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					Forensic Psychiatry Services
    Comprehensive Psychiatric, Neurological and
      Neuropsychological Evaluation Services
   Traumatic Brain Injury:
Impact on Rights and Treatment in the
          Forensic Setting
         Cameron L. McGavin M.D.
        Forensic Psychiatry Services
    Western Psychiatric Institute and Clinic
• Significance
• TBI in the Forensic
• A Case Study
• Relevant Case Law
• Competence and
• Treatment Options
• Conclusions
   Public Health Significance of Traumatic Brain Injury
According to the CDC each year approximately 1.5 million
Americans survive a traumatic brain injury or TBI, with
roughly 230,000 requiring hospitalization.

                                                 Approximately 50,000 Americans die each
                                                        year following TBI representing one
                                                 third of all injury-related deaths and this is
                                                                likely a conservative estimate.

Adolescents and young adults as well as the elderly form the 2
arms of the
are at highest risk of these injuries; the
Most common causes are attributed to
motor vehicle crashes, falls, and violence.
Annually in the United States:
• 1.4 million people will sustain a TBI
• 50,000 people will die annually as a
  result of TBI
• 80,000 people will be disabled in the
  long-term due to TBI
• 5.3 million Americans currently living
  with a disability as a result of a TBI
Centers for Disease Control "Traumatic Brain Injury
in the United States: A Report to Congress."
                TBI Statistics
• The CDC's National Center for Injury Prevention
  and Control estimates that 2% of U.S. citizens
  are living with disability as a result of a TBI.
  • 235,000 hospitalizations annually for TBI
  • 1.1 million are treated and discharged from an
    emergency department
• About 75% are concussions or other forms of
  (fairly) mild TBI
• Head injuries are twice as common in men as in
• Majority by MVA’s, falls, sports, assaults
 Centers for Disease Control "Traumatic Brain Injury in the
            United States: A Report to Congress."
               $ Costs of TBI $
Annual economic burden of TBI in the U.S. in 1985
Was roughly $37.8 billion.
This included:
  •   $4.5 billion in direct expenditures for hospital care
  •   extended care, and other medical care and services
  •   $20.6 billion in injury-related work loss and disability
  •   $12.7 billion in lost income from premature death
               Traumatic Brain Injury in the United States:
                           A Report to Congress
                        TBI statistics

Blasts are the leading cause of
TBI among active duty military
personnel in war zones
TBI in the Forensic
TBI in the Forensic Population
              • 25-87% of inmates report TBI
              • 8.5% reported in a general
              • In male prisoners history of
                TBI is strongly associated
                with domestic/other violence
              • Children and teenagers
                convicted of a crime and
                female inmates convicted of a
                violent crime are more likely
                to have had a pre-crime TBI
                and/or physical abuse
Sarapata et al., 1998
         Two studies:
         • Non-violent felons avoided
           incarceration by participating in a
           day reporting program,
             • 50% reported a prior history of head
               injury and current problems in
               cognitive and emotional functioning.
               Only 5% of a college sample in the
               first investigation and 15% of a
               community sample in the second
               investigation reported prior head
         Second study:
         • 83% of felons with self-reported TBI
            also reported :
             – TBI date preceding first involvement
               with law enforcement
             – Some had no legal history until after
               a TBI in their late 30’s
           Brower and Price, 2001
• Vietnam Head Injury Study (VHIS)
Soldiers with frontal lobe lesions only showed
Higher rates of aggression when aggressive
and violent behaviors compared to
pts with non-frontal head injury and controls
without head injury
• Association between increased aggression and focal MFC and MFC
   injury on CT
• Evidence of simliar patterns in other illnesses related to disinhibiton
Bogner et al., 2001
        • One year study of 351 individuals
          with TBI
        • Roughly 80 percent of persons with
          violence-related causes of TBI had a
          history of substance abuse.
        • MVA most most common cause of
          traumatic brain injury overall,
        • Those with drug and alcohol abuse
          were most likely to sustain violent
           •   Substance abuse is a factor leading to
               brain injury
           •   Substance misuse also occurs post-injury
                    Walker et al., 2003
Self-reports of 661 drug-using
inmates with self-reported TBI, health
problems and mental health problems
Three groups :
   • no head injury
   • one head injury
   • two or more head injuries.
Inmates with head injuries:
   • higher levels of alcohol and marijuana use
   • higher rates of depression, anxiety, suicidal
   • attentional problems
   • difficulty controlling violent behavior
   • greater number of health problems
             Langevin, 2006

• Study of 476 male sexual
  offenders, at university
  psychiatric hospital for
  forensic assessment
• nearly 50% had sustained
  TBI with LOC
• nearly 25% had evidence of
  neurological damage
            A Case Study

Phineas Gage

“Passage of an Iron Rod
  Through the Head”
 John M. Harlow, M.D.
 Phineas Gage

“The powder exploded, driving the iron against the left
side of the face, immediately anterior to the angle of the
Inferior maxillary bone. Taking a direction upward and
Backward toward the median line, it penetrated the
integuments, the masseter and temporal muscles, passed
under the zygomatic arch, and probably fracturing the
temporal portion of the sphenoid bone, and the floor of
the orbit of the left eye, entered the cranium, passing
through the anterior left lobe of the cerebrum, and made
its exit in the median line, at the junction of the coronal
and sagittal sutures, lacerating the longitudinal sinus,
fracturing the parietal and frontal bones extensively,
breaking up considerable portions of brain, and
protruding the globe of the left eye from its socket by
nearly one half its diameter.”
                         Phineas Gage
“The tamping iron is round, and rendered comparatively smooth by use. It

is pointed at the end which entered first, and is three feet, Seven inches in

length, one and one quarter inch in diameter, and weighs 13 1/4 pounds. I

am informed that the patient was thrown upon his back, and gave a few

convulsive motions of the extremities, but spoke in a few minutes. His men

(with whom he was a great favorite) took him in their arms and carried him

to the road, only a few rods distant, and sat him into an ox cart, in which

he rode, sitting erect, full three quarters of a mile, to the hotel of Mr.

Joseph Adams, in this village. He got out of the cart himself, and with a

little assistance walked up a long flight of stairs into the hall”.
                  Phineas Gage
“His contractors, who regarded him as the most efficient
and capable foreman in their employ previous to his injury,
considered the change in his mind so marked that they could
not give him his place again. He is fitful, irreverent, indulging
at times in the grossest profanity (which was not previously
his custom), manifesting but little deference for his fellows,
impatient of restraint or advice when it conflicts with his
desires, at times pertinaciously obstinate, yet capricious and
vacillating, devising many plans of future operation, which
are no sooner arranged than they are abandoned in turn for
others appearing more feasible. In this regard, his mind was
radically changed, so decidedly that his friends and
acquaintances said he was “no longer Gage.””
                             Phineas Gage
It is known that, from 1851 until just before his
death, Gage worked as a coach driver, first in a livery
stable at the Dartmouth Inn, in Hanover, New
Hampshire, for about 18 months, and then in Chile
for some 7 years. At some point in 1859, with his
health deteriorating, Gage went to live with his
He died in San Francisco on 20th May, 1860, some 13
years after his accident, of complications arising as a
result of seizures.
An autopsy on Gage's brain was not conducted. Dr.
Harlow obtained consent from Mr. Gage's
family to obtain the skull and tamping iron which are
now in the collection of the Warren Anatomic
Museum at Harvard University.
TBI Lesions
 Superior mesial lesions=akinetic mutism
 Inferior mesial lesions=anterograde
 and retrograde amnesia and confabulation

 Dorsolateral prefrontal cortex involved in
 planning, strategy, executive function

 Dorsolateral prefrontal lesions= apathy,
 personality change, impaired planning,
 sequencing, poor verbal or spatial
 working memory (dependent on laterality,

 Left frontal opercular lesions=Broca’s aphasia

 Right opercular lesions=expressive aprosodia
                          “acquired psychopathy”
                            “orbital personality”

Orbitofrontal cortex may impair
response inhibition
Orbitofrontal lesions lead to
   • disinhibition, jocular attitude,
     sexual disinhibition
   • impulsivity
   • emotional lability
   • memory disorders
   • puerility
   • lack of empathy or concern for
• CTST raised in roughly 5-7.5% of all
• About 16% of these defendants found
• Differences in ITST finding based on
• diagnosis:
   • 100% of 11 defendants with an
   • brain disorder were found ITST
   • 60% of 79 defendants with other
   • diagnoses were found ITST

• Presumption of CTST may be
  questioned by defense
  counsel, the prosecutor, or the
  trial judge.
• When defense counsel raises
  an issue about a defendant's
  competence to stand trial and
  does so in good faith and with
  supporting evidence, a trial
  court must allow further
  inquiry into the competency of
  the defendant to stand trial.
                                CTST criteria
•   understanding of available legal defenses
•   planning a legal strategy to include available pleas and bargaining
•   pleas that would be possible including plea bargain
•   functions of the officers of the court
     •   Defense attorney
     •   District attorney
     •   Judge
     •   Jury number and function
     •   Defendant
     •   Witnesses
•   understanding of court procedure
•   purpose of trial and methods of enacting a trial
•   appreciation of charges
•   likely outcome of trial

•   quality of relation to attorney including capacity to disclose pertinent information to
•   wherewithal to challenge prosecution witness statements
•   capacity to testify in a relevant manner
•   behavior in the courtroom
Relevant Case Law
              Dusky v. U.S.
Test for CTST:
• “whether the defendant has sufficient
  present ability to consult with his lawyer
  with a reasonable degree of rational
  understanding--and whether he has a
  rational as well as factual understanding
  of the proceedings against him."
           Dusky v. United States, 362 U.S. 402 (1960)
  Wilson v. United States, 1968
USSC ruled amnesia for an alleged
offense does not automatically constitute
    Wilson v. United States, 1968
Court of Appeals held that six factors should be considered in determining
whether a defendant's amnesia impaired the ability to stand trial:
1. Defendant's ability to consult with and assist his lawyer
2. Ability to testify in his own behalf.
3. The extent to which the evidence can be extrinsically reconstructed including
Evidence relating to the crime itself as well as any reasonable possible alibi.
4. Extent to which the government had to aid in reconstruction.
5. The strength of the prosecution's case; i.e. whether the case is strong
enough to negate all reasonable claims of innocence. If there is any substantial
possibility that the accused could, but for his amnesia, establish an alibi or other
defense, it should be presumed that he would have been able to do so.
6. Any other facts/circumstances which would indicate a fair trial or otherwise
                  Wilson v. United States, 1968, pp. 463-464
       Drope v. Missouri, 1975
• USSC ruled that a “bona fide doubt” must exist
in order to obtain an evaluation of the defendant’s
• The court clear that threshold for obtaining a
CTST determination was low, that factors that
might be indicative of mental illness should be
Pate v. Robinson, 1966
       • Conviction of an incompetent
         defendant violates the 14th
         Amendment right to due
       • Illustrates the complexity in
         distinguishing between mental
         state at the time of the offense
         (insanity) and mental state at
         the time of trial (competency)
         Pate v. Robinson, 1966
“The import of our decision in Pate v.
Robinson is that evidence of a defendant's
irrational behavior, his demeanor at trial,
and any prior medical opinion on
competence to stand trial are all relevant
in determining whether further inquiry is
required, but that even one of these facts
standing alone may, in some
circumstances, be sufficient. There are, of
course, no fixed or immutable signs which
invariably indicate the need for further
inquiry to determine fitness to proceed;
the question is often a difficult one in
which a wide range of manifestations and
subtle nuances are implicated.”
           Drope v. Missouri, 420 U.S., at 180
Pate v. Robinson, 1966
             If the defendant is incapable
             of understanding the nature
             and purpose of the
             proceedings against him can
             he be informed of the nature
             and cause of the accusation?

             If defendant is incapable of
             assisting counsel in
             conducting his defense, can
             he truly have the assistance
             of counsel for his defense?
      Godinez v. Moran, 1992
USSC ruled that a defendant
Found CTST:
   Is competent to “knowingly and
   voluntarily” waive any of their
   constitutional rights e.g. the
   to a jury trial or to be assisted
       Godinez v. Moran, 1992
• "Setting out varying competency standards for
  each decision and stage of a criminal proceeding
  would disrupt the orderly course of trial and,
  from the standpoint of all parties, prove
  unworkable both at trial and on appellate
• Justice Kennedy commented that this holding
  may seem harsh in equating all competencies as
  essentially equal
• Are all competencies truly equal in the TBI
             Godinez v. Moran, 1992
Justice Thomas wrote for the majority:
“The standard adopted by the Ninth Circuit is whether a
defendant … has the capacity for "reasoned choice" among the
alternative available to him.
How this standard is different from (much less higher than) the
Dusky standard
   “whether the defendant has a 'rational understanding' of
   the proceedings - is not readily apparent to us.
   While the decision to plead guilty is undeniably a profound one, it is no
   More complicated than the sum total of decisions that a defendant may be
   called upon to make during the course of a trial. Nor do we think that a
   defendant who waives his
   right to the assistance of counsel must be more competent than the
   defendant who does not, since there is no reason to believe that t
                Missouri v. Davis, 1983
      Defendant suffering from amnesia due to a TBI.
 Missouri Supreme Court held that amnesia by itself was not
     a sufficient reason to bar the trial of an otherwise
                    competent defendant
             Montana v. Austed, 1983
  Montana Supreme court held that the bulk of the evidence
   against the defendant was physical and not affected by
            Morrow v. Maryland, 1982
    Maryland Supreme Court due to the potential for fraud,
   amnesia does not justify a finding of ITST. The court also
stated that amnesia is universal to some degree as time erodes
Rates of competency referral range from 2% to
      8% of felony arrests
Finding of ICST range from 7% to 60%
    •    variations in examiner training
    •    use of forensically relevant evaluation
    •    availability of pretrial mental health services
    •    nature of referral system
    •    inadequate treatment services for the
         chronically mentally ill
    •    prosecution of the SPMI population
    •    extent to which judges scrutinize “bona fide
         doubt” about defendant's CTST before
    •    granting evaluation
    •    Modal jurisdiction typically finds only 20% of
         those referred found ICST
Competence and Incompetence
       What is Competence ?
• That degree of mental soundness
  necessary to make decisions about a
  specific issue or to carry out a specific act
• Competence is assumed as default
• The burden of proof rests on the party
  alleging incompetence
  Components of Competence:
• Ability to understand the relevant
• Ability to appreciate the situation and it’s
• Ability to manipulate the necessary
  information rationally and relevantly
  (contains both cognitive and affective
• Ability to effectively communicate a choice
        Criminal Competencies
• Waive rights, confess
• Competence to enter
  a plea
• Competence to waive
• Testimonial capacity
Diminished Capacity
        • Diminished capacity
          defense contends that a
          certain defendant is
          incapable of intending to
          cause a death, and
          therefore must have
          caused death recklessly
        • Successful diminished
          capacity defense in a
          murder trial would likely
          result in the charge
          being reduced to
      Pennsylvania Crimes Code
§ 2501. Criminal homicide.
   (a) Offense defined.-A person is guilty of criminal homicide if he
   intentionally, knowingly, recklessly or negligently causes the
   death of another human being.
   (b) Classification.-Criminal homicide shall be classified as murder,
   voluntary manslaughter, or involuntary manslaughter.
§ 2502. Murder.
   (a) Murder of the first degree.-A criminal homicide constitutes
   murder of the first degree when it is committed by an intentional
   (b) Murder of the second degree.-A criminal homicide constitutes
   murder of the second degree when it is committed while
   defendant was engaged as a principal or an accomplice in the
   perpetration of a felony.
   (c) Murder of the third degree.-All other kinds of murder shall be
   murder of the third degree.
   Pennsylvania Crimes Code
Section 2503. Voluntary Manslaughter
   (a) A person who kills an individual without lawful justification commits
   voluntary manslaughter if at the time of the killing he is acting under a
   sudden and intense passion resulting from serious provocation by:
   (1) the individual killed; or
   (2) another whom the actor endeavors to kill, but he negligently or
   accidentally causes the death of the individual killed.
   (b) Unreasonable belief killing justifiable - A person who intentionally or
   knowingly kills an individual commits voluntary manslaughter if at the time
   of the killing he believes the circumstances to be such that, if they existed,
   would justify the killing under Chapter 5 of this title (relating to general
   principles of justification),
   but his belief is unreasonable.
   (c) Grading - Voluntary manslaughter is a felony of the
   first degree.
  Pennsylvania Crimes Code
§ 2504. Involuntary manslaughter
(a) A person is guilty of involuntary manslaughter
  when as a direct result of the doing of an
  unlawful act in a reckless or grossly negligent
  manner, or the doing of a lawful act in a reckless
  or grossly negligent manner, he causes the
  death of another person
(b) Grading.-Involuntary manslaughter is a
  misdemeanor of the first degree
TBI Effects
     Possible impairments:
       •   Personality change
       •   Memory
       •   Attention
       •   Executive dysfunction
       •   Processing speed
       •   Language
            • expressive
            • receptive
                   TBI Effects
Personality Changes:
• Behavior problems
• Regression
• Disinhibition
• Socially inappropriate
  speech or behaviors
• Restlessness
• Emotional lability
• Loss of spontaneity
• Decreased social
TBI Sx/Syndromes
TBI Sx/Syndromes
TBI Sx/Syndromes
TBI Sx/Syndromes
(A) Lack of motivation relative to the patient’s previous level of
functioning or the standards of his or her age and culture as
indicated either by subjective account or observation by others.
(B) Presence for at least 4 weeks during most of the day, of at
least 1 symptom belonging to each of the following three
Diminished goal directed behaviour
1. Lack of effort or energy to perform everyday activities.
2. Dependency on prompts from others to structure everyday
Diminished goal directed cognition
1. Lack of interest in learning new things, or in new
2. Lack of concern about one’s personal problems.
Diminished concomitants of goal directed behaviour
1. Unchanging or flat affect
2. Lack of emotional responsivity to positive or negative events.
(C) The symptoms cause clinically significant distress or impairment
in social, occupational or other important areas of functioning.
(D) The symptoms are not due to diminished level of consciousness
or the direct physiological effects of a substance
                   TBI Effects
• Language impairment may limit expressive,
  receptive communication
• Slowed verbal and physical responses may
  impair ability to
   • respond to questions in a timely manner
   • prompt attorney regarding witness testimony respond
     to redirection in the courtroom
   • may be interpreted as purposefully misleading
• TBI may render defendant suggestible
• Memory impairment can include confabulation
   • may appear to be purposeful dishonesty
• Inflexibility may impair ability to work with
  attorney, consider options
   • e.g. plea bargain
                      TBI Effects
• Attentional deficits impair ability to focus on required
  tasks, respond to directions
    • May appear to be purposeful defiance
•   Memory deficits impair ability to remember rules or
•   directions
•   Impulsivity can lead to rash decision-making, outbursts
•   Disinhibition can lead to inappropriate comments,
•   language or deportment
    • May negatively influence jury
• Lack of persistence may affect ability to withstand
  questioning, avoid confession, tolerate trial
• Impaired self-awareness (45-97% of TBI) can affect
  perspective and social interaction
       Godinez v. Moran, 1992
• "Setting out varying competency standards for
  each decision and stage of a criminal proceeding
  would disrupt the orderly course of trial and,
  from the standpoint of all parties, prove
  unworkable both at trial and on appellate
• Are all competencies truly equal in the TBI
Criminal Competencies:
            • Waive rights,
            • Competence to
              enter a plea
            • Competence to
              waive counsel
            • Testimonial
            • CTST
Treatment Options
  Chronic Treatment and Long-Term
        Rehabilitation of TBI

• Counseling/ group therapy/
  support groups
• Individual psychotherapy
• Pharmacotherapy
• Physical therapy
• Occupational therapy
• Speech therapy
• Assistive technologies
   • e.g. wheelchairs, specialized
             TBI and Psychiatric Sx

    Mania, lability                    OCD
     Impulsivity,                      PTSD
                                   Other Anxiety
      impairment                “Pseudodementia”
      Cognition,                Memory impairment
  processing speed               Drug/EtOH misuse
     Depression                      Psychosis
    Impulsivity/Lability Spectrum:
    •   Mania, lability
         •   Impulsivity, disinhibition
    •   “Pseudopsychopathy”
    Mood stabilizers:
         Depakote, Tegretol (comorbid SZ D/O)
         Lithium (SE)
         SSRI’s to target impulsivity (no TCA’s, MAOI’s)
         Risperdal, Seroquel
         Haldol ( PM&R/Psychiatry traditions)
• Attentional/Motivational
   •   Apathy
   •   Abulia
   •   Impaired attention/concentration
   •   Processing speed
• Amantadine
• Modafinil (Provigil)
• Methlphenidate (Ritalin,
• Atomoxetine (Strattera)
• Bupropion (Wellbutrin)
        •   Memory impairment
        •   Apraxia
        •   Aphasia
        •   Agnosia
   • Acetylcholinesterase inhibitors
      • Tacrine (Cognex)
      • Donepezil (Aricept)
      • Rivastigmine (Exelon)
   • May improve secondary symptoms of
     dementia such as behaviors,
     psychiatric Sx
   • N-methyl-D-aspartate (NMDA)
      • Memantine ( Namenda)
• Depression:
  • Typical algorithm for
    treatment of depression
  • Avoid TCA’s, MAOI’s
• Psychosis
  • Typical algorithm for
    treatment of psychosis
  • Exercise care with dosing
• Anxiety
  • Typical algorithm for
    treatment of anxiety D/O’s
  • Avoid BZD’s
                       TBI Treatment
• Comorbid Drug/EtOH
• Therapy/behavioral
   • MI
   • 12-Step programs
   • Support
• Pharmacotherapy
   • Disulfiram (Antabuse)
   • Acamprosate (Campral)
   • Naltrexone (ReVia)
• Functional Impairments
   • Assistive technologies
       • e.g. wheelchairs, specialized keyboard
             Treatment of TBI
Individual psychotherapy
       • Supportive
    Assessed and dependent
       • individual strengths
       • cognitive function
       • symptoms
• Despite acceptance of organic illness by courts TBI is
  infrequently assessed unless evidence is overwhelming
• TBI has wide-ranging effects on function and
  competency, not all readily apparent
• TBI should constitute part of every competency
  evaluation with referral as appropriate to assess extent
  of impairment
• Due to the nature of the population there may be
  suspicions regarding malingering which are
  unnnvotunate by comarison
• Further study is needed to:
   • develop screening instruments for TBI in forensic populations
   • relate dysfunction to factors directly involved in competency
•   Centers for Disease Control. "Traumatic Brain Injury in the United States: A Report to Congress."
•   http: www: Centers for Disease Control, (January 16, 2001)
•   U.S.S.G. § 5K2.13. See also United States v. Cook, 53 F.3d 1029 (9th Cir. 1994)
•   Melton, Gary (1997). Psychological Evaluations for the Courts: A Handbook for Mental Health Professionals and Lawyers, 2nd, New
    York: The Guilford Press, pp 156–157, 165–167
•   "Salvador Godinez, Waden, Petitioner v. Richard Allan Moran". University of Pittsburgh Law School.
•   Samuel J. Brakel, Alexander D. Brooks. "Law and Psychiatry in the Criminal Justice System”
•   Head injury among drug abusers: an indicator of co-occurring problems.
    Walker R, Hiller M, Staton M, Leukefeld CG Journal of Psychoactive Drugs. 35(3):343-53, 2003 Jul-Sep.
•   Traumatic brain injury among Australian prisoners: rates, recurrence and sequelae.
    Schofield PW, Butler TG, Hollis SJ, Smith NE, Lee SJ, Kelso WMBrain Injury. 20(5):499-506, 2006 May
•   The role of head injury in cognitive functioning, emotional adjustment and criminal behaviour.
•   Thurman DJ, Sniezek JE, Johnson D, et al. Guidelines for Surveillance of Central Nervous System Injury. Centers for
•    Disease Control and Prevention, 1995
•    Bittman, B.J. & Convit, A. (1993). Competency, civil commitment, and the dangerousness of the mentally ill. Journal of
•    Forensic Science, 38(6), 1460-1466.
•    Carbonell, J.L., Heilbrun, K., & Friedman, F.L. (1992). Predicting who will regain trial competency: Initial promise unfulfilled.
•    Forensic Reports, 5, 67-76.
•    Drope v. Missouri, 420 U.S. 12 (1975).
•    Dusky v. United States, 362 U.S. 402 (1960).
•    Godinez v. Moran, 113 S.Ct. 810 (1992).
•    Golding, S.L. & Roesch, R. (1988). Competency for adjudication: An international analysis. In D.N. Weisstub (Ed.), Law
•    and mental health: International perspectives (Vol. 4, pp. 73-109). New York: Pergamon Press. Golding, S.L., Roesch, R., &
•    Schreiber, J. (1984).
•    Assessment and conceptualization of competency to stand trial: Preliminary data on the Interdisciplinary Fitness
•    Interview. Law and Human Behavior, 8, 321-334.
Forensic Psychiatry Services
Comprehensive Psychiatric, Neurological and Neuropsychological
                     Evaluation Services

Description: Attorney Francisco Head Injury San document sample