Early trajectory of psychiatric symptoms after traumatic brain injury: relationship to patient and injury characteristics

Acute Management of Moderate to Severe Traumatic Brain Injury

The focus of this article is on the acute management of traumatic brain injury. The article focuses on the classification of traumatic brain injury, general acute management of traumatic brain injury, the role of the physiatrist on this team, and lastly, behavioral and family considerations in the acute care setting. The article includes a focus on physiologic systems, strategies for the management of various aspects of brain injury, and consideration of factors associated with the continuum of care. Overall, the article reviews this critical period of brain injury recovery and provides a primer for the physiatrist.

The Brief Symptom Inventory in the Swiss general population: Presentation of norm scores and predictors of psychological distress

Psychological distress is an important and frequent health problem. The Brief Symptom Inventory (BSI) allows screening for psychological distress in clinical, general and research populations. We aimed to provide normative data for the BSI and the BSI-18 for the Swiss general population: We 1) present psychometric properties, 2) develop a Swiss T-standardization and validate it using a clinical sample, 3) describe psychological distress in the Swiss general population and the clinical sample, and 4) compare the means and T-standardized scores of the Swiss general population to different German norm populations. Using a cross-sectional study design, we invited a representative sample of the Swiss general population aged 18-75 years to the study. A sample of psychotherapy outpatients had competed the BSI before start of their therapy. We calculated scores for the nine scales of the BSI (three of them constitute the BSI-18), the T-standardization and the following BSI indices: Global Severity Index (GSI), Positive Symptom Total (PST), Positive Symptom Distress Index (PSDI), and Caseness (reaching T≥63 on the GSI or T≥63 on at least two of the scales). A total of 1238 general population participants completed the BSI (41.8% male; mean age 48.9 years). The BSI had good psychometric properties. The Swiss T-standardization showed good validity when applied in the clinical sample. Females reached a significantly higher GSI score than males (p<0.001). Older participants (p = 0.026), those with higher education (p <0.001), and those employed or retired (p<0.001) reached lower scores than participants aged 18-25 years, those with compulsory schooling, and unemployed participants, respectively. A total of 18.1% (CI: 16.0-20.5) participants of the general population and 75.2% (CI: 73.7-76.7) of the psychotherapy patients were considered cases with psychological distress. Our study presents detailed normative data for the BSI and the BSI-18 based on a representative sample of the Swiss general population. This information will be helpful for clinical applications and research in the Swiss and international context.

Studying the social mind: An updated summary of findings from the Vietnam Head Injury Study

Lesion mapping studies allow us to evaluate the potential causal contribution of specific brain areas to human cognition and complement other cognitive neuroscience methods, as several authors have recently pointed out. Here, we present an updated summary of the findings from the Vietnam Head Injury Study (VHIS) focusing on the studies conducted over the last decade, that examined the social mind and its intricate neural and cognitive underpinnings. The VHIS is a prospective, long-term follow-up study of Vietnam veterans with penetrating traumatic brain injury (pTBI) and healthy controls (HC). The scope of the work is to present the studies from the latest phases (3 and 4) of the VHIS, 70 studies since 2011, when the Raymont et al. paper was published (Raymont et al., 2011). These studies have contributed to our understanding of human social cognition, including political and religious beliefs, theory of mind, but also executive functions, intelligence, and personality. This work finally discusses the usefulness of lesion mapping as an approach to understanding the functions of the human brain from basic science and clinical perspectives.

The metabolic overdrive hypothesis: hyperglycolysis and glutaminolysis in bipolar mania

Evidence from diverse areas of research including chronobiology, metabolomics and magnetic resonance spectroscopy indicate that energy dysregulation is a central feature of bipolar disorder pathophysiology. In this paper, we propose that mania represents a condition of heightened cerebral energy metabolism facilitated by hyperglycolysis and glutaminolysis. When oxidative glucose metabolism becomes impaired in the brain, neurons can utilize glutamate as an alternative substrate to generate energy through oxidative phosphorylation. Glycolysis in astrocytes fuels the formation of denovo glutamate, which can be used as a mitochondrial fuel source in neurons via transamination to alpha-ketoglutarate and subsequent reductive carboxylation to replenish tricarboxylic acid cycle intermediates. Upregulation of glycolysis and glutaminolysis in this manner causes the brain to enter a state of heightened metabolism and excitatory activity which we propose to underlie the subjective experience of mania. Under normal conditions, this mechanism serves an adaptive function to transiently upregulate brain metabolism in response to acute energy demand. However, when recruited in the long term to counteract impaired oxidative metabolism it may become a pathological process. In this article, we develop these ideas in detail, present supporting evidence and propose this as a novel avenue of investigation to understand the biological basis for mania.

An Examination of Racial/Ethnic Differences on the Neurobehavioral Symptom Inventory Among Veterans Completing the Comprehensive Traumatic Brain Injury Evaluation: A Veterans Affairs Million Veteran Program Study

OBJECTIVE

The purpose of this study was to explore racial/ethnic differences in neurobehavioral symptom reporting and symptom validity testing among military veterans with a history of traumatic brain injury (TBI).

METHOD

Participants of this observational cross-sectional study (N = 9,646) were post-deployed Iraq-/Afghanistan-era veterans enrolled in the VA's Million Veteran Program with a clinician-confirmed history of TBI on the Comprehensive TBI Evaluation (CTBIE). Racial/ethnic groups included White, Black, Hispanic, Asian, Multiracial, Another Race, American Indian or Alaska Native, and Native Hawaiian or Other Pacific Islander. Dependent variables included neurobehavioral symptom domains and symptom validity assessed via the Neurobehavioral Symptom Inventory (NSI) and Validity-10, respectively.

RESULTS

Chi-square analyses showed significant racial/ethnic group differences for vestibular, somatic/sensory, and affective symptoms as well as for all Validity-10 cutoff scores examined (≥33, ≥27, ≥26, >22, ≥22, ≥13, and ≥7). Follow-up analyses compared all racial/ethnic groups to one another, adjusting for sociodemographic- and injury-related characteristics. These analyses revealed that the affective symptom domain and the Validity-10 cutoff of ≥13 revealed the greatest number of racial/ethnic differences.

CONCLUSIONS

Results showed significant racial/ethnic group differences on neurobehavioral symptom domains and symptom validity testing among veterans who completed the CTBIE. An enhanced understanding of how symptoms vary by race/ethnicity is vital so that clinical care can be appropriately tailored to the unique needs of all veterans. Results highlight the importance of establishing measurement invariance of the NSI across race/ethnicity and underscore the need for ongoing research to determine the most appropriate Validity-10 cutoff score(s) to use across racially/ethnically diverse veterans.

Network analysis of anxiety and depressive symptoms one year after traumatic brain injury

We used network analysis to explore interrelationships between anxiety and depressive symptoms after traumatic brain injury (TBI). At one year post-injury, 882 adult civilians who received inpatient rehabilitation for moderate-severe TBI self-reported anxiety and depressive symptoms (Hospital Anxiety and Depression Scale). The severity of TBI was characterized acutely by the duration of post-traumatic amnesia (PTA), and TBI-related functional disability was rated by an examiner at one year post-injury using a structured interview (Glasgow Outcome Scale - Extended). We estimated two cross-sectional, partial correlation networks. In the first network, anxiety and depressive symptoms were densely interconnected yet formed three distinct, data-driven communities: Hyperarousal, Depression, and General Distress. Worrying thoughts and having difficulty relaxing were amongst the most central symptoms, showing strong connections with other symptoms within and between communities. In the second network, TBI severity was directly negatively associated with hyperarousal symptoms but indirectly positively associated with depressive symptoms via greater functional disability. The results highlight the potential utility of simultaneous, transdiagnostic assessment and treatment of anxiety and depressive symptoms after moderate-severe TBI. Worrying thoughts, having difficulty relaxing, and the experience of disability may be important targets for treatment, although future studies examining symptom dynamics within individuals and over time are required.

Effects and mechanisms of extremely cold environment on body response after trauma

With the outbreak of the Ukrainian crisis, extremely cold environment warfare has once again become the focus of international attention. People exposed to extremely cold environments may suffer from cold damage, further aggravate trauma, trigger high disability and mortality rates, and even cause serious sequelae. To declare the effects and mechanisms of the extremely cold environment on the body after trauma, this paper reviews, firstly, physiological reaction of human body in an extremely cold environment. Then, the post-traumatic body response in an extremely cold environment was introduced, and finally, the sequelae of trauma in extremely cold environment was further summarized in the paper. The results indicated that extremely cold environment can cause a series of damage to the body, especially the body after trauma. The extremely cold factor is a double-edged sword, showing a favorable and unfavorable side in different aspects. Moreover, in addition to the trauma suffered by the body, the subsequent sequelae such as cognitive dysfunction, anxiety, depression and even post-traumatic stress disorder may also be induced. The paper summarizes the human body's physiological response in an extremely cold environment, and declares the effects and mechanisms of the extremely cold environment on the body after trauma, which may provide a theoretical basis for effectively improving the level of combat trauma treatment in extremely cold regions.

Mediators, Moderators, and Covariates: Matching Analysis Approach for Improved Precision in Cognitive-Communication Rehabilitation Research

PURPOSE

The dual goals of this tutorial are (a) to increase awareness and use of mediation and moderation models in cognitive-communication rehabilitation research by describing options, benefits, and attainable analytic approaches for researchers with limited resources and sample sizes and (b) to describe how these findings may be interpreted for clinicians consuming research to inform clinical care.

METHOD

We highlight key insights from the social sciences literature pointing to the risks of common approaches to linear modeling, which may slow progress in clinical-translational research and reduce the clinical utility of our work. We discuss the potential of mediation and moderation analyses to reduce the research-to-practice gap and describe how researchers may begin to implement these models, even in smaller sample sizes. We discuss how these preliminary analyses can help focus resources for larger trials to fully encapsulate the heterogeneity of individuals with cognitive-communication disorders.

RESULTS

In rehabilitation research, we study groups, but we use the findings from those studies to treat individuals. The most functional clinical research is about more than establishing only whether a given effect exists for an "average person" in the group of interest. It is critical to understand the active ingredients and mechanisms of action by which a given treatment works (mediation) and to know which circumstances, contexts, or individual characteristics might make that treatment most beneficial (moderation).

CONCLUSIONS

Increased adoption of mediation and moderation approaches, executed in appropriate steps, could accelerate progress in cognitive-communication rehabilitation research and lead to the development of targeted treatments that work for more clients. In a field that has made limited progress in developing successful interventions for the last several decades, it is critical that we harness new approaches to advance clinical-translational research results for complex, heterogeneous groups with cognitive-communication disorders.

Transitional care programs to improve outcomes in patients with traumatic brain injury and their caregivers: A systematic review and meta-analysis

Background

Effective nursing interventions for caring for patients with moderate to severe traumatic brain injury are still challenging during a transition from hospital to home. Since traumatic brain injury has deep-rooted sequelae, patients and their caregivers require better arrangement and information on the condition to achieve improved outcomes after discharge.

Objective

This study aimed to assess transitional care programs to improve outcomes of patients with traumatic brain injury and their caregivers.

Methods

A systematic review and meta-analysis were performed on studies retrieved from ProQuest, PubMed, Science Direct, CINAHL, and Google Scholar from January 2010 to July 2021. RevMan 5.4.1 software was used for meta-analysis.

Results

Nine studies were systematically selected from 1,137 studies. The standard approaches of interventions used in patients with traumatic brain injury and their caregivers were education, mentored problem-solving, home-and community-based rehabilitation, counseling, skill-building, and psychological support. We observed that there was significant evidence indicating beneficial effects of intervention in increasing the physical functioning of patients with traumatic brain injury (SMD = -0.44, 95% CI -0.60 to -0.28, p <0.001), reducing the psychological symptoms among caregivers (SMD = -0.42, 95% CI -0.59 to -0.24, p <0.001), and increasing the satisfaction (SMD = -0.35, 95% CI -0.60 to -0.11, p = 0.005).

Conclusion

Education, skill-building, and psychological support should be the main components in transitional care nursing programs for patients with traumatic brain injury and their caregivers.

Depression in Older Adults 12 Months Following Traumatic Brain Injury: A TRACK-TBI Study

OBJECTIVE

To investigate depression at 12 months following traumatic brain injury (TBI) in older compared with younger adults.

DESIGN

Prospective longitudinal cohort study of persons with medically documented mild, moderate, and severe TBI at 12 months post-injury.

SETTING

Eighteen participating Level One trauma centers in the U.S.

PARTICIPANTS

1,505 participants with TBI and primary outcome data at 12-month follow-up.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURE

Patient Health Questionnaire-9 (PHQ-9).

RESULTS

PHQ-9 total scores were significantly lower for older adults (age≥65)(M = 3.2) as compared with younger adults (age<65)(M = 5.0) (B = -1.63, p < .001), indicating less depressive symptoms in older adults. Age did not interact with education, sex, race/ethnicity, psychiatric history, substance use, or GCS severity to impact PHQ-9 scores. Of the 29% of older adults who endorsed symptoms consistent with depression, 14% were classified as minor depression and 15% as major depression. The odds of older adults falling in the major depression vs. no depression group was significantly lower (decreased by 56%) as compared with younger adults (OR = 0.44, p =.001).

CONCLUSIONS

At 12-months post-TBI, older adults endorse lower depressive symptoms than their younger counterparts and are less likely to experience major depression; however, over one-fourth of older adults endorsed symptoms consistent with depression, warranting evaluation and treatment.

Duration of post-traumatic amnesia is uniquely associated with memory functioning in chronic moderate-to-severe traumatic brain injury

BACKGROUND

Disrupted memory circuitry may contribute to post-traumatic amnesia (PTA) after traumatic brain injury (TBI). It is unclear whether duration of PTA (doPTA) uniquely impacts memory functioning in the chronic post-injury stage.

OBJECTIVE

To examine the relationship between doPTA and memory functioning, independent of other cognitive abilities, in chronic moderate-to-severe TBI.

METHODS

Participants were 82 individuals (median chronicity = 10.5 years) with available doPTA estimates and neuropsychological data. Composite memory, processing speed (PS), and executive functioning (EF) performance scores, as well as data on subjective memory (SM) beliefs, were extracted. DoPTA-memory associations were evaluated via linear modeling of doPTA with memory performance and clinical memory status (impaired/unimpaired), controlling for PS, EF and demographic covariates. Interrelationships between doPTA, objective memory functioning, and SM were assessed.

RESULTS

DoPTA was significantly related to memory performance, even after covariate adjustment. Impairment in memory, but not PS or EF, was associated with a history of longer doPTA. SM was associated with memory performance, but unrelated to doPTA.

CONCLUSIONS

Findings suggest a specific association between doPTA-an acute injury phenomenon-and chronic memory deficits after TBI. Prospective studies are needed to understand how underlying mechanisms of PTA shape distinct outcome trajectories, particularly functional abilities related to memory processing.

Ferroptosis and traumatic brain injury

Traumatic brain injury (TBI) is a worldwide health problem contributing to significant economic burden. TBI is difficult to treat partly due to incomplete understanding of pathophysiology. Ferroptosis is a type of iron-dependent programmed cell death which has gained increasing attention due to its possible role in TBI. Current studies have demonstrated that ferroptosis is related to the pathology of TBI, and inhibition of ferroptosis may improve long term outcomes of TBI. Therefore, clarification of the exact association between ferroptosis and traumatic brain injury is necessary and may provide new targets for treatment. This review describes (1) the ferroptosis pathways following traumatic brain injury, (2) the role of ferroptosis during the chronic phase of traumatic brain injury, and (3) potential therapies targeting the ferroptosis pathways.

Mental Health Outcomes Among Military Service Members After Severe Injury in Combat and TBI

INTRODUCTION

Studies examining the mental health outcomes of military personnel deployed into combat zones have focused on the risk of developing post-traumatic stress disorder conferred by mild or moderate traumatic brain injury (TBI). However, other mental health outcomes among veterans who sustained critical combat injuries have not been described.

MATERIALS AND METHOD

We examined the associations of moderate and severe TBI and combat injury with the risk for anxiety and mood disorders, adjustment reactions, schizophrenia and other psychotic disorders, cognitive disorders, and post-traumatic stress disorder. We conducted a retrospective cohort study of U.S. military service members critically injured in combat during military operations in Iraq and Afghanistan from February 1, 2002, to February 1, 2011. Health care encounters from (1) the Department of Defense (DoD) Trauma Registry (TR), (2) acute and ambulatory care in military facilities, and (3) civilian facilities are reimbursed by Tricare. Service members who sustained severe combat injury require critical care. We estimated the risk of mental health outcomes using risk-adjusted logit models for demographic and clinical factors. We explored the relationship between TBI and the total number of mental health diagnoses.

RESULTS

Of the 4,980 subjects who met inclusion criteria, most injuries occurred among members of the Army (72%) or Marines (25%), with mean (SD) age of 25.5(6.1) years. The prevalence of moderate or severe TBI was 31.6% with explosion as the most common mechanism of injury (78%). We found 71% of the cohort was diagnosed with at least one poor mental health condition, and the adjusted risk conferred by TBI ranged from a modest increase for anxiety disorder (odds ratio, 1.27; 95% confidence interval [CI], 1.11-1.45) to a large increase for cognitive disorder (odds ratio, 3.24; 95% CI, 2.78-3.77). We found TBI was associated with an increased number of mental health diagnoses (incidence rate ratio, 1.52; 95% CI, 1.42-1.63).

CONCLUSIONS

Combat-associated TBI may have a broad effect on several mental health conditions among critically injured combat casualties. Early recognition and treatment for trauma-associated mental health are crucial to improving outcomes among service personnel as they transition to post-deployment care in the DoD, Department of Veterans Affairs, or community health systems.

Integrated neuropsychological and cognitive behavioural therapy after acquired brain injury: A pragmatic randomized clinical trial

After acquired brain injury (ABI) many patients suffer from persistent cognitive and emotional disturbances. The aim of this study was to investigate the treatment outcome of an integrated intervention, combining neuropsychological and cognitive behavioural therapy (nCBT), against waitlist (WL) in outpatients with ABI. Individuals seeking outpatient treatment for cognitive and emotional problems after ABI were randomly allocated to nCBT (n = 27) or WL (n = 29) and completed assessments at baseline, post-treatment/WL and at six-month follow-up. The primary outcome measures were general psychopathology and functional activity in daily life. The nCBT group showed significant improvement for general psychopathology post-treatment when compared to WL. nCBT was also superior to WL regarding the secondary outcomes, i.e., the reduction of negative affect and the improvement of quality of life. No significant differences for functional activity and community integration were observed. Significant pre-post effect sizes ranged between small for functional activity and medium for quality of life. The positive effects were maintained at follow-up. The majority of patients with cognitive and emotional problems after ABI benefit from an integrated approach that offers cognitive remediation and psychotherapy. However, the heterogeneous sequelae of ABI and the moderate sample sizes in clinical trials present a methodological challenge to ABI research.

Depression following traumatic brain injury: a comprehensive overview

Traumatic brain injury (TBI) represents a major health concern affecting the neuropsychological health; TBI is accompanied by drastic long-term adverse complications that can influence many aspects of the life of affected individuals. A substantial number of studies have shown that mood disorders, particularly depression, are the most frequent complications encountered in individuals with TBI. Post-traumatic depression (P-TD) is present in approximately 30% of individuals with TBI, with the majority of individuals experiencing symptoms of depression during the first year following head injury. To date, the mechanisms of P-TD are far from being fully understood, and effective treatments that completely halt this condition are still lacking. The aim of this review is to outline the current state of knowledge on the prevalence and risk factors of P-TD, to discuss the accompanying brain changes at the anatomical, molecular and functional levels, and to discuss current approaches used for the treatment of P-TD.

Traumatic brain injury in the acute care setting: assessment and management practices of speech-language pathologists

PRIMARY OBJECTIVE

To characterize current knowledge, beliefs, confidence, and practice patterns of acute care speech-language pathologists (SLPs) in assessing and managing cognitive-communication disorders following traumatic brain injury (TBI).

RESEARCH DESIGN

We developed an online survey to learn more about current TBI knowledge and practice patterns of acute care SLPs, with the goal of establishing a baseline upon which changes in SLP training and practice standards may be measured.

METHODS AND PROCEDURES

We distributed the survey to 1800 SLPs in 18 states via postal mail, in addition to posting it to relevant online groups. One hundred and eighty-two practicing acute care SLPs responded to the survey.

MAIN OUTCOMES AND RESULTS

Respondents were highly variable in their training and knowledge about TBI, their beliefs about cognitive-communication rehabilitation, and their practice patterns in assessing, managing, and communicating about TBI during the acute stage of injury.

CONCLUSIONS

These results highlight the need for more consistent training about cognitive-communication deficits during and after graduate school, as well as the development of sensitive, specific, and standardized assessment tools, education protocols, and shared language for describing patients with TBI along the continuum of care.

Psychoeducational Interventions for Problematic Anger in Chronic Moderate to Severe Traumatic Brain Injury: A Study of Treatment Enactment

OBJECTIVES

Treatment enactment, a final stage of treatment implementation, refers to patients' application of skills and concepts from treatment sessions into everyday life situations. We examined treatment enactment in a two-arm, multicenter trial comparing two psychoeducational treatments for persons with chronic moderate to severe traumatic brain injury and problematic anger.

METHODS

Seventy-one of 90 participants from the parent trial underwent a telephone enactment interview at least 2 months (median 97 days, range 64-586 days) after cessation of treatment. Enactment, quantified as average frequency of use across seven core treatment components, was compared across treatment arms: anger self-management training (ASMT) and personal readjustment and education (PRE), a structurally equivalent control. Components were also rated for helpfulness when used. Predictors of, and barriers to, enactment were explored.

RESULTS

More than 80% of participants reported remembering all seven treatment components when queried using a recognition format. Enactment was equivalent across treatments. Most used/most helpful components concerned normalizing anger and general anger management strategies (ASMT), and normalizing traumatic brain injury-related changes while providing hope for improvement (PRE). Higher baseline executive function and IQ were predictive of better enactment, as well as better episodic memory (trend). Poor memory was cited by many participants as a barrier to enactment, as was the reaction of other people to attempted use of strategies.

CONCLUSIONS

Treatment enactment is a neglected component of implementation in neuropsychological clinical trials, but is important both to measure and to help participants achieve sustained carryover of core treatment ingredients and learned material to everyday life.

Behavioral Activation Augmented With Mobile Technology for Depression and Anxiety in Chronic Moderate-Severe Traumatic Brain Injury: Protocol for a Randomized Controlled Trial

Objective

To describe and provide the rationale for a randomized controlled trial for depression or anxiety after moderate to severe traumatic brain injury (TBI), which will test 2 treatments based on behavioral activation (BA), a promising model to promote both positive mood and increased activity in this population.

Design

Randomized controlled trial with masked outcome assessment.

Setting

Outpatient catchment area of 1 TBI treatment center.

Participants

Community-dwelling persons (N=60) with moderate-severe TBI at least 6 months prior to enrollment and greater than mild depression or anxiety.

Interventions

Participants will be randomized 2:1 into an 8-session treatment, behavioral activation with technology, consisting of 6 face-to-face sessions and 2 via phone, with mood and activity monitoring conducted via ecological momentary assessment on a smartphone; or a single session incorporating BA principles followed by 8 weeks of activity reminders in the form of implementation intentions, delivered as text messages.

Main Outcome Measures

Brief Symptom Inventory-18 (primary outcome); Environmental Reward Observation Scale, Behavioral Activation for Depression Scale, Participation Assessment with Recombined Tools-Objective, Diener Satisfaction With Life Scale, Quality of Life after Brain Injury scale, Patient Global Impression of Change. Outcomes are measured midway through intervention, after treatment cessation (primary outcome), and at 2-month follow-up. A treatment enactment interview is administered after the follow-up to ascertain to what extent participants continue to engage in activities and use strategies promoted during trial participation.

Results

N/A.

Conclusions

N/A.

Depression and anxiety among traumatic brain injury patients in Malaysia

BACKGROUND

Depression and anxiety are common psychiatric sequelae of traumatic brain injury (TBI). However, there is lack of data on comorbid depression and anxiety, and depression and anxiety in TBI patients were often evaluated using non-validated diagnostic tools. This study aims to determine the rates, their comorbidity, and factors associated with depressive and anxiety disorders in TBI patients.

METHODS

In this cross-sectional study, 101 TBI patients were interviewed using the Structured Clinical Interview for DSM-IV Axis I Disorders to assess the rates of depressive and anxiety disorders after TBI. The association of socio-demographic and clinical factors with depressive and anxiety disorders were determined using Pearson's Chi-Square test.

RESULTS

A total of 25% of TBI patients (n = 25/101) were diagnosed with depressive disorders, of which 15% had major depressive disorder (n = 15/101) and 10% had minor depression (n = 10/101). Fourteen percent of TBI patients had anxiety disorders (n = 14/101), of which post-traumatic stress disorder (PTSD) was the commonest anxiety disorder (9%, n = 9/101). Seven percent of TBI patients (n = 7/101) had comorbid depressive and anxiety disorders. The only factor associated with depressive disorder was the duration of TBI (≥ 1 year) while the only factor associated with anxiety disorder was the mechanism of trauma (assault).

CONCLUSION

Major depressive disorder, minor depression and PTSD are common psychiatric complications of TBI. Clinicians should screen for depressive and anxiety disorders in TBI patients, particularly those with ≥1 year of injury and had sustained TBI from assault.

A Cross-Study Analysis for Reproducible Sub-classification of Traumatic Brain Injury

Objective: To identify reproducible sub-classes of traumatic brain injury (TBI) that correlate with patient outcomes.

Methods: Two TBI datasets from the Federal Interagency Traumatic Brain Injury Research (FITBIR) Informatics System were utilized, Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) Pilot and Citicoline Brain Injury Treatment Trial (COBRIT). Patients included in these analyses had closed head injuries with Glasgow Comas Scale (GCS) scores of 13–15 at arrival at the Emergency Department (ED). Sparse hiearchical clustering was applied to identify TBI sub-classes within each dataset. The reproducibility of the sub-classes was evaluated by investigating similarities in clinical variable profiles and patient outcomes in each sub-class between the two datasets, as well as by using a statistical metric called in-group proportion (IGP).

Results: Seven TBI sub-classes were identified in the first dataset. There were between-class differences in patient outcomes at 90 days (Glasgow Outcome Scale Extended (GOSE): p < 0.001) and 180 days (Trail Making Test (TMT): p = 0.03). Four of seven sub-classes were reproducible in the second dataset with very high IGPs (94, 100, 99, 97%). Seven TBI sub-classes were also identified in the second dataset. There were significant between-class differences in patient outcomes at 180 days (GOSE: p = 0.024; Brief Symptom Inventory (BSI) p = 0.007; TMT: p < 0.001). Three of seven sub-classes were reproducible in the second dataset with very high IGPs (100% for all).

Conclusions: Reproducible TBI sub-classes were identified across two independent datasets, suggesting that these sub-classes exist in a general population. Differences in patient outcomes according to sub-class assignment suggest that this sub-classification could be used to guide post-TBI prognosis.

Anger Self-Management Training for Chronic Moderate to Severe Traumatic Brain Injury: Results of a Randomized Controlled Trial

OBJECTIVE

To test efficacy of 8-session, 1:1 treatment, anger self-management training (ASMT), for chronic moderate to severe traumatic brain injury (TBI).

SETTING

Three US outpatient treatment facilities.

PARTICIPANTS

Ninety people with TBI and elevated self-reported anger; 76 significant others (SOs) provided collateral data.

DESIGN

Multicenter randomized controlled trial with 2:1 randomization to ASMT or structurally equivalent comparison treatment, personal readjustment and education (PRE). Primary outcome assessment 1 week posttreatment; 8-week follow-up.

PRIMARY OUTCOME

Response to treatment defined as 1 or more standard deviation change in self-reported anger.

SECONDARY OUTCOMES

SO-rated anger, emotional and behavioral status, satisfaction with life, timing of treatment response, participant and SO-rated global change, and treatment satisfaction.

MAIN MEASURES

State-Trait Anger Expression Inventory-Revised Trait Anger (TA) and Anger Expression-Out (AX-O) subscales; Brief Anger-Aggression Questionnaire (BAAQ); Likert-type ratings of treatment satisfaction, global changes in anger and well-being.

RESULTS

After treatment, ASMT response rate (68%) exceeded that of PRE (47%) on TA but not AX-O or BAAQ; this finding persisted at 8-week follow-up. No significant between-group differences in SO-reported response rates, emotional/behavioral status, or life satisfaction. ASMT participants were more satisfied with treatment and rated global change in anger as significantly better; SO ratings of global change in both anger and well-being were superior for ASMT.

CONCLUSION

ASMT was efficacious and persistent for some aspects of problematic anger. More research is needed to determine optimal dose and essential ingredients of behavioral treatment for anger after TBI.

Apolipoprotein E ε4 Genotype Is Associated with Elevated Psychiatric Distress in Veterans with a History of Mild to Moderate Traumatic Brain Injury

As few studies have examined the relationship between the apolipoprotein E (APOE) gene and clinical outcomes after military-related traumatic brain injury (TBI), we aimed to determine whether the ε4 allele of the APOE gene influences neuropsychiatric symptoms in veterans with a history of mild-to-moderate TBI. Participants included 133 veterans (TBI = 79; military controls [MC] = 54) who underwent APOE genotyping and were divided into ε4⁺ (TBI = 18; MC = 15) and ε4^- (TBI = 61; MC = 39) groups. All participants underwent evaluation of psychological distress using the Beck Depression Inventory-II, Beck Anxiety Inventory, and PTSD Checklist-Military Version. Two-way analyses of variance were conducted to examine the effect of group (TBI vs. MC) and APOE-ε4 status (ε4⁺ vs. ε4^-) across symptom measures. There was a significant main effect of group across all symptom measures (TBI > MC; all p values <0.001), no main effect of ε4 genotype (p = 0.152-0.222), and a significant interaction of group by ε4 genotype across all measures (p = 0.027-0.047). Specifically, for TBI participants, ε4⁺ veterans demonstrated significantly higher symptom scores across all measures when compared to ε4^- veterans (p = 0.007-0.015). For MC participants, ε4 status had no effect on the severity of psychiatric symptom scores (p = 0.585-0.708). Our results demonstrate that, in our well-characterized sample of veterans with history of neurotrauma, possession of the ε4 allele conveys risk for increased symptomatology (i.e., depression, anxiety, and post-traumatic stress disorder), even well outside of the acute phase of injury. Findings suggest a meaningful relationship between APOE genotype and psychiatric distress post-TBI, and they suggest that there is a brain basis for the complex neuropsychiatric presentation often observed in this vulnerable population. Future longitudinal studies are needed in order to further our understanding of how genetic factors influence response to TBI.

Duration of Posttraumatic Amnesia Predicts Neuropsychological and Global Outcome in Complicated Mild Traumatic Brain Injury

OBJECTIVES

Examine the effects of posttraumatic amnesia (PTA) duration on neuropsychological and global recovery from 1 to 6 months after complicated mild traumatic brain injury (cmTBI).

PARTICIPANTS

A total of 330 persons with cmTBI defined as Glasgow Coma Scale score of 13 to 15 in emergency department, with well-defined abnormalities on neuroimaging.

METHODS

Enrollment within 24 hours of injury with follow-up at 1, 3, and 6 months.

MEASURES

Glasgow Outcome Scale-Extended, California Verbal Learning Test II, and Controlled Oral Word Association Test. Duration of PTA was retrospectively measured with structured interview at 30 days postinjury.

RESULTS

Despite all having a Glasgow Coma Scale Score of 13 to 15, a quarter of the sample had a PTA duration of greater than 7 days; half had PTA duration of 1 of 7 days. Both cognitive performance and Extended Glasgow Outcome Scale outcomes were strongly associated with time since injury and PTA duration, with those with PTA duration of greater than 1 week showing residual moderate disability at 6-month assessment.

CONCLUSIONS

Findings reinforce importance of careful measurement of duration of PTA to refine outcome prediction and allocation of resources to those with cmTBI. Future research would benefit from standardization in computed tomographic criteria and use of severity indices beyond Glasgow Coma Scale to characterize cmTBI.

Psychometric properties and correlates of the PHQ-2 and PHQ-9 after traumatic brain injury

PRIMARY OBJECTIVE

To determine the predictive accuracy of the Patient Health Questionnaire (PHQ)-2 in predicting PHQ-9 findings and to examine demographic, historical, and injury correlates of PHQ-9 ratings.

RESEARCH DESIGN

Retrospective analysis of data collected as part of routine clinical outpatient care over a period of 30 months on 168 persons with mild to severe traumatic brain injury, who were referred for neuropsychological evaluation within 1-12 months after injury.

MAIN OUTCOMES AND RESULTS

PHQ-2 scores ≥2 had a sensitivity of 0.90 in predicting PHQ-9 scores ≥10, and a sensitivity of 0.95 in predicting endorsement of any passive or active suicidal thoughts on the PHQ-9. Premorbid history of having experienced personal abuse was the strongest predictor of post-injury PHQ-9 ratings.

CONCLUSIONS

The PHQ-2 has adequate sensitivity in predicting PHQ-9 findings and can be used as a screener in clinical practice in persons with traumatic brain injury, as long as formal psychometric assessment is supplemented with a comprehensive review of premorbid history.

Suicidal Ideation After Mild Traumatic Brain Injury: A Consecutive Canadian Sample

This study aims to elucidate psychosocial and injury features contributing to SI following concussion or mild traumatic brain injury (mTBI) and the time course for its development. Between 1998 and 2012, a sample of 871 patients referred to a follow-up clinic after concussion treatment in an urban tertiary care ED were consecutively offered enrollment at 3 months post injury. Data from psychiatric and social-demographic assessments were consecutively collected at 2 visits (3 and 6 months after injury) respectively. Chi-square and t-tests were performed to identify associations between variables related with SI. Logistic regression analysis was performed to identify factors independently associated. During the enrolment period, 2,296 patients with mTBI presented to the ED. 871 adults completed psychiatric and social demographic clinic assessments at 3 months, and 500 returned at 6 months. Suicidal ideation was expressed by 6.3% at 3 months and 8.2% at 6 months. Regression models showed SI independently associated with: speaking English as a second language (ESL) and injury mechanism (MVC passenger) at 3 and 6 months; and history of depression and marital status at 3 months only. SI is common 3 months after mTBI, and appears more at 6 month follow up. These findings suggest earlier screening for predisposing factors and closer monitoring of those at risk for suicidality.

A narrative literature review of depression following traumatic brain injury: prevalence, impact, and management challenges

Depression is one of the most common conditions to emerge after traumatic brain injury (TBI), and despite its potentially serious consequences it remains undertreated. Treatment for post-traumatic depression (PTD) is complicated due to the multifactorial etiology of PTD, ranging from biological pathways to psychosocial adjustment. Identifying the unique, personalized factors contributing to the development of PTD could improve long-term treatment and management for individuals with TBI. The purpose of this narrative literature review was to summarize the prevalence and impact of PTD among those with moderate to severe TBI and to discuss current challenges in its management. Overall, PTD has an estimated point prevalence of 30%, with 50% of individuals with moderate to severe TBI experiencing an episode of PTD in the first year after injury alone. PTD has significant implications for health, leading to more hospitalizations and greater caregiver burden, for participation, reducing rates of return to work and affecting social relationships, and for quality of life. PTD may develop directly or indirectly as a result of biological changes after injury, most notably post-injury inflammation, or through psychological and psychosocial factors, including pre injury personal characteristics and post-injury adjustment to disability. Current evidence for effective treatments is limited, although the strongest evidence supports antidepressants and cognitive behavioral interventions. More personalized approaches to treatment and further research into unique therapy combinations may improve the management of PTD and improve the health, functioning, and quality of life for individuals with TBI.

Goal intention reminding in traumatic brain injury: A feasibility study using implementation intentions and text messaging

OBJECTIVE

To examine feasibility of participant-created implementation intentions, delivered as text message reminders, to enhance goal-related activity in persons with chronic, moderate/severe traumatic brain injury (TBI).

DESIGN

Pilot randomized controlled trial on effects of 8 weeks receiving goal-related implementation intentions (GI) compared to control condition, educational review regarding goals (GR).

PARTICIPANTS

Eight persons with moderate/severe TBI nearing discharge from intensive outpatient brain injury treatment.

MEASURES

Neuropsychological tests to characterize cognitive status; Participation with Recombined Tools-Objective (PART-O) assessing community activity, social relations and productivity; Brief Symptom Inventory-18 (BSI-18) assessing depression, anxiety and overall distress; Goal Attainment Scales (GAS). PART-O, BSI-18 and GAS were completed at baseline and 8 weeks; significant others provided ratings on PART-O and GAS.

RESULTS

Participants replied to SMS messages at high rates. Statistically significant group × time interactions with medium-to-large effect sizes favouring the GI group were observed on PART-O community activity and social relations. Neither BSI-18 nor GAS revealed differences or trends by group. Qualitative results suggested overall acceptance and success of SMS reminders.

CONCLUSIONS

Given positive preliminary findings, implementation intentions delivered by text holds promise as a simple, low-cost intervention to help people with moderate/severe TBI to implement goal-relevant behaviours.

Validity of the Brief Symptom Inventory-18 (BSI-18) for identifying depression and anxiety in young adult cancer survivors: Comparison with a Structured Clinical Diagnostic Interview

The Brief Symptom Inventory-18 (BSI-18) is widely used to assess psychological symptoms in cancer survivors, but the validity of conventional BSI-18 cut-off scores in this population has been questioned. This study assessed the accuracy of the BSI-18 for identifying significant anxiety and depression in young adult cancer survivors (YACS), by comparing it with a "gold standard" diagnostic interview measure. Two hundred fifty YACS, age 18-40 completed the BSI-18 and the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; SCID) interview assessing anxiety and depressive disorders. BSI-18 results were compared with SCID criteria using receiver operating characteristics (ROC) analyses. Forty four participants (17.7%) met criteria for ≥1 SCID diagnoses, and an additional 20 (8.0%) met criteria for clinically significant SCID symptoms without a diagnosis. General concordance between the BSI-18 GSI scale and SCID diagnosis was good (AUC = 0.848), but the 2 most widely used BSI-18 case rules failed to identify a majority of survivors with SCID diagnoses, and no alternative BSI-18 cut-off scores met study criteria for clinical screening. Analyses aimed at identifying survivors with significant SCID symptoms or a SCID diagnosis had similar results, as did analyses examining depression and anxiety separately. The BSI-18 shows good overall concordance with a psychiatric interview, but recommended cut-off scores fail to identify a majority of YACS with psychiatric diagnosis. Clinicians should not rely on the BSI-18 alone as a screening measure for YACS. Alternative BSI-18 scoring algorithms optimized for detecting psychiatric symptoms in YACS may be an important step to address this limitation. (PsycINFO Database Record

Citicoline for traumatic brain injury: a systematic review & meta-analysis

BACKGROUND

Traumatic Brain Injury (TBI) is the leading cause of mortality and morbidity especially in young ages. Despite over 30 years of using Neuroprotective agents for TBI management, there is no absolute recommended agent for the condition yet.

METHODS

This study is a part of a scoping review thesis on "Neuroprotective agents using for Traumatic Brain Injury: a systematic review & meta-analyses", which had a wide proposal keywords and ran in "Cochrane CENTRAL", "MedLine/PubMed", "SCOPUS", "Thomson Reuters Web of Science", "SID.ir", "Barket Foundation", and "clinicaltrials.gov" databases up to September 06, 2015. This study limits the retrieved search results only to those which used citicoline for TBI management. The included Randomized Clinical Trials' (RCTs) were assessed for their quality of reporting by adapting CONSORT-checklist prior to extracting their data into me-ta-analysis. Meta-analyses of this review were conducted by Glasgow Outcome Scale (GOS) in acute TBI patients and total neuropsychological assessments in both acute and chronic TBI management, mortalities and adverse-effects.

RESULTS

Four RCTs were retrieved and included in this review with 1196 participants (10 were chronic TBI impaired patients); the analysis of 1128 patients for their favorable GOS outcomes in two studies showed no significant difference between the study groups; however, neuropsychological outcomes were significantly better in placebo/control group of 971 patients of three studies. Mortality rates and adverse-effects analysis based on two studies with 1429 patients showed no significant difference between the study groups. However, two other studies have neither mortality nor adverse effects reports due to their protocol.

CONCLUSIONS

Citicoline use for acute TBI seems to have no field of support anymore, whereas it may have some benefits in improving the neuro-cognitive state in chronic TBI patients. It's also recommended to keep in mind acute interventions like Psychological First Aid (PFA) during acute TBI management.

Depression Trajectories during the First Year after Traumatic Brain Injury

Major depression is prevalent after traumatic brain injury (TBI) and associated with poor outcomes. Little is known about the course of depression after TBI. Participants were 559 consecutively admitted patients with mild to severe TBI recruited from inpatient units at Harborview Medical Center, a Level I trauma center in Seattle, WA. Participants were assessed with the Patient Health Questionnaire-9 (PHQ-9) depression measure at months 1-6, 8, 10, and 12 post-injury. We used linear latent class growth mixture modeling (LCGMM) of PHQ-9 total scores to identify homogeneous subgroups with distinct longitudinal trajectories. A four-class LCGMM had good fit indices and clinical interpretability. Trajectory groups were: low depression (70.1%), delayed depression (13.2%), depression recovery (10.4%), and persistent depression (6.3%). Multinomial logistic regression analyses were used to distinguish trajectory classes based on baseline demographic, psychiatric history, and clinical variables. Relative to the low depression group, the other three groups were consistently more likely to have a pre-injury history of other mental health disorders or major depressive disorder, a positive toxicology screen for cocaine or amphetamines at the time of injury, and a history of alcohol dependence. They were less likely to be on Medicare versus commercial insurance. Trajectories based on LCGMM are an empirical and clinically meaningful way to characterize distinct courses of depression after TBI. When combined with baseline predictors, this line of research may improve our ability to predict prognosis and target groups who may benefit from treatment or secondary prevention efforts (e.g., proactive telephone counseling).

Randomized Placebo-Controlled Trial of Methylphenidate or Galantamine for Persistent Emotional and Cognitive Symptoms Associated with PTSD and/or Traumatic Brain Injury

We report findings from a 12-week randomized double-blinded placebo-controlled trial of methylphenidate or galantamine to treat emotional and cognitive complaints in individuals (n=32) with a history of PTSD, TBI, or both conditions. In this small pilot study, methylphenidate treatment was associated with clinically meaningful and statistically significant improvement compared with placebo on the primary outcome, a measure of cognitive complaints (Ruff Neurobehavioral Inventory-Postmorbid Cognitive Scale), as well as on the secondary outcomes reflecting post-concussive (Rivermead Post Concussive Symptom Questionnaire) and post-traumatic stress symptoms (Posttraumatic Stress Disorder Checklist). Treatment was well tolerated. These results suggest the need for a larger RCT to replicate and confirm these findings. Design considerations for such a trial should include the need for multiple sites to facilitate adequate recruitment and extension of the treatment and follow-up periods.

Psychometric properties and normative data for the Brief Symptom Inventory-18 (BSI-18) in high school and collegiate athletes

OBJECTIVE

Assessment of emotional functioning is important in sport-related concussion (SRC) management, although few standardized measures have been validated in this population, and appropriate normative data are lacking. We investigated the psychometric properties of the Brief Symptom Inventory-18 (BSI-18) in high school and collegiate athletes at risk of SRC and compiled normative data.

METHOD

Athletes (n = 2,031) completed the BSI-18 and other measures of concussion symptoms, cognition, and psychological functioning. A subset of healthy individuals was re-evaluated at approximately 7, 30, 45, and 165 days. Psychometric analyses of test-retest reliability, internal consistency reliability, and concurrent validity were performed. Given significant differences between sexes and education levels (high school or college student) on the BSI-18 Global Severity Index and all subscales, normative conversion tables were produced after stratifying by these variables.

RESULTS

The BSI-18 showed good internal consistency, fair to poor test-retest reliability, and good convergent validity with other measures of emotional functioning.

CONCLUSIONS

These data indicate that the BSI-18 may be a valuable measure of emotional state in concussed athletes and may provide unique information beyond post-concussive symptoms for research on the role of psychological factors in SRC recovery. The limited divergent validity of the BSI-18 depression and anxiety scales implies that they tap into general distress more so than specific mood or anxiety symptoms; therefore, BSI-18 scores should be not relied upon for differential diagnosis of mood and anxiety disorders. Normative data provided can be readily applied to clinical cases with high school and collegiate athletes.

Prospective longitudinal evaluation of the effect of deployment-acquired traumatic brain injury on posttraumatic stress and related disorders: results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

OBJECTIVE

Traumatic brain injury (TBI) is increasingly recognized as a risk factor for deleterious mental health and functional outcomes. The purpose of this study was to examine the strength and specificity of the association between deployment-acquired TBI and subsequent posttraumatic stress and related disorders among U.S. Army personnel.

METHOD

A prospective, longitudinal survey of soldiers in three Brigade Combat Teams was conducted 1-2 months prior to an average 10-month deployment to Afghanistan (T0), upon redeployment to the United States (T1), approximately 3 months later (T2), and approximately 9 months later (T3). Outcomes of interest were 30-day prevalence postdeployment of posttraumatic stress disorder (PTSD), major depressive episode, generalized anxiety disorder, and suicidality, as well as presence and severity of postdeployment PTSD symptoms.

RESULTS

Complete information was available for 4,645 soldiers. Approximately one in five soldiers reported exposure to mild (18.0%) or more-than-mild (1.2%) TBI(s) during the index deployment. Even after adjusting for other risk factors (e.g., predeployment mental health status, severity of deployment stress, prior TBI history), deployment-acquired TBI was associated with elevated adjusted odds of PTSD and generalized anxiety disorder at T2 and T3 and of major depressive episode at T2. Suicidality risk at T2 appeared similarly elevated, but this association did not reach statistical significance.

CONCLUSIONS

The findings highlight the importance of surveillance efforts to identify soldiers who have sustained TBIs and are therefore at risk for an array of postdeployment adverse mental health outcomes, including but not limited to PTSD. The mechanism(s) accounting for these associations need to be elucidated to inform development of effective preventive and early intervention programs.

Trajectories of life satisfaction after traumatic brain injury: Influence of life roles, age, cognitive disability, and depressive symptoms

OBJECTIVES

(a) Identify life satisfaction trajectories after moderate to severe traumatic brain injury (TBI); (b) establish a predictive model for these trajectories across the first 5 years postinjury; and (c) describe differences in these life satisfaction trajectory groups, focusing on age, depressive symptoms, disability, and participation in specific life roles.

RESEARCH METHOD

Analysis of the longitudinal TBI Model Systems National Database was performed on data collected prospectively at 1-, 2-, and 5-years post-TBI. Participants (n = 3,012) had a moderate to severe TBI and were 16 years old and older.

RESULTS

Four life satisfaction trajectories were identified across the first 5 years postinjury, including: stable satisfaction, initial satisfaction declining, initial dissatisfaction improving, and stable dissatisfaction. Age, depressive symptoms, cognitive disability, and life role participation as a worker, leisure participant, and/ or religious participant at 1-year postinjury significantly predicted trajectory group membership. Life role participation and depressive symptoms were strong predictors of life satisfaction trajectories across the first 5 years post-TBI.

CONCLUSIONS

The previously documented loss of life roles and prevalence of depression after a moderate to severe TBI make this a vulnerable population for whom low or declining life satisfaction is a particularly high risk. Examining individual life role participation may help to identify relevant foci for community-based rehabilitation interventions or supports.

Rehabilitation after traumatic brain injury

Traumatic brain injury (TBI) is a growing problem in the US, with significant morbidity and economic implications. This diagnosis spans a wide breath of injuries from concussion to severe TBI. Thus, rehabilitation is equally diverse in its treatment strategies targeting those symptoms that are functionally limiting with the ultimate goal of independence and community reintegration. In severe TBI, rehabilitation can be lifelong. Acute care rehabilitation focuses on emergence from coma and prognostication of recovery. Therapeutic modalities and exercise, along with pharmacologic intervention, can target long-term motor and cognitive sequelae. Complications of severe TBI that are functionally limiting and impede therapy include heterotopic ossification, agitation, dysautonomia, and spasticity. In mild TBI, most patients recover quickly but education on repeat exposure is imperative, with the implications of consecutive injuries being potentially devastating. Furthermore, rehabilitation targets lingering symptoms including sleep disturbance, visuospatial deficits, headaches, and cognitive dysfunction. As research on the entire TBI population improves, commonalities in the disease process may emerge, helping rationalize therapeutic interventions and providing more robust targets for treatment.

Anger self-management in chronic traumatic brain injury: protocol for a psycho-educational treatment with a structurally equivalent control and an evaluation of treatment enactment

Anger and irritability are important and persistent clinical problems following traumatic brain injury (TBI). Treatment options include medications, behavioral modification, and psychotherapies, but some are impractical and none have proven efficacy with this population. We describe a randomized multi-center clinical trial testing a novel, one-on-one, 8-session psychoeducational treatment program, Anger Self-Management Training (ASMT), designed specifically for people with TBI who have significant cognitive impairment. The trial is notable for its use of a structurally equivalent comparison treatment, called Personal Readjustment and Education (PRE), which was created for the study and is intended to maximize equipoise for both participants and treaters. Fidelity assessment is conducted in real time and used in therapist supervision sessions. The primary outcome is change in self-reported anger on validated measures from pre-treatment to 1 week after the final session. Secondary outcomes include participant anger as reported by a significant other; emotional distress in domains other than anger/irritability; behavioral functioning; and quality of life. An interim assessment after the 4th session will allow examination of the trajectory of any observed treatment effects, and a follow-up assessment 2 months after the end of intervention will allow examination of persistence of effects. A treatment enactment phase, in which participants are interviewed several months after the last therapy session, is designed to provide qualitative data on whether and to what extent the principles and techniques learned in treatment are still carried out in daily life.