Brain injury: More clues to symptom validity


I appreciate Current Psychiatry’s emphasis on sharpening one’s psychiatric diagnostic skills (“Neurocognitive impairment: Feigned, exaggerated, or real?” Current Psychiatry, August 2007). I have found a few additional questions may help validate symptoms of neurocognitive impairment during a psychiatric interview. These questions were developed as a result of my informal survey of individuals with head injuries, usually months after the injury.

Ask about a patient’s job. Significant changes in employment status—such as job loss or changes in job responsibilities or how others relate to the individual in the workplace— usually occur in the first 6 months after an injury.

Has the patient thought about or obtained a gun permit? In response to their perceived weaker status, many patients acquired weapons. I have no knowledge if these guns were misused.

In an informal survey, I also asked these injured individuals to name their favorite movie and actor. The Godfather: Part II and/or the film’s actors Robert De Niro, Al Pacino, and James Caan were chosen by 85% of patients from a certain generation. One possible reason for this choice was suggested by a 14-year veteran of the Canadian Forces, who felt that the motion picture allowed one to fantasize about striking out at others without harming oneself. Positive answers to 1 or more of these questions suggested symptom validity.

The psychologist’s documentation of an organic cause of the neurocognitive impairment compared favorably to an abnormal finding on a computerized brain mapping electroencephalogram (EEG). The recent computerization of multiple EEGs will allow physicians to identify abnormal patterns of electrical activity and suggest a diagnosis. A finding of 2 standard deviations from average may indicate neurocognitive impairment.

Leonard R. Friedman, MD
Revere, MA

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