TL was referred for a follow-up neuropsychological evaluation to find out current symptomatology and level of functioning in light of exec dysfunction possibly manifesting itself, following traumatic brain damage incurred during a motor vehicle personal injury in November, 2008.
TL is a 44 time old, right-handed men. Leaving school at years 15, he pursued a profession in marketing and publishing. Ahead of injury, he previously been living and employed in Asia for the past 13 years, where his partner and child continue to be to date. TL presently locates himself struggling to mentally deal with past working environment requirements, where resultant financial issues make wedding caterers for his family unfeasible. History of alcohol maltreatment since age group 16 has necessitated repeated AA participation. He currently leads an extremely restricted lifestyle, living alone in one room and struggling to take care of normal daily obstacles. He has offered as an inpatient in hospital, as well as having had a deal of care create at home.
TL exhibits no recollection of the accident itself, where upon regaining awareness, required time for you to orient himself. Unusual retrograde amnesic episodes have been reported since, where he considers day-to-day memory to have advanced markedly. TL has also experienced sporadic tonic seizures, for which he is getting anti-epileptics. Most noticeably, he experiences challenges structuring daily life through multi-tasking and organization, where reliance on a notebook provides security, but is retained somewhat chaotically. Magnetic-resonance-imaging revealed harm to large servings of the kept frontal lobe and anterior temporal pole, as well as superficial sclerosis pursuing intra-cerebral haemorrhages in the cerebrospinal liquid.
TL expressed frustrations about lack of ability to work and the implications for reunifying his family, but looked generally optimistic that with time, normality would gain.
Behaviour during testing
TL attended the time unaccompanied and punctually, showing sober. He was attentive and focused to time, location and the investigator. There is no evidence of speech or hearing impairments, and motor unit motions and dexterity came out normal. He was co-operative and stimulated to engage with presented tasks but was ardent about minimizing severeness of his condition, insisting on marked improvements and expected return to normality. Based on these observations, test outcomes are deemed legitimate estimations of present cognitive functioning but extreme caution was carried out in examining self-reports in light of tendencies to reduce difficulties and constrained insights to possess condition.
General intellectual abilities
Taking into consideration educational and occupational backdrop, his pre-morbid performing as interpreted by the National-Adult-Reading-Test-(NART-FSIQ) was average. Intellectual assessment using the Wechsler-Adult-Intelligence-Scale-(WAIS-III) suggests that verbal IQ was preserved, with abilities in vocabulary skills by defining words, reasoning skills and simple arithmetic falling within normal range. On the other hand, his performance IQ, reflecting focus on aspect, sequencing and abstract conceptualization ability, was markedly reduced and approximated substandard, highlighting significantly impaired problem-solving abilities since the car accident.
Formal memory assessments indicated a severe global deficit in capacity to consolidate and recall information in both immediate and postponed tasks, substantiating storage deficits recorded in everyday routine. This impairment extended to both verbal and non-verbal items, delivering marked challenges in immediately recognizing words and encounters (<5%ile and 5th%ile, respectively) and later reproducing a sophisticated figure he primarily registered properly and a brief story, rating in the <5th%ile and 5-10th%ile, respectively.
Language and Literacy skills
Whilst vocabulary in natural chat appeared to be largely maintained, formal diagnosis of basic language functioning exposed poor shows on graded naming testing and incredibly poor semantic fluency task performance, credit scoring below the 1st%ile. Throughout the procedure, TL was communicative and exhibited fluency in speech and volume but presented considerable repetition, being heavily reliant on formulaic phrases and daily habit exclamations. He expressed inabilities to be specific in response to questions fond of him, resorting to confabulation by producing long-winded but essentially unfilled answers.
Visual-Perceptual and Visuo-spatial skills
TL exhibited satisfactory level of visible processing skills as evaluated by the Visual-Object-and-Space-Perception-(VOSP) object decision task and direct replication of an complex figure. It is of remember that whilst a spatially coherent backup was created, the manner by which this is achieved was highly disorganized, TL implementing a chaotic procedure.
Formal assessment open profound executive performing deficits, TL scoring below the 1st%ile in a phonemic fluency activity. Whilst executing better on letter 'A' than 'F', he exhibited appreciable repetition that he himself was unacquainted with, as well as an failure to constrain behavior to outlined guidelines. On methods of the Revised Wisconsin-Card-Sorting-Test-(M-WCST), he similarly scored below average, obtaining only 3 out of 6 solutions and was struggling to identify a 3rd sorting category, highlighting novel idea era deficits.
Severe deficits in speed-of-information-processing became evident when required to learn abstract relationships between volumes and icons, as evaluated by the Symbol-Digit-Modalities-Test-(SDMT). Scoring the same as significantly less than 1% of people taking the test (<1st %ile) is regular with low WAIS-III performance scores, which may likewise reveal impaired information processing, and deficits in carrying out cognitive procedures automatically and under time constraints.
TL is presently performing well below typical generally in most cognitive domains evaluated, with visuo-perceptual and verbal reasoning skills maintained. The nature of his neuropsychological account appears regular with impairments seen following frontal lobe harm. Frontal area functions have a variety of behavioural outputs, damage therefore leading to diverse symptoms presentations. These mirror difficulties manifested in TL's everyday activity, such as reported failure to arrange and organize daily jobs, as well as deficits in working memory and insufficient drive, regarding going back life to normality. Overall, this alludes to a severe, standard executive dysfunction underlying the registered impairments in unique, albeit related domains.
Formal assessments confirmed deep deficits in exec control and control, specifically novel notion era and modifying guideline regulated behaviour. We were holding augmented by poor information examination during response coordination and poor cause and result associations, as assessed by sub-tests of the WAIS-III. Deficits in cognitive reasoning and control reflection reported daily planning troubles and are quality of implicated damage to the dorsolateral-prefrontal-cortex, an area in charge of strategy development.
WAIS-III results discovered that whilst verbal comprehension and manipulation were conserved, performance tasks needing recruitment of problem-solving, response planning and reasoning skills proved to be a challenge because the car accident. These results may be attributed to reduced abstract conceptualization and sequencing abilities instead of visual handling deficits which continued to be unimpaired in chosen visuo-perceptual tasks. Conditioning this view is the observation that whilst an sufficient figure copy was made, a disorganized manner was used to do this, reflecting chaotic approaches to life.
Whilst almost all damage was incurred on the left side, considered to mediate verbal handling, extreme caution must be exercised in supposing selective terms impairment, especially in light of average verbal IQ scores. Whilst formal terminology and literacy assessments revealed profound impairment, these jobs weren't necessarily immune system from relying on professional control. His terminology impairments, specifically on semantic fluency testing, may be attributable to difficulties in novel principle generation, adopting new strategies and inhibiting pre-potent replies. This is substantiated by preservation of everyday vocabulary and natural conversation, where there existed marked lack of ability to answer questions specifically, with heavy reliance on repetitive and formulaic phrases.
Manifestation of storage area problems extended to both verbal and non-verbal domains, where verbalisation often accompanies non-verbal tasks, detailing poor performance on both. However, face acknowledgement scores were in the same way impaired, which as a pure non-verbal identification test, was not diluted by verbalisation. This gives further evidence for general storage impairment, instead of selective terminology impairment. This view is strengthened by various WAIS-II techniques relying on working ram strategies, possibly accounting for poor performance.
Numerous procedures count on active handling and re-evaluation of information before ram consolidation. Working recollection is therefore inextricably linked to attention, where TL's capacity to rapidly attend to and utilize new information was below average. This could mirror a general ram deficit with roots in decreased focus on relevant sensory stimuli and inefficient consolidation of these in coordinating and performing responses. This is echoed by TL's detachment and general out of sync-ness along with his environment, not responding to daily demands.
In final result, TL presents a complex clinical profile in which a variety of problems may interact, notably excessive alcoholic beverages use, episodic seizures and distressing brain personal injury. Many factors donate to the pathology of frontal lobe syndrome, and the structure and seriousness of symptoms since accident in unique, albeit related cognitive domains directs attention to a chronic, declining professional dysfunction.
Keen to deflect from his disordered lifestyle, this very system ironically brings about lack of insight into his own case. Along with highly limited cognitive resources, this obstructs mistake monitoring and adopting novel ways of update behaviour accordingly, which allows him to reap the benefits of rehabilitative work and lead a structured lifestyle.
Word Matter: 1, 500
APPENDIX: Test Results
Scores attained on Assessment Day: 10/03/2010
Estimated Pre-Morbid Functioning
Current Intellectual Functioning
Delayed Recall (AMIPB)
Graded Difficulty Naming Test
Semantic Fluency (Pets or animals)
VOSP Object Decision
AMIPB Shape Copy
Phonemic Fluency (FAS)
Speed of Information Processing:
http://site. wpspublish. com/images/pobtrans. gifSymbol Digit Modalities Test (SDMT)
*Performance below average
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