Behaviours of concern following moderate to severe traumatic brain injury in individuals living in the community.

PRIMARY OBJECTIVE: Behaviours of Concern (BoC) following traumatic brain injury (TBI) have a significant negative impact on the daily functioning and quality of life for the individual and their family. However, there has been limited research examining the nature and severity of BoC beyond the acute recovery period, including the perspective of the individual with TBI as well as close others (COs). METHODS AND PROCEDURE: Eighty-nine individuals with predominantly severe TBI, at a mean of 11.4 years' post-injury, were identified through a no-fault accident compensation system database. Structured interviews were completed with 65 individuals with TBI, and 62 COs. Current BoC were documented using the Overt Behaviour Scale (OBS). MAIN OUTCOMES AND RESULTS: 70.5% of participants exhibited BoC on the OBS, with an average of 3 behaviours. Verbal aggression and socially inappropriate behaviour were the most common BoC. Self-report of behaviour change was endorsed by 81% of the sample. There was generally poor concordance between the perspectives of the individual with the TBI and their CO. CONCLUSION: Severe BoC, across multiple behaviour types, may be evident many years following predominantly severe TBI. There is a need to provide long-term behaviour support for these individuals.

A prospective examination of Axis I psychiatric disorders in the first 5 years following moderate to severe traumatic brain injury.

BACKGROUND: Psychiatric disorders commonly emerge during the first year following traumatic brain injury (TBI). However, it is not clear whether these disorders soon remit or persist for long periods post-injury. This study aimed to examine, prospectively: (1) the frequency, (2) patterns of co-morbidity, (3) trajectory, and (4) risk factors for psychiatric disorders during the first 5 years following TBI. METHOD: Participants were 161 individuals (78.3% male) with moderate (31.2%) or severe (68.8%) TBI. Psychiatric disorders were diagnosed using the Structured Clinical Interview for DSM-IV, administered soon after injury and 3, 6 and 12 months, and 2, 3, 4 and 5 years post-injury. Disorder frequencies and generalized estimating equations were used to identify temporal relationships and risk factors. RESULTS: In the first 5 years post-injury, 75.2% received a psychiatric diagnosis, commonly emerging within the first year (77.7%). Anxiety, mood and substance-use disorders were the most common diagnostic classes, often presenting co-morbidly. Many (56.5%) experienced a novel diagnostic class not present prior to injury. Disorder frequency ranged between 61.8 and 35.6% over time, decreasing by 27% [odds ratio (OR) 0.73, 95% confidence interval (CI) 0.65-0.83] with each year post-injury. Anxiety disorders declined significantly over time (OR 0.73, 95% CI 0.63-0.84), whilst mood and substance-use disorder rates remained stable. The strongest predictors of post-injury disorder were pre-injury disorder (OR 2.44, 95% CI 1.41-4.25) and accident-related limb injury (OR 1.78, 95% CI 1.03-3.07). CONCLUSIONS: Findings suggest the first year post-injury is a critical period for the emergence of psychiatric disorders. Disorder frequency declines thereafter, with anxiety disorders showing greater resolution than mood and substance-use disorders.

Efficacy of motivational interviewing and cognitive behavioral therapy for anxiety and depression symptoms following traumatic brain injury.

BACKGROUND: Anxiety and depression are common following traumatic brain injury (TBI), often co-occurring. This study evaluated the efficacy of a 9-week cognitive behavioral therapy (CBT) program in reducing anxiety and depression and whether a three-session motivational interviewing (MI) preparatory intervention increased treatment response. METHOD: A randomized parallel three-group design was employed. Following diagnosis of anxiety and/or depression using the Structured Clinical Interview for DSM-IV, 75 participants with mild-severe TBI (mean age 42.2 years, mean post-traumatic amnesia 22 days) were randomly assigned to an Adapted CBT group: (1) MI + CBT (n = 26), or (2) non-directive counseling (NDC) + CBT (n = 26); or a (3) waitlist control (WC, n = 23) group. Groups did not differ in baseline demographics, injury severity, anxiety or depression. MI and CBT interventions were guided by manuals adapted for individuals with TBI. Three CBT booster sessions were provided at week 21 to intervention groups. RESULTS: Using intention-to-treat analyses, random-effects regressions controlling for baseline scores revealed that Adapted CBT groups (MI + CBT and NDC + CBT) showed significantly greater reduction in anxiety on the Hospital Anxiety and Depression Scale [95% confidence interval (CI) -2.07 to -0.06] and depression on the Depression Anxiety and Stress Scale (95% CI -5.61 to -0.12) (primary outcomes), and greater gains in psychosocial functioning on Sydney Psychosocial Reintegration Scale (95% CI 0.04-3.69) (secondary outcome) over 30 weeks post-baseline relative to WC. The group receiving MI + CBT did not show greater gains than the group receiving NDC + CBT. CONCLUSIONS: Findings suggest that modified CBT with booster sessions over extended periods may alleviate anxiety and depression following TBI.

Virtual reality as a method of cognitive training of processing speed, working memory, and sustained attention in persons with acquired brain injury: a protocol for a randomized controlled trial.

BACKGROUND: Acquired brain injury (ABI) often leads to persisting somatic, cognitive, and social impairments. Cognitive impairments of processing speed, sustained attention, and working memory are frequently reported and may negatively affect activities of daily living and quality of life. Rehabilitation efforts aiming to retrain these cognitive functions have often consisted of computerized training programs. However, few studies have demonstrated effects that transfer beyond the trained tasks. There is a growing optimism regarding the potential usefulness of virtual reality (VR) in cognitive rehabilitation. The research literature is sparse, and existing studies are characterized by considerable methodological weaknesses. There is also a lack of knowledge about the acceptance and tolerability of VR as an intervention method for people with ABI. The present study aims to investigate whether playing a commercially available VR game is effective in training cognitive functions after ABI and to explore if the possible effects transfer into everyday functioning. METHODS: One hundred participants (18-65 years), with a verified ABI, impairments of processing speed/attention, and/or working memory, and a minimum of 12 months post injury will be recruited. Participants with severe aphasia, apraxia, visual neglect, epilepsy, and severe mental illness will be excluded. Participants will be randomized into two parallel groups: (1) an intervention group playing a commercial VR game taxing processing speed, working memory, and sustained attention; (2) an active control group receiving psychoeducation regarding compensatory strategies, and general cognitive training tasks such as crossword puzzles or sudoku. The intervention period is 5 weeks. The VR group will be asked to train at home for 30 min 5 days per week. Each participant will be assessed at baseline with neuropsychological tests and questionnaires, after the end of the intervention (5 weeks), and 16 weeks after baseline. After the end of the intervention period, focus group interviews will be conducted with 10 of the participants in the intervention group, in order to investigate acceptance and tolerability of VR as a training method. DISCUSSION: This study will contribute to improve understanding of how VR is tolerated and experienced by the ABI population. If proven effective, the study can contribute to new rehabilitation methods that persons with ABI can utilize in a home setting, after the post-acute rehabilitation has ended.

The nature, frequency and course of psychiatric disorders in the first year after traumatic brain injury: a prospective study.

BACKGROUND: Psychiatric disorders are common following traumatic brain injury (TBI). However, few studies have examined the course of disorder development and the influence of pre-injury psychiatric history. The present study aimed to examine the frequency of, and association between, psychiatric disorders occurring pre- and post-injury, and to examine the post-injury course of disorders. METHOD: Participants were 102 adults (75.5% male) with predominantly moderate-severe TBI. Participants were initially assessed for pre-injury and current disorders, and reassessed at 3, 6 and 12 months post-injury using the Structured Clinical Interview for DSM-IV Disorders (SCID). RESULTS: Over half of the participants had a pre-injury psychiatric disorder; predominantly substance use, mood, and anxiety disorders. In the first year post-injury, 60.8% of participants had a psychiatric disorder, commonly anxiety and mood disorders. Post-injury disorders were associated with the presence of a pre-injury history (p<0.01), with 74.5% of participants with a pre-injury psychiatric history experiencing a post-injury disorder, which commonly presented at initial assessment or in the first 6 months. However, 45.8% of participants without a pre-injury history developed a novel post-injury disorder, which was less likely to emerge at the initial assessment and generally developed later in the year. CONCLUSIONS: Despite evidence that most post-injury psychiatric disorders represent the continuation of pre-existing disorders, a significant number of participants developed novel psychiatric disorders. This study demonstrates that the timing of onset may differ according to pre-injury history. There seem to be different trajectories for anxiety and depressive disorders. This research has important implications for identifying the time individuals are most at risk of psychiatric disorders post-injury.

Efficacy of methylphenidate in the rehabilitation of attention following traumatic brain injury: a randomised, crossover, double blind, placebo controlled inpatient trial.

OBJECTIVES: Most previous studies evaluating the use of methylphenidate following traumatic brain injury (TBI) have been conducted many years post-injury. This study evaluated the efficacy of methylphenidate in facilitating cognitive function in the inpatient rehabilitation phase. METHODS: 40 participants with moderate-severe TBI (mean 68 days post-injury) were recruited into a randomised, crossover, double blind, placebo controlled trial. Methylphenidate was administered at a dose of 0.3 mg/kg twice daily and lactose in identical capsules served as placebo. Methylphenidate and placebo administration was randomised in a crossover design across six sessions over a 2 week period. Primary efficacy outcomes were neuropsychological tests of attention. RESULTS: No participants were withdrawn because of side effects or adverse events. Methylphenidate significantly increased speed of information processing on the Symbol Digit Modalities Test (95% CI 0.30 to 2.95, Cohen's d = 0.39, p = 0.02), Ruff 2 and 7 Test-Automatic Condition (95% CI 1.38 to 6.12, Cohen's d = 0.51, p = 0.003), Simple Selective Attention Task (95% CI -58.35 to -17.43, Cohen's d = 0.59, p = 0.001) and Dissimilar Compatible (95% CI -70.13 to -15.38, Cohen's d = 0.51, p = 0.003) and Similar Compatible (95% CI -74.82 to -19.06, Cohen's d = 0.55, p = 0.002) conditions of the Four Choice Reaction Time Task. Those with more severe injuries and slower baseline information processing speed demonstrated a greater drug response. CONCLUSIONS: Methylphenidate enhances information processing speed in the inpatient rehabilitation phase following TBI. This trial is registered with the Australian New Zealand Clinical Trials Registry (12607000503426).

Financial and recovery worry one year after traumatic injury: A prognostic, registry-based cohort study.

BACKGROUND: Levels of stress post-injury, especially after compensable injury, are known to be associated with worse long-term recovery. It is therefore important to identify how, and in whom, worry and stress manifest post-injury. This study aimed to identify demographic, injury, and compensation factors associated with worry about financial and recovery outcomes 12 months after traumatic injury. METHODS: Participants (n = 433) were recruited from the Victorian Orthopaedic Trauma Outcomes Registry and Victorian State Trauma Registry after admission to a major trauma hospital in Melbourne, Australia. Participants completed questionnaires about pain, compensation experience and psychological wellbeing as part of a registry-based observational study. RESULTS: Linear regressions showed that demographic and injury factors accounted for 11% and 13% of variance in financial and recovery worry, respectively. Specifically, lower education, discharge to inpatient rehabilitation, attributing fault to another and having a compensation claim predicted financial worry. Worry about recovery was only predicted by longer hospital stay and attributing fault to another. In all participants, financial and recovery worry were associated with worse pain (severity, interference, catastrophizing, kinesiophobia, self-efficacy), physical (disability, functioning) and psychological (anxiety, depression, PTSD, perceived injustice) outcomes 12 months post-injury. In participants who had transport (n = 135) or work (n = 22) injury compensation claims, both financial and recovery worry were associated with sustaining permanent impairments, and reporting negative compensation system experience 12 months post-injury. Financial worry 12 months post-injury was associated with not returning to work by 3-6 months post-injury, whereas recovery worry was associated with attributing fault to another, and higher healthcare use at 6-12 months post-injury. CONCLUSIONS: These findings highlight the important contribution of factors other than injury severity, to worry about finances and recovery post-injury. Having a compensation claim, failure to return to work and experiencing pain and psychological symptoms also contribute to elevated worry. As these factors explained less than half of the variance in worry, however, other factors not measured in this study must play a role. As worry may increase the risk of developing secondary mental health conditions, timely access to financial, rehabilitation and psychological supports should be provided to people who are not coping after injury.

The impact of intrinsic motivation on session attendance and reliable cognitive improvement in cognitive remediation in schizophrenia.

OBJECTIVE: Cognitive remediation (CR) is considered a potentially effective method of improving cognitive function in people with schizophrenia. Few studies, however, have explored the role of intrinsic motivation on treatment utilization or training outcomes in CR in this population. This study explored the impact of task-specific intrinsic motivation on attendance and reliable cognitive improvement in a controlled trial comparing CR with a computer game (CG) playing control. METHODS: Forty-nine participants with schizophrenia or schizoaffective disorder, allocated to 10 weeks of group-based CR (n = 25) or CG control (n = 24), provided complete outcome data at baseline. Forty-three participants completed their assigned intervention. Cognition, psychopathology and intrinsic motivation were measured at baseline and end-treatment. Regression analyses explored the relative contribution of baseline motivation and other clinical factors to session attendance as well as the association of baseline and change in intrinsic motivation with the odds of reliable cognitive improvement (calculated using reliable change indices). RESULTS: Baseline reports of perceived program value were the only significant multivariable predictor of session attendance when including global cognition and psychiatric symptomatology. The odds of reliable cognitive improvement significantly increased with greater improvements in program interest and value from baseline to end-treatment. Motivational changes over time were highly variable between participants. CONCLUSION: Task-specific intrinsic motivation in schizophrenia may represent an important patient-related factor that contributes to session attendance and cognitive improvements in CR. Regular evaluation and enhancement of intrinsic motivation in cognitively enhancing interventions may optimize treatment engagement and the likelihood of meaningful training outcomes.

The effect of traumatic brain injury on the timing of sleep.

While there have been single case reports of the development of circadian rhythm sleep disorders, most commonly delayed sleep phase syndrome following traumatic brain injury (TBI), to our knowledge there have been no group investigations of changes to sleep timing in this population. The aim of the present study was to investigate sleep timing following TBI using the dim light melatonin onset (DLMO) as a marker of circadian phase and the Morningness-Eveningness Questionnaire (MEQ) as a measure of sleep-wake behavior. A sleep-wake diary was also completed. It was hypothesized that the timing of DLMO would be delayed and that there would be a greater tendency toward eveningness on the MEQ in a post-acute TBI group (n=10) compared to a gender and age matched control group. Participants were recruited at routine outpatient review appointments (TBI) and from the general population (control) as part of a larger study. They attended the sleep laboratory where questionnaires were completed, some retrospectively, and saliva melatonin samples were collected half-hourly according to a standard protocol. The results show that the TBI and control groups reported similar habitual sleep times and this was reflected on the MEQ. There was, however, significant variability in the TBI group's change from the pre-injury to the current MEQ score. The timing of melatonin onset was not different between the groups. While subtle changes (advances or delays) in this small sample may have cancelled each other out,. the present study does not provide conclusive objective evidence of shift in circadian timing of sleep following TBI. Furthermore, although participants did report sleep timing changes, it is concluded that the MEQ may not be suitable for use with this cognitively impaired clinical group.

Cerebral control of saccades and neuropsychological test results after head injury.

Abnormalities in the control of saccades have been described in patients with cerebral pathology.(1, 2) We assessed control of visually guided, reflexive and volitional saccades in 16 patients suffering severe traumatic brain injury and 12 controls and related the results to deficits on neuropsychological tests of speed of information processing and goal directed behaviour. All saccadic latencies were prolonged. Suppression of inappropriate saccades was impaired on volitional saccade tests which proved to be more sensitive in identifying impairment of goal directed behaviour than the neuropsychological test results. Patients' self-paced saccade rate was lower than controls' and correlated with performance on several visually mediated neuropsychological test results. Patients' visually guided, reflexive saccades were hypometric; this hypometria correlated with both visual and non-visual neuropsychological test results and with post-traumatic amnesia duration. Hypometria in reflexive saccades may reflect diffuse brain injury. Re-examination after 12 months revealed that the control of volitional saccades improved but there was no improvement in the visually guided reflexive saccade measures. The volitional saccade tests may be useful in documenting both impairment and subsequent recovery.

Sleep disturbance and melatonin levels following traumatic brain injury.

OBJECTIVES: Sleep disturbances commonly follow traumatic brain injury (TBI) and contribute to ongoing disability. However, there are no conclusive findings regarding specific changes to sleep quality and sleep architecture measured using polysomnography. Possible causes of the sleep disturbances include disruption of circadian regulation of sleep-wakefulness, psychological distress, and a neuronal response to injury. We investigated sleep-wake disturbances and their underlying mechanisms in a TBI patient sample. METHODS: This was an observational study comparing 23 patients with TBI (429.7 +/- 287.6 days post injury) and 23 age- and gender-matched healthy volunteers on polysomnographic sleep measures, salivary dim light melatonin onset (DLMO) time, and self-reported sleep quality, anxiety, and depression. RESULTS: Patients with TBI reported higher anxiety and depressive symptoms and sleep disturbance than controls. Patients with TBI showed decreased sleep efficiency (SE) and increased wake after sleep onset (WASO). Although no significant group differences were found in sleep architecture, when anxiety and depression scores were controlled, patients with TBI showed higher amount of slow wave sleep. No differences in self-reported sleep timing or salivary DLMO time were found. However, patients with TBI showed significantly lower levels of evening melatonin production. Melatonin level was significantly correlated with REM sleep but not SE or WASO. CONCLUSIONS: Reduced evening melatonin production may indicate disruption to circadian regulation of melatonin synthesis. The results suggest that there are at least 2 factors contributing to sleep disturbances in patients with traumatic brain injury. We propose that elevated depression is associated with reduced sleep quality, and increased slow wave sleep is attributed to the effects of mechanical brain damage.

Attentional deficits following closed-head injury.

Aimed to assess, in the light of current attentional theories, the nature of the attentional deficit in a group of severely traumatically head-injured subjects, relative to a group of orthopaedic rehabilitation patients, and to establish which neuropsychological measures best reflected the deficit. Three separate studies were conducted in order to meet these aims. The first study focused on selective attention; the second, on vigilance or sustained attention; the third, on the Supervisory Attentional System. Results provided no evidence for the presence of deficits of focused attention, sustained attention, or supervisory attentional control, but ample evidence for the presence of a deficit in speed of information processing. Those neuropsychological measures shown to be the best measures of this deficit included the Symbol Digit Modalities Test, simple and choice reaction-time tasks, colour naming and word reading scores on the Stroop, and the Paced Auditory Serial Addition Test.

Evaluation of a remedial programme for attentional deficits following closed-head injury.

Although the frequency and implications of disorders of attention in head-injured subjects have been recognised in recent years, there have been few carefully controlled attempts to evaluate remedial interventions. The present study employed a multiple baseline across subjects design to evaluate a computer-mediated programme for the remediation of deficits in speed of information processing in 10 severely head-injured subjects, aged 17-38 years. Following a baseline period, the effectiveness of computer training alone was compared with that combined with therapist feedback and reinforcement in separate training phases, each lasting 3 weeks. The final phase involved a return to baseline conditions. Dependent measures of attention, taken across all phases, included psychometric measures of processing speed, a rating scale completed by the patient's Occupational Therapist, and a video of the patient working in therapy. Results suggested that, once spontaneous recovery and practice effect were controlled, the patients showed little response to the interventions in terms of the dependent measures used.

Conversational assessment following traumatic brain injury: a comparison across two control groups.

Although changes in discourse are frequently referred to in the traumatic brain injury (TBI) literature, they are difficult to objectify and measure. It is not always easy, therefore, for clinicians to differentiate between discourse behaviours which may have been present premorbidly, and those which are uniquely associated with TBI. The major aim of this study was to systematically examine and describe the nature of conversational impairment following severe TBI, with particular reference to the premorbid sociolinguistic characteristics of the TBI population. A second aim of the study was to examine the relationship between discourse impairment following TBI and severity of injury. Twenty-six TBI participants were compared with 26 non-brain-injured orthopaedic patients, and 26 university students, using Damico's Clinical Discourse Analysis (CDA). As predicted, global measures derived from the CDA did not differentiate the groups. The TBI group was, however, found to differ significantly from both control groups on a modified measure (CDA-M) which removes discourse errors that occurred with similar frequency across the three groups. Performance on this measure correlated significantly with severity of injury. Further, it was found that there were quantitative and qualitative differences between two seventy subgroups in the TBI group with respect to their CDA-M profiles. While nearly all members of the TBI group made errors associated with information transfer, only the more fundamental 'rules' of conversational interaction. The results are discussed in relation to the psychosocial implications of the findings, together with issues in sampling and measuring conversational discourse in the TBI population.

Transient global amnesia--a hippocampal phenomenon?

A case of transient global amnesia of clear vascular aetiology is described. Results of neuropsychological testing carried out during the attack clarify the nature of the memory disorder and suggest that the critical region of ischaemia is the medial temporal area around the hippocampus. Follow-up testing suggests that no lasting memory impairment resulted.

Conversational discourse abilities following severe traumatic brain injury: a follow-up study.

The major aim of this study was to describe the conversational abilities of a group of severely injured TBI speakers, at a minimum of 2 years post-injury. The association between conversational impairment and (a) selected measures of executive function and (b) psychosocial handicap was also examined. Twenty-four members of the group of 26 severely injured TBI speakers who had initially been assessed between 3 and 6 months post-injury were reviewed at a minimum of 2 years post-injury (mean = 2 years, 10 months). At initial assessment, TBI speakers were compared with non-TBI orthopaedic patients and with a group of university students. At follow-up, however, they were compared only with the orthopaedic patients. Conversational assessment was carried out using a modified form of Damico's Clinical Discourse Analysis. As a group, the TBI speakers' conversational abilities did not improve over time. There was, however, a subgroup (n = 8) of speakers who did improve, and these could be distinguished by greater initial severity of injury and a significantly longer period of speech-language pathology intervention than the speakers who either remained the same or worsened over time. Modest associations between conversational discourse skills and measures of executive function and a measure of psychosocial handicap were identified. These findings indicate that disruptions in conversation persist into the longer term. More assiduous efforts may need to be made to (a) identify subtle discourse changes in the early months after injury and (b) engage TBI speakers in speech-language pathology services. Such services are also required over a longer time frame, in community-based models of service provision.

The role of imagery in sexual arousal disturbances in the male traumatically brain injured individual.

Over 50% of individuals who suffer traumatic brain injury (TBI) demonstrate a decrease in sexual arousal post-injury. This study investigated the basis of this loss and hypothesized that it occurred as a consequence of the effect of the injury on cognition: specifically, diminution of the ability to form and manipulate sexually arousing imagery. The study compared 14 male participants who identified themselves as having alteration in sexual functioning following traumatic brain injury with a further 14 non-brain injured participants, case matched to them for age and education. All TBI participants were assessed after 2 years following injury, and had had a loss of consciousness of 3 days or greater. The results indicated that the two groups differed in terms of their performance on the Bett's QMI Scale, the Gordon Test of Visual Imagery Control, the Vividness of Sexual Imagery Scale of the Imaginal Processes Inventory, the State Trait Anxiety Inventory, and the Beck Depression Inventory. After correction for the level of depression by analysis of covariance, the TBI participants still featured lower levels of performance on the Sexual Imagery sub-scale of the Imaginary Processes Inventory. The results indicate that sexual arousal disturbances may exist above and beyond the disturbances to affect associated with the psychosocial effects of the TBI.

A profile of outcome: 2 years after traumatic brain injury.

A group of 175 traumatic brain injury (TBI) patients who had undergone intensive rehabilitation at Bethesda Hospital attended a follow-up interview 2 years after injury. The majority of patients had suffered severe TBI. Outcome was documented in ten areas: medical/physical, mobility, activities of daily living (ADLs) accommodation, marital status, leisure and recreation, employment/study, communication, cognition and behaviour. Whilst most patients were physically independent and competent in personal and domestic activities of daily living, a third of the group were still reliant on assistance with community skills and transport, and more than half of those who previously had a job, were not working at 2 years post-injury. Around two-thirds of the sample reported cognitive, behavioural and emotional changes. There is clearly a need for ongoing community-based support and assistance in dealing with practical difficulties and psychological problems as they are experienced after return to the community.