Assessment of impaired self-awareness after moderate-to-severe traumatic brain injury: a comparison of assessment tools.

OBJECTIVE: To compare different assessment methods of impaired self-awareness (ISA). METHODS: We included 37 patients with moderate-to-severe traumatic brain injury (TBI) at a subacute/chronic stage, and 33 healthy controls. ISA was assessed with three methods: discrepancy scores (comparison between patient and proxy ratings) on three scales (Patient Competency Rating Scale (PCRS), Awareness Questionnaire (AQ) and Dysexecutive Questionnaire (DEX)); clinician rating with the Self-Awareness of Deficits Interview (SADI); and the difference between prediction or estimation of performance and actual performance on two cognitive tasks. RESULTS: Clinician-patient discrepancy scores appeared more sensitive than relative-patient discrepancy. The AQ was the most sensitive. The discrepancy scores were strongly correlated one with each other. Correlations with the SADI were weaker. Patients did not overestimate their performance on cognitive tasks, and the prediction did not significantly correlate with other measures of ISA. DISCUSSION/CONCLUSION: Results support the multidimensional nature of ISA: discrepancy scores assess meta-cognitive knowledge (understanding that a function/skill is affected), while the SADI takes into account anticipatory awareness (ability to set realistic goals) and estimation of performance assesses anticipatory and situational awareness. Assessment of these different domains may provide a comprehensive overview of an individual's self-awareness.

Self-defining memories after severe traumatic brain injury: A preliminary study.

Autobiographical memory plays a major role in the (re)construction of sense of identity, a recurrent issue after a traumatic brain injury (TBI). Although the recall of specific autobiographical events is frequently impaired in patients with TBI, little is known about how these changes affect their sense of self and identity. Thus, we examined self-defining memories (SDMs), that is, the most significant personal memories supporting one's sense of identity, in 16 patients with severe TBI and in matched controls. To this end, participants recalled three SDMs and rated their emotions in response to memory retrieval. In addition, characteristics of SDMs such as specificity, meaning-making, self-connections that reflect identity stability or identity change, content (theme, presence of tension, and redemption sequences) were analysed by independent raters. The main results showed that patients' SDMs were less specific and contained fewer redemption sequences than did those of controls but did not significantly differ in thematic content, presence of tension, meaning-making, self-connections that reflect identity stability or identity change and affective responses to memory retrieval. Furthermore, among the patients' memories that refer to the TBI-related event itself, only one contained an explicit meaning. Despite the lack of specificity in memories, patients with severe TBI were able to extract meaning from personal memories although they could struggle with integrating the TBI-related event into their sense of identity. These characteristics of SDMs may contribute to disturbances in sense of self and continuity in patients with severe TBI, as well as difficulties in personal or social adjustment. These results also open up relevant prospects for psychological interventions in identity-related issues in patients with TBI.

Self-appraisals and episodic memory: Different psychological factors related to patient versus informant reports of apathy in severe traumatic brain injury.

INTRODUCTION: Apathy is a core feature in patients with traumatic brain injury (TBI). The psychological processes underlying apathy are still unclear, and the few studies conducted on this subject have essentially focused on cognitive processes and informant reports of apathetic manifestations. The aims of the present study were to examine self-reports versus informant reports of diminished initiative/interest, as well as their relationship with different cognitive factors (attention/executive mechanisms, episodic memory, and multitasking) and personal identity factors (self-esteem and self-efficacy beliefs). METHOD: To this end, 74 participants (38 patients with severe TBI matched with 36 control participants) were given three questionnaires to assess self-esteem, general self-efficacy beliefs, and anxio-depressive symptoms and five tasks to assess cognitive processes, including real-life multitasking. In addition, a questionnaire that assessed self-awareness of functional competencies and a questionnaire that assessed lack of initiative/interest were administered to each participant and their relatives. RESULTS: The main results showed that patients demonstrated an awareness of their lack of initiative/interest and that self-reported lack of initiative/interest was best predicted by low general self-efficacy beliefs and self-esteem, whereas informant-reported lack of initiative/interest was predicted by episodic memory difficulties. CONCLUSIONS: These results shed new light on the psychological processes related to apathetic manifestations, as well as the differing perspectives and lived experiences of patients and external observers in the TBI population, which opens interesting prospects for psychological interventions.

Does multitasking mediate the relationships between episodic memory, attention, executive functions and apathetic manifestations in traumatic brain injury?

Apathy is frequently described in patients with traumatic brain injury (TBI); its negative consequences particularly affect functional independence. Among apathetic manifestations, lack of initiative and lack of interest have mainly been associated with cognitive impairments. However, few studies have been conducted to precisely identify the underlying cognitive processes. Our aims were (1) to determine the best predictor of apathy from among several cognitive processes, including episodic memory and attention/executive mechanisms and multitasking, and (2) to examine to what extent multitasking could mediate the relationships between specific cognitive processes and lack of initiative/interest. Seventy participants (34 patients with TBI matched with 36 control participants) were given a questionnaire to assess anxio-depressive symptoms, four tasks to assess specific cognitive processes, and one task to assess real-life multitasking. Participants' relatives completed an apathy questionnaire. Multitasking, as assessed by the number of goals not achieved, was the only significant predictor of apathetic manifestations. In addition, the mediation analyses revealed that multitasking performance mediated the relationships between verbal episodic memory and lack of initiative/interest, whereas executive and attentional functions were only indirectly related to lack of initiative/interest due to their significant impacts on multitasking. These results shed new light on the aetiology of apathetic manifestations in patients with TBI, indicating how specific cognitive deficits are expressed in real-life multitasking, and consequently, how they may lead to the development and/or maintenance of apathetic manifestations.

Longitudinal Course and Predictors of Apathetic Symptoms after Severe Traumatic Brain Injury.

OBJECTIVES: Apathy is one of the most common behavioral symptoms encountered after traumatic brain injury (TBI). However, very little is known about the longitudinal course and predictors of apathetic manifestations. The aims of the present study were to examine how apathy changes and the predictive value of cognitive factors (memory, attention/executive mechanisms, and multitasking) and personal identity factors (self-esteem and self-efficacy beliefs) for apathy over a period of 10 months. METHOD: To this end, 68 participants (32 patients with severe TBI matched with 36 control participants) living in the community were enrolled. At Time 1, participants were given three questionnaires to assess self-esteem, self-efficacy beliefs, anxiety and depression symptoms, and five tasks to assess cognitive processes. Simultaneously, a close relative of each participant completed a questionnaire that assessed lack of initiative/initiative. At Time 2, all questionnaires were re-administered to each patient and their relatives. RESULTS: Patients displayed a significant lack of initiative/interest at all post-injury assessments. At the individual level, the results revealed that a majority of patients had no change in their apathetic symptoms over the 10-month follow-up, whereas in the others, apathetic symptoms mostly increased. Furthermore, impaired memory was the only mechanism that significantly predicted later apathetic manifestations. Complementary profile analyses indicated that patients with worsening symptoms over the follow-up period showed higher inaccurate memory at Time 1 than patients with stable symptoms. CONCLUSIONS: These results provide valuable insight into the longitudinal evolution and predictors of apathy after TBI, which opens interesting prospects for psychological interventions.

Apathetic symptom presentations in patients with severe traumatic brain injury: Assessment, heterogeneity and relationships with psychosocial functioning and caregivers' burden.

OBJECTIVES: Apathy is frequently described following traumatic brain injury (TBI) and defined on the basis of three dimensions (emotional blunting, lack of initiative, lack of interest), which are commonly assessed by the Apathy Inventory (AI). The aims were (1) to explore the psychometric properties of this scale in the TBI population and the relationships between the dimensions; and (2) to determine whether sub-groups of patients differing with respect to the three AI dimensions could be identified and to examine their differences on psychosocial functioning and caregivers' burden. PARTICIPANTS AND MEASURES: Close relatives of 68 patients with severe TBI were given the AI and two questionnaires to assess their subjective burden and patients' changes in psychosocial functioning. RESULTS: The scores distribution and the sensitivity of each sub-scale showed that the AI can be used as a screening tool in the TBI population. Four clusters were identified: one group with high scores on each dimension, one group with low scores on each dimension, one group with high emotional blunting alone and another with elevated lack of initiative/interest. The high apathetic group and the lack of initiative/interest group were associated with poorer psychosocial functioning and the high apathetic group was related to subjective burden. CONCLUSIONS: These results shed new light on the concept of apathy in patients with TBI and underline the necessity to take into account the various profiles of symptoms of apathy.

A multidimensional approach to apathy after traumatic brain injury.

Apathy is commonly described following traumatic brain injury (TBI) and is associated with serious consequences, notably for patients' participation in rehabilitation, family life and later social reintegration. There is strong evidence in the literature of the multidimensional nature of apathy (behavioural, cognitive and emotional), but the processes underlying each dimension are still unclear. The purpose of this article is first, to provide a critical review of the current definitions and instruments used to measure apathy in neurological and psychiatric disorders, and second, to review the prevalence, characteristics, neuroanatomical correlates, relationships with other neurobehavioural disorders and mechanisms of apathy in the TBI population. In this context, we propose a new multidimensional framework that takes into account the various mechanisms at play in the facets of apathy, including not only cognitive factors, especially executive, but also affective factors (e.g., negative mood), motivational variables (e.g., anticipatory pleasure) and aspects related to personal identity (e.g., self-esteem). Future investigations that consider these various factors will help improve the understanding of apathy. This theoretical framework opens up relevant prospects for better clinical assessment and rehabilitation of these frequently described motivational disorders in patients with brain injury.

Transient improvement of poststroke apathy with zolpidem: a single-case, placebo-controlled double-blind study.

We report the case of a 44-year-old patient with severe and disabling apathy nearly 2 years after a right hemisphere haemorrhagic stroke. The effect of a single dose of zolpidem was tested over a 2-week period, in alternation with either no treatment or a placebo in a double-blind randomised trial. Zolpidem was associated with a dramatic improvement in apathy, as assessed with the Apathy Inventory and the Behavioral Dysexecutive Syndrome Inventory. No adverse effect occurred during the trial.