

3Virginia Commonwealth University / Medical College of Virginia

Introduction

Conventional wisdom, and the guiding principle for virtually all cognitive and neuropsychological rehabilitation efforts, assumes that awareness of impairments is a necessary first step in the rehabilitation of such residual brain injury deficits as memory, problem solving, and self-control difficulties. While this assumption is intuitively appealing, facilitating increased self-awareness in some brain injured individuals may also restrict and block rehabilitation interventions. Improperly applied, it can even undermine the optimization of adaptive behavior, a higher level goal that transcends the development of self-awareness.

Unawareness of deficit, often referred to as anosagnosia, has been recognized in the neurological literature for over a century. Increasingly, the phenomenon of unawareness has resurfaced in brain injury literature because it can generate significant dilemmas for rehabilitation. In the treatment of acquired brain injury (ABI), unawareness of deficits is often considered by clinicians to be a core problem that impedes progress and greatly influences outcome. An accumulating body of research has confirmed the clinical view that unawareness is both prevalent in ABI and predictive of poor outcome. In fact, large sample studies of persons with ABI indicate that a high proportion present with some degree of unawareness of deficit (Prigatano, 1996). This unawareness can seriously impede participation in rehabilitation by persons with TBI, and cause problems with motivation, engagement in therapy tasks, compliance with suggestions for behavioral change, and the use of compensatory strategies (Fleming, Strong, & Ashton, 1998).

A number of factors have been identified as possibly influencing the development of self awareness, including severity of injury as measured by initial Glasgow Coma Scale (GCS), length of coma, or length of posttraumatic amnesia (PTA), and location of brain lesion. Lesion site may impact the degree of self-awareness possible, as damage to frontal systems could produce a general decrease in levels of self-awareness, for example. McGlynn and Schachter (1989) have theorized that generalized unawareness of deficits  and cognitive deficits in particular  is due to impaired executive cognitive abilities associated with anterior cerebral dysfunction. In an applied sense, individuals capable of increased self-awareness after ABI pose a significant challenge to any rehabilitation team. An individualís ability to deny their deficits may be adaptive in the sense that this allows for the preservation of self-esteem and hope for the future. Therefore, treatment methods that highlight deficits in a confrontative way may trigger deeper depression and catastrophic reactions and be counterproductive in some individuals.

Denial of acquired disability has been proposed as a coping strategy for loss of previous life style in those with acquired injury and in those with major diseases such as stroke, lung cancer, and heart disease. It has also been suggested that both the prevalence and persistence of unawareness in those with ABI is more complicated in that it is brought about because of some mixture of organic impairment and psychological factors. Prigatano commented, "patients cannot maintain a productive lifestyle unless they have come to face the realities of their life and this means improving self-awareness and self-acceptance." (Fleming et al., 1998, p. 40). With respect to the hypothesis that self-awareness is necessary for successful ABI rehabilitation, however, the research findings have been mixed. In fact, a number of studies have failed to support the hypothesis that self-awareness of deficits positively impacts TBI outcome. Hence, the question remains whether or not self-awareness is necessary for ABI Rehabilitation.

Research Findings: Awareness and TBI Rehabilitation

The literature is more conclusive regarding the positive correlation between increased self-awareness and greater risk of experiencing emotional distress. Extreme emotional reactions (e.g., depression, anxiety, and catastrophic reactions) sometimes accompany the development of self-awareness and influence or compete with level of motivation. Several studies indicate a relationship between enhanced emotional reactions and increased self-awareness. For instance, Prigatano and Fordyce (1986) found a negative correlation between unrealistic self-appraisal and emotional distress. In this study, those patients who overestimated their abilities (relative to staff members) experienced less emotional distress. Ranseen, Bohaska, and Schmitt (1990), in their study of 32 TBI patients, found a modest correlation (r=-36; P=.041) between self-report of depression and the discrepancy between patient and staff ratings of competency. They observed relatively higher levels of depression in those patients with self-ratings closer to staff ratings. Linn, Allen, and Willer (1994), in a study of 60 TBI patients who were 6 years post injury, demonstrated that higher self-ratings of cognitive disability and social aggression were associated with higher depression. Godfrey, Partridge, Knight, and Bishara (1993), in a cross-sectional study of groups of TBI subjects at 6 months, 1 year, and 2 to 3 years post injury, demonstrated that greater self-awareness of behavioral deficits was associated with greater emotional distress at later stage post injury. The question remains as to whether the effects of emotional distress may impede involvement in rehabilitation and ultimately compromise outcome, or whether such distress serves as a motivator to rehabilitate for certain patients.

Fleming et al. (1998) found relatively greater motivation to change and more emotional distress among a high self-awareness group. This finding is consistent with the theories and anecdotal reports proposed by those who have observed a negative relationship between denial and depression, a positive relationship between motivational and emotional states, and complex interactions among denial and self-awareness, motivation, and emotion. Less clear is the relationship of self-awareness with outcome. Several researchers have reported better participation (Lam, McMahon, Priddy, & Gehred-Schultz, 1988) and better outcomes (e.g., Ezrachi, Ben-Yishay, Kay, Diller, & Rattok, 1991; Prigatano et al., 1994) for those postacute brain injury rehabilitation patients who demonstrated the most accurate self-awareness (Malec & Moessner, 2000). On the other hand, in their research, Fleming et al. (1998) hypothesized that persons with greater self-awareness of deficits would achieve better functional outcomes and community integration as a result of their enhanced motivation to comply with treatment, adopt compensatory strategies, and engage in behavioral change.

Findings failed to support this hypothesis, however, as no significant differences emerged in any of the outcome variables between the high self-awareness and low self-awareness groups. Explanations for this finding included the following:

  1. In the high self-awareness group, depression formed a feedback loop influencing motivational state, which led to a reduction in positive coping behaviors.
  2. No differences between high and low self-awareness groups may reflect measurements that were taken prematurely (1-year follow up). Perhaps given more time, the high self-awareness group may work through their emotional distress, and the high involvement in rehabilitation may begin to show results.

Other research (e.g., Fordyce & Roueche, 1986; Cavallo et al., 1992) has similarly failed to find a positive relationship between self-awareness and rehabilitation outcome (as measured by vocational or employment status) from traumatic brain injury.

Case Studies

The following is a striking example of overzealous attempts to increase awareness. A 23 year old severe brain injury survivor was unaware of the extent of his residual memory, mobility and behavior problems and seemed to cope with job and friend loss through excessive drinking. He initially was referred to a clinical psychologist who immediately proscribed drinking and enlisted family support to restrict purchase of alcohol. Within one week of forced sobriety, the survivor attempted to commit suicide and almost succeeded. Fortunately, his treatment provider consulted a rehabilitation neuropsychologist, and the new treatment plan called for specific assistance in coping with loss of job and friends, setting incremental goals for finding new friends, improving chances of sustaining reasonable employment through stepwise efforts, finding new, constructive activities to replace previous drinking, and education regarding drinking after brain injury. With simple encouragement and supportive counseling aimed at improving situational stress and general coping skills , drinking gradually reduced to infrequent.

In other cases, we have observed where significant improvements in behavior and coping are achieved without much or any increase in awareness. The following recent example is illustrative. A 47 year old New York executive who sustained a severe TBI almost 10 years ago had been treated at the best brain injury rehabilitation centers in the country. Despite this, and despite having received very specific, targeted, aggressive treatment for unawareness, he continued to interact with others in an insulting, impatient, aggressive, too frequently dictatorial and sometimes abusive manner. Initial treatment efforts with this clinician involved trying to identify his red flag situations (change in schedule, having to wait for a request, etc.), teaching him to recognize these, and respond with a strategic self corrective procedure. After a lot of practice and consistent staff intervention to help make it become a habit, this strategy showed some benefit. However, it was still a multiple-step procedure with room for error and misuse, it did not work on bad days or when he was already angry or for new situations that did not exactly fit with the red flag list> Further,, even though it was an easy procedure, he had trouble remembering, especially when angry, and the requirements for divided attention presented an additional obstacle. Subsequently, a much simpler and easier approach was tried. This approach did not require awareness, did not even involve confrontation with any unpleasant realizations about personal weaknesses. Instead, it emphasized an acceptable premorbid style relating to his being a New York native and instead even allowed jokes about his New York style. With practice, this strategy was soon adopted as a habit that worked pretty effectively in most situations. The strategy essentially involved instruction to increase smiling when talking with others..."the more important the communication, or the stronger you feel, the more you smile". Shaping to reinforce this habit was liberally provided and clearly assisted with acquisition.

In this second case example, a simple and intermittently present behavior, smiling, was increased as a habit. Importantly, smiling tends to produce pleasant interactions. It is incompatible with insult, aggression and an interpersonally abusive style. By itís increased presence, it tended to produce noticeably mellowed responses that were more pleasant and less impatient, aggressive or dictatorial in style. As a result, he continues to receive more satisfactory responses from others, which removes reasons for anger and increases reasons to smile. As time passed, the positive responses from others and the more satisfactory responses to his requests reward his smiling, in a cyclic and self perpetuating fashion.

Finally, there are situations where limited cognitive abilities, including concrete thinking, may leave persons unable to adequately increase awareness of problem behaviors. A recent illustrative example is that of a fairly bright 40 year old severe TBI survivor who had some unusual residual "holes" in cognitive abilities. He was treated for three years at some of the better brain injury rehabilitation centers and was transferred between institutions without improvement in persistent childish behaviors and lack of self awareness and self control. Attempts to incrementally increase awareness as a prerequisite step to modifying behavior failed, as did simple behavioral modification programs aimed at rewarding more adaptive behaviors. After several months at his fourth treatment program, it was determined that a combination of an unusual and concrete thinking style, an Axis II premorbid personality style and significant hysterical and other psychiatric symptoms made increasing awareness a near impossibility. As a result, his treatment program was modified considerably. Rather than emphasizing awareness, which was apparently too complex, behavioral interpretations were simplified and paired with dichotomous "positive" or "negative" labels. Explanations and attempts to appreciate his behavior beyond this were curtailed. A list of "negative" behaviors along with alternatively desirable "positive" behaviors was devised and reviewed extensively. Rewards were assigned for increasing ratios of good to bad behaviors and staff provided encouragement and praise for increasing semblance of "positive" behavior. In a short period of time, a pattern of consistent increases in appropriate behavior, and decreases in inappropriate behaviors, was observed.

Conclusions

Because the development of increased self-awareness is helpful in rehabilitative efforts for some TBI patients (and potentially harmful to others), devising reliable ways to identify candidates who would benefit from insight-oriented interventions is of paramount importance. Prigatano (1999), in his 10th Principle of neuropsychological rehabilitation, noted that "failure to identify which patients can and cannot be helped by different (neuropsychological) rehabilitation approaches creates a lack of credibility for the field" (p. 4). Facilitating self-awareness in certain TBI patients may have dire consequences if such persons are unable to cope with increased psychological insight. Individuals with relatively more severe organic deficits and/or psychologically fragile individuals might experience overwhelming distress when their customary defenses are disabled. In short, the increased knowledge of factors influencing self-awareness may assist rehabilitation professionals to determine which patients will benefit most from "insight-oriented" rehabilitation programs.

We argue that increasing awareness without first evaluating a personís self-esteem, abstract or higher level reasoning, or general coping abilities, is a "beginnerís mistake" for any therapist. Inexperienced therapists, for example, might employ confrontational strategies without realizing that a patientís unawareness may defend against powerful feelings of grief and/or helplessness. Stripping patients of primitive defense mechanisms without first offering new coping strategies may bring about overwhelming stress and/or emotional and behavioral deterioration that will hamper rehabilitation efforts. As such, approaching TBI rehabilitation from a stress/coping perspective, old and ineffective strategies should be replaced with newer, more effective ones. We believe that ineffective coping strategies are preferable to none at all, however, and that existing coping strategies (ineffective or not) should remain until another is offered in its place.

In summary, although increasing awareness about deficits and maladaptive coping that results from brain injury is often important, and although it is often a logical or necessary first step in modifying ineffective behavior, it is not always necessary. In fact, there are many situations in where efforts to increase awareness before new coping strategies are acquired will cause increased emotional distress and catastrophic fears to the point that more harm than good can occur. Further, there are situations where it is infinitely easier to change a behavior than change awareness. Finally, there are situations where limited cognitive abilities, including concrete thinking, may leave persons unable to increase awareness of problem behaviors. In these situations, simplifying expectations and rewarding desirable behaviors, in order to build desirable habits, is a more effective alternative to increasing awareness.

References:

Cavallo, M. M., Kay, T., Ezrachi, O. (1992). Problems and changes after traumatic brain injury: Differing perceptions within and between families. Brain Injury, 6, 327-335.

Ezrachi, O., Ben-Yishay, Y., Kay, T., et al. (1991). Predicting employment in traumatic brain injury following neuropsychological rehabilitation. Journal of Head Trauma Rehabilitation, 6, 71-84.

Fleming, J. M., Strong, J., & Ashton, R. (1998). Cluster analysis of self-awareness levels in adults with traumatic brain injury and relationship to outcome. Journal of Head Trauma Rehabilitation, 13(5), 39-51.

Fordyce, D. J. & Roueche, J. R. (1986). Changes in perspective of disability among patients, staff, and relatives during rehabilitation of brain injury. Rehabilitation Psychology, 31, 217-229.

Godfrey, H. P. D., Partridge, F. M., Knight, R. G., Bishara, S. (1993). Course of insight disorder and emotional dysfunction following closed head injury: A controlled cross-sectional follow-up study. Journal of Clinical Experimental Neuropsychology, 15, 503-515.

Hart, T., Giovannetti, T., Montgomery, M. W., & Schwartz, M. F. (1998). Awareness of errors in naturalistic action after traumatic brain injury. Journal of head trauma rehabilitation, 13(5), 16-28.

Lam, C. S., McMahon, B. T., Priddy, P. A., Gehred-Schultz, A. (1988). Deficit awareness and treatment performance among traumatic head injured adults. Brain Injury, 2, 235-242.

Malec, J. F., & Moessner, A. M. (2000). Self-awareness, distress, and postacute rehabilitation outcome. Rehabilitation Psychology, 45(3), 227-241.

McGlynn, S. M., & Schachter, D. L. (1989). Unawareness of deficits in neuropsychological syndromes. Journal of Clinical and Experimental Neuropsychology, 11, 143-205.

Prigatano, G. P. (1991). Disturbance of self-awareness of deficit after traumatic brain injury. In: Prigatano, G. P., Schachter, D. L., eds. Awareness of Deficit After Brain Injury. New York, NY: Oxford University Press.

Prigatano, G. P., Klonoff, P. S., OíBrien, K. P., Altman, I. M., Amin, K., Chiapello, D., Shepard, J., Cunningham, M., & Mora, M. (1994). Prductivity after neuropsychologically oriented milieu rehabilitation. Journal of Head Trauma Rehabilitation, 9(1), 91-102.

Prigatano, G. P. (1996). Behavioral limitations TBI patients tend to underestimate: A replication and extension to patients with lateralized cerebral dysfunction. Clinical Neuropsychology, 10, 191-201.

Prigatano, G. P. (1999). Principles of Neuropsychological Rehabilitation. New York, NY: Oxford University Press.

Ranseen, J. D., Bohaska, L. A., & Schmitt, F. A. (1990). An investigation of anosagnosia following traumatic head injury. International Journal of Neuropsychology, 12, 29-36.

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Martelli, M.F. and Zasler, N.D. & Pickett, T. (2000). Integrated Neuropsychologic and Neuromedical Assessment of Response Bias Following ABI. Archives of Clinical Neuropsychology, 15, 8, 661.

Poster presentation at the National Academy of Neuropsychology Annual Meeting, Orlando, FL 2000.

A Model for Neurologic and Neuromedical

Motivation Assessment Profiling (MAPíing) of

Response Bias Following ABI

Michael F. Martelli, PhD, Nathan D. Zasler, MD and Treven C. Pickett, ABD

Concussion Care Centre of Virginia, Pinnacle Rehabilitation and Tree of Life

Richmond-Glen Allen, Virginia

Medical College of Virginia and Virginia Commonwealth University

Abstract

Neuropsychological and neuromedical evaluative procedures for assessing ABI sequelae are critically reviewed. Neuropsychological assessment frequently provides the primary evidence of neurologic impairment following mild and moderate brain injury. The validity of this assessment, however, is dependent upon the cooperation and motivation of the client. Notably, litigation introduces a situation where financial incentive to perform poorly frequently exits. In this proposal, neuropsychological and neuromedical evaluative procedures for assessing neurologic impairment following acquired brain injury are critically reviewed. The literature relating to current instruments and procedures for assessing motivation and response bias is summarized, with special emphasis on currently available instruments and interpretive findings from commonly used tests and interview procedures. A multiaxial conceptual model is presented and a procedural instrument for completing a profile of motivation and response bias which incorporates a wide array of findings from commonly employed instruments and procedures during ABI evaluation that are derived from neuropsychology, in addition to psychology, psychiatry, neurology and physiatry. Finally, explicit and comprehensive recommendations for enhancing motivation, assessing response bias, and increasing efficiency, utility and ecological validity of ABI assessment are offered.

Introduction

With regard to neuropsychological assessment, response bias represents an especially important threat to validity. Neuropsychological assessment usually begins with interview about self-reported symptoms and subsequently relies heavily on standardized measures of performance on well-normed tests. Hence, its validity and utility requires the veracity, cooperation and motivation of the examinee for obtaining valid performance measures. Increasing evidence, however, clearly demonstrates that self-reported symptoms associated with neuropsychological deficits can be unreliable and non-descriminatory (e.g., Lees-Haley, Williams, Zasler and Margulies, in press). This is especially true with post-concussive deficits since these symptoms often appear with similar frequency in both non neurologic groups and even the general population (Lees-Haley and Brown, 1993). Further, the demonstrated ability of neuropsychologists to accurately detect malingering in test protocols has been less than impressive (e.g., Loring, 1995). Additionally, the common utilization of technicians to administer tests has been called into question in the 1996 Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology for reasons that include concerns about the adequacy to utilize behavioral observation information and appreciate qualitative aspects of test performance to maximize testing utility; detection and management of testing response bias issues are at least implied. Nonetheless, various instruments, techniques and strategies are available which have demonstrated at least some utility in detecting response bias, especially malingering, as a means of increasing confidence in motivation and effort during neuropsychological tests, and hence the validity of performance findings.

Importantly, examinee expectancy in independent examinations is a relevant topic that has been underappreciated with regard to effect on behavior during neuropsychological examinations. The first +author gathered survey data to evaluate examinee expectation against the backdrop of an adversarial legal and health system. Attitudinal data from professionals who work with injured Workers Compensation (WC) patients was collected. A summary of the preliminary data are quite compelling. Overall, approximately 25% of WC patients are believed to be exaggerating or malingering, which suggests a general skepticism and distrust faced by injured persons during evaluations. In contrast, the majority of professionals filling out the survey believed they would be treated unfairly by the WC system if they were injured, suggesting the corrolary of a general skepticism and perhaps greater distrust of the extant systems that evaluate and treat injury and disability.Although preliminary and from small samples, and although generalizability across situations cannot be assumed, these data seem nonetheless compatible with the levels of diffuse distrust observed by the authors in medicolegal situations. These data highlight the importance of considering the presumably different set of motivational factors that operate on examinees who present to independent evaluations. They also argue strongly for assessment of response bias during medicolegal examinations. Finally, the suggest that consideration should be given to thorough preparation of examinees prior to the examination in order to reduce response bias.

Finally, in the case of most neuropsychological evaluations, additional medical examinations are also conducted. Although many medical tests are considered objective, and hence less prone to motivation or effort effects, the fact remains that significant portions of most medical examinations still rely on examinee complaints and history as well as physical exam procedures that are susceptible to response bias.

Procedure

A multiaxial conceptual model and associated procedure for completing a profile of motivation and response bias which incorporates a wide array of findings from common instruments during ABI evaluation, including multiple medical fields as well as neuropsychology. Finally, explicit and comprehensive recommendations for enhancing motivation, assessing response bias, and increasing efficiency, utility and ecological validity of ABI assessment are offered.

In the included table, an illustrative summary of some specific response bias detection strategies is presented, in an integrated format. Importantly, these strategies are presented as illustrations of indicators of important information for interpreting neuropsychological test data within a larger context of multidisciplinary evaluation for ABI. This approach integrates contextual information, history, behavioral observation, interview data, collaborative data, personality data, with measures of effort or performance (or symptom exaggeration or malingering) and neuropsychological and medical examination performance data. This approach potentially offers increased reliability with regard to estimating the degree to which an examinee is exerting full effort or withholding or distorting effort or performance, and the degree to which specific and general test results from multiple assessment areas are reliable and valid and reflect true abilities.

This multiaxial conceptual model is presented with a methodology and procedural instrument for completing a profile of motivation and response bias which incorporates a wide array of findings from common instruments during ABI evaluation. Empirical support exists indicating that each of these indicators has some utility in detecting suboptimal effort. Examining the pitfalls and limitations of each of these procedures, both conceptual and methodological, is well beyond the scope of this poster. However, increasing evidence exists for improved discrimination and increased reliability when multiple measures are employed. The conceptual approach offered by the proposed Motivation Assessment Profiling (MAPing) is one where behavioral observation, interview, collaborative, historical and personality and contextual data with neuropsychological and medical performance data and measures of effort or performance (or response bias) are integrated as an optimal method for estimating the degree of effort or performance and the degree to which test results are reliable and valid and reflect actual abilities. This conceptual model and a procedure (MAP) for estimating motivation economically incorporates currently available instruments and methods and, and the available published research, for direct and indirect measurement of motivation and response bias.

Notably, these strategies are not offered individually and are not intended to support a simple dualistic model that assumes examinees either try hard or malinger, or that evidence of less than full effort on any one test necessarily implies absence of impairment in other areas of testing or in real world abilities. Although they are also not offered with specific guidelines (e.g., failure on any one, or any two, or any three, etc., represents inadequate performance, or symptom exaggeration or malingering), they are offered with the suggestion that:

Notably, a significant disparity exists between the adversarial legal process and responsibility of attorneys as client advocates versus the more dispassionate and objective scientific ethics expected of psychologists and physicians, especially in the independent examiner role. The danger of attorney "coaching" based on utilization of this material cannot be underestimated. This, of course, would then represent a form of "stealth" threat to the validity of examination data. This threat, or expected consequence of collision between the disparate legal and scientific ethics, has recently been documented in a national publication, noting a case of attorney client coaching (Youngjohn, 1996). However, compared to simpler models where only a couple of isolated response bias measures are used, it seems extremely unlikely that the multiple measures employed in the MAP approach could be understood and manipulated.

Finally, enhancing response bias detection as a means of optimizing interpretability of neuropsychological test and neuromedical examination results, critical as it is, should not be considered the final step. Decreasing response bias must certainly be considered a more efficacious and economic approach to enhancing utility of neuropsychological and neuromedical assessment.

Table 3: Motivation Assessment Profiile Neuropsychological Assessment (MAP  NA)

Performance Patterns on Existing Neuropsychological Tests

Full Scale IQ

Low (vs. expected, estimated, etc.)

 

Digit Span (Floor Effect)

**Age Scale Score < 7

 

Digit Span: Testing Limits with "Chunking"

Non-improvement with "chunking"

 

Arithmetic and Orientation scale Performance

"Near-miss" (Ganser errors).

 

WMS-R Malingering Index: Attention/ Concentration Index versus Memory Index

Attention-Concentration Index Score < General Memory Index(AC-GMI)

 

Paired Associate learning: Easy vs. Hard item Performance

Hard Items >= Easy Items

 

General Neuropsych Deficit Scale (Reitan & Wolfson, 1988)

**GNDS Score < 44

 

Speech Sounds Perception Test Performance

*>17 errors (Poor)

 

Seashore Rhythm Test Performance

*>8 errors (Poor)

 

Finger Tapping Test

Unusually low w/o gross motor deficit

 

Tactual Stimulation Performance

Errors bilaterally vs. laterally

 

Finger Tip Number Writing  Errors

**> 5

 

Finger Agnosia  Errors

*> 3

 

Grip Strength

Unusually low w/o gross motor deficit

 

Categories Test Performance

Rare or "spike three" errors; Or > 1 Error on Trials I or II

 

Wisconsin Card sorting Test Errors

Discrepant # Perseverative vs. # Category Errors

 

Recognition memory (RAVLT)

*< 6

 

Recognition memory (CVLT)

*< 13

 

List Learning Serial Order Effects

Abnormal patterns

 

Warrington Recognition Memory Test (RMT)

Score < 38 (RMW), < 26 (RMF)

 

Rey Complex Figure and Recognition Trial

Atypical Recognition Errors (>=2); Recognition Failure Error

 

Word Stem Priming Task Performance

Poor or unusual performance

 

Instruments to Specifically Evaluate Level of Effort/Response Bias

Symptom Validity Testing (SVT)

< 50% chance level responding

 

Hiscock Forced Choice Procedure (HFCP)

< 50% chance level responding, <66 correct

 

Victoria Symptom Validity Test (VSVT)

< 50% chance level responding, <16 on easy and/or hard items

 

Portland Digit Recognition Test (PDRT)

< 50%, chance responding

 

21-Item Test

<5 on free recall, <3 on free recall, <13 on recognition, <9 on recognition

 

Test of Memory Malingering (TOMM)

< 50% chance level responding

 

Forced Choice test of Nonverbal Ability (FCTNA; Frederick & Foster, 1991)

< 50% chance level responding

 

Dot Counting Test (DCT)

Correct/incorrect responses

 

Computer Assessment of Response Bias (CARB)

< 89% raises suspicion

 

Autobiographical Interview (Wiggins & Brandt, 1988)

>3 errors

 

Memorization of 16 Items Test (MSIT)

>8 Omissions, >6 Omissions, <6 Total Correct

 

Rey Word Recognition List (WRL)

<6 correct, <5 (total correct minus false positives)

 

Rey Memory for 15 Items Test (MFIT)

Lezak (1983), < 3 complete sets, <9 items

 

Priming/Implicit Memory Tests

Word Completion Memory Test (WCMT)

R<9 or Inclusion <15

 

Personality Instruments with Built-in Detection Designs

Personality Assessment Inventory (PAI)

  • Inconsistency (INC), Infrequency (INF), Positive Impression Management (PIM), and Negative Impression Management (NIM) scales.
  • 8 score patterns thought to comprise a "Malingering Index" (Morey, 1996).
  • >2 patterns malingering suspected
  • >4 patterns likely malingering

 

Minnesota Multiphasic Personality Inventory (MMPI-2)

  • Validity indices (L, F, Fb, Fp, Ds, K, VRIN, TRIN), F-K (Gough, 1954)
  • The Fake Bad Scale (Lees-Haley, 1991)
  • Compare subtle to obvious items
  • Rogers et al (1994)  cutoff scores:

Liberal:

  1. F-Scale raw score > 23
  2. F-Scale T-Score > 81
  3. F-K Index > 10
  4. Obvious  subtle score > 83

Conservative:

  1. F-scale raw > 30
  2. F-K index > 25
  3. Obvious  subtle score > 190

 

Qualitative Variables in Assessing Response Bias

Time /Response Latency Comparisons Across Similar Tasks

Inconsistencies across tasks

 

Performance on Easy Tasks Presented as Hard

Low scores or unusual errors

 

Remote Memory Report

Difficulties, especially if < recent memory, or severely impaired in absence of gross amnesia

 

Personal Information

Very poor personal information in absence of gross amnesia

 

Comparison Between Test Performance & Behavioral Observations

Discrepancies

 

Inconsistencies in History and/or Complaints, Performance

Inconsistencies across time, interviewer, etc.

 

Comparisons for Inconsistencies Within Testing Session (Quantitative & Qualitative):

  • A. Within Tasks (e.g., Easy vs. Hard Items)
  • B. Between Tasks (e.g., Easy vs. Hard)
  • c.. Across Repetitions of same/parallel tasks (R/O fatigue),
  • d. Across similar tasks under different motivational sets

 

Comparisons Across Testing Sessions (Qualitative, Quantitative)

Poorer/inconsistent performance on re-testing

 

Symptom Self Report: Complaints

High Freq. of complaints; patient complaints > significant othersí

 

Main & Spanswick, 1995

  • Failure to comply with reasonable treatment
  • Report of severe pain with no associated psychological effects
  • Marked inconsistencies in effects of pain on general activities
  • Poor work record and history of persistent appeals against awards
  • Previous litigation

 

 

Symptom Self Report: Early vs. Late Symptom Complaint

Early Symptoms reported late

 

NEUROMEDICAL INDICATORS

 

Hooverís test

Test for malingered lower extremity weakness associated with normal crossed extensor response

 

Astasia abasia

"drunken type" gait with near-falls but no actual falls to ground

 

Non-organic sensory loss

Patchy sensory loss, midline sensory loss, large scotoma in visual field, tunnel vision

 

Non-organic upper extremity drift

Long tract involvement results in pronator type drift. Proximal shoulder girdle weakness and malingering typically present with downward drift while in supination.

 

Stengerís Test

Test for malingered hearing loss during audiologic evaluation.

 

Gait discrepancies when observed versus not observed

If organic should be consistent regardless of whether observed or not.

 

Gait discrepancies relative to direction of requested ambulation

Gait for a patient with hemiparesis should present similarly in all directions; malingerers do not as a rule practice a feigned gait in all directions.

 

Forearm pronation, hand clasping and forearm supination test for digit/finger sensory loss

Malingered finger sensory loss is difficult to maintain in this perceptually confusing, intertwined hand/finger position

 

Pain versus temperature discrepancies

Due to the fact that both sensory modalities run in the spinothalamic tract, they should be found to be commensurately impaired contralateral to the side of the CNS lesion.

 

Lack of atrophy in a chronically paretic/paralytic limb

Lack of atrophy in a paralyzed/paretic limb suggests the limb is being used or is getting regular electrical stimulation to maintain mass.

 

Impairment diminishes under influence of sodium amytal, hypnosis or lack of observation

All these observations are most consistent with non-organic presentations including consideration of malingering or conversion disorder.

 

Incongruence between neuroanatomical imaging and neurologic examination

Lack of any static imaging findings on brain CT or MRI in the presence of a dense motor or sensory deficit suggests non-organicity.

 

Face-hand test in "low level" examinee

An aware patient malingering profound alteration in consciousness will not let their own hand be held over their head and dropped onto their face.

 

Presence of ipsilateral findings when implied neuroanatomy would dictate contralateral findings

An examinee claiming severe right brain damage who claims right eye blindness and right-sided weakness and sensory loss.

 

Tell me "when Iím not touching" responses

An examinee with claimed sensory loss who endorses that he does not feel you touch him when you ask him to tell you "if you do not feel this".

 

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Martelli, M.F. and Zasler, N.D. & Pickett, T. (2000). Utility / Can EEG Biofeedback Help With Remediation of Post Concussive Disorders. Archives of Clinical Neuropsychology, 15, 8, 671.

Presentation at the National Academy of Neuropsychology

Annual Meeting, Orlando, FL 2000

Can EEG Biofeedback Help with Remediation of Post Concussive Disorders?

Michael F. Martelli, Ph.D, Nathan D. Zasler, MD and Treven C. Pickett, MS

Concussion Care Centre of Virginia and Pinnacle Rehabilitation

Introduction to EEG Biofeedback

EEG Biofeedback, also known, unfortunately, as Neurofeedback, Brain Wave Training, and Neurotherapy, is an application of the traditional biofeedback self regulation model. Like all biofeedback applications, the goal of EEG Biofeedback is enhanced control of patholophysiologic function. An extensive technical neuroanatomical and bioelectrochemical narrative is beyond the scope and intent of this paper. Briefly, however, brain waves are brought about by groups of cortical neurons firing in synchrony, resulting in a wave-like effect measurable as electrochemical activity via Electroencephalography, or EEG. A number of wave frequency types have been identified, including: Delta (2-3 c.p.s.), Theta (4-7 c.p.s.) Alpha (8-12 c.p.s.) Low Beta or Sensory Motor Rhythm (13-15 c.p.s.), Beta (16-20 c.p.s.) and High Beta (21-40 c.p.s.). Associated with each frequency range are characteristics of consciousness, as for example slow wave activity, which is associated with a meditative state of consciousness, and Beta range frewquencies, associated with active concentration.

The practice of applied biofeedback, simply stated, is based on the observation and principle that enhanced feedback about apparently involuntary physiologic processes allows increased control of these systems. New applications to EEG biofeedback training emerged in the early 1970ís with replicated demonstrations of efficacy, specifically the suppression of seizures in animal and human subjects, who had been exposed to seizure-inducing jet fuel. EEG biofeedback training techniques were later successfully employed with poorly controlled and drug resistant epileptics. More recently, clinical report, case study evidence, and initial group study data supporting the utility of EEG biofeedback training for attentional disorders has appeared. There is mounting evidence biofeedback interventions may be helpful in treating learning disabilities, symptoms of depression and anxiety, and fatigue and sleep disorders. Applied research supports the viability of neurofeedback as a useful adjunct intervention for a variety of presenting clinical presentations. Some findings support EEG biofeedback interventions as useful in the rehabilitation of CVA (Rozelle & Budzynski, 1995), the treatment of psychophysiologic insomnia (e.g., Hauri, Percy, Hellekson, Hartmann, & Russ, 1982), ADD/ADHD (e.g., Kaiser & Othmer), and epilepsy (Kotchoubey et al., 1977). Lubar & Seifert (1975) published the first article dealing with the reduction in seizure activity by using neurofeedback training. Lubar and Bahler (1976) published a series of case studies showing the effectiveness of SMR training in reducing seizures, replicating Stermanís (1973) findings. The practice of clinical psychophysiology / applied biofeedback, which is predicated on the provision of enhanced feedback about pathophysiologic processes in order to increase control over and restore normal function, has well-documented clinical efficacy for musculoskeletal and vascular responses. The practice of applied biofeedback, simply stated, is based on the observation and principle that enhanced feedback about apparently involuntary physiologic processes allows increased control of these systems.

Applications of EEG Biofeedback in the Remediation of Post-Concussive Symptoms

More recently, preliminary evidence is emerging which also suggests that EEG Biofeedback training may be useful for simultaneously reducing frequently seen abnormalities in EEG patterns and the remediation of persistent cognitive, emotional, fatigue and sleep related problems following TBI. The symptoms which accompany minor head injury include principally loss of energy; headaches and chronic pain; dizziness and vertigo; memory impairment; difficulty concentrating; anxiety, depression, and mood swings; sleep disturbances; irritability; visual perception problems and dyslexia; and even apparent personality changes. These common persisting impairments following traumatic brain injury (TBI) present formidable challenges to the field of brain injury rehabilitation. The long-term consequences of Minor Traumatic Brain Injury (MTBI) have recently become more widely acknowledged. Persons suffering loss of function due to minor head injuries were usually given CAT scans and MRI scans, which might not reveal any organic injury. As a result, victims were often not taken seriously, and accused of fabricating their symptoms and malingering. More recently, tests of brain function have demonstrated a basis for the symptoms that are described. Such tests include PET scans, topographic brain mapping of EEG activity, and evoked response measurements. These functional tests reveal changes in cortical activation, anomalous EEG activity traceable to head injury, and slowed response.

Normative quantitative EEG data have been collected which demonstrate consistent abnormalities in EEG patterns in patients with TBI (e.g., Thatcher, Walker, Gerson, Geisler, 1989). Related training efforts to normalize these identified patterns have been associated in case study and preliminary data with improvement in clinical symptomatology (e.g., Byers, 1995; Hoffman, Stockdale, Hicks, Schwaninger, 1995). Further, there are additional suggestions that these results can be obtained, with longer training duration, in cases of moderate and severe TBI (e.g., Ayers, 1988). The practice of clinical psychophysiology / applied biofeedback, which is predicated on the provision of enhanced feedback about pathophysiologic processes in order to increase control over and restore normal function, has well-documented clinical efficacy for musculoskeletal and vascular responses. More recently, preliminary evidence is emerging which also suggests that EEG Biofeedback training may be useful for simultaneously reducing frequently seen abnormalities in EEG patterns and the remediation of persistent cognitive, emotional, fatigue and sleep related problems following TBI.

Initial findings by the authors from three subjects with persistent post-concussive symptoms following TBI who underwent serial EEG Biofeedback training, Relaxation training, and Cranial Electrical Stimulation (CES - microcurrent to the scalp, which produces increased alpha brain waves) offer support for moderate self-rated symptom improvement. Results indicated greater self-reported symptom resolution following both EEG Biofeedback training and Cranial Electrical Stimulation (known to produce a strong temporary SensoriMotor Rhythm) versus a tape based relaxation procedure and Cranial Electrical Stimulation. These initial results are promising and further investigation is being conducted. Importantly, if reports of clinical utility can be given empirical substantiation, then a promising new treatment modality will become available at a time that technology has made this option extremely affordable.

Other research by Len Ochs, Ph.D., evaluated the efficacy of EEG-driven photic stimulation in the treatment of twenty consecutively-admitted outpatient mild-to-moderate traumatic closed head injury patients, with heterogeneous secondary psychiatric diagnoses, 3-years post accident. Treatments consisted of an average of 16, daily, 20-minute exposures of EEG-driven photic stimulation. The dominant EEG, between 1 and 40 Hz, was extracted 128 times a second and used to reset the strobe frequency 128 times a second. The strobe frequency was always offset from the dominant frequency. After the treatments, 19 of 20 patients reported more energy during the day, better sleeping at night, much less depression, irritability, and explosiveness, better sense of humor and assertiveness, better concentration, much greater ability to get things done (without ambivalence), and increased ability to absorb written and verbal information. Additionally, subtle neuropsychological skill recovery was observed in attention/concentration, social reasoning and judgement, and academic domains. While this treatment is non-cognitive and non-psychotherapeutic, as compared to traditional EEG biofeedback treatment methods, EEG activity results were similar to those obtained in EEG biofeedback, except obtained in 20% the typical treatment time.

EEG Biofeedback and ADHD

EEG Biofeedback applications in the treatment of ADD/ADHD grew out of serendipitous findings of improved attentional skills during training of epileptics. EEG biofeedback teaches children to control and regulate brainwave activity in ways that increase frequencies associated with improved attentional focus and decreased distractibility, impulsivity, and hyperactivity.

Using computerized video arcade type programs, children are shaped to use "EEG feedback" to recognize and better regulate brainwave patterns. With continuing feedback, coaching, and practice, children can learn to produce stronger brainwaves in frequency ranges associated with higher states of alertness and more focused, sustained attention spans, and decreased impulsivity, restlessness, etc. .

Observed benefits of EEG training for ADD/ADHD, across numerous replicated case studies and a few group studies include: Decreased impulsivity/ hyperactivity; Increased mood stability; Improved sleep patterns; Increased attention span; Improved academic performance; Increased retention and memory; Improved self-esteem.

Numerous theories and protocols have been proposed for using EEG Biofeedback as an effective assessment and treatment option for ADHD children, including Satterfieldís (1973) "low-arousal "hypothesis that proposed an cortical under-arousal and decreased beta amplitudes. Later case studies by Shouse and Lubar (1976) determined that neurofeedback training using SMR with theta inhibition was an effective treatment intervention with ADHD children. Lubar began treating ADHD children using neurofeedback in 1976. He found excessive theta activity and deficit beta production.in children with attention and reading difficulties, but not with hyperactivity problems. Lubar, Bianchini, Calhoun, and Lambert (1985) provided a strong rationale concerning theta suppression. From 1986 to 1991, topographic brain mapping studies demonstrated differences in EEGís between ADHD and matched controls. Mann, Lubar, Zimmerman, et al. (1992) compared brain mapping of ADHD and non-ADHD boys, revealing increased theta production and decreased beta production in ADHD boys; also EEG frequency for the ADHD boys corresponded to younger children. Rossiter and LaVaque (1995) offered evidence that EEG Biofeedback is a viable alternative to the use of stimulant medication. Other more recent studies (Linden, Habib, & Radojevic, 1996; Lubar, Swartwood, Swartwood, & OíDonnell, 1995) continue to provide evidence for effectiveness of EEG BF for ADHD children.

Lubar, Research on Neurofeedback in Children with ADD

University of Tennessee - after 40-60 Sessions:

Treatment Protocols

THATCHER QEEG MILD TBI ASSESSMENT PROCEDURE

MARGARET AYRES NEUROTHERAPY PROTOCOL

FLEXYX NEUROTHERAPY SYSTEM: LEN OCHS (EEG Driven Stimulation)

ALPHA-THETA TRAINING (PENNISTON) cf. Period 3 (V. Brown)

BARRY STERMAN EPILEPSY PROTOCOL: SMR TRAINING

QUIRK SMR PROTOCOL

ALPHA ASSYMETRY AFFECTIVE DISORDERS PROTOCOL (J Peter Rosenfeld)

WIDEBAND AMPLITUDE REDUCTION (Dan Maust) or

Sequential Quieting Across the Spectral Horizon (SQUASH: Mike Martelli) or

Peak Achievement Trainer (Jonathon Cowan)

MAUST CLINICAL USES OF WIDEBAND AMPLITUDE REDUCTION

PEAK ACHIEVEMENT TRAINING FOR CONCENTRATION AND NEW LEARNING (J.Cowan)

The Concentration and Relaxation Cycle in Everyday Experience

Alpha and Theta are Actually Signs That the Cortex is Idling

A Major Goal of Peak Achievement Training is to Activate the Executive Attention Network

A Major Goal of Training is to Fine Tune the Concentration-Relaxation Cycle

Training Concentration - Relaxation Cycle: Relaxation II via breathing as cue for relaxed microbreaks

Developing Transfer Techniques

REFERENCES:

References on EEG Biofeedback and Attention Deficit