Axis II psychopathology in individuals with traumatic brain injury

A Transdiagnostic, Hierarchical Taxonomy of Psychopathology Following Traumatic Brain Injury (HiTOP-TBI)

Psychopathology, including depression, anxiety, and post-traumatic stress, is a significant yet inadequately addressed feature of moderate-severe traumatic brain injury (TBI). Progress in understanding and treating post-TBI psychopathology may be hindered by limitations associated with conventional diagnostic approaches, specifically the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD). The Hierarchical Taxonomy of Psychopathology (HiTOP) offers a promising, transdiagnostic alternative to psychiatric classification that may more effectively capture the experiences of individuals with TBI. However, HiTOP lacks validation in the TBI population. To address this gap, we administered a comprehensive questionnaire battery, including 56 scales assessing homogeneous symptom components and maladaptive traits within HiTOP, to 410 individuals with moderate-severe TBI. We evaluated the reliability and unidimensionality of each scale and revised those with psychometric problems. Using a top-down, exploratory latent variable approach (bass-ackwards modeling), we subsequently constructed a hierarchical model of psychopathological dimensions tailored to TBI. The results showed that, relative to norms, participants with moderate-severe TBI experienced greater problems in the established HiTOP internalizing and detachment spectra, but fewer problems with thought disorder and antagonism. Fourteen of the 56 scales demonstrated psychometric problems, which often appeared reflective of the TBI experience and associated disability. The Hierarchical Taxonomy of Psychopathology Following Traumatic Brain Injury (HiTOP-TBI) model encompassed broad internalizing and externalizing spectra, splitting into seven narrower dimensions: Detachment, Dysregulated Negative Emotionality, Somatic Symptoms, Compensatory and Phobic Reactions, Self-Harm and Psychoticism, Rigid Constraint, and Harmful Substance Use. This study presents the most comprehensive empirical classification of psychopathology after TBI to date. It introduces a novel, TBI-specific transdiagnostic questionnaire battery and model, which addresses the limitations of conventional DSM and ICD diagnoses. The empirical structure of psychopathology after TBI largely aligned with the established HiTOP model (e.g., a detachment spectrum). However, these constructs need to be interpreted in relation to the unique experiences associated with TBI (e.g., considering the injury's impact on the person's social functioning). By overcoming the limitations of conventional diagnostic approaches, the HiTOP-TBI model has the potential to accelerate our understanding of the causes, correlates, consequences, and treatment of psychopathology after TBI.

Prevalence of comorbidities post mild traumatic brain injuries: a traumatic brain injury model systems study

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.

Measuring anxiety-like behavior in a mouse model of mTBI: Assessment in standard and home cage assays

Traumatic brain injury (TBI) is a primary global health concern and one of the most common causes of neurological impairments in people under 50. Mild TBI (mTBI) accounts for the majority of TBI cases. Anxiety is the most common complaint after mTBI in humans. This study aims to evaluate behavioral tests designed to assess anxiety-like phenotypes in a mice model of mTBI. ICR mice underwent mTBI using the weight-drop model. Seven days post-injury, mice were subjected to one of five different behavioral tests: Elevated Plus Maze (EPM), Open Field apparatus (OF), Marble Burying test (MBT), Light Dark Box (LDB), and the Light Spot test within the PhenoTyper home cage (LS). In the EPM and OF tests, there were no significant differences between the groups. During the 30-min test period of the MBT, mTBI mice buried significantly more marbles than control mice. In the LDB, mTBI mice spent significantly less time on the far side of the arena than control mice. In addition, the time it took for mTBI mice to get to the far side of the arena was significantly longer compared to controls. Results of LS show significant within-group mean differences for total distance traveled for mTBI mice but not for the control. Furthermore, injured mice moved significantly more than control mice. According to the results, the anxiety traits exhibited by mTBI mice depend upon the time of exposure to the aversive stimulus, the apparatus, and the properties of the stressors used. Therefore, the characterization of anxiety-like behavior in mTBI mice is more complicated than was initially suggested. Based on our findings, we recommend incorporating a variety of stressors and test session lengths when assessing anxiety-like behavior in experimental models of mTBI.

Are GABAergic drugs beneficial in providing neuroprotection after traumatic brain injuries? A comprehensive literature review of preclinical studies

Traumatic brain injuries (TBI) caused by physical impact to the brain can adversely impact the welfare and well-being of the affected individuals. One of the leading causes of mortality and dysfunction in the world, TBI is a major public health problem facing the human community. Drugs that target GABAergic neurotransmission are commonly used for sedation in clinical TBI yet their potential to cause neuroprotection is unclear. In this paper, I have performed a rigorous literature review of the neuroprotective effects of drugs that increase GABAergic currents based on the results reported in preclinical literature. The drugs covered in this review include the following: propofol, benzodiazepines, barbiturates, isoflurane, and other drugs that are agonists of GABAA receptors. A careful review of numerous preclinical studies reveals that these drugs fail to produce any neuroprotection after a primary impact to the brain. In numerous circumstances, they could be detrimental to neuroprotection by increasing the size of the contusional brain tissue and by severely interfering with behavioral and functional recovery. Therefore, anesthetic agents that work by enhancing the effect of neurotransmitter GABA should be administered with caution of TBI patients until a clear and concrete picture of their neuroprotective efficacy emerges in the clinical literature.

A Study of 309 Patients and at One Year Follow-Up for Depression after Traumatic Brain Injury

Traumatic brain injury (TBI) is one the major causes of death and morbidity in developing countries, where depression is a common psychiatric condition among individuals with TBI. The objectives were to investigate the occurrence and severity of depression one-year post-TBI; the association between radiological findings and depression; and the risk factors. We report a cross-sectional study among adult patients who were hospitalized because of TBI in the past one year. A structured data collection form was used to collect patients' demographic data during TBI, while the Patient Health Questionnaire (PHQ)-9 questionnaire was administered to assess the level of depression at one-year post-TBI. Of the 309 patients in this study; 46.6%, 26.2%, and 27.2% had mild, moderate, and severe TBI, respectively. The overall rate of depression was 33.7%, where 22.3%, 8.7%, and 2.6% had mild, moderate, and moderately severe depression, respectively. There was a significant, positive correlation between severity of TBI and level of depression; r_s (0.427), p < 0.0001. The risk factors for depression at one-year post-TBI are moderate-severe TBI (odds ratio [OR]: 3.75, 95% confidence interval [CI] 2.03-6.90, p < 0.00), being unmarried (OR: 2.67, 95% CI 1.51-4.72, p = 0.001), female gender (OR: 2.62, 95% CI 1.25-5.46, p = 0.011), alcohol consumption (OR: 2.38, 95% CI 1.12-5.06, p = 0.024) and frontal lobe injury (OR: 1.96, 95% CI 1.05-3.68, p = 0.035). Increasing severity of TBI is associated with worsening levels of depression. Patients with frontal lobe injury have the highest risk of depression, while diffuse injury is associated with occurrence of moderate and moderately severe depression.

Incidence of New Neuropsychiatric Disorder Diagnoses Following Traumatic Brain Injury

BACKGROUND

Neuropsychiatric disturbances (NPDs) are common following traumatic brain injury (TBI) and associated with poor recovery. Prior estimates of NPD following TBI failed to account for preexisting NPDs or potential confounding.

METHODS

We estimated the risk of anxiety, posttraumatic stress disorder (PTSD), bipolar disorder, and alcohol and substance dependence disorder diagnoses associated with TBI using administrative claims data from a large insurer in the United States, 2008-2014. We calculated rates of new NPD diagnoses during the 12 months before and 24 months after TBI and estimated the risk of NPD following TBI using a difference-in-difference approach and adjusting for confounders.

RESULTS

Before the TBI occurred, rates of NPD diagnoses were more than double in the TBI cohort (n = 207 354) relative to the no-TBI cohort (n = 414 708). TBI was associated with an increased risk of anxiety (rate ratio [RtR] = 1.08; 95% confidence interval [CI], 1.05-1.12) and PTSD (RtR = 1.41; 95% CI, 1.24-1.60) diagnoses. Rates of alcohol (RtR = 0.32; 95% CI, 0.30-0.34) and substance use disorder (RtR = 0.57; 95% CI, 0.55-0.59) diagnoses decreased following TBI.

CONCLUSIONS

In this large national study, rates of NPD were much higher among individuals with TBI than those in a non-TBI cohort, even before the TBI took place. TBI was associated with an increased risk of anxiety and PTSD diagnoses. Results from this study also suggest that individuals who sustain TBI have increased contact with the healthcare system during the months prior to injury, providing a window for intervention, especially for individuals diagnosed with alcohol dependence disorder.

In search of the 'self': Holistic rehabilitation in restoring cognition and recovering the 'self' following traumatic brain injury: A case report

BACKGROUND

Following mild-moderate traumatic brain injury (TBI), an individual experiences a range of emotional changes. It is often difficult for the patient to reconcile with their post-injury persona, and the memory of pre-injury personhood is particularly painful. Insight into one's cognitive deficits subsequent to injury can lead to an existential crisis and a sense of loss, including loss of self.

OBJECTIVE

Restoration of cognitive functions and reconciliation with loss of pre-traumatic personhood employing a holistic method of neuropsychological rehabilitation in a patient suffering from TBI.

METHODS

Ms. K.S, a 25-year-old female, presented with emotional disturbances following TBI. She reported both retrograde and anterograde amnesia. A multidimensional holistic rehabilitation was planned. Treatment addressed cognitive deficits through the basic functions approach. Cognitive behavioural methods for emotional regulation like diary writing helped reduce irritability and anger outbursts. Use of social media created new modes of memory activation and interactions. Compensatory strategies were used to recover lost skills, music-based attention training helped foster an individualised approach to the sense of one's body and self.

RESULTS

As a result of these differing strategies, changes were reflected in neuro-psychological tests, depression score and the patient's self-evaluation. This helped generate a coherent self-narrative.

CONCLUSION

Treatment challenges in such cases are increased due to patient's actual deficits caused by neuronal/biochemical changes. Innovative and multi-pronged rehabilitation strategies which involve everyday activities provided an answer to some of these problems. This method of rehabilitation may provide an optimistic context for future research.

The impact of a Housing First intervention and health-related risk factors on incarceration among people with experiences of homelessness and mental illness in Canada

OBJECTIVE

To examine the effect of a Housing First (HF) intervention and health-related risk factors on incarceration among adults with experiences of homelessness and mental illness.

METHODS

Participants (N = 508) were recruited at the Toronto site of the At Home/Chez Soi study. The outcome was incarceration in Ontario from 2009 to 2014. Exposures were intervention group (HF vs. treatment as usual), Axis I mental health diagnoses, emergency department (ED) visit, and history of traumatic brain injury (TBI). Logistic regression was used to examine the association between exposures and incarceration.

RESULTS

Of 508 participants, 220 (43.3%) were incarcerated at least once during the study period. Among those incarcerated, 81.9% were male, 52.7% had been diagnosed with alcohol dependence/abuse, 60.9% had been diagnosed with substance dependence/abuse, 65.1% reported having visited an ED within the last 6 months, and 66.4% had a history of TBI. After adjusting for demographic covariates, substance dependence/abuse (aOR: 2.06; 95% CI: 1.40, 3.03), alcohol dependence/abuse (aOR: 1.52, 95% CI: 1.04, 2.22), ED visit (aOR: 1.54; 95% CI: 1.02, 2.32), and history of TBI (aOR: 2.60; 95% CI: 1.75, 3.85) were associated with incarceration. We found no significant effect of the HF intervention on incarceration outcome (aOR: 1.08; 95% CI: 0.76, 1.55).

CONCLUSIONS

Among adults with experiences of homelessness and severe mental illness, those with substance and alcohol dependence/abuse disorders, history of TBI, and recent ED visits were at increased odds of incarceration. Strategies are needed to prevent and reduce incarceration for this population, including treatment of mental illness in the community.

Personality Traits and Social Supports in Adolescents With Persistent Postconcussion Symptoms

OBJECTIVES

To determine whether adolescents with persistent postconcussion symptoms (PPCS) differ from healthy peers in their personality traits and social supports.

SETTING

Specialty Concussion Clinic and Primary Care Clinic affiliated with an academic medical center.

PARTICIPANTS

Ninety-seven adolescents (42 with PPCS, 55 healthy peers; age: 15 ± 2 years).

DESIGN

Participants completed a web-based survey that included medical and demographic characteristics, mechanisms of concussion, 10-item Big Five Inventory, and Child and Adolescent Social Support Scale. A Student's 2-tailed t test with multiple testing corrections was used to compare the youths with PPCS to healthy peers.

MAIN MEASURES

The primary outcome was PPCS, defined by the presence of 2 or more concussion-related symptoms on the Post-Concussion Symptom Scale (PCSS), lasting for more than 4 weeks after initial injury. The secondary outcome was perceived personality traits and social support, based on the 10-item Big Five Inventory and the Child and Adolescent Social Support Scale, respectively.

RESULTS

The PPCS group had higher neuroticism scores on their Big Five Inventory than healthy peers. They also reported less social support from teachers and classmates than healthy peers.

CONCLUSION

Youths with PPCS report specific personality and social support characteristics that differ from their peers. These findings suggest that individual personality and school-based social supports may influence concussion recovery.

Behavioral responses following repeated bilateral frontal region closed head impacts and fear conditioning in male and female mice

The frontal lobes are among the most vulnerable sites in traumatic brain injuries. In the current study, a balanced 2 × 2 × 2 design (n = 18 mice/group), female and male C57Bl/6J mice received repeated bilateral frontal concussive brain injury (frCBI) and underwent fear conditioning (FC) to assess how injured mice respond to adverse conditions. Shocks received during FC impacted behavior on all subsequent tests except the tail suspension test. FC resulted in more freezing behavior in all mice that received foot shocks when evaluated in subsequent context and cue tests and induced hypoactivity in the open field (OF) and elevated zero maze (EZM). Mice that sustained frCBI learned the FC association between tone and shock. Injured mice froze less than sham controls during context and cue tests, which could indicate memory impairment, but could also suggest that frCBI resulted in hyperactivity that overrode the rodent's natural freezing response to threat, as injured mice were also more active in the OF and EZM. There were notable sex differences, where female mice exhibited more freezing behavior than male mice during FC context and cue tests. The findings suggest frCBI impaired, but did not eliminate, FC retention and resulted in an overall increase in general activity. The injury was characterized pathologically by increased inflammation (CD11b staining) in cortical regions underlying the injury site and in the optic tracts. The performance of male and female mice after injury suggested the complexity of possible sex differences for neuropsychiatric symptoms.

A Systematic Review and Meta-Analysis of Personality Disorder Prevalence and Patient Outcomes in Emergency Departments

The objectives of this study were to perform a systematic review and meta-analysis of studies reporting prevalence of personality disorders (PDs) in emergency departments (EDs) and evaluate the effect of comorbid PDs on clinical outcomes. A systematic search of five databases along with manual searching and expert consultation was performed. A quality appraisal was conducted. A total of 29 articles were included. Prevalence of PDs in ED attendees varied depending on presenting complaint, Q(4) = 577.5, p < .01, with meta-analytic prevalence rates of suicide and self-harm at 35% and 22%, respectively. The assessment method had a significant effect on prevalence rates, Q(3) = 17.36, p < .01. Comorbid PD was a risk factor for repeating presenting complaint, subsequent ED return, and hospitalization. Better identification of PDs using screening tools in EDs could improve patient management and clinical outcomes. Future research should focus on PD prevalence in unselected ED populations using validated diagnostic interviews.

Anxiety Disorders in Adults With Childhood Traumatic Brain Injury: Evidence of Difficulties More Than 10 Years Postinjury

OBJECTIVE

To explore long-term psychiatric outcomes in individuals with a history of childhood traumatic brain injury (TBI) or orthopedic injury (OI).

SETTING

Hospital emergency department, medical admission records and outpatient settings.

PARTICIPANTS

There were 95 males (M = 22.78 years, SD = 3.44 years) and 74 females (M = 22.27 years, SD = 3.09 years), 65 with mild TBI (M = 23.25 years, SD = 3.58 years), 61 with moderate-severe TBI (M = 22.34 years, SD = 2.79 years), and 43 with OI (M = 21.81 years, SD = 3.36 years).

DESIGN

Longitudinal, between-subjects, cross-sectional design using retrospective and current data.

MAIN MEASURES

Semistructured interview to obtain psychiatric diagnoses and background information, and medical records for identification of TBI.

RESULTS

Group with moderate-severe TBI presented with significantly higher rates of any anxiety disorder (χ2 = 6.81, P = .03) and comorbid anxiety disorder (χ2 = 6.12, P < .05). Group with overall TBI presented with significantly higher rates of any anxiety disorder (χ1 = 5.36, P = .02), panic attacks (χ1 = 4.43, P = .04), specific phobias (χ1 = 4.17, P = .04), and depression (χ1 = 3.98, P < .05). Prediction analysis revealed a statistically significant model (χ7 = 41.84, P < .001) explaining 23% to 37% of the variance in having any anxiety disorder, with significant predictors being group (TBI) and gender (female).

CONCLUSIONS

Children who have sustained a TBI may be vulnerable to persistent anxiety, panic attacks, specific phobias, and depression, even 13 years after the injury event.

Postconcussion symptom reporting is not associated with diffusion tensor imaging findings in the subacute to chronic phase of recovery in military service members following mild traumatic brain injury

INTRODUCTION

The purpose of this study was to examine the relation between white matter integrity of the brain and postconcussion symptom reporting following mild traumatic brain injury (MTBI).

METHOD

Participants were 109 U.S. military service members (91.7% male) who had sustained a MTBI (n = 88) or orthopedic injury without TBI (trauma controls, TC, n = 21), enrolled from the Walter Reed National Military Medical Center, Bethesda, Maryland. Participants completed a battery of neurobehavioral symptom measures and underwent diffusion tensor imaging (DTI; General Electric 3T) of the whole brain, on average 44.9 months post injury (SD = 42.3). Measures of fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD) were generated for 18 regions of interest (ROIs). Participants in the MTBI group were divided into two subgroups based on International Classification of Diseases-10th Revision (ICD-10) Category C criteria for postconcussion syndrome (PCS): PCS-present (n = 41) and PCS-absent (n = 47).

RESULTS

The PCS-present group had significantly worse scores on all 13 neurobehavioral measures than the PCS-absent group (p < .001, d = 0.87-2.50) and TC group (p < .003, d = 0.84-2.06). For all ROIs, there were no significant main effects across the three groups for FA, MD, AD, and RD (all ps >.03). Pairwise comparisons revealed no significant differences for all ROIs when using FA and RD, and only two significant pairwise differences were found between PCS-present and PCS-absent groups when using MD and AD [i.e., anterior thalamic radiation and cingulate gyrus (supracallosal) bundle].

CONCLUSIONS

Consistent with past research, but not all studies, postconcussion symptom reporting was not associated with white matter integrity in the subacute to chronic phase of recovery following MTBI.

Post-traumatic psychiatric disorders: PTSD is not the only diagnosis

Traumatic events and their consequences are often hidden or minimised by patients for reasons linked to the post-traumatic stress disorder itself (inexpressibility, shame, depressive thoughts, fear of stigmatisation, etc.). Although post-traumatic stress disorder (PTSD) remains the most widely known disorder, chronic post-traumatic psychiatric disorders are many and varied. After a trauma, the practitioner has to check for the different clinical forms of post-traumatic psychological consequences: PTSD is not the only diagnosis. Based on our own clinical experience compared to the international literature, we think necessary to build a didactic classification describing chronic post-traumatic symptoms and syndromes. Post traumatic depressions and bereavement lead to high risk of suicidal crisis and self-harm behaviours. Re-experiencing are felt with anxiety, hyper arousal increases anxious reactivity, and avoidance strategies increase anticipatory anxiety, indicating post-traumatic anxiety disorders (agoraphobia, specific phobia, obsessive compulsive disorder, separation anxiety, social phobia). Characterising an often-severe clinical picture, the co-occurrence of post-traumatic and chronic psychotic symptoms is not unusual (post-traumatic schizophrenia, post-traumatic depression with mood-congruent psychotic features, non-schizophrenic post-traumatic psychotic disorder, and bipolar reaction to trauma). A physical injury occurring at the same time as a traumatic exposure increases the risk of developing post-traumatic stress disorder later which, in turn, afflicts the subjective perception of the physical health (development of somatoform and psychosomatic disorders, comorbidity with a post-concussion syndrome). The trauma may cause a rupture in the biography of a person, also in his/her internal physiological functioning as in his/her social activities (impacts of instinctive functions and behaviours, personality changes, and adjustment difficulties on professional and personal life). Although a nomenclature is necessary for semiological descriptions, a thorough analysis of the patient's general psychological functioning must also be conducted.

Association between cognitive impairments and obsessive-compulsive spectrum presentations following traumatic brain injury

This study examined the association between self-reported obsessive-compulsive spectrum symptomatology and cognitive performance in a sample of patients with traumatic brain injury (TBI). Twenty-four adults with a moderate-severe TBI accessing a community brain injury rehabilitation service were recruited. Age ranged between 19 and 69 years. Participants completed a battery of neuropsychological tasks assessing memory, executive functioning, and speed of information processing. Self-report questionnaires assessing obsessive-compulsive (OC) symptoms and obsessive-compulsive personality disorder (OCPD) traits were also completed. Correlational analyses revealed that deficits in cognitive flexibility were associated with greater self-reported OC symptomatology and severity. Greater OC symptom severity was significantly related to poorer performance on a visual memory task. Verbal memory and speed of information processing impairments were unrelated to OC symptoms. Performance on tasks of memory, executive functioning, and speed of information processing were not associated with OCPD traits. Overall, results indicate that greater OC symptomatology and severity were associated with specific neuropsychological functions (i.e., cognitive flexibility, visual memory). OCPD personality traits were unrelated to cognitive performance. Further research is needed to examine the potential causal relationship and longer-term interactions between cognitive sequelae and obsessive-compulsive spectrum presentations post-TBI.

Emotional Risk Factors and Postconcussional Disorder

Emotional risk factors were examined in 129 litigant and nonlitigant patients diagnosed with Postconcussional Disorder (PCD) following Mild Traumatic Brain Injury (MTBI). According to Millon Clinical Multiaxial Inventory (MCMI) criteria, four subgroups emerged: (a) 14.7% met criteria for an Axis I disorder, (b) 24.8% for an Axis II disorder, (c) 24.0% for bout Axis I and II disorders, and (d) 36.4% fell below threshold for psychopathology. Thus, 63.5% endorsed emotional pathology. Of the four groups, those with both Axis I and II psychopathology presented the greatest number of emotional complaints in a clinical interview and manifested the lowest neurocognitive test scores. Motor skills, verbal abilities, memory functioning, and IQ were primarily affected. With the exception of post-morbid emotional complaints, no significant differences were identified between litigants and nonlitigants. Our analysis suggests that the combination of both Axis I and II psychopathology is associated with greater impairment following MTBI.

Evidence of Big-Five personality changes following acquired brain injury from a prospective longitudinal investigation

OBJECTIVE

Many studies using different assessment methods have reported personality changes after acquired brain injury (ABI). However, to our knowledge, no prospective study has yet been conducted to examine whether previous cross-sectional and retrospective results can be replicated in a longitudinal prospective design. Further, because clinical control groups were only rarely used, it remains debatable if the personality changes found are unique to patients with ABI or if they also affect patients with other disabilities.

METHODS

This study examined personality change in 114 participants with different kinds of ABI, 1321 matched controls (general control, GC), and 746 matched participants with restrictive impairments other than brain injury (clinical control, CC) in a prospective longitudinal design using data from the panel survey Household, Income and Labour Dynamics in Australia (HILDA).

RESULTS

Participants with ABI showed significantly larger declines in Extraversion and Conscientiousness compared with the GC group. When the ABI participants were compared with the CC group, only the difference in Conscientiousness remained significant.

CONCLUSION

Our prospective data corroborate evidence from previous cross-sectional studies that patients with ABI experience larger declines in Extraversion and Conscientiousness than the general population. Whereas the effect on Conscientiousness was unique to patients with ABI, the decline in Extraversion was also observed in participants with other impairments.

Predicting mild traumatic brain injury patients at risk of persistent symptoms in the Emergency Department

OBJECTIVE

To identify factors that can predict which emergency department (ED) patients with mTBI are likely to develop persistent post-concussion symptoms (PPCS).

DESIGN

A matched case-control study was conducted at a Level 1 trauma centre between June 2006 and July 2009. Patients diagnosed with mTBI in the ED and diagnosed at a concussion management programme with at least one PPCS (85 cases) were compared to patients diagnosed with mTBI in the ED (340 controls) to determine if factors assessed at the time of ED presentation could predict patients likely to develop persistent symptoms.

RESULTS

Multivariable hierarchical logistic regression with variables indicating increased risk for PPCS (prior mTBI, history of depression, history of anxiety, multiple injury, forgetfulness/poor memory, noise sensitivity, or light sensitivity) resulted in a final predictive model including prior mTBI, history of anxiety, forgetfulness/poor memory and light sensitivity. The final model had a specificity of 87.9% and a sensitivity of 69.9%.

CONCLUSIONS

A strong prediction model to identify those ED patients with mTBI at risk for PPCS was developed and could be easily implemented in the ED; therefore, helping to target those patients who would potentially benefit from close follow-up.

Diffusion tensor imaging findings are not strongly associated with postconcussional disorder 2 months following mild traumatic brain injury

OBJECTIVE

To examine the relation between diffusion tensor imaging (DTI) of the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI).

PARTICIPANTS

Sixty patients with MTBI and 34 patients with orthopedic/soft-tissue injuries (Trauma Controls) prospectively enrolled from consecutive admissions to a level 1 trauma center.

PROCEDURE

Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury. Participants also completed a postconcussion symptom checklist. The MTBI group was divided into 2 subgroups based on the International Classification of Diseases, Tenth Revision symptom criteria for postconcussion disorder (PCD): PCD Present (n = 21), PCD Absent (n = 39).

MAIN OUTCOME MEASURES

Measures of fractional anisotropy and mean diffusivity for the genu, body, and splenium of the corpus callosum. Participants also completed the British Columbia Post-Concussion Symptom Inventory.

RESULTS

The MTBI group reported more postconcussion symptoms than the trauma controls. There were no significant differences between MTBI and trauma control groups on all DTI measures. In the MTBI sample, there were no significant differences on all DTI measures between those who did and did not meet the International Classification of Diseases, Tenth Revision research criteria for postconcussion disorder.

CONCLUSIONS

These data do not support an association between white matter integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI.

Role and impact of cognitive rehabilitation

Cognitive rehabilitation interventions are theoretically based and empirically validated treatments designed to ameliorate the cognitive, behavioral, and emotional impairments commonly experienced by individuals with traumatic brain injury (TBI). Cognitive rehabilitation can play many roles in facilitating recovery after TBI, such as improving impaired cognitive functions, increasing awareness of injury-related deficits, improving mood, facilitating vocational and community involvement, and reducing the probability of secondary disability. The considerable evidence documenting the impact of cognitive rehabilitation on improving the day-to-day function of individuals with TBI is described.

Psychiatric disorders following traumatic brain injury: their nature and frequency

OBJECTIVES

To retrospectively establish the nature and frequency of Axis I psychiatric disorders pre- and post-TBI.

PARTICIPANTS

One hundred participants who were 0.5 to 5.5 years post mild to severe TBI and 87 informants, each evaluated at a single time point.

MAIN MEASURE

The Structured Clinical Interview for DSM-IV Disorders (SCID-I).

RESULTS

Preinjury, 52% received a psychiatric diagnosis, most commonly substance use disorder (41%), followed by major depressive disorder (17%) and anxiety (13%). Postinjury, 65% received a diagnosis, of which major depression became the most common (45%), followed by anxiety (38%) and substance use disorder (21%). Frequency of depression, generalized anxiety disorder, posttraumatic stress disorder, panic disorder, and phobias rose from preinjury to postinjury. More than two-thirds of postinjury depression and anxiety cases were novel and showed poor resolution rates. Few novel cases of substance use disorder were noted. Psychotic disorders, somatoform disorders, and eating disorders occurred at frequencies similar to those in the general population.

CONCLUSIONS

A high frequency of postinjury psychiatric disorders was evident up to 5.5 years postinjury, with many novel cases of depression and anxiety. Individuals with TBI should be screened for psychiatric disorders at various time points post-injury without reliance on history of psychiatric problems to predict who is at risk, so that appropriate intervention can be offered.

Inhibition and object relations in borderline personality traits after traumatic brain injury

This study aims to assess the nature and severity of borderline traits after traumatic brain injury (TBI). Thirty subjects with moderate or severe TBI were compared to 30 normal controls on the Revised Diagnostic Interview for Borderlines (DIB-R), a dimensional measure of borderline traits, the Go-no go inhibition task, the Complexity of Representations of People and Affect-Tone Relationships Paradigms, two scales from the Social Cognition and Object Relations Scale (SCORS) evaluating the quality of object relations, an estimation of pre-morbid borderline severity, the Beck Depression Inventory (BDI) and various neuropsychological measures. Results indicate that TBIs present more borderline symptoms and traits than controls. However, the severity of borderline symptomatology remains comparatively low for the vast majority. As expected, the TBI group showed a poorer performance on the Go-no go task, a characteristic neuropsychological inhibition deficit. Yet, both samples present similar profiles on the SCORS. Finally, the DIB-R was correlated with the Affect-Tone scale, the BDI and with the pre-morbid severity estimation. Results suggest that post-TBI borderline traits remain rare and relate more to the affective quality of object relations, negative affects and pre-morbid borderline pathology than inhibition deficits.

Longitudinal Study of Suicide After Traumatic Injury

BACKGROUND

Suicide risk after discharge among trauma patients could be influenced by multiple factors. The aim of this study is to establish whether patients discharged from a trauma center experience an increased suicide rate and whether this can be explained by defined demographic, injury, or alcohol abuse risk factors.

METHODS

Patients admitted between July 1, 1983, and June 30, 1995, and discharged alive from a Level I trauma center (n = 27,399) were followed for 1.5 to 14.5 years to determine whether they had died. Death determination was made by an epidemiologic support service, which had created a repository of death certificates. Variables used in the analyses included age, gender, race, Injury Severity Score, discharge disposition, mechanism of injury, and alcohol toxicology. General and trauma populations were compared using standard mortality rates. Risk factors for suicide within the trauma population were explored using Pearson's chi2, Mantel-Haenszel chi2, Cox proportional hazards, and Mantel-Cox log-rank methodology.

RESULTS

Suicide was more common in the trauma than in the general population (standard mortality rate = 1.71). This difference may be attributed primarily to alcohol use problems. Suicide risk in the trauma population increased with age from 25 to 44 years, male gender, Caucasian race, and positive alcohol toxicology. Disability (as measured by discharge disposition), but not injury severity, also seemed to have an influence on suicide rates.

CONCLUSION

Interventions that address modifiable risk factors for suicide (substance abuse, psychiatric disorders, hopelessness, and social isolation) could benefit trauma patients known to be at higher risk for suicide, particularly those abusing alcohol.

Psychiatric disturbances after traumatic brain injury: neurobehavioral and personality changes

Traumatic brain injuries (TBI) are frequently accompanied by psychiatric disturbances, which can include striking to relatively minor alterations in personality, behavior, and emotional regulation. The persistence of these neurobehavioral syndromes often leads to deleterious effects on recovery and rehabilitation outcomes. A recent surge of studies has emerged in the past several years to quantify the extent of psychiatric disorders in TBI and to describe differential clinical presentations. Various pre- and post-injury factors also have been hypothesized to contribute to the development and maintenance of psychiatric symptoms in survivors of brain injuries. The identification of high-risk individuals with distinct neuropathophysiological and psychosocial features permits the development of multidisciplinary and tailored approaches to the assessment, prevention, and management of the negative effects of personality and behavioral changes in TBI. This article summarizes the most recent research in these areas and highlights the gaps that need to be filled in subsequent future.

Cognition in mania and depression: psychological models and clinical implications

Affective disorders, including bipolar disorder and major depressive disorder, are highly prevalent throughout the world and are extremely disabling. Diagnostic and Statistical Manual criteria and psychological models strongly implicate cognitive dysfunctions as being integral to our understanding of these disorders. We review the findings from studies that have used neurocognitive tests and functional imaging techniques to explore abnormal cognition in affective disorders. In particular, we highlight the evidence for cognitive dysfunctions that persist into full clinical remission, and the recent trend toward the use of "hot" processing tasks, involving emotionally charged stimuli, as a means of differentiating between the cognitive underpinnings of mania and depression. The clinical relevance of these developments is discussed.

Suicidal behavior and mild traumatic brain injury in major depression

Traumatic brain injury (TBI) is associated with psychiatric illness, suicidal ideation, suicide attempts, and completed suicide. We investigated the relationship between mild TBI and other risk factors for suicidal behavior in major depressive episode. We hypothesized that mild TBI would be associated with suicidal behavior at least partly because of shared risk factors that contribute to the diathesis for suicidal acts. Depressed patients (N = 325) presenting for treatment were evaluated for psychopathology, traumatic history, and suicidal behavior. Data were analyzed using Student t -test, chi-square statistic, or Fisher exact test. A backward stepwise logistic regression model (N = 255) examined the relationship between attempter status and variables that differed in the TBI and non-TBI patients. Forty-four percent of all subjects reported mild TBI. Subjects with TBI were more likely to be male, have a history of substance abuse, have cluster B personality disorder, and be more aggressive and hostile compared with subjects without TBI. They were also more likely to be suicide attempters, although their suicidal behavior was not different from that of suicide attempters without TBI. Attempt status was mostly predicted by aggression and hostility, but not the presence of TBI. Of note, for males, a history of TBI increased the likelihood of being a suicide attempter, whereas the risk was elevated for females regardless of TBI history. Our data suggest that suicidal behavior and TBI share antecedent risk factors: hostility and aggression. Future studies may yield confirmation using a prospective design.

Obsessive-compulsive disorder after traumatic brain injury

Traumatic brain injury ( TBI) neuropsychiatric sequelae are a significant cause of morbidity in TBI victims. Among the recognized sequelae are anxiety, obsessions, compulsions and obsessive-compulsive disorder (OCD). This review addresses the emergence of OCD and OCD symptoms after TBI with an emphasis on neural circuits that underlie OCD symptom expression that may be affected by the injury. Current studies suggest that post-TBI emergent psychopathology, including OCD, is influenced by underlying sub-clinical diathesis, brain injury lesions sites, environmental stressors and the rehabilitation process. Pre-morbid status can be obtained by structured psychiatric interviews, and TBI brain lesions can be defined with advanced neuroimaging techniques. This information along with the management of family and environmental stressors and the enhanced clinical identification of symptoms of anxiety and OCD can be used in the rehabilitation process to improve prognosis after TBI.