Explanation of Brain Injury Medicine and Neuropsychiatry

• Brain Injury Medicine describes a medical understanding and treatment of brain function and recovery from injury.
• “Neuropsychiatry” describes the intersection of psychiatry and brain function including disorders of the brain.  It is not the same as Neurology. [1]
• “Neuropsychiatry” describes complementary and overlapping expertise. Recognition by Board-Certification is in flux but not yet offered by the ABPN or ABMS. [2]
• Brain Injury Medicine, Psychiatry and Forensic Psychiatry are Board-Certified by the American Board of Psychiatry and Neurology. [3]

Brain disorders involve a range of medical, physical, neurological, cognitive and psychiatric disorders with consequences for key areas of life.

Medico-Legal Implications, Conclusions and Testimony

An Expert Witness with co-credentials in Brain Injury Medicine (BIM) and Forensic Psychiatry is suited to testify about relevant claimed damages. An Expert Witness must be objective and unbiased. Forensic training becomes especially important in rendering medical opinions in the interface of psychiatry and law. This includes by written report and in testimony.

Diagnosis and Damages

Proper diagnosis is essential in assessing damages, another task of the Forensic Psychiatrist which is not in the training of a doctor who has no Forensic Psychiatric training.

Ruling out the presence of a brain injury is as important as considering if there is an injury.

Impact of a Brain Injury

The presence of a brain injury, if proven can impact life in a variety of ways. Assessing damages in a lawsuit will be important for the jury or trier of fact to understand. Some consequences of a brain injury can include:

Psychosocial

Psychosocial is a term describing the intersection between managing social conditions and mental health, individual thought, and behavior. Social fears, like Social Anxiety Disorder [4], might develop after a brain injury, for example. For example, a person’s level of confidence in a group environment, public speaking, or managing a job interview changes.

Educational

Learning disorders, or worsened pre-existing learning disorders, can develop after a brain injury. It is more likely to see this in a student vs. a non-student because a student’s learning ability is tested on a regular basis. A change in grades or taking longer to do work are easy to spot. That doesn’t mean a non-student won’t exhibit learning deficits, only that they may become apparent differently.

Skills

Acquiring new skills or change in mastery of previous skills can be impaired after a brain injury. I also consider dementias, like Alzheimer’s and may recommend testing by a neuropsychologist.

Job / vocational

When a brain injury impacts the ability to perform one’s job, there can be long-term implications for earnings. Retraining for a different field is the usual mitigating solution absent a brain injury. Unfortunately, if acquiring new skills is also impaired, this mitigation might not be an option.

Inability to master day to day skills like hygiene, cooking, driving or childcare

Occupational Medicine doctors work with rehabilitation; they rarely have Forensic training or testify in Court, although their treatment records are considered by an expert in Brain Injury Medicine as evidence a person can no longer manage life as they once did.

A specialist in BIM would have expertise in other central nervous system disruptions, e.g., encephalopathies (brain diseases,) or anoxia (oxygen deprivation,) with similar neurocognitive and psychiatric symptoms.

Qualifications of a Brain Injury Medicine Expert Witness – Board-Certification Enhancing a Forensic Psychiatrist’s Opinions

I am Board-Certified in Brain Injury Medicine as well as Psychiatry and Forensic Psychiatry by the American Board of Psychiatry and Neurology (ABPN). At last count, there were fewer than 12 physicians with this combination of Board-Certification.

Board-Certification in Brain Injury Medicine follows a rigorous course of study and examination. Qualified Board-Certified Psychiatrists, Neurologists, Physiatrists (Physical Medicine and Rehab) and Sports Medicine physicians are permitted to take the exam.

What are the Benefits of Qualification in Brain Injury Medicine and Forensic Psychiatry?

​BIM qualifications enable the forensic psychiatrist to treat and render medico-legal opinions on the neuropsychiatric manifestations of Traumatic Brain Injury (TBI), Mild Traumatic Brain Injury (mTBI) such as a concussion, stroke and diseases of the brain like Dementia, with a high level of expertise.  The psychiatrist with this training is not a substitute for a Neurologist. The relationship between Brain Injury and Psychiatry speaks to behavior, personality and emotional response-the primary purview of the Psychiatrist.   There is overlap with Neurology and it may make sense in a lawsuit involving a brain injury, or suspected brain injury, to assemble a team of experts including a Forensic Psychiatrist with BIM Board Certification, a Neurologist and a Neuropsychologist. A Neuropsychologist is trained to conduct testing and interpret data.

Applications in Law

Examples of litigated actions in which a brain injury might be relevant. Ruling out a brain injury is an equally important diagnostic step.

Criminal Allegations and TBI

About half of all criminal offenders have a history of TBI. In criminal cases, TBI may play a role in Mitigation, Competency to Stand Trial and Insanity (NGRI) questions. A brain injury can interfere with decision-making, clarity and even behavior, including criminal behavior.

Personal Injury cases

If a physical injury to the body includes the brain, such as in a motor vehicle accident, psychiatric conditions should not be automatically attributed as an emotional response to the accident.  If an MVA is followed by chronic pain associated with a physical injury, we might see severe depression. It is logical for an attorney, or even a psychiatrist without BIM or Forensic training, to conclude the depression is associated with pain. That may not be the case.

If the depression is related to a brain injury, diagnosis, prognosis and, ultimately, damages awarded in litigation, can look very different.  If one expert believes brain injury to drive other psychiatric conditions, but that expert does not have the qualifications to opine in this way, it behooves an attorney to consider an expert witness who is better qualified in this area.

Testimony is only one piece, but in the case of deposition, it can be a piece that impacts settlement. An attorney preparing to depose an expert witness who has rendered an opinion might want to consult with a BIM Board-Certified doctor to prepare questions that invite a better understanding of an expert’s opinions–including if they are founded on sound experience and qualifications.

Competency, Testamentary Capacity, Undue Influence

Competency implies the exercise of free will with clear-thinking and lucid decision-making–and a functioning brain.

Testamentary Capacity cases, and susceptibility to undue influence, especially alleged in the elderly, can be associated with mental impairment.

Further, poor brain function can impact a person’s vulnerability and emotional decision-making.  Lucid decision-making and self-advocacy—key to both testamentary capacity and undue influence–could be associated with a Traumatic Brain Injury or a degenerative Brain Disease. Degenerative brain diseases include Alzheimer’s and other Dementias.

Competency to Stand Trial

Dr. Adhia describes a case study on this site in “Incompetent to Stand Trial and a Case Study in Malingering” where a defendant claimed a childhood brain injury rendered him incompetent to stand trial. Dr. Adhia found the brain injury did not impact competency to stand trial. His findings also addressed the presence of malingering (lying for secondary gain.) The defendant was later convicted for a heinous crime.

Please call me to discuss your Brain Injury case.

Endnotes

[1]  Neurology is a distinct and separate specialty from Psychiatry. While it is also Board-Certified by the American Board of Psychiatry and Neurology, the training, qualification, requirements for Board-Certification and practice of Neurology is not within the scope of this article.

[2] Merriam-Webster unhelpfully defines Neuropsychiatry as “a branch of medicine concerned with both neurology and psychiatry.”

The American Board of Psychiatry and Neurology Board-Certifies Psychiatry, Neurology and Forensic Psychiatry but not Neuropsychiatry. The United Council of Neurologic Subspecialties (UCN) offers a a Neuropsychiatry Board-Certification but it does not carry the same weight as the ABPN or ABMS.  Increasingly, Fellowships and more rigorous training is evolving around a Neuropsychiatry specialization. Board-Certification in Neuropsychiatry may be recognized in the future by the ABMS and/or ABPN though that is not the case now.

[3] The American Board of Psychiatry and Neurology partners with the American Board of Physical Medicine and Rehabilitation to offer Board-Certification in Brain Injury Medicine.

[4] Social Anxiety Disorder, or Social Phobia, is an Anxiety Disorder involving discomfort around social interaction, and concern about being embarrassed and judged by others. There are 10 diagnostic criteria identified in the DSM5. (See DSM5, p. 189)

Sanjay Adhia, M.D., Forensic Psychiatrist