#4 "4 Mueller M.D."

Peter S. Muller, M.D., P.A., 601 Ewing Street Suite B-3
Princeton, New Jersey 08540, Telephone: 609 924-4061

March 2007

Department of Veterans Affairs
Regional Office Raab James W.
20 Washington Place xxx xx xxxx
Newark, NJ 07102 March 2007

To whom it may concern,

Mr. James Raab (DOB 9/21/48 and service number RA11761750) was seen by me on 6/18/98 when brought by one of his neighbors to me because of his longstanding severe confusion and psychotic upset. I determined very quickly that he had two separate disorders which developed proximate to the date of his 1969-70 service in Vietnam. These two disorders were Post Traumatic Stress Disorder (DSM IV # 309.81) and Post Traumatic Temporal Lobe Epilepsy (TCD9 cm # 345.51). I will discuss these two disorders separately and define why they were service connected to this 1970 period.

1. Post Traumatic Stress Disorder (PTSD) as defined by the official American Psychiatric Association Diagnostic Statistical Manual (DSM IV) included here, this disorder is characterized by experiencing involuntarily the stress that precipitated this disorder almost like a “fingerprint.” The specific details are relived and specifically avoided after the traumatic events. This then leads to a sustained neuropsychiatric disorder with hallucinatory flashbacks of the trauma, severe social withdrawal, confusion, memory defects, severe mood swings, panic attacks, and obsessive acts symbolizing the traumatic event. Mr. Raab’s “fingerprint” is defined by severe disabling anxiety and avoidance of, 1. Driving in the rain. 2. Being under a canopy of trees. 3. Inability to continue driving forward. (Then due to the mud but now due to traffic) and 4. Loud noise, particularly helicopters. He had never experienced such pathology prior to being unable to move his truck in a rainstorm, and having to run for his life from the gunfire through the canopy of trees with the sound of helicopters in the background.

The results of this reaction are recorded in the DSM IV checklist enclosed. As can be seen, he had every positive symptom and all dated to this traumatic event in the jungle of Vietnam. It is important to note that he had no sign of such problems upon his arrival to Vietnam. Prior to this injury, he was known to have a near photographic memory, was accepted into the Army Security Agency, and excelled in ASA school training. After this traumatic event he had marked problems with memory and organization, exactly proximate to this time in Vietnam.

As added note is that upon return to New Jersey, he became severely pathologically obsessive-compulsive. He collected and displayed weaponry exterior to his dwelling and suspended a skeleton in a cage in his yard. He related this to the trauma he experienced in Vietnam and his attempt to protect himself. Treatment by me has markedly relieved these symptoms but 30+ years too late.

2. Post Traumatic Temporal Lobe Epilepsy (TCD9 cm # 345.51): This disorder is frequently a product of closed head injury which this patient experienced in 1970 while on duty in Vietnam both in a fall from the guard tower and in his attempt to avoid gunfire in the jungle. I have enclosed some medical journal article on this disorder which clearly illustrates Mr. Raab’s problem and the pathognomonic symptoms of TLE which he suffers from. I also included the extensive neuropsychological testing, a positive brain SPECT scan showing his right temporal lobe epileptic focus, and my TLE checklist. As can be seen, Mr. Raab had 37 of the 41 symptoms of TLE. Only 10 of the 41 were required by Verduyne to include the patient in the study. The maximum number of symptoms noted by any of their patients was 30, 7 less than Mr. Raab exhibited.

More importantly, the symptoms Mr. Raab suffered from when I first examined him, many which persist today, are absolutely characteristic of this totally disabling disorder and include smell, taste, visual, tactile, and auditory hallucinations (not characteristic of any psychiatric disorder), rage outbursts with amnesia, rapid mood cycles, d’eja’vu, jamais’vu, breaks in awareness, staring spells, multiple memory gaps, confusion, marked mental decline, irresistible sleepiness, epigastric rising, urinary urgency, nocturnal sweats, migraine headaches, environmental distortions with metamorphopsia, and loss of reading skills. He had none of these problems prior to being in Vietnam in 1970 prier to the sudden onset of these problems with his head injuries. There are no other disorders which can involve simultaneously all these 4 areas of brain function (sensory, psychological, cognitive, and autonomic) other than significant damage to the temporal-limbic brain area. There was no other cause for this sudden development of these multiple characteristics of temporal lobe epilepsy, simple partial seizures type (without losses of consciousness or motor seizure symptoms) (See the chapter 7 of the Schachter and Schomer book on page 133 where marked). I would also like to quote extensively from his recent neuropsychological testing by Dr Peter Manto (a former MP in the Marines). He clearly defines the cause of Mr. Raab’s brain damage by closed head injury. He also was able to define the extent of his multiple problems of brain dysfunction by sophisticated testing, and to define as well prognosis and limitations for Mr. Raab’s future function. The full report is included for all the references for Dr. Manto’s conclusion. This testing was performed while Mr. Raab was on full medication treatment for his problems and therefore his maximum possible performance.

1. “Background and observation assessment of cognitive function in connection with possible temporal lobe epilepsy is requested. Evidence of disability in connection with pending claims for VA benefits is sought.

Interview: Mr. Raab presented as a somewhat rumpled, casually clad man whose physical appearance is consistent with his stated age. His speech is noted to be articulate, fluent and of normal melody. His communication is deemed to be well paced, relevant and coherent. His visage is frowning and crestfallen, his demeanor somber with little liveliness of spontaneity. He is deemed to be somewhat uncertain as a historian, but judged to be adequately accurate with probing.

Mr. Raab served in Viet Nam from 1969 to 1970. During this time, he asserted that he fell some distance from a watchtower ladder, experienced a lapse of awareness and awakened on the ground. He alleges that sequelae of this event have impaired his functional competence from that time forward. Memory problems and marked irritability are described as particular problems.

He was honorably discharged from the military in 1971 and found employment as a repairman for the Telephone Company. Thereafter he held a variety of jobs, never retaining employment for as much as a year. Typically, he would have a contretemps with a co-worker or supervisor. These difficulties are said to have arisen due to his emotional volatility and irritability. After some six years of spotty employment he was reduced to working at odd jobs. Contiguous with his declining level of employment, his general physical appearance deteriorated such that he grew his hair and beard long and went about in seedy clothing. He asserted that he allowed his appearance to deteriorate in order to keep people distant: interpersonal contact typically engendered irritable volatility.

In addition to affective instability (irritability and emotional liability) he experiences an array of anxiety symptoms. He is continuously hyper vigilant and hyper reactive ("like I was still in Viet Nam"). He indicated that he had not been a combat soldier, but had been shot at and under mortar fire. He recalled an instance in which the vehicle he was driving was struck and stranded in mire, he stated that he became distressed and confused, unable to choose a course of action. During his year in Viet Nam he felt himself always to be under threat to life.

He indicated that his recall of his time in Viet Nam is poor. However, since his return he has experienced terrifying flash-backs engendered by loud noises, the sound of a helicopter or the smell of fuel. He experiences intrusive imagery of aircraft, has goose bumps and profuse sweating: these episodes are said to last from 30 minutes to an hour. In an attempt to establish a sense of safety he constructed trenches and bunkers on his property as havens in connection with irrational fear.

Although affective instability emerged immediately post Viet Nam, memory problems developed somewhat later. He frequently misplaces objects and forgets pots on the burner. Continuity of memory is easily disrupted: for instance he may turn on water, respond to a phone call and leave water running. When he misplaces an object he searches avidly and is seized with the certain belief that he has been "messed with."

Relevant history: Educational & vocational. Mr. Raab was reared in Newark, NJ and graduated from a vocational-technical high school having majored in electronics. From high school he entered military service. He appears to have been an average student at academic high school, but asserted that he did "very well" at the vocational-technical high school.

Health: He recalled having undergone appendectomy prior to enlisting in the Army; he also recalled severely cutting his left elbow. He began to treat with Dr. Peter Mueller in 1998 and indicated that in about 2002 through the use of a cocktail of prescribed medications, "I got my act together - I began to come out of my antisocial bubble."

2. Discussion: Neuropsychological assessment is based on observation of the performance of normal and brain injured subjects on various mental tasks; based on these observations, extensive normative tables have been developed. Experience has shown that significant deficits in mental functions (intelligence, abstract thinking, concentration, memory, language, and sensorimotor integration) are correlated with brain injury. Thus, if the pattern of neuropsychological results reveals a consistent, substantial deficit that affects several mental functions one can make an inference (with a specified level of statistical confidence) that cerebral injury is present.

The AIR statistic is used in this report as a debiasing procedure: to reduce the likelihood of evaluator bias. Clinical judgment is buttressed by explicit decision rules. That is, the patient's performance is compared to groups of normal and brain-injured subjects who have completed the same battery of tests. Specific cutting scores are employed with respect to each of the tests administered.

3. An AIR as high as 2.33 indicates a probability of cerebral dysfunction of 99% and would occur by chance once in 100 cases. Therefore it is likely that cerebral injury is present.

4. The cerebral consequences of closed head injury (CHI) research has revealed that closed head injury is chiefly caused by abrupt rotational acceleration of the brain within the skul1. Rotational acceleration may be imparted by direct impact, or by sudden movement of the head, impulse (engendered by impact elsewhere in the body, as with "whiplash" movement of the head on the neck). This rotational force produces shearing strain on brain tissue and results in the stretching, rupture and possible degeneration ofaxons therein. Diffuse Axonal Injury (DAI), thus engendered, is the fundamental consequence of rotational acceleration of the brain. DAI is generally microscopic and, therefore, not discernible by means of CT scan (Peerless & Rewcastle, 1967; Strich, 1970; Ommaya, and Gennarelli, 1974; Kelly, et al., 1991). Degeneration of brain cells, secondary to brain trauma, has been noted to cause 'thinning' of specific areas of the Corpus Callosum pointing to a probable decrease in interhemispheric communication (Sterling, et aI., 1996).

The brain is, essentially, spherical; therefore, rotational force is greater at the surface of the cerebrum than at the inner regions (the core or brain stem). The greater the vector of rotational force the deeper is shearing damage likely to be. Damage is likely to proceed from surface to center; outer cortical layers are more likely to be injured than deeper brain regions.

The morphology of skull and brain interacts with this force (protuberances at the anterior of the skull and tissue interfaces within the brain of differing densities) to engender a diffuse, or multifocal distribution of DAI. A small shearing force may produce diffuse synaptic electrical disorganization in the cerebral hemispheres and not extend to the brain stem (Grade l); larger forces would cause structural injury, diffusely, In the hemispheres engendering discontinuity of memory function, partial impairment of awareness and amnesia (Grades II & Ill); even greater shearing force will result in injury to the mid-brain reticular formation with loss of consciousness (Grade IV) In this formulation, injury to the mid-brain indicates that injury to outer brain layers is more severe, injury to the mid-brain cannot occur in isolation. As the grade of concussion increases, reversibility of the effects of injury decreases: more permanent sequelae are expected (Ommaya, and Gennarelli, 1974; Simon & Sayre, 1987).

Regardless of the site of impact on the skull and even when no specific impact to the skull has occurred, the most frequent loci of cerebral injury are the frontal and temporal poles (Levin, et aI., 1987). This observation appears to be attributable to the location of these regions in close proximity to bony protrusions of the interior of the skull as well as the greater variation of tissue density in these regions, both are factors that are likely to enhance shearing effects. (Ommaya, and Gennarelli, 1974; Simon & Sayre, 1987). Injury to these regions is likely to result in deficits in memory, concentration, abstract thinking and purposive behavior. Sterling (1996)reported that atrophy of the Corpus Callosum after brain trauma occurs in the genu and isthmus (corresponding to the anterior and lateral frontal regions of the temporal and parietal lobes); whereas, the rostral midbody was found to be virtually unaffected (an area containing large fibers connecting motor cortex). These findings correspond to the frequent occurrence of cognitive deficit with the absence of significant motor impairment following CHI.

In addition, various emotional symptoms may be engendered by cerebral injury (depression, emotional lability, irritability). A neurosis-like cluster of symptoms, subsumed as postconcussion syndrome, are likely to be noted: headache, vertigo, tinnitus, fatigability, hypersensitivity to noise and light, distractibility, lapses of memory, emotional lability, poor frustration tolerance and personality change (disinhibition or apathy).

Inferences regarding brain function. The AIR score indicates that cerebral injury is present. The pattern of dysfunction is not consistent with preferential lateralization of injury. However, anterior brain regions appear to be more affected than posterior regions.

Marked functional impairment of executive function is evident: his thinking is perseverative and inflexible; he fails to benefit from error feedback or monitor his behavior so that problem solving is defective; he is unable to plan, organize and carry out goal-directed activity. Recent memory function for both verbal and non verbal input is severely impaired: both acquisition and retrieval functions are defective. Information processing is defective: mental processing speed is substantially slowed so that increases of the rate or complexity of information flow engenders registration errors. Language skills, motor speed and intelligence are intact.

Mr. Raab experiences affective instability (irritability and emotional lability) that is consistent with a history of head trauma. Depressed mood with a sense of emptiness is reported and repetitive intrusive imagery as a manifestation of anxiety is also said to occur.

The impact of the symptoms and deficits on four areas of functional competence is summarized: Affective instability impairs his quality of life. He is interpersonally alienated and socially isolated. Cognitive impairment and affective instability impair his employability. Affective instability and alienation impair his ability to adjust to the social milieu or to engage in productive employment.

Recovery: Spontaneous recovery of brain function occurs fairly rapidly within the first few months post-trauma. Thereafter, improvement is in decreasing increments. In general, the majority of recovery that will occur is complete within several months, 85% of the total of recovery that will occur is complete within 18 months. In many instances brain function does not return to the pre-trauma level, cognitive deficits that are evident 12 to 24 months post-trauma may be considered permanent.

Affective instability is said to have emerged immediately subsequent to his tour of duty in Viet Nam whereas memory dysfunction is said to have emerged somewhat later. The symptoms observed are said to have been extant for more than 30 years and spontaneous recovery is extremely unlikely. Some amelioration of deficit is said to have been obtained through the use of anticonvulsant medication, such treatment should be continued, however, the underlying dysfunction is likely to remain.

Conclusion: Mr. Raab was injured in a fall and displays cognitive dysfunction and affective instability that are consistent with the presence of cerebral injury. He also experiences symptoms of depression and anxiety. Functional deficiency is such as to impair his quality of life, social function, behavioral efficiency and adaptability. His dysfunction is likely to be a permanent residual of injury but he may gain symptomatic relief through continued use of psychiatric medications.

The symptoms and deficits set forth in the body of this report constitute a significant, consequential and probably permanent limitation of the function of the brain.”

It is incredible that this man with the sudden onset of these multiple problems in the war zone of Vietnam in 1970 was not diagnosed and treated for these problems. These are very well-known disorders taught in 2nd year medical school. This has resulted in 37 years or more (and counting) of a lost life given in the service of his country. He was so confused and helpless when I first treated him that he was utterly defenseless. I was readily able to get him the meager support of Social Security Disability. For some unknown and cruel reason the US army has failed to live up to the responsibility to this still totally disabled man whose problems can be directly related by time and disability characteristics to 1970 in Vietnam and the injuries suffered in that war zone. Please call me for further details of this glaringly outrageous neglect of this soldier.

Sincerely,
Peter S Mueller

Thank You, Jim Raab http://jimraab.blogspot.com/