The Case of Mary: A Tbi Case Study

The Case of Mary: A TBI Case Study

Joseph M. King

Kaplan University

Introduction

Traumatic brain injury (TBI) is often referred to as “an injury involving the brain resulting from some type of impact and/or acceleration/deceleration of the brain” (Lezak, Howieson, Biglter & Tranel, p.180). This can be caused by a person experiencing an external force impacting them and causing the brain to be damaged. This damage could result in the brain bruising, bleeding or swelling to the point that it causes alterations in brain functioning. It is vital for psychologist and neuropsychologist alike to accurately diagnose, develop interventions and find a prognosis in TBI patients.

Mary

Mary, a seventeen-year-old Latina female, has been presented as a popular student in her junior year of high school. Prior to the injury, Mary enjoyed the company of her friends and often went to weekend parties. However, she was never in the top twenty-five percent of her class.

During a party, Mary had been dared by her friends to jump off the second-floor balcony into the pool. Upon attempting to jump, Mary slipped which caused her to not make it directly into the pool but striking her head along the side of the pool before entering. Mary remained unconscious and her friends had to pull her from the pool and take her to the hospital. Mary had blood coming from the side of her head.

Once at the hospital, the staff conducted a positron emission tomography (PET) scan of her brain and found that the brain had bruising and hemorrhaging. Approximately after three hours of unconsciousness, on life support, Mary woke up moaning and moving. When assessed by a neurologist, Mary responded strongly to verbal and tactile by opening her eyes. Upon request, Mary moved her fingers however, did not speak. As time progressed throughout the night, so did Mary’s responsiveness. In the morning, Mary could respond coherently and was released to her parents a few days later.  

Recovery Period and Symptoms

During the first week, Mary slowly recovered. After the first week, Mary was cleared to start school when she felt ready. Mary stayed at home for an additional two weeks before starting school again. On her first day of school after the injury, Mary complained to her parents that she did not want to go back to school. Mary stated that she could not keep up with the rest of the class in taking notes or doing coursework. She also stated that she had problems remember what the teacher had said and experienced concentration problems. Mary also stated that she didn’t want to see her friends and wanted to stay home for the remainder of the day and slammed her door. When her parents called her for dinner, they had to call her name several times before she responded.

Diagnosis

Glasgow Coma Scale.

The Glasgow Coma Scale is an assessment used to determine the conscious state of a patient for initial injuries as well as subsequent assessments (Glasgowcomascale.org, 2017). This scale monitors eye, verbal and motor responses. In the case of Mary, a “totally unresponsive” grade of 3 would be given once she struck her head on the side of the pool. During the first three hours at the hospital, Mary would still be considered “totally unresponsive” because she had not eye opening response, no verbal response and no motor response. Once Mary started coming out of her unresponsive state, she would then move into the “comatose” state. Initially, she had no eye-opening responses, but had incomprehensible sounds and abnormal movement. During the assessment of the neurologist, Mary has moved between “best response” and “comatose”. She spontaneously opened her eyes and obeyed commands for motor movements, however, still had no verbal responses. It wasn’t until the following morning that Mary was moved into the “best response” category where she was spontaneously opening her eyes, verbally recognizing people and obeying motor commands. With these findings, it can be suggested that Mary has suffered a severe TBI because she scored below “comatose” during the first three-four hours following her injuries

DSM-5.

As though the Glasgow Coma Scale (GCS) would indicate a severe TBI, the diagnostic statistical manual for mental disorders, version 5, (DSM-5) provides a table to for identifying mild, moderate and severe TBI. In Mary’s case, because she had a loss of consciousness for less than twenty-four hours but had an initial assessment score of 3-8 on the GCS, she would fall in the range of moderate to severe TBI (APA, 2013). In the diagnosis criteria, Mary has met the criteria of mild to major TBI. In section B, Mary experienced a loss of consciousness of approximately three hours. In section C, Mary is experiencing neurocognitive disorders that immediately presented itself after the injury. Also, these dysfunctions are persistent.

Some associated features supporting this diagnosis, as outlined in the DSM-5, are aligned with Mary’s symptoms. Mary has shown symptoms of irritability and frustration. These are considered disturbances in emotional functioning. In regards to personality changes, Mary has shown symptoms of apathy towards school work and socializing. She has also shown signs of aggression towards her parents by screaming at them and slamming her bedroom door.

Assessments

Pre-morbid level of intellectual functioning

        Neuropsychological assessments provide important information to clinicians in order to come up with an intervention and a prognosis. The pre-morbid measure of functioning assesses the patient’s performance prior to, during and post intervention. For Mary, there have been no initial assessments completed before the brain injury, so it may make it a bit difficult to estimate her baseline, or normative scores. However, with the data that is collected, it can be predicted from the using a rate of regression to predict scores at retest from scores of initial testing. Using the information from school records could prove to be an asset in this case as with using the regression prediction in that Mary has never achieved the top twenty-five percent in school.

One way to test this pre-morbid level of intellectual functioning is by using the North American Adult Reading Test (NAART). The NAART is a test that uses sixty-one individual, irregularly pronounced words so that neuropsychologist can assess the English user on their use of the English language (Johnstone, Callahan, Kapila & Bouman, 1996). This assessment has a high validity on consistency with the test-retest method.  

Another assessment to use for pre-morbid level of intellectual functioning is the Wechsler Test of Adult Reading (WTAR). The WTAR is typically co-normed with the Wechsler Adult Intelligence and Memory Scales (WAIS-III) to test and estimate the IQ of individuals (Holdnack, 2001). The intelligence quotient is based on reading performance and demographic information. Since there were no IQ given from the school, the prediction for improvement is based upon the regression of the test results. As one study by Green, Melo, Christensen, Ngo, Monette & Bradbury (2008) there was a direct correlation between TBI patients raw scores on the WTAR and WAIS-III assessments two months’ post injury as opposed to five months’ post injury. This correlation showed that the patients intelligence and pre-morbid functioning had in fact improved over a three-month span. In Mary’s case, as raw score could be obtained and then used as a baseline to compare the scores of the retest at differentiating time markers, taking the assumption that her scores could improve over time has her injury improves.