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Algorithm for Symptom Attribution and Classification Following Possible Mild Traumatic Brain Injury
Theresa Louise-Bender Pape1, Amy A Herrold, Bridget Smith
1The Department of Veterans Affairs (VA), Edward Hines, Jr. VA Hospital, Research Service, Hines, Illinois (Drs Pape and Herrold); The Department of Veterans Affairs (VA), Edward Hines, Jr. VA Hospital, Center for Innovation for Complex Chronic Healthcare, Hines, Illinois (Drs Pape, Herrold, Smith, and Evans); Departments of Psychiatry & Behavioral Sciences (Dr Herrold) and Physical Medicine and Rehabilitation (Dr Pape), Northwestern University, Feinberg School of Medicine, Chicago, Illinois; The Department of Veterans Affairs (VA), Lexington VAMC C-306, Lexington, Kentucky (Ms Jenkins and Drs Schleenbaker and High); Departments of Physical Medicine and Rehabilitation, Neurosurgery, and Psychology, University of Kentucky, Lexington (Ms Jenkins and Drs Schleenbaker and High); The Department of Veterans Affairs (VA), Spinal Cord Injury QUERI, Edward Hines, Jr. VA Hospital, Hines, Illinois (Drs Smith and Evans); Northwestern University, Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, and Department of Pediatrics, Child Health Research Program, Stanley Manne Children's Research Institute, Chicago, Illinois (Dr Smith); Department of Psychology, University of Kentucky, Lexington (Mr Harp and Dr Shandera-Ochsner); Northwestern University, Feinberg School of Medicine, Center for Healthcare Studies, Institute for Public Health and Medicine, Chicago, Illinois (Dr Evans); and The Department of Veterans Affairs (VA), Southern AZ VA Health Care System (3-124), Tucson, Arizona (Dr Babcock-Parziale).
Objective:
To present a heuristic model of a symptom attribution and classification algorithm (SACA) for mild traumatic brain injury (mTBI).
Setting:
VA Polytrauma sites.
Participants:
422 Veterans.
Design:
Cross-sectional.
Main Measures:
SACA, Comprehensive TBI Evaluation (CTBIE), Structured TBI Diagnostic Interview, Minnesota Multiphasic Personality Inventory (MMPI-2-RF), Letter Memory Test, Validity-10.
Results:
SACA and CTBIE diagnoses differ significantly (P < .01). The CTBIE, compared with SACA, attributes 16% to 500% more symptoms to mTBI, behavioral health (BH), mTBI + BH and symptom resolution. Altering SACA criteria indicate that (1) CTBIE determination of cognitive impairment yields 27% to 110% more mTBI, mTBI + BH and symptom resolution diagnoses, (2) ignoring timing of symptom onset yields 32% to 76% more mTBI, mTBI + BH and Other Condition diagnoses, (3) Proportion of sample having questionably valid profiles using structured TBI diagnostic interview and MMPI-2-RF and Letter Memory Test is 26% whereas with CTBIE item number 23 and Validity-10 is 6% to 26%, (4) MMPI-2-RF F-scale is the only measure identifying Veterans with posttraumatic amnesia for more than 24 hours as having questionably valid profiles.
Conclusions:
Symptom attribution-based diagnoses differ when using status quo versus the SACA. The MMPI-2-RF F-scale, compared with the Validity-10 and Letter Memory Test, may be more precise in identifying questionably valid profiles for mTBI + BH. The SACA provides a framework to inform clinical practice, resource allocation, and future research.
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