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How mild?  Since we make the MTBI diagnosis on the basis of symptoms and disability patterns on neuropsychological testing, this functional information also serves as the basis for our assessment of the severity of the brain injury.  We have to let go of our dependence on CT and MRI brain scans as well as on the degree and duration of changes in consciousness.  The MTBI diagnostic category is mild in name only.  Even though this category name contains the word “mild,” it does not indicate the degree of functional disability.

The majority of the head injury cases I evaluate in my clinical and forensic practices meet the criteria for an MTBI diagnosis.  The functional impairments that these patients experience in their daily lives and on testing, however, range broadly from minimal, transient problems with word fluency and mental tracking to significant and disabling problems that persist indefinitely.  The patients who function at the two extreme ends of cognitive impairment within the MTBI diagnostic category have sustained very different kinds of injuries even though they meet the same criteria for the MTBI diagnosis.  We can’t validate these differences with “objective” evidence from brain scans or by ratings on the Glasgow Coma Scale.  We have no basis for deciding that a patient has too much functional impairment for “this type of injury” and therefore must be malingering or exaggerating, and we ought to avoid facile psychological “reasons” for why these patients remain disabled.

We need to admit that we don’t know what has been injured inside the skull in an MTBI and that these unknown injuries vary enormously from one patient to the next.  Within this diagnostic category, our tests indicate a broad range of disability severity. I have evaluated
several significantly impaired MTBI cases within a month of their injuries whose test performances are consistent with very significant brain dysfunction.  These patients had great difficulty staying focused on any particular test for very long, they lost track of what they were working on very quickly, and their attempts to persist on testing led to a deterioration in the quality of their performances.  They did not return to work easily, they did not regain their pre-accident abilities and they never recovered completely.  Their brain injuries were not mild even though their diagnoses still fall within the MTBI diagnostic category.

I have followed several of these patients after they returned to their lives and their work, long after their litigation settled.  I counseled them as they encountered problems and struggled to maintain a positive attitude in the face of their persistent symptoms.  Although they initially strive to regain the lives they lost, they eventually come to accept a different role for themselves both personally and professionally (see Essay 3, Section IV).  They have sustained serious brain injuries even though our diagnostic category classifies them as “mild.”
 
 
 
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