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K. E. Thornton, Ph.D. Neuroscience Center

9635 Southern Pine Blvd. Ste. 105, Charlotte, NC, 28273-5558Telephone 980-229-4962 NJ Lic. 35S100168200 NC Lic. 4294

Web: chp-neurotherapy.com Email: [email protected]

DATE OF REPORT

Mr.NAME:SEX: MaleAGE: 46

HANDEDNESS: RightEDUCATION: 16

DATE OFEVALUATION

DATE OFACCIDENT:

TIMEDIFFERENCE

REASON FOR REFERRAL

TESTS ADMINISTEREDMinnesota Multiphasic Personality Test -

IIWeschler Logical Memory

Test Test of Memory Malingering (TOMM)

Continuous Performance Test California Verbal Learning Test Shipley Institute of Living Scale

Calcap Reaction Time

Visual Scanning Test

Multi-Digit Memory TestCognitive Questionnaire

Wisconsin Card Sorting testCategory Test

Smell Test Mr. X was referred for neuropsychological evaluation to assess for the possible cognitive

consequences of a head injury, which occurred during a motorcycle accident. Mr. X was driving his Honda motorcycle on X street in Y at about 5 PM. He was traveling straight on a one way street and was approaching an intersection. Another car ran a stop sign on his right at the intersection and cut in front of him, causing his cycle to hit the left front of the other car. He was thrown over the hood of the car and landed on the concrete. His helmet was badly bruised. He was unconscious for several minutes. He next recalls hearing someone near the ambulance saying that he was unconscious. He felt dazed, was in shock and pain immediately following the accident. The pain was in his left leg, right shoulder, right index finger and he was bruised in many places. He was taken to the hospital. His memory for the events prior the accident are poor as he could only recall a week prior. His memory for events following the accident was reported to be good. He was in the hospital for 3 days. The following morning he experienced headaches, excruciating pain and pain in his neck, back and left leg. X-rays and CT scans were conducted. He was supplied with pain medication.

PRESENT SYMPTOMS At the time of the initial evaluation Mr. X was reporting pain in his back (lower), neck,

some pain in his right shoulder and right chest area. He denied any vision problems, reported numbness in his legs and arms, dizziness (occasionally in the morning upon rising). He denied any facial pain but did report hearing problems (ringing in the both ears) and headaches (anterior)

which were occurring 2-3 times a week. There has been some no improvement in the headaches.

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9635 Southern Pine Blvd. Ste. 105, Charlotte, SC, 28273-5558 Telephone 980-229-4962 NJ Lic. 35S100168200 NC Lic. 4294


Subjective emotional symptoms following the accident include the onset of anxiety while driving in cars. As a passenger, he finds that he nags the driver and hits an imaginary brake with his foot. He denied any flashbacks of the accident or nightmares but did report occasional obsessive ruminations about the interactions with the police. He reported an increase in depression symptoms and irritability. Mr. X is also reporting an increase in appetite as well as a decrease in energy level. He also reported the onset of sleeping problems. He averages about 4-5 hours per night. Problems in memory and concentration were also noted. The following subjective symptoms were reported. Severity level is indicated by the number. 1-mild; 2-moderate; 3-severe. Visual problems: difficulty focusing for long periods of time (3), Motor problems: muscle weakness (3), muscle twitching(3), muscle spasms(3), trouble walking

(2), coordination problems (2), balance problems (2), tremors or shakiness (2), dropping objects (1), handwriting problems (1),

Tactile problems: numbness (2), tingling skin (2), pins and needles (2), burning skin (2), loss of

feeling (1), and loss of telling hot from cold (1) headaches (2), Subjective reports of emotional symptoms: problems in controlling anger (3), irritability (3),

worry or guilt (3), and personality changes (3). Spatial thinking problems: following directions (3), reading a map (3), confusing left and right

(2), telling time (2), and getting lost often (2). Receptive Speech problems: misunderstanding others (2), and following conversations (2), Expressive Speech problems: finding the right word (2), misusing words (1), substituting words

(1), mispronouncing words (1), making up words (1), misnaming objects (1), and putting sentences together incorrectly (1),

Reading & Writing problems: misspelling words (1), slower reading speed (3), not

understanding what was read (1),Mathematical problems include: difficulty balancing checkbook(1), inability to calculate

without writing numbers down (1),Memory problems include: where objects are placed (2), conversations (1), directions

(1),appointments (2), items on a grocery list(2), intentions

(1), and the point of aconversation (1),

Attentional problems include: easily distracted (3), in maintaining concentration (3), losing the

train of his thought (2),

MEDICAL/PSYCHOLOGICAL REPORTS A QEEG was performed to assess for underlying electrophysiological problems, which

could be clinically correlated with the Neuropsychological testing. Activation procedures were conducted directed towards memory, reading and problem

solving. The electrophysiological variables obtained during the procedure are consistent with the effects of a traumatic brain injury (Thornton, 1999, 2000, 2003). A separate report on the results of the activation QEEG study will be prepared.




PSYCHOSOCIAL BACKGROUND Family Background

He was born in X on 7/4/19XX and raised in X, Y in a family of 1 brother (presently age 52). Mr. X moved to New Jersey in 19XX. He described his relationship with his sibling as good when he was growing up and good presently. He described his relationship with his parents as good when he was growing up and good presently. He described his general feeling when he was growing up as average. When he was on his own for several years, he felt normal. During the past several years he had been feeling normal prior the accident. Presently, both his parents reside in YY.

Academic/Vocational History He has not been classified by the school system. He reported that during his elementary

schools years his grades were average and that during his high school years the grades were average. In College, his grades were above average. He was strong in math. He obtained a law degree in the US. He has been employed as an assistant attorney.

MEDICAL/PSYCHIATRIC/ACCIDENT HISTORY He reported the following medical history: high blood pressure, hand, and shoulder injury. He

is taking the following medications at present: none. He reported the following psychiatric/psychological history: none. He reported the following history of psychiatric problems in his family: none. He reported the following history of alcohol problems in the family: none. He denied any history of criminal behavior, alcohol abuse or drug abuse.

CURRENT SITUATION He is presently divorced from first spouse, a relationship which had lasted for 3 years. He has

no children. Presently, he resides in a house alone. He enjoys the following hobbies: “love tennis but can not play” and spends his free time watching TV. The main source of income for Mr. X is his “sick, leave pay”.

CURRENT MENTAL STATUS There was no evidence of a body odor. His fingernails and his hair were clean. There were

no indications of hallucinatory experiences, delusions and paranoid ideation. There was no indication of assault or suicidal ideation. There was no evidence of depersonalization symptomatology. There was no evidence of compulsive tendencies. He related the following fears: none.

There was no evidence of manic symptomatology. There were no indications of difficulty with eating behavior. In terms of his sleeping pattern, there were indications of difficulty in this area. He reported obtaining approximately 4 hours of sleep per night. The subject's sexual behavior revealed no problems in functioning. There were no responses indicative of problems in the areas of drug and alcohol use. There were no indications of any problems in terms of activities of daily living.

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TEST BEHAVIOR Mr. X is a 5 foot X inch tall 1XX pound male who has X hair and X eyes and was

appropriately dressed during the interview. The testing results are considered to be a valid reflection of his current cognitive functioning.

DISCUSSION OF FORMAT OF TEST RESULTS The following reporting of numerical results follows the interpretative structure developed by

Dr. Heaton. A fuller discussion of this method and its implications is presented at the end of the text section, following the bibliography. In general, impairment is reflected in lower numbers and is indicated in the tables by the red color Table #1 and Chart #1 present the format of the presentation of the results.

ATTENTIONAL TESTS The Visual Scanning test requires the subject to cross out 4 figures (2 letters & 2 figures)

on a paper with some 1200 letters and figures which have embedded in them 128 targets to identify. This test is under experimental development by the author and is a variant of other tests similar in task requirements. As this task does not have norms available, the Heaton structure of labeling is not followed. The author renders judgments in terms of either impaired or not impaired. On this task he demonstrated deficits in terms of accuracy but not speed.

The Continuous Performance task requires the subject to press the space bar whenever the letter A appears on the computer screen. The computer presents letters in the middle of the screen approximately one a second. There are two types of exposure on this task. The first exposure requires the subject to respond to the letter A, while the second task requires the subject to tap the space bar whenever the letter A follows an X. This variation of the Continuous Performance Test was developed by Dr. Loong of Wang Neuropsychological Laboratories and employs the norms he developed. As deviations on this task can quickly become outside the range of normal values for T scores, etc a cut off of 2 standard deviations is employed as a criteria for interpretation of problems in attentional vigilance. On this test he displayed deficits in terms of maintaining accurate attention on both of the two tasks. The numeric results of the CPT and visual scanning test are presented at the end of the report in table 2. The results of the remaining tests employ the labeling presented in Table 1.

REACTION TIME MEASURES The measure of reaction time employed was CALCAP (California Computerized

Assessment Package) developed by E. Miller, Ph.D. to measure cognitive decline associated with HIV positive dementia. The test consists of seven subtests, which can be presented in English or Spanish. The following descriptions are taken from the manual provided with the test. The results are presented in Table 3 at the end of the report. Simple Reaction Time (SRT 1-3): Subjects are asked to press a key as soon as they see anything at all on the screen. This procedure provides a basal measure of reaction time. This task is given at the beginning, middle and end of the computerized procedures to allow the examiner to assess fatigue effects. The results do not indicate any fatiguing effects. Mr. X’s performance resulted in Z scores of: 0.37, 0.19, and -2.2 respectively.

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Simple Reaction Time: Non-Dominant Hand (SRT NOND): This measure is the same as SRT but employs the non-dominant hand Mr. X's performance resulted in a Z score of: 0.13 (average performance). Choice Reaction Time for Single Digits (CRT Base): Subjects are asked to press a key as soon as they see a specific number such as 7, otherwise they do nothing. This procedure adds a simple element of memory. Mr. X’s performance resulted in a Z score of: -2.11 (moderate deficits in performance). Serial Pattern Matching (Sequential Reaction Time-CRT-SEQ1): Subjects are asked to press a key only when they see two of the same number in sequence, for example, if they see the number 3 followed by a second occurrence of the number 3. This procedure adds a more complex element of memory since the subject must keep in mind the last number that was seen Mr. X’s performance resulted in a Z score of: -1.49 (mild deficits in performance). Lexical Discrimination (CRT-LEX): Subjects are asked to press a key when they see a word which fits into a specific category such as animal names (such as, COW or HORSE), but not when they see a word which fits into a category of non-animals (such as DESK or FOOD). This procedure introduces an additional level of language skills by requiring meaningful differentiation between semantic categories. The task requires rapid language processing and should be sensitive to any disruption in language skills Mr. X’s performance resulted in a Z score of: -2.91 (moderate to severe deficits in performance). Visual Selective Attention (CRT-DIST): Subjects are asked to press a key as soon as they see a specific word such as SEVEN in the center of the screen. An additional set of the words are displayed around the periphery of the target stimulus located in the center of the screen. These distractors require that the subject focus his or her attention much more narrowly. Mr. X’s performance resulted in a Z score of: -1.19 (mild deficits in performance). Response Reversal and Rapid Visual Scanning (CRT-RVRS): This task is identical to task 5 described above, but the subject must ignore the stimuli presented in the middle of the screen while responding to target stimuli displayed around the periphery of the screen. This task taps into the subject's ability to change cognitive set from the previous task, and requires more rapid visual scanning across the entire display screen. Mr. X’s performance resulted in a Z score of: -1.9 (moderate deficits in performance). Form Discrimination (CRT-FORM): Subjects are shown three geometric figures simultaneously and asked to press a key only when two of the figures are identical. This task requires rapid comparison of non-namable forms, and, because of the brief exposure time, may measure the subject's ability to retain an iconic memory of the figures. Mr. X’s performance resulted in a Z score of: -0.46 (average performance).

An examination of the true/false positives during the testing revealed that Mr. X’s performance resulted in normal range on all of the tasks. Norms are not available for the False Positive Figures.

MEMORY TESTING The California Verbal Learning Test requires the subject to listen to a shopping list of

16 words which are members of 4 categories(clothing, tools, fruits, spices & herbs) and recall as many as possible after each presentation. The list is presented 5 times, and then an additional list of

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another 16 items are presented once. The subject is then required to recall the first list and is then presented with the categories to ascertain if the categories aid in recall. A delay of twenty minutes is filled with other nonverbal activity. The subject is then asked to recall the items on the first list without any aid and is then provided the categories. The last part of the test asks the subject if they can recognize the words from the first list among 40 other words. The scoring for the test examines many aspects of the subject's performance and are presented in table 4 as raw scores, standardized scores and the normal raw score for the appropriate age and sex.

In terms of the Recall Measures (Number Correct), Mr. X performed in the mildly impaired range on the category list a (trial 1), average range on the category list a (trial 5) and moderately impaired range on the category list b

On other measures of Delayed Recall ability, Mr. X performed in the average range on the category short delay (free recall), above average range on the category short delay (cued recall), above average range on the category long delay (free recall) and on the category long delay (cued recall).

On the Learning Characteristics (List A, Trials 1-5) scoring categories, Mr. X performed (on the scales which assess strategy in recall) in the mildly impaired range on the semantic cluster category and on the serial cluster category.

On measures assessing grouping of recall by position, Mr. X performed in the mildly impaired range on the primacy score, average range on the middle region score and on the recency score.

On additional measures, Mr. X performed in the above average range on the learning slope score and mildly impaired range on the percent recall consistency score.

On the Recall Errors (Lists A and B) scoring categories, Mr. X performed in the impaired range on the perseveration score, on the free recall/intrusions score and non-impaired range on the cued recall/intrusions score.

On the Recognition Measures, Mr. X performed in the average or above range on the discriminability score and non-impaired range on the false positive score. The results of the CVLT are presented at the end of the report in table 4.

The Wechsler Memory Scale - Revised II (Logical Memory) requests that the subject listens to two short stories and then asks for immediate recall and then a delayed (30 minute) recall. The test was chosen to be included in the battery as it has face validity in terms of everyday functioning, as individuals communicate with each other many times in terms of short paragraphs of information. On this subtest, Mr. X performed in the 25th percentile range on the immediate recall section and 29th percentile on the delayed (30 minutes) test. These scores represent below average performance on the immediate recall task and Mr. X performed with a raw score of 17.5 on the immediate recall task and a raw score of 14.5 on the delayed recall task. This figure represents a savings score of 83 percent.

Problem Solving / Set Sifting The Wisconsin Card Sorting test requires the subject to match a card to one of

four possible matches. The cards can be matched on the basis of color, form, or number and the computer changes the matching principle six times during the test. Feedback regarding the accuracy of the response is provided by sound and words on the screen.

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On the measures designed to assess overall concept formation ability, Mr. X's performance demonstrated significant deficits in terms of total categories completed and in terms of trials to the first category.

On measures of attentional and learning factors, Mr. X’s performance significant deficits in terms of his ability to maintain set and average performance in terms of learning to learn.

On error measures, Mr. X’s performance demonstrated deficits in terms of total percent errors.

On Perseverative measures, Mr. X’s performance demonstrated deficits in terms of total number of perseverative responses, in terms of total number of perseverative errors and total percent perseverative errors. He demonstrated impaired performance in terms of total percent perseverative errors.

The percentile ranks and T scores obtained for the subject's performance were generated from Heaton's Manual published by Psychological Assessment Resources. The numeric results of the Wisconsin are presented at the end of the report in table 6. The T scores developed on the computerized administration of the Wisconsin developed by Dr. Loong are presented for comparison, as the test was computer administered.

The Category test presents the subject with seven separate tasks. In each of the tasks the subject is presented with a shape or series of shapes on the computer screen. The subject task is to press a number from 1 to 4 which corresponds to what she thinks the shape or shapes are trying to convey. There is an underlying principle behind each series. For example, the second series places different number of objects on the screen. When there is only one object the subject should press 1, and when there are three objects, the subject should press the number 3. Thus for this task the principle is number.

The Category test developed by Psychological Assessment Resources by Nick A. DeFilippis, PhD was employed. The standard 208 item test was computer administered. Mr. X’s performance reflected 57 errors, which indicates impaired functioning.

Smell Test As Mr. X was reporting problems in olfaction, the Smell Identification Test was

administered. The Smell test was developed by Dr. Doty, PhD of Univ. of Pennsylvania with over 1600 individuals and meets standard statistical criteria (i.e. reliability, validity) for psychological measurement. The test involves the subject scratching a small area which contains the scent and then to choose between 4 alternative smells (i.e. watermelon, peanut, rose, paint thinner). There are 40 items administered. Mr. X was able to correctly identify 25 of the 40, which placed him in the severe microsmia category.

PSYCHOLOGICAL TESTING MINNESOTA MULTIPHASIC PERSONALITY INVENTORY II

Mr. X responses on the MMPI-2 indicated that he responded to the items in manner which could be interpreted as a “cry for help” or overstatement of symptoms. In terms of the main clinical scales, there were significant elevations (above 64) on the following scales: F Scale, Hypochondriasis, Depression, Hysteria, Psychopathic Deviate, Paranoia, Psychasthenia, and Schizophrenia scales.

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In terms of the Supplementary scales, there were significant elevations on the following: Repression, College Maladjustment, Post-Traumatic Stress/Keane, Post-Traumatic Stress/Schlenger scales. In terms of the SI subscales, there were significant elevations on the following: Alienation Self & Others and Anxiety.

The Content scales showed elevations on Fears, Depression, Health Concerns, Bizarre Mentation, Low Self Esteem, Work Interference, Negative Treatment Indicators, and Subjective Depression scales. The Harris-Lingoes subscales showed elevations on Physical Malfunctioning, Mental Dullness, Brooding, Lassitude-Malaise, Somatic Complaints, Social Alienation, Self Alienation, Persecutory Ideas, Poignancy, Social Alienation, Emotional Alienation, Lack of Ego Mastery/Cognitive, Lack of Ego Mastery/Cognitive, Lack of Ego Mastery/Defective Inhibition, and Bizarre Sensory Experiences scales.

It should be kept in mind that the names of the scales should not be interpreted at face value, as multiple factors can produce elevations. The pattern of results indicates that is experiencing significant levels of internal distress which is being experienced as depression, anxiety and paranoia. The results of the testing are presented in Table 8.

CONCLUSIONS AND SUMMARY: CONTRIBUTORY EFFECTS OF OTHER FACTORS TO TESTING RESULTS

In order to as fully understand the test results, it is important to note the possible contributory effects of present emotional status, preexisting cognitive/intellectual status, and possibility of malingering (conscious/unconscious exaggeration). In terms of present emotional functioning, his responses on the MMPI-2 indicated significant levels of depression and significant levels of anxiety. However, research by Otto (1992) and others indicate that the depression is experiencing is not sufficient to fully explain the results of the testing. In terms of preexisting cognitive/intellectual status, his performance on the Shipley (IQ=115) and ability to complete law school argue for at least a preexisting normal level of intellectual functioning. In addition there was no evidence of malingering on two tests designed to assess for that possibility.

THEORETICAL / CLINICAL CONCLUSIONS An analysis of the overall testing results indicates that he is demonstrating significant

problems in attentional abilities (CPT, Visual Scanning, Reaction Time), auditory memory abilities and problem solving /set shifting. The emotional and neuropsychological deficits reported are a direct result of the accident. This causative statement is derived from the test results and the client's report of the appearance of the above stated cognitive problems and other problems soon after the accident. In addition the client did not report any history of learning disability or problems in the areas tested. It is evaluator's opinion that the deficits noted in this report are due to the accident within a reasonable degree of psychological certainty

RECOMMENDATIONS It is recommended that he engage in a part-time outpatient cognitive rehabilitation program

(1-3 times a week, 6-12 months) to address the problems noted in this report. The program would consist of EEG biofeedback to address the cognitive problems as well as psychotherapy and

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biofeedback to address the emotional sequelae. The prognosis for recovery of function, without continued treatment, is guarded to fair. The following diagnoses are appropriate:

DIAGNOSTIC IMPRESSION AXIS I: CLINICAL SYNDROMES DSM IV 294.90 Cognitive Disorder, NOS DSM IV 309.81 Posttraumatic Stress Disorder DSM IV 296.23 Major Depression, Single Episode, Moderate DSM IV 307.89 Pain Disorder, Associated with both Psychological Factors and a General Medical Condition ICD 9: 310.2 Post-Concussion Syndrome ICD 9 309.81 Posttraumatic Stress Disorder AXIS II: DEVELOPMENTAL DISORDERS/PERSONALITY DISORDERS none AXIS III: PHYSICAL DISORDERS AND CONDITIONS see medical and present symptoms section AXIS IV: SEVERITY OF PSYCHOSOCIAL STRESSORS 3-moderate Acute: motorcycle accident Chronic: cognitive and emotional effects of accident AXIS V: GLOBAL ASSESSMENT OF FUNCTIONING 60 - Moderate symptoms - (cognitive difficulties, depression, anxiety, moderate to severe difficulty in social, occupational or school functioning)

Kirtley Thornton, PhD Licensed Clinical Psychologist




REFERENCES Heaton, R.K, Chelune, G. J.,Talley, J.L.,Kay, G.G.,Curtiss, G.,Wisconsin Card Sorting Test

Manual, Psychological Assessment Resources, Inc.1993 King, D,A., Caine, ED, Cox,C., Influence of Depression and Age on Selected Cognitive

Functions, The Clinical Neuropsychologists, Vol. 7. NO. 4,1993 Moses, J.A.,Jr., (1983), An Orthogonal Factor Solution of the Luria-Nebraska

Neuropsychological Battery Items: I. Motor, Rhythm, Tactile and Visual Scales, Clinical Neuropsychology, V, 181-185

Moses, J.A.,Jr.,(1984a), An Orthogonal Factor Solution of the Luria-Nebraska Neuropsychological Battery Items: II. Receptive Speech, Expressive Speech, Writing And Reading Scales, The International Journal of Clinical Neuropsychology, VI,

24-28 Moses, J.A., Jr., (1984b), An Orthogonal Factor Solution of the Luria-Nebraska

Neuropsychological Battery Items: III Arithmetic, Memory and Intelligence Scales, The International Journal of Clinical Neuropsychology, VI, 103-106

Moses, J.A., Jr., (1984c), An Orthogonal Factor Solution of the Luria-Nebraska Neuropsychological Battery Items: IV. Pathonogmonic, Right Hemisphere, and Left Hemisphere Scales, The International Journal of Clinical Neuropsychology, VI,

161-165 Newman, P.J., Silverstein, M.L., Neuropsychological Test Performance among Major Clinical

Subtypes of Depression, Archives of Clinical Neuropsychology, Vol. 2, 1987 Otto, M.W., Bruder G.E., Fava M, Delis, D.,Quitkin F. M., Rosenbau, J.F., Norms for

Depressed Patients for the California Verbal Learning Test: Associations with Depression Severity and Self Report of Cognitive Difficulties, Archives of Clinical

Neuropsychology, Vol. 9, pp 81-88. 1994

Raskin, A, 1986, Partialing out the Effects of Depression and Age on Cognitive Functions: Experimental Data and Methodologic issues, in L Poon (ED) Handbook for Clinical Memory Assessment of Older Adults, pgs 244-256

Sackeim, HA, et al, Effects of Major Depression on Estimates of Intelligence, Journal of Clinical and Experimental Neuropsychology, 1992, Vol 14, No 2, pp 266-8

Thornton, K. (1999). Exporatory Investigation into mild brain injury and discriminant analysis with high frequency bands (32-64 Hertz), Brain Injury, 13 (7), 477-488.

Thornton, K. (2000). Exploratory Analysis: Mild Head Injury, Discriminant Analysis with High Frequency Bands (32-64 Hz) under Attentional Activation Conditions & Does Time Heal?, Journal of Neurotherapy, 3 (3/4) 1-10.

Thornton, K. (2001). Electrophysiology of Auditory Memory of Paragraphs: Towards a Projection/Activation Theory of the Mind, J. of Neurotherapy, Vol. 4 (3), p. 45-73

Thornton, K. (2003). The Electrophysiological Effects of a brain injury on auditory memory functioning: The QEEG correlates of impaired memory, Archives of Clinical Neuropsychology, 17, 1-17.

Thornton, K. (2002). Electrophysiology (QEEG) of Effective Reading Memory: Towards a Generator/Activation Theory of the Mind, J. of Neurotherapy, 6(3), 37-66.

Thornton, K. (2005). EEG Biofeedback for Reading Disabilities and Traumatic Brain Injuries: Child and Adolescent Psychiatric Clinics of North America, 14 (1), 137-163

Thornton, K., Carmody, D. (2008). Efficacy of Traumatic Brain Injury Rehabilitation: Interventions of QEEG-Guided Biofeedback, Computers, Strategies, and Medications, Applied Psychophysiology and Biofeedback, 2008, 101-124. 10

K. E. Thornton, Ph.D. Neuroscience Center9635 Southern Pine Blvd. Ste. 105, Charlotte, NC, 28273-5558

Phone: 980-229-4962 Fax: 803-675-0969 Email: [email protected] NC Lic. 4294

Thornton, K., Carmody, D. (2008). Efficacy of Traumatic Brain Injury Rehabilitation: Interventions of QEEG-Guided Biofeedback, Computers, Strategies, and Medications, Applied Psychophysiology and Biofeedback, 2008, 101-124.

Thornton, K., Carmody, D. (2009). Traumatic Brain Injury Rehabilitation: QEEG Biofeedback Treatment Protocols, Applied Psychophysiology and Biofeedback, 2009, (34) 1, 59-68.

Thornton, K., Carmody, D. (2009). Integrative Clinical Psychology, Psychiatry and Behavioral Medicine: Perspectives, Practices and Research Chapter Title: Traumatic Brain

Injury and the Role of the Quantitative EEG in the assessment and

remediation of cognitive sequelae, 12/2009.463-508.

Veiel, A Preliminary Profile of Neuropsychological Deficits associated with Major Depression, J. of Clinical and Experimental Neuropsychology, 1997, 19 (4), 587-603

Discussion of Format of Reporting The use of the labels in Table 1 to describe the deficits noted in the report follows the

Heaton Manual on the Halstead Reitan in terms of verbal classification of deviations. The Table presents the verbal label with the corresponding IQ Score, Z score, T Score and Percentile Score. The IQ scores are provided as a comparison scale, since most people are more familiar with this type of scale. Heaton maintains that by employing this classification scheme and a cut off T score below 40, the examiner accepts a false positive rate of about 12% and false negative rate of 20%. The test results and data are presented in either as T scores, Standard Scores, Z scores or Percentile Ranks, depending upon how the test was developed and results generated.

Due to statistical issues regarding the distribution of the original samples (kurtosis, skewness); it is not possible to translate all of the scores to a single format to ease the reader's task. When appropriate the numerical results were adjusted to the direction which is consistent with the interpretative structure provided above, that is lower scores reflect impairment. For example, on the Category test a high T score on the Failure to Maintain Set category would represent impairment. Thus a category which has a negative implication in terms of functioning presents a high score as representing impairment. To maintain consistency in presentation and to ease the reader's task, the T Scores, etc. are adjusted accordingly so that a lower number represents the direction of difficulty and a higher number is in the direction of adequate or above performance. It should be kept in mind that the interpretations are based on the assumption of an average reference group. If there is substantial evidence that the individual was functioning at a higher than normal level prior the incident, then interpretations require adjustment. For example, if an individual is performing at an average level on a particular test, and yet his preexisting IQ was above 130, then his performance would reflect moderate impairment and he would fall in the 1st to 2nd percentile range in terms of the appropriate reference group. The opposite is correspondingly true. If the individual was operating at a lower than average level, then interpretations have to be adjusted accordingly.

Chart #1 represents the relationships between these different ways of scoring in terms of the normal bell curve. Some of additional tests are presented in a computerized format to the subject (Wisconsin, CPT, Calcap). Norms on the CPT and Calcap were all developed on the basis of computerized administration. Only the Wisconsin Card Sorting test employs the Heaton norms,

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mailto:[email protected]



which were generated from individual administration. The computerized norms developed at Wang Laboratories are also presented in the appropriate table.

To estimate the subject's preexisting intelligence level, the Shipley Institute of Living Scale was administered. This task requires the subject to pick out among four alternatives the closest alternate meaning to a word presented. It is a vocabulary recognition task. As vocabulary skills are generally considered to be the least vulnerable to an insult to the brain and correlate the highest (among the other WAIS or WAIS-R subtests) with overall IQ in a general population, this measure can be considered a reasonable, albeit not perfect, method of estimating preexisting IQ. The method employed was to employ only the Vocabulary section (not the Abstraction part) and calculate the WAIS IQ result using this number. His responses reflected an IQ of 115. Employing Heaton's classification scheme, this numerical result would place the subject in the above average range. A traumatic brain injury can be expected to reduce IQ scores about 9 points.

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CHART # 1

Conversion Table # 1Label IQ Scores Z Score T Score % Rank

Highly Elevated 146+ 3.0+ 81+ 99+Moderately to Highly 139-145 2.5-3.0 76-80 99+

Moderately 131-138 2.0-2.5 71-75 98-99Mildly to Moderately 123-130 1.5-2.0 66-70 91-97

Mildly Elevated 116-122 1.0-1.5 61-65 81-90Above Average 108-115 .50-1.0 55-60 67-80

Average 93-107 -.50 to +.50 45-54 30-66Below Average

Borderline85-92 -1.0 to -.50 40-44 16-29

Mildly Impaired 77-84 -1.5 to -1.0 35-39 6-15Mildly to Moderately 70-76 -2.0 to -1.5 30-34 2-5

Moderately 63-69 -2.5 to -2.0 25-29 1-2Moderately-Severely 55-62 -3.0 to -2.5 20-24 <1

Severe<=under

<54 -4.0 to -3.0 1-19 <1




CONTINUOUS PERF.TEST TABLE 2no condition RAW MEAN SD T SCORETOTAL CORRECT 157 199.7 0.87 *TOTAL INCORRECT 45 0.78 1.22 *MISSED 43 0.3 0.87 *ABSOLUTE % 79 99.85 0.44 *RELATIVE % 78 99.61 0.61 *with condition RAW MEAN SD T SCORETOTAL CORRECT 56 98.83 1.68 *TOTAL INCORRECT 31 1.35 1.43 *MISSED 44 1.17 1.68 *ABSOLUTE % 56 98.83 1.68 *RELATIVE % 64 98.68 1.39 **=t score under 40Visual Scanning Test Quadrant

Left Right TotalUpper 12 14 26Lower 15 10 25Total 27 24 51

Minutes Sec.Time 4 21

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TABLE 3CALCAP REACTION

Simple RxTime-Dominant Hand Simple RxTime-Nondominant Hand Choice DigitsSequential RxTimeLanguage DiscriminationSimple RxTime2 Dominant Hand Degraded Words/DistractionResponse Reversal-WordsForm DiscriminationRxTime3-Dominant Hand

Choice/Digits(14-15)**Sequential RxTime1(13-20)Language Discrimination(18-24) Degraded Words(7-15)Response Reversal/Words(6-15) Form Discrmination(5-20)**=#s represent normal range *=no norms available for false positivesred=impaired scores

TIME TESTZ SCORE

0.370.13-2.11-1.49-2.910.19-1.19-1.90-0.46-2.20True False *

Positives Positives14 618 923 312 29 213 11

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TABLE 4 CALIFORNIA VERBAL LEARNING Ss Raw Norm Raw T ScoreLIST A/TOTAL 49 50 44

Z ScoreLIST A/TRIAL 1 6 8-9 -1LIST A/TRIAL 5 13 14 0LIST B 4 7-8 -2LIST ASHORT DELAY/FREE RECALL 10 12-13 0SHORT DELAY/CUED RECALL 13 13-14 1LONG DELAY/FREE RECALL 13 13-14 1LONG DELAY/CUED RECALL 13 14 1LEARNING CHARACTERISTICSSEMANTIC CLUSTER RATIO 1 2.1-2.8 -1SERIAL CLUSTER RATIO 1 1.3-2.7 -1% OF RECALLPRIMACY REGION 24 27-31 -1MIDDLE REGION 43 41-46 0RECENCY REGION 33 26-31 0SLOPE(INCREMENT OVER 5 TRIALS) 2 1.2-1.6 1% RECALL CONSISTENCY 75 83-91 -1RECALL ERRORSPERSEVERATIONS 7 5-7 1FREE RECALL/INTRUSIONS 4 1-3 1CUED RECALL INTRUSIONS 1 1 0INTRUSIONS/TOTAL 5 not normedRECOGNITION MEASURESRECOGNITION HITS 16 16 1DISCRIMINABILITY 95 95-100 0FALSE POSITIVES 2 0-1 0RESPONSE BIAS 0 -.2-.1 1CONTRAST MEASURESLIST B VS. LIST A/TRIAL 1 -33 -0.04 -1SHORT DELAY FREE VS LIST A./TR 5 -23 -0.07 0LONG VS SHORT DELAY FREE 30 0.05 1RECOGNITION VS LONG DELAY FREE 23 -0.10 0DISCRIMINABILITY VS. LONG DELAY FREE 0 -0.05 -1

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Table 5Logical Memory

Raw Score% RankImmediate Recall 18 25Delayed Recall 15 29

WangTable 6 LabWisconsin Card Test Heaton Norms Norms

SUBJECT NORM % Rank T Scores T scoreDURATION 0:10:45AVERAGE RESPONSE TIME 3TOTAL CATEGORIESCOMPLETED 2 6 >16TOTAL # OF TRIALS 107TRIALS TO CATEGORY #1 31 10-13 2-5TOTAL # CORRECT 50TOTAL % INCORRECT 55TOTAL ERRORS 61 23 7 35TOTAL % ERRORS 50 23 8 36# OF PERSEVERATIVE RES. 18 13 16 30# OF PERSEVERATIVE ERRORS 20 12 14 29 27% PERSEVERATIVE ERRORS 16 12 16 29 29#NON PERSEVERATIVE ERRORS 14 10 4 32 17# OF OTHER RESPONSES 3% CONCEPTUAL LEVEL RESP. 42 72 10 25 30# FAILURE TO MAINTAIN SET 2 0-2 >16

≥-LEARNING TO LEARN 4 1.50 >16SHIPLEY VERBAL 1Q 115

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Minnesota Multiphasic Personality Inventory II

Table # 7 - MMPI II Main Clinical Scales no answer 11L Scale 61F Scale 98K Scale 54Hypochondriasis 96Depression 106Hysteria 90Psychopathic Deviate 72M-F: masculine 55M-F: feminine 64Paranoia 102Psychasthenia 93Schizophrenia 97Mania 60Introversion-Extraversion 61

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