I will apologise at first if this post may come across as elitist or class orientated it isn’t intended to be.

Over the many months I have been visiting the board, I have noticed that even with the limitations of our injuries the majority of the posts are articulate, well reasoned and informative. However, one of the common themes is that the NeuroPsychological and even Psychological assessment falls short of our expectations.

One thing that I have been wondering more and more is it the generic nature of the NeuroPsychological assessment and that the “system” is not tailored to deal with those whom previously had a high capability for logical thought, speech or even artistic ability. Looking at some of assessment test they seem to be based on the “average man in the street” and do not take into account the different perspectives that academic or business achievement would bring. One of the popular tests has questions on whether you would like to work in a library or would be prepared to sneak into a movie if you knew you could get away with it. If you were someone whom loves working outdoors a library might be your version of hell but heaven to an academic. Likewise sneaking into a cinema would be abhorrent to a business or person with strong religious or moral beliefs. Obviously, depending on how these (and others) were answered determines you evaluation.

I think the problems really occur when articulate people describe their symptoms to clinicians because all they see is someone whom is articulate, logical and can present a good account of their injuries therefore – there can’t be anything wrong with them and it must be psychological than physical. They seem to disregard that allthouhg there is a relatively high capacity this is much reduced than before, mental effort it took to give the explanation or how easy it would have been pre injury. Similarly I have tried some of the NP tests on 3 non injured friends who dropped out of school early and work in the service industry, all of which scored just below the level I did.

For example I described a problem I encountered to my GP – I had to work out the number of hours between 17:00 and 07:00. My mind first suggested 10 hours but something in my mind told me it was wrong and it should be 12. My mind kept on telling me that it is still wrong – so I broke it into 17:00 to 24:00 and 00:00 to 07:00 to get the right answer of 14. My GP’s view was most people would have got that wrong so what the problem? Pre accident, I would have worked out the answer without thought.

So my question is do Academic or Artistic people miss out on the diagnostic processes ?

Hi Sospan,

I tend to agree with you. Clinicians can only go by what they see at the time and compare it to the average.

That being said, there are some things which can improve the assessment process.

1. If you have a GP who was following you for a long time before your injury, they are more likely to see changes in your presentation pre and post concussion. (I have a 20 year history with my GP - he diagnosed me as post-concussion syndrome when my symptoms did not improve after 2 weeks).

2. Ask if you can bring someone to the assessment who knew you before the injury so they can provide collateral history on how you were before and what changes they have observed. (I work in a specialty psychiatric clinic for patients with Mood Disorders and we ask them to bring in someone who can provide collateral pre and post illness episode).

3. Understand that most Neuropsych testing is only beneficial in determining what level you are functioning at now and quantifying improvements in your functioning. (My GP is sending me for Neuropsych testing now and wants it repeated in 6 months in order to see what improvements I make).

Hope that this helps

Cheers

sospan,

I think you have a good point but there are more aspects to this problem. There are many different tests used in a NeuroPsych Assessment (NPA). Some do a better job of diagnosing condition than others. Most do a poor job of diagnosing causation. In PCS subjects, the Halsted Reitan battery has been the gold standard but many NP's do a much shorter battery. The MMPI-II (the abstract questions are usually the MMPI-II) does not accurately differentiate between psychological caused symptoms and concussion caused symptoms, especially those symptoms/answers that are due to dealing with PCS.

There is also a problem with the intelligence interpretation. A high score on WAIS IQ's but low scores on Wechsler memory scales will cause the NP to question the results. In my case, I scored in the top 12 to 2% in WAIS IQ and bottom 5 to 12% in the Wechsler memory and at the bottom 10% for WAIS processing speed. Then, I scored 49/50 and 50/50 in the validity (not malingering) scales showing no evidence of malingering. 37/50 and below is considered the threshold for a malingerer. I also show no evidence of depression in the MMPI-II. Despite this, the NP reported that I has serious dysfunctions that were caused by depression and faking the tests. He denied any organicity claiming my high WAIS IQ would have been low with an organic cause.

I had a repeat NPA 5 years later by a different clinic with the same scales and similar conflicting report. Both had refused to provide scoring information until a forceful request was made stating the possibility of the subject rejecting the interpretation as presented in the report. DUH......

The NP's both were obviously of lower IQ's as demonstrated by their conversation during the interview portion. I believe they reject the high achiever as not being organically injured due to a conflict/jealousy/distrust of the highly intelligent.

Research and anecdotal reports show there is a higher level of symptoms and complaints with the high achievers than with average achievers. This can be attributed to a multitude of reasons: High achievers have a much higher level of expectation of themselves. High achievers are more thorough in their self-analysis of their symptoms thus better able to present the symptoms to professionals. The high achieving brain is more susceptible to noticeable injury since it is more like a finely tuned machine and any disruption of this fine tuning is more noticeable.

So, the challenge to the high achiever is two fold. Convincing the NPA reviewer/interpreter that the dysfunctions are real and due to organic causes. Overcoming any biases against high achievers the NP may have. Plus, there is the added problem of high achievers are part of a very small percentage of a research cohort. If only 2% of the population are very high achievers and 5 to 10% high achievers, how can a research study adequately include enough of these high and very high achievers to see how they fit in the study results. Plus, with so few high and very high achievers likely to need to be assessed with the NPA, there is not as much need for the study to include them.

An analogy to this problem could be made using a automobile comparison. Say an average car runs strong and develops its needed horsepower at 3500 to 5000 RPMs. (engine Revolutions Per Minute) A high performance car needs 6000 to 10,000 RPM to develop its expected horsepower. The average car does not need to be finely tuned and highly balanced to obtain these RPMs. The high performance car needs precision tuning and engine balancing to reach these RPM's.

The average car can run a bit rough and still achieve most of its expected power. The high performance car, if it is running rough and out of balance will not only be only able to produce 50% of the expected horsepower, if an attempt is made to rev the engine to maximum RPM's, the engine will fail catastrophically. The observer who compares the high performance car to his average car will think, "You can still get as much horsepower out of the high performance car as I ever get from my average car. So, what is the problem?"

The high performance car owner replies, "Sure, I can still drive the high performance car to work and get to work reliably but if I need to use the expected power to quickly accelerate to merge with high speed traffic, I risk destroying the engine. This could put many others at risk besides me and my high performance car."

The high performance car owner can install a rev limiter or engine governor to limit the engine's power output but this requires a wholesale discounting of the value of the high performance car.

It is like the NP trying to tell the high achiever to stop being such a high achiever and the symptoms will not be noticed nor cause a problem. The brain does not respond to a governor (meds) very well. Reducing the intensity of high achieving thought also reduces the ability of the low intensity thought. Maybe an occasional glass of wine or beer can be tolerated but 24/7 medication can make life miserable.

My way of dealing with this starts with acceptance of the dysfunction. Then, I work to find new ways of achieving the same high levels of function. It usually requires that I use far more time to accomplish the same task but at least I can get the task done. The work place does not tolerate the very slow high achiever. The term is considered an oxymoron. We struggle enough internally/individually with this 'very slow high achiever' concept. How can we expect others to understand and accept it?

I have spent most of my lifetime trying to understand these issues since I first became aware of my struggles in 1971. As I said, It is difficult enough for us to internally/individually accept and understand this concept. Expecting others to understand is a wild dream. It has only been in the last 5 years that my wife of 32 years is just beginning to understand this.

For those of you who can read and understand what I just posted, my hat is off to you. On a mediocre day, I myself would get lost in my own post. To those who have spaced out trying to read it, I understand your frustration.

btw, The psychologist who interviewed my wife before testing me understood my condition. The two NP's who did not interview my wife ended up clueless.

My best to you all.

Thanks for that. I like the car analogy a lot.

It is true about knowledge frightening certain medical professionals. A physio once told me to "become my own expert, as no one knows more about your symptoms and treatment than you". Very wise words and I think this leads us to do our own research and i think this is where the problem lie as we become better informed than than the clinicians we see. Since we know about the injury and the potential treatments, it is easy for them to label us as fixated about the injury or accuse of inventing symptoms we have researched.

It is also true about the comments from the injured partner holding a lot of sway during an assessment. In an assessment session, the person whom was reviewing my symptoms was quite dismissive. Then he asked my wife "what do you think about your husbands problems ?" Completely without coaching she said "my husband, no he is someone different ?".

The change in the assessment was immediate at the guy actually started to listen. A simultaneous wave of relief and anger swept over me.