I was asked by a defendant to evaluate a man who was struck in the head while riding a motorcycle.  The question asked was had he suffered any emotional distress as a result of his depressed skull fracture, and how much neuropsychological function had he recovered from his usual level of functioning.  This last question was a challenge since the attorney for the defense already knew that this individual had done poorly in school all of his life and had a sketchy employment history for the preceding 20 years.  There already was an index of suspicion he suffered from a learning disorder prior to the head injury and his reported difficulties coping with the aftermath of the head injury was due, at least in part, to a pre-existing problem and not the product of any head trauma.

Another fact surrounding the head trauma involved pre-injury impulsiveness and poor judgment.  Reckless driving by the plaintiff was witnessed by an independent third party approximately shortly feet before the impact.  Also, the plaintiff was driving without a valid driver’s license and had no insurance on his motorcycle.  This case occurred in a jurisdiction of ‘relative liability,’ (not applicable in California) where liability rests with the defendant unless the plaintiff is responsible for 51% of the accident, in which case, the defendant has no liability.  The capacity for judgment of the plaintiff prior to the accident was, therefore, a real factor in the question of relative liability.  How good was defendant’s pre-accident judgment?  Was it a likely factor in the accident?  To an extent, the question of liability and my psychiatric evaluation of the defendant became linked.

I was examining the plaintiff as a damages expert in order to assess what, if any, problems he had prior to the head trauma, what was his prognosis post-injury, and his need for treatment.  He had been worked-up at a local hospital following the injury and the evaluating neuropsychologist four months post-injury believed he was progressing normally and no neurocognitive rehabilitation therapeutic interventions were necessary.  The plaintiff, however, complained that he was “not getting better.”

I reviewed all of the medical records and all of the collateral information prior to examining the plaintiff.  There was one entry where the plaintiff’s mother stated to the treating doctor at the time of the admission to the hospital that her son suffered from Paranoid Schizophrenia.  This history was given to a non-mental health professional but was contained in the medical records.  The evaluating psychiatrist did not mention this history in his work-up of the patient.

I examined the patient near his home because he and his attorney alleged he was unfit to travel.  At the conclusion of my examination, I believed he suffered from Schizophrenia.  This is an important diagnosis for head injury patients because when neuropsychological testing is performed some of the symptoms of Schizophrenia will test as a neurocognitive deficit (executive ability and organizational ability).  If the neuropsychologist does not conduct psychological testing to rule out Schizophrenia and the psychiatrist does not address this issue in his differential diagnosis, then the diagnosis and extent of post-traumatic dementia may come into question.

In the course of my career, I have evaluated hundreds of patients suffering from Schizophrenia.  I also am aware that peer-reviewed literature exists about the development of Schizophrenia occurring rarely after the occurrence of a serious head trauma.  It, therefore, is possible that a person who was not Schizophrenic before the head trauma can appear to be Schizophrenic after the head trauma because of it.

Based on the weight of the medical evidence and particularly relying on the mother’s statement to the physical therapist, even though she later recanted the statement, I believed that the medical evidence better supported a diagnosis of prior Schizophrenia coexisting in a person who had probably suffered some permanent brain injury.  As such, I found myself in disagreement with the plaintiff’s expert when he stated that all of the residual problems with cognitive organizational ability were attributable to the head trauma.  I also relied on the plaintiff’s preceding many year history of never holding a job for more than six months, irregularly living with his parents into his 40s, and having been given a general discharge from the military because of behavioral problems.

If pre-existing Schizophrenia existed, then many of the abnormal neuropsychological tests could be attributed to Schizophrenia.  The diagnosis became crucial in establishing damages.

Ultimately the case settled.

My “take away” from this case was a renewed appreciation that pre-existing Schizophrenia may confound opinions about disability and permanent injury in an individual who has had a permanent brain injury.  As a forensic medical expert, I am already well familiar with the concept that symptoms seeming to arise near an event cannot be assumed to have derived from that event and must be taken, along with all medical evidence, into the bigger picture, in this case, the whole of the plaintiff’s life.