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New Jersey Law Journal
June 28, 2004
PERSONAL INJURY LAW
Brain Injuries Affect More than Cognition
By Dr. GERALD TRAMONTANO
Attorneys must examine the emotional, social and
behavioral implications of their clients with head trauma
Ronald Brown (not his real name), a
truck driver for a large hauling
company, suffered a mild traumatic
brain injury while driving on the job.
Initial MRI and CT scans ruled out any
hemorrhage, blood clots or structural
damage. Mr. Brown never lost consciousness
and experienced no amnesia.
After several weeks, once he recovered
from typical post-concussive symptoms
— feelings of nausea, headaches, sensitivity
to light and temporary cognitive
impairment — he returned to work.
Months later, as a result of his
injuries, he sued his employer and
insurance company. Defense attorneys
countered by arguing since there was no
structural brain damage evidenced, and
no permanent cognitive or memory
loss, they were not liable for damages.
Mr. Brown’s lawyer acknowledged
this, but based his case on the outcome
of a battery of neuropsychological tests
that we administered to Mr. Brown to
assess cortical functions and standardized
questionnaires administered to
family members. Neuropsychological
assessment can detect neuropathology
that cannot be diagnosed by traditional
neurological and psychiatric exams. It
can show brain pathology even when
there is little if any cognitive impairment
or memory loss.
Based on our testing of Mr. Brown,
we found extensive personality, interpersonal
and behavioral changes that
are consistent with an injury to the
orbital frontal structures of the brain. In
fact, this is an area where virtually no
cognitive networks exist and, so, cognition
often remains intact. Rather, it controls
emotional and social functioning.
In Ron Brown’s case, we found that
his ability to regulate his emotions and
make appropriate social decisions had
been devastated by the injury. As a
result, he suffered from bouts of depression,
anxiety and irritability. He experienced
mood swings and was emotionally
labile. His social judgment was
impaired; he said things out of context,
acted impulsively, and had problems in
developing new relationships and maintaining
existing ones. Members of his
family, when interviewed, all agreed
that while his intellect seemed unaffected,
his personality had changed dramatically.
Based on testimony relating
these findings, Mr. Brown received a
significant financial settlement.
Unfortunately, many plaintiff’s
attorneys fail to consider these neuropsychiatric
symptoms of a post-concussive
syndrome (sometimes referred
to as one of the invisible neurobehavioral
syndromes) that are often more
disabling then the cognitive deficits of
mild TBI. This is a mistake, since a mild
TBI can have major repercussions on
the injured party’s ability to function
emotionally, socially and vocationally.
These are individuals who look fine
until placed in interpersonal situations,
at which time the symptoms come to
life.
Attorneys need to be aware that their
mild TBI clients may suffer from
“Organic Personality Syndrome,” which,
simply put, means that they don’t regulate
their emotions or interpersonal
world well. They don’t make appropriate
judgments like they did before their
injury. They may possess a lack of cognitive
stamina, a low frustration tolerance,
mood swings, and attention
deficits. In the case of one young
woman, it prevented her from fostering a
positive and enduring relationship with
her boyfriend who broke off their
engagement to be married some years
after the injury. In the case of an older
man, it resulted in his family restricting
their time with him due to frequent hurtful
and inappropriate remarks he made to
other family members, including his own
grandchildren. Both were cognitively
intact, but proved limited in their ability
to deal with the social nuances of life.
Consider the case of Rhonda. As a
project director at a major pharmaceutical
company, Rhonda handled a very
challenging and hectic job that meant
juggling a number of different responsibilities.
A head injury minimally affected
her cognitive ability, due to her enormous
cognitive reserves. However, the
price of this compensation was too high
and she was unable to maintain her
employment due to an inability to cope
with the stress or manage her disabling
fatigue. The stress took over every
aspect of her life. She became disabled
not because of the cognitive change
itself — she remains exceedingly bright
and talented — but the incapacity to
modulate stress.
Much of this emotional deregulation
doesn’t show itself overnight. It
happens once patients become more
and more integrated into each layer of
their life. During the weeks following
the injury, mild TBI victims are typically
taking it easy, recovering from the
nausea, the fatigue, the fuzziness and
light-headedness. Once they start feeling
better, and are confronted with the
full spectrum that life has to deliver,
they become more symptomatic.
Psychologically, they may experience
secondary and tertiary reactions that
make it worse. Once they begin to sense
the changes in themselves, they may
become more anxious and depressed,
even suicidal.
During the first year, many patients
see that progress is being made in their
psychological reactions to the injury.
This may hold certain symptoms in
abeyance. It’s only when the gains slow
down and then stop, say in year two,
that the realization comes that emotionally
this is who they are. This is when
depression and anxiety can hit hard.
A neuropsychological workup is
the only standard test for evaluating
cortical functions. While a psychological
test will diagnose psychiatric disorders
like post-traumatic stress disorder
and schizophrenia, it will not discern
neurocognitive and neurobehavioral
syndromes such as dysbula, dysexecutive
syndromes or apraxia. Since psychiatric
disorders, like major depression,
can also affect brain functions, a
psychiatric exam is built into every neuropsychological
evaluation. When it
comes to patients with injuries to the
orbital frontal structure, the assessment
itself may include a range of exams
from a smell identification test (the
olfactory bulb sits right in the middle of
the orbital front cortexes) to asking
family members to rate the individual
on personality and emotional/social
functions before and after the injury.
This kind of testing is not only a
valuable tool for the attorney who needs
to show, quantify and document evidence
of brain pathology, but it can demonstrate
normal brain functioning. This can help
identify those individuals who are malingering
or embellishing their cognitive
and psychiatric symptoms.
The bottom line is that attorneys
need to look past the cognitive and
memory loss of their mild TBI clients,
to also examine the emotional, social
and behavioral implications of their
clients with head trauma. These, too,
can have a major, life-altering affect on
one’s life.
Tramontano, a clinical neuropsychologist,
is the clinical director of The
NeuroRehab Institute with offices in Mt.
Arlington and Newark, as well as a
Clinical Assistant Professor of Psychiatry
at UMDNJ-Robert Wood Medical School
and an Adjunct Assistant Professor of
Psychology in Neuropsychology at St.
John’s University in New York City.
This article is reprinted with permission from the JUNE 28, 2004 issue of the New Jersey Law Journal. ©2004 ALM Properties, Inc. Further duplication without permission is prohibited. All rights reserved.
2 NEW JERSEY LAW JOURNAL, JUNE 28, 2004 176 N.J.L.J. 1237
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