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Liu X, Liu M, Ai G, Hu N, Liu W, Lai C, Xu F, Xie Z. Sleep and mental health during the COVID-19 pandemic: findings from an online questionnaire survey in China. Front Neurol 2024; 15:1396673. [PMID: 38952466 PMCID: PMC11215081 DOI: 10.3389/fneur.2024.1396673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 05/27/2024] [Indexed: 07/03/2024] Open
Abstract
Introduction The online study investigated the sleep, psychological conditions, and risk factors during the wave of transmission of COVID-19 since December 7, 2022. Methods We distributed questionnaires through networking mediums to residents to gather information about COVID-19 infection, sleep, and mental status. Results During the extraordinary period in China, 91.9% of 1094 participants claimed to be infected with COVID-19, 36.8% reported poor sleep quality, 75.9% reported anxiety, and 65.5% reported depression. In retrospect, people have experienced lower sleep quality, longer sleep latency, enhanced rising time, and decreased sleep efficiency after the infection wave. After adjusting confounding factors, the elderly, women, urban residents, people with comorbidity, anxiety, depression, stress state, and COVID-19 infection have high risks for sleep disorders during the period. Discussion The survey indicates that sleep disturbance caused by COVID-19 involves multiple dimensions, such as physiology, psychology, and society. The COVID-19 infection-related sleep problem should be taken seriously. Apart from conventional treatment, psychological issues of insomnia can not be ignored.
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Affiliation(s)
- Xuqian Liu
- Department of Neurology, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Mingyue Liu
- Department of Neurology, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Guangyuan Ai
- Department of Neurology, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Naijun Hu
- Department of Neurology, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Wenhan Liu
- Department of Neurology, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Chao Lai
- Department of Neurology, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Feng Xu
- School of Management, Shandong University, Jinan, China
| | - Zhaohong Xie
- Department of Neurology, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
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Abu K, Bedard-Gilligan M, Moodliar R, Bulger EM, Hernandez A, Knutzen T, Shoyer J, Birk N, Conde C, Engstrom A, Ryan P, Wang J, Russo J, Zatzick DF. Can stepped collaborative care interventions improve post-traumatic stress disorder symptoms for racial and ethnic minority injury survivors? Trauma Surg Acute Care Open 2024; 9:e001232. [PMID: 38287923 PMCID: PMC10824071 DOI: 10.1136/tsaco-2023-001232] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 01/07/2024] [Indexed: 01/31/2024] Open
Abstract
Objectives No large-scale randomized clinical trial investigations have evaluated the potential differential effectiveness of early interventions for post-traumatic stress disorder (PTSD) among injured patients from racial and ethnic minority backgrounds. The current investigation assessed whether a stepped collaborative care intervention trial conducted at 25 level I trauma centers differentially improved PTSD symptoms for racial and ethnic minority injury survivors. Methods The investigation was a secondary analysis of a stepped wedge cluster randomized clinical trial. Patients endorsing high levels of distress on the PTSD Checklist (PCL-C) were randomized to enhanced usual care control or intervention conditions. Three hundred and fifty patients of the 635 randomized (55%) were from non-white and/or Hispanic backgrounds. The intervention included care management, cognitive behavioral therapy elements and, psychopharmacology addressing PTSD symptoms. The primary study outcome was PTSD symptoms assessed with the PCL-C at 3, 6, and 12 months postinjury. Mixed model regression analyses compared treatment effects for intervention and control group patients from non-white/Hispanic versus white/non-Hispanic backgrounds. Results The investigation attained between 75% and 80% 3-month to 12-month follow-up. The intervention, on average, required 122 min (SD=132 min). Mixed model regression analyses revealed significant changes in PCL-C scores for non-white/Hispanic intervention patients at 6 months (adjusted difference -3.72 (95% CI -7.33 to -0.10) Effect Size =0.25, p<0.05) after the injury event. No significant differences were observed for white/non-Hispanic patients at the 6-month time point (adjusted difference -1.29 (95% CI -4.89 to 2.31) ES=0.10, p=ns). Conclusion In this secondary analysis, a brief stepped collaborative care intervention was associated with greater 6-month reductions in PTSD symptoms for non-white/Hispanic patients when compared with white/non-Hispanic patients. If replicated, these findings could serve to inform future American College of Surgeon Committee on Trauma requirements for screening, intervention, and referral for PTSD and comorbidities. Level of evidence Level II, secondary analysis of randomized clinical trial data reporting a significant difference. Trial registration number NCT02655354.
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Affiliation(s)
- Khadija Abu
- Psychiatry & Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
| | - Michelle Bedard-Gilligan
- Psychiatry & Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
| | - Rddhi Moodliar
- Department of Psychology, University of California Los Angeles, Los Angeles, California, USA
| | - Eileen M Bulger
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Alexandra Hernandez
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Tanya Knutzen
- Psychiatry & Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
| | - Jake Shoyer
- Psychiatry & Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
| | - Navneet Birk
- Psychiatry & Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
| | - Cristina Conde
- Psychiatry & Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
| | - Allison Engstrom
- Psychiatry & Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
| | - Paige Ryan
- Psychiatry & Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
| | - Jin Wang
- Psychiatry & Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
| | - Joan Russo
- Psychiatry & Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
| | - Douglas F Zatzick
- Psychiatry & Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
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Sudhakar SK, Sridhar S, Char S, Pandya K, Mehta K. Prevalence of comorbidities post mild traumatic brain injuries: a traumatic brain injury model systems study. Front Hum Neurosci 2023; 17:1158483. [PMID: 37397857 PMCID: PMC10309649 DOI: 10.3389/fnhum.2023.1158483] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 05/26/2023] [Indexed: 07/04/2023] Open
Abstract
Traumatic brain injury (TBI) is associated with an increased risk of long-lasting health-related complications. Survivors of brain trauma often experience comorbidities which could further dampen functional recovery and severely interfere with their day-to-day functioning after injury. Of the three TBI severity types, mild TBI constitutes a significant proportion of total TBI cases, yet a comprehensive study on medical and psychiatric complications experienced by mild TBI subjects at a particular time point is missing in the field. In this study, we aim to quantify the prevalence of psychiatric and medical comorbidities post mild TBI and understand how these comorbidities are influenced by demographic factors (age, and sex) through secondary analysis of patient data from the TBI Model Systems (TBIMS) national database. Utilizing self-reported information from National Health and Nutrition Examination Survey (NHANES), we have performed this analysis on subjects who received inpatient rehabilitation at 5 years post mild TBI. Our analysis revealed that psychiatric comorbidities (anxiety, depression, and post-traumatic stress disorder (PTSD)), chronic pain, and cardiovascular comorbidities were common among survivors with mild TBI. Furthermore, depression exhibits an increased prevalence in the younger compared to an older cohort of subjects whereas the prevalence of rheumatologic, ophthalmological, and cardiovascular comorbidities was higher in the older cohort. Lastly, female survivors of mild TBI demonstrated increased odds of developing PTSD compared to male subjects. The findings of this study would motivate additional analysis and research in the field and could have broader implications for the management of comorbidities after mild TBI.
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Self-perception of cognitive functions in patients with neurological impairments as measured against a translated Cognitive Change Index. Int J Rehabil Res 2023; 46:86-91. [PMID: 36727983 DOI: 10.1097/mrr.0000000000000564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The primary purpose of the study was to compare the results of neuropsychological assessments with results obtained using a translated Cognitive Change Index (CCI) on patients with diagnosed brain pathology. Our study included 54 patients diagnosed with neurologic pathology (stroke, TBI, or brain tumor) at the University Rehabilitation Institute Soca (average age = 51 years, SD = 15 years). The results of neuropsychological evaluations and anamnestic data were also obtained for the clinical subsample. Confirmatory factor analysis of the translated CCI performed on responses of 151 normative elderly participants supported a one-factor structure of the questionnaire. Cronbach's α was 0.77 in the clinical sample. A significant correlation was found between lower scores for attention and visual abilities using objective measurement tools and a person's self-assessment of impairment in their own cognitive functions (score on CCI). Individuals can perceive that their attention and visual abilities are impaired when those abilities also score low in diagnostic tests.
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Volumetric MRI Findings in Mild Traumatic Brain Injury (mTBI) and Neuropsychological Outcome. Neuropsychol Rev 2023; 33:5-41. [PMID: 33656702 DOI: 10.1007/s11065-020-09474-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 12/20/2020] [Indexed: 10/22/2022]
Abstract
Region of interest (ROI) volumetric assessment has become a standard technique in quantitative neuroimaging. ROI volume is thought to represent a coarse proxy for making inferences about the structural integrity of a brain region when compared to normative values representative of a healthy sample, adjusted for age and various demographic factors. This review focuses on structural volumetric analyses that have been performed in the study of neuropathological effects from mild traumatic brain injury (mTBI) in relation to neuropsychological outcome. From a ROI perspective, the probable candidate structures that are most likely affected in mTBI represent the target regions covered in this review. These include the corpus callosum, cingulate, thalamus, pituitary-hypothalamic area, basal ganglia, amygdala, and hippocampus and associated structures including the fornix and mammillary bodies, as well as whole brain and cerebral cortex along with the cerebellum. Ventricular volumetrics are also reviewed as an indirect assessment of parenchymal change in response to injury. This review demonstrates the potential role and limitations of examining structural changes in the ROIs mentioned above in relation to neuropsychological outcome. There is also discussion and review of the role that post-traumatic stress disorder (PTSD) may play in structural outcome in mTBI. As emphasized in the conclusions, structural volumetric findings in mTBI are likely just a single facet of what should be a multimodality approach to image analysis in mTBI, with an emphasis on how the injury damages or disrupts neural network integrity. The review provides an historical context to quantitative neuroimaging in neuropsychology along with commentary about future directions for volumetric neuroimaging research in mTBI.
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Feasibility of Risk Factor-Based Screening for Posttraumatic Stress Disorder in Trauma. J Trauma Nurs 2023; 30:27-33. [PMID: 36633342 DOI: 10.1097/jtn.0000000000000696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Posttraumatic stress disorder (PTSD) following traumatic injury can have severe psychiatric consequences. Current recommendations from the American College of Surgeons Committee on Trauma require implementing PTSD screening but specify neither who should be screened nor how. It is unknown whether narrowed screening selection criteria could identify an acceptable proportion of patients with PTSD. OBJECTIVE This study aimed to determine the feasibility of implementing risk factor-based PTSD screening in trauma patients by evaluating the sensitivity and clinical practicality. METHODS This is a prospective diagnostic study of a consecutive series of general ward patients at an urban Level I trauma center from December 2021 to March 2022. Screening indications included (a) interpersonal injury, (b) surgery, (c) intracranial hemorrhage, (d) less than 30 years of age, or (e) clinical suspicion. The protocol was assessed by measuring the proportion of positive screens captured by only clinical suspicion to estimate sensitivity and by qualitatively evaluating barriers to implementation. RESULTS Among the 200 patients screened, the number of patients who screened positive was 51 (25.5%). Eight patients were screened on clinical suspicion alone, seven (87.5%) of whom had positive screens, compared with 44 of the 192 (22.9%) patients who were screened for indications. Thus, 7 of 51 (13.7%; 95% confidence interval: 6.8%-26.7%) patients with PTSD-level symptoms would not have been screened on the basis of their risk factors. There were also practical difficulties in implementation. CONCLUSION Limiting PTSD screening to only those injured patients with additional risk factors would have reduced overall sensitivity at our center. Consequently, we have implemented universal screening instead.
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The 12-Month Effects of the Trauma Collaborative Care Intervention: A Nonrandomized Controlled Trial. J Bone Joint Surg Am 2022; 104:1796-1804. [PMID: 36000769 DOI: 10.2106/jbjs.22.00475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Studies have suggested that patient-centered collaborative care in the early phases of recovery may assist providers and patients in managing the multifactorial consequences of injury and may lead to better outcomes. This cluster-controlled trial, conducted at 12 U.S. Level-I trauma centers, was designed to evaluate the impact of the Trauma Collaborative Care (TCC) program on 1-year outcomes following severe musculoskeletal injury. METHODS Patients with high-energy orthopaedic trauma requiring surgical fixation were prospectively enrolled. Six sites implemented the TCC intervention as well as the Trauma Survivors Network (TSN), and the other 6 sites provided the standard of care. Participants were followed for 1 year, and a composite primary outcome measure composed of the Short Musculoskeletal Function Assessment (SMFA) Dysfunction Index, Patient Health Questionnaire-9 (PHQ-9), and Posttraumatic Stress Disorder Checklist (PCL) was assessed. A 2-stage, Bayesian hierarchical statistical procedure was used to characterize treatment effects. Sensitivity analyses were conducted to account for an error in the delivery of the intervention. RESULTS There were 378 patients enrolled at 6 trauma centers implementing the TCC program, and 344 patients enrolled at 6 trauma centers providing usual care. Patient utilization of treatment components varied across the intervention sites: 29% of patients in the intervention group received all 5 key components (TSN handbook education, peer visits, recovery assessment, and calls before and after recovery assessment). Posterior estimates of the intention-to-treat effect suggested that the intervention did not have an appreciable effect: the odds of the composite outcome for the TCC group increased by 5% (95% credible interval, -40% to 63%). The estimates of the effect of receiving all 5 key intervention components were similar. CONCLUSIONS Despite prior work showing early positive effects, this analysis suggests that the TCC program as delivered did not have positive effects on patient outcomes at 1 year. It is not known whether programs that improve compliance or target specific subgroups would better meet the psychosocial needs of trauma survivors. LEVEL OF EVIDENCE Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.
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Klimova A, Breukelaar IA, Bryant RA, Korgaonkar MS. A comparison of the functional connectome in mild traumatic brain injury and post-traumatic stress disorder. Hum Brain Mapp 2022; 44:813-824. [PMID: 36206284 PMCID: PMC9842915 DOI: 10.1002/hbm.26101] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 08/25/2022] [Accepted: 09/07/2022] [Indexed: 01/25/2023] Open
Abstract
Post-traumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI) often co-occur in the context of threat to one's life. These conditions also have an overlapping symptomatology and include symptoms of anxiety, poor concentration and memory problems. A major challenge has been articulating the underlying neurobiology of these overlapping conditions. The primary aim of this study was to compare intrinsic functional connectivity between mTBI (without PTSD) and PTSD (without mTBI). The study included functional MRI data from 176 participants: 42 participants with mTBI, 67 with PTSD and a comparison group of 66 age and sex-matched healthy controls. We used network-based statistical analyses for connectome-wide comparisons of intrinsic functional connectivity between mTBI relative to PTSD and controls. Our results showed no connectivity differences between mTBI and PTSD groups. However, we did find that mTBI had significantly reduced connectivity relative to healthy controls within an extensive network of regions including default mode, executive control, visual and auditory networks. The mTBI group also displayed hyperconnectivity between dorsal and ventral attention networks and perceptual regions. The PTSD group also demonstrated abnormal connectivity within these networks relative to controls. Connectivity alterations were not associated with severity of PTSD or post-concussive symptoms in either clinical group. Taken together, the similar profiles of intrinsic connectivity alterations in these two conditions provide neural evidence that can explain, in part, the overlapping symptomatology between mTBI and PTSD.
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Affiliation(s)
- Aleksandra Klimova
- Brain Dynamics Centre, Westmead Institute for Medical ResearchThe University of SydneyWestmeadAustralia
| | - Isabella A. Breukelaar
- Brain Dynamics Centre, Westmead Institute for Medical ResearchThe University of SydneyWestmeadAustralia,School of PsychologyUniversity of New South WalesSydneyAustralia
| | - Richard A. Bryant
- Brain Dynamics Centre, Westmead Institute for Medical ResearchThe University of SydneyWestmeadAustralia,School of PsychologyUniversity of New South WalesSydneyAustralia
| | - Mayuresh S. Korgaonkar
- Brain Dynamics Centre, Westmead Institute for Medical ResearchThe University of SydneyWestmeadAustralia,Department of Psychiatry, Faculty of Medicine and HealthUniversity of SydneyWestmeadAustralia
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Williamson MLC, Stickley MM, Armstrong TW, Jackson K, Console K. Diagnostic accuracy of the Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) within a civilian primary care sample. J Clin Psychol 2022; 78:2299-2308. [PMID: 35763419 DOI: 10.1002/jclp.23405] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 05/24/2022] [Accepted: 06/09/2022] [Indexed: 01/06/2023]
Abstract
OBJECTIVE This study aims to evaluate the diagnostic accuracy of the Primary Care Posttraumatic Stress Disorder (PTSD) Screen for Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5) (PC-PTSD-5) as a screening tool for the identification of PTSD among a civilian sample receiving behavioral health treatment within a primary care setting. Validation within a civilian sample will increase the generalizability of the PC-PTSD-5 as a brief screening measure to identify PTSD within primary care practices. METHOD The present study is a retrospective review of data (N = 198) collected as part of a patient registry for an integrated behavioral health consultation service within a primary care clinic. The PC-PTSD-5 was administered as part of a standardized set of brief screening measures and a standard clinical interview. Diagnostic validation was accomplished via a consensus model between a board-certified family medicine physician and a licensed psychologist along with medical/psychology trainees. RESULTS Fifty-two participants (26.26%) out of 198 who completed the PC-PTSD-5 were diagnosed with PTSD. The PC-PTSD-5 demonstrated excellent diagnostic accuracy (area under the curve = 0.933, 95% confidence interval [CI]: 0.901-0.965). A cutoff score of 4 maximized sensitivity (sensitivity% = 100) while maintaining acceptable specificity (specificity% = 85.2). This score also maximized efficiency (κ[0.5] = 0.77, SE = 0.05, 95% CI: 0.67-0.86) and maintained a good (≥0.60) quality index for specificity (κ[0] = 0.61). CONCLUSION The PC-PTSD-5 maintained strong diagnostic accuracy within a civilian primary care sample.
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Affiliation(s)
- Meredith L C Williamson
- Department of Primary Care & Population Health, Texas A&M Health Science Center, College of Medicine, Bryan, Texas, USA
| | - Mariah M Stickley
- Department of Psychiatry & Behavioral Sciences, Texas A&M Health Science Center, College of Medicine, Bryan, Texas, USA
| | - Trey W Armstrong
- Department of Psychiatry & Behavioral Sciences, Texas A&M Health Science Center, College of Medicine, Bryan, Texas, USA
| | - Kaylee Jackson
- Department of Psychiatry & Behavioral Sciences, Texas A&M Health Science Center, College of Medicine, Bryan, Texas, USA
| | - Katie Console
- Department of Psychiatry & Behavioral Sciences, Texas A&M Health Science Center, College of Medicine, Bryan, Texas, USA
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Weil ZM, White B, Whitehead B, Karelina K. The role of the stress system in recovery after traumatic brain injury: A tribute to Bruce S. McEwen. Neurobiol Stress 2022; 19:100467. [PMID: 35720260 PMCID: PMC9201063 DOI: 10.1016/j.ynstr.2022.100467] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 05/25/2022] [Accepted: 06/02/2022] [Indexed: 11/21/2022] Open
Abstract
Traumatic brain injury (TBI) represents a major public health concern. Although the majority of individuals that suffer mild-moderate TBI recover relatively quickly, a substantial subset of individuals experiences prolonged and debilitating symptoms. An exacerbated response to physiological and psychological stressors after TBI may mediate poor functional recovery. Individuals with TBI can suffer from poor stress tolerance, impairments in the ability to evaluate stressors, and poor initiation (and cessation) of neuroendocrine stress responses, all of which can exacerbate TBI-mediated dysfunction. Here, we pay tribute to the pioneering neuroendocrinologist Dr. Bruce McEwen by discussing the ways in which his work on stress physiology and allostatic loading impacts the TBI patient population both before and after their injuries. Specifically, we will discuss the modulatory role of hypothalamic-pituitary-adrenal axis responses immediately after TBI and later in recovery. We will also consider the impact of stressors and stress responses in promoting post-concussive syndrome and post-traumatic stress disorders, two common sequelae of TBI. Finally, we will explore the role of early life stressors, prior to brain injuries, as modulators of injury outcomes.
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Villalobos D, Bivona U. Post-traumatic Stress Disorder after Severe Traumatic Brain Injury: A Systematic Review. Arch Clin Neuropsychol 2021; 37:583-594. [PMID: 34933334 DOI: 10.1093/arclin/acab095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE The review aimed to summarize the existing knowledge base regarding post-traumatic stress disorder after severe traumatic brain injury (TBI) and try to guide future research. METHOD Web of Science, Scopus, and PubMed databases were used to identify original studies that explored the relationship between severe TBI and post-traumatic stress disorder. RESULTS A total of 13 studies were included in the review. They have been examined in terms of potentially compatible and incompatible mechanisms, as well as of possible confounding factors in relation to the diagnosis of post-traumatic stress disorder after severe TBI. CONCLUSION Only a few studies in the literature have addressed the present topic; therefore, the prevalence of post-traumatic stress disorder in patients with severe TBI still needs to be further investigated. In particular, future studies should be conducted only in severe TBI populations, considering their premorbid personality characteristics and their reactivity alteration. They should also obtain an accurate and appropriate assessment of post-traumatic stress disorder with clinical interviews as well as clarifying the role of post-traumatic amnesia in this population by incorporating control groups of patients.
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Affiliation(s)
- Dolores Villalobos
- Department of Experimental Psychology, School of Psychology, Complutense University, Madrid, Spain.,Laboratory of Cognitive and Computational Neuroscience, Center for Biomedical Technology (Technical University of Madrid and Complutense University of Madrid), Madrid, Spain.,The European Centre of Neuroscience, Madrid, Spain
| | - Umberto Bivona
- IRCCS Fondazione Santa Lucia, Neuroriabilitazione 2, Rome, Italy
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Engstrom A, Moloney K, Nguyen J, Parker L, Roberts M, Moodliar R, Russo J, Wang J, Scheuer H, Zatzick D. A Pragmatic Clinical Trial Approach to Assessing and Monitoring Suicidal Ideation: Results from A National US Trauma Care System Study. Psychiatry 2021; 85:13-29. [PMID: 34932440 PMCID: PMC8916972 DOI: 10.1080/00332747.2021.1991200] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Few investigations have comprehensively described methods for assessing and monitoring suicidal ideation in pragmatic clinical trials of mental health services interventions. This investigation's goal was to assess a collaborative care intervention's effectiveness in reducing suicidal ideation and describe suicide monitoring implementation in a nationwide protocol. METHOD The investigation was a secondary analysis of a stepped wedge cluster randomized trial at 25-Level I trauma centers. Injury survivors (N = 635) were randomized to control (n = 370) and intervention (n = 265) conditions and assessed at baseline hospitalization and follow-up at 3-, 6- and 12-months post-injury. The Patient Health Questionnaire (PHQ-9) item-9 was used to evaluate patients for suicidal ideation. Mixed model regression was used to assess intervention versus control group changes in PHQ-9 item-9 scores over time and associations between baseline characteristics and development of suicidal ideation longitudinally. As part of the study implementation process assessment, suicide outreach call logs were also reviewed. RESULTS Over 50% of patients endorsed suicidal ideation at ≥1 assessment. Intervention patients relative to control patients demonstrated reductions in endorsements of suicidal ideation that did not achieve statistical significance (F[3,1461] = 0.74, P = .53). The study team completed outreach phone calls, texts or voice messages to 268 patients with PHQ-9 item-9 scores ≥1 (n = 161 control, n = 107 intervention). CONCLUSIONS Suicide assessment and monitoring can be feasibly implemented in large-scale pragmatic clinical trials. Intervention patients demonstrated less suicidal ideation over time; however, these comparisons did not achieve statistical significance. Intensive pragmatic trial monitoring may mask treatment effects by providing control patients a supportive intervention. TRIAL REGISTRATION ClinicalTrials.gov NCT02655354.
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Affiliation(s)
- Allison Engstrom
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, USA
| | - Kathleen Moloney
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, USA
| | - Jefferson Nguyen
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, USA
| | - Lea Parker
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, USA
- Department of Psychology, Drexel University College of Arts and Sciences, Philadelphia, US
| | - Michelle Roberts
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, USA
- Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, USA
| | - Rddhi Moodliar
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, USA
- Department of Psychology, University of California, Los Angeles, USA
| | - Joan Russo
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, USA
| | - Jin Wang
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, USA
- Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle, USA
| | - Hannah Scheuer
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, USA
- School of Social Work, University of Washington, Seattle, USA
| | - Douglas Zatzick
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, USA
- Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle, USA
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Zatzick D, Jurkovich G, Heagerty P, Russo J, Darnell D, Parker L, Roberts MK, Moodliar R, Engstrom A, Wang J, Bulger E, Whiteside L, Nehra D, Palinkas LA, Moloney K, Maier R. Stepped Collaborative Care Targeting Posttraumatic Stress Disorder Symptoms and Comorbidity for US Trauma Care Systems: A Randomized Clinical Trial. JAMA Surg 2021; 156:430-474. [PMID: 33688908 DOI: 10.1001/jamasurg.2021.0131] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance To date, few multisite investigations have evaluated early interventions for injured patients with posttraumatic stress disorder (PTSD) symptoms. Objective To simultaneously assess the effectiveness and implementation of a brief stepped collaborative care intervention targeting PTSD and comorbidity. Design, Setting, and Participants A stepped-wedge cluster randomized clinical trial was conducted at 25 US level I trauma centers. Participants included hospitalized survivors of physical injury who underwent a 2-step evaluation for PTSD symptoms. Patients reporting high levels of distress on the PTSD Checklist (PCL-C) were randomized (N = 635) per the stepped-wedge protocol to enhanced usual care control (n = 370) or intervention (n = 265) conditions. The study was conducted from January 4, 2016, through November 2018. Data analysis was performed from November 4, 2019, to December 8, 2020. Interventions The Trauma Survivors Outcomes and Support collaborative care intervention included proactive injury case management that assisted patients transitioning from hospital inpatient to outpatient and community settings. The intervention also integrated evidence-based pharmacotherapy and psychotherapeutic elements targeting PTSD symptoms and comorbidity. Main Outcomes and Measures The primary study outcome was PTSD symptoms assessed with the PCL-C at baseline in the surgical ward and at 3, 6, and 12 months postinjury. Secondary outcomes included depressive symptoms, alcohol use, and physical function. Subgroup analyses examined the effect of baseline risk factors for enduring PTSD and quality of protocol implementation on study outcomes. Primary statistical analyses were conducted using the intent-to-treat sample. Results A total of 327 men (51.5%) were included in analysis; mean (SD) age was 39.0 (14.2) years. The investigation attained follow-up of 75% to 80% of the participants at 3 to 12 months. The intervention lasted a mean (SD) of 122 (132) minutes. Mixed model regression analyses revealed statistically significant changes in PCL-C scores for intervention patients compared with control patients at 6 months (difference, -2.57; 95% CI, -5.12 to -0.03; effect size, 0.18; P < .05) but not 12 months (difference, -1.27; 95% CI, -4.26 to 1.73; effect size, 0.08; P = .35). Subgroup analyses revealed larger PTSD treatment effects for patients with 3 or more baseline risk factors for enduring PTSD and for patients, including firearm injury survivors, treated at trauma centers with good or excellent protocol implementation. Intervention effects for secondary outcomes did not attain statistical significance. Conclusions and Relevance A brief stepped collaborative care intervention was associated with significant 6-month but not 12-month PTSD symptom reductions. Greater baseline PTSD risk and good or excellent trauma center protocol implementation were associated with larger PTSD treatment effects. Orchestrated efforts targeting policy and funding should systematically incorporate the study findings into national trauma center requirements and verification criteria. Trial Registration ClinicalTrials.gov Identifier: NCT02655354.
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Affiliation(s)
- Douglas Zatzick
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle.,Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle
| | - Gregory Jurkovich
- Department of Surgery, UC Davis School of Medicine, Sacramento, California
| | - Patrick Heagerty
- Department of Biostatistics, University of Washington School of Public Health, Seattle
| | - Joan Russo
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle
| | - Doyanne Darnell
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle
| | - Lea Parker
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle.,Department of Psychology, Drexel University College of Arts and Sciences, Philadelphia, Pennsylvania
| | - Michelle K Roberts
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle.,Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle
| | - Rddhi Moodliar
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle.,Department of Psychology, University of California, Los Angeles
| | - Allison Engstrom
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle
| | - Jin Wang
- Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle
| | - Eileen Bulger
- Department of Surgery, University of Washington School of Medicine, Seattle
| | - Lauren Whiteside
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle
| | - Deepika Nehra
- Department of Surgery, University of Washington School of Medicine, Seattle
| | - Lawrence A Palinkas
- Department of Children, Youth and Families, USC Suzanne Dworak-Peck School of Social Work, Los Angeles, California
| | - Kathleen Moloney
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle
| | - Ronald Maier
- Department of Surgery, University of Washington School of Medicine, Seattle
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14
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Moriarty H, Robinson KM, Winter L. The additional burden of PTSD on functioning and depression in veterans with traumatic brain injury. Nurs Outlook 2021; 69:167-181. [PMID: 33608113 DOI: 10.1016/j.outlook.2020.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 10/20/2020] [Accepted: 11/03/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Many United States veterans and active military with a history of traumatic brain injury (TBI) also experience challenges from comorbid posttraumatic stress disorder (PTSD), yet the additional burden of PTSD is not clear. PURPOSE To address this knowledge gap, this study examined the relationship of PTSD to cognitive, social, and physical functioning and depressive symptoms in veterans recently diagnosed with TBI. METHODS Veterans were recruited from a VA rehabilitation clinic. The Patient Competency Rating Scale and Center for Epidemiologic Studies Depression Scale measured functioning and depression, respectively. Chart review captured PTSD diagnosis. FINDINGS In the sample of 83 veterans, 65% had a current PTSD diagnosis. After controlling for sociodemographic variables and TBI severity, PTSD was a significant predictor of lower cognitive, social, and physical functioning and higher depressive symptomatology. DISCUSSION Clinicians should incorporate PTSD assessment in their work with veterans with TBI. Integrated behavioral health and rehabilitation interventions that provide strategies for veterans to manage TBI symptoms and PTSD are critical.
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Affiliation(s)
- Helene Moriarty
- Villanova University, M. Louise Fitzpatrick College of Nursing, Villanova, PA; Corporal Michael J. Crescenz Veterans Affairs Medical Center, Nursing Service, Philadelphia, PA.
| | - Keith M Robinson
- University of Pennsylvania, Perelman School of Medicine, Department of Physical Medicine and Rehabilitation, Philadelphia, PA; Corporal Michael J. Crescenz Veterans Affairs Medical Center, Rehabilitation Medicine Service, Philadelphia, PA
| | - Laraine Winter
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Nursing Service, Philadelphia, PA
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15
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Hicks AJ, Clay FJ, Hopwood M, James AC, Perry LA, Jayaram M, Batty R, Ponsford JL. Efficacy and Harms of Pharmacological Interventions for Anxiety after Traumatic Brain Injury: Systematic Review. J Neurotrauma 2020; 38:519-528. [PMID: 33045912 DOI: 10.1089/neu.2020.7277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
After a traumatic brain injury (TBI), many persons experience significant and debilitating problems with anxiety. The aim of this systematic review was to critically evaluate the evidence regarding efficacy of pharmacological interventions for anxiety after TBI. We reviewed studies published in English before July 2020 and included original research on pharmacological interventions for anxiety after TBI in adults ≥16 years of age. MEDLINE, PubMed, CINAHL, EMBASE, PsycINFO, and CENTRAL databases were searched, with additional searching of key journals, clinical trials registries, and international drug regulators. The primary outcomes of interest were reduction in symptoms of anxiety and occurrence of harms. The secondary outcomes of interest were changes in depression, cognition, quality of life, and participation. Data were summarized in a narrative synthesis, and evidence quality was assessed using the Cochrane Risk of Bias tool. Only a single non-peer-reviewed, randomized controlled trial of 19 male military service members with mild TBI met inclusion criteria. This study found no significant effect of citalopram on anxiety symptoms over a 12-week intervention. The trial was stopped early because of poor recruitment, and much of the study detail was not included in the report. The methodological quality of the study was difficult to assess because of the lack of detail. No recommendations could be drawn from this review. There is a critical need for adequately powered and controlled studies of pharmacological interventions for anxiety after TBI across all severities that examine side-effect profiles and consider issues of comorbidity and effects of long-term pharmacotherapy.
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Affiliation(s)
- Amelia J Hicks
- Monash-Epworth Rehabilitation Research Centre, Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
| | - Fiona J Clay
- Department of Psychiatry, Albert Road Clinic, University of Melbourne, Melbourne, Victoria, Australia.,Department of Forensic Medicine, Monash University, Southbank, Victoria, Australia.,Professorial Psychiatry Unit, Albert Road Clinic, University of Melbourne, Melbourne, Victoria, Australia
| | - Malcolm Hopwood
- Department of Psychiatry, Albert Road Clinic, University of Melbourne, Melbourne, Victoria, Australia.,Professorial Psychiatry Unit, Albert Road Clinic, University of Melbourne, Melbourne, Victoria, Australia
| | - Amelia C James
- Monash-Epworth Rehabilitation Research Centre, Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
| | - Luke A Perry
- Department of Psychiatry, Albert Road Clinic, University of Melbourne, Melbourne, Victoria, Australia
| | - Mahesh Jayaram
- Department of Psychiatry, Albert Road Clinic, University of Melbourne, Melbourne, Victoria, Australia
| | - Rachel Batty
- Department of Psychiatry, Albert Road Clinic, University of Melbourne, Melbourne, Victoria, Australia
| | - Jennie L Ponsford
- Monash-Epworth Rehabilitation Research Centre, Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
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16
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Geier TJ, Hunt JC, Hanson JL, Heyrman K, Larsen SE, Brasel KJ, deRoon-Cassini TA. Validation of Abbreviated Four- and Eight-Item Versions of the PTSD Checklist for DSM-5 in a Traumatically Injured Sample. J Trauma Stress 2020; 33:218-226. [PMID: 32277772 DOI: 10.1002/jts.22478] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 07/25/2019] [Accepted: 08/30/2019] [Indexed: 01/26/2023]
Abstract
Rates of posttraumatic stress disorder (PTSD) are three times higher in traumatically injured populations than the general population, yet limited brief, valid measures for assessing PTSD symptom severity exist. The PTSD Checklist for DSM-5 (PCL-5) is a valid, efficient measure of symptom severity, but its completion is time consuming. Subsequently, abbreviated four- and eight-item versions were developed using the Mini-International Neuropsychiatric Interview-7 PTSD module and validated in Veteran samples. This study aimed to validate these abbreviated versions using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), the gold standard for PTSD diagnosis, in a traumatically injured civilian population. Participants were 251 traumatically injured adults (Mage = 42.52 years; 69.3% male; 50.2% Caucasian) recruited from a Level 1 trauma center inpatient unit; 32.3% and 17.9% of participants experienced a motor vehicle crash or gunshot wound, respectively. The CAPS-5 and PCL-5 were administered approximately 6.5 months postinjury. We examined whether compared to the full PCL-5, the abbreviated versions would adequately differentiate between participants with and without a CAPS-5 PTSD diagnosis. The abbreviated versions were highly correlated with the total scale and showed good-to-excellent internal consistency. The diagnostic utility of the abbreviated measures was comparable to that of the total scale regarding sensitivity, suggesting they may be useful as abbreviated screening tools; however, the total scale functioned better regarding specificity. The abbreviated versions of the PCL-5 may be useful screening instruments in the long-term care of traumatic injury survivors and may be more likely to be implemented across routine clinical and research contexts.
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Affiliation(s)
- Timothy J Geier
- Department of Surgery, Division of Trauma & Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Joshua C Hunt
- Department of Surgery, Division of Trauma & Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jessica L Hanson
- Department of Psychology, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
| | - Katelyn Heyrman
- Department of Educational Psychology, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
| | - Sadie E Larsen
- Clement J. Zablocki VA Medical Center, Milwaukee, WI, USA.,Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Karen J Brasel
- Oregon Health & Science University, Portland, Oregon, USA
| | - Terri A deRoon-Cassini
- Department of Surgery, Division of Trauma & Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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17
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Van Praag DLG, Fardzadeh HE, Covic A, Maas AIR, von Steinbüchel N. Preliminary validation of the Dutch version of the Posttraumatic stress disorder checklist for DSM-5 (PCL-5) after traumatic brain injury in a civilian population. PLoS One 2020; 15:e0231857. [PMID: 32310970 PMCID: PMC7170250 DOI: 10.1371/journal.pone.0231857] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 04/02/2020] [Indexed: 11/18/2022] Open
Abstract
The Posttraumatic stress disorder checklist (PCL) is the most widely used questionnaire to screen for symptoms of posttraumatic stress disorder (PTSD), based on the Diagnostic and Statistical manual of Mental disorders (DSM-IV) criteria. In the latest edition of the DSM (DSM-5), the criteria for PTSD were revised leading to the development of the PCL-5. So far, there is no validated Dutch version of the PCL-5. The aim of this study is to determine psychometric characteristics of the Dutch translation and linguistic validation of the PCL-5 and to evaluate internal consistency, criterion and structural validity. In a population of 495 civilian, traumatic brain injury patients, the PCL-5, the Generalized anxiety disorder questionnaire and the Depression scale of the Patient health questionnaire were administered. The PCL-5 was translated in Dutch following a strict procedure of linguistic validation and cognitive debriefing. Results show an excellent internal consistency and high criterion validity. Confirmatory factor analysis demonstrated a good fit for the four-factor DSM-5 model, but a superior fit for the six-factor Anhedonia model and the seven-factor Hybrid model, similar to the English version of the PCL-5. Preliminary validation of the Dutch translation of the PCL-5 was proven to be psychometrically sound and can be used for clinical and academic purposes, specifically for TBI patients. Future research should examine concurrent and discriminant validity for the Dutch translation in broader populations at risk for PTSD, and include a structured interview to evaluate diagnostic utility.
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Affiliation(s)
- Dominique L. G. Van Praag
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
- * E-mail:
| | - Haghish Ebad Fardzadeh
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen (UMG)/Georg-August-University, Göttingen, Germany
| | - Amra Covic
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen (UMG)/Georg-August-University, Göttingen, Germany
| | - Andrew I. R. Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Nicole von Steinbüchel
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen (UMG)/Georg-August-University, Göttingen, Germany
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18
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Singh A, Zeig-Owens R, Hall CB, Liu Y, Rabin L, Schwartz T, Webber MP, Appel D, Prezant DJ. World Trade Center exposure, post-traumatic stress disorder, and subjective cognitive concerns in a cohort of rescue/recovery workers. Acta Psychiatr Scand 2020; 141:275-284. [PMID: 31721141 DOI: 10.1111/acps.13127] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/10/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To determine whether World Trade Center (WTC)-exposure intensity and post-traumatic stress disorder (PTSD) are associated with subjective cognitive change in rescue/recovery workers. METHOD The population included 7875 rescue/recovery workers who completed a subjective cognition measure, the Cognitive Function Instrument (CFI), between 3/1/2018 and 2/28/2019 during routine monitoring, indicating whether they had experienced cognitive and functional difficulties in the past year. Higher scores indicated greater self-perceived cognitive change. Probable PTSD, depression, and alcohol abuse were evaluated by validated mental health screeners. Logistic regression assessed the associations of WTC exposure and current PTSD with top-quartile (≥2) CFI score, and of early post-9/11 PTSD with top-quartile CFI in a subpopulation (N = 6440). Models included demographics, smoking, depression, and alcohol abuse as covariates. RESULTS Mean age at CFI completion was 56.7 ± 7.7 (range: 36-81). Participants with high-intensity WTC exposure had an increased likelihood of top-quartile CFI score (odds ratio[OR] vs. low exposure: 1.32, 95%CI: 1.07-1.64), controlling for covariates. Current and early PTSD were both associated with top-quartile CFI (OR: 3.25, 95%CI: 2.53-4.19 and OR: 1.56, 95%CI: 1.26-1.93) respectively. CONCLUSIONS High-intensity WTC exposure was associated with self-reported cognitive change 17 years later in rescue/recovery workers, as was PTSD. Highly WTC-exposed subgroups may benefit from additional cognitive evaluation and monitoring of cognition over time.
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Affiliation(s)
- A Singh
- The Bureau of Health Services and the FDNY World Trade Center Health Program, Fire Department of the City of New York, Brooklyn, NY, USA.,Pulmonary Medicine Division, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - R Zeig-Owens
- The Bureau of Health Services and the FDNY World Trade Center Health Program, Fire Department of the City of New York, Brooklyn, NY, USA.,Pulmonary Medicine Division, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Division of Epidemiology, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - C B Hall
- Division of Biostatistics, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA.,Saul R. Korey Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Y Liu
- The Bureau of Health Services and the FDNY World Trade Center Health Program, Fire Department of the City of New York, Brooklyn, NY, USA.,Pulmonary Medicine Division, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - L Rabin
- Department of Psychology, Brooklyn College and The Graduate Center of CUNY, Brooklyn, NY, USA
| | - T Schwartz
- The Bureau of Health Services and the FDNY World Trade Center Health Program, Fire Department of the City of New York, Brooklyn, NY, USA.,Pulmonary Medicine Division, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - M P Webber
- The Bureau of Health Services and the FDNY World Trade Center Health Program, Fire Department of the City of New York, Brooklyn, NY, USA.,Division of Epidemiology, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - D Appel
- The Bureau of Health Services and the FDNY World Trade Center Health Program, Fire Department of the City of New York, Brooklyn, NY, USA.,Pulmonary Medicine Division, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - D J Prezant
- The Bureau of Health Services and the FDNY World Trade Center Health Program, Fire Department of the City of New York, Brooklyn, NY, USA.,Pulmonary Medicine Division, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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19
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Bremner JD, Wittbrodt MT, Shah AJ, Pearce BD, Gurel NZ, Inan OT, Raggi P, Lewis TT, Quyyumi AA, Vaccarino V. Confederates in the Attic: Posttraumatic Stress Disorder, Cardiovascular Disease, and the Return of Soldier's Heart. J Nerv Ment Dis 2020; 208:171-180. [PMID: 32091470 PMCID: PMC8214871 DOI: 10.1097/nmd.0000000000001100] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Da Costa originally described Soldier's Heart in the 19th Century as a syndrome that occurred on the battlefield in soldiers of the American Civil War. Soldier's Heart involved symptoms similar to modern day posttraumatic stress disorder (PTSD) as well as exaggerated cardiovascular reactivity felt to be related to an abnormality of the heart. Interventions were appropriately focused on the cardiovascular system. With the advent of modern psychoanalysis, psychiatric symptoms became divorced from the body and were relegated to the unconscious. Later, the physiology of PTSD and other psychiatric disorders was conceived as solely residing in the brain. More recently, advances in psychosomatic medicine led to the recognition of mind-body relationships and the involvement of multiple physiological systems in the etiology of disorders, including stress, depression PTSD, and cardiovascular disease, has moved to the fore, and has renewed interest in the validity of the original model of the Soldier's Heart syndrome.
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Affiliation(s)
- J. Douglas Bremner
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Emory University, Atlanta
- Department of Radiology, Emory University School of Medicine, Emory University, Atlanta
- Atlanta VA Medical Center, Decatur
| | - Matthew T. Wittbrodt
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Emory University, Atlanta
| | - Amit J. Shah
- Atlanta VA Medical Center, Decatur
- Department of Medicine (Cardiology), Emory University School of Medicine, Emory University
| | - Bradley D. Pearce
- Department of Epidemiology, Rollins School of Public Health, Emory University
| | - Nil Z. Gurel
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, Georgia
| | - Omer T. Inan
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, Georgia
- Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, Georgia
| | - Paolo Raggi
- Mazankowski Alberta Heart Institute and Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Tené T. Lewis
- Department of Epidemiology, Rollins School of Public Health, Emory University
| | - Arshed A. Quyyumi
- Department of Medicine (Cardiology), Emory University School of Medicine, Emory University
| | - Viola Vaccarino
- Department of Medicine (Cardiology), Emory University School of Medicine, Emory University
- Department of Epidemiology, Rollins School of Public Health, Emory University
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20
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A Systematic Review and Meta-analysis on PTSD Following TBI Among Military/Veteran and Civilian Populations. J Head Trauma Rehabil 2020; 35:E21-E35. [DOI: 10.1097/htr.0000000000000514] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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21
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Early Effects of the Trauma Collaborative Care Intervention: Results From a Prospective Multicenter Cluster Clinical Trial. J Orthop Trauma 2019; 33:538-546. [PMID: 31634286 DOI: 10.1097/bot.0000000000001581] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To evaluate the impact of the Trauma Collaborative Care (TCC) program's early intervention components on 6-week outcomes. TCC was developed to improve psychosocial sequelae of orthopaedic trauma and includes the Trauma Survivors Network and additional collaborative care services. DESIGN Prospective, multicenter, cluster clinical trial. SETTING Level I Trauma Centers. PATIENTS Individuals with high-energy orthopaedic injuries requiring surgery and hospital admission: 413 patients at 6 trauma centers implementing the TCC program and 374 patients at 6 trauma centers receiving usual care. INTERVENTION TCC early intervention: patient education, peer visits, and coaching calls. MAIN OUTCOME MEASUREMENTS Pain rating scale, Patient Health Questionnaire-9 depression, Post-Traumatic Stress Disorder Checklist, and self-efficacy for return to work and managing finances. For each outcome, a hybrid Bayesian statistical procedure, accounting for clustering within sites and differences in baseline characteristics between sites, was used to estimate the intention-to-treat (ITT) effect and the effect under full receipt of early intervention components. RESULTS Sites varied substantially in utilization of intervention components. The posterior estimates of the ITT (full receipt) effect favor TCC for 4 (5) of the 5 endpoints. The posterior probabilities of a favorable (ITT; full receipt) TCC effect were as follows: depression (89%-93%), pain (84%-74%), post-traumatic stress disorder (68%-68%), self-efficacy for return to work (74%-76%), and self-efficacy for managing finances (47%-61%). CONCLUSIONS Results suggest TCC may have a small positive effect on early outcomes, but use of the services was highly variable among sites. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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22
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Roberts AL, Pascual-Leone A, Speizer FE, Zafonte RD, Baggish AL, Taylor H, Nadler LM, Courtney TK, Connor A, Grashow R, Stillman AM, Marengi DA, Weisskopf MG. Exposure to American Football and Neuropsychiatric Health in Former National Football League Players: Findings From the Football Players Health Study. Am J Sports Med 2019; 47:2871-2880. [PMID: 31468987 PMCID: PMC7163246 DOI: 10.1177/0363546519868989] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Former American football players have a higher prevalence of cognitive impairment than that of the US general population. It remains unknown what aspects of playing football are associated with neuropsychiatric outcomes. HYPOTHESIS It was hypothesized that seasons of professional football, playing position, and experience of concussions were associated with cognition-related quality of life (QOL) and indicators of depression and anxiety. STUDY DESIGN Descriptive epidemiology study. METHODS The authors examined whether seasons of professional football, playing position, and experience of concussions, as measured by self-report of 10 symptoms, were associated with cognition-related QOL and indicators of depression and anxiety in a cross-sectional survey conducted 2015 to 2017. Cognition-related QOL was measured by the short form of the Quality of Life in Neurological Disorders: Applied Cognition-General Concerns. The Patient Health Questionnaire-4 measured depression and anxiety symptoms. Of 13,720 eligible men with apparently valid contact information, 3506 players returned a questionnaire at the time of this analysis (response rate = 25.6%). RESULTS Seasons of professional play (risk ratio [RR] per 5 seasons = 1.19, 95% CI = 1.06-1.34) and playing position were associated with cognition-related QOL. Each 5 seasons of play was associated with 9% increased risk of indicators of depression at borderline statistical significance (P = .05). When compared with former kickers, punters, and quarterbacks, men who played any other position had a higher risk of poor cognition-related QOL, depression, and anxiety. Concussion symptoms were strongly associated with poor cognition-related QOL (highest concussion quartile, RR = 22.3, P < .001), depression (highest quartile, RR = 6.0, P < .0001), and anxiety (highest quartile, RR = 6.4, P < .0001), even 20 years after last professional play. CONCLUSION The data suggest that seasons of play and playing position in the NFL are associated with lasting neuropsychiatric health deficits. Additionally, poor cognition-related QOL, depression, and anxiety appear to be associated with concussion in the long term.
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Affiliation(s)
- Andrea L. Roberts
- Andrea L. Roberts, PhD,
Department of Environmental Health, Harvard T.H. Chan School of Public Health,
677 Huntington Ave, Boston, MA 02115, USA (
)
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23
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McCarty CA, Zatzick D, Hoopes T, Payne K, Parrish R, Rivara FP. Collaborative care model for treatment of persistent symptoms after concussion among youth (CARE4PCS-II): Study protocol for a randomized, controlled trial. Trials 2019; 20:567. [PMID: 31533799 PMCID: PMC6749638 DOI: 10.1186/s13063-019-3662-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 08/19/2019] [Indexed: 11/26/2022] Open
Abstract
Background Currently, there is limited evidence to guide intervention and service delivery coordination for youth who suffer a concussion and subsequently experience persistent post-concussive symptoms (PCS) (Lumba-Brown et al. JAMA Pediatr 172(11):e182853, 2018; Lumba-Brown A et al. JAMA Pediatr 172(11):e182847, 2018). We have developed a collaborative care intervention with embedded cognitive-behavioral therapy, care management, and stepped-up psychotropic medication consultation to address persistent PCS and related psychological comorbidities. The CARE4PCS-II study was designed to assess whether adolescents with persistent symptoms after sports-related concussion will demonstrate better outcomes when receiving this collaborative care intervention compared to a usual care (control) condition. Methods/design This investigation is a randomized comparative effectiveness trial to receive intervention (collaborative care) or control (usual care). Two hundred sports-injured male and female adolescents aged 11–18 years with three or more post-concussive symptoms that persist for at least 1 month but less than 9 months after injury will be recruited and randomized into the study. The trial focuses on the effects of the intervention on post-concussive, depressive, and anxiety symptoms measured 3, 6, and 12 months after baseline. Discussion The CARE4PCS II study is a large comparative effectiveness trial targeting symptomatic improvements in sports injured adolescents after concussion. The study is unique in its adaptation of the collaborative care model to a broad spectrum of primary care, sports medicine, and school settings. The investigation incorporates novel elements such as the delivery of CBT through HIPAA complaint video conferenceing technology and has excellent widespread dissemination potential should effectiveness be demonstrated. Trial registration ClinicalTrials.gov, NCT03034720. Registered on January 27, 2017. Electronic supplementary material The online version of this article (10.1186/s13063-019-3662-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Carolyn A McCarty
- Seattle Children's Research Institute, P.O. Box 5371, M/S: CW8-5, Seattle, WA, 98145-5005, USA. .,Department of Pediatrics, University of Washington, Seattle, USA.
| | - Douglas Zatzick
- Department of Psychiatry and Behavioral Sciences, University of Washington, Harborview Medical Center 325 9th Avenue, Box 359911, Seattle, WA, 98104-2499, USA
| | - Teah Hoopes
- Seattle Children's Research Institute, P.O. Box 5371, M/S: CW8-5, Seattle, WA, 98145-5005, USA
| | - Katelyn Payne
- Seattle Children's Research Institute, P.O. Box 5371, M/S: CW8-5, Seattle, WA, 98145-5005, USA
| | - Rebecca Parrish
- Seattle Children's Research Institute, P.O. Box 5371, M/S: CW8-5, Seattle, WA, 98145-5005, USA
| | - Frederick P Rivara
- Seattle Children's Research Institute, P.O. Box 5371, M/S: CW8-5, Seattle, WA, 98145-5005, USA.,Department of Pediatrics, University of Washington, Seattle, USA
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Van Praag DLG, Cnossen MC, Polinder S, Wilson L, Maas AIR. Post-Traumatic Stress Disorder after Civilian Traumatic Brain Injury: A Systematic Review and Meta-Analysis of Prevalence Rates. J Neurotrauma 2019; 36:3220-3232. [PMID: 31238819 PMCID: PMC6857464 DOI: 10.1089/neu.2018.5759] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Post-traumatic stress disorder (PTSD) is a commonly diagnosed psychiatric disorder following traumatic brain injury (TBI). Much research on PTSD and TBI has focused on military conflict settings. Less is known about PTSD in civilian TBI. We conducted a systematic review and meta-analysis on the prevalence of PTSD after mild and moderate/severe TBI in civilian populations. We further aimed to explore the influence of methodological quality and assessment methods. A systematic literature search was performed on studies reporting on PTSD in civilian TBI, excluding studies on military populations. The risk of bias was assessed using the MORE (Methodological evaluation of Observational REsearch) checklist. Meta-analysis was conducted for overall prevalence rates for PTSD with sensitivity analyses for the severity of TBI. Fifty-two studies were included, of which 31 were graded as low risk of bias. Prevalence rates of PTSD in low risk of bias studies varied widely (2.6–36%) with a pooled prevalence rate of 15.6%. Pooled prevalence rates of PTSD for mild TBI (13.5%, 95% confidence interval [CI]: 11.7–15.3; I2 = 2%) did not differ from moderate/severe TBI (11.8, 95% CI: 7.5–16.1; I2 = 63%). Similar rates were reported in studies using different approaches and times of assessment. Although most studies that compared participants with TBI with trauma patients and healthy controls found no difference in prevalence rates of PTSD, a meta-analysis across studies revealed a higher prevalence of PTSD in patients with TBI (odds ratio [OR]: 1.73, 95% CI: 1.21–2.47). This review highlights variability between studies and emphasizes the need for higher-quality studies. Further research is warranted to determine risk factors for the development of PTSD after TBI.
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Affiliation(s)
- Dominique L G Van Praag
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Maryse C Cnossen
- Center for Medical Decision Making, Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - Suzanne Polinder
- Center for Medical Decision Making, Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - Lindsay Wilson
- Division of Psychology, University of Stirling, Stirling, United Kingdom
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
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Weppner J, Linsenmeyer M, Ide W. Military Blast-Related Traumatic Brain Injury. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2019. [DOI: 10.1007/s40141-019-00241-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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26
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Investigating the Connection Between Traumatic Brain Injury and Posttraumatic Stress Symptoms in Adolescents. J Head Trauma Rehabil 2019; 33:210-218. [PMID: 28520669 DOI: 10.1097/htr.0000000000000319] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To identify potentially modifiable individual and social-environmental correlates of posttraumatic stress symptoms (PTSS) among adolescents hospitalized for traumatic brain injury (TBI). SETTING Four pediatric hospitals and 1 general hospital in the United States. PARTICIPANTS Children ages 11 to 18 years, hospitalized for moderate-severe TBI within the past 18 months. DESIGN Retrospective cross-sectional analysis. MAIN MEASURES The University of California at Los Angeles (UCLA) Post-traumatic Stress Disorder (PTSD) Reaction Index and the Youth Self-Report (YSR) PTSD subscale. RESULTS Of 147 adolescents enrolled, 65 (44%) had severe TBI, with an average time since injury of 5.8 ± 4 months. Of the 104 who completed the UCLA-PTSD Reaction Index, 22 (21%) reported PTSS and 9 (8%) met clinical criteria for PTSD. Of the 143 who completed the YSR-PTSD subscale, 23 (16%) reported PTSS and 6 (4%) met clinical criteria for PTSD. In multivariable analyses, having a negative approach to problem solving and depressive symptoms were both associated (P < .001) with higher levels of PTSS based on the UCLA-PTSD Reaction Index (β = 0.41 and β = 0.33, respectively) and the YSR-PTSD subscale (β = 0.33 and β = 0.40, respectively). CONCLUSION Targeting negative aspects of problem solving in youths after brain injury may mitigate PTSS.
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Racial Disparities in Outpatient Mental Health Service Use Among Children Hospitalized for Traumatic Brain Injury. J Head Trauma Rehabil 2019; 33:177-184. [PMID: 29194176 DOI: 10.1097/htr.0000000000000348] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine racial differences in mental health service utilization after hospitalization for traumatic brain injury (TBI) among children with Medicaid insurance. DESIGN AND MAIN MEASURES Retrospective analysis of the MarketScan Multi-State Medicaid database from 2007 to 2012 was performed. Outpatient mental health service utilization (psychiatric and psychological individual and group services) was compared at TBI hospitalization, from discharge to 3 months and from 4 to 12 months after discharge, between children of non-Hispanic white (NHW), non-Hispanic black (NHB), Hispanic, and "Other" racial groups. Multivariable mixed-effects Poisson regression models with robust standard errors were utilized. RESULTS A total of 5674 children (aged <21 years) were included in the study. There were no differences by race/ethnicity in mental health service utilization during hospitalization. At 3 months postdischarge, NHB children and children in the "Other" racial category were significantly less likely to receive outpatient mental health services than NHW children (NHB relative risk [RR] = 0.84; 95% confidence interval [CI], 0.72-0.98; Other RR = 0.72; 95% CI, 0.57-0.90). At 12 months, all racial minority children were significantly less likely to receive outpatient mental health services than NHW children (NHB RR = 0.84; 95% CI, 0.75-0.94; Hispanic RR = 0.72; 95% CI, 0.55-0.94; Other RR = 0.71; 95% CI, 0.60-0.84). CONCLUSIONS Racial disparities in utilization of outpatient mental health services exist for minority children hospitalized for TBI and insured by Medicaid. Future research should focus on improving transitions of care from inpatient to outpatient services for these children.
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Volume and shape analysis of the Hippocampus and amygdala in veterans with traumatic brain injury and posttraumatic stress disorder. Brain Imaging Behav 2019; 14:1850-1864. [DOI: 10.1007/s11682-019-00127-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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29
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Li CMF, Robinson LR, Tam AKH. Addressing posttraumatic amnesia-Recommendations for improving patient lives after brain injury. J Trauma Acute Care Surg 2019; 86:1033-1038. [PMID: 31124903 DOI: 10.1097/ta.0000000000002233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Cathy Meng Fei Li
- From the University of Toronto (C.M.F.L.), Ontario, M5S1A8; Division of Physical Medicine and Rehabilitation (L.R.L.), Sunnybrook Health Sciences Centre, Ontario, M4N3M5; and Division of Physical Medicine & Rehabilitation, Department of Medicine (A.K.H.T.), University of Toronto, Ontario, M5S1A8
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30
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Ewing-Cobbs L, DeMaster D, Watson CG, Prasad MR, Cox CS, Kramer LA, Fischer JT, Duque G, Swank PR. Post-Traumatic Stress Symptoms after Pediatric Injury: Relation to Pre-Frontal Limbic Circuitry. J Neurotrauma 2019; 36:1738-1751. [PMID: 30672379 DOI: 10.1089/neu.2018.6071] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Pre-frontal limbic circuitry is vulnerable to effects of stress and injury. We examined microstructure of pre-frontal limbic circuitry after traumatic brain injury (TBI) or extracranial injury (EI) and its relation to post-traumatic stress symptoms (PTSS). Participants aged 8 to 15 years who sustained mild to severe TBI (n = 53) or EI (n = 26) in motor vehicle incidents were compared with healthy children (n = 38) in a prospective longitudinal study. At the seven-week follow-up, diffusion tensor imaging was obtained in all groups; injured children completed PTSS ratings using a validated scale. Using probabilistic diffusion tensor tractography, pathways were seeded from bilateral amygdalae and hippocampi to estimate the trajectory of white matter connecting them to each other and to targeted pre-frontal cortical (PFC) regions. Microstructure was estimated using fractional anisotropy (FA) in white matter and mean diffusivity (MD) in gray matter. Pre-frontal limbic microstructure was similar across groups, except for reduced FA in the right hippocampus to orbital PFC pathway in the injured versus healthy group. We examined microstructure of components of pre-frontal limbic circuitry with concurrently obtained PTSS cluster scores in the injured children. Neither microstructure nor PTSS scores differed significantly in the TBI and EI groups. Across PTSS factors, specific symptom clusters were related positively to higher FA and MD. Higher hyperarousal, avoidance, and re-experiencing symptoms were associated with higher FA in amygdala to pre-frontal and hippocampus to amygdala pathways. Higher hippocampal MD had a central role in hyperarousal and emotional numbing symptoms. Age moderated the relation of white and gray matter microstructure with hyperarousal scores. Our findings are consistent with models of traumatic stress that implicate disrupted top-down PFC and hippocampal moderation of overreactive subcortical threat arousal systems. Alterations in limbic pre-frontal circuitry and PTSS place children with either brain or body injuries at elevated risk for both current and future psychological health problems.
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Affiliation(s)
- Linda Ewing-Cobbs
- 1 Children's Learning Institute and Department of Pediatrics, University of Texas Health Science Center at Houston, Houston, Texas
| | - Dana DeMaster
- 1 Children's Learning Institute and Department of Pediatrics, University of Texas Health Science Center at Houston, Houston, Texas
| | - Christopher G Watson
- 1 Children's Learning Institute and Department of Pediatrics, University of Texas Health Science Center at Houston, Houston, Texas
| | - Mary R Prasad
- 1 Children's Learning Institute and Department of Pediatrics, University of Texas Health Science Center at Houston, Houston, Texas
| | - Charles S Cox
- 2 Department of Pediatric Surgery, University of Texas Health Science Center at Houston, Houston, Texas
| | - Larry A Kramer
- 4 Department of Interventional Radiology, University of Texas Health Science Center at Houston, Houston, Texas
| | - Jesse T Fischer
- 5 Department of Psychology, University of Houston, Houston, Texas
| | - Gerardo Duque
- 1 Children's Learning Institute and Department of Pediatrics, University of Texas Health Science Center at Houston, Houston, Texas
| | - Paul R Swank
- 3 School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas
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31
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Polich G, Iaccarino MA, Zafonte R. Psychopharmacology of traumatic brain injury. HANDBOOK OF CLINICAL NEUROLOGY 2019; 165:253-267. [PMID: 31727216 DOI: 10.1016/b978-0-444-64012-3.00015-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The pathophysiology of traumatic brain injury (TBI) can be highly variable, involving functional and/or structural damage to multiple neuroanatomical networks and neurotransmitter systems. This wide-ranging potential for physiologic injury is reflected in the diversity of neurobehavioral and neurocognitive symptoms following TBI. Here, we aim to provide a succinct, clinically relevant, up-to-date review on psychopharmacology for the most common sequelae of TBI in the postacute to chronic period. Specifically, treatment for neurobehavioral symptoms (depression, mania, anxiety, agitation/irritability, psychosis, pseudobulbar affect, and apathy) and neurocognitive symptoms (processing speed, attention, memory, executive dysfunction) will be discussed. Treatment recommendations will reflect general clinical practice patterns and the research literature.
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Affiliation(s)
- Ginger Polich
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Boston, MA, United States
| | - Mary Alexis Iaccarino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Boston, MA, United States
| | - Ross Zafonte
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Boston, MA, United States.
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Wilson JL, Hunter WM, O’Rourke JJF, Soble JR. Restructuring Blank Spaces: The Role of Cognitive-Behavioral Interventions for Two Patients With Post-traumatic Amnesia After Severe Traumatic Brain Injury. Mil Med 2019; 184:e266-e271. [DOI: 10.1093/milmed/usy179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 06/29/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jennifer L Wilson
- South Texas Veterans Health Care System – Polytrauma Rehabilitation Center, 7400 Merton Minter Boulevard, San Antonio, TX
| | - William M Hunter
- South Texas Veterans Health Care System, 7400 Merton Minter Boulevard, San Antonio, TX
| | - Justin J F O’Rourke
- South Texas Veterans Health Care System – Polytrauma Rehabilitation Center, 7400 Merton Minter Boulevard, San Antonio, TX
| | - Jason R Soble
- Department of Psychiatry, University of Illinois College of Medicine, 912 S. Wood Street, MC 913, Chicago, IL
- Department of Neurology, University of Illinois College of Medicine, 912 S. Wood Street, MC 913, Chicago, IL
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Abstract
Visual dysfunctions and symptoms are commonly experienced after even mild traumatic brain injury (TBI) despite excellent visual acuity. All individuals who have experienced a TBI/concussion should be screened for vision symptoms and visual dysfunction. A TBI-specific eye examination is necessary to identify the visual sequelae of TBI and address any vision/ocular issues that may be contributing to other post-TBI complaints. A vision rehabilitation plan that includes vision therapy can improve visual dysfunction secondary to TBI. Combining office-based and home-based vision therapy training will maximize visual potential and functional results.
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Affiliation(s)
- Sandra M Fox
- Surgical Service, Ophthalmology, Polytrauma Rehabilitation Center, South Texas Veterans Healthcare System, 7400 Merton Minter, San Antonio, TX 78229, USA.
| | - Paul Koons
- Blind Rehabilitation Service, Major Charles Robert Soltes, Jr. O.D. Blind Rehabilitation Center (BRC), Tibor Rubin VA Medical Center, 5901 East 7th Street, Long Beach, CA 90822, USA
| | - Sally H Dang
- Optometry Service, VA Long Beach Healthcare System, 5901 East 7th Street, Long Beach, CA 90822, USA
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Klimova A, Korgaonkar MS, Whitford T, Bryant RA. Diffusion Tensor Imaging Analysis of Mild Traumatic Brain Injury and Posttraumatic Stress Disorder. BIOLOGICAL PSYCHIATRY: COGNITIVE NEUROSCIENCE AND NEUROIMAGING 2018; 4:81-90. [PMID: 30616750 DOI: 10.1016/j.bpsc.2018.10.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 09/13/2018] [Accepted: 09/13/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND Debate exists over the extent to which dysfunctions arising from mild traumatic brain injury (mTBI) are distinct from posttraumatic stress disorder (PTSD). METHODS This study investigated 1) the white matter integrity of participants with either mTBI or PTSD, and 2) the relationship between white matter integrity and postconcussive syndrome. The sample comprised 110 civilians (mTBI group = 40; PTSD group = 32; age- and sex-matched trauma-exposed control subjects = 38) recruited from community advertising. Indicators of white matter abnormalities were fractional anisotropy, mean diffusivity, axial diffusivity, and radial diffusivity. PTSD symptoms were indexed by the Clinician-Administered PTSD Scale, and postconcussive symptoms were assessed using the Somatic and Psychological Health Report measure. RESULTS Fractional anisotropy was reduced in mTBI participants in the corpus callosum, tracts of the brainstem, projection fibers, association fibers, and limbic fibers compared with both PTSD and trauma-exposed control subjects. This decrease in fractional anisotropy was observed in the context of concurrent changes in radial diffusivity, axial diffusivity, and mean diffusivity. Postconcussive symptoms were largely explained by PTSD severity rather than by changes in brain white matter. mTBI appears to be characterized by distinct reductions in white matter integrity, and this cannot be attributed to PTSD. CONCLUSIONS PTSD symptoms appear to be more strongly associated with postconcussive syndrome than with white matter compromise. These findings extend epidemiological evidence of the relative associations of PTSD and mTBI with postconcussive syndrome.
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Affiliation(s)
- Aleksandra Klimova
- School of Psychology, University of New South Wales, Sydney, Australia; Brain Dynamics Centre, Westmead Institute for Medical Research, Westmead, Australia
| | | | - Thomas Whitford
- School of Psychology, University of New South Wales, Sydney, Australia
| | - Richard A Bryant
- School of Psychology, University of New South Wales, Sydney, Australia; Brain Dynamics Centre, Westmead Institute for Medical Research, Westmead, Australia.
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Abstract
PURPOSE OF REVIEW We review recent research addressing neurocognitive and information processing abnormalities in posttraumatic stress disorder (PTSD), including studies informing direction of causality. We additionally consider neurocognition in the context of co-morbid mild traumatic brain injury (TBI) and psychosocial treatments for PTSD. RECENT FINDINGS Learning, memory, attention, inhibitory functions, and information processing biases frequently accompany PTSD, reflecting potential bi-directional relationships with PTSD. Although mild TBI is associated with increased risk of PTSD development and maintenance, TBI does not typically contribute significantly to sustained neurocognitive deficits in individuals with PTSD. Whereas better learning and memory is associated with mildly enhanced response to psychosocial interventions, such interventions may also improve neurocognitive performance and can be effectively provided to patients with TBI history. PTSD is associated with cognitive abnormalities in processing both emotionally relevant and emotionally neutral information and, although mild, may underlie some PTSD symptom expression.
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Affiliation(s)
- Jennifer J Vasterling
- Psychology (116B), National Center for PTSD at VA Boston Healthcare System, 150 S. Huntington Ave., Boston, MA, 02130, USA.
- Boston University School of Medicine, Boston, MA, USA.
| | - Kimberly A Arditte Hall
- Psychology (116B), National Center for PTSD at VA Boston Healthcare System, 150 S. Huntington Ave., Boston, MA, 02130, USA
- Boston University School of Medicine, Boston, MA, USA
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Salinsky M, Rutecki P, Parko K, Goy E, Storzbach D, O'Neil M, Binder L, Joos S. Psychiatric comorbidity and traumatic brain injury attribution in patients with psychogenic nonepileptic or epileptic seizures: A multicenter study of US veterans. Epilepsia 2018; 59:1945-1953. [DOI: 10.1111/epi.14542] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 07/24/2018] [Accepted: 07/24/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Martin Salinsky
- VA Portland Health Care System; Portland Oregon
- Oregon Health & Science University; Portland Oregon
| | - Paul Rutecki
- William S. Middleton Memorial Veterans Affairs Medical Center; Madison Wisconsin
| | - Karen Parko
- San Francisco Veterans Affairs Medical Center; San Francisco California
| | | | | | - Maya O'Neil
- VA Portland Health Care System; Portland Oregon
| | | | - Sandra Joos
- VA Portland Health Care System; Portland Oregon
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Paredes Molina CS, Berry S, Nielsen A, Winfield R. PTSD in civilian populations after hospitalization following traumatic injury: A comprehensive review. Am J Surg 2018; 216:745-753. [PMID: 30103902 DOI: 10.1016/j.amjsurg.2018.07.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 06/01/2018] [Accepted: 07/17/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Injuries and their comorbidities affect victims far beyond their physical recovery period. Some study-measures show that more than half of patients hospitalized for a traumatic injury suffer from Acute Stress Disorder, alcohol dependence, and recurrent trauma. Overall, this literature review serves to review risk factors for PTSD, screening tools, follow-up strategies, and gaps in the literature for achieving feasible patient-centered interventions for the prevention of PTSD after a traumatic injury. DATA SOURCES A literature review was performed from August 1, 2017 to March 19, 2018, from 3 Databases: PubMed, CINAHL and Cochrane, with keywords: "PTSD", "Post-traumatic Stress Disorder", "Civilians", "Traumatic", "Injury", "Follow-up", "Treatment", "Referral", "surgery", "surgical", "Intervention", and "Insured", "underinsured". CONCLUSIONS Reported risk factors for PTSD were: prior psychiatric disorder, gunshots, and lack of social support. Most articles use the Posttraumatic Stress Disorder Checklist - Civilian version. Follow-up strategies mainly focus on multidisciplinary intervention protocols, including social workers, behavioral health specialists, and psychiatrists. Finally, gaps in the literature show the need for bilingual/bicultural patient-centered care for elderly, diverse ethnic backgrounds, and insured vs. uninsured patients.
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Affiliation(s)
| | - Stepheny Berry
- The University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS, 66160, USA
| | - Alexandra Nielsen
- The University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS, 66160, USA
| | - Robert Winfield
- The University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS, 66160, USA.
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Ellis J, Zaretsky A. Assessment and Management of Posttraumatic Stress Disorder. ACTA ACUST UNITED AC 2018; 24:873-892. [PMID: 29851883 DOI: 10.1212/con.0000000000000610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE The goal of this article is to increase clinicians' understanding of posttraumatic stress disorder (PTSD) and improve skills in assessing risk for and diagnosing PTSD. The importance and sequelae of lifetime trauma burden are discussed, with reference to trends in prevention, early intervention, and treatment. RECENT FINDINGS PTSD has different clinical phenotypes, which are reflected in the changes in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria. PTSD is almost always complicated by comorbidity. Treatment requires a multimodal approach, usually including medication, different therapeutic techniques, and management of comorbidity. Interest is growing in the neurobiology of childhood survivors of trauma, intergenerational transmission of trauma, and long-term impact of trauma on physical health. Mitigation of the risk of PTSD pretrauma in the military and first responders is gaining momentum, given concerns about the cost and disability associated with PTSD. Interest is also growing in screening for PTSD in medical populations, with evidence of improved clinical outcomes. Preliminary research supports the treatment of PTSD with repetitive transcranial magnetic stimulation. SUMMARY PTSD is a trauma-related disorder with features of fear and negative thinking about the trauma and the future. Untreated, it leads to ongoing disruption of life due to avoidance, impaired vocational and social functioning, and other symptoms, depending on the phenotype. Despite a theoretical understanding of underlying mechanisms, PTSD remains challenging to treat, although evidence exists for benefit of pharmacologic agents and trauma-focused therapies. A need still remains for treatments that are more effective and efficient, with faster onset.
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Comorbid Posttraumatic Stress Disorder and Traumatic Brain Injury: Generalization of Prolonged-Exposure PTSD Treatment Outcomes to Postconcussive Symptoms, Cognition, and Self-Efficacy in Veterans and Active Duty Service Members. J Head Trauma Rehabil 2018; 33:E53-E63. [DOI: 10.1097/htr.0000000000000344] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Heinz AJ, Pennington DL, Cohen N, Schmeling B, Lasher BA, Schrodek E, Batki SL. Relations Between Cognitive Functioning and Alcohol Use, Craving, and Post-Traumatic Stress: An Examination Among Trauma-Exposed Military Veterans With Alcohol Use Disorder. Mil Med 2018; 181:663-71. [PMID: 27391620 DOI: 10.7205/milmed-d-15-00228] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Cognitive dysfunction is commonly observed among individuals with alcohol use disorder (AUD) and trauma exposure and is, in turn, associated with worse clinical outcomes. Accordingly, disruptions in cognitive functioning may be conceptualized as a trans-disease phenomenon representing a potential high-yield target for intervention. Less is known though about how different cognitive functions covary with alcohol use, craving, and post-traumatic stress symptom severity among trauma-exposed individuals with AUD. Sixty-eight male and female trauma-exposed military veterans with AUD, entering treatment trials to reduce alcohol use, completed measures assessing alcohol use and craving, post-traumatic stress symptom severity, and cognitive functioning. In multivariate models, after controlling for post-traumatic stress symptom severity, poorer learning and memory was associated with higher alcohol consumption and higher risk taking/impulsivity was associated with stronger preoccupations with alcohol and compulsions to drink. Alcohol consumption and craving, but not performance on cognitive tests, were positively associated with post-traumatic stress symptom severity. Findings suggest that interventions to strengthen cognitive functioning might be used as a preparatory step to augment treatments for AUD. Clinicians are encouraged to consider a standard assessment of cognitive functioning, in addition to post-traumatic stress symptom severity, in treatment planning and delivery for this vulnerable and high-risk population.
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Affiliation(s)
- Adrienne J Heinz
- National Center for Post-Traumatic Stress Disorder, Center for Innovation to Implementation, Palo Alto Veterans Affairs Health Care System, 795 Willow Road, Menlo Park, CA 94025
| | - David L Pennington
- San Francisco Veteran Affairs Medical Center 4150 Clement Street, San Francisco, CA 94121
| | - Nicole Cohen
- National Center for Post-Traumatic Stress Disorder, Center for Innovation to Implementation, Palo Alto Veterans Affairs Health Care System, 795 Willow Road, Menlo Park, CA 94025
| | - Brandi Schmeling
- Palo Alto University, 1791 Arastradero Road, Palo Alto, CA 94304
| | - Brooke A Lasher
- San Francisco Veteran Affairs Medical Center 4150 Clement Street, San Francisco, CA 94121
| | - Emily Schrodek
- San Francisco Veteran Affairs Medical Center 4150 Clement Street, San Francisco, CA 94121
| | - Steven L Batki
- San Francisco Veteran Affairs Medical Center 4150 Clement Street, San Francisco, CA 94121
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Kaplan GB, Leite-Morris KA, Wang L, Rumbika KK, Heinrichs SC, Zeng X, Wu L, Arena DT, Teng YD. Pathophysiological Bases of Comorbidity: Traumatic Brain Injury and Post-Traumatic Stress Disorder. J Neurotrauma 2017; 35:210-225. [PMID: 29017388 DOI: 10.1089/neu.2016.4953] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The high rates of traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) diagnoses encountered in recent years by the United States Veterans Affairs Healthcare System have increased public awareness and research investigation into these conditions. In this review, we analyze the neural mechanisms underlying the TBI/PTSD comorbidity. TBI and PTSD present with common neuropsychiatric symptoms including anxiety, irritability, insomnia, personality changes, and memory problems, and this overlap complicates diagnostic differentiation. Interestingly, both TBI and PTSD can be produced by overlapping pathophysiological changes that disrupt neural connections termed the "connectome." The neural disruptions shared by PTSD and TBI and the comorbid condition include asymmetrical white matter tract abnormalities and gray matter changes in the basolateral amygdala, hippocampus, and prefrontal cortex. These neural circuitry dysfunctions result in behavioral changes that include executive function and memory impairments, fear retention, fear extinction deficiencies, and other disturbances. Pathophysiological etiologies can be identified using experimental models of TBI, such as fluid percussion or blast injuries, and for PTSD, using models of fear conditioning, retention, and extinction. In both TBI and PTSD, there are discernible signs of neuroinflammation, excitotoxicity, and oxidative damage. These disturbances produce neuronal death and degeneration, axonal injury, and dendritic spine dysregulation and changes in neuronal morphology. In laboratory studies, various forms of pharmacological or psychological treatments are capable of reversing these detrimental processes and promoting axonal repair, dendritic remodeling, and neurocircuitry reorganization, resulting in behavioral and cognitive functional enhancements. Based on these mechanisms, novel neurorestorative therapeutics using anti-inflammatory, antioxidant, and anticonvulsant agents may promote better outcomes for comorbid TBI and PTSD.
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Affiliation(s)
- Gary B Kaplan
- 1 Mental Health Service , VA Boston Healthcare System, Brockton, Massachusetts.,2 Department of Psychiatry, Boston University School of Medicine , Boston, Massachusetts.,3 Department of Pharmacology and Experimental Therapeutics, Boston University School of Medicine , Boston, Massachusetts
| | - Kimberly A Leite-Morris
- 2 Department of Psychiatry, Boston University School of Medicine , Boston, Massachusetts.,3 Department of Pharmacology and Experimental Therapeutics, Boston University School of Medicine , Boston, Massachusetts.,4 Research Service, VA Boston Healthcare System , Jamaica Plain, Massachusetts
| | - Lei Wang
- 5 Division of Spinal Cord Injury Research, VA Boston Healthcare System , West Roxbury, Massachusetts.,6 Departments of Physical Medicine and Rehabilitation and Neurosurgery, Harvard Medical School , Boston, Massachusetts
| | - Kendra K Rumbika
- 7 Research Service, VA Boston Healthcare System , West Roxbury, Massachusetts
| | - Stephen C Heinrichs
- 7 Research Service, VA Boston Healthcare System , West Roxbury, Massachusetts
| | - Xiang Zeng
- 5 Division of Spinal Cord Injury Research, VA Boston Healthcare System , West Roxbury, Massachusetts.,6 Departments of Physical Medicine and Rehabilitation and Neurosurgery, Harvard Medical School , Boston, Massachusetts
| | - Liquan Wu
- 5 Division of Spinal Cord Injury Research, VA Boston Healthcare System , West Roxbury, Massachusetts.,6 Departments of Physical Medicine and Rehabilitation and Neurosurgery, Harvard Medical School , Boston, Massachusetts
| | - Danielle T Arena
- 7 Research Service, VA Boston Healthcare System , West Roxbury, Massachusetts
| | - Yang D Teng
- 5 Division of Spinal Cord Injury Research, VA Boston Healthcare System , West Roxbury, Massachusetts.,6 Departments of Physical Medicine and Rehabilitation and Neurosurgery, Harvard Medical School , Boston, Massachusetts
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42
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Falkenberg L, Zeckey C, Mommsen P, Winkelmann M, Zelle BA, Panzica M, Pape HC, Krettek C, Probst C. Long-term outcome in 324 polytrauma patients: what factors are associated with posttraumatic stress disorder and depressive disorder symptoms? Eur J Med Res 2017; 22:44. [PMID: 29084612 PMCID: PMC5663112 DOI: 10.1186/s40001-017-0282-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 09/28/2017] [Indexed: 12/14/2022] Open
Abstract
Background Physical impairment is well-known to last for many years after a severe injury, and there is a high impact on the quality of the survivor’s life. The purpose of this study was to examine if this is also true for psychological impairment with symptoms of posttraumatic stress disorder or depression after polytrauma. Design Retrospective cohort outcome study. Setting Level I trauma centre. Population 637 polytrauma trauma patients who were treated at our Level I trauma centre between 1973 and 1990. Minimum follow-up was 10 years after the injury. Methods Patients were asked to fill in a questionnaire, including parts of the Posttraumatic Stress Diagnostic Scale, the Impact of Event Scale-Revised and the German Hospital Anxiety and Depression Scale, to evaluate mental health. Clinical outcome was assessed before by standardised scores. Results Three hundred and twenty-four questionnaires were evaluated. One hundred and forty-nine (45.9%) patients presented with symptoms of mental impairment. Quality of life was significantly higher in the mentally healthy group, while the impaired group achieved a lower rehabilitation status. Conclusions Mental impairment can be found in multiple trauma victims, even after 10 years or more. Treating physicians should not only focus on early physical rehabilitation but also focus on early mental rehabilitation to prevent long-term problems in both physical and mental disability.
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Affiliation(s)
- Lisa Falkenberg
- Trauma Department, Hannover Medical School, Hannover, Germany
| | - Christian Zeckey
- Trauma Department, Hannover Medical School, Hannover, Germany. .,Department of General, Trauma and Reconstructive Surgery, Ludwig-Maximilians-Universität München, Munich, Germany.
| | - Philipp Mommsen
- Trauma Department, Hannover Medical School, Hannover, Germany
| | | | - Boris A Zelle
- Division of Orthopaedic Traumatology, Department of Orthopaedic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Martin Panzica
- Trauma Department, Hannover Medical School, Hannover, Germany
| | - Hans-Christoph Pape
- Department of Trauma Surgery, University Hospital Zurich, Zurich, Switzerland
| | | | - Christian Probst
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Center, University of Witten/Herdecke, Cologne, Germany
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Abstract
The past 50 years have been a period of exciting progress in neuropsychological research on traumatic brain injury (TBI). Neuropsychologists and neuropsychological testing have played a critical role in these advances. This study looks back at three major scientific advances in research on TBI that have been critical in pushing the field forward over the past several decades: The advent of modern neuroimaging; the recognition of the importance of non-injury factors in determining recovery from TBI; and the growth of cognitive rehabilitation. Thanks to these advances, we now have a better understanding of the pathophysiology of TBI and how recovery from the injury is also shaped by pre-injury, comorbid, and contextual factors, and we also have increasing evidence that active interventions, including cognitive rehabilitation, can help to promote better outcomes. The study also peers ahead to discern two important directions that seem destined to influence research on TBI over the next 50 years: the development of large, multi-site observational studies and randomized controlled trials, bolstered by international research consortia and the adoption of common data elements; and attempts to translate research into health care and health policy by the application of rigorous methods drawn from implementation science. Future research shaped by these trends should provide critical evidence regarding the outcomes of TBI and its treatment, and should help to disseminate and implement the knowledge gained from research to the betterment of the quality of life of persons with TBI. (JINS, 2017, 23, 806-817).
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Ewing-Cobbs L, Prasad MR, Cox CS, Granger DA, Duque G, Swank PR. Altered stress system reactivity after pediatric injury: Relation with post-traumatic stress symptoms. Psychoneuroendocrinology 2017; 84:66-75. [PMID: 28667938 PMCID: PMC5555029 DOI: 10.1016/j.psyneuen.2017.06.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 05/22/2017] [Accepted: 06/08/2017] [Indexed: 12/14/2022]
Abstract
Injury is the leading cause of death and disability in childhood. Injured children are at high risk for developing alterations in stress response systems and post-traumatic stress symptoms (PTSS) that may compromise long-term physical and psychological health. In a prospective, observational cohort study, we examined individual differences in, and correlates of, stress-reactivity of the hypothalamic-pituitary-adrenal axis (HPA; salivary cortisol) and autonomic nervous system (ANS; salivary alpha amylase, sAA) following pediatric injury. Participants were 8-15 years of age and hospitalized for traumatic brain injury (TBI; n=55; M age=13.9 yrs; 40 males) or extracranial injury (EI; n=29; M age 12.3 yrs, 20 males) following vehicular accidents. Six months post-injury, saliva was collected before and after the Trier Social Stress Test and later assayed for cortisol and sAA. Relative to a healthy non-injured comparison group (n=33; M age=12.5 yrs, 16 males), injured children (ages 8-12 years), but not adolescents (ages 13-15 yrs), had higher cortisol levels; regardless of age, injured participants showed dampened cortisol reactivity to social evaluative threat. Compared to participants with EI, children with TBI had elevated cortisol and adolescents had elevated sAA. With respect to PTSS, individual differences in sAA were negatively correlated with avoidance in the TBI group and positively correlated with emotional numbing within the EI group. Importantly, psychological and neurobiological sequelae were weakly related to injury severity. Given the high prevalence of pediatric injury, these sequelae affect many children and represent a significant public health concern. Consequently, surveillance of post-traumatic sequelae should include the full spectrum of injury severity. Monitoring the activity, reactivity, and regulation of biological systems sensitive to environmental insults may advance our understanding of individual differences in sequelae and adaptation following traumatic pediatric injury.
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Affiliation(s)
- Linda Ewing-Cobbs
- Department of Pediatrics and Children's Learning Institute, University of Texas Health Science Center at Houston, United States.
| | - Mary R Prasad
- Department of Pediatrics and Children's Learning Institute, University of Texas Health Science Center at Houston, United States
| | - Charles S Cox
- Department of Pediatric Surgery, University of Texas Health Science Center at Houston, United States
| | - Douglas A Granger
- Department of Psychology and Social Behavior, Pediatrics, and Public Health and Institute for Interdisciplinary Salivary Bioscience, University of California Irvine, United States; School of Nursing, Bloomberg School of Public Health, and School of Medicine, Johns Hopkins University, United States
| | - Gerardo Duque
- Department of Pediatrics and Children's Learning Institute, University of Texas Health Science Center at Houston, United States
| | - Paul R Swank
- School of Public Health, University of Texas Health Science Center at Houston, United States
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45
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Main KL, Soman S, Pestilli F, Furst A, Noda A, Hernandez B, Kong J, Cheng J, Fairchild JK, Taylor J, Yesavage J, Wesson Ashford J, Kraemer H, Adamson MM. DTI measures identify mild and moderate TBI cases among patients with complex health problems: A receiver operating characteristic analysis of U.S. veterans. Neuroimage Clin 2017; 16:1-16. [PMID: 28725550 PMCID: PMC5503837 DOI: 10.1016/j.nicl.2017.06.031] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 06/10/2017] [Accepted: 06/23/2017] [Indexed: 01/10/2023]
Abstract
Standard MRI methods are often inadequate for identifying mild traumatic brain injury (TBI). Advances in diffusion tensor imaging now provide potential biomarkers of TBI among white matter fascicles (tracts). However, it is still unclear which tracts are most pertinent to TBI diagnosis. This study ranked fiber tracts on their ability to discriminate patients with and without TBI. We acquired diffusion tensor imaging data from military veterans admitted to a polytrauma clinic (Overall n = 109; Age: M = 47.2, SD = 11.3; Male: 88%; TBI: 67%). TBI diagnosis was based on self-report and neurological examination. Fiber tractography analysis produced 20 fiber tracts per patient. Each tract yielded four clinically relevant measures (fractional anisotropy, mean diffusivity, radial diffusivity, and axial diffusivity). We applied receiver operating characteristic (ROC) analyses to identify the most diagnostic tract for each measure. The analyses produced an optimal cutpoint for each tract. We then used kappa coefficients to rate the agreement of each cutpoint with the neurologist's diagnosis. The tract with the highest kappa was most diagnostic. As a check on the ROC results, we performed a stepwise logistic regression on each measure using all 20 tracts as predictors. We also bootstrapped the ROC analyses to compute the 95% confidence intervals for sensitivity, specificity, and the highest kappa coefficients. The ROC analyses identified two fiber tracts as most diagnostic of TBI: the left cingulum (LCG) and the left inferior fronto-occipital fasciculus (LIF). Like ROC, logistic regression identified LCG as most predictive for the FA measure but identified the right anterior thalamic tract (RAT) for the MD, RD, and AD measures. These findings are potentially relevant to the development of TBI biomarkers. Our methods also demonstrate how ROC analysis may be used to identify clinically relevant variables in the TBI population.
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Key Words
- AD, axial diffusivity
- Axon degeneration
- CC, corpus callosum
- Concussion
- DAI, diffuse axonal injury
- DTI, diffusion tensor imaging
- FA, fractional anisotropy
- GN, genu
- Imaging
- LAT, left anterior thalamic tract
- LCG, left cingulum
- LCH, left cingulum – hippocampus
- LCS, left cortico-spinal tract
- LIF, left inferior fronto-occipital fasciculus
- LIL, left inferior longitudinal fasciculus
- LSL, left superior longitudinal fasciculus
- LST, left superior longitudinal fasciculus – temporal
- LUN, left uncinate
- MD, mean diffusivity
- Neurodegeneration
- PTSD, post-traumatic stress disorder
- RAT, right anterior thalamic tract
- RCG, right cingulum
- RCH, right cingulum – Hippocampus
- RCS, right cortico-spinal tract
- RD, radial diffusivity
- RIF, right inferior fronto-occipital fasciculus
- RIL, right inferior longitudinal fasciculus
- ROC, receiver operating characteristic
- RSL, right superior longitudinal fasciculus
- RST, right superior longitudinal fasciculus – temporal
- RUN, right uncinate
- SP, splenium
- TBI, traumatic brain injury
- Traumatic brain injury
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Affiliation(s)
- Keith L. Main
- War Related Illness and Injury Study Center, Veterans Affairs, Palo Alto Health Care System (VAPAHCS), Palo Alto, CA, United States
- Defense and Veterans Brain Injury Center (DVBIC), Silver Spring, MD, United States
- General Dynamics Health Solutions (GDHS), Fairfax, VA, United States
| | - Salil Soman
- War Related Illness and Injury Study Center, Veterans Affairs, Palo Alto Health Care System (VAPAHCS), Palo Alto, CA, United States
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Franco Pestilli
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, IN, United States
| | - Ansgar Furst
- War Related Illness and Injury Study Center, Veterans Affairs, Palo Alto Health Care System (VAPAHCS), Palo Alto, CA, United States
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, United States
| | - Art Noda
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States
| | - Beatriz Hernandez
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States
| | - Jennifer Kong
- War Related Illness and Injury Study Center, Veterans Affairs, Palo Alto Health Care System (VAPAHCS), Palo Alto, CA, United States
| | - Jauhtai Cheng
- War Related Illness and Injury Study Center, Veterans Affairs, Palo Alto Health Care System (VAPAHCS), Palo Alto, CA, United States
| | - Jennifer K. Fairchild
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States
| | - Joy Taylor
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States
| | - Jerome Yesavage
- War Related Illness and Injury Study Center, Veterans Affairs, Palo Alto Health Care System (VAPAHCS), Palo Alto, CA, United States
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States
| | - J. Wesson Ashford
- War Related Illness and Injury Study Center, Veterans Affairs, Palo Alto Health Care System (VAPAHCS), Palo Alto, CA, United States
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States
| | - Helena Kraemer
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States
| | - Maheen M. Adamson
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States
- Department of Neurosurgery, Stanford School of Medicine, Stanford, CA, United States
- Defense and Veterans Brain Injury Center (DVBIC), Veterans Affairs, Palo Alto Health Care System (VAPAHCS), Palo Alto, CA, United States
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46
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Hellstrøm T, Westlye LT, Server A, Løvstad M, Brunborg C, Lund MJ, Nordhøy W, Andreassen OA, Andelic N. Volumetric and morphometric MRI findings in patients with mild traumatic brain injury. Brain Inj 2016; 30:1683-1691. [PMID: 27996331 DOI: 10.1080/02699052.2016.1199905] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE This study compared cortical and sub-cortical volumes between patients with complicated (i.e. presence of intracranial abnormality on the day-of-injury CT) and uncomplicated (i.e. absence of intracranial abnormality) mild traumatic brain injury (MTBI) 4 weeks post-injury. The study hypothesized regionally decreased brain volumes and reduced cortical thickness in patients with complicated MTBIs compared with uncomplicated MTBI. METHODS This study was part of a larger 2 years cohort study on MTBI. Baseline clinical and magnetic resonance imaging (MRI) data were compared for those with complicated and uncomplicated MTBI. It identified 168 patients with MTBI (90 uncomplicated and 78 complicated), aged 16-65 years. 3T MRI-system (Signa HDxt, GE Medical Systems, Milwaukee, WI) and cortical reconstruction and volumetric segmentation by FreeSurfer software have been used. RESULTS No significant differences between uncomplicated and complicated MTBIs were found in neuroanatomic volumes and cortical thickness after controlling for age, gender and education. The complicated MTBI group showed larger ventricles compared with the uncomplicated group, but this effect diluted when adjusting for potential confounders. CONCLUSION The study findings suggest that the classification of complicated and uncomplicated MTBI may be too broad to differentiate volumetric and morphometric effects of injury in the early post-injury phase.
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Affiliation(s)
- T Hellstrøm
- a Department of Physical Medicine and Rehabilitation , Oslo University Hospital , Oslo , Norway
| | - L T Westlye
- b KG Jebsen Centre for Psychosis Research/Norwegian Centre for Mental Disorder Research (NORMENT), Division of Mental Health and Addiction , Oslo University Hospital , Oslo , Norway.,c Department of Psychology , University of Oslo , Oslo , Norway
| | - A Server
- d Department of Radiology and Nuclear Medicine , Oslo University Hospital , Oslo , Norway
| | - M Løvstad
- c Department of Psychology , University of Oslo , Oslo , Norway.,e Sunnaas Rehabilitation Hospital, Department of Research , Nesoddtangen , Norway
| | - C Brunborg
- f Oslo Centre for Biostatistics and Epidemiology, Research Support Services , Oslo University Hospital , Oslo , Norway
| | - M J Lund
- b KG Jebsen Centre for Psychosis Research/Norwegian Centre for Mental Disorder Research (NORMENT), Division of Mental Health and Addiction , Oslo University Hospital , Oslo , Norway
| | - W Nordhøy
- g The Intervention Centre , Oslo University Hospital , Oslo , Norway
| | - O A Andreassen
- b KG Jebsen Centre for Psychosis Research/Norwegian Centre for Mental Disorder Research (NORMENT), Division of Mental Health and Addiction , Oslo University Hospital , Oslo , Norway
| | - N Andelic
- a Department of Physical Medicine and Rehabilitation , Oslo University Hospital , Oslo , Norway.,h CHARM Research Centre for Habilitation and Rehabilitation Models & Services, Institute of Health and Society, University of Oslo , Oslo , Norway
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47
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Parks AC, Gfeller J, Emmert N, Lammert H. Detecting feigned postconcussional and posttraumatic stress symptoms with the structured inventory of malingered symptomatology (SIMS). APPLIED NEUROPSYCHOLOGY-ADULT 2016; 24:429-438. [PMID: 27284810 DOI: 10.1080/23279095.2016.1189426] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The Structured Inventory of Malingered Symptomatology (SIMS) is a standalone symptom validity test (SVT) designed as a screening measure to detect a variety of exaggerated psychological symptoms. A number of studies have explored the accuracy of the SIMS in litigious and clinical populations, yet few have examined the validity of the SIMS in detecting feigned symptoms of postconcussional disorder (PCD) and posttraumatic stress disorder (PTSD). The present study examined the sensitivity of the SIMS in detecting undergraduate simulators (N = 78) feigning symptoms of PCD, PTSD, and the comorbid presentation of both PCD and PTSD symptomatologies. Overall, the SIMS Total score produced the highest sensitivities for the PCD symptoms and PCD+PTSD symptoms groups (.89 and .85, respectively), and to a lesser extent, the PTSD symptoms group (.69). The Affective Disorders (AF) subscale was most sensitive to the PTSD symptoms group compared to the PCD and PCD+PTSD symptoms groups. Additional sensitivity values are presented and examined at multiple scale cutoff scores. These findings support the use of the SIMS as a SVT screening measure for PCD and PTSD symptom exaggeration in neuropsychological assessment.
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Affiliation(s)
- Adam C Parks
- a Department of Psychiatry and Psychology , Mayo Clinic Florida , Jacksonville , Florida , USA
| | - Jeffrey Gfeller
- b Department of Psychology , Saint Louis University , Saint Louis , Missouri , USA
| | - Natalie Emmert
- b Department of Psychology , Saint Louis University , Saint Louis , Missouri , USA
| | - Hannah Lammert
- c Department of Psychology , University of Minnesota Duluth , Duluth , Minnesota , USA
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48
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Haarbauer-Krupa J, Taylor CA, Yue JK, Winkler EA, Pirracchio R, Cooper SR, Burke JF, Stein MB, Manley GT. Screening for Post-Traumatic Stress Disorder in a Civilian Emergency Department Population with Traumatic Brain Injury. J Neurotrauma 2016; 34:50-58. [PMID: 26936513 DOI: 10.1089/neu.2015.4158] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Post-traumatic stress disorder (PTSD) is a condition associated with traumatic brain injury (TBI). While the importance of PTSD and TBI among military personnel is widely recognized, there is less awareness of PTSD associated with civilian TBI. We examined the incidence and factors associated with PTSD 6 months post-injury in a civilian emergency department population using measures from the National Institute of Neurological Disorders and Stroke TBI Common Data Elements Outcome Battery. Participants with mild TBI (mTBI) from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot study with complete 6-month outcome batteries (n = 280) were analyzed. Screening for PTSD symptoms was conducted using the PTSD Checklist-Civilian Version. Descriptive measures are summarized and predictors for PTSD were examined using logistic regression. Incidence of screening positive for PTSD was 26.8% at 6 months following mTBI. Screening positive for PTSD was significantly associated with concurrent functional disability, post-concussive and psychiatric symptomatology, decreased satisfaction with life, and decreased performance in visual processing and mental flexibility. Multi-variable regression showed injury mechanism of assault (odds ratio [OR] 3.59; 95% confidence interval [CI] 1.69-7.63; p = 0.001) and prior psychiatric history (OR 2.56; 95% CI 1.42-4.61; p = 0.002) remained significant predictors of screening positive for PTSD, while education (per year OR 0.88; 95% CI 0.79-0.98; p = 0.021) was associated with decreased odds of PTSD. Standardized data collection and review of pre-injury education, psychiatric history, and injury mechanism during initial hospital presentation can aid in identifying patients with mTBI at risk for developing PTSD symptoms who may benefit from closer follow-up after initial injury care.
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Affiliation(s)
- Juliet Haarbauer-Krupa
- 1 Division of Unintentional Injury, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention , Atlanta, Georgia
| | - Christopher A Taylor
- 1 Division of Unintentional Injury, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention , Atlanta, Georgia
| | - John K Yue
- 2 Department of Neurological Surgery, University of California , San Francisco, San Francisco, California.,3 Brain and Spinal Injury Center, San Francisco General Hospital , San Francisco, California
| | - Ethan A Winkler
- 2 Department of Neurological Surgery, University of California , San Francisco, San Francisco, California.,3 Brain and Spinal Injury Center, San Francisco General Hospital , San Francisco, California
| | - Romain Pirracchio
- 4 Department of Anesthesia and Perioperative Care, University of California , San Francisco, San Francisco, California
| | - Shelly R Cooper
- 2 Department of Neurological Surgery, University of California , San Francisco, San Francisco, California.,3 Brain and Spinal Injury Center, San Francisco General Hospital , San Francisco, California.,5 Department of Psychology, Washington University in St. Louis , St. Louis, Missouri
| | - John F Burke
- 2 Department of Neurological Surgery, University of California , San Francisco, San Francisco, California.,3 Brain and Spinal Injury Center, San Francisco General Hospital , San Francisco, California
| | - Murray B Stein
- 6 Department of Psychiatry, University of California , San Diego, San Diego, California.,7 Department of Family and Preventive Medicine, University of California , San Diego, San Diego, California
| | - Geoffrey T Manley
- 2 Department of Neurological Surgery, University of California , San Francisco, San Francisco, California.,3 Brain and Spinal Injury Center, San Francisco General Hospital , San Francisco, California
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49
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Zatzick DF, Russo J, Darnell D, Chambers DA, Palinkas L, Van Eaton E, Wang J, Ingraham LM, Guiney R, Heagerty P, Comstock B, Whiteside LK, Jurkovich G. An effectiveness-implementation hybrid trial study protocol targeting posttraumatic stress disorder and comorbidity. Implement Sci 2016; 11:58. [PMID: 27130272 PMCID: PMC4851808 DOI: 10.1186/s13012-016-0424-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 04/20/2016] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Each year in the USA, 1.5-2.5 million Americans are so severely injured that they require inpatient hospitalization. Multiple conditions including posttraumatic stress disorder (PTSD), alcohol and drug use problems, depression, and chronic medical conditions are endemic among physical trauma survivors with and without traumatic brain injuries. METHODS/DESIGN The trauma survivors outcomes and support (TSOS) effectiveness-implementation hybrid trial is designed to test the delivery of high-quality screening and intervention for PTSD and comorbidities across 24 US level I trauma center sites. The pragmatic trial aims to recruit 960 patients. The TSOS investigation employs a stepped wedge cluster randomized design in which sites are randomized sequentially to initiate the intervention. Patients identified by a 10-domain electronic health record screen as high risk for PTSD are formally assessed with the PTSD Checklist for study entry. Patients randomized to the intervention condition will receive stepped collaborative care, while patients randomized to the control condition will receive enhanced usual care. The intervention training begins with a 1-day on-site workshop in the collaborative care intervention core elements that include care management, medication, cognitive behavioral therapy, and motivational-interviewing elements targeting PTSD and comorbidity. The training is followed by site supervision from the study team. The investigation aims to determine if intervention patients demonstrate significant reductions in PTSD and depressive symptoms, suicidal ideation, alcohol consumption, and improvements in physical function when compared to control patients. The study uses implementation science conceptual frameworks to evaluate the uptake of the intervention model. At the completion of the pragmatic trial, results will be presented at an American College of Surgeons' policy summit. Twenty-four representative US level I trauma centers have been selected for the study, and the protocol is being rolled out nationally. DISCUSSION The TSOS pragmatic trial simultaneously aims to establish the effectiveness of the collaborative care intervention targeting PTSD and comorbidity while also addressing sustainable implementation through American College of Surgeons' regulatory policy. The TSOS effectiveness-implementation hybrid design highlights the importance of partnerships with professional societies that can provide regulatory mandates targeting enhanced health care system sustainability of pragmatic trial results. TRIAL REGISTRATION ClinicalTrials.gov NCT02655354 . Registered 27 July 2015.
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Affiliation(s)
- Douglas F Zatzick
- Department of Psychiatry & Behavioral Sciences, University of Washington, 325 Ninth Ave, Box 359911, Seattle, WA, 98104, USA.
- Harborview Injury Prevention Research Center, University of Washington, 325 Ninth Ave, Box 359960, Seattle, WA, 98104, USA.
| | - Joan Russo
- Department of Psychiatry & Behavioral Sciences, University of Washington, 325 Ninth Ave, Box 359911, Seattle, WA, 98104, USA
| | - Doyanne Darnell
- Department of Psychiatry & Behavioral Sciences, University of Washington, 325 Ninth Ave, Box 359911, Seattle, WA, 98104, USA
| | - David A Chambers
- Division of Cancer Control and Population Sciences, National Cancer Institute, BG 9609 MSC 9760, 9609 Medical Center Drive, Bethesda, MD, 20892-9760, USA
| | - Lawrence Palinkas
- School of Social Work, University of Southern California, Montgomery Ross Fisher Building, Room 339, Los Angeles, CA, 90089, USA
| | - Erik Van Eaton
- Department of Surgery, University of Washington, 325 Ninth Ave, Box 359796, Seattle, WA, 98104, USA
| | - Jin Wang
- Harborview Injury Prevention Research Center, University of Washington, 325 Ninth Ave, Box 359960, Seattle, WA, 98104, USA
| | - Leah M Ingraham
- Department of Psychiatry & Behavioral Sciences, University of Washington, 325 Ninth Ave, Box 359911, Seattle, WA, 98104, USA
| | - Roxanne Guiney
- Department of Psychiatry & Behavioral Sciences, University of Washington, 325 Ninth Ave, Box 359911, Seattle, WA, 98104, USA
| | - Patrick Heagerty
- Department of Biostatistics, University of Washington, 1705 NE Pacific St, Box 357232, Seattle, WA, 98195, USA
| | - Bryan Comstock
- Department of Biostatistics, University of Washington, 1705 NE Pacific St, Box 357232, Seattle, WA, 98195, USA
| | - Lauren K Whiteside
- Division of Emergency Medicine, University of Washington, 25 Ninth Ave, Box 359702, Seattle, WA, 98104, USA
| | - Gregory Jurkovich
- Department of Surgery, University of California in Davis, 2221 Stockton Blvd, Cypress #3111, Sacramento, CA, 95817, USA
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Predicting Posttraumatic Stress Symptoms Following Mild, Moderate, and Severe Traumatic Brain Injury: The Role of Posttraumatic Amnesia. J Head Trauma Rehabil 2016; 30:283-9. [PMID: 24816155 DOI: 10.1097/htr.0000000000000043] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To explore the relation between posttraumatic amnesia (PTA) and posttraumatic stress symptoms in traumatic brain injury. DESIGN Single-site prospective cohort study. PARTICIPANTS A total of 1114 individuals between the ages of 18 and 65 years with a traumatic brain injury seen on average 3 months following injury. Participants were divided into 4 groups according to their duration of PTA: less than 1 hour; 1 to 24 hours; 24 hours to 1 week; and more than 1 week. MAIN MEASURES Glasgow Coma Scale, PTA, computed tomographic brain scan abnormalities, Impact of Event Scale, the 28-item General Health Questionnaire, and Rivermead Postconcussion Disorder Questionnaire. RESULTS The duration of PTA less than 1 hour was associated with more avoidant (P < .01) and intrusive (P < .001) posttraumatic stress symptoms and more anxiety according to the General Health Questionnaire (P < .01) than other groups. Regression analysis identified PTA and 3 concussive symptoms (light sensitivity, noise intolerance, and difficulties concentrating) as independent predictors of intrusive posttraumatic stress symptoms. CONCLUSION Our data, representative of the full range of traumatic brain injury severity, indicate that a brief duration of PTA is a significant risk factor for the development of posttraumatic stress disorder symptoms. The persistence of certain symptoms of postconcussion disorder adds to the risk by possibly acting as a trigger for reminders of the traumatic event.
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