Moderator: Richard Naugle, PhD
Discussants: Robin Hilsabeck, PhD; Marc Norman, PhD & Mike Schoenberg, PhD
Using Qualitative Observations for Differential Diagnosis in a Complicated Presentation
A 62-year-old female presented for neuropsychological evaluation and met DSM-IV criteria for Dementia. She possessed poly-etiologic factors and demonstrated atypical symptom development and striking behavioral abnormalities. Diagnoses initially considered included frontotemporal dementia, vascular dementia, posterior cortical atrophy, and progressive supranuclear palsy. Differential diagnosis and patient recommendations largely relied upon behavioral observation. Patient reported progressive confusion and memory problems 3 years prior to assessment. Contributing factors include a history of alcohol abuse and cigarette smoking as well as domestic violence, with multiple injuries to the head. EEG and all labs were within normal limits. MRI identified non-specific findings indicative of potential small vessel ischemic disease, demyelinating disorders, vasculitis, or normal aging with evidence of a venous angioma in the high left frontoparietal cortex. Patient demonstrated impairments across all domains; executive functions, spatial attention, memory, and language were most severe. Especially noteworthy was the patient's difficulty with the procedural tasks of spelling and name writing during consent. Upon presentation of visual stimuli, she demonstrated disinhibition, poor planning, perseverations, and closing in and stimulus bound behavior. Left/right confusion was present during praxis examination, as were errors to transitive and intransitive gestures with both hands, agraphesthesia, and Gerstmann's syndrome. Patient displayed gleeful, child-like affect and did not register social cues. Following comprehensive assessment, several diagnoses remained plausible, including the possibility of malingering/secondary gain. Although a definitive etiology could not be determined, behavioral observations were essential for making appropriate recommendations, highlighting the importance of both quantitative and qualitative data in diagnosis and case formulation.
The Multiplicity of Effects Related to Toxin Exposure and Multiple Concussions: A Neuropsychological Case Study
The aim is to identify the specific cognitive profile of a patient with multiple brain insults. Mr Z is a 57-year-old, European-American male with 19 years of formal education. He presented with a history of multiple concussions and exposure to environmental toxins (Agent Orange, lead, radiation, black mold, mercury, toluene, xylene). The goal of this case presentation is to examine the neuropsychological consequences of poly-etiological factors related to cognitive dysfunction. Mr Z reported decreased cognitive functioning over the past 10 years and since the summer of 2011 noted worsening cognitive and physical symptoms. Most notably, slow processing speed, confusion, fatigue, multi-tasking difficulties, and periodic procedural and episodic memory loss. Physical symptoms included tremors, numbness, swallowing difficulty, and balance issues. Mr Z's PET scan revealed reduced thalamic metabolism. His MRI scan was unremarkable. A previous neuropsychological evaluation was conducted in October 2012 which revealed deficits in working memory, verbal memory, and motor speed tasks. His neuropsychological profile was consistent with and unchanged from the neuropsychological evaluation completed in October 2012. More specifically, cognitive impairments were observed in the domains of processing speed, fine motor speed, working memory, and contextual immediate and delayed memory. The present case can be used as a model for discussion regarding the cumulative effects of toxin exposure combined with multiple concussions. The examination of clinical data and battery of neuropsychological tests will serve in clarifying Mr Z's neurocognitive profile. Unfortunately, differentiating the effects of environmental toxin exposure and multiple concussions is not possible.
Differential Diagnosis in a Patient with TBI and CVA: Will the Real Brain Injury Please Stand Up?
This case describes a patient who sustained a mild traumatic brain injury, followed by a stroke about 17 months later. The history was also complicated by pre-existing outpatient psychiatric treatment. This presentation will describe ways to use reliable and valid methods of determining the relationship between a patient's current neuropsychological evaluation and various candidate causative factors in that patient's history.