VISN 19 MIRECC Staff: Dr. Hal S. Wortzel

Dr. Hal S. Wortzel 

Title: Director VA Advanced Fellowship Program in Mental Illness - Psychiatry Director of Neuropsychiatry Consultation Services
Contact:
303.399.8020 ext. 5644
hal.wortzel@va.gov

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Research Projects

Blister Packaging Medication to Increase Treatment Adherence and Clinical Response: Impact on Suicide

Research Team: Peter M. Gutierrez PhD, Lisa A. Brenner PhD, Hal Wortzel MD, Jeffrey Rings PhD, Steve Bartlett RPh, Jeri E.Forster PhD, Becky Leitner BA

Medication overdoses account for substantial numbers of suicide-related behaviors. Non-adherence is a significant issue for those with psychiatric illness.

Keywords: Suicide Prevention

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Lithium Augmentation for Hyperarousal Symptoms of PTSD: Pilot Study

Research Team: Hal S. Wortzel MD, Pamela Staves RN MS NP, Thomas Beresford MD, Lisa A. Brenner PhD, Peter Gutierrez PhD, Jeri E.Forster PhD, Jeffrey Rings PhD, Latoya Conner BA

The proposed investigation is a pilot study intended to establish the safety and tolerability of lithium augmentation of standard psychopharmacological treatment of PTSD for combat veterans seeking treatment at the Denver VA Medical Center.

Keywords: Evidence-Based Treatments, Post Traumatic Stress Disorder (PTSD)

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Recent Presentations

TBI and Aggression: Forensic Neuropsychiatric Evaluation

10/28/11

Hal S. Wortzel, MD 

Appleton CBOC

Keywords: Assessment, Brain & Biology, TBI

PowerPoint | PDF 

Neuroimaging For Forensic Psychologists

9/23/11

Hal S. Wortzel, MD 

Denver CARES

Keywords: Brain & Biology, Incarcerated Veterans

PowerPoint | PDF 

Disrobing Associated with Epileptic Seizures and Forensic Implications

7/6/11

Hal S. Wortzel, MD 

University of Colorado School of Medicine Behavioral Neurology & Neuropsychiatry Case Conference

Keywords: Brain & Biology, Incarcerated Veterans

PowerPoint | PDF 

Suicide Risk Assessment: A Medicolegal Perspective

5/5/11

Hal S. Wortzel, MD

Boulder Mental Health Center

Keywords: Assessment, Incarcerated Veterans, Suicide Prevention

PowerPoint | PDF 

Risk of TBI, PTSD & Suicide in OEF/OIF Veterans

11/1/10

Hal S. Wortzel, MD

29th Annual Conference of the Brain Injury Association of Ohio: “Building Community: Recognition, Response, Resilience”, Columbus, OH

Keywords: OEF/OIF/OND Veterans, Post Traumatic Stress Disorder (PTSD), Suicide Prevention, TBI

PowerPoint | PDF

Neurotoxin Exposure in Forensic Assessment: “Look what my meds made me do…” - A Case of Alleged Mefloquine-Induced Criminal Behavior

10/23/10

Hal S. Wortzel, MD

41^st Annual Meeting of the American Academy of Psychiatry and the Law, Tucson, AZ

Keywords: Brain & Biology, Incarcerated Veterans

PowerPoint | PDF

Review of Clinical Neuroscience for Forensic Psychiatry: Forensic Neuropsychiatric Assessment of Cognition

10/22/10

Hal S. Wortzel, MD

41^st Annual Meeting of the American Academy of Psychiatry and the Law, Tucson, AZ

Keywords: Brain & Biology, Incarcerated Veterans

PowerPoint | PDF

Forensic Applications of Diffusion Tensor Imaging in Mild Traumatic Brain Injury:  Current Status

10/21/10

Hal S. Wortzel, MD

41^st Annual Meeting of the American Academy of Psychiatry and the Law, Tucson, AZ

Keywords: Brain & Biology, Incarcerated Veterans, TBI

PowerPoint | PDF

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Recent Publications (since 2009)

Arciniegas, D. B., Frey, K. L., Newman, J., & Wortzel HS (2010). Evaluation and management of posttraumatic cognitive impairments. Psychiatric Annals, 40(11), 540-552.

Psychiatrists are increasingly called upon to care for individuals with cognitive, emotional, and behavioral disturbances after TBI, especially in settings serving military service personnel and Veterans. In both the early and late post-injury periods, cognitive impairments contribute to disability among persons with TBI and are potentially substantial sources of suffering for persons with TBI and their families. In this article, the differential diagnosis, evaluation, and management of posttraumatic cognitive complaints is reviewed. The importance of pre-treatment evaluation as well as consideration of non-cognitive contributors to cognitive problems and functional limitations is emphasized first. The course of recovery after TBI, framed as a progression through posttraumatic encephalopathy, is reviewed next and used to anchor the evaluation and treatment of posttraumatic cognitive impairments in relation to injury severity as well as time post-injury. Finally, pharmacologic and rehabilitative interventions that may facilitate cognitive and functional recovery at each stage of posttraumatic encephalopathy are presented.

Keywords: Traumatic Brain Injury (TBI)

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Binswanger IA, Wortzel HS (2009) Treatment for Individuals With HIV/AIDS Following Release From Prison. [Letter to the Editor.] JAMA 302(2):147, 2009

No abstract available.

Keywords: Incarcerated Veterans

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Boyer, J., Wortzel HS, & Martinez, R. (2010). Ineffective counsel in a death penalty case. Legal Digest, 38(3), 427-429.

Keywords: Incarcerated Veterans

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Foote, A., Wortzel HS, & Martinez, R. (2010) Competency to waive postconviction review for a death sentence. Legal Digest, 38(3), 425-427.

In Corcoran v. Buss, 551 F.3d 703 (7th Cir. 2008), the Seventh Circuit Court of Appeals affirmed the U.S. District Court and Indiana Supreme Court decision ruling that a person with a diagnosis of schizophrenia is competent to waive postconviction review of the death sentence despite unanimous expert opinions to the contrary.

Keywords: Incarcerated Veterans

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Hoffman TR, Wortzel HS, Martinez R. (2009) Admissibility of Demeanor Evidence from a Police Interrogation Videotape. Journal of the American Academy of Psychiatry and the Law 37(3):408-10.

No abstract available.

Keywords: Incarcerated Veterans

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Maxey, J. J., Wortzel HS, & Martinez, R. (2011). Duty to warn or protect. The Journal of the American Academy of Psychiatry and the Law, 39, 430-432.

No abstract available.

Keywords: Incarcerated Veterans

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Meng, A., Wortzel HS, & Martinez, R. (2009). Limitations of Attorney Work Product and Physician-Patient Privilege. Journal of the American Academy of Psychiatry and the Law 37(3), 410-412

In Cardenas v. Jerath, 180 P.3d 415 (Colo. 2008), the Supreme Court of Colorado ruled in two areas of confidentiality involving civil malpractice claims. In the first instance, the Colorado Supreme Court ruled that notes created by an attorney retained by the hospital for purposes of assessing the potential for liability on the part of the hospital could not be shielded by the usual attorney work product privilege. In this case where a child was born with severe neurological injuries, the Colorado Supreme Court recognized that the hospital had failed to conduct a standard risk management assessment, bypassing such a process by retaining an outside attorney. Since the attorney's work product represented the only available documentation of events during the alleged negligence, the plaintiff was able to establish substantial need and inability to obtain equivalent materials by an alternative process without creating an undue burden on the plaintiff. In the second instance involving confidentiality, the Colorado Supreme Court ruled that the mother, in filing on behalf of her child injured during birth, placed her own health at issue, thereby limiting her physician-patient privilege.

Keywords: Incarcerated Veterans

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Thurman, M. T., Wortzel HS, & Martinez, R. (2011). Mental health evaluation/counseling as a special condition of supervised release. The Journal of the American Academy of Psychiatry and the Law, 39, 432-434.

Abstract not available

Keywords: Incarcerated Veterans

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Wagner PJ, Wortzel HS, Frey KL, Anderson CA, Arciniegas DB. (2011) Clock-Drawing Performance Predicts Inpatient Rehabilitation Outcomes After Traumatic Brain Injury. The Journal of Neuropsychiatry and Clinical Neurosciences 2011; 23:449–453

The authors used clock-drawing performance to assess cognition and predict inpatient rehabilitation outcomes among persons with traumatic brain injury. Clock-drawing performance, as assessed with the Clock Drawing Interpretation Scale, predicts rehabilitation length of stay as well as Functional Independence Measure scores at the time of neurobehavioral assessment and rehabilitation discharge.

Keywords: Brain & Biology, Traumatic Brain Injury (TBI)

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Wortzel HS & Arciniegas, D. B. (2010). Combat veterans and the death penalty: A forensic neuropsychiatric perspective. Journal of the American Academy of Psychiatry and the Law, 38(3), 407-414.

With our nation's present conflicts, a new generation of veterans are returning home, many of whom have substantial psychopathology and are encountering significant barriers in accessing care. Headlines from around the nation reflect that some of these wounded warriors go on to commit offenses that are potentially punishable by death. Existing circumstances speak to the urgency with which the subject of combat veterans with post-traumatic stress disorder (PTSD), traumatic brain injury (TBI), or both facing capital crimes ought to be addressed. This publicity has led to a recent call for a legislatively or judicially enacted, narrow, categorical exclusion for combat veterans who were affected by either PTSD or TBI at the time of their capital offenses. In the present article, we illustrate the reality that combat veterans who commit capital offenses may face execution, summarize legal arguments offered in favor of a categorical exclusion, and provide a neuropsychiatric perspective on PTSD, TBI, and aggression, to help inform further dialogue on this weighty subject.

Keywords: Incarcerated Veterans

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Wortzel HS & Arciniegas, D. B. (2011). Cognitive impairment and rehabilitation. In C. Coffey & J. Cummings (Eds.), Textbook of Geriatric Neuropsychiatry, Third Edition. (pp. 331-351). Arlington, VA: American Psychiatric Publishing.

Abstract not available

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Wortzel HS, Binswanger, I. A., Anderson, C. A. & Adler, L. E. (2009). Suicide among incarcerated veterans. Journal of the American Academy of Psychiatry and the Law, 37(1), 82-91.

Both veterans and jail/prison inmates face an increased risk of suicide. The incarcerated veteran sits at the intersection of these two groups, yet little is known about this subpopulation, particularly its risk of suicide. A Pubmed/Medline/PsycINFO search anchored to incarcerated veteran suicide, veteran suicide, suicide in jails/prisons, and veterans incarcerated from 2000 to the present was performed. The currently available literature does not reveal the suicide risk of incarcerated veterans, nor does it enable meaningful estimates. However, striking similarities and overlapping characteristics link the data on veteran suicide, inmate suicide, and incarcerated veterans, suggesting that the veteran in jail or prison faces a level of suicide risk beyond that conferred by either veteran status or incarceration alone. There is a clear need for a better characterization of the incarcerated veteran population and the suicide rate faced by this group. Implications for clinical practice and future research are offered.

Keywords: Incarcerated Veterans, Suicide

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Wortzel HS, Frey, K. L., Anderson, C. A., & Arciniegas, D. B. (2009). Subtle neurological signs predict the severity of subacute cognitive and functional impairments after traumatic brain injury. Journal of Neuropsychiatry and Clinical Neuroscience, 21, 463-466.

The presence of paratonia and primitive reflexes ("frontal release signs"), such as glabellar, snout, suck, grasp, and palmomental responses, after traumatic brain injury predicts performance on bedside cognitive assessments, level of functional independence, and duration of acute inpatient rehabilitation.

Keywords: Traumatic Brain Injury (TBI)

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Wortzel HS, Gutierrez PM, Homaifar BY, Breshears RE, Harwood JE. Surrogate endpoints in suicide research. Suicide Life Threat Behav. 2010 Oct;40(5):500-5.

Surrogate endpoints frequently substitute for rare outcomes in research. The ability to learn about completed suicides by investigating more readily available and proximate outcomes, such as suicide attempts, has obvious appeal. However, concerns with surrogates from the statistical science perspective exist, and mounting evidence from psychometric, neurochemical, genetic, and neuroimaging studies suggests that surrogates may be particularly problematic in suicide research. The need for greater phenotypic refinement of suicide-related behaviors, development of and adherence to a shared suicide nomenclature, and conservative interpretation of investigational results that are limited to the precise population and suicide-related behavior under examination are discussed.

Keywords: Suicide

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Wortzel HS, Frey KL, Anderson CA, Arciniegas DB. Subtle neurological signs predict the severity of subacute cognitive and functional impairments after traumatic brain injury. J Neuropsychiatry Clin Neurosci. 2009 Fall;21(4):463-6.

The presence of paratonia and primitive reflexes ("frontal release signs"), such as glabellar, snout, suck, grasp, and palmomental responses, after traumatic brain injury predicts performance on bedside cognitive assessments, level of functional independence, and duration of acute inpatient rehabilitation.

Keywords: Traumatic Brain Injury (TBI)

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Wortzel HS, Kraus MF, Filley CM, Anderson CA, Arciniegas DB. Diffusion tensor imaging in mild traumatic brain injury litigation. J Am Acad Psychiatry Law. 2011;39(4):511-23.

A growing body of literature addresses the application of diffusion tensor imaging (DTI) to traumatic brain injury (TBI). Most TBIs are of mild severity, and their diagnosis and prognosis are often challenging. These challenges may be exacerbated in medicolegal contexts, where plaintiffs seek to present objective evidence that supports a clinical diagnosis of mild (m)TBI. Because DTI permits quantification of white matter integrity and because TBI frequently involves white matter injury, DTI represents a conceptually appealing method of demonstrating white matter pathology attributable to mTBI. However, alterations in white matter integrity are not specific to TBI, and their presence does not necessarily confirm a diagnosis of mTBI. Guided by rules of evidence shaped by Daubert v. Merrell Dow Pharmaceuticals, Inc., we reviewed and analyzed the literature describing DTI findings in mTBI and related neuropsychiatric disorders. Based on this review, we suggest that expert testimony regarding DTI findings will seldom be appropriate in legal proceedings focused on mTBI.

Keywords: Incarcerated Veterans, Traumatic Brain Injury (TBI)

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Wortzel HS, Strom LA, Anderson AC, Maa EH, Spitz M. Disrobing Associated with Epileptic Seizures and Forensic Implications. J Forensic Sci. 2011 Dec 8. doi: 10.1111/j.1556-4029.2011.01995.x. [Epub ahead of print]

Little is known about the clinical aspects and medico-legal consequences of disrobing in the context of epileptic seizures. Seizure-related disrobing may occur either as an ictal automatism or during the postictal period. Some patients may experience a seizure while already in the unclothed state, engage in ictal wandering, and thereby appear in public in the nude. Two cases involving disrobing associated with seizures captured via video-monitored electroencephalography are offered. An additional case reveals the legal consequences endured by one patient who experienced a nocturnal seizure and began wandering in an unclothed state. Collectively, these cases illustrate the medical reality of seizure-related disrobing and the related adverse effects on patients' quality of life. Disrobing associated with epileptic seizures carries the potential for serious legal consequences if not properly identified as an ictal phenomenon.

Keywords: Brain & Biology

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