Joseph W. Fink

Official Position of the Military TBI Task Force on the Role of Neuropsychology and Rehabilitation Psychology in the Evaluation, Management, and Research of Military Veterans with Traumatic Brain Injury

This Position Statement is a summary of the literature and learning regarding current issues raised by the occurrence, treatment, and study of traumatic brain injury in military service members and veterans. The Report has been approved by the American Academy of Clinical Neuropsychology (AACN), Divisions 40 (Neuropsychology) and 22 (Rehabilitation Psychology) of the American Psychological Association (APA), and the National Academy of Neuropsychology (NAN), with the goal of providing information of relevance on an important public policy matter within their respective areas of expertise. The Report is not intended to establish guidelines or standards for the professional practice of psychology, nor has it been adopted as official policy by the American Psychological Association or any other division or subunit of APA.

Neuropsychological changes following electrical injury

The clinical presentation of electrical injury commonly involves physical, cognitive, and emotional complaints. Neuropsychological studies, including case reports, have indicated that electrical injury (EI) survivors may experience a broad range of impaired neuropsychological functions, although this has not been clarified through controlled investigation. In this study, we describe the neuropsychological test findings in a series of 29 EI patients carefully screened and matched to a group of 29 demographically similar healthy electricians. Participants were matched by their estimated premorbid intellectual ability. Multivariate analysis of variance was used to assess group differences in the following neuropsychological domains: attention and mental speed, working memory, verbal memory, visual memory, and motor skills. EI patients performed significantly worse on composite measures of attention/mental speed and motor skills, which could not be explained by demographic differences, injury parameters, litigation status, or mood disturbance. Results suggest that cognitive changes do occur in patients suffering from electrical injury.

The Neuropsychological Effects of Electrical Injury: New Insights

Although electricity has been used for commercial purposes since the 19th century, surprisingly little is known about the pathogenesis of neuropsychological and psychiatric changes following electrical injury (EI). As first noted in our review of this area, there primarily have been single case studies and retrospective investigations of EI patients that have been limited by small sample sizes, lack of appropriate control group comparisons, nonrandom selection procedures, and methodological variability.1 Yet, these studies seem to suggest that EI patients can have diverse clinical presentations in both type of symptoms (i.e., ranging from significant cognitive and/or emotional) and time of onset (i.e., immediate vs. delayed). Since our review of the neuropsychological effects of electrical injury first published in this book series in 1994, several new case reports have appeared in the literature that have documented posttraumatic stress disorder following electric shock2 and the presence of parasomnia as a neuropsychiatric complication of electrical injury.3 Additionally, one study surveyed a large support group of lightning and electrical injury survivors for behavioral symptoms4 and several retrospective neuropsychological studies have been published by a group of University of Iowa neuroscientists based on their series of electrical injury patients.5,6 Unfortunately, in our view, the critical factors that influence the neurocognitive and psychiatric consequences of exposure to electricity have not been clearly identified. However, many assumptions about EI are made by mental health professionals despite the lack of empirical evidence. These assumptions include the following: (1) the worse the visible burn, the worse the psychological difficulties that someone will have; (2) low voltage exposures will not cause significant neuropsychological problems; (3) EI patients who experience changes are not premorbidly psychologically stable; or (4) electrically injured patients are faking their difficulties for secondary gain. The purpose of this article is to summarize the new insights gained into the neuropsychological effects of electrical injury based on a series of studies conducted by the University of Chicago Electrical Trauma Program over the past five years,7–11 emphasizing that much more work still needs to be done. The goals of our research program continue to be the clarification of the central nervous system effects of electrical injury as reflected by postinjury neurocognitive and psychiatric functioning as

Psychiatric morbidity following electrical injury and its effects on cognitive functioning

OBJECTIVE This study examines the prevalence of psychiatric morbidity in a large sample of electrical injury (EI) patients in three phases of recovery and its effects on cognitive functioning. METHODS Eight-six self-referred EI patients received psychiatric and neuropsychological evaluations. Descriptive statistics were conducted to examine the prevalence of psychiatric morbidity. Polytomous logistic regression was used to identify predictors of psychiatric diagnosis. Between-subjects analysis of variances (ANOVA) was conducted to examine the effects of psychiatric morbidity on cognitive functioning. RESULTS Seventy-eight percent of subjects warranted a psychiatric diagnosis. Long-term patients compared to acute patients were more likely to be diagnosed with two diagnoses than not having any diagnosis (OR=14.30, 95% CI 1.40-38.71). Patients with two diagnoses performed worse than both patients with a single or no diagnosis on all cognitive outcome measures (P<.05). Voltage level, chronic pain and litigation status did not predict psychiatric morbidity. CONCLUSIONS Psychiatric difficulties commonly emerge and persist following EI. EI patients with psychiatric conditions exhibited poorer cognitive performance as compared to EI patients with no post-injury psychiatric difficulties. Health care professionals need to devote careful attention to psychiatric and cognitive status when treating survivors of EI.

Life after electrical injury. Risk factors for psychiatric sequelae

ABSTRACT: Long‐term cognitive and emotional deficits have been commonly reported in electrical injury (EI) survivors. However, it remains undetermined what factors may lead to the development of such effects in some patients and not in others. In this study, we hypothesized that certain elements of subjective EI experience may predict specific psychiatric sequelae. A group of 73 postacute EI patients were included in this retrospective study. Statistical associations were examined between major psychiatric diagnoses (posttraumatic stress disorder and major depression) and such EI descriptors as having experienced “no‐let‐go” or having been knocked away on contact, as well as loss of consciousness or altered states of consciousness at the scene of the accident (including amnesia for the event). The study results will help physicians determine which patients may be at increased risk of developing psychiatric symptoms and address these issues as part of their total rehabilitation plan.

MMPI-2 Patterns in Electrical Injury: A Controlled Investigation

The psychological consequences of electrical injury (EI) are many. Depression, posttraumatic stress disorder, anxiety, and somatic preoccupation are often concomitant with this type of injury (Kelley, Pliskin, Meyer, & Lee, 1994). The present study utilized the MMPI-2 as a tool for characterizing profiles of psychological distress in EI. We examined MMPI-2 profiles in 79 EI patients and their relationship to both injury parameters (i.e., time since injury, LOC, voltage), and extra-diagnostic factors, such as litigation status. EI patient profiles were also compared to individuals with mild traumatic brain injury (TBI), and chronic pain sufferers (CP). Results indicated that in EI, clinical elevations (T ≥ 65) were found on the Hs and Hy scales, and approached clinical levels on the D scale. The injury parameter of time since injury was predictive of a distinctive profile, with individuals in the post acute phase experiencing more distress. Compared to other clinical groups, MMPI-2 scores on the Hs and Hy scales were significantly higher within the EI cohort as compared with their CP peers, with higher scores on the Pd scale for CP than EI. No statistically significant differences emerged between the EI and TBI groups. However, TBI patients showed significant elevations on Hy and D compared to CP, and EI patients endorsed more somatic symptoms than CP patients. Implications of these findings and future directions will be discussed.

Mood and Cognition after Electrical Injury: A Follow-up Study

Individuals who have experienced an electrical injury have been reported to demonstrate both acute and delayed cognitive and psychiatric symptoms. The present study assessed 20 electrically injured patients who underwent neuropsychological evaluations twice following their injury. Time since injury, time between assessments, and longitudinal mood changes were evaluated for their potential impact on simple and complex attention outcomes. As an overall group, there was little change over time from low average to average baseline attention/concentration performance. However, results indicated that longitudinal increases in depressive symptoms were consistently associated with poorer performance on a measure of simple and complex attention. Loss of consciousness, litigation status, baseline injury status (acute vs. post-acute), and time between evaluations were not significant predictors of changes in cognitive performance. Implications for the treatment of comorbid psychiatric issues and for future research on victims of electrical trauma are discussed.

Psychiatric Outcome Over a Decade After Electrical Injury: Depression as a Predictor of Long-Term Adjustment.

Electrical injury (EI) produces a variety of physical, cognitive, and emotional consequences. Psychiatric and neurocognitive symptoms may complicate survivors’ psychosocial adjustment and ability to return to work. However, due to a paucity of longitudinal research, the long-term course of EI remains poorly understood. The purpose of this study was to investigate psychiatric and functional status in EI patients over a decade after injury. Fourteen EI patients who originally underwent baseline neuropsychological evaluation participated in this long-term follow-up. Participants completed a telephone survey of functional status, neuropsychological symptom checklist, and the Psychosocial Adjustment to Illness Scale Self-Report. Participants were grouped according to baseline Beck Depression Inventory (BDI) scores. After an average of 12.36 years postinjury, participants with elevated baseline BDI scores experienced difficulty across multiple domains of psychosocial adjustment at follow-up. This group was also less likely to return to work and exhibited a significant increase in psychological distress. EI results in significant chronic psychiatric complaints for many survivors. In the current sample, psychiatric sequelae of EI continue to persist over a decade after injury. Moreover, elevated baseline BDI scores predicted worse outcomes for vocational and psychosocial adjustment. Findings underscore the impact of emotional symptoms on recovery and need for specialized psychiatric intervention immediately following injury.