Neurologists, neuropsychologists, and psychiatrists are frequently called upon to examine traumatic brain injury (TBI) claimants and to serve as expert witnesses in personal injury cases involving reported postconcussive symptoms. With dreary predictability, we read plaintiff experts' reports detailing horrific injuries resulting in catastrophically disabling symptoms and life-altering impairments. Then we turn to the defense experts' reports documenting, with equal surety, that - surprise! - there's really no impairment at all, that the patient is making the whole thing up, that he's cheating and deliberately underperforming on all the neuropsychological tests, that he's been coached by family members, doctors, or his attorney, and that the defense neuropsychologist can prove that the claimant is a big fat liar by his performance on a battery of "malingering tests."

And so the diagnostic menu often boils down to two choices: either the claimant is as blown away as he says he is, or he's malingering, which is tantamount to calling him a perjuror and a thief. Bring 'em on! The claimant, who may really have had some minor impairment that could be addressed with conservative treatment, now feels disrespected and humiliated by the legal and insurance systems, and, fearing his plaints are being ignored and his rights abused, essentially "turns up the volume" of the signs and symptoms, and transforms the case into a grudge match to redress the indignity of being branded as a sleazy liar. The plaintiff's attorney, for his or her part, is only too glad to find new and better experts to document a growing list of impairments, in response to which the defense attorney deputizes more hired guns to smoke out the duplicitous varmint who's trying to rob the insurance company stagecoach.

If you're an attorney who likes a good fight and has plenty of money to spend on it, then read no further. But if you'd really like to represent your client fairly - plaintiff or defendant - and need a range of interpretive psychological options to deal with traumatic disability syndromes including TBI, and if you'd like more choices that either "I'm crippled, give me lots of drugs and money," or "You're a lying sack of dirt, be glad we don't throw your malingering butt in jail," then read on.

TBI AND THE POSTCONCUSSION SYNDROME

In the United States, an estimated 400,000 people are admitted to hospitals with TBI's every year, and about one million suffer from head injury effects at any given time. The constellation of somatic, cognitive, and behavioral symptoms seen after TBI was first termed the "postconcussion syndrome" in 1934 by Strauss and Savitsky. Today, the postconcussion syndrome describes a cluster of symptoms that occur following a closed head injury - frequently a "mild" head injury - and it continues to be a source of clinical and forensic controversy.

Postconcussion Symptoms

Many of the commonly reported postconcussive symptoms may be confused with psychological stress reactions or other psychopathology, and in fact coexist with these syndromes after an injury. Postconcussive symptoms that may become the focus of particular clinical-forensic diagnostic confusion include the following:

Difficulties in Attention and Concentration: Patients have trouble following the train of conversations, keeping on track with reading material, or remembering why they got up to go into another room. They are distractible and slow to focus on tasks, or to figure out what to do. A typical complaint is that "I'm not as sharp as I used to be."

Learning and Memory Problems: These include difficulty retaining material heard or read, forgetting people's names or faces, confusing one person with another, having trouble recalling information "that I know I used to know," and struggling to remember things that used to be learned easily. In general, it is harder for new information to get processed, and what does get in seems to be forgotten more quickly.

Slowness and Inefficiency: Things take longer to do and they may have to be done over and over again. In many cases, the basic skills and knowledge necessary to perform a task may be essentially preserved, but the quickness and efficiency with which those abilities are applied to the task or problem at hand have been impaired.

Concreteness: TBI patients generally do better with tasks and in situations that are familiar rather than novel, structured rather than open-ended, and specific rather than ambiguous. Patients may not appreciate jokes that involve shifting or reversing one's point of view, and they may have difficulty perceiving more than one side (their own) of an argument or putting themselves in "another person's shoes" - which is often interpreted by others as shallowness or selfishness.

Depression and Mood Swings: Patients may show a "Jekyll-and-Hyde" lability of emotional responsiveness over the course of minutes, hours, or days. Irritable outbursts or crying spells may occur with minimal provocation. Manic highs may alternate with depressive lows, and family members may feel forcefully yoked to the patient's emotional roller-coaster, the caretakers never relaxed, always vigilant for the next stormlike mood surge.

Agitation, Irritability, Paranoia, and Rage: A smoldering edginess may be seen, and the patient's persistent carping, complaining, and hostility may strain family, job, and other interpersonal relationships. Many patients seem to have developed a "short fuse" that at intervals flares into aggression and rage, in part fueled by the increased suspiciousness and paranoia that sometimes develop after TBI.

Impulsivity and Inertia: Patients may alternate between mute inactivity and frenetic running about, starting and leaving unfinished all sorts of tasks and projects, going on irresponsible buying sprees, taking dangerous physical and social risks, and generally showing little foresight or judgement. This type of syndrome may be especially associated with damage to the brain's frontal lobes, the "executive control system" for modulating thought, feeling, and action.

Fatigue and Low Energy: Patients describe "having the stuffing knocked out of me," of becoming exhausted after even the simplest and most routine physical and mental tasks. This problem is often complicated by disruptions in the sleep cycle that occur after brain injury.

PSYCHOLOGICAL SYNDROMES
ASSOCIATED WITH TRAUMATIC INJURIES

At least one expert has commented that "the first step to making a diagnosis is to think of it." Correct differential diagnosis and description of other psychological syndromes that may be the consequence of, co-occur with, or predate individual cases of TBI and its postconcussive sequelae is important both for effective treatment planning and for adjudication in civil and criminal forensic cases. While certain syndromes (e.g. PTSD) may arise as a fairly direct consequence of a traumatic injury, several other traits, disorders, and syndromes described below represent longstanding features of personality and coping style that may come into play and dominate the clinical picture in the wake of a traumatic injury.

Posttraumatic Stress Disorder

Although persisting and debilitating stress reactions to wartime and civilian traumas have been recorded for centuries, posttraumatic stress disorder, or PTSD, first achieved status as a codified psychiatric syndrome in 1980. Diagnostically, PTSD is a syndrome of emotional and behavioral disturbance following exposure to a traumatic stressor that injures or threatens self or others, and that involves the experience of intense fear, helplessness, or horror. As a result, there develops a characteristic set of symptoms, which may include the following.

Anxiety: Patients describe a continual state of free-floating anxiety, and maintain an intense hypervigilance, scanning the environment for impending threats of danger. Panic attacks may be occasional or frequent.

Physiological Arousal: The patient's nervous system is on continual alert, producing increased bodily tension in the form of muscle tightness, tremors, restlessness, heightened startle response, fatigue, heart palpitations, breathing difficulties, dizziness, headaches, or other physical symptoms.

Irritability: There is a pervasive edginess, impatience, loss of humor, and quick anger over seemingly trivial matters. Friends get annoyed and shun the patient, and family members may feel abused and alienated. This may be confused with, or overlap with postconcussive irritability.

Avoidance/Denial: Patients try to blot out the event from their mind. They avoid thinking about or talking about the traumatic event, as well as news items, conversations, or TV shows that remind them of the incident. Part of this is a deliberate, conscious effort to avoid trauma-reminders, while part involves an involuntary psychic numbing that blunts incoming threatening stimuli. In some cases, this may mimic TBI-related frontal lobe inertia and emotional flattening.

Intrusion: Despite patients' best efforts to keep the traumatic event out of their mind, the disturbing incident pushes its way into their consciousness, typically in the form of intrusive images or flashbacks by day and/or frightening dreams at night.

Repetitive Nightmares: Sometimes the patient's nightmares replay the actual traumatic event. More commonly, however, the dreams echo the general theme of the trauma, but avoid the specific content. The emotional intensity of the original traumatic experience is retained, but the dream may partially disguise the actual event.

Impaired Concentration and Memory: Friends and family may note that the patient has become a "space cadet," while supervisors report deteriorating work performance. Social and recreational functioning may be impaired as patients have difficulty remembering names, lose the train of conversations, or can't keep their mind focused on reading material or games. Many of these symptoms are similar to TBI cognitive impairment.

Withdrawal/Isolation: The patient shuns friends, schoolmates, and family members, having no tolerance for the petty, trivial concerns of everyday life. The hurt feelings this engenders in those rebuffed may spur resentment and counteravoidance, leading to a vicious cycle of mutual rejection and eventual social ostracism of the patient.

Acting-Out: More rarely, traumatized patients may walk off worksites, wander out of their familiar neighborhood, take unaccustomed risks by driving too fast, associating with unsavory persons, using substances, gambling, or going on abrupt "trips." The similarity to frontal lobe impulsivity may lead to diagnostic confusion.

Depression

Many patients who have suffered a traumatic disability eventually come to realize that some degree of impairment may be permanent, that they may never be quite the same person they were, that their disability might affect important aspects of their vocational and social lives, and that achieving the clinical validation and financial compensation they feel they deserve constitutes a landmine-filled gauntlet of stonewalling insurance companies, accusatory attorneys, and bought-and-sold IME "experts." Understandably enough, many of these patients become depressed over their ordeal. In some cases, this is severe enough to represent a major depressive disorder, which can add disabling psychological symptoms of its own, many of which can overlap with postconcussion symptoms, and many of which, because they are primarily subjective, will be seen by hostile examiners as being "made up." These include the following.

Low Energy and Motivation: The patient may feel like he's paralyzed or drugged, unable to get up and do even the simplest things without tremendous effort and urging by others.

Depressed Mood and/or Agitation: Most people don't realize that anxious agitation can be as much a part of depression as low mood. The patient may describe a perpetual state of "jumping out of my skin," never able to relax or experience a normal mood. Irritability and anger may be part of the syndrome, further alienating potential sources of support.

Sleep and Appetite Disturbance: Impaired sleep further contributes to agitation and fatigue. His physical condition may deteriorate as the patient eats poorly and neglects other important aspects of health and hygiene.

Cognitive Impairment: Disturbances of attention, concentration, and memory can be so severe, that clinicians have described a pseudodementia syndrome of depression. In fact, patients and their families and clinicians are often puzzled about cognitive impairment in physically injured patients who have experienced no head trauma per se, yet who report cognitive impairment almost identical to a postconcussion syndrome. When severe depression co-occurs with an existing postconcussion syndrome, skeptical clinicians and attorneys may doubt that such a "minor" brain injury could produce a report of severe cognitive impairment, if they fail to take the patient's depressed state into account.

Substance Abuse: Although great care must be taken in differentiating a prior history of substance abuse, many disabled patients turn to drugs and alcohol for self-medication, which in turn can further impair cognitive functioning and general health.

Suicide and Violence: Mood dysregulation often leads to impaired judgment and impulsive behavior. Suicide may be a risk, as well as violence directed outward. Substance abuse may exacerbate this. Again, it's always important to have a good premorbid psych history to guide your assessment.

Somatoform Disorders

The common feature of the somatoform disorders involves the presence of subjective physical symptoms that suggest a medical illness or syndrome, but are not fully explainable by, or attributable to, a general medical condition, substance abuse, or other type of mental disorder. In TBI cases, there is almost always some underlying physiological injury, albeit varying in severity, but a superimposed somatoform disorder may result in an exaggerated presentation of reported distress and functional impairment that may jeopardize the credibility of the case. In the current classification of DSM-IV, somatoform disorders include several subtypes.

Somatization Disorder, formerly referred to as "Briquet's syndrome" or "hysteria," involves a history of multiple unexplained physical symptoms and complaints, beginning before age 30, and often traced to childhood and adolescence. Outbreaks of numerous and varied symptoms may occur in clusters that wax and wane over time, often in response to interpersonal, vocational, and other stressors. Associated features include anxiety, depression, impulsivity, relationship problems, psychosocial discord, and substance abuse. Symptoms in somatization disorder may closely mimic standard syndromic clusters associated with postconcusssion symdrome and PTSD, or they may be atypical or even bizarre in quality, location, or duration. The underlying motivation is frequently inferred to be a quest for support, reassurance, manipulation of the affection of a significant other, and/or the satisfaction of dependency needs by reliance on the protective role of medical authority.

Conversion Disorder: The essential feature is the presence of sensory or motor deficits that appear to suggest a neurologic or medical illness or injury. The unconscious motivation typically involves the attempted resolution of psychological conflict, such as dependency wishes, by channeling them into physical impairment. Alternatively, there may be an actual symbolic "conversion" of a particular psychological conflict into a representative somatic expression, as in paralysis of an arm in a patient who fears acting on a hostile impulse. Exacerbations are typically precipitated by psychosocial stresses related to job or family, or the stress of the accident itself, with the resultant financial and legal hassles. A common psychodynamic force in traumatic disability cases is a combination of anger and derailment of overcompensated striving that had previously been utilized as a defense against unconscious dependency wishes.

Pain Disorder: The essential feature is chronic pain that causes significant distress or impairment in social, occupational, or other important areas of functioning, and in which psychological factors are judged to play a significant role in the onset, severity, exacerbation, or maintenance of the pain. The pain is not intentionally produced or feigned as in malingering or factitious disorder (see below), but rather expresses, represents, or disguises an unconscious need, fear, or conflict, as in somatization disorder. Pain is a frequent accompanier of both postconcussion syndrome and PTSD - indeed, these three often comprise the "triple threat" of many TBI cases.

Hypochondriasis: The conviction that one has a serious illness or injury, in the face of numerous medical pronouncements to the contrary, is the defining characteristic of this disorder. Unlike the polysymptomatic presentation in somatization disorder, hypochondriacs tend to focus on one or a few chosen symptoms and remain preoccupied with these, even though the focus may shift over time from one symptom or disorder to another, e.g. from memory impairment, to headaches, to dizziness in TBI cases. Unlike conversion disorder, there may be no actual observed or experienced impairment: it the fear of "hidden" undiagnosed or future catastrophic postinjury impairment that is the preoccupation of concern. Often, the unconscious motivation involves a deflection of anxiety away from issues of broader life roles, such as career or relationships, with a focus on a more delimited, and hence "controllable" source of concern in the form of somatic symptoms and fear of further injury.

Body Dysmorphic Disorder: Although not as commonly seen in TBI and other injury cases, body dysmorphic disorder may occur where the injury has resulted in some degree of physical disfigurement or disturbance of cognitive function that impacts on the patient's self-image. Diagnostically, this disorder involves a preoccupation with an imagined defect in appearance, or overconcern with a minor defect. This may include facial scars or asymmetry, lost athletic prowess, or diminished intellectual skills after a TBI. Unconsciously, the motivation may involve deep-seated and longstanding feelings of self-loathing which are now, postinjury, projected onto a more objectifiable physical or mental impairment.

Factitious Disorder

Factitious disorder is diagnostically separated from the somatoform disorders, and is defined as the deliberate production, manipulation, or feigning of physical or psychological signs and symptoms. Because the intentionality is clearly conscious and deliberate, it is not classified as a somatoform disorder. However, unlike malingering, where a utilitarian motive for the deception can usually be discerned (see below), the motive in factitious disorder is typically to assume the sick role, with all the attendant care, solicitous concern, and relief from responsibilities of normal life that this entails, even at the price of substantial cost in money, health, or freedom. Often, there also appears to be great satisfaction and ego-gratification, perhaps at least partly unconscious, derived from manipulating the medical system and "fooling the experts."

Sometimes referred to as "Munchausen's syndrome," the manifestations of factitious disorder are limited only by the imagination and ingenuity of the patients. Medically sophisticated patients, such as nurses or mental health clinicians, may be quite clever in feigning credible medical and psychiatric illnesses and impairments by the surrepetitious use of chemical substances or medical apparatus, or by displaying realistic postconcussive or PTSD symptoms. Less knowledgeable patients may resort to cruder methods such as drinking toxic concoctions, bruising or cutting themselves to simulate injuries, or acting like their imagined version of a "brain-damaged" or "crazy" person.

Malingering

This is the term you'll hear most often, even though, in the world of mental health diagnosis, malingering is not actually regarded as a true psychiatric disorder at all. Rather, malingering is defined as the conscious and intentional simulation of illness or impairment for the purpose of obtaining financial compensation or other reward; evading duty, responsibility, obligation; or exculpation or mitigation for the consequences of criminal or other illicit behavior. In other words, there is a practical and "sensible" - albeit ill-intended - motive for the simulation and therefore it does not represent a true "symptom" of psychopathology. This does not mean, however, that malingerers of one symptom may have true symptoms of other disorders. The incidence of malingering differs across clinical and forensic settings and populations, with estimates ranging from 1% to 50%. Indeed, this wide disparity of estimates shows just how confused clinicians are by this phenomenon.

Malingering can be categorized into four main categories, which I have summarized by the mnemonic acronym, FEEM:

Fabrication: The patient has no symptoms or impairments resulting from the injury, but fraudulently represents that he has. Symptoms may be atypical, inconsistent, or bizarre, or they may be perfect "textbook" replicas of real syndromes. In common clinical and forensic practice, this wholesale invention of an impairment syndrome is the rarest form of malingering.

Example: A man trips in a store, gets up, has no symptoms other than momentary embarrassment, but a week later decides to file a false claim for damages against the store owner, claiming severe "brain damage." On neuropsychological examination, he reports multiple symptoms that he secretly looked up in the library, and purposely performs extremely poorly on neuropsychological tests.

Exaggeration: The patient has symptoms or impairments caused by the injury, but represents them to be worse than they really are. This is probably the commonest form of malingering in clinical and forensic practice.

Example: A woman is jostled in the course of a low-speed auto collision, is momentarily dazed, and subsequently experiences a moderate headache, some neck soreness, and transient chest irritation and shoulder soreness from the seatbelt. On clinical examination, she shows up wearing a cervical collar, and falsely reports unrelenting, excruciating headaches, shoulder and arm weakness, severe memory impairment that precludes her from working, and virtual neck immobility from "whiplash."

Extension: The patient has experienced symptoms or impairments caused by the injury, and these have now recovered or improved, but he falsely represents them as continuing unabated, or even as having worsened over time.

Example: After 6 months, the headaches, dizziness, and impaired concentration and memory caused by a work-related head injury have virtually disappeared, but on his follow-up neurologic examination, the patient falsely reports being as impaired as ever: "There's been no improvement, Doc - in fact, everybody tells me I'm getting worse."

Misattribution: The patient has symptoms or impairments that preceded, postdated, or were otherwise unrelated to the index injury, but he fraudulently attributes them to that injury.

Example: A middle-aged woman reports that she was "just fine" until 10 months ago when a department store employee accidentally shoved her as he was rushing to help another customer, and in the process, her head banged into a display counter. She is suing the retail chain because she now has difficulty standing or walking, she experiences spells of "amnesia," where she doesn't know where she is, and she can hardly read and write anymore. Further exploration reveals a history of a stroke five years ago, which resulted in a variety of focal and generalized deficits, including the ones now reported. In addition, two years ago, she fell in her home, striking her head, but never reported this incident or sought medical attention.

As noted above, malingered exaggeration of existing symptoms is more frequent than pure fabrication of totally nonexistent illnesses or injuries. Also, more than one category of malingering may be observed in the same patient at the same or different times. To compound matters further, more than one syndrome may be the subject of different types or degrees of malingering, e.g. postconcussion syndrome, chronic pain, fibromyalgia, toxic exposure, anxiety, depression, PTSD, etc. Finally, malingering can co-occur with other psychological syndromes, such as the somatoform disorders or personality disorders. In many cases, malingering is suspected when patients exaggerate impairment beyond the level of clinical believability, or when they are observed (e.g. on insurance company surveillance) performing activities that they are supposedly incapable of doing. It is here that the knowledge and experience of a trained clinical and forensic expert is crucially in discerning patterns of causation and disability and making the correct diagnosis and appropriate clinical or forensic recommendations. This is something no "malingering test" can do.

Personality Disorders

Personality disorders are longstanding patterns of dysfunctional thought, mood, and behavior, and are consequently not disability syndromes per se, but they may influence the psychopathological reaction to injury and thereby complicate recovery.

Antisocial Personality Disorder is a pattern of disregard for, and violation of, the rights of others. It is typically associated with impulsivity, criminal behavior, sexual promiscuity, substance abuse, and an exploitive, parasitic, and/or predatory lifestyle. These "psychopaths" or "sociopaths" have no qualms about malingering impairment for material gain and may be quite slick, engaging, and convincing in their performances, often eliciting sympathy from well-meaning clinicians and attorneys.

Histrionic Personality Disorder is a pattern of excessive emotionality and attention-seeking. Symptoms will typically be reported with flamboyant theatricality, and all attempts at medical explanation or reassurance will be evaded or resisted by persistent complaints of total, catastrophic, and heart-wrenching disability. These patients are most liable to develop somatoform disorders that complicate their disability.

Borderline Personality Disorder is a pattern of instability in interpersonal relationships, self-image, and emotion, along with marked impulsivity, including self-injury and suicidality. The pervasive anger of many borderlines, along with their tendency to alternately idealize and devalue others, may impel them to furiously pursue lawsuits to "punish" treacherous tortfeasors or insurance companies for hurting or betraying the patient. Borderlines may also alternately idealize and devalue their clinicians and attorneys, complicating clinical and forensic cooperation.

Paranoid Personality Disorder is a pattern of distrust and suspiciousness, so that others' actions and motives are interpreted as persecutory or malevolent. Believing that "the system is out to get me," the patient may feel no compunction about "beating the bastards at their own game" by exaggerating impairment and making excessive disability claims.

Narcissistic Personality Disorder is a pattern of grandiosity, entitlement, need for admiration, and lack of empathy. "How dare the defendant or insurance company not compensate me for my loss and suffering?" They may feel they have the right to feign or exaggerate disability in order to win their case and get what they "deserve." Less maliciously, their wounded narcissistic pride at not being able to return to work or other important roles because of the injury, may spur exaggerated claims of injury simply to save face by presenting themselves as "totally disabled" and therefore "unable" to work, rather than not working simply because they feel they shouldn't have to.

Dependent Personality Disorder is a pattern of submissive and clinging behavior that stems from an excessive need to be taken care of. These patients may latch onto the sick role as a way of conscripting and prolonging the nurturing care and support of doctors, family members, and solicitous attorneys.

Avoidant Personality Disorder is a pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation or criticism.

Schizoid Personality Disorder is a pattern of aloof detachment from social interaction, with a restricted range of emotional expression.

Avoidants fear people and schizoids don't need people, so both of these types may welcome the enforced invalidism of a traumatic disability syndrome to maintain their isolation from unwanted social interaction and intrusion on their privacy.

Obsessive-Compulsive Personality Disorder is a pattern of preoccupation with orderliness, perfectionism, and control. These patients may drive doctors and lawyers crazy with their incessant and repetitive demands for reassurance and details about the progress of their cases. Heightened anxiety and obsessive hypochodriacal preoccupation may lead to the overinterpretation of mild symptoms or deficits as catastrophic and life-altering.

Passive-Aggressive Personality Disorder is a pattern of negativistic attitudes and passive resistance to demands for appropriate behavior. Often noted for their cynical demeanor, these patients may derive great satisfaction from the power to deceive, control, and manipulate clinicians, attorneys, and caretakers. They may be particularly prone to malingering or factitious disorders. To perpetuate their martyred victimhood, they may sabotage their own treatment and legal cases, all the while maintaining the appearance of innocent pseudocooperation. The boundary between how much of this is unconscious vs. deliberate is not always clear.

IMPLICATIONS FOR CASE STRATEGY

Plaintiff attorneys who litigate traumatic disability cases should understand that, in most jurisdictions, psychological injuries that can be causally related to negligence or other actions of the defendant are compensable torts in their own right. So, let's say a mildly brain-injured patient is having nightmares of her assault by the angry restaurant waiter, is unable to concentrate at work, is afraid to go into shopping malls, can no longer eat out with her family, and has become fearfully preoccupied with the pain in her elbow and shoulder, terrified that she will be unable to care for her kids. There's no need to come up with all kinds of hypothetical mechanisms to relate the psychological symptoms to occult diffuse axonal injury, hypothalamic microtrauma, limbic kindling, and other constructs (although these do legitimately occur in a few cases). Just prove the lady was functioning okay prior to the injury, and now is impaired on a psychological basis. You'll probably have greater success getting legitimate medical experts to document such impairment, than trying to force their conclusions in the procrustean bed of twisted neuromythology. The important point is for your expert to be able to show that "mental" doesn't necessarily equal "unreal."

Defense attorneys who litigate these cases should understand that the claimant may very well have suffered from real injuries, physical or psychological, but that in most cases, these injuries are treatable. Few traumatic disability syndromes in the "mild-to-moderate" category need result in permanent catastrophic disability. Just my two cents of observation from 25 years of practice: By validating the legitimate injuries the patient has, offering appropriate treatment early on, and agreeing to make reasonable compensation for any residual deficits, you can avoid the entrenched, take-no-prisoners attitude that too often leads to patients' "turning up the volume" of their complaints because they feel they're not being heard, or resolving to "show those s.o.b.'s they can't get over on me" by having their attorneys make ridiculously high demands, which then spend years in litigation and waste all kinds of money for both sides.

Sure, there will always be professional b.s. artists who will try to milk the system, but in my experience, these can be more quickly unmasked by treating every patient fairly at first, resolving most cases equitably (and relatively inexpensively), and then seeing which truly malingering dregs remain at the bottom of the personal injury barrel. As noted earlier, "the first step to making a diagnosis is to think of it." Utilizing the clinical wisdom of appropriate experts in the context of adequate attorney knowledge of basic psychology can help resolve cases faster, less expensively, and more fairly.

Laurence Miller, PhD is a clinical, forensic, and consulting psychologist in Boca Raton, Florida. Dr. Miller can be reached at (561) 392-8881 or by email at docmilphd@aol.com.

FOR FURTHER REFERENCE

  • Barton, W.A. (1990). Recovering for Psychological Injuries (2nd ed.). Washington DC: ATLA Press.
  • Evans, R.W. (1994). The postconcussion syndrome: 130 years of controversy. Seminars in Neurology, 14, 32-39.
  • Hall, H.V. & Pritchard, D.A. (1996). Detecting Malingering and Deception: Forensic Distortion Analysis. Delray Beach: St. Lucie Press.
  • Miller, L. (1992). Neuropsychology, personality, and substance abuse in the head injury case: Clinical and forensic issues. International Journal of Law and Psychiatry, 15, 303-316.
  • Miller, L. (1993). Psychotherapy of the Brain-Injured Patient: Reclaiming the Shattered Self. New York: Norton.
  • Miller, L. (1996a). Making the best use of your neuropsychology expert: What every neurolawyer should know. Neurolaw Letter, 6, 93-99.
  • Miller, L. (1996b). Malingering in mild brain injury: Toward a balanced view. Neurolaw Letter, 6, 85-91.
  • Miller, L. (1997). Typical and atypical postconcussion syndromes: Making clinical and forensic sense. Neurolaw Letter, 6, 109-116.
  • Miller, L. (1998a). Malingering in brain injury and toxic tort cases. In E. Pierson (Ed.), 1998 Wiley Expert Witness Update: New Developments in Personal Injury Litigation (pp. 225-289). New York: Wiley.
  • Miller, L. (1998b). Not just malingering: Recognizing psychological syndromes in personal injury litigation. Neurolaw Letter, 8, 25-30.
  • Miller, L. (1998c). Shocks to the System: Psychotherapy of Traumatic Disability Syndromes. New York: Norton.
  • Miller, L. (1999a). Psychological syndromes in personal injury litigation. In. E. Pierson (Ed.), 1999 Wiley Expert Witness Update: New Developments in Personal Injury Litigation (pp. 263-308). Rockville: Aspen.
  • Miller, L. (1999b). "Mental stress claims" and personal injury: Clinical, neuropsychological, and forensic issues. Neurolaw Letter, 8, 39-45.
  • Miller, L. (2000). Psychological syndromes in brain injury litigation: Personality, psychopathology, and disability. Brain Injury Source, 4(3), 18-19, 40-43.
  • Miller, L. (2001). Not just malingering: Syndrome diagnosis in traumatic brain injury litigation. Neurorehabilitation, 16, 109-122.
  • Miller, L. (2002). What is the true spectrum of functional disorders in rehabilitation? Physical Medicine and Rehabilitation: State of the Art Reviews, 16, 1-20.
  • Parker, R.S. Concussive Brain Trauma: Neurobehavioral Impairment and Maladaptation. Boca Raton: CRC Press.
  • Simon, R.I. (1995). Toward the development of guidelines in the forensic psychiatry examination of posttraumatic stress disorder claimants. In R.I. Simon (Ed.), Posttraumatic Stress Disorder in Litigation: Guidelines for Forensic Assessment (pp. 31-84). Washington DC: American Psychiatric Press.
  • Strauss, I. & Savitsky, N. (1934). Head injury: Neurologic and psychiatric aspects. Archives of Neurology and Psychiatry, 31, 893-955.
  • Taylor, J.S. (1997). Neurolaw: Brain and Spinal Cord. Washington DC: ATLA Press.
  • Taylor, J.S. (1999). The legal environment pertaining to clinical neuropsychology. In J.J. Sweet (Ed.), Forensic Neuropsychology: Fundamentals and Practice (pp. 421-442). Lisse: Swets & Zeitlinger.
  • Thibault, G.E. (1992). Clinical problem solving: Failure to resolve a diagnostic inconsistency. New England Journal of Medicine, 327, 26-39.
  • Wilson, J.P. (1994). The historical evolution of PTSD diagnostic criteria: From Freud to the DSM-IV. Journal of Traumatic Stress, 7, 681-698.

Article © 2004, Laurence Miller, PhD. All rights reserved. This article may not be reproduced in whole or in part without express written permission of the author.