Post-traumatic Confusional State: A Case Definition and Diagnostic Criteria.

In response to the need to better define the natural history of emerging consciousness after traumatic brain injury and to better describe the characteristics of the condition commonly labeled posttraumatic amnesia, a case definition and diagnostic criteria for the posttraumatic confusional state (PTCS) were developed. This project was completed by the Confusion Workgroup of the American Congress of Rehabilitation Medicine Brain Injury Interdisciplinary Special Interest group. The case definition was informed by an exhaustive literature review and expert opinion of workgroup members from multiple disciplines. The workgroup reviewed 2466 abstracts and extracted evidence from 44 articles. Consensus was reached through teleconferences, face-to-face meetings, and 3 rounds of modified Delphi voting. The case definition provides detailed description of PTCS (1) core neurobehavioral features, (2) associated neurobehavioral features, (3) functional implications, (4) exclusion criteria, (5) lower boundary, and (6) criteria for emergence. Core neurobehavioral features include disturbances of attention, orientation, and memory as well as excessive fluctuation. Associated neurobehavioral features include emotional and behavioral disturbances, sleep-wake cycle disturbance, delusions, perceptual disturbances, and confabulation. The lower boundary distinguishes PTCS from the minimally conscious state, while upper boundary is marked by significant improvement in the 4 core and 5 associated features. Key research goals are establishment of cutoffs on assessment instruments and determination of levels of behavioral function that distinguish persons in PTCS from those who have emerged to the period of continued recovery.

An exploration of diagnosis threat and group identification following concussion injury.

Cognitive performance can be impacted by many non-neurological factors, including preexisting expectations. The phenomenon of stereotype threat, or reduced cognitive performance due to preexisting beliefs, can apply to individuals following neurological injury (i.e., ''diagnosis threat''). We examined the effect of diagnosis threat on cognitive performance and symptom reporting following concussions while accounting for group identification (i.e., extent to which one's identity is tied to being concussed). We also examined gender stereotype threat (i.e., women and math ability) to understand how these two related threat effects compare. Participants with a history of concussion were randomly assigned to one of three instructional sets emphasizing concussion history or gender, or neutral instructions. Individuals without a history of concussion served as a comparison group. Results revealed an effect of diagnosis threat on cognitive performance after group identification was taken into account, but only in male participants. In contrast, an underlying gender stereotype threat was observed in females across conditions, which was counteracted in the gender stereotype condition (i.e., stereotype reactance effect) due to the type of threat cues used. Also, controls exhibited greater symptom reporting than individuals with a concussion. Our findings highlight the importance of considering non-neurological factors impacting cognitive performance.

Multidyad memory notebook intervention for very mild dementia: a pilot study.

This pilot study examines the efficacy of a group memory notebook intervention. Five individuals with very mild dementia and 4 spouses who served as coaches attended 14 group treatment sessions. Therapists use educational strategies and learning activities packets to teach memory notebook use. At posttreatment, coaches report fewer symptoms of depression, and participants with very mild dementia report greater confidence in ability to obtain support. Modified laboratory memory testing reveals that participants with dementia demonstrate improved posttreatment memory scores because of increased note-taking behavior and more frequent referencing of notes. Although more frequent everyday memory strategies use is reported at posttreatment, this does not translate into reports of fewer everyday memory failures or greater everyday independence for the participants with dementia. This study demonstrates that a multidyad group intervention can successfully be used to teach patients with very mild dementia to use a memory notebook, with beneficial effects for both members of the care dyad.

Prospective memory after moderate-to-severe traumatic brain injury: a multinomial modeling approach.

OBJECTIVE: Prospective memory (PM), which can be understood as the processes involved in realizing a delayed intention, is consistently found to be impaired after a traumatic brain injury (TBI). Although PM can be empirically dissociated from retrospective memory, it inherently involves both a prospective component (i.e., remembering that an action needs to be carried out) and retrospective components (i.e., remembering what action needs to be executed and when). This study utilized a multinomial processing tree model to disentangle the prospective (that) and retrospective recognition (when) components underlying PM after moderate-to-severe TBI. METHOD: Seventeen participants with moderate to severe TBI and 17 age- and education-matched control participants completed an event-based PM task that was embedded within an ongoing computer-based color-matching task. RESULTS: The multinomial processing tree modeling approach revealed a significant group difference in the prospective component, indicating that the control participants allocated greater preparatory attentional resources to the PM task compared to the TBI participants. Participants in the TBI group were also found to be significantly more impaired than controls in the when aspect of the retrospective component. CONCLUSIONS: These findings indicated that the TBI participants had greater difficulty allocating the necessary preparatory attentional resources to the PM task and greater difficulty discriminating between PM targets and nontargets during task execution, despite demonstrating intact posttest recall and/or recognition of the PM tasks and targets.

Longitudinal outcome of patients with disordered consciousness in the NIDRR TBI Model Systems Programs.

Few studies address the course of recovery from prolonged disorders of consciousness (DOC) after severe traumatic brain injury (TBI). This study examined acute and long-term outcomes of persons with DOC admitted to acute inpatient rehabilitation within the National Institute on Disability and Rehabilitation Research (NIDRR) TBI Model Systems Programs (TBIMS). Of 9028 persons enrolled from 1988 to 2009, 396 from 20 centers met study criteria. Participants were primarily male (73%), Caucasian (67%), injured in motor vehicle collision (66%), with a median age of 28, and emergency department Glasgow Coma Scale (GCS) score of 3. Participant status was evaluated at acute rehabilitation admission and discharge and at 1, 2, and 5 years post-injury. During inpatient rehabilitation, 268 of 396 (68%) regained consciousness and 91 (23%) emerged from post-traumatic amnesia (PTA). Participants demonstrated significant improvements on GCS (z=16.135, p≤0.001) and Functional Independence Measure (FIM) (z=15.584, p≤0.001) from rehabilitation admission (median GCS=9; FIM=18) to discharge (median GCS=14; FIM=43). Of 337 with at least one follow-up visit, 28 (8%) had died by 2.1 years (mean) after discharge. Among survivors, 66 (21%) improved to become capable of living without in-house supervision, and 63 demonstrated employment potential using the Disability Rating Scale (DRS). Participants with follow-up data at 1, 2, and 5 years post-injury (n=108) demonstrated significant improvement across all follow-up evaluations on the FIM Cognitive and Supervision Rating Scale (p<0.01). Significant improvements were observed on the DRS and FIM Motor at 1 and 2 years post-injury (p<0.01). Persons with DOC at the time of admission to inpatient rehabilitation showed functional improvement throughout early recovery and in years post-injury.

A pilot study examining effects of group-based Cognitive Strategy Training treatment on self-reported cognitive problems, psychiatric symptoms, functioning, and compensatory strategy use in OIF/OEF combat veterans with persistent mild cognitive disorder and history of traumatic brain injury.

We aimed to determine whether group-based Cognitive Strategy Training (CST) for combat veterans with mild cognitive disorder and a history of traumatic brain injury (TBI) has significant posttreatment effects on self-reported compensatory strategy usage, functioning, and psychiatric symptoms. Participants included 21 veterans returning from conflicts in Iraq or Afghanistan with a diagnosis of Cognitive Disorder, Not Otherwise Specified and a history of combat-related TBI. Participants attended 6- to 8-week structured CST groups designed to provide them training in and practice with a variety of compensatory cognitive strategies, including day planner usage. Of the participants, 16 completed pre- and posttreatment assessment measures. Following CST, participants reported significantly increased use of compensatory cognitive strategies and day planners; an increased perception that these strategies were useful to them; increased life satisfaction; and decreased depressive, memory, and cognitive symptom severity. Group-based CST is a promising intervention for veterans with mild cognitive disorder, and randomized controlled trials are required to further evaluate its efficacy.

The influence of antiviral therapy on psychiatric symptoms among patients with hepatitis C and schizophrenia.

BACKGROUND: Antiviral therapy for chronic infection with HCV is associated with significant neuropsychiatric side effects. Research indicates that patients with mental illness are less likely to receive antiviral therapy, despite limited data regarding the influence of antiviral therapy on psychiatric symptoms in patients with specific psychiatric disorders. The aim of this study was to determine whether antiviral therapy is associated with higher rates of psychiatric symptoms in patients with schizophrenia (SCHZ). METHODS: A regional Veterans Healthcare Administration database was used to identify veterans meeting criteria for this retrospective chart review. Patients confirmed to have SCHZ and to have received antiviral therapy for HCV between 1998 and 2006 (n=30) were compared with a control group of demographically matched (age, race and gender) patients with SCHZ who did not receive antiviral therapy (n=30). Clinicians blinded to antiviral therapy status used chart notes to evaluate whether patients exhibited prominent symptoms of SCHZ, depression or mania during a 6 month pre-treatment period, the treatment period and a 6 month post-treatment period (or during equivalent periods for the control group). RESULTS: Groups did not significantly differ in rates of symptoms of SCHZ, depression or mania during any study period. During the treatment period, groups did not significantly differ in rates of emergency room visits or inpatient hospitalizations. CONCLUSIONS: Our retrospective chart review suggests that patients with SCHZ experience similar rates of psychiatric symptoms on and off antiviral therapy. Despite limitations and constraints of the methods, our data suggest that SCHZ is not a contraindication to antiviral therapy for HCV.

The relationship between cerebral hemisphere volume and receptive language functioning in dyslexia and attention-deficit hyperactivity disorder (ADHD).

Because poor comprehension has been associated with small cerebral volume and there is a high comorbidity between developmental dyslexia, attention-deficit hyperactivity disorder (ADHD), and specific language impairment, the goal of this study was to determine whether cerebral volume is reduced in dyslexia and attention-deficit hyperactivity disorder in general, as some suggest, or whether the reduction in volume corresponds to poor receptive language functioning, regardless of the diagnosis. Participants included 46 children with and without dyslexia and attention-deficit hyperactivity disorder, aged 8 to 12 years. Our results indicated that cerebral volume was comparable between those with and without dyslexia and attention-deficit hyperactivity disorder overall. However, when groups were further divided into those with and without receptive language difficulties, children with poor receptive language had smaller volumes bilaterally as hypothesized. Nonetheless, the relationship between cerebral volume and receptive language was not linear; rather, our results suggest that small volume is associated with poor receptive language only in those with the smallest volumes in both dyslexia and attention-deficit hyperactivity disorder.

Long-term retention of skilled visual search following severe traumatic brain injury.

We examined the long-term retention of a learned automatic cognitive process in 17 severe TBI participants and 10 controls. Participants had initially received extensive consistent-mapping (CM) training (i.e., 3600 trials) in a semantic category visual search task (Schmitter-Edgecombe & Beglinger, 2001). Following CM training, TBI and control groups demonstrated dramatic performance improvements and the development of an automatic attention response (AAR), indicating task-specific and stimulus-specific skill learning. After a 5- or 10-month retention interval, participants in this study performed a New CM task and the originally trained CM task to assess for retention of task-specific and stimulus-specific visual search skills, respectively. No significant group differences were found in the level of retention for either skill type, indicating that individuals with severe TBI were able to retain the learned skills over a long-term retention interval at a level comparable to controls. Exploratory analyses revealed that TBI participants who returned at the 5-month retention interval showed nearly complete skill retention, and greater skill retention than TBI participants who returned at the 10-month interval, suggesting that "booster" or retraining sessions may be needed when a skill is not continuously in use.