Using the St Andrew's - Swansea Neurobehavioural Outcome Scale (SASNOS) to determine prevalence and predictors of neurobehavioural disability amongst survivors with traumatic brain injury in the community.

Studies using the St Andrew's - Swansea Neurobehavioural Outcome Scale (SASNOS) confirm neurobehavioural disability (NBD) is highly prevalent in inpatient Neurobehavioural Rehabilitation and Stroke samples. However, a recent study amongst a Danish community sample of acquired brain injury survivors found a relative paucity of NBD symptoms; and when symptoms were present, they tended to be of mild severity. The current observational study employed the SASNOS to explore prevalence of NBD in survivors with traumatic brain injury (TBI) living in the community, the extent of survivors' self-awareness of NBD symptoms, and constructed prediction models of NBD. A de-identified data set was compiled, comprising data for 97 TBI survivors (74.2% men, mean time since injury 2.8 years). In addition to SASNOS self- and proxy-ratings, various demographic, clinical and injury-related characteristics were captured. NBD was found to be highly characteristic, although severity varied depending on subtype. Statistical comparison of self- and proxy-ratings did not support reduced self awareness regarding NBD, whereas treating the problem as one of inter-rater reliability suggested this was an issue. Executive impairment, depressed mood and sex were especially prognostic of NBD. Reasons accounting for differences in NBD between the community samples are discussed and recommendations for future research made.

Lacking Pace but Not Precision: Age-Related Information Processing Changes in Response to a Dynamic Attentional Control Task.

Age-related decline in information processing can have a substantial impact on activities such as driving. However, the assessment of these changes is often carried out using cognitive tasks that do not adequately represent the dynamic process of updating environmental stimuli. Equally, traditional tests are often static in their approach to task complexity, and do not assess difficulty within the bounds of an individual's capability. To address these limitations, we used a more ecologically valid measure, the Swansea Test of Attentional Control (STAC), in which a threshold for information processing speed is established at a given level of accuracy. We aimed to delineate how older, compared to younger, adults varied in their performance of the task, while also assessing relationships between the task outcome and gender, general cognition (MoCA), perceived memory function (MFQ), cognitive reserve (NART), and aspects of mood (PHQ-9, GAD-7). The results indicate that older adults were significantly slower than younger adults but no less precise, irrespective of gender. Age was negatively correlated with the speed of task performance. Our measure of general cognition was positively correlated with the task speed threshold but not with age per se. Perceived memory function, cognitive reserve, and mood were not related to task performance. The findings indicate that while attentional control is less efficient in older adulthood, age alone is not a defining factor in relation to accuracy. In a real-life context, general cognitive function, in conjunction with dynamic measures such as STAC, may represent a far more effective strategy for assessing the complex executive functions underlying driving ability.

The Psychosocial Impact of Neurobehavioral Disability.

Neurobehavioral disability (NBD) comprises elements of executive and attentional dysfunction, poor insight, problems of awareness and social judgement, labile mood, altered emotional expression, and poor impulse control, any or all of which can have a serious impact upon a person's decision-making and capacity for social independence. The aim of this narrative review is to explore some of the more intrusive forms of NBD that act as obstacles to psychosocial outcome to act as a frame of reference for developing effective rehabilitation interventions. Special consideration is given to the psychosocial impact of three core forms of NBD: a failure of social cognition, aggressive behavior, and problems of drive/motivation. Consideration is also given to the developmental implications of sustaining a brain injury in childhood or adolescence, including its impact on maturational and social development and subsequent effects on long-term psychosocial behavior.

Measuring Neurobehavioral Disabilities Among Severe Brain Injury Survivors: Reports of Survivors and Proxies in the Chronic Phase.

Background: Neurobehavioral disability (NBD) has a major influence on long-term psychosocial outcome following acquired brain injury, as it affects not only the survivor of the brain injury, but the whole family. Objectives: To investigate (1) the frequency of NBD among survivors of severe brain injury measured by the Danish version of the St Andrew's-Swansea Neurobehavioural Outcome Scale (SASNOS) rated by patients and proxies, (2) factors associated with NBD, and (3) concordance between reports of NBD completed by patients and proxies. Methods: SASNOS was administered at an outpatient unit as a part of a follow-up assessment after discharge from intensive neurorehabilitation. SASNOS consists of five factors describing the following domains: Interpersonal Behavior, Cognition, Aggression, Inhibition and Communication, and both the patient and a proxy were asked to complete the questionnaire. Data collection was conducted over a period of 2 years, and 32 patients and 31 proxies completed the questionnaire. Mean time since injury was 19.4 months (10.0 SD). Most patients were male (68.8%), and most proxies were female (58.1%). Most of the patients had suffered a traumatic brain injury (68.8%). Results: A fourth of this patient group reported themselves below the normal range on the major domains of Interpersonal Behavior and Cognition. Significant associations between proxies' reports and time since injury, cohabitant status, and the patient's score on the Extended Glasgow Outcome Scale were found. Furthermore, significant differences were found between patient and proxy ratings. Proxies rated patients as having fewer problems on the Interpersonal Behavior domain, and more problems in relation to Cognition. Cognition was the only domain, where patients rated themselves higher indicating fewer problems, compared with their proxies. On both the Aggression and Communication domains, proxies rated patients higher indicating fewer problems than the patients themselves. Conclusion: Danish brain injury survivors experienced NBD as measured by SASNOS. Differences were found between patient and proxy ratings in relation to Cognition and Interpersonal Behavior. The NBDs identified can affect the survivor's ability to reintegrate and participate in activities of daily living, emphasizing how a systematic assessment is required.

Alexithymia is associated with aggressive tendencies following traumatic brain injury.

OBJECTIVE: Aggressive behavior is a frequent legacy of traumatic brain injury (TBI). This study explores the question of how alexithymia, which is associated with deficits in social cognition and empathy, may predispose individuals to aggressive tendencies after head trauma. METHOD: A total of 47 individuals referred for routine neuropsychological assessment and advice on the management of long-term neuropsychological sequelae after TBI and 72 demographically matched controls completed the 20-Item Toronto Alexithymia Scale (TAS-20) and Buss Perry Aggression Questionnaire (BPAQ; self and proxy). RESULTS: The incidence of alexithymia and aggressive tendencies was significantly higher in the group with TBI. After controlling for covariates, alexithymia explained an additional 29% of variance in BPAQ total scores in the group with TBI and 11.1% in the control group. Of the three TAS-20 sub-scales, 'difficulty describing feelings' emerged as a consistent unique predictor of aggression scores. CONCLUSIONS: Higher levels of alexithymia are associated with greater aggressive tendencies post-TBI. The findings offer important theoretical and empirical insights into the prediction of aggression after TBI.

Apathy following traumatic brain injury: A review.

Apathy is a common problem after traumatic brain injury (TBI) and can have a major impact on cognitive function, psychosocial outcome and engagement in rehabilitation. For scientists and clinicians it remains one of the least understood aspects of brain-behaviour relationships encompassing disturbances of cognition, motivation, emotion and action, and is variously an indication of organic brain disease or psychiatric disorder. Apathy can be both sign and symptom and has been proposed as a diagnosis in its own right as well as a secondary feature of other conditions. This review considers previous approaches to apathy in terms of relevant psychological constructs and those neural counterparts most likely to be implicated after TBI. Neurobehavioural disorders of apathy are characterised chiefly by dysfunction of executive control of goal-oriented behaviour or the neural substrates of reward-based and emotional learning. We argue that it is possible to distinguish a primary disorder of apathy as an organic neurobehavioural state from secondary presentations due to an impoverished environment or psychological disturbance which has implications for treatment.

Perceived personality change after traumatic brain injury II: comparing participant and informant perspectives.

OBJECTIVE: The objective of this paper was to correlate informant personality change (PC) judgements following moderate-severe traumatic brain injury with quantitative neurobehavioural measures and to contrast the neurobehavioural correlates of informant and participant judgements of PC. PARTICIPANTS: Informant-participant pairs were recruited from a medico-legal clinic passing effort tests (N = 31) and a National Health Service clinic (N = 40). MEASURES: Participants were assessed on Wechsler tests of general ability, tests of executive functioning (Zoo Map and Fluency) and emotional distress (Beck Depression Inventory-FastScreen, Hospital Anxiety and Depression Scale and State-Trait Anger Expression Inventory-II). Informants' expressed emotion towards participants was assessed with the family questionnaire. Both completed the DEX, the Frontal and Social Behavior Questionnaire and PC ratings. RESULTS: The correlates of participant and informant ratings of participant PC partially overlapped. For example, participant self-reported PC was associated with self-reported dysexecutive symptoms and emotional distress. In contrast, informant report of participant PC was associated with lower perceived emotional recognition and empathy, informant report of dysexecutive symptoms and high informant expressed emotion. CONCLUSIONS: It is argued that whilst researchers aim to exhaustively quantify specific neurobehavioural changes and their clusters, partially overlapping subsets of these changes evoke the PC judgements of participants and informants. The clinical implications of this are briefly considered.

The development of a measure of social cognition following acquired brain injury.

Deficits in social cognition following acquired brain injury (ABI) have been found to be both prevalent and disabling. Despite this, relatively little attention has been given to identifying the characteristics of such deficits in a systematic way. We describe the development of self and informant versions of a new questionnaire designed to measure the changes in social cognition that may occur following ABI, the Brain Injury Rehabilitation Trust (BIRT) Social Cognition Questionnaire (BSCQ). Seventy-two participants (Mean age = 36 years, SD = 12), with different forms of ABI (76% traumatic brain injury, 8% cerebrovascular accident, 15% other) and who were on average 20 months post-injury (SD = 16), took part in the study. The measure demonstrates excellent psychometric properties, including high test-retest (.94) and split-half (.92) reliability, high internal consistency (Cronbach's alpha = .92), and good concurrent validity. The questionnaire measures characteristics that are distinguishable from measures of cognitive ability. There was moderate overlap between self-report and informant versions of the questionnaire (r = .50), but the informant version had the strongest predictive value of outcome, measured with the Mayo-Portland Adaptability Inventory III, one year later. The potential uses of the measure in relation to theory and practice are discussed. The results suggest that the BSCQ is a useful screening tool for those with ABI.

When normal scores don't equate to independence: Recalibrating ratings of neurobehavioural disability from the 'St Andrew's - Swansea Neurobehavioural Outcome Scale' to reflect context-dependent support.

PRIMARY OBJECTIVE: Context is critical to the interpretation of measurement instruments that capture acquired brain injury (ABI) outcomes. Ratings reflect behaviours and abilities observed in a particular setting; it cannot be assumed that results are generalizable beyond these. This study explored the utility of a method to convey the impact of context-dependent support given on ratings of neurobehavioural disability (NBD) using the St Andrews-Swansea Neurobehavioural Outcome Scale (SASNOS). METHODS AND PROCEDURES: A supplementary SASNOS scoring system was developed using a mixed-methods approach. Dependency ratings were used to recalibrate standardised SASNOS scores to reflect support received. To aid interpretation, an expert panel reviewed SASNOS ratings for 50 ABI cases participating in residential neurobehavioural rehabilitation programmes. An end-user survey was undertaken to explore some of its psychometric properties. Finally, a representative case study was employed to illustrate its clinical utility. MAIN OUTCOMES: The expert panel identified three dependency profiles: (1) Normal/Independent; (2) Normal/Dependent; and (3) Abnormal/Review. Survey results supported face and construct validity of the supplementary system; the case study demonstrated benefits of discriminating between dependency profiles. CONCLUSIONS: The supplementary scoring system enables SASNOS to convey the impact of support received on ratings of NBD, solidifying its usefulness for measuring outcomes in rehabilitation.

Neurobehavioral Abnormalities Associated with Executive Dysfunction after Traumatic Brain Injury.

Objective: This article will address how anomalies of executive function after traumatic brain injury (TBI) can translate into altered social behavior that has an impact on a person's capacity to live safely and independently in the community. Method: Review of literature on executive and neurobehavioral function linked to cognitive ageing in neurologically healthy populations and late neurocognitive effects of serious TBI. Information was collated from internet searches involving MEDLINE, PubMed, PyscINFO and Google Scholar as well as the authors' own catalogs. Conclusions: The conventional distinction between cognitive and emotional-behavioral sequelae of TBI is shown to be superficial in the light of increasing evidence that executive skills are critical for integrating and appraising environmental events in terms of cognitive, emotional and social significance. This is undertaken through multiple fronto-subcortical pathways within which it is possible to identify a predominantly dorsolateral network that subserves executive control of attention and cognition (so-called cold executive processes) and orbito-frontal/ventro-medial pathways that underpin the hot executive skills that drive much of behavior in daily life. TBI frequently involves disruption to both sets of executive functions but research is increasingly demonstrating the role of hot executive deficits underpinning a wide range of neurobehavioral disorders that compromise relationships, functional independence and mental capacity in daily life.

Accelerated cognitive aging following severe traumatic brain injury: A review.

OBJECTIVE: The primary objective of this review was to examine relevant clinical and experimental literatures for information on the long-term cognitive impact of serious traumatic brain injury (TBI) with regard to the process of cognitive aging. METHOD: Online journal databases were queried for studies pertaining to cognitive aging in neurologically healthy populations, as well as the late cognitive effects of serious TBI. Additional studies were identified through searching bibliographies of related publications and using Google search engine. RESULTS AND CONCLUSIONS: Problems of cognition exhibited by young adults after TBI resemble many cognitive weaknesses of attention deficit and poor working memory that are usually seen in an elderly population who have no neurological history. The current state of the literature provides support for the argument that TBI can result in diminished cognitive reserve which may accelerate the normal process of cognitive decline, leading to premature aging, potentially increasing the risk of dementia.

Measuring Change in Symptoms of Neurobehavioural Disability: Responsiveness of the St Andrew's-Swansea Neurobehavioural Outcome Scale.

OBJECTIVE: Neurobehavioural disability (NBD) after acquired brain injury (ABI) is often associated with poor outcome. The "St Andrew's-Swansea Neurobehavioural Outcome Scale" (SASNOS) was developed to measure NBD in a range of applications. Two of the "holy trinity" of psychometric properties, reliability and validity, have been comprehensively mapped, but the extent to which SASNOS meets the third, responsiveness, has not been investigated. Demonstrating responsiveness is essential in instruments employed in repeated measurement scenarios to confirm their ability to discriminate real change from error. However, there is no single agreed method for determining responsiveness. For some instruments, this property remains unexplored. A difference in scores attaining statistical significance for aggregate data is frequently cited as support for this construct, but this approach remains heavily criticized. This study explores responsiveness of SASNOS. METHOD: Consecutive SASNOS assessments completed over varying times for 145 individuals participating in neurobehavioural rehabilitation, drawn from multiple services, were compiled into a retrospective sample of convenience. Multiple methods were employed to confirm internal responsiveness, including those identifying statistically significant change, minimally detectable change and minimally important change. RESULTS: All methods confirmed responsiveness as a psychometric property of SASNOS; the extent depended on method used and NBD domain investigated. A number of indicators are presented, which equip clinicians and researchers with options to interpret results from repeated assessments, including the individual level in the context of rehabilitation. CONCLUSIONS: SASNOS reliably measures change over time in NBD symptoms, further confirming its suitability as an instrument for investigating multidimensional outcomes of ABI.

Unsupervised categorization with individuals diagnosed as having moderate traumatic brain injury: Over-selective responding.

PRIMARY OBJECTIVE: This study explored over-selectivity (executive dysfunction) using a standard unsupervised categorization task. Over-selectivity has been demonstrated using supervised categorization procedures (where training is given); however, little has been done in the way of unsupervised categorization (without training). METHODS AND PROCEDURE: A standard unsupervised categorization task was used to assess levels of over-selectivity in a traumatic brain injury (TBI) population. Individuals with TBI were selected from the Tertiary Traumatic Brain Injury Clinic at Swansea University and were asked to categorize two-dimensional items (pictures on cards), into groups that they felt were most intuitive, and without any learning (feedback from experimenter). This was compared against categories made by a control group for the same task. OUTCOMES AND RESULTS: The findings of this study demonstrate that individuals with TBI had deficits for both easy and difficult categorization sets, as indicated by a larger amount of one-dimensional sorting compared to control participants. Deficits were significantly greater for the easy condition. CONCLUSIONS: The implications of these findings are discussed in the context of over-selectivity, and the processes that underlie this deficit. Also, the implications for using this procedure as a screening measure for over-selectivity in TBI are discussed.

Exploration of correlates of self-reported personality change after moderate-severe traumatic brain injury.

OBJECTIVE: Individuals with traumatic brain injury (TBI) often express concern that their personality has changed. Factors generating that conclusion are rarely explored quantitatively. Accordingly, this study examines neurobehavioural correlates of self-reported personality change. METHODS: Seventy-one participants and informants were interviewed M = 57.9 (SD = 46.9) months after a moderate-severe TBI. The degree of self-reported personality change was correlated with scores on measures of general cognitive functioning, executive functioning, olfaction, social-emotional behaviour, emotional distress and the Expressed Emotion close informants directed towards them. RESULTS: As expected, self-reported personality change correlated with dysexecutive symptoms and depression. Although anosmia (a putative index of ventral frontal damage) correlated with reduced self-reported emotional recognition and empathy, against prediction, the latter measures did not correlate with self-reported personality change. Neither were the predicted positive correlations found between high Expressed Emotion (criticism and emotional over-involvement) and self-reported personality change. DISCUSSION: These findings are discussed in the context of previous work. A need to replicate and extend the present findings is suggested. A strategy to further clarify the relationships perceived personality change have with (a) self-reported change in specific behaviours and (b) identity change is advocated. Implications for intervention are suggested.

The impact of alexithymia on burnout amongst relatives of people who suffer from traumatic brain injury.

BACKGROUND: Although previous research has provided some indication of the association of alexithymia and burnout, this is the first study exploring the association of these two variables in a sample of relatives of individuals who have sustained traumatic brain injury (TBI). OBJECTIVE: To explore the degree to which relatives experience burnout and the extent to which alexithymia acts as a pre-disposing factor, controlling for depression and coping strategies. METHOD: Toronto Alexithymia Scale-20, Maslach Burnout Inventory-Human Services, Estonian COPE Dispositional Inventory and Beck Depression Inventory-II were completed by 60 relatives of patients with TBI drawn from a tertiary head injury clinic population. RESULTS: Levels of emotional exhaustion, reduced personal accomplishment and depression were significantly higher in the sub-group of relatives with alexithymia than in the sub-group of relatives without alexithymia. Difficulty describing feelings and externally oriented thinking style were significant predictors of emotional exhaustion, while difficulty identifying feelings and difficulty describing feelings were important predictors of depersonalization. CONCLUSIONS: Relatives who present with alexithymia need to be identified at an early stage to minimize risks of burnout leading to adverse effects on patient-caregiver relationships.

Anxiety sensitivity and alexithymia as mediators of postconcussion syndrome following mild traumatic brain injury.

OBJECTIVE: To examine the influence of anxiety sensitivity (AS) and alexithymia as potential mediators for the development of psychological distress and postconcussion syndrome after mild traumatic brain injury (mTBI). PARTICIPANTS: Sixty-one patients with mTBI assessed at a mean of 2.38 weeks after injury and demographically matched healthy controls (n = 61). MEASURES: Twenty-item Toronto Alexithymia Scale, Anxiety Sensitivity Index, State-Trait Anxiety Inventory, and Rivermead Post Concussion Questionnaire. RESULTS: The mTBI group reported significantly higher levels of AS, alexithymia, psychological distress, and postconcussion (PC) symptom scores than controls. High AS and alexithymia in the mTBI group were associated with a greater number of PC symptoms and higher levels of psychological distress than patients scoring low on these measures and controls. In the mTBI group, a combination of AS and low mood explained 52.6% of the variance in PC symptom reporting. A combination of trait-anxiety, alexithymia, and PC symptoms explained 77.2% of the variance in levels of mood. CONCLUSION: A combination of low mood and high AS may act as a psychological diathesis for the development of persisting PC symptoms. Early identification could provide a focus for early intervention to prevent the development of postconcussion syndrome after mTBI.

Stimulus over-selectivity in temporal brain injury: mindfulness as a potential intervention.

OBJECTIVE: The current study aimed to investigate the impact of brief mindfulness training on the performance of a sample of patients with TBI in an over-selectivity task. PARTICIPANTS: Twenty-four patients who had suffered TBI and reported problems with focused or sustained attention. METHOD: The study was a between-subjects design (mindfulness intervention vs control) with difference between number of most and least chosen stimulus selections on an over-selectivity task as the dependent measure. RESULTS: The results of this study indicated that stimulus over-selectivity was present in a group of patients with TBI. However, the level of emergent over-selectivity was significantly reduced by a mindfulness induction when compared to a no- intervention control group. CONCLUSIONS: The findings are discussed in terms of the efficacy of mindfulness training in reducing TBI-related cognitive deficits.

The costs of traumatic brain injury: a literature review.

OBJECTIVE: The purpose of this study was to review the literature relating to the psychosocial costs associated with traumatic brain injury (TBI). METHODS: Nine online journal databases, including MEDLINE, CINAHL, PsychINFO, and PUBMED, were queried for studies between July 2010 and May 2012 pertaining to the economic burden of head injuries. Additional studies were identified through searching bibliographies of related publications and using Google internet search engine. RESULTS: One hundred and eight potentially relevant abstracts were identified from the journal databases. Ten papers were chosen for discussion in this review. All but two of the chosen papers were US studies. The studies included a cost-benefit analysis of the implementation of treatment guidelines from the US brain trauma foundation and a cost-effectiveness analysis of post-acute traumatic brain injury rehabilitation. CONCLUSION: Very little research has been published on the economic burden that mild and moderate traumatic brain injury patients pose to their families, careers, and society as a whole. Further research is needed to estimate the economic burden of these patients on healthcare providers and social services and how this can impact current health policies and practices.

Recognising and assessing neurobehavioural disability after traumatic brain injury.

BACKGROUND: Neurobehavioural disability often leads to serious social handicap. Many individuals never recover full social independence and will remain largely dependent upon family support, imposing a significant and potentially life-long psychological burden on those who care for injured relatives. Close relationships are at risk and many partnerships break down, increasing the risk of social isolation and subsequent psychological distress to the survivor. OBJECTIVES: The aim of this paper is to examine the nature of some cardinal features of neurobehavioural disability that contribute to poor psychosocial outcome; consider their organic origins, and problems associated with standardised methods of assessment. METHODS: A review of clinical literature addressing neurobehavioural disability after TBI. RESULTS: Many forms of neurobehavioural disability are subtle but have a pervasive impact on psychosocial outcome in general and relationships in particular. CONCLUSIONS: Caution is recommended when employing standardised tests to identify the complex and often subtle nature of neurobehavioural disorders. More work is needed to define the nature and impact of different forms of neurobehavioural disorders that comprise this complex form of disability.