#6 "Manto PhD"

Peter G Manto, PhD.
Clinical Neurophysiologist.

142 Palisade Avenue. November 21, 2006.
Suite 210.
Jersey City, NJ 07306.
(908) 581-5904; Fax (201) 963-0827.

Peter S. Mueller, MD
601 Ewing Street, B-3
Princeton, NJ 08540.

NEUROPSYCHOLGICAL EVALUATION

James Raab Age 58 Tested 11/15/06.

Tests: Halstead-Reitan Battery (HRB).

Category Test (CT)
Complex Figure Test (CFT)
Trail Making Test (TMT)
Selective Reminding Test (SRT)
Speech-Sounds Perception Test (SPT)
Seashore Rhythm Test (RT)
Aphasia Screening Test (AST)
Finger Oscillation Test (FaT)
Minnesota Multiphasic Personality Inventory (MMPI).
Wechsler Adult Intelligence Test, Third Edition (W AIS-III).
Digit Vigilance Test (DVT)

BACKGROUND & OBSERVATIONS: 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.
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James Raab
November 21. 2006

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".

RELEVENT 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 vo-tech.
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James Raab
November 21.2006

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". He denied alcohol abuse but admitted to occasional use of marijuana, an activity said to have been initiated in Viet Nam where it was considered de rigeur.

TEST RESULTS: All scores are reported as percentiles. That is, the particular score obtained is compared to the scores obtained by a normative group. The scores are then expressed in comparison to that group. Based on experience and convention, certain HRB test scores are rated, in accordance with norms (Heaton et aI., 1991; Spreen & Strauss, 1991; Karzmark et aI., 1984; Russell et aI., 1984; Russell et aI., 1970), as follows:

IR’s percentiles & probability of dysfunction for normal subject

Impairment rating Norm Dysfunction
0 Above Average (>85th %ile) Nil
1 Average (=50th%ile) Nil
2 Borderline Defective (<15th%ile) ir =" 0" vc=" 109;" po=" 118;" wm="." ps=" 84." ir=" 0" rating =" 2]" ir=" 0" rating =" 3]" ir=" 0">36 <35 rating =" 3]" ir =" 0">2 X *>7 >13 >19 X >22
[Impairment Rating = 1]

Ability to discriminate beginning and ending consonant sounds was assessed by means of the SPT. The SPT is a continuous attention task with respect to auditory, verbal stimuli... [This, too, is a complex attention task.]
# of errors: 14
IR= 0 1 2 3 4 5
o >1 *>8 >13 X >23 >35
[Impairment Rating = 3]

The Digit Symbol test is a number to symbol translation task. A derivative score, that is, the W AIS-III scaled score (SS) for this test is compared to the subjects PIQ (pC+MR+BD/3-1). If the SS is lower than the comparison measure of PIQ, performance is judged to be poorer (this relationship is indicated by +, - or =.
SS: 7-
IR= 0 1 2 3 4 5
>12 <12 5="X" 3=" <4,1=" rating =" 2]" ir=" 0">294 *>461 >555 >601 X
errors: 2
o >1 X *>11 >22 >36 >60

Memory. Verbal memory was assessed by means of the SRT. A list of 12 words is presented. After the initial trial, only those words that the subject failed to recall on the previous trial are re-presented, 12 trials are given. This procedure permits the separate assessment of storage and retrieval functions. Consistent Long Term Retrieval (CL TR), that is, the number of words recalled consistently without reminding is reported as the number of words consistently retrieved per trial. The most sensitive measure yielded is Total Long Term Retrieval (TL TR) is CL TR plus words that were retrieved one or more times without reminding, but not consistently from initial retrieval to the final trial. Delayed retrieval (DR) is the number of words recalled, without forewarning, following a 30 minute delay.

IR= 0 1 2 3 4 5
CLTR: 3.2
>10.0 <9.9>11.0 <10.9>12 11 *9 8 7 6 X
[Impairment Rating = 4]

Visual memory was assessed by means of the CFT (memory administration), that is the subject is asked to draw the complex figure from memory about 30 minutes after copying the design. No warning is given that this will be required. The relevant score is the number of correct line connections in the design.
# correct: 5
IR= 0 1 2 3 4 5
>29 <28 ir=" 0"> >1 X *>8 >13 >19 >22
[Impairment Rating] = 1]
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James Raab
November21.2006

Motor function. Repetitive motor speed (finger tapping speed) is assessed by means of the FOT. The relevant measure is the average number of taps for each hand over several repeated 10 second trials.

IR= 0 1 2 3 4 5
Taps dominant: 50.3
>63 <63>55 <54 X *<42 <36 <34 <28 [Impairment Rating] = 1] Personality. The MMPI reflected validity scales configuration (F!***"'+/KL) that rendered the clinical scales uninterpretable. Profile validity is questionable. The Dissimulation Index (+24) is consistent with over subscription to symptoms and foibles and may reflect exaggeration as a 'cry for help'. 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 Page 7 James Raab November 21.2006 Average Impairment Rating (AIR). The IRis obtained for the selected tests are summed and averaged to obtain the AIR as shown below: CT 3 TMT (B) 3 AST 1 RT 1 SPT 3 SRT 4 FOT (POOREST 1 Digtal Symbols 2 21/=2.3=AIR The following table reflects percentile levels and probabilities of dysfunction associated with values of the AIR. The center column reflects ~IR performance of 1,080 normal subjects (percentiles and probabilities of dysfunction); the right hand column reflects AIR performance of 642 brain-injured subjects (percentiles): Table 2 AIR scores & percentiles for normal and brain-injured subjects. AIR %ile / prob %ile BI 0.05 85 / --- 99 1.00 50 / --- 95 1.50 15 / 85% 85 1.81 .05 / 95% 72 2.00 .02 / 98% 64 2.35 .01 / 99% 47 For a score of 1.81: 95 percent of normal subjects would score lower than this; only 28 percent of brain-injured subjects would obtain a score this low, the rest would score higher. Ninety nine percent of normal subjects would score better than 2.35, a score just below average among brain-injured subjects. The higher the AIR score (above 1.50), the greater the likelihood that the subject belongs in the brain-injured population (the curve on the right in figure 2, below). The following figure portrays the relationships described in the above table as the AIR score increases (above the cutting score of 1.50); the score is more likely to refer to the brain-injured population: Page 8 James Raab November 21. 2006 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. The norms displayed in table B1, are based on a sample that ranged in age from 15 to 80+ years and in education from six to 18+ years. More comprehensive norms (Heaton, et aI., 1991) permit comparison of his performance to a reference of 55 to 59 year old men with 12 years of education. In comparison to this reference his performance is placed at the 5th percentile, or inferior to 95 percent of age and education peers. 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). Page 9 James Raab November 21.2006 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. Functional impairment. Marked 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. Page 10 James Raab November 21. 2006 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 below: Daily life activity. Affective instability impairs his quality of life. Social functioning. He is interpersonally alienated and socially isolated. Behavioral efficiency. Cognitive impairment and affective instability impair his employability. Adaptability. 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 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, Page 11 James Raab November 21.2006 Diagnostic impression: (DSM IV Axial Diagnosis) Axis I 293.9, Mental disorder NOS due to head trauma: postconcussion syndrome with cognitive dysfunction and affective instability. 311, Depressive disorder NOS as a direct consequence of cerebral injury, or reaction to losses of self-esteem and competence secondary to injury, or some combination of both factors. 300, Anxiety disorder NOS with hyperreacitivity and intrusive imagery. Axis II V71.09, no diagnosis. Axis III 850.0, Concussion, from history. Axis IV Inability to sustain productive employment. Axis V GAF = 55, Moderate to severe impairment of quality of life, social function, behavioral efficiency and adaptability. Peter G Manto, PhD Clinical Neurophysiologist 142 Palisade Avenue Suite 210 Jersey City, NJ 07306 (908) 581-5904; Fax (201) 963-0827

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