Socratic guided feedback therapy after acquired brain injury: A multicenter randomized controlled trial to evaluate effects on self-awareness.

Impaired self-awareness after acquired brain injury (ABI) challenges neuropsychological rehabilitation. The current study aimed to compare the effects of Socratic Guided Feedback therapy to usual care in a multicenter randomized controlled trial with 64 participants with reduced self-awareness after ABI. The objectives were to study the effects on (1) self-awareness and (2) motivation for and participation in therapy, mood, quality of life, and social participation. Patients were recruited from rehabilitation centres in The Netherlands and Belgium. They were 50.8 (±16) years old and 2.7 months (±1.8) post-injury at baseline. Session duration ranged from 20-60 minutes and the number of sessions ranged from 1 to 162 sessions. Self-awareness increased over time in both groups. Between 9 and 12 months after baseline measurement, self-awareness (Patient Competency Rating Scale discrepancy score between patient and significant other) improved in the experimental group and deteriorated in care as usual. No significant differences were found on secondary outcome measures. In conclusion, Socratic Guided Feedback therapy is as effective as care as usual but provides a structure for therapists. We recommend further investigation of the added value of Socratic Guided Feedback therapy in later follow-up measurements, group therapy settings, and on other outcome domains such as caregiver burden.

Validity of the Groningen Effort Test in patients with suspected chronic solvent-induced encephalopathy.

INTRODUCTION: The use of performance validity tests (PVTs) in a neuropsychological assessment to determine indications of invalid performance has been a common practice for over a decade. Most PVTs are memory-based; therefore, the Groningen Effort Test (GET), a non-memory-based PVT, has been developed. OBJECTIVES: This study aimed to validate the GET in patients with suspected chronic solvent-induced encephalopathy (CSE) using the criterion standard of 2PVTs. A second goal was to determine diagnostic accuracy for GET. METHOD: Sixty patients with suspected CSE referred for NPA were included. The GET was compared to the criterion standard of 2PVTs based on the Test of Memory Malingering and the Amsterdam Short Term Memory Test. RESULTS: The frequency of invalid performance using the GET was significantly higher compared to the criterion of 2PVTs (51.7% vs. 20.0% respectively; p < 0.001). For the GET index, the sensitivity was 75% and the specificity was 54%, with a Youden's Index of 27. CONCLUSION: The GET showed significantly more invalid performance compared to the 2PVTs criterion suggesting a high number of false positives. The general accepted minimum norm of specificity for PVTs of >90% was not met. Therefore, the GET is of limited use in clinical practice with suspected CSE patients.

The Assessment of Burden of ColoRectal Cancer (ABCRC)-tool; a validity and reliability study.

INTRODUCTION: Follow-up care after treatment for colorectal cancer (CRC) is increasingly focused on health-related quality of life (HRQoL) and functional outcomes. The Assessment of Burden of ColoRectal Cancer (ABCRC)-tool is developed to measure these outcomes and support patient-oriented care. The tool comprises items assessing burden of disease and lifestyle parameters. It consists of a generic module combined with one of the three CRC specific modules. The objective of this study is to assess the construct validity and reliability of the items of the ABCRC-tool. METHODS: Patients who were receiving follow-up care after surgical CRC treatment were invited to complete the ABCRC-tool together with other validated patient-reported outcome measures (PROMs). Construct validity was assessed by testing expected correlations between items of the ABCRC-tool and domains of other PROMs and by examining predefined hypotheses regarding differences in subgroups of patients. Patients completed the ABCRC-tool twice, with 8 days apart, to evaluate its reliability. RESULTS: In total, 177 patients participated (64% male) with a mean age of 67 years (range 33-88). The colon, rectum and stoma module were completed by subsequently 89, 53 and 35 patients. Most items correlated as expected with anticipated domains of the EORTC QLQ-C30 or EORTC QLQ-CR29 (all p-values <0.05). Furthermore, the ABCRC-tool could discriminate between subgroups of patients. The intraclass correlation coefficient (ICC) was good (>0.70) for most items, indicating good reliability. CONCLUSION: The ABCRC-tool is a valid and reliable instrument that is ready for use in a clinical setting to support personalized follow-up care after CRC treatment.

Trajectories of fatigue and related outcomes following mild acquired brain injury: a multivariate latent class growth analysis.

OBJECTIVE: Fatigue is a common symptom following acquired brain injury although the severity and course differs for many individuals. This longitudinal study aimed to identify latent trajectory classes of fatigue and associated outcomes following mild brain injury. METHODS: 204 adults with mild traumatic brain injury (159; 78%) or minor stroke (45; 22%) were assessed 4 times over 1 year. Subjective measures of fatigue, anxiety, depression, cognitive complaints and societal participation were collected. Multivariate Latent Class Growth Analysis identified classes of participants with similar longitudinal patterns. Demographic and injury characteristics were used to predict class membership. RESULTS: Analysis revealed four classes. Class 1 (53%) had mild, decreasing fatigue with no other problems. Class 2 (29%) experienced high persistent fatigue, moderate cognitive complaints and societal participation problems. Class 3 (11%) had high persistent fatigue with anxiety, depression, cognitive complaints and participation problems. Class 4 (7%) experienced decreasing fatigue with anxiety and depression but no cognitive or participation problems. Women and older individuals were more likely to be in class 2. CONCLUSION: Half the participants had a favourable outcome while the remaining classes were characterised by persistent fatigue with cognitive complaints (class 2), decreasing fatigue with mood problems (class 4) or fatigue with both cognitive and mood problems (class 3). Fatigue treatment should target combinations of problems in such individual trajectories after mild brain injury.

Feasibility of a novel blended-care intervention for fatigue after acquired brain injury: a pilot study of the Tied by Tiredness intervention.

PURPOSE: Evidence-based treatments for fatigue after brain injury are scarce and often not personalized. An approach to foster personalization is Experience Sampling Methodology (ESM), consisting of repeated daily measurements of fatigue and related factors in daily life. We investigated the feasibility and usability of a novel six-week ESM-based intervention for fatigue after brain injury. MATERIALS AND METHODS: Ten individuals with acquired brain injury (six men; four women) aged between 36-70 years (M = 53.3, SD = 12.9) used a mHealth application for three days each week during six-weeks; seven completed the intervention. Momentary fatigue, activities, mood, worrying, and social context were assessed with ESM and participants received weekly personalized feedback by a therapist.. RESULTS: 56% of ESM-questionnaires (568/1008) were completed, providing detailed insights into individual fatigue patterns. No statistically significant decrease in response rate was found over the course of treatment. Qualitative feedback from participants revealed increased insight into factors underlying fatigue, and no problems with treatment duration or difficulties using the app. Five participants showed a decline in fatigue level during treatment. CONCLUSIONS: This pilot study provides initial support for the feasibility and usability of this novel blended-care intervention, aimed at alleviating fatigue through personalized feedback and treatment strategies.

Visual associative learning to detect early episodic memory deficits and distinguish Alzheimer's disease from other types of dementia.

OBJECTIVE: We investigated how well a visual associative learning task discriminates Alzheimer's disease (AD) dementia from other types of dementia and how it relates to AD pathology. METHODS: 3,599 patients (63.9 ± 8.9 years old, 41% female) from the Amsterdam Dementia Cohort completed two sets of the Visual Association Test (VAT) in a single test session and underwent magnetic resonance imaging. We performed receiver operating curve analysis to investigate the VAT's discriminatory ability between AD dementia and other diagnoses and compared it to that of other episodic memory tests. We tested associations between VAT performance and medial temporal lobe atrophy (MTA), and amyloid status (n = 2,769, 77%). RESULTS: Patients with AD dementia performed worse on the VAT than all other patients. The VAT discriminated well between AD and other types of dementia (area under the curve range 0.70-0.86), better than other episodic memory tests. Six-hundred forty patients (17.8%) learned all associations on VAT-A, but not on VAT-B, and they were more likely to have higher MTA scores (odds ratios range 1.63 (MTA 0.5) through 5.13 for MTA ≥ 3, all p < .001) and to be amyloid positive (odds ratio = 3.38, 95%CI = [2.71, 4.22], p < .001) than patients who learned all associations on both sets. CONCLUSIONS: Performance on the VAT, especially on a second set administered immediately after the first, discriminates AD from other types of dementia and is associated with MTA and amyloid positivity. The VAT might be a useful, simple tool to assess early episodic memory deficits in the presence of AD pathology.

Internet-based cognitive rehabilitation for working cancer survivors: results of a multicenter randomized controlled trial.

BACKGROUND: Cognitive problems contribute to decline in work performance. We evaluated (1) the effectiveness of basic self-management and extensive therapist-guided online cognitive rehabilitation on attainment of individually predetermined work-related goals among occupationally active cancer survivors, and (2) whether effectiveness of the programs differed for survivors with and without formal cognitive impairment. METHODS: In a 3-arm randomized controlled trial (NCT03900806), 279 non-central nervous system cancer survivors with cognitive complaints were assigned to the basic program (n = 93), the extensive program (n = 93), or a waiting-list control group (n = 93). Participants completed measurements pre-randomization (T0), 12 weeks post-randomization upon program completion (T1), and 26 weeks post-randomization (T2). Mixed-effects modeling was used to compare intervention groups with the control group on goal attainment, and on self-perceived cognitive problems, work ability, and health-related quality of life. RESULTS: Participants in the extensive program achieved their predetermined goals better than those in the control group, at short- and long-term follow-up (effect size [ES] = .49; P < .001; ES = .34; P = .014). They also had fewer recovery needs after work (ES = -.21; P = .011), more vitality (ES = .20; P = .018), and better physical role functioning (ES = .0.43 P = .015) than controls. At long-term follow-up, this finding persisted for physical role functioning (ES = .42; P = .034). The basic program elicited a small positive nonsignificant short-term (not long-term) effect on goal attainment for those with adequate adherence (ES = .28, P = .053). Effectiveness of the programs did not differ for patients with or without cognitive impairment. CONCLUSIONS: Internet-based therapist-guided extensive cognitive rehabilitation improves work-related goal attainment. Considering the prevalence of cognitive problems in survivors, it is desirable to implement this program.

Why to test for dementia: perspectives of patients, significant others and general practitioners.

BACKGROUND: This study aims to provide greater insight into the current decision-making process on diagnostic testing for dementia by exploring the expectations, needs and experiences of patients with memory complaints, significant others and general practitioners (GPs). METHODS: We performed semi-structured interviews with patients (>60 years) who consulted their GP on memory complaints, significant others and GPs. Participants were recruited until data saturation was reached in thematic analysis of interview transcripts. RESULTS: We performed 51 interviews (patients n = 20, significant others n = 15, GPs n = 16). Thematic analysis revealed four themes: (i) 'drivers to (not) testing', i.e. need to act on symptoms, beliefs on the necessity and expected outcomes of diagnostic testing; (ii) 'patient preferences and context are critical in the actual decision', i.e. in the actual decision-making process interpretation of symptoms, GPs' desire to meet patient preferences, social context and healthcare system dynamics guided the decision; (iii) 'need for individualised communication in the decision-making process', i.e. for patients feeling heard was a prerequisite for decision-making and GPs tailored communication strategies to individual patients and (iv) 'GP practice and barriers to shared decision-making (SDM)', i.e. although GPs value SDM in the decision on diagnostic testing for dementia, patients express limited awareness of the decision and options at stake. CONCLUSIONS: Decision-making on diagnostic testing for dementia is a multifactorial and preference-guided process for all involved stakeholders, but decisions are often not explicitly jointly made. Development of patient decision aids could facilitate better involvement and more informed choices by patients.

Exploring diagnostic strategies for memory complaints in older adults: A retrospective general practice database study.

OBJECTIVES: For older people who worry about their memory, their general practitioner (GP) is often the first healthcare professional they turn to. This study aims to increase knowledge of GPs' daily practice on diagnostic strategies for patients who present themselves with memory complaints and/or worries about dementia for the first time in general practice and to explore associations of patients' characteristics with these strategies. METHOD: Retrospective observational study using electronic patient records from patients presenting with memory complaints between 2012 and 2019. The patient records are derived from a Dutch primary care registration network. The decision on diagnostic strategy was extracted and categorized as (1) wait and see, (2) diagnostic testing in primary care, or (3) referral. Patient characteristics (gender, age, general practice, level of comorbidities, chronic polypharmacy, and the number of consultations on memory complaints), fear of developing dementia, and information on why the first consultation on memory complaints was scheduled were extracted. RESULTS: A total of 228 patients were included. Most patients were cared for within primary care, either for further primary care diagnostics (56.1%) or because a wait-and-see strategy was pursued (14.9%). One-third (28.9%) of patients were referred. Differences between diagnostic strategies in patient characteristics, fear of developing dementia, or reason for first consultation between these diagnostic strategies were not found, nor were these variables predictive of referral. CONCLUSION: Most Dutch patients with memory complaints and/or worries about dementia who seek help from their GP for the first time are cared for in the primary care setting for the following 6 months. The lack of association between included patient characteristics and diagnostic strategies highlights the complexity of the decision-making process on diagnostic testing for dementia in general practice.

Performance Validity Test Failure in the Clinical Population: A Systematic Review and Meta-Analysis of Prevalence Rates.

Performance validity tests (PVTs) are used to measure the validity of the obtained neuropsychological test data. However, when an individual fails a PVT, the likelihood that failure truly reflects invalid performance (i.e., the positive predictive value) depends on the base rate in the context in which the assessment takes place. Therefore, accurate base rate information is needed to guide interpretation of PVT performance. This systematic review and meta-analysis examined the base rate of PVT failure in the clinical population (PROSPERO number: CRD42020164128). PubMed/MEDLINE, Web of Science, and PsychINFO were searched to identify articles published up to November 5, 2021. Main eligibility criteria were a clinical evaluation context and utilization of stand-alone and well-validated PVTs. Of the 457 articles scrutinized for eligibility, 47 were selected for systematic review and meta-analyses. Pooled base rate of PVT failure for all included studies was 16%, 95% CI [14, 19]. High heterogeneity existed among these studies (Cochran's Q = 697.97, p < .001; I2 = 91%; τ2 = 0.08). Subgroup analysis indicated that pooled PVT failure rates varied across clinical context, presence of external incentives, clinical diagnosis, and utilized PVT. Our findings can be used for calculating clinically applied statistics (i.e., positive and negative predictive values, and likelihood ratios) to increase the diagnostic accuracy of performance validity determination in clinical evaluation. Future research is necessary with more detailed recruitment procedures and sample descriptions to further improve the accuracy of the base rate of PVT failure in clinical practice.

Experiences of people with dementia and informal caregivers with post-diagnostic support: Data from the international COGNISANCE study.

OBJECTIVES: The study aims to describe people with dementia and informal caregivers' respective experiences of support after diagnosis and compares these experiences. Additionally, we determine how people with dementia and informal caregivers who are satisfied with support differ from those dissatisfied. METHODS: A cross-sectional survey study in Australia, Canada, the Netherlands, Poland, and United Kingdom was carried out to examine people with dementia and informal caregivers experience with support (satisfaction with information, access to care, health literacy, and confidence in ability to live well with dementia). The separate surveys contained closed questions. Analysis consisted of descriptive statistics and Chi-square tests. RESULTS: Ninety people with dementia and 300 informal caregivers participated, and 69% of people with dementia and 67% of informal caregivers said support after diagnosis helped them deal more efficiently with their concerns. Up to one-third of people with dementia and informal caregivers were dissatisfied with information about management, prognosis, and strategies for living positively. Few people with dementia (22%) and informal caregivers (35%) received a care plan. People with dementia were more often satisfied with information, had more often confidence in their ability to live well with dementia, and were less often satisfied with access to care compared to informal caregivers. Informal caregivers who were satisfied with support were more satisfied with information and access to care compared to informal caregivers not satisfied with support. CONCLUSIONS: Experience of dementia support can be improved and people with dementia and informal caregiver differ in their experiences of support.

Understanding patients' and significant others' preferences on starting a diagnostic trajectory for dementia: An integrative review.

OBJECTIVE: To explore the preferences of people with memory complaints (PwMC) and their significant others regarding starting a diagnostic trajectory for dementia. METHODS: A systematic literature search was conducted in PubMed, PsycINFO, CINAHL, Web of Science, and Embase. Selection of abstracts and papers was performed independently by two researchers. Methodological quality was assessed with the Mixed Method Appraisal Tool. Result sections of the selected papers were thematically synthesized. RESULTS: From 2497 citations, seven qualitative studies and two mixed methods studies published between 2010 and 2020 were included. Overall quality of the studies was high to moderate. A thematic synthesis showed that preferences for starting a diagnostic trajectory arose from the feeling of needing to do something about the symptoms, beliefs on the necessity and expected outcomes of starting a diagnostic trajectory. These views were influenced by normalization or validation of symptoms, the support or wishes of the social network, interactions with health care professionals, the health status of the PwMC, and societal factors such as stigma and socioeconomic status. CONCLUSION: A variety of considerations with regard to decision-making on starting a diagnostic trajectory for dementia were identified. This emphasizes the need to explore individual preferences to facilitate a timely dementia diagnosis.

Neural Correlates of Impaired Self-awareness of Deficits after Acquired Brain Injury: A Systematic Review.

Self-awareness is essential for the process and outcome of rehabilitation but is often affected by acquired brain injury (ABI). While many studies investigated the psychological aspects of self-awareness deficits, the biological underpinnings are not well understood. The aim of this systematic review was to identify the neural correlates of self-awareness after ABI. Results indicate that anticipation of future problems is associated with lesions and decreased neural functioning in the right frontal lobe, as well as increased diffusivity throughout the white matter of the brain. Poor behavioral adjustment on implicit awareness tasks is associated with less functional connectivity of anterior cingulate cortex and right or middle inferior frontal gyri to the fronto-parietal control network, as well as more activation in the left insula and left parietal operculum during error processing. Recognition of mistakes is associated with internetwork connectivity of anterior or posterior default mode network to salience network. In conclusion, after ABI, different results in brain activation and connectivity are found depending on level of awareness measured. Future studies are necessary to confirm these findings.

The association of personality traits with poststroke fatigue in daily life: An exploratory experience sampling method and cross-sectional study.

Fatigue is a frequently occurring and persistent symptom after stroke. Many biological, psychosocial, and behavioural factors are associated with poststroke fatigue, but research into associations with personality traits is relatively sparse. In this study, we explored whether personality traits were related to poststroke fatigue measured with conventional fatigue questionnaires as well as experience sampling methodology (ESM). Twenty-four individuals with stroke completed 10 daily questionnaires about momentary (here-and-now) fatigue for six consecutive days using the mHealth ESM application PsyMateTM. Further, they completed questionnaires assessing personality (NEO-FFI and LOR-T) and fatigue (FSS). Results showed that higher extraversion (ß = -.44, SE = .12, p = .001; 95% CI = -.67-.19) and optimism (ß = -.18, SE = .06, p = .007; 95% CI = -.30-.05) were associated with lower momentary fatigue. No association was found between neuroticism and momentary fatigue, but higher neuroticism (r = 0.531, p = .008, 95% CI = .160-.759; r = .574, p = .003, 95% CI = .245-.767) was associated with higher scores on the retrospective FSS scales. We conclude that personality traits differentially influence poststroke fatigue, but this also depends on the way fatigue is measured (with retrospective or with momentary measures). When functional gains are not in line with expected progress during the rehabilitation treatment of fatigue, it may be appropriate to take into account how person characteristics are related to momentary fatigue.

Neuropsychological test performance and self-reported cognitive functioning associated with work-related outcomes in occupationally active cancer survivors with cognitive complaints.

PURPOSE: To assess cognitive functioning in occupationally active non-central nervous system cancer survivors with cognitive complaints using neuropsychological tests, and to investigate the association between (1) formally assessed cognitive functioning and self-reported work-related outcomes and (2) self-reported cognitive functioning at work and self-reported work-related outcomes. METHODS: Baseline data of a multicenter, randomized controlled trial (n = 279) were used. Associations between neuropsychological test performance (Amsterdam Cognition Scan) and self-reported cognitive functioning (Cognitive Symptom Checklist-work) with work ability (Work Ability Index) and work functioning (Work Role Functioning Questionnaire) were examined using multivariate linear regression. RESULTS: Thirty percent of cancer survivors had lower than expected performance on neuropsychological tests. Higher overall neuropsychological test performance was associated with better work ability (Cohen's f2 = 0.014) and physical functioning at work (Cohen's f2 = 0.13). Furthermore, higher motor performance was associated with better work ability (Cohen's f2 = 0.018). In addition, self-reported work-related cognitive complaints were associated with self-reported work-related outcomes (Cohen's f2 = 0.13-0.35). CONCLUSIONS: The percentage of cancer survivors with lower than expected performance on neuropsychological tests exceeded the percentage expected in a normal population. This neuropsychological test performance was weakly associated with various aspects of work ability and work functioning. Stronger associations were found between self-reported cognitive functioning at work with self-reported work-related outcomes. IMPLICATIONS FOR CANCER SURVIVORS: A cognitive rehabilitation approach that specifically aims at reducing cognitive symptoms at work could be a valuable part of interventions that aim to improve work-related outcomes. Trial registration The study is registered at ClinicalTrials.gov (NCT03900806) at 03 April 2019 (current status: ongoing), https://clinicaltrials.gov/ct2/show/NCT03900806?term=NCT03900806&draw=2&rank=1.

Sex-Specific Associations of Diabetes With Brain Structure and Function in a Geriatric Population.

Introduction: Globally, women with dementia have a higher disease burden than men with dementia. In addition, women with diabetes especially are at higher risk for cognitive impairment and dementia compared to men with diabetes. Differences in the influence of diabetes on the cerebral vasculature and brain structure may contribute to these sex-specific differences. We examined sex-specific patterns in the relationship between diabetes and brain structure, as well as diabetes and cognitive function. Methods: In total, 893 patients [age 79 ± 6.6 years, 446 (50%) women] from the Amsterdam Ageing Cohort with available data on brain structures (assessed by an MRI or CT scan) and cognitive function were included. All patients underwent a thorough standardized clinical and neuropsychological assessment (including tests on memory, executive functioning, processing speed, language). Brain structure abnormalities were quantified using visual scales. Results: Cross-sectional multivariable regression analyses showed that diabetes was associated with increased incidence of cerebral lacunes and brain atrophy in women (OR 2.18 (1.00-4.72) but not in men. Furthermore, diabetes was associated with decreased executive function, processing speed and language in women [B -0.07 (0.00-0.13), -0.06 (0.02-0.10) and -0.07 (0.01-0.12) resp.] but not in men. Conclusions: Diabetes is related to increased risk of having lacunes, brain atrophy and impaired cognitive function in women but not in men. Further research is required to understand the time trajectory leading up to these changes and to understand the mechanisms behind them in order to improve preventive health care for both sexes.

Episodic recognition memory based on incidental learning of visual associations is largely preserved compared to recall in amnestic mild cognitive impairment and mild Alzheimer's disease.

We investigated preserved episodic recognition memory based on incidental learning of visual associations in Alzheimer's disease (AD). In a cross-sectional design, we analyzed episodic memory score profiles of patients with amnestic mild cognitive impairment (a-MCI) (n = 42) or mild AD (n = 19) who had hippocampal atrophy, and healthy elderly controls (n = 43). The Visual Association Test-Extended served as a measure of episodic memory. Multiple-choice cued recognition was compared with paired associate recall and free recall within groups. Results showed that patients recognized learned material much better compared to when they had to recall material, resulting in large effect sizes (Cohen's d) ranging from 1.3 to 3.5. We conclude that episodic recognition memory based on incidental learning of visual associations is largely preserved when compared to recall in a-MCI and mild AD. This suggests that the episodic memory impairment in AD may be characterized as a retrieval impairment rather than a consolidation impairment, indicating that preserved recognition compared to recall may be compatible with AD being the correct diagnosis. Measuring the episodic memory impairment in AD may benefit from using tests that capture different aspects of memory processes such as incidental learning of visual associations.

Client experiences with holistic neuropsychological rehabilitation: "It is an ongoing process".

The effectiveness of holistic neuropsychological rehabilitation for people with acquired brain injury has previously been demonstrated by means of standardized and routinely administered outcome measures. However, the most important outcomes from the perspective of former clients are largely unknown. This study explored the experience of participating in a holistic neuropsychological rehabilitation programme by conducting three focus groups with twelve former clients who had sustained a brain injury. Data were transcribed verbatim and analysed using thematic analysis. "It is an ongoing process" emerged as the overarching theme for the experience of recovery from brain injury. Four subthemes, or phases, were identified. Participants went through (1) a phase of confrontation, after which they (2) trained their skills and strategies, and (3) experimented with these in daily life. In the end, clients reached a phase of (4) coming to terms with their injury. Participants described increased levels of self-esteem, sense of competence, and adaptation as the most important outcomes of the programme, as these factors helped them regain a sense of identity. The results indicate that including these factors in outcome evaluations of complex interventions after brain injury may be important as they appear essential for capturing the client's perspective on change.

Impaired self-awareness and denial of disability in a community sample of people with traumatic brain injury.

PURPOSE: To examine the nature and severity of impaired self-awareness (ISA) and denial of disability (DD) in a community-dwelling traumatic brain injury (TBI) population. Additionally, to investigate reliability, internal consistency, and feasibility of the Clinician's Rating Scale for evaluating Impaired Self-Awareness and Denial of Disability after brain injury (CRS-ISA-DD). MATERIALS AND METHODS: ISA and DD were studied using the CRS-ISA-DD in a cross-sectional study with 78 TBI patients (3.1 years post-injury). RESULTS: 42% of individuals approached consented to participate in this study. Most participants showed one or more symptoms of ISA and DD, but severity scores were in the lower range (ISA: 13.2 ± 16.2; DD: 9.4 ± 10.7). The CRS-ISA-DD takes <10 min to complete, has excellent inter-rater reliability (ISA: ICC(2,1) = 0.928; DD: ICC(2,1) = 0.835), and acceptable-good internal consistency (ISA: α = 0.819; DD: α = 0.645). ISA severity correlated with neuropsychological test scores (rs = -0.30 to -0.47) and injury severity. DD severity correlated with anxiety (rs = -0.22) but not with avoidance coping or defense mechanisms. CONCLUSIONS: Low levels of ISA and DD occurred in this sample of TBI patients. The CRS-ISA-DD is a reliable and feasible instrument. We recommend using it as a diagnostic tool to differentiate between ISA and DD once self-awareness problems have been identified.IMPLICATIONS FOR REHABILITATIONUnawareness of deficits can persist into the chronic stage when rehabilitation treatment has ended.The two main factors of unawareness, impaired self-awareness and denial of disability, are related to different neurological and psychological mechanisms.The Clinician's Rating Scale for evaluating Impaired Self-Awareness and Denial of Disability after brain injury (CRS-ISA-DD) can be used to distinguish the two main factors of unawareness.

Performance Validity and Outcome of Cognitive Behavior Therapy in Patients with Chronic Fatigue Syndrome.

OBJECTIVE: There is limited research examining the impact of the validity of cognitive test performance on treatment outcome. All known studies to date have operationalized performance validity dichotomously, leading to the loss of predictive information. Using the range of scores on a performance validity test (PVT), we hypothesized that lower performance at baseline was related to a worse treatment outcome following cognitive behavioral therapy (CBT) in patients with Chronic Fatigue Syndrome (CFS) and to lower adherence to treatment. METHOD: Archival data of 1081 outpatients treated with CBT for CFS were used in this study. At baseline, all patients were assessed with a PVT, the Amsterdam Short-Term Memory test (ASTM). Questionnaires assessing fatigue, physical disabilities, psychological distress, and level of functional impairment were administered before and after CBT. RESULTS: Our main hypothesis was not confirmed: the total ASTM score was not significantly associated with outcomes at follow-up. However, patients with a missing follow-up assessment had a lower ASTM performance at baseline, reported higher levels of physical limitations, and completed fewer therapy sessions. CONCLUSIONS: CFS patients who scored low on the ASTM during baseline assessment are more likely to complete fewer therapy sessions and not to complete follow-up assessment, indicative of limited adherence to treatment. However, if these patients were retained in the intervention, their response to CBT for CFS was comparable with subjects who score high on the ASTM. This finding calls for more research to better understand the impact of performance validity on engagement with treatment and outcomes.