Non-credible language deficits following mild traumatic brain injury

Abstract

Identification of non-credible memory and other cognitive symptoms has received widespread attention within the past two decades. However, minimal information is available regarding patterns of non-credible language symptoms. We present the case of a 36-year-old female civil litigant who displayed delayed onset, severe, relatively focal speech and language symptoms, including difficulties with articulation, dysfluent speech, expressive language impairments with minor receptive difficulties, and lack of prosody, subsequent to a minor head trauma. On neuropsychological evaluation 3 years post injury, the patient presented with the same speech/language characteristics, but additionally exhibited a vague "foreign accent." Cognitive scores generally were normal with the exception of poor performance on many language tasks and processing/motor speed. The patient showed passing performance on most measures of response bias, but she failed effort indicators requiring rapid letter discrimination (b Test), rapid verbal repetition (timed forward digit span), and sensory function (finger agnosia errors) while passing effort indicators falling within the domains of memory, math/number skills, visuo-constructional ability, and attention. Thus, the type of failed effort indicators predicted the categories of standard cognitive tests on which she underperformed. Personality testing revealed patterns generally consistent with hysterical personality orientation. Given her long-standing history of multiple unexplained medical symptoms, the patient was diagnosed with a somatization disorder, as well as a current conversion disorder involving language symptoms. However, given her compensation-seeking status, the possibility of additional conscious feigning of symptoms could not be ruled out. The need for validation of additional measures to detect feigned language impairment is recommended.

Official Position of the American Academy of Clinical Neuropsychology Social Security Administration Policy on Validity Testing: Guidance and Recommendations for Change

“…Most dedicated PVTs involve memory paradigms, but it is now understood that test takers can elect to feign thinking speed ("slowness"), attention, visual spatial, motor dexterity, multi-tasking and problem-solving, reading, math, and language deficits (Boone, 2009;Cottingham & Boone, 2010). Dozens of "embedded" performance validity indicators have now been validated across these various cognitive domains (see Boone, 2013, for listing) and are available for nearly every commonly used neurocognitive measure.…”

Long-Term Exercise Improves Memory Deficits via Restoration of Myelin and Microvessel Damage, and Enhancement of Neurogenesis in the Aged Gerbil Hippocampus After Ischemic Stroke

“…6,7 In particular, neurological deterioration of the hippocampus can lead to loss of memory and other cognitive functions because the hippocampus plays an important role in learning and memory. [8][9][10] Therapeutic exercise is recommended for the rehabilitation of patients with stroke; it has been shown to minimize the severity of functional deficits and reduce the risk of recurrence. 11,12 The positive correlation between physical exercise and memory recovery has been extensively studied in animal models of ischemic insults.…”

Perceptual Accent Rating and Attribution in Psychogenic FAS: Some Further Evidence Challenging Whitaker’s Operational Definition

“… Although the analysis of the patient’s grammatical disturbances falls outside the scope of the current study, the bizarre and inconsonant pattern of her speech errors might shed an additional light on the nature of her verbal output disorder. As was the case in Cottingham and Boone’s ( 2010 ) patient, the current patient also inconsistently split numbers into separate digits. For instance, she admitted having been addicted to psychoactive substances for 12 years (pronounced “douze”; twelve ), which caused her to lose weight and to weigh 39 kg (pronounced “trois neuf” [ three nine ] instead of “trente-neuf” [ thirty-nine ]).…”

“…A neurological and radiological work-up did not reveal any neurological deficit. Other psychogenic case studies would follow (Verhoeven et al, 2005 ; Poulin et al, 2007 ; Reeves et al, 2007 ; Cottingham and Boone, 2010 ; Haley et al, 2010 ; Jones et al, 2011 ; Lewis et al, 2012 ; Roy et al, 2012 ; Polak et al, 2013 ). Close inspection of the FAS case studies – irrespectively of etiological substrate – reveals that this disorder rarely occurs as a “stand-alone phenomenon.” Rather, there is a rich spectrum of possible comorbid speech and language impairments that can accompany FAS.…”

“…In psychogenic FAS, the only comorbid speech/language impairments that have been attested over the years are a “pre-FAS”-muteness (Van Borsel et al, 2005 ; Jones et al, 2011 ), and grammatical anomalies (Van Borsel et al, 2005 ; Verhoeven et al, 2005 ; Poulin et al, 2007 ; Cottingham and Boone, 2010 ). The previously mentioned 32-year-old right-handed patient reported by Van Borsel et al ( 2005 ) presented with grammatical errors, not explicable by any neurological damage.…”