Q&As

Dr Arthur Shores on Brain and Psychiatric Injuries: The Neuropsychologist's Perspective

Tuesday May 8, 2018

Dr Arthur Shores trained as a Clinical Neuropsychologist at Melbourne University and has a PhD in Medicine from the University of Sydney. He is an Adjunct Professor in the Psychology Department at Macquarie University where he was previously the Director of the Postgraduate Neuropsychology Programs (1996-2011).

Arthur Shores

He is a past National Chair of the Australian Psychological Society College of Clinical Neuropsychologists and the Chair-Elect (2018) for the NSW Branch. He was made a Fellow of the Australian Psychological Society in 2006 and in 2007 received the Award of Distinction from the College of Clinical Neuropsychologists. In terms of international recognition, he is a Chartered Psychologist and an Associate Fellow of the British Psychological Society and a Fellow of the National Academy of Neuropsychology (USA). 

We had the pleasure of sitting down with Dr Arthur Shores recently to discuss key challenges and opportunities facing the industry today.

Read the Q&A below and hear more from Dr Shores at the Psychiatric Injury Claims: Practical Perpectives seminar.

What are some of the key trends and developments in neuropsychology that may be relevant to those working in personal injury law/traumatic brain injury claims?

There are a number of key trends and developments in neuropsychology that may be relevant to those working in personal injury law/traumatic brain injury claims. To my mind three standout.

(i)   The availability of objective and prospective measurement of post-traumatic amnesia (PTA) in the Emergency Department. This allows for medical staff to determine the severity of any potential brain injury and promotes early and confident discharge of those not at risk, while preventing discharge of those at risk. The medico-legal implication is that severity of any brain injury is documented early in the recovery process and provides reliable prognostic information.

(ii)   There is a burgeoning literature that attests to the non-specificity of so-called post-concussion symptoms. Symptoms that were once considered specific to traumatic brain injury/concussion are now known to also be reported by patients without brain injury who have sustained orthopaedic injuries, chronic pain conditions and other conditions such as post-traumatic stress disorder (PTSD) and depression. Some are also commonly reported in the general population even when there is no history of physical trauma or head injury. In the medico-legal context this produces a significant challenge for differential diagnosis.

(iii)   The recognition by professional bodies that cognitive assessments should include objective measures of level of effort or performance and symptom validity. This has now also been recognised by the courts with a recent judgement that has highlighted the difference between medico-legal clinicians who accept at face value a claimant’s report of symptoms or performance on testing as opposed to those who use objective measures of performance and symptom validity, overcoming what was termed the frailty of subjective human judgement.

Briefly, what are some of the different methods of assessing brain injuries and what determines which method should be used in a given situation?

In the acute post-injury stage following head injury, the potential for an acquired traumatic brain injury is typically assessed using the Glasgow Coma Scale (GCS), duration of post-traumatic amnesia (PTA) and CT brain scan imaging. The different measures are not interchangeable but rather, complement one another. Thus ideally you would require all three in all cases. In the more chronic phase, neuropsychological assessment and MRI brain scans are typically used to assess for the presence and/or severity of any brain injury. These two methods also complement one another and again it would be ideal to always have both measures in all cases.

What is the post-concussion syndrome (PCS) controversy and how is it relevant to psychiatric injuries in the medico-legal context? 

"It is of considerable medico-legal significance that the fifth and current version of the Diagnostic and Statistical Manual of the American Psychiatric Association fifth edition (DSM-5), a diagnostic guideline widely accepted by the courts, no longer includes PCS as a diagnostic entity."

The term postconcussion syndrome (PCS) was first used in 1934 by Strauss and Savitsky to describe the subjective symptoms of headache, dizziness, inordinate fatigue on effort, intolerance to intoxicants and vasomotor instability, as organic and dependent on a disturbance in intracranial equilibrium due directly to a blow to the head. Strauss and Savitsky cautioned that psychogenic factors always complicate the clinical picture if the socio-economic and other difficulties following the trauma last long enough.

Since that time there has been fierce debate with one camp, at one extreme, holding that PCS reflects persisting brain dysfunction, and another camp, at the other extreme, holding that PCS is a misnomer and that the brain makes a full or close to full recovery after a head injury and that any ongoing symptoms reflect emotional distress. It is of considerable medico-legal significance that the fifth and current version of the Diagnostic and Statistical Manual of the American Psychiatric Association fifth edition (DSM-5), a diagnostic guideline widely accepted by the courts, no longer includes PCS as a diagnostic entity.

Dr Shores has a long-term interest in the assessment of severity of traumatic brain injury. The Westmead PTA Scale, of which he is the senior developer, is widely used in Australasian hospitals and increasingly in other parts of the world. He is also the senior developer of the Abbreviated Westmead PTA Scale for use in Emergency Departments. He has contributed to over 100 articles, national and international presentations and sets of government and professional guidelines in relation to brain impairment and assessment. Research in which he has been involved has been cited on over 3600 occasions in the scientific literature (Google Scholar).

He is the co-convener of the Australasian Faculty of Rehabilitation Medicine (AFRM) Clinical Neuropsychology External Training Module and holds an appointment on the AFRM Register of Examiners. He is on the Editorial Board of the journal Applied Neuropsychology: Adult, and the journal Frontiers in Neurology: Neurotrauma. He has completed training in the evaluation of impairment (Nervous System) conducted by the MAA. He was a member of the NSW MAA working party that revised the Guidelines for Neuropsychological Assessment for the NSW CTP Scheme and the LTCS Scheme, 2013. He held an appointment as an MAA Medical Assessor (Treatment Disputes) 2000-2015. He currently holds an appointment as a SIRA DRS Medical Assessor.

You can hear more from Dr Shores at the Psychiatric Injury Claims: Practical Perpectives seminar, being held on Thursday 7 June at the Primus Hotel Sydney, Sydney.

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