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Nonimpact Brain Injury: Neuropsychological and Behavioral Correlates With Consideration of Physiological Findings: Reply to Lang

The purpose of our study was to report on the relations in the data that we had collected over the last 12 years in this unique patient sample as a good first step in promoting a better scientific understanding of nonimpact brain injury from a clinical perspective as well as fostering an open dialogue among colleagues. We agree that the methodology we employed has its limitations, but in Lang’s worldview, it would appear that only research without shortcomings would be worthy of publication. Lang begins by attacking the study’s design, yet in the title we clearly state that we are discussing “correlates,” that is, relations between variables. He then erroneously reports that “follow-up” was 1 week to over 5 years, when in fact it was the neuropsychological testing that was conducted during this time frame, not follow-up. It is true that most of our sample was in litigation, and we reported this, yet Lang implies that this factor was responsible for the observed relations, and that somehow this is an American phenomenon. He conveniently fails to mention that we demonstrated that all participants who underwent malingering testing, two thirds of our sample, passed with no evidence of diminished motivation. He also conveniently fails to mention a number of research studies that have shown that secondary gain does not figure prominently in influencing functionality of these patients (Swartzman, Teasell, Shapiro, & McDermid, 1986), that the recovery rate is similar for both litigants and nonlitigants (Hohl, 1974), and that most patients are still symptomatic when litigation is over (Mendelsohn, 1982). As Lang and others know, before the modern era all postconcussional cases in the United States were attributed to “accident neurosis.” Is Lang advocating a return to times when life was more simple? I think not. Somehow Lang is of the belief that test selection was arbitrary, and “a fact” that we “tried to excuse by using the term ‘flexible approach.’” Test selection was anything but arbitrary; rather it was based on clinical experience coupled with adoption of a hypothesis-testing approach that influenced test selection as deficits emerged during testing. The fact that testing was carried out over 12 years in several different laboratories by different examiners contributed to some variability in test selection techniques. However, as time passed, it became clear that some tests, such as the Paced Auditory Serial Addition Test and Auditory Consonant Trigrams, were simply more sensitive than other tests, and thus were given more routinely. Lang cites one study in a weak attempt to explain symptom expression in our patient sample as a base rate phenomenon. Yet, we cited six different base rate studies in our article to alert the reader that this was taken under consideration. We found it to be less compelling