It is highly complex task to evaluate patients with traumatic brain injury(TBI) for legal and/or insurance reimbursement purposes. The brain injured patients may complain multiple symptoms and functional impairments, which are mainly subjective in nature and cannot be easily quantified. In addition the criteria for grading the level of disability may be different in each appraiser. Therefore individual discrepancy is inevitable among appraisers. There may be no single best way to assess the severity of disability associated with symptoms and functional impairments following TBI, but standardized rating scales can be used to quantified the extent of disability. Thus we recommend the administration of rating scales to reduce the discrepancies and enhance the reliabilities between appraisers as part of the forensic neuropsychiatric evaluation Several scales are presented for these purposes.
For the assessment of overall psychosocial functioning, the Social and Occupational Functioning Assessment Scale (SOFAS) in DSM-IV can be used. The SOFAS is different from the Global Assessment of Functioning Scale in that it focuses exclusively on the individual's level of social and occupational functioning and is not directly influenced by the overall severity of the individual's psychological symptoms.
The severity of each neurobehavioral symptom and impairment can be assessed by the Neurobehavioral Rating Scale(NRS). The NRS is a 27-item instrument that measures psyciatric and behavioral disturbances, in addition to cognitive impairment. The instrument is modified into four factor scores as McBride's scale that measures the cognitive and noncognitive symptoms in patients with TBI.
The ability to accomplish functional activities can be measured by Functional Assessment Scale(FAS), which provides important information that complements the assessment of cognitive skills. The FAS also reveals the need for assistance with activities, which is important to the medico-legal aspects of TBI. FAS includes the four groups of activities; activities of daily living(ADL), instrumental ADL, skilled performance, and social-role performance. An observer determines whether the patient is independently able to perform each of these activities.
Further the careful assessment of patient's premorbid status and truthfulness of information presented by patient is the bed-rock of forensic neuropsychiatric practice. The structured interview form for evaluating premorbid psychosocial functioning and the malingering index of suspicion for malingering or exaggerating patient are proposed.
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