The review and analysis of claims involving PTSD and TBI may include functional Magnetic Resonance Imaging (fMRI), which measures brain activity by detecting changes associated with blood flow, an acknowledgement that cerebral blood flow and neuronal activation are coupled.

Claims examiners and defense lawyers often ask my colleagues and me to review and analyze medical records involving Traumatic Brain Injury (TBI).  The difficulty of getting to the truth of these complex litigation and insurance-related matters was recently underscored by a report presented to the annual meeting of the American Academy of Psychiatry and the Law.

The author of the report — forensic psychiatrist Jeffrey Guina, MD –­ noted the difficulty of diagnosis and treatment of TBI.  That’s partly because of the complexity of brain physiology, the nature of the claimant’s injury or condition and TBI’s similarities to Post-Traumatic Stress Disorder (PTSD).

As reported in the October 29, 2018, issue of MedPage Today,

Since PTSD and TBI have similar symptoms and are both most commonly diagnosed in veterans, it may be increasingly difficult to distinguish between the two, particularly since anywhere from 6% to 44% of those with TBI also have PTSD.

While PTSD generally results from past trauma, and TBI often follows a physical brain injury such as direct force, a blast injury, or diffuse axonal shearing, both can have similar Functional Magnetic Resonance Imaging (fMRI) findings, particularly within the dorsolateral prefrontal, orbitofrontal, medial frontal, and anterior cingulate cortices….

These diagnostic similarities and the difficulty of a reliable analysis often come into play when reviewing the medical records for a TBI or PTSD claim for evidence of possible malingering.  A recent case of ours illustrates this.

The difficulty of performing an accurate analysis is compounded by the claims and awards process.  As MedPage Today explains, some patients may deliberately falsify their symptoms in order to up their disability payments or to expand medical costs and impairment.  Moreover, while moderate forms of PTSD are automatically qualified to receive 50% disability in the VA disability system, a moderate form of TBI may get 30% to 40% of disability.

In other words, the differences in the way the VA and private disability systems function may be contributing to patients reporting false claims of either illness.

Key take-aways and best practices

  1. Do a thorough review of ALL the medical records, especially pre-injury records. Request any missing records.
  2. Remember that different conditions (i.e. PTSD, TBI, concussion, other psychological conditions, etc.) can have similar complaints, symptoms or clinical pictures.
  3. Review all raw data, especially any neurological, cognitive or psychological testing; don’t simply accept the written report.
  4. Analyze the timeframes as to when subjective complaints and objective findings were documented, especially as it pertains to your event.  For instance is there a pre-injury event or condition that could be impacting/influencing your specific injury?  Brain injury symptoms are typically seen at the time (acutely) of the injury; PTSD may present several weeks, months or even years after the event.
  5. Look at all the medications — pre and post injury — as the medications can be indicators of underlying and possibly contributory conditions, not to mention potential side effects.
  6. Remember the cognitive and intellectual baselines may not be readily available, so look at school, employment and military records for hints into the pre-morbid state.

So, remember that a thorough review of a claimant’s medical records is just part of the quest for the truth.  Getting to the bottom of a claim requires an experienced eye and the ability to analyze what’s in the record…and what isn’t there.

KARI