Expressed emotion and its relationship to anxiety and depression after traumatic brain injury

Diet's Impact on Post-Traumatic Brain Injury Depression: Exploring Neurodegeneration, Chronic Blood-Brain Barrier Destruction, and Glutamate Neurotoxicity Mechanisms

Traumatic brain injury (TBI) has a profound impact on cognitive and mental functioning, leading to lifelong impairment and significantly diminishing the quality of life for affected individuals. A healthy blood-brain barrier (BBB) plays a crucial role in guarding the brain against elevated levels of blood glutamate, making its permeability a vital aspect of glutamate regulation within the brain. Studies have shown the efficacy of reducing excess glutamate in the brain as a treatment for post-TBI depression, anxiety, and aggression. The purpose of this article is to evaluate the involvement of dietary glutamate in the development of depression after TBI. We performed a literature search to examine the effects of diets abundant in glutamate, which are common in Asian populations, when compared to diets low in glutamate, which are prevalent in Europe and America. We specifically explored these effects in the context of chronic BBB damage after TBI, which may initiate neurodegeneration and subsequently have an impact on depression through the mechanism of chronic glutamate neurotoxicity. A glutamate-rich diet leads to increased blood glutamate levels when contrasted with a glutamate-poor diet. Within the context of chronic BBB disruption, elevated blood glutamate levels translate to heightened brain glutamate concentrations, thereby intensifying neurodegeneration due to glutamate neurotoxicity.

Chronic Anxiety- and Depression-Like Behaviors Are Associated With Glial-Driven Pathology Following Repeated Blast Induced Neurotrauma

Long-term neuropsychiatric impairments have become a growing concern following blast-related traumatic brain injury (bTBI) in active military personnel and Veterans. Neuropsychiatric impairments such as anxiety and depression are common comorbidities that Veterans report months, even years following injury. To understand these chronic behavioral outcomes following blast injury, there is a need to study the link between anxiety, depression, and neuropathology. The hippocampus and motor cortex (MC) have been regions of interest when studying cognitive deficits following blast exposure, but clinical studies of mood disorders such as major depressive disorder (MDD) report that these two regions also play a role in the manifestation of anxiety and depression. With anxiety and depression being common long-term outcomes following bTBI, it is imperative to study how chronic pathological changes within the hippocampus and/or MC due to blast contribute to the development of these psychiatric impairments. In this study, we exposed male rats to a repeated blast overpressure (~17 psi) and evaluated the chronic behavioral and pathological effects on the hippocampus and MC. Results demonstrated that the repeated blast exposure led to depression-like behaviors 36 weeks following injury, and anxiety-like behaviors 2-, and 52-weeks following injury. These behaviors were also correlated with astrocyte pathology (glial-fibrillary acid protein, GFAP) and dendritic alterations (Microtubule-Associated Proteins, MAP2) within the hippocampus and MC regions at 52 weeks. Overall, these findings support the premise that chronic glial pathological changes within the brain contribute to neuropsychiatric impairments following blast exposure.

Psychosocial and Functional Predictors of Depression and Anxiety Symptoms in Veterans and Service Members With TBI: A VA TBI Model Systems Study

OBJECTIVE

To identify psychosocial and functional predictors of self-reported depression and anxiety symptoms at year 2 following traumatic brain injury (TBI).

SETTING

Five Department of Veterans Affairs (VA) Polytrauma Rehabilitation Centers (PRCs) within the TBI Model Systems (TBIMS).

PARTICIPANTS

A total of 319 service members/veterans enrolled in VA TBIMS who were eligible for and completed both 1- and 2-year follow-up evaluations.

DESIGN

Secondary analysis from multicenter prospective longitudinal study.

MAIN MEASURES

Demographic, injury-related, military, mental health, and substance use variables. Questionnaires included the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), and Neurobehavioral Symptom Inventory. Rating scales included the Participation Assessment with Recombined Tools-Objective and Disability Rating Scale.

RESULTS

The final sample was largely male (96%) and predominantly White (65%), with a median age of 27 years. In unadjusted analyses, pre-TBI mental health treatment history and year 1 employment status, community activity, sleep difficulties, and self-reported depression and anxiety symptoms were associated with year 2 PHQ-9 scores; pre-TBI mental health treatment history and year 1 community activity, social contact, problematic substance use, sleep difficulties, and self-reported depression and anxiety symptoms were associated with year 2 GAD-7 scores. In multivariable analyses, only year 1 community activity and depression symptoms uniquely predicted year 2 PHQ-9 scores, and only year 1 employment status, community activity, problematic substance use, and anxiety symptoms uniquely predicted year 2 GAD-7 scores.

CONCLUSION

Anxiety and depression commonly occur after TBI and are important treatment targets. Some predictors (eg, participation and substance use) are modifiable and amenable to treatment as well. Early identification of anxiety and depression symptoms is key.

Correlates of the personality change judgments of individuals who have MS

Objectives: This is the first study to estimate prevalence of self-reported personality change (PC) in people with multiple sclerosis (MS). Methods developed in traumatic brain injury studies explore physical, and psychosocial triggers for PC judgments.Participants: 69 MS clinic attendees living with their partner.Measures: Participants rated the degree of PC. 28 Current and pre-MS characteristics were rated. The Multiple Sclerosis Impact Scale, the MS Neuropsychological Questionnaire, the Beck Depression Inventory-FastScreen, and the Hospital Anxiety and Depression Scale quantified neuropsychological status. The Family Questionnaire, McMaster Assessment Device and the Social Provisions Scale sampled perceived social influences.Results: 54% perceived substantial PC. Current characteristics predicted PC better than perceived behavior changes. PC was associated with specific characteristics denoting stress reactions, emotional distress, perceived cognitive impairment and poorer family functioning. PC was not significantly related to severity of physical symptoms or social support. This study also suggested that the specific characteristics questionnaire probed at least 2 components of reconstructed identity: PC/Reactivity and Disability.Conclusions: This study raises methodological concerns about measures that simply sum ratings of characteristics related to self-identity. It also proposes possible ways of collaborating with individuals in their efforts to respond constructively to PC and other changes. .

Efficacy and Harms of Pharmacological Interventions for Anxiety after Traumatic Brain Injury: Systematic Review

After a traumatic brain injury (TBI), many persons experience significant and debilitating problems with anxiety. The aim of this systematic review was to critically evaluate the evidence regarding efficacy of pharmacological interventions for anxiety after TBI. We reviewed studies published in English before July 2020 and included original research on pharmacological interventions for anxiety after TBI in adults ≥16 years of age. MEDLINE, PubMed, CINAHL, EMBASE, PsycINFO, and CENTRAL databases were searched, with additional searching of key journals, clinical trials registries, and international drug regulators. The primary outcomes of interest were reduction in symptoms of anxiety and occurrence of harms. The secondary outcomes of interest were changes in depression, cognition, quality of life, and participation. Data were summarized in a narrative synthesis, and evidence quality was assessed using the Cochrane Risk of Bias tool. Only a single non-peer-reviewed, randomized controlled trial of 19 male military service members with mild TBI met inclusion criteria. This study found no significant effect of citalopram on anxiety symptoms over a 12-week intervention. The trial was stopped early because of poor recruitment, and much of the study detail was not included in the report. The methodological quality of the study was difficult to assess because of the lack of detail. No recommendations could be drawn from this review. There is a critical need for adequately powered and controlled studies of pharmacological interventions for anxiety after TBI across all severities that examine side-effect profiles and consider issues of comorbidity and effects of long-term pharmacotherapy.

Good things better? Reappraisal and discrete emotions in acquired brain injury

There has been substantial interest in emotion after acquired brain injury (ABI), but less attention paid to emotion regulation (ER). Research has focused primarily on the ER strategy of reappraisal for regulating negative emotions, without distinguishing between classes of emotion, and there has been no attempt at exploring these differences in patients with ABI. The present study explored components of reappraisal, across classes of emotion, and their associated neuropsychological mechanisms. Thirty-five patients with ABI and twenty-two matched healthy control participants (HCs) completed two questionnaires, a battery of cognitive tasks, and an emotion regulation task (the Affective Story Recall Reappraisal task). Results suggest that those with ABI take longer, and generate fewer reappraisals than HCs across several discrete emotions. Notably, their ability to decrease emotional intensity did not differ significantly to HCs for negative emotions, but findings suggest that their reappraisals are less effective when up-regulating neutral emotions to positive. Working memory was the only significant predictor of the total number of reappraisals generated, and the time taken to produce a first reappraisal. Implications of these findings are discussed in the context of neuropsychological rehabilitation, including the role of the relatives in implementing and reinforcing micro-interventions.

Transcranial light-emitting diode therapy for neuropsychological improvement after traumatic brain injury: a new perspective for diffuse axonal lesion management

The cost of traumatic brain injury (TBI) for public health policies is undeniable today. Even patients who suffer from mild TBI may persist with cognitive symptoms weeks after the accident. Most of them show no lesion in computed tomography or conventional magnetic resonance imaging, but microstructural white matter abnormalities (diffuse axonal lesion) can be found in diffusion tensor imaging. Different brain networks work together to form an important part of the cognition process, and they can be affected by TBI. The default mode network (DMN) plays an important central role in normal brain activities, presenting greater relative deactivation during more cognitively demanding tasks. After deactivation, it allows a distinct network to activate. This network (the central executive network) acts mainly during tasks involving executive functions. The salience network is another network necessary for normal executive function, and its activation leads to deactivation of the DMN. The use of red or near-infrared (NIR) light to stimulate or regenerate tissue is known as photobiomodulation. It was discovered that NIR (wavelength 800-900 nm) and red (wavelength 600 nm) light-emitting diodes (LEDs) are able to penetrate through scalp and skull and have the potential to improve the subnormal, cellular activity of compromised brain tissue. Based on this, different experimental and clinical studies were done to test LED therapy for TBI, and promising results were found. It leads us to consider developing different approaches to maximize the positive effects of this therapy and improve the quality of life of TBI patients.

Expressed emotion in couples facing breast cancer in women is associated with psychological distress in the first year after surgery

The aim of this study was to assess the links between partners' and women's expressed emotion with the distress of one another during the first year after surgery for breast cancer in women. The design was longitudinal. A sample of 61 couples participated in the study at 2 weeks, 3 months, and 12 months after the surgery. Expressed emotion was assessed with the Five-Minute Speech Sample. Psychological distress was assessed with a self-reported questionnaire. Mixed-model analyses showed that partners' expressed emotion is associated with heightened psychological distress in women during the first year after surgery, even after medical data were controlled for.

Anxiety and comorbid depression following traumatic brain injury in a community-based sample of young, middle-aged and older adults

BACKGROUND

Anxiety is common following a traumatic brain injury (TBI), but who is most at risk, and to what extent, is not well understood.

METHODS

Longitudinal data from a randomly-selected community sample (Wave 1: 7397, Wave 2: 6621 and Wave 3: 6042) comprising three adult cohorts (young: 20-24 years of age, middle-aged: 40-44, older: 60-64), were analysed. The association between TBI history, anxiety and comorbid depression was assessed, controlling for age, sex, marital/employment status, medical conditions, recent life events, alcohol consumption, social support and physical activity.

RESULTS

Thirteen percent of the sample had sustained a TBI by Wave 3, 35% of whom had sustained multiple TBIs. Cross-sectional analyses revealed that clinically-significant anxiety was more common in people who had sustained a TBI. Longitudinal analyses demonstrated an increased risk of anxiety post-TBI, even after controlling for potential demographic, health and psychosocial confounds. Anxiety was more common than depression, although 10% of those with a TBI experienced comorbid anxiety/depression.

LIMITATIONS

TBIs were not medically confirmed and anxiety and depression were only assessed every four years by self-report, rather than clinical interview. Sample attrition resulted in the retention of healthier individuals at each wave.

CONCLUSIONS

TBIs are associated with a lifelong increased risk of experiencing clinically-significant anxiety, highlighting the chronic nature of TBI sequelae. Positive lifestyle changes (e.g., increasing physical activity, reducing alcohol consumption) may decrease the risk of anxiety problems in the early years after a TBI. Comorbid anxiety and depression was common, indicating that both should be monitored and treated.

The relationship between family expressed emotion, perceived criticism and criticism sensitivity and psychiatric outcomes following traumatic brain injury

Family expressed emotion (EE) is a strong predictor of outcome in a range of psychiatric and medical conditions. This study aimed to examine the relationship between family EE-criticism, patient perceived criticism and criticism sensitivity and psychiatric disorders following moderate to severe traumatic brain injury (TBI). Participants were 60 patients with TBI and their family members. Patients were assessed for psychiatric disorders using the Structured Clinical Interview for DSM-IV (SCID-I) and completed the Perceived Criticism Measure (PCM) to determine levels of perceived criticism and criticism sensitivity. Family members completed the Family Questionnaire (FQ) to assess patient directed EE-criticism. Patients were reassessed approximately 12-months post-baseline. After controlling for diagnostic status at baseline, high criticism sensitivity at baseline was associated with greater probability of psychiatric diagnosis at follow-up (odds ratio=3.99, 95% CI=1.15-13.71). Family EE-criticism and perceived criticism were not predictive of patient diagnostic status at follow-up, but patients with high EE-family members were more likely to have a concurrent psychiatric diagnosis at baseline. Findings suggest that sensitivity to interpersonal criticism may have a role in the development and course of psychiatric disorders following TBI.

Disrupted White Matter Microstructure and Mood Disorders after Traumatic Brain Injury

Traumatic brain injury (TBI) is associated with an elevated frequency of mood disorders that may, in part, be explained by changes in white-matter microstructure. This study is the first to examine the relationship between mood disorders and white-matter pathology in a sample of patients with mild to severe TBI using a standardized psychiatric interview. This study reports on a sub-sample of 29 individuals recruited from a large prospective study that examined the evolution of psychiatric disorders following complicated, mild to severe TBI. Individuals with TBI were also compared with 23 healthy control participants. Individuals were invited to complete the Structured Clinical Interview for DSM-IV Disorders (SCID) to diagnose psychiatric disorders. Participants who developed a mood disorder within the first 3 years were categorized into a TBI-Mood group. Diffusion tensor tractography assessed white matter microstructure using atlas-based tract-averaged and along-tract approaches. Fractional anisotropy (FA) was used as the measure of white-matter microstructure. TBI participants with and without a mood disorder did not differ in regard to injury severity and other background factors. Nevertheless, TBI participants diagnosed with a mood disorder displayed significantly lower tract-averaged FA values for the right arcuate fasciculus (p = 0.011), right inferior longitudinal fasciculus (p = 0.009), and anterior segments I (p = 0.0004) and II (p = 0.007) of the corpus callosum, as well as the left (p = 0.014) and right (p = 0.015) fronto-occipital longitudinal fasciculi. The pattern of white matter disruption identified in the current study provides further support for a neurobiological basis of post-TBI mood disorders. Greater understanding of individuals' underlying neuropathology may enable better characterization and prediction of mood disorders. Integration of neuropathology may also inform the potential efficacy of pharmacological and psychological interventions.

Exploration of correlates of self-reported personality change after moderate-severe traumatic brain injury

OBJECTIVE

Individuals with traumatic brain injury (TBI) often express concern that their personality has changed. Factors generating that conclusion are rarely explored quantitatively. Accordingly, this study examines neurobehavioural correlates of self-reported personality change.

METHODS

Seventy-one participants and informants were interviewed M = 57.9 (SD = 46.9) months after a moderate-severe TBI. The degree of self-reported personality change was correlated with scores on measures of general cognitive functioning, executive functioning, olfaction, social-emotional behaviour, emotional distress and the Expressed Emotion close informants directed towards them.

RESULTS

As expected, self-reported personality change correlated with dysexecutive symptoms and depression. Although anosmia (a putative index of ventral frontal damage) correlated with reduced self-reported emotional recognition and empathy, against prediction, the latter measures did not correlate with self-reported personality change. Neither were the predicted positive correlations found between high Expressed Emotion (criticism and emotional over-involvement) and self-reported personality change.

DISCUSSION

These findings are discussed in the context of previous work. A need to replicate and extend the present findings is suggested. A strategy to further clarify the relationships perceived personality change have with (a) self-reported change in specific behaviours and (b) identity change is advocated. Implications for intervention are suggested.

Effect of Mild Traumatic Brain Injury and Demographic Factors on Psychological Outcome

Background

It is well-known that severe brain injury can make people susceptible to psychological symptoms. However, mild traumatic brain injury (MTBI) is still open for discussion.

Objectives

This study aimed to compare psychological symptoms of MTBI patients with those without MTBI considering demographic auxiliary variables.

Patients and Methods

This prospective cohort study was conducted on 50 MTBI patients and 50 healthy subjects aged 15 - 65 years. Psychological assessment was carried out six months post-injury using a series of self-report measures including the brief symptom inventory (BSI) scale. Other information of the individuals in the two groups was recorded prospectively. Data were analyzed using the chi-square test, t-test, and multiple linear regression tests.

Results

There was a significant difference between the MTBI patients and healthy subjects in all subscales and total score of BSI. Our findings showed that obsession-compulsion and anxiety subscales were significantly more common in the MTBI patients than in the healthy subjects. Also, multivariate regression analysis six months post- injury showed that head trauma and substance abuse can have an effect on psychological symptoms.

Conclusions

Mild traumatic brain injuries despite of the normal CT scan and history of substance abuse are closely related to psychological symptoms. Therefore, it is recommended that patients with brain trauma 6 months post-injury and subjects with a history of substance abuse be evaluated for psychological distress to support better rehabilitation.

Parents' traumatic brain injury increases their children's risk for use of psychiatric care: the 1987 Finnish Birth Cohort study

OBJECTIVE

Traumatic brain injury (TBI) of a parent causes significant changes in their family life and parent-children relationships. However, the number of children affected by parental TBI and the long-term consequences for these children remain unknown. We estimated the prevalence of children affected by parental TBI and investigated whether these children had greater use of psychiatric services than their peers.

METHODS

This a retrospective population-based register study. All 60,069 children born in Finland in 1987 were followed up through national health and social registers from 1987 to 2008.

RESULTS

During the 21-year follow-up, 1532 (2.6%) children had a parent with TBI. Overall, 22.5% of those having a parent with TBI were treated in specialized psychiatric care. Use of psychiatric care was significantly increased among those cohort members with a parent with mild [odds ratio (OR) 1.80, 95% confidence interval (CI) 1.37-2.38] or severe (OR 1.49, 95% CI 1.12-1.98) TBI compared to their peers.

CONCLUSIONS

Parental TBI is associated with increased use of specialized psychiatric services by children. Adult health care services must have appropriate systems in place to address the psychosocial needs and support the welfare and development of children of patients with TBI.

Mental Health is Central to Good Neurorehabilitation after TBI

Those after traumatic brain injury (TBI) who suffer mental health problems, by which I mean problems that a psychiatrist might understand as falling within their remit, suffer a double whammy. Not only do they suffer the stigma of the disabled, but even within this group they may be stigmatised. It has often been my experience that while families will allow for their injured loved one to be under the care of rehabilitation services, including a psychologist, they baulk at the possibility that their loved one may need psychiatric care. This comes to a head when it comes to detaining a patient, in England and Wales, under the Mental Health Act; this may be vigorously resisted by family because of what they infer this says about their loved one's sanity.