The psychiatric sequelae of head injury: a review

Personality traits beyond Neuroticism predict post-concussive symptomatology in the post-acute period after mild traumatic brain injury in premorbidly healthy adults

There is growing evidence that an individual's personality traits are related to post-concussion symptomatology beyond the acute period after mild traumatic brain injury (mTBI). Few studies, however, have analyzed this impact beyond the personality trait of Neuroticism. We examined the impact of personality traits on post-concussion symptoms (PCS) by measuring the Big Five personality domains and their lower-order aspects in 87 pre-morbidly healthy participants assessed 6-12 weeks post-mTBI (n = 53) or physical trauma (n = 34). As expected, Neuroticism predicted PCS endorsement in both groups. Conscientiousness and Openness/intellect were predictive of lower PCS endorsement, but only in the mTBI group. Withdrawal, one aspect within the Neuroticism domain, independently predicted PCS endorsement in the mTBI group; the remaining Neuroticism aspect, Volatility, did not predict PCS endorsement in either group. These findings suggest that individuals high in Neuroticism are more likely to report PCS following mTBI and that this relationship is driven by susceptibility to depression/anxiety symptoms (Withdrawal aspect) rather than irritability (Volatility aspect). Further, they suggest that the current focus on the relationship between Neuroticism and PCS reporting in individuals with mTBI should be broadened to include other personality domains, such as Conscientiousness and Openness/intellect.

What is the Korsakoff syndrome? - a paper in tribute to Prof Alwyn Lishman

INTRODUCTION

Alwyn Lishman was interested in how memory research could be applied to clinical psychiatry. After a brief review of his major contributions, this paper will focus on his research on the alcoholic Korsakoff syndrome. It will consider how his findings relate to contemporary debates, particularly on how the syndrome should be defined, and its relationship to broader alcohol-induced cognitive impairments.

METHODS

A review of the contribution of Alwyn Lishman, Robin Jacobson and colleagues to our knowledge of Korsakoff's syndrome, together with a review of the pertinent recent literature.

RESULTS

Lishman and colleagues followed earlier authors in defining the Korsakoff syndrome in terms of disproportionate memory impairment, but they also noted a variable degree of IQ, frontal-executive, and timed visuo-spatial impairment in their cases. More recent authors have included such features in their definitions of the syndrome. Lishman also argued for a specific "alcoholic dementia". The present paper argues that recent definitions of the Korsakoff syndrome confound its core and associated features, and also fail to recognise the multifactorial basis of alcohol-related brain damage.

CONCLUSIONS

Korsakoff's syndrome is best defined in terms of disproportionate memory impairment, and more widespread cognitive impairment is best encompassed within "alcohol-related brain damage".

The effectiveness of cognitive behaviour therapy for reducing anxiety symptoms following traumatic brain injury: A meta-analysis and systematic review

BACKGROUND

Anxiety is a common neuropsychological sequela following traumatic brain injury (TBI). Cognitive Behaviour Therapy (CBT) is a recommended, first-line intervention for anxiety disorders in the non-TBI clinical population, however its effectiveness after TBI remains unclear and findings are inconsistent.

OBJECTIVE

There are no current meta-analyses exploring the efficacy of CBT as an intervention for anxiety symptoms following TBI, using controlled trials. The aim of the current study, therefore, was to systematically review and synthesize the evidence from controlled trials for the effectiveness of CBT for anxiety, specifically within the TBI population.

METHOD

Three electronic databases (Web of Science, PubMed and PsycInfo) were searched and a systematic review of intervention studies utilising CBT and anxiety related outcome measures in a TBI population was performed through searching three electronic databases. Studies were further evaluated for quality of evidence based on Reichow's (2011) quality appraisal tool. Baseline and outcome data were extracted from the 10 controlled trials that met the inclusion criteria, and effect sizes were calculated.

RESULTS

A random effects meta-analysis identified a small overall effect size (Cohen's d) of d = -0.26 (95%CI -0.41 to -0.11) of CBT interventions reducing anxiety symptoms following TBI.

CONCLUSIONS

This meta-analysis tentatively supports the view that CBT interventions may be effective in reducing anxiety symptoms in some patients following TBI, however the effect sizes are smaller than those reported for non-TBI clinical populations. Clinical implications and limitations of the current meta-analysis are discussed.

Neuropsychologic assessment

In this chapter, we review the use of neuropsychologic assessment in epidemiologic studies. First, we provide a brief introduction to the history of clinical neuropsychology and neuropsychologic assessment. We expand on the principal components of a neuropsychologic assessment and cognitive domains most commonly examined. This chapter also seeks to highlight specific domains and tests with validated psychometric properties that are widely accepted in clinical practice, as well as how data from a neuropsychologic test should be interpreted. Additionally, the important roles that neuropsychologic assessments play in tracking normative changes, patient diagnoses, care, and research will be discussed. Factors to consider when deciding on the inclusion of test instruments for a research study will also be reviewed. Lastly, we shed light on the contributions that neuropsychology has played in epidemiologic studies, as well as some challenges frequently faced when participating in this field of research.

Mood disorders

Mood disturbances, especially depressive disorders, are the most frequent neuropsychiatric complication of traumatic brain injury (TBI). These disorders have a complex clinical presentation and are highly comorbid with anxiety, substance misuse, and other behavioral alterations such as impulsivity and aggression. Furthermore, once developed, mood disorders tend to have a chronic and refractory course. Thus, the functional repercussion of these disorders is huge, affecting the rehabilitation process and the long-term outcome of TBI patients. The pathophysiology of mood disorders involves the interplay of factors that precede trauma (e.g., genetic vulnerability and previous psychiatric history), factors that pertain to the traumatic injury itself (e.g., type, extent, and location of brain damage) and factors that influence the recovery process (e.g., family and social support). It is hardly surprising that mood disorders are associated with structural and functional changes of neural circuits linking brain areas specialized in emotional processing such as the prefrontal cortex, basal ganglia, and amygdala. In turn, the onset of mood disorders may contribute to further prefrontal dysfunction among TBI patients. Finally, in spite of the prevalence and impact of these disorders, there have been relatively few rigorous studies of therapeutic options. Development of treatment strategies constitutes a priority in this field of research.

The impacts of injury at the individual, community and societal levels: a systematic meta-review

OBJECTIVES

Injury is a major public health problem. While the impacts of injury on the injured person are well documented, there is relatively little knowledge about the impacts of injury on those individuals and groups in the community connected to the injured person. This study seeks to describe this breadth of research using a meta-review methodology.

STUDY DESIGN

Systematic meta-review.

METHODS

To gain a better understanding of the known impacts of injury on family, community and society, a systematic meta-review of injury outcomes research literature was conducted. Seventy-eight peer-reviewed published literature reviews were included in the meta-review.

RESULTS

Of these, 70 reported outcomes at the level of the injured person including mortality, body functions, activity and participation limitations. Nine reviews reported impacts at the level of the community including impacts on family members, work colleagues and carers. Six studies reported impacts at the societal level including economic, health system and injury compensation system impacts.

CONCLUSIONS

In summary, the meta-review identified a substantial body of knowledge at the individual level outcomes of injury, and a relative lack of information regarding the community and societal impacts of injury. An injury outcome framework is proposed on the basis of the findings of the meta-review to guide future research activity, particularly with regard to injury outcome domains where there is currently limited evidence. A comprehensive framework that takes account of all levels of impact is necessary for effective policies, systems and strategies to support recovery following injury.

Focal retrograde amnesia and the attribution of causality: An exceptionally critical view

A detailed critique of the literature on focal retrograde amnesia is provided. Some of the cases commonly cited in this literature had, in fact, severely impaired anterograde memory, most often involving visuospatial material. Other cases showed poor anterograde memory in more moderate or subtle form, begging the question of whether "like" had really been compared with "like" across the retrograde and anterograde domains: there may be alternative explanations for the observed patterns of performance. One suggestion is that these patients suffer an impairment of long-term consolidation, an attractive hypothesis but one which requires much more rigorous testing than has occurred to date and which implies that the underlying problem is not specific to retrograde memory. Moreover, within the literature on cases of focal retrograde amnesia, differing patterns of performance on tests of autobiographical memory or remote semantic knowledge have been reported, and sometimes these may have reflected factors other than the sites of lesions. Many of the most convincing cases in this literature have been those in whom there was an initially severe anterograde amnesia as well as an extensive retrograde loss: in these cases, the critical issue is what determines differential patterns of recovery across these domains-it is likely that both physiological and psychological factors are important. A second, somewhat different, group are patients with semantic dementia, who show a pronounced recency effect in remote memory but, in these cases, the most parsimonious explanation may be in terms of predominantly semantic/linguistic and/or strategic factors. A third group are those with transient epileptic amnesia but, in these cases, the memory gaps may reflect past (anterograde) ictal activity. A fourth group are those in whom psychogenic factors may well be relevant. Although it is difficult to "prove" psychological causation, the logical difficulties in attributing causation where brain lesions are either very subtle or multiple have been considerably underestimated in the neuropsychological literature. Given these problems, in uncertain or equivocal cases, it is as critical to present the relevant psychological data for the reader to evaluate as it is to provide the pertinent memory test scores: this is underemphasised in many of the studies reviewed. Publication of cases in the absence of such data may lead to faulty clinical, neuropsychological, and cognitive conclusions. Abbreviations : AA: anterograde amnesia; AMI: Autobiographical Memory Interview; PTA: posttraumatic amnesia; RA: retrograde amnesia; RMT: Recognition Memory Test; TEA: transient epileptic amnesia; TGA: transient global amnesia; WMS: Wechsler Memory Scale.

A Systematic Review of Acceptance and Commitment Therapy (ACT) for Managing Anxiety: Applicability for People With Acquired Brain Injury?

Acceptance and commitment therapy (ACT) is increasingly used in clinical practice to manage anxiety conditions. This psychotherapeutic approach focuses on the following: (1) acceptance of an individual's experience of the spectrum of psychological and emotional states, (2) choosing valued direction for the individual's life, and (3) commitment to action that leads the individual in the direction of those values. This article presents an empirical review of ACT for treatment of anxiety in two parts. In the first part we systematically review the literature for studies examining ACT for anxiety management in the general population with anxiety problems. In the second part, we discuss applicability of acceptance-based approaches for a health population in which these techniques may have applicability, that is, for people with acquired brain injury (ABI). Electronic searches for the review were conducted on PsycINFO and Medline. Inclusion criteria were as follows: (1) used an ACT intervention study, (2) the target of the intervention was an anxiety disorder or anxiety symptomatology, (3) the intervention used a randomised controlled trial (RCT) or single case experimental design (SCED) methodology, and (4) the paper was available in English. Studies were rated for methodological quality using standardised assessment procedures. Four RCTs provided support for ACT for obsessive compulsive disorder (OCD), maths anxiety, trichotillomania (TTM), and mixed anxiety and depression. Three SCED trials scoring in the high range on the scale of methodological quality revealed some support for ACT for managing TTM, skin picking, and OCD. Although no studies were identified that investigated ACT for managing anxiety in people with ABI, the review highlights issues for consideration when applying ACT in this population.

Pre-Injury, Injury and Early Post-Injury Predictors of Long-Term Functional and Psychosocial Recovery After Severe Traumatic Brain Injury

Background: Findings from prognostic studies of functional and psychosocial recovery after traumatic brain injury (TBI) reported to date have been limited by the restricted timeframe for prediction, generally within the first 5 years post-trauma. This investigation examined prediction of functional and psychosocial recovery in the medium-term (6 years post-trauma; Time 1) and long-term (23 years post-trauma; Time 2). Methods: The participants comprised a consecutive series of the first 100 patients with severe TBI receiving their primary rehabilitation at a regionally based unit. At the 23-year follow-up, 91% of the sample was traced: 17 had died, 5 declined participation, and 69 were interviewed, with 68 participating at both Time 1 and Time 2. Five outcome domains were examined: mobility, self-care, employability, relationships and living skills. Results: Very few of seven pre-injury variables were significantly correlated with any of the outcome variables. A series of logistic regression analyses successfully predicted levels of recovery in all domains using four predictor variables: pre-injury occupational status, duration of post-traumatic amnesia, and physical and neuropsychological disability at rehabilitation discharge. At Time 1, 60% or more of the variance was accounted for in four of the five domains, and at Time 2, more than 40% of the variance was accounted for in all domains. Sensitivity ranged from 62% (self-care) to 90% (mobility). With a single exception (employability at Time 2), specificity was also high, ranging from 80% (relationships) to 98% (mobility). Comparable accuracy rates were also found for positive and negative predictive power. Conclusions: These results demonstrate impressive predictive capacity of early post-trauma variables for the very long-term levels of recovery. They provide guidance for the tailoring of individual rehabilitation programs and the identification of people who may require special supports after rehabilitation discharge.

Effects of psychological and biomechanical trauma on brain and behavior

The current conflicts in Iraq and Afghanistan have resulted in a large cohort of military personnel exposed to combat-related psychological trauma as well as biomechanical trauma, including proximity to blast events. Historically, the long-term effects of both types of trauma have been viewed as having different neural substrates, with some controversy over the proper attribution of such symptoms evident after each of the major conflicts of the last century. Recently, great effort has been directed toward distinguishing which neuropsychiatric sequelae are due to which type of trauma. Of interest, however, is that the chronic effects of exposure to either process are associated with a significant overlap in clinical symptoms. Furthermore, similar brain regions are vulnerable to the effects of either psychological or biomechanical trauma, raising the possibility that shared mechanisms may underlie the clinically observed overlap in symptom profile. This paper reviews the literature on the neural substrate of biomechanical and psychological injury and discusses the implications for evaluation and treatment of the neuropsychiatric sequelae of these processes.

Role of premorbid factors in predicting safe return to driving after severe TBI

PRIMARY OBJECTIVE

The present study explored the possibility of predicting post-injury fitness to safe driving in patients with severe traumatic brain injury (TBI) (n = 66).

METHODS AND PROCEDURE

Sixteen different measures, derived from four domains (demo/biographic, medico-functional, neuropsychological, and psychosocial) were used as predictor variables, whereas driving outcomes were assessed in terms of driving status (post-TBI drivers versus non-drivers) and driving safety (number of post-TBI car accidents and violations).

MAIN OUTCOMES AND RESULTS

About 50% of the patients resumed driving after TBI. Compared to post-TBI non-drivers, post-injury drivers had shorter coma duration. With regard to driving safety, the final multiple regression model combined four predictors (years post-injury, accidents and violations before TBI, pre-TBI-risky-personality-index, and pre-TBI-risky-driving-style-index) and explained 72.5% of variance in the outcome measure.

CONCLUSIONS

Since the best three predictors of post-injury driving safety addressed patients' premorbid factors, the results suggest that in order to evaluate the actual possibility of safe driving after TBI, it would be advisable to consider carefully patients' pre-TBI histories.

Behavioural interventions for children and adults with behaviour disorders after TBI: A systematic review of the evidence

OBJECTIVE

To systematically review the evidence for the effectiveness of behavioural interventions for children and adults with behaviour disorders after TBI.

DESIGN

Using a variety of search procedures, 65 studies were identified. This literature was reviewed using a set of questions about participants, interventions, outcomes and research methods.

PARTICIPANTS

The 65 studies included 172 experimental participants, including children and adults.

INTERVENTIONS

A number of specific intervention procedures were used, falling into three general categories: traditional contingency management, positive behaviour interventions and supports and combined.

RESULTS

All of the studies reported improvements in behavioural functioning.

CONCLUSIONS

Behavioural intervention, not otherwise specified, can be considered a treatment guideline for children and adults with behaviour disorders after TBI. Both traditional contingency management procedures and positive behaviour support procedures can be said to be evidence-based treatment options. However, a variety of methodological concerns block stronger conclusions.

Assessment of the psychosocial outcome after severe head injury

Rehabilitation services for the severely brain injured are often inadequate and one of the chief factors responsible is undue emphasis on the contribution of physical disability with scant attention to the serious emotional and intellectual handicaps incurred. Weakness, spasticity and dysphasis tend to recover eventually to a variable extent but mental handicap is often the cause of serious and lasting disablement. For a determination of the outcome of severe brain injury in terms of its effect on daily living, the relation between physical disability, mental handicap and social reintegration has been assessed quantitatively. Three assessment scales have been constructed and used in a study of 58 severely brain damaged patients. This revealed that the duration of post-traumatic amnesia correlates highly with the degree of social, mental and physical disability incurred. Daily living was affected primarily by impairment of intellect and personality and, to a lesser extent, by physical incapacity, but only rarely by the developments of symptoms of mental illness. Using the Wechsler Adult Intelligence Scale, the time course of cognitive recovery was also assessed. Recovery curves and the relation of cognitive impairment to social and physical handicap will be demonstrated.

[Cholinergic hypothesis in psychosis following traumatic brain injury and cholinergic hypothesis in schizophrenia: a link?]

INTRODUCTION

While traumatic brain injury is a major public health issue, schizophrenia-like psychosis following traumatic brain injury is relatively rare and poorly studied. Yet the risk of developing schizophrenia-like psychosis after traumatic brain injury is 3 times more important than in the general population.

LITERATURE FINDINGS

Risk factors associated with onset of psychosis after traumatic brain injury include: left hemispheric lesions, closed head injury and coma of duration superior to 24 hours. Most patients develop symptoms of psychosis after a moderate to severe traumatic brain injury and often have lesions of the frontal and temporal lobes. CHOLINERGIC HYPOTHESIS:

ARGUMENTS

Neuropathologic, electrophysiological and pharmacologic evidence show that cognitive impairment including attention, memory and executive functioning impairment may be related with cholinergic dysfunction in patients with traumatic brain injury. The cholinergic hypothesis is also incriminated in the genesis of schizophrenia. The same biochemical disorders found in schizophrenia which imply many neurotransmitters are often present immediately after traumatic brain injury. However in chronic cognitive disorders secondary to traumatic brain injury, the cholinergic system alone seems to be specifically implied. This is due to the fragility of the cholinergic fibres and a chronic yet reversible reduction of the cholinergic reserves after traumatic brain injury. Cholinergic function can be studied by the P50 evoked response to paired auditory stimuli.While this is disturbed in patients presenting with cognitive impairment after traumatic brain injury its normalisation can be obtained after administration of an acetylcholine esterase inhibitor. In schizophrenic patients there is also an abnormal P50 evoked response due in part to a low number of alpha 7 nicotinic receptors which are implicated in sensory filtering in the frontal lobe. Moreover in schizophrenia, post-mortem studies show a negative correlation between the activity of acetylcholine transferase in the parietal cortex and the severity of the cognitive deficits, as well as a lesser density of the muscarinic M1 and M4 receptors in the frontal lobe. The lower concentration of M1 receptors in the frontal cortex is correlated with the severity of the positive symptoms. THERAPEUTICAL PERSPECTIVES: Antipsychotics have emerged as the first line treatment of psychotic disorders. In research, their ability for enhancing cognitive function could result in the increase of acetylcholine in the medial prefrontal cortex. Acetylcholinesterase inhibitors have been widely used for treatment of cognitive impairment in Alzheimer's disease. Galantamine could be interesting in schizophrenia and psychosis following traumatic brain injury because it has a dual mechanism of action: selective competitive inhibition of acetylcholinesterase and allosteric potentialisation of nicotinic receptor response. Therefore Galantamine remains active in nicotine addicted schizophrenic patients who may smoke as an auto treatment. Galantamine has shown efficacy in adjunction to Risperidone in one patient presenting with psychosis following traumatic brain injury and in 3 case reports of schizophrenic patients.

CONCLUSION

Further systematic studies are needed to confirm this hypothesis.

Psychological treatment for anxiety in people with traumatic brain injury

BACKGROUND

Psychological treatments are commonly used in the management of anxiety. Certain types of psychological treatments are well suited to needs of people with traumatic brain injury (TBI). We have systematically reviewed studies examining the effectiveness of these approaches for TBI.

OBJECTIVES

To assess the effects of psychological treatments for anxiety in people with TBI.

SEARCH STRATEGY

We searched the following databases up until March 2006: Cochrane Injuries Group's specialised register, Cochrane Depression, Anxiety and Neurosis Group's specialised register, Cochrane Central Register of Controlled Trials, MEDLINE, PsycINFO, EMBASE, CINAHL, AMED, ERIC, and PsycBITE. Additionally, key journals were handsearched and reference lists of included trials were examined to identify further studies meeting inclusion criteria.

SELECTION CRITERIA

Randomised controlled trials of psychological treatments for anxiety, with or without pharmacological treatment, for people with TBI were included in the review. Pharmacological treatments for anxiety in isolation (without psychological intervention) were excluded.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed methodological quality and extracted data from the included trials.

MAIN RESULTS

Three trials were identified in this review as satisfying inclusion criteria. Results of all three trials were evaluated, however, one of these trials had compromised methodological quality and, therefore the focus was placed on the other two trials. Data were not pooled due to the heterogeneity between trials. The first trial (n = 24) showed a benefit of cognitive behavioural therapy (CBT) in people with mild TBI and acute stress disorder. Fewer people receiving CBT had diagnosis of post-traumatic stress disorder (PTSD) at post-treatment compared to the control supportive counselling group, with maintenance of treatment gains found at six-month follow up. The second trial (n = 20) showed that post-treatment anxiety symptomatology of people with mild to moderate TBI was lower in the combined CBT and neurorehabilitation group compared to the no intervention control group.

AUTHORS' CONCLUSIONS

This review provides some evidence for the effectiveness of CBT for treatment of acute stress disorder following mild TBI and CBT combined with neurorehabilitation for targeting general anxiety symptomatology in people with mild to moderate TBI. These findings need to be viewed in light of the small number, small sample size and heterogeneous characteristics of current trials published in this area. More trials focusing on comparable psychological interventions, severity of injury of participants and diagnosis of anxiety disorder(s) are needed.

Differential diagnosis between borderline personality disorder and organic personality disorder following traumatic brain injury

Organic personality disorder (OPD) is the traditional diagnostic category used to account for personality disturbances after traumatic brain injury (TBI). The recent use of Axis-II personality disorders, notably borderline personality disorder (BPD), has appeared in the TBI literature as an alternative to OPD. This would presumably offer a better description and understanding of the multiple clinical manifestations of these personality changes and disorders. This article offers a view that it is possible and fruitful to use both diagnoses in a complementary manner. An accurate recognition of the respective phenomenologies of both BPD and OPD is a key factor in achieving a differential diagnosis, including, if required, a dual diagnosis. The phenomenology of both conditions in reference to DSM-IV criteria is compared and illustrated through two clinical vignettes.

Pathophysiologic aspects of major depression following traumatic brain injury

Mood disorders, particularly major depression, are the most frequent complication of traumatic brain injury. Major depression is present in about 40% of patients hospitalization for a traumatic brain injury. Anxiety disorders, substance abuse, dysregulation of emotional expression, and aggressive outbursts are frequently associated with major depression, and their coexistence constitutes a marker of a more disabling clinical course. The complex interactions of genetic, developmental, and psychosocial factors determine patients' vulnerability to developing affective disturbances following a traumatic brain injury. Symptoms of depression cluster into the domains of low mood and distorted self-attitude, lack of motivation and anhedonia, subjective cognitive complaints, and hyperactive and disinhibited behavior. It is reasonable to assume that these symptomatic clusters have specific underlying mechanisms that need to be integrated in a comprehensive pathophysiologic model.

Traumatic brain injury, dissociation, and posttraumatic stress disorder in road traffic accident survivors

This study investigated the symptom profiles of acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) in participants who did and did not sustain traumatic brain injury (TBI), following a road traffic accident. The participants were assessed at three time points: as soon as possible posttrauma as well as at 6 weeks and 3 months posttrauma. At the first assessment, fewer participants from the TBI group recalled feeling fear and helplessness at the time of the trauma, fewer TBI participants reported recurrent intrusive thoughts and images, and more TBI participants reported dissociation since the trauma, relative to the non-TBI group. At the second assessment, fewer participants from the TBI group recalled feeling intense helplessness at the time of the trauma. Fewer TBI participants also reported reliving and physiological reactions on trauma reminders relative to the non-TBI group. At 3 months posttrauma, there was no difference in PTSD symptom profile between non-TBI and TBI groups. Our findings indicate that the presence of TBI is likely to influence the distribution of certain symptoms, but need not be a significant barrier to diagnosing ASD and PTSD.

Non-pharmacological management of psychiatric disturbances after traumatic brain injury

Persons who suffer traumatic brain injury (TBI) often demonstrate a variety of psychiatric and neuropsychiatric disturbances. Some of those disturbances may be managed by non-pharmacological methods. The methods draw heavily on established principles of psychotherapy and behavioral modification. However, the unique problems imposed by neurocognitive deficits must be factored into any form of non-pharmacological intervention with this patient group. A simple model consolidates information about the important ingredients in the non-pharmacological management of psychiatric disturbances in TBI patients.

Mood disorders following traumatic brain injury

Mood disorders are a frequent complication of traumatic brain injury that exerts a deleterious effect on the recovery process and psychosocial outcome of brain injured patients. Prior psychiatric history and impaired social support have been consistently reported as risk factors for developing mood disorders after traumatic brain injury (TBI). In addition, biological factors such as the involvement of the prefrontal cortex and probably other limbic and paralimbic structures may play a significant role in the complex pathophysiology of these disorders. Preliminary studies have suggested that selective serotonin reuptake inhibitors such as sertraline, mood stabilizers such as sodium valproate, as well as stimulants and ECT may be useful in treating these disorders. Mood disorders occurring after TBI are clearly an area of neuropsychiatry in which further research in etiology as well as treatment is needed.

Acquired Brain Injury and Return to Work in Australia and New Zealand

The purpose of this paper is to review the return-to-work rates following acquired brain injury in Australia and New Zealand (ANZ). The reported return-to-work rates for the nine ANZ studies varied from 29% to 64% with a median of 46% and for 23 international studies the return-to-work rates varied from 19% to 88% (median also 46%). When the results of all ANZ studies were combined to form a total of 1010 subjects then the overall return-to-work rate was 44%. A number of methodological concerns were raised and it was estimated that only about 7–10% of persons with an acquired brain injury are likely to return to the same job.

Event-related potential assessment of information processing after closed head injury

We evaluated alterations in information processing after closed head injury as a function of task demands and stimulus modality. Visual and auditory discrimination tasks were administered to 11 survivors of a head injury and 16 matched healthy controls. In auditory tasks, compared with controls, the survivors had smaller N100s, smaller and later N200s, a more posterior scalp distribution of N200, and longer P300 and response latencies. Auditory N200 and P300 correlated highly with duration of unconsciousness. In contrast, in visual tasks, only a reduced N200 in the survivors differentiated the groups. Our results indicate that processing of auditory stimuli, including the perception and discrimination of stimulus features and the evaluation and categorization of stimuli, may be impaired after head trauma. Visual sensory processing may be spared, but higher-order visual processing involved in stimulus classification may be compromised.

Positive supports for people who experience behavioral and cognitive disability after brain injury: a review

BACKGROUND

Behavioral and cognitive problems are among the most common and troubling consequences of traumatic brain injury. Furthermore, behavioral and cognitive challenges typically interact in complex ways, necessitating an integrated approach to intervention and support.

OBJECTIVES

This article reviews literature on behavioral outcome in children and adults with traumatic brain injury, traditional approaches to behavioral intervention and cognitive rehabilitation, and the history, principles, and assessment and treatment procedures associated with context-sensitive, support-oriented approaches to behavioral and cognitive intervention. We propose a clinical framework that integrates cognitive and behavioral intervention themes.

Psychiatric aspects of traumatic brain injury

TBI is a complex heterogenous disease that can produce a variety of psychiatric disturbances, ranging from subtle deficits in cognition, mood, and behavior to severe disturbances that cause impairment in social, occupational, and interpersonal functioning. With improvement and sophistication in acute trauma care, a number of individuals are able to survive the trauma but are left with several psychiatric sequelae. It is important for psychiatrists to be aware of this entity because an increasing number of psychiatrists will be involved in the care of these patients. Treatment should be interdisciplinary and multifaceted, with the psychiatrist working in collaboration with the patient, caregiver, family, other physicians, and therapists. The goal of treatment should be to stabilize symptoms; maximize potential; minimize disability; and increase productivity socially, occupationally, and interpersonally.

Social, neuroradiologic, medical, and neuropsychologic correlates of sexually aberrant behavior after traumatic brain injury: a controlled study

OBJECTIVE

To identify social, neuroradiological, medical, and neuropsychological correlates of sexually aberrant behavior (SAB) after traumatic brain injury (TBI).

DESIGN

A controlled study using a retrospective file review.

SETTING

A brain injury unit providing inpatient and outpatient rehabilitation services.

PARTICIPANTS

A sample of males (n = 25) exhibiting SABs and a control group (n = 25) matched for gender, severity of injury, age at injury, and time after injury.

MAIN OUTCOME MEASURES

A protocol that recorded data on demographic, injury, radiological, medical, and neuropsychological variables.

RESULTS

The SAB group had a significantly higher incidence of postinjury psychosocial disturbance in areas of nonsexual crime and failure to return to work than the matched TBI group. There were no significant differences between the two groups in the incidence of premorbid psychosocial disturbance or postinjury radiological, medical, or neuropsychological variables.

CONCLUSIONS

The study results caution against simplistic explanations of SAB as the product of damage to the frontal-lobe systems or premorbid psychosocial disturbance. Furthermore, the results suggest that a wide-ranging assessment of people with TBI who exhibit SABs is required, because results of neuropsychological examination alone cannot be considered conclusive. Future research into the etiology of SABs could examine additional factors such as lack of insight, lack of empathy, and premorbid history of family dysfunction.

Psychiatric treatment outcome following traumatic brain injury

The relationship between self-reported history of traumatic brain injury (TBI) and psychiatric treatment outcome was investigated. TBI was hypothesized to be frequent, associated with cognitive deficits on neuropsychological testing, and less amenable to standard psychiatric treatment. Subjects were 42 psychiatric patients with a self-reported history of TBI and 25 psychiatric patients with no TBI history. Subjects received approximately 2 weeks of inpatient psychiatric treatment. Subjects received neuropsychological testing and completed the Brief Symptom Inventory weekly. TBI was frequent (66% of subjects); multiple injuries were common. Neuropsychological performance was generally average in both groups with few group differences. Subjects, on average, reported significantly decreased psychiatric symptoms on discharge. However, the TBI group appeared to improve less than the control group; group status was a significant predictor of treatment outcome. Implications of results for assessment and treatment of psychiatric disorders in patients with a history of TBI are discussed.

Neuropsychiatric sequelae of traumatic brain injury

The authors review the psychiatric disturbances associated with traumatic brain injury. They highlight the close link between traumatic brain injury and psychiatry and provide an overview of the epidemiology, risk factors, classification, and mechanisms of traumatic brain injury. They describe various neuropsychiatric sequelae, and the respective treatments are outlined with emphasis on a multidisciplinary approach.

Recovery from mild head injury

The subjective and objective sequelae accompanying mild head injury (MHI) are discussed in an attempt to clarify MHI's immediate and long-term consequences. Areas covered included epidemiology, classification, the post-concussive syndrome (PCS), malingering, extent of recovery, rehabilitation and guidelines for clinical practice. Special emphasis is placed on the poor relationship between subjective complaint and objective measures of impairment. Also discussed are some of the methodological problems in the MHI literature, including attempts to match MHI subjects and controls with respect to cognitive and emotional complaint and the possible confounding effects of practice. The evidence for long-lasting (i.e. more than 1 year), subtle neurobehavioral impairment after MHI indicates that additional research is required on MHI 1 year or more after injury.

Executive dysfunction and characterological changes after traumatic brain injury: two sides of the same coin?

This study examined the capacity of neuropsychological variables indicative of dysfunction in the regulation of executive abilities (e.g. noncompliance with rules) to reflect changes in character associated with disturbances in regulatory abilities (e.g. impulsivity). A close relative of 30 participants with traumatic brain injury (TBI) was administered the Current Behaviour Scale (CBS) at admission (rating premorbid character) and six months posttrauma (rating current character). The TBI group was examined neuropsychologically at six months posttrauma, along with 30 nonbrain-damaged (NBD) participants. Significant increases in CBS factors, Loss of Emotional Control and Loss of Motivation, occurred in the TBI group posttrauma. Differences between TBI and NBD groups were found for most executive variables. Those TBI participants with impairments on the neuropsychological Rule Breaking variable showed significant posttrauma increases in Loss of Emotional Control. There was also a trend for individuals with frontal lesions to make rule-breaking and perseverative errors.

Frontal lobe psychopathology: mania, depression, confabulation, catatonia, perseveration, obsessive compulsions, and schizophrenia

The frontal lobes can be subdivided into major functional neuroanatomical domains, which, when injured, surgically destroyed, or reduced in activity or volume, give rise to signature pathological and psychiatric symptomology. A review of case reports and over 50 years of research, including magnetic resonance imaging, positron emission tomography, and single photon emission computed tomography scans, indicates that apathy, "blunted" schizophrenia, major depression, and aphasic-perseverative disturbance of speech and thought are associated with left lateral as well as bilateral frontal (and striatal) abnormalities. Impulsiveness, confabulatory verbosity, grandiosity, increased sexuality, and mania are associated with right frontal (as well as bilateral) disturbances. Gegenhalten, catatonia, and disturbances of "will" are indicative of medial frontal injuries. Disinhibitory states and obsessive-compulsive perseverative abnormalities are more frequently observed with orbital frontal lobe dysfunction, including frontal-striatal disturbances. These associations, however, are not always clear-cut as patients with the same diagnosis may demonstrate different symptoms that may be due to an additional abnormality in a different region of the brain. Moreover, as the frontal subdivisions are richly interconnected, and as frontal lobe abnormalities are not always discrete or well localized, a wide array of seemingly divergent waxing and waning symptoms may be manifest, sometimes simultaneously, including manic depression and what has been referred to as the "frontal lobe personality."

Depression after mild traumatic brain injury: a review of current research

Research pertaining to the occurrence of depression and/or depression symptomatology after a Mild Traumatic Brain Injury (MTBI) was reviewed. We found that methodological differences such as the criteria used to assess MTBI and depression, time that elapsed since brain injury, and control group variations confounded comparisons across studies. Nevertheless, the studies are consistent with at least a 35% prevalence of, and left frontal damage with depression after MTBI, an overlap of symptoms of depression and Postconcussion Syndrome (PCS), and indicate that depression can continue for many years following the injury. Our conclusion is that MTBI is the triggering event for a set of pathophysiological changes and a concomitant depressive episode in a vulnerable subset of the population. Due to a paucity of research, it cannot be definitively concluded that the underlying substrates of depression seen after MTBI and clinical depression are the same. Implications for future investigations are discussed.

Head injury and sexual dysfunction

An extensive review of the head injury and human sexuality literature was completed, to augment an understanding of the impact of traumatic head injury on sexual functioning. Despite clinical evidence that sexual dysfunction after head injury is prevalent and of great import, sexual concerns have been neglected in much of the post-traumatic head injury and rehabilitation literature. Characteristics of head injury concerning cerebral physiology, post-traumatic sequelae, and the effects on sexual functioning are examined. Rehabilitation and family/spouse literature was also examined for information on sexuality. The majority of this article reviews research on sexual sequelae after head injury, such as impulsiveness/inappropriateness, changes in libido and sexual frequency, global sexual difficulties, and specific sexual dysfunctions. Treatment models for the sexual problems after head injury are also reviewed and found to be limited in number. Treatment issues and suggestions are addressed. This article provides information about the sexual problems of head-injured patients to facilitate the development of diagnostic and intervention programmes.

The agitated brain injured patient. Part 1: Definitions, differential diagnosis, and assessment

This two-part review provides a critical analysis of the scientific and clinical literature on the agitated brain injured patient. Part 1 reviews nomenclature and classification issues, differential diagnosis, and assessment instruments designed for evaluation of the patient. Pathophysiology and treatment approaches will be discussed in Part 2 in a subsequent issue of the Archives. The review was unfortunately hampered by a lack of consistency in definitions, little scientific study of the neuroanatomic and neurochemical basis for the disorder, few outcome studies, and no randomized controlled treatment trials. Part 1 sets forth an interdisciplinary definition of agitation, establishes a differential diagnostic approach, and describes and critiques the assessment instruments available for clinical evaluation of the agitated patient. Part 2 will address treatment interventions including pharmacological, environmental, and behavioral approaches to this patient population.

Minor head injury: attempts at clarifying the confusion

Traumatic brain injury (TBI) refers to a broad range of neurological, cognitive and emotional factors that result from the application of a mechanical force to the head. Mechanical force can be applied on a continuum from none to very severe, and the extent of brain injury is related to the severity of this force. A review of the literature reveals that, while considerable research has been done on minor head injury, there remain several major sources of confusion. First, one of the most noticeable problems relates to the fact that the mild head injury has lower limits which are vaguely defined. This leads to individuals being categorized as having sustained a mild TBI despite minimal or no neurological damage being present. A second source of confusion in the literature is related to the failure to differentiate between cognitive consequences of TBI and post-concussion symptoms (PCS). Since PCS can occur in the absence of head injury, and are often present beyond the period of cognitive recovery from mild TBI, the two clearly result from different factors. Researchers have often failed to separate these two factors when studying recovery of function, and this has led to varying findings on outcome. Finally, many pre-injury factors (age, education, emotional adjustment) and post-injury factors (pain, family support, stress) interact with cognitive functioning and significantly affect recovery from TBI. These problems are reviewed and discussed.

Very late outcome after focal wartime brain wounds

This paper reviews outcome studies of wartime head-injury in Europe and North America. These include Goldstein's major but neglected contribution. intensive clinical and experimental studies of World War I veterans, in which he emphasizes the need for rehabilitation and community care. The present paper reports a follow-up, in Oxford U.K., of a cohort of World War II veterans drawn from over a thousand head-injured servicemen admitted to St Hugh's Military Hospital in Oxford, usually within one to two days of wounding. This cohort was initially examined in 1963 and thereafter until the present day. Behavioural outcome is remarkably good. Cognitive data show a striking preservation of ability in the group as a whole, despite previously reported selective impairments related to specific loci of lesion. Psychiatric illness is rare; and there is little difference in self-report on rating scales between the veterans and a carefully recruited, age-matched control panel. This positive outcome is attributed to a number of factors, including the psychosocial context of World War II for British servicemen, the expert and systematic medical care that commenced within hours of wounding, and the positive attitude of the civilian population. It reinforces the crucial importance of after-care.

Sexual functioning among women with physical disabilities

OBJECTIVE

Three a priori hypotheses were tested: (1) There are significant differences in sociosexual behaviors of women with physical disabilities compared with women without disabilities; (2) the sexual functioning of women with disabilities is significantly related to age at onset of disability; (3) psychological factors explain more of the variance in the sexual functioning of women with physical disabilities than do disability, social and environmental factors.

DESIGN

Case-comparison study using written survey.

SETTING

General community.

PARTICIPANTS

The questionnaire was mailed to 1,150 women with physical disabilities who were recruited as volunteers or through independent living centers. Each woman gave a second copy of the questionnaire to an able-bodied female friend, which comprised the comparison group. The response rate was 45%, with 475 cases and 425 comparisons eligible to participate. The most common disability type was spinal cord injury (24%), followed by polio (18%), muscular dystrophy (11%), cerebral palsy (11%), multiple sclerosis (10%), joint disorders (7%), and skeletal abnormalities (5%).

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Sexual-functioning, consisting of four factors: (1) sexual desire, (2) sexual activity, (3) sexual response, (4) sexual satisfaction.

RESULTS

Highly significant differences were found in level of sexual activity (p = .000001), response (p = .000009), and satisfaction (p=.000001) between women with and without disabilities. No significant differences were found between groups on sexual desire. Severity of disability was not significantly related to level of sexual activity.

CONCLUSIONS

Psychological and social factors exert a strong impact on the sexual functioning of women with physical disabilities. Further investigations is needed of the effect of social environment on development of self-esteem and sexual self-image, and how these influences affect levels of sexual functioning in women with physical disabilities.

Four case reports illustrating the contribution of intensive cognitive rehabilitation in patients neuropsychologically handicapped as a result of brain damage

The authors describe the principles and functioning of a 7-week course of interdisciplinary treatment for small groups of patients with cognitive and behavioral difficulties resulting from brain damage. The programme is intended for patients with less severe physical disability. It outlines a programme of individual, practically oriented workshops and of more theoretical group sessions working on cognitive and communications handicaps. The work is based on conceptual explanations, coping strategies and training techniques. The neurological and neuropsychological consequences of four subjects accepted on such a programme are presented, as well as some of the principles of treatment used for these patients. The efficacy of such programmes is discussed, given the classical post-traumatic picture of brain-injured patients. The programme consists of 1 week of evaluation and 6 weeks of therapeutic sessions.

Impaired avoidance learning after closed-head injury: dissociation between two tasks due to classical conditioning

Like controls, a Closed-Head Injury (CHI) group learned quickly to press a button during a 3-s warning stimulus in order to avoid a noxious buzzer. In a similar task, however, the CHI group had greater difficulty achieving the learning criterion compared to controls when required to prevent an innocuous visual display (i.e., a circle). The difficulty levels of these two avoidance tasks were identical. The major differences concerned the temporal contiguity of the warning cue with the stimulus to be avoided and the intrinsic aversiveness of the buzzer compared to the appearance of a circle on a computer screen. We hypothesize that, although both tasks were operant in essential character, the buzzer may have produced a degree of classical conditioning. These results suggest that CHI survivors may have some difficulty forming connections between arbitrary stimuli when performance depends almost entirely upon conscious, effortful processing. When a stimulus is sufficiently noxious to be capable of producing an affective or autonomic response, however, automatic processes may aid in the formation of associations.

Course of attention and memory after common whiplash: a two-years prospective study with age, education and gender pair-matched patients

Attentional functioning and memory of common whiplash patients were evaluated during the first two years after experiencing injury. The study was based on a non-selected sample of 117 whiplash patients referred from primary care and recruited according to a strict injury definition. All patients had a similar socioeconomic background, all being injured in automobile accidents and fully covered by insurance plans. Two years following initial trauma, 21 patients remained symptomatic. For each of these 21 patients, a counterpart matched by age, educational attainment and gender was selected from the group of patients who had fully recovered during the follow-up period. Symptomatic patients and matched controls were compared with regard to baseline, six-months and two-years findings. Examinations included testing of different aspects of attention (i.e. Digit Span, Corsi Block-Tapping Test, Trail Making Test, Number Connection Test, Paced Auditory Serial Addition Task) and memory functioning (California Verbal Learning Test). Cognitive functioning was assessed in conjunction with self-ratings of cognitive abilities (Cognitive Failures Questionnaire), well-being (Well-being Scale), headache and neckpain intensity, utilized medication and subjective complaints. Results show no impairment of memory in symptomatic patients. In attentional functioning, different levels of improvement were found for symptomatic patients and matched counterparts, with the former showing difficulty at follow-up with tasks of divided attention. Utilized medication and pain intensity could not explain this difference in recovery of attentional functioning between the groups. These findings suggest problems in selective aspects of attentional functioning after common whiplash, which under real life circumstances may explain these patients' cognitive complaints and cause adaptational problems in daily life.