Table Of ContentT B I
R AUMATIC R AIN NJURY
Methods for Clinical and Forensic
Neuropsychiatric Assessment
R P. G
OBERT RANACHER
CRC PR ESS
Boca Raton London New York Washington, D.C.
©2003 CRC Press LLC
Library of Congress Cataloging-in-Publication Data
Granacher, Robert P., 1941-
Traumatic brain injury : methods for clinical and forensic neuropsychiatric assessment /
Robert P. Granacher, Jr.
p. ; cm.
Includes bibliographical references and index.
ISBN 0-8493-1429-1 (alk. paper)
1. Brain damage—Diagnosis. I. Title.
[DNLM: 1. Brain Injuries—complications. 2. Brain Injuries—diagnosis. 3. Expert
Testimony. 4. Forensic Psychiatry—methods. 5. Neuropsychological Tests. WL 354 G748t 2003]
RC387.5.G73 2003
616.8'0475—dc21 2003046073
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Preface
Approximately 2 million traumatic head injuries occur in the U.S. yearly. These in turn produce
more than 50,000 deaths annually. There is a biphasic distribution of brain injury, with the highest
incidence found among young people 15 to 24 years of age and a second group of citizens greater
than 75 years of age. Almost 25% of head injuries require hospitalization, and nearly 100,000
persons yearly are left with some level of chronic brain impairment.
This text has a specific focus. It provides not only methods for clinical examination but also
the forensic evaluation of traumatically brain-injured persons. The reader can be selective in using
this book. If he or she is interested only in clinical assessment, treatment planning, and neuropsy-
chiatric treatment, the first eight chapters of the book will suffice. On the other hand, for the
physician performing a forensic neuropsychiatric examination, the entire book should be useful. If
the clinician is already highly skilled in the clinical evaluation of traumatic brain injury but wishes
to learn further forensic issues, he or she may focus only on the last four chapters of this text.
There is a simple logic to the book. It follows traditional medical evaluation concepts with a
neuropsychiatric focus. It demarcates differences in the adult evaluation vs. the child evaluation.
Chapter 8 integrates the clinical section of this text, whereas Chapter 11 integrates the forensic
section of the text. The seven preceding chapters in the clinical section of the book proceed logically
to a culmination of data analysis and case studies in Chapter 8. The same format applies to the
forensic section, Chapters 9 to 12. Chapters 9 to 11 provide the forensic analysis database, and
Chapter 12 offers the forensic expert guidance for the writing of neuropsychiatric traumatic brain
injury reports and the providing of neuropsychiatric testimony.
This text is not intended to provide complete information regarding the multiple advances
within the entire field of traumatic brain injury. For instance, it provides only a limited focus on
management of acute traumatic brain injury. This is better left to neurosurgeons and trauma
physicians. Its primary intent is to provide the physician, at some time well after the brain injury,
with a clinically tested schema for either evaluating and treating a patient or examining a plaintiff
or defendant. The genesis for this text comes from the author’s database of almost 3000 traumatically
brain-injured persons, or those alleging a traumatic brain injury, examined by extensive historical,
physical, imaging, neuropsychological, and laboratory procedures. It is hoped that the reader will
find this to be a practical text providing pragmatic information either for evaluation and treatment
of one’s patient or for providing a state-of-the-art forensic examination of an alleged traumatic
brain injury.
©2003 CRC Press LLC
Author
Robert P. Granacher Jr., M.D., D.F.A.P.A., is president and executive director of the Lexington
Forensic Institute in Lexington, Kentucky. For more than 25 years he has taught at the University
of Kentucky College of Medicine within the Department of Psychiatry, and he currently functions
as clinical professor of psychiatry in that division. He has a full-time private practice as a treating
psychiatrist and as a forensic psychiatrist. He is board-certified by the American Board of Psychiatry
and Neurology in general psychiatry, with added qualifications in geriatric psychiatry and forensic
psychiatry. He is also board-certified in forensic psychiatry by the American Board of Forensic
Psychiatry, Inc. He is a diplomate and board-certified in sleep medicine by the American Board of
Sleep Medicine, and he is certified in psychopharmacology by the American Society of Clinical
Psychopharmacology. He serves on the board of directors of St. Joseph Hospital, a 630-bed
medical–surgical tertiary care facility, and from 1999 to 2002, he served as chairman of the board.
He is a director of C.B.A. Pharma, an oncology and research pharmaceutical company.
Dr. Granacher received his bachelor’s degree in chemistry from the University of Louisville
and his doctor of medicine degree from the University of Kentucky, Lexington. He served as resident
and chief resident in psychiatric medicine at the University of Kentucky Hospital, and later as
resident and fellow at the Harvard Medical School and the Massachusetts General Hospital, Boston.
He has specialized in the areas of treatment and evaluation of traumatic brain injury, perinatal birth
injury, and toxic brain injury for more than 25 years. He has personally evaluated by complex
neuropsychiatric assessment almost 3000 traumatic brain injury cases.
Dr. Granacher is a member of numerous professional associations, including the American
Medical Association, American Psychiatric Association, American Neuropsychiatric Association,
American Academy of Sleep Medicine, American Society of Clinical Psychopharmacology, Ken-
tucky Medical Association, Kentucky Psychiatric Association, and Fayette County (Kentucky)
Medical Society. He received the Exemplary Psychiatrist Award from the National Alliance for the
Mentally Ill in 1996. He is a distinguished fellow of the American Psychiatric Association.
This text is Dr. Granacher’s second book. He and Aaron Mason, M.D. previously published
The Clinical Handbook of Antipsychotic Drug Therapy. In addition to books, Dr. Granacher has
published widely in the medical literature, including book chapters and scientific articles. He
currently serves on two important committees of the American Academy of Psychiatry and the
Law: the Private Practice Committee and the Forensic Neuropsychiatry Committee. He also serves
on the Core Forensic Committee of the American Society of Clinical Psychopharmacology. His
forensic psychiatry practice is national in scope, and he consults to plaintiff lawyers, defense
lawyers, courts, the U.S. Department of Justice, corporations, and school systems.
©2003 CRC Press LLC
Table of Contents
Chapter 1 The Epidemiology and Pathophysiology of Traumatic Brain Injury
Introduction
Epidemiology of Traumatic Brain Injury
Classification of Head Injury
Neuropathology of Traumatic Brain Injury
Biomechanic Mechanisms in Traumatic Brain Injury
Pathophysiology of Traumatic Brain Injury
Neurochemical Changes Following Traumatic Brain Injury
Free Radical and Inflammatory Changes Following Traumatic Brain Injury
Apoptosis Following Traumatic Brain Injury
Typology of Traumatic Brain Damage
Skull Fracture
Focal Brain Damage
Contusions and Lacerations
Hemorrhage and Hematoma
Extradural (Epidural) Hematoma
Subdural Hematoma
Subarachnoid Hemorrhage
Intraparenchymal Hemorrhage
Intraventricular Hemorrhage
Diffuse Brain Damage
Diffuse Axonal Injury
Ischemic Brain Injury
Brain Swelling
Secondary Injury after Head Trauma
Vascular Failure
Intracranial Hypertension
Brain Shift and Herniation
Relationship of Traumatic Brain Injury to Late-Appearing Neurodegeneration
Trauma-Induced Beta Amyloid Deposition
The Genetic Component of Traumatic Brain Injury
Cholinergic Mechanisms and Neurodegeneration
References
Chapter 2 Neuropsychiatric and Psychiatric Syndromes Following Traumatic Brain
Injury
Neuropsychiatric Syndromes
Introduction
Adult Cognitive Disorders
Disorders of Attention
Disorders of Memory
Disorders of Language
Visual-Perceptual Disorders
©2003 CRC Press LLC
Executive Disorders
Intellectual Disorders
Child Cognitive Disorders
Disorders of Attention
Disorders of Memory
Disorders of Language
Executive Disorders
Intellectual Disorders
Frontal Lobe Syndromes
Disinhibited (Orbitofrontal) Syndromes
Disorganized (Dorsolateral) Syndromes
Apathetic and Akinetic (Mediofrontal) Syndromes
Posttraumatic Seizure Disorders
Posttraumatic Headache
Normal-Pressure Hydrocephalus
Posttraumatic Hypersomnolence
Psychiatric Syndromes
Introduction
Mood Disorders
Depression
Mania
Anxiety Disorder
Psychotic Disorders
Personality Changes Following Traumatic Brain Injury
Aggression and Anger
References
Chapter 3 Gathering the Neuropsychiatric History Following Brain Trauma
Introduction
Taking the Adult Brain Injury History
Posttrauma Symptoms and Treatment
Attention
Speech and Language
Memory and Orientation
Visuospatial and Constructional History
Executive Function History
Obtaining the History of Affective and Mood Changes
Taking the History of Thought Processing
Questioning the Patient about Risk to Self or Others
History of Behavioral Treatment Following Traumatic Brain Injury
Activities of Daily Living
Past Medical History
Past Neuropsychiatric History
Family History
Social History
Review of Systems
Taking the Child Brain Injury History
Posttrauma Symptoms and Treatment
Attention
Speech and Language
©2003 CRC Press LLC
Memory and Orientation
Visuospatial and Constructional History
Executive Function History
Obtaining the History of Affective and Mood Changes
Activities of Daily Living
Neuropsychiatric Development History
Past Pediatric History
Past Pediatric Neuropsychiatric History
Family History
Social History
Review of Systems
Review of the Medical Records
Emergency Room Records
The Hospital Record
Cognitive Rehabilitation Records
Occupational and Physical Therapy Records
Speech and Language Pathology Records
Taking the Collateral History
References
Chapter 4 The Neuropsychiatric Mental Status and Neurological Examinations Following
Traumatic Brain Injury
Introduction
The Adult Mental Examination
Appearance and Level of Consciousness
Attention.
Speech and Language
Memory and Orientation
Visuospatial and Constructional Ability
Executive Function
Affect and Mood
Thought Processing, Content, and Perception
Risk to Self or Others
Mental Screening Examination
The Adult Neurological Examination
Cranial Nerve Examination
Cranial Nerve I
Cranial Nerve II
Cranial Nerves III, IV, and VI
Cranial Nerve V
Cranial Nerve VII
Cranial Nerve VIII
Cranial Nerves IX and X
Cranial Nerve XI
Cranial Nerve XII
Motor Examination
Muscle Tone
Muscle Strength
Abnormal Involuntary Movements
Sensory Examination
©2003 CRC Press LLC
