Case Studies in Neuropsychology

Two women were recently referred for neuropsychological assessment by
their physicians due to numerous cognitive complaints and suspicion of
head injury.  Both women were similar in age (40s), education, and
history.  Neither woman was responding well to medical treatment.

Woman #1 was involved in a minor automobile accident.  Significant
injuries included a sprained wrist, back, and neck pain.  She was evaluated
on the scene by paramedics but refused to be taken to the hospital.  There
was no head impact or loss of consciousness.  However, she reported being
in a daze afterwards for several hours, and could not drive herself home.  
In addition to the wrist, neck, and back pain for which she sought and
received treatment, she complained of chronic headaches after the
accident and an inability to concentrate and focus.  She returned to work
immediately after the accident.  She had been a successful self-employed  
business owner.  Upon her return to work, she began experiencing
difficulties managing her affairs, remembering to schedule crucial business
appointments, and accomplishing necessary tasks.  As a result, she began to
feel frustrated and overwhelmed.  Her moods became dysphoric, she could
not sleep well, and she was fatigued.  After several weeks, she concluded
that she was unable to manage her business.  A family member took over
management of the business.  

Woman #1 was referred for an evaluation.  Her presentation was suspect
initially due to the reported low impact of the automobile accident, and
interest in secondary gain via litigation.  A thorough malingering analysis
was performed.  The results revealed no evidence of symptom
exaggeration.  Her history was significant for a severe automobile accident
20 years prior which resulted in a 10-day coma.  She completed a
neuropsychological assessment. The results revealed significant deficits in
attention and executive functioning.  The difficulties with attention were
obvious.  However, impaired executive functioning could only be revealed
through an assessment.  This impairment impacted her judgment, her
ability to reason and problem-solve, attend to multiple tasks
simultaneously, and utilize abstract thought.  This hindered her ability to
successfully manage her business, which she was able to do prior to the
accident, and resulted in frustration and depressive symptoms.  Although in
a low-impact accident, the significant previous head injury likely
decreased her threshold for future head injury.  The treatment plan
consisted on an educational component regarding her deficits, counseling to
develop improved coping mechanisms, and cognitive rehabilitation
focusing on problem-solving and compensatory strategies.  

Woman #2 was in a moderate-impact automobile accident which resulted
in neck and back injuries, and minor facial lacerations from flying glass.  
There was no significant head impact or loss of consciousness.  She was
taken to an area hospital, treated, and released after a brief two-hour
observation.  Her complaints included head, neck, and back pain.  She also
reported numerous complaints to include an inability to concentrate,
problematic memory, dysphoric mood, anxiety, sleep disturbance,
excessive worries, nightmares of the accident, and fatigue.  She returned
to work for three weeks.  Although receiving physical therapy and
treatment for pain, she reported that she could not perform duties as a
secretary due to her physical and cognitive deficits, and took sick leave.  
After several months of limited success in treatment, her physician
referred her for a neuropsychological assessment.  

Woman #2 was evaluated at the Neuropsychology Assessment Service.  She
performed poorly on a malingering analysis, indicating that she was
exaggerating symptoms to a significant degree.  Her history was significant
for two previous low-impact automobile accidents which resulted in a
similar pattern of symptoms.   Neuropsychological evaluation revealed a
completely normal brain functioning, although her performance on memory
and concentration tests were impaired.  Personality testing revealed
elevated scales in hysteria and hypochondriasis, indicating that she was
likely to exaggerate symptoms.  Her presentation was consistent with an
anxiety disorder, possibly Post-Traumatic Stress Disorder, with concomitant
depressive symptoms.  Treatment planning consisted of counseling to
develop improved coping mechanisms, and systematic desensitization to
alleviate anxiety.  

These are examples of how two patients with similar patterns of
symptoms, dysfunction, and impairment present with differing etiologies
requiring different treatment approaches.  Based upon the
neuropsychological evaluation, effective treatment plans could be
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Case Studies in Neuropsychology