Early Impaired Self-awareness, Depression, and Subjective Well-being Following Traumatic Brain Injury

Factors associated with self-awareness impairment in an inpatient brain injury rehabilitation cohort

BACKGROUND

Self-awareness impairment is common following acquired brain injury and can impact rehabilitation outcomes. Knowledge of factors associated with impaired self-awareness may assist with rehabilitation planning.

OBJECTIVES

To identify factors associated with self-awareness and determine predictors of self-awareness impairment for adults with traumatic brain injury (TBI) and stroke.

DESIGN AND METHODS

A retrospective cohort study of rehabilitation inpatients was conducted by medical record audit. Self-awareness was measured using the Self-awareness of Deficits Interview (SADI). Relationships between SADI scores and demographic and clinical variables were identified with non-parametric statistics. Predictors of SADI scores were identified using ordinal regression analyses for TBI and stroke groups.

RESULTS

Participants were 149 adults (18-70 years) with TBI (n = 110) and stroke (n = 39). For TBI, longer post-traumatic amnesia (PTA), lower functional cognition/communication, and behaviors of concern (BoC) were significantly associated with higher SADI scores (i.e. impaired self-awareness). For stroke, lower functional cognition/communication and motor scores were associated with higher SADI scores. Impaired self-awareness was predicted by PTA duration, acute length of stay and presence of BoC for the TBI group, and by functional cognition/communication for the stroke group.

CONCLUSION

Different factors were associated with impaired self-awareness for individuals with TBI and stroke during inpatient rehabilitation.

Self-Awareness and therapeutic alliance in speech-language treatment of traumatic brain injury

Purpose: To investigate the relationships among client self-awareness, client perception of the therapeutic alliance, and speech-language pathologist (SLP) communicative self-awareness in dyads of SLPs and traumatic brain injury (TBI) clients.Method: Nineteen SLP-TBI client dyads (N = 38) engaged in the same collaborative therapy task. At baseline, client self-awareness and client perception of the therapeutic alliance was assessed. SLP communicative self-awareness was measured by 1) a prediction/reflection questionnaire about their own communicative behaviour, administered pre- and post-treatment sessions, and 2) self-evaluation during a novel procedure using video review within three hours after the session.Result: Client self-awareness was not associated with client perceptions of the therapeutic alliance. Client perceptions of the therapeutic alliance were related to specific communicative intentions of the SLP. Regarding SLP communicative self-awareness, SLPs predicted their primary communication modality with 66% accuracy. The video review procedure yielded more detailed SLP communicative self-awareness ratings and was completed within real-world clinical settings.Conclusion: TBI client self-awareness may not impact the establishment of a strong therapeutic alliance between SLP and client. The finding that specific communicative intentions of the SLP were related to client perception of the therapeutic alliance should prompt further efforts to measure SLP communicative intentions and behaviours during TBI treatment sessions.

Redefining "masstige" luxury consumption in the post-COVID era

The concept of "new luxury" has challenged the conventional marketing of luxury goods as prestigious, leading to greater expansion of mass luxury meaning. This has become more evident since the outbreak of COVID-19, which has been a catalyst for consumption in the luxury market. This paper investigates the mass marketing of luxury goods and explores the essence of masstige luxury consumption since the outbreak of COVID-19. An interpretive approach was conducted based on semi-structured, in-depth interviews with 31 participants. It analyzes four themes of mass luxury: self as content, self as process, self as context, and self-other. We further argue that the mass consumption of luxury reduces cognitive dissonance, with the pandemic resolving the dark side of conventional luxury consumption. Our findings provide important insights for both scholars and practitioners in the development of a more holistic understanding of masstige in the post-COVID era.

Modulation of Metacognitive Confidence Judgments Through Provision of Performance Feedback in Moderate to Severe Traumatic Brain Injury

OBJECTIVE

Traumatic brain injury (TBI) may result in metacognitive impairments. Enhancing memory in healthy adults can improve metacognitive accuracy, but it is unclear whether such interventions apply to individuals with TBI. This study examined the effects of manipulating target memory experiences on metacognitive accuracy in TBI.

PARTICIPANTS

Fourteen community-dwelling adults with TBI and 17 healthy controls.

MAIN MEASURES

Memory was manipulated through performance feedback (monetary, nonmonetary, or none) presented during a word-pair learning task. Recognition of the word pairs was assessed, and metacognition was evaluated by retrospective confidence judgments.

RESULTS

Both groups demonstrated greater recognition performance for items learned with nonmonetary feedback. Healthy individuals demonstrated improved metacognitive accuracy for items learned with nonmonetary feedback, but this effect was not seen in individuals with TBI. A notable (but statistically nonsignificant) effect was observed whereby adults with TBI overestimated performance for items learned with monetary feedback compared with other feedback conditions.

CONCLUSION

Provision of feedback during learning enhances recognition performance. However, target memory experiences may be utilized differently after injury to facilitate confidence judgments. In addition, the type of feedback provided may have different effects on metacognitive accuracy. These results have implications for rehabilitative efforts in the area of memory and metacognition after injury.

Momentary and longitudinal relationships of mindfulness to stress and anxiety among Chinese elementary school students: mediations of cognitive flexibility, self-awareness, and social environment

Mindfulness could benefit elementary school students' mental health, but little is known about the mechanisms of mindfulness in the elementary school context. The current studies explored mindfulness's relationship to stress and anxiety in elementary school students and potential mediators in the connections from proximal and distal perspectives.

DESIGN

In Study 1, a daily diary approach was used to examine the mediating role of cognitive flexibility on mindfulness's dynamic association to stress and anxiety. In Study 2, we examined the longitudinal relationships between mindfulness at baseline and stress and anxiety at 6-month follow-up and the mediating roles of self-awareness (i.e., self-esteem and self-identity) and social environment (i.e., student-teacher relationship and peer relationship).

MAIN OUTCOMES

From a proximal perspective, cognitive flexibility mediated the negative relationship of state mindfulness to stress and anxiety. From a distal standpoint, self-esteem mediated the relationship between dispositional mindfulness and anxiety. Perceived peer relationship mediated the association of dispositional mindfulness to stress and anxiety.

CONCLUSION

For elementary school students, state mindfulness showed immediate effects, and dispositional mindfulness showed long-term effects on reducing anxiety and stress through different mechanisms. Limitations and implications were discussed.

Insular Connectivity Is Associated With Self-Appraisal of Cognitive Function After a Concussion

Concussion is associated with acute cognitive impairments, with declines in processing speed and reaction time being common. In the clinical setting, these issues are identified via symptom assessments and neurocognitive test (NCT) batteries. Practice guidelines recommend integrating both symptoms and NCTs into clinical decision-making, but correlations between these measures are often poor. This suggests that many patients experience difficulties in the self-appraisal of cognitive issues. It is presently unclear what neural mechanisms give rise to appraisal mismatch after a concussion. One promising target is the insula, which regulates aspects of cognition, particularly interoception and self-monitoring. The present study tested the hypothesis that appraisal mismatch is due to altered functional connectivity of the insula to frontal and midline structures, with hypo-connectivity leading to under-reporting of cognitive issues and hyper-connectivity leading to over-reporting. Data were collected from 59 acutely concussed individuals and 136 normative controls, including symptom assessments, NCTs and magnetic resonance imaging (MRI) data. Analysis of resting-state functional MRI supported the hypothesis, identifying insular networks that were associated with appraisal mismatch in concussed athletes that included frontal, sensorimotor, and cingulate connections. Subsequent analysis of diffusion tensor imaging also determined that symptom over-reporting was associated with reduced fractional anisotropy and increased mean diffusivity of posterior white matter. These findings provide new insights into the mechanisms of cognitive appraisal mismatch after a concussion. They are of particular interest given the central role of symptom assessments in the diagnosis and clinical management of concussion.

Metacognitive knowledge and functional outcomes in adults with acquired brain injury: A meta-analysis

Pronounced difficulties in functional outcomes often follow acquired brain injury (ABI), and may be due, in part, to deficits in metacognitive knowledge (being unaware of one's cognitive strengths and limitations). A meta-analytic review of the literature investigating the relationship between metacognitive knowledge and functional outcomes in ABI is timely, particularly given the presence of apparently inconsistent findings. Twenty-two articles revealed two distinct methods of measuring metacognitive knowledge: (1) absolute (the degree of inaccurate self-appraisal regardless of whether the error tends towards under- or over-confident estimations) and (2) relative (the degree and the direction of the inaccuracy) discrepancy. Separate meta-analyses were conducted for absolute and relative discrepancy studies to assess the relationship between metacognitive knowledge and functional outcomes (affect-related quality of life, family and community integration, and work outcomes). The pattern of results found suggested that better metacognitive knowledge is related to better overall functional outcomes, but the relationship may differ depending on the outcome domain. These findings generally support the importance of focusing on metacognitive knowledge to improve outcomes following ABI. Nonetheless, the relatively small effect sizes observed suggest that other predictors of functional outcome should be investigated, including other subdomains of metacognition.

Prefrontal gray matter volume predicts metacognitive accuracy following traumatic brain injury

OBJECTIVE

To examine metacognitive ability (MC) following moderate to severe traumatic brain injury (TBI) using an empirical assessment approach and to determine the relationship between alterations in gray matter volume (GMV) and MC.

METHOD

A sample of 62 individuals (TBI n = 34; healthy control [HC] n = 28) were included in the study. Neuroimaging and neuropsychological data were collected for all participants during the same visit. MC was quantified using an approach borrowed from signal detection theory (Type II area under the receiver operating characteristic curve calculation) to evaluate judgments during a modified version of the 3rd edition of the Wechsler Adult Intelligence Scale's Matrix Reasoning subtest where half of the items were presented randomly and half were presented in the order of increasing difficulty. Retrospective confidence judgments were collected on an item-by-item basis. Brain volumetric analyses were conducted using FreeSurfer software.

RESULTS

Analyses of the modified Matrix Reasoning task data demonstrated that HCs significantly outperformed TBIs (ordered: d = .63; random: d = .58). There was a significant difference between groups for MC for the randomly presented stimuli (d = .54) but not the ordered stimuli. There was an association between GMV and MC in the TBI group between the right orbital region and MC (R2 = .11). In the HC group, there were associations between the left posterior (R2 = .17), left orbital (R2 = .29), and left dorsolateral (R2 = .21) regions and MC.

CONCLUSIONS

These results are consistent with those of previous research on MC in the cognitive neurosciences, but this study demonstrates that injury may moderate the regional contributions to MC. (PsycINFO Database Record

Intensive and standard group-based treatment for persons with social communication difficulties after an acquired brain injury: study protocol for a randomised controlled trial

INTRODUCTION

Social communication difficulties (SCDs) occur frequently after an acquired brain injury (ABI) and have disabling consequences, but effective interventions are scant. Group Interactive Structured Treatment (GIST) is a holistic group treatment targeting SCD that has received empirical support.

OBJECTIVE

To determine the efficacy of two GIST protocols, standard GIST and a newly developed intensive GIST, comparing standard GIST results to a wait-list control group (WL), as well as to intensive GIST received by participants following WL. The within subject results for WL and intensive GIST will also be examined.

METHODS AND ANALYSIS

Sixty adults (18-75 years) with SCD after ABI will be recruited for this randomised controlled trial. Standard GIST (n=30) will be delivered via outpatient sessions for 2.5 hours once per week for 12 weeks, plus one initial orientation session. Participants will be assessed at preintervention and postintervention and at 3-month and 6-month follow-ups (T1-T4). Intensive GIST (n=30) participants will be admitted to an inpatient rehabilitation unit for 4 weeks (two times 3 days/week, two times 4 days/week) and receive full-day sessions each week. Those participants will complete four assessments (T1-T4) in 12-week intervals as part of WL, assessments preintensive and postintensive GIST and at 3-month and 6-month follow-ups (T4-T7). The primary outcome measure is the La Trobe Questionnaire (self-report). Secondary outcome measures include the Profile of Pragmatic Impairment in Communication, a test of emotion recognition, the Goal Attainment Scale and questionnaires addressing social, emotional and cognitive functions, self-efficacy and quality of life.

ETHICS AND DISSEMINATION

Results will be communicated through international, peer-reviewed and popular science journals and presentations at scientific conferences. The study is approved by the Regional Committees for Medical and Health Research Ethics Norway (2017/1360). The trial will be conducted in accordance with the Declaration of Helsinki and reported in accordance with the Consolidated Standards of Reporting Trials 2010 statement and Standard Protocol Items: Recommendations for Interventional Trials recommendations.

TRIAL REGISTRATION NUMBER

NCT03636399.

Depression, apathy and impaired self-awareness following severe traumatic brain injury: a preliminary investigation

Primary Objective: The primary aim of this study was to determine the frequency of severe impaired self-awareness (ISA) in patients with severe traumatic brain injury (TBI) and the correlates of selected clinical, neuropsychiatric and cognitive variables. The secondary aim of the study was to assess depression and apathy on the basis of their level of self-awareness. Methods: Thirty patients with severe TBI and 30 demographically matched healthy control subjects (HCs) were compared on measures of ISA, depression, anxiety, alexithymia, neuropsychiatric symptoms and cognitive flexibility. Results: Twenty percent of the patients demonstrated severe ISA. Severe post-acute ISA was associated with more severe cognitive inflexibility, despite the absence of differences in TBI severity, as evidenced by a Glasgow Coma Scale (GCS) score lower than 9 in all cases in the acute phase. Patients with severe ISA showed lower levels of depression and anxiety but tended to show more apathy and to have greater difficulty describing their emotional state than patients with severe TBI who showed minimal or no disturbance in self-awareness. Conclusion: These findings support the general hypothesis that severe ISA following severe TBI is typically not associated with depression and anxiety, but rather with apathy and cognitive inflexibility.

Injury Severity and Depressive Symptoms in a Post-acute Brain Injury Rehabilitation Sample

This study explored the relationship between injury severity and depressive symptoms for treatment-seeking individuals with traumatic brain injury (TBI). The Mayo Classification System was used to classify TBI severity in 72 participants who completed the Patient Health Questionnaire at admission and at dismissal from rehabilitation. Patients with mild TBI reported more depressive symptoms than those with moderate or severe TBI at admission and at dismissal. Although injury severity groups differed by gender composition, gender had no effect on severity of depressive symptoms. All participants reported fewer depressive symptoms at dismissal from rehabilitation, including lower endorsement of dysphoria by discharge. Participants with mild TBI, however, continued to report depressive symptoms of a mild severity at dismissal, with residual problems with anhedonia. These findings underscore the benefit of interdisciplinary post-acute rehabilitation services for persons with TBI of any severity, including those with mild injury.

Employment Stability in the First 5 Years After Moderate-to-Severe Traumatic Brain Injury

OBJECTIVE

To characterize employment stability and identify predictive factors of employment stability in working-age individuals after moderate-to-severe traumatic brain injury (TBI) that may be clinically addressed.

DESIGN

Longitudinal observational study of an inception cohort from the Traumatic Brain Injury Model Systems National Database (TBIMS-NDB) using data at years 1, 2, and 5 post-TBI.

SETTING

Inpatient rehabilitation centers with telephone follow-up.

PARTICIPANTS

Individuals enrolled in the TBIMS-NDB since 2001, aged 18-59, with employment data at 2 or more follow-up interviews at years 1, 2, and 5 (N=5683).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Employment stability, categorized using post-TBI employment data as no paid employment (53.25%), stably (27.20%), delayed (10.24%), or unstably (9.31%) employed.

RESULTS

Multinomial regression analyses identified predictive factors of employment stability, including younger age, white race, less severe injuries, preinjury employment, higher annual earnings, male sex, higher education, transportation independence postinjury, and no anxiety or depression at 1 year post-TBI.

CONCLUSIONS

Employment stability serves as an important measure of productivity post-TBI. Psychosocial, clinical, environmental, and demographic factors predict employment stability post-TBI. Notable predictors include transportation independence as well as the presence of anxiety and depression at year 1 post-TBI as potentially modifiable intervention targets.

The Norwegian version of the QOLIBRI - a study of metric properties based on a 12 month follow-up of persons with traumatic brain injury

BACKGROUND

Consequences after Traumatic brain injury (TBI) affect the injured person's self-image and quality of life. The purpose was to assess the health related quality of life (HRQoL) at 12 months after a TBI in patients admitted to regional trauma centres, and to evaluate the metric properties of the Norwegian version of the Quality of Life After Brain Injury (QOLIBRI) questionnaire.

METHODS

Two hundred four patients with TBI of all severities were included. HRQoL at 12 months post-injury was measured by the QOLIBRI. It has a total scale and 6 subscales (satisfied with Cognition, Self, Daily Life and Autonomy and Social Relationships, and bothered by Emotions and Physical Problems). Demographic and injury related data were registered. Disability was registered by Glasgow Outcome Scale Extended (GOSE) and Rivermead Post-Concussion Questionnaire, and mental health by Hospital Anxiety and Depression Scale. Descriptive statistics, internal consistency by Cronbach's alpha and Corrected Item-Total Correlations were calculated. Rasch analysis, Principal Component Analysis (PCA) and Structural Equation Modelling (SEM) were applied.

RESULTS

Mean age was 37.6 (SD 15.4) years; 72% were men, and 41% had higher education. Over 60% were severely injured. Mean Glasgow Coma Scale score was 9.3 (SD 4.5). According to the GOSE 5.9% had severe disability, 45.5% had moderate disability, and 48.5% had good recovery at 12 months post-injury. The QOLIBRI scales had a high internal consistency (α = 0.75-0.96), and only Physical Problems had an α < 0.85. In the Rasch analysis all subscales and their items fit the Rasch model, except for the depression item in the Emotion subscale. PCA and SEM analyses supported a six-factor structure in a second-order latent model. The QOLIBRI supports an underlying unidimensional HRQoL model. The SEM model fit statistics of the second-order model indicated a moderate fit to the observed data (CFI = 0.86, TLI = 0.85, RMSEA = 0.076, SRMR = 0.061, χ2 = 1315.76, df = 623, p-value < 0.001).

CONCLUSION

The Norwegian QOLIBRI has favourable psychometric properties, but there were some weaknesses related to its measurement properties of the total score when tested on a TBI population where many had severe TBI, and many had good recovery.

Cognitive Rehabilitation After Traumatic Brain Injury: A Reference for Occupational Therapists

Nearly 1.7 million Americans sustain a traumatic brain injury (TBI) each year. These injuries can result in physical, emotional, and cognitive consequences. While many individuals receive cognitive rehabilitation from occupational therapists (OTs), the interdisciplinary nature of TBI research makes it difficult to remain up-to-date on relevant findings. We conducted a literature review to identify and summarize interdisciplinary evidence-based practice targeting cognitive rehabilitation for civilian adults with TBI. Our review summarizes TBI background, and our cognitive remediation section focuses on the findings from 37 recent (since 2006) empirical articles directly related to cognitive rehabilitation for individuals (i.e., excluding special populations such as veterans or athletes). This manuscript is offered as a tool for OTs engaged in cognitive rehabilitation and as a means to highlight arenas where more empirical, interdisciplinary research is needed.

Validation of the Safe at Home Screening with Adults Who Have Acquired Brain Injury

The Safe at Home Screening (SAH) is an occupational therapy assessment tool designed to quickly assess home safety awareness and skills through the use of mock hazardous situations in a kitchen setting. The SAH has been standardized on community-dwelling adults. This research project involves psychometric analyses using the SAH on a sample of adults with acquired brain injuries (ABI; N = 31), and compares their SAH outcome scores with those of the Kohlman Evaluation of Living Skills (KELS). The scores on the two tests were found to be moderately correlated. An aspect of content validity was explored by asking the clients' occupational therapists to make predictions about their clients' functioning in the realm of home safety. Correlations between the expert opinions of potential client scores and actual SAH test scores were moderate.

Benefits of order: the influence of item sequencing on metacognition in moderate and severe traumatic brain injury

The ability to appraise one's own ability has been found to have an important role in the recovery and quality of life of clinical populations. Examinee and task variables have been found to influence metacognition in healthy students; however the effect of these variables on the metacognitive accuracy of adults with neurological insult, such as traumatic brain injury (TBI), remains unknown. Twenty-two adults with moderate and severe TBI and a matched sample of healthy adults participated in this study examining the influence of item sequencing on metacognitive functioning. Retrospective confidence judgments were collected while participants completed a modified version of the Matrix Reasoning subtest. Significant influence of item sequence order was found, revealing better metacognitive abilities and performance when participants completed tasks where item difficulty progressed in order from easy to difficult. We interpret these findings to suggest that the sequencing of item difficulty offers "anchors" for gauging and adjusting to task demands.

Neuropsychological assessment: principles, rationale, and challenges

Neuropsychological assessments are increasingly in demand for a wide range of patients. This paper offers a survey of the basic aspects of neuropsychological assessment that are of greatest importance for professionals (e.g., psychologists, psychiatrists, social workers, and lawyers) who are not trained in neuropsychological testing, but who refer clients for neuropsychological assessment. This survey could also serve neuropsychologists in their early stages of training, by addressing some of the major issues related to the assessment process. The range of goals that neuropsychological assessment may attain is first outlined. Next, a model is presented that explains the rationale enabling generalization from assessment to real-world functions that are the focus of interest and the target of prediction. Issues that need to be considered before deciding to conduct a neuropsychological evaluation are then introduced, and sources of information available to the assessor are described. A description is provided of what a neuropsychological assessment includes, with an emphasis on its cognitive aspects. Finally, mention is made of some of the difficulties and challenges that must be confronted in the course of a neuropsychological assessment.

Metacognitive monitoring in moderate and severe traumatic brain injury

The ability to engage in self-reflective processes is a capacity that may be disrupted after neurological compromise; research to date has demonstrated that patients with traumatic brain injury (TBI) show reduced awareness of their deficits and functional ability compared to caretaker or clinician reports. Assessment of awareness of deficit, however, has been limited by the use of subjective measures (without comparison to actual performance) that are susceptible to report bias. This study used concurrent measurements from cognitive testing and confidence judgments about performance to investigate in-the-moment metacognitive experiences after moderate and severe traumatic brain injury. Deficits in metacognitive accuracy were found in adults with TBI for some but not all indices, suggesting that metacognition may not be a unitary construct. Findings also revealed that not all indices of executive functioning reliably predict metacognitive ability.

Relationship between psychiatric disorders and 1-year psychosocial outcome following traumatic brain injury

OBJECTIVE

To investigate the relationship of psychiatric functioning with psychosocial functioning at 1 year following traumatic brain injury (TBI), after controlling for relevant demographic, injury-related, and concurrent factors.

DESIGN

Prospective 1-year longitudinal study.

PARTICIPANTS

Participants were 122 individuals with TBI and 88 proxy informants.

SETTING

Rehabilitation hospital.

MAIN MEASURES

The Structured Clinical Interview for DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision)) Axis I Disorders, Hospital Anxiety and Depression Scale, Sydney Psychosocial Reintegration Scale, and Glasgow Outcome Scale--Extended.

RESULTS

At 1 year postinjury, occupational activities were the area of most change after TBI followed by interpersonal relationships and independent living skills, according to the Sydney Psychosocial Reintegration Scale. The majority of participants were rated as having moderate disability on the Glasgow Outcome Scale--Extended. After controlling for relevant background factors, preinjury, acute postinjury, and concurrent psychiatric disorders were significantly related to 1-year psychosocial outcome.

CONCLUSION

Screening in the acute postinjury stage for presence of preinjury psychiatric history or current distress may help identify individuals who require more intensive rehabilitation and psychiatric support and more active postdischarge monitoring. Further research exploring potential causal mechanisms for these findings is required.

Acceptance rates in state-federal vocational rehabilitation of clients with brain injury: Is racial disparity an issue?

PRIMARY OBJECTIVE

To utilize Aday and Andersen's Framework for the Study of Access to examine racial disparity within the State-Federal vocational rehabilitation system, among clients with brain injury. Research questions included: Do pre-disposing characteristics such as age, race, ethnicity, gender, marital status and education influence vocational rehabilitation acceptance rates in the US? Do enabling characteristics such as referral source, insurance coverage and primary source of support at application influence vocational rehabilitation acceptance rates in the US? Is there a difference, based on race, in the reason for case closure for vocational rehabilitation services?

METHODS AND PROCEDURES

Exhaustive CHAID analysis was conducted with acceptance for rehabilitation as the criterion variable and pre-disposing characteristics as predictor variables. Chi-square analysis was calculated with regard to reason for closure.

MAIN OUTCOMES AND RESULTS

Descriptive findings are presented. Of the pre-disposing factors, the most significant predictor of acceptance rate was education level. Pearson Chi-square analyses revealed significant differences between White and non-White clients with brain injury with regard to reason for closure.

CONCLUSIONS

The data indicate that racial differences were only a small part of the overall equation and again that distinct disparity by race is not evidenced in the RSA-911 data for persons with a primary or secondary diagnosis of brain injury.

Prediction of depression and anxiety 1 year after moderate-severe traumatic brain injury

This study examined three scales of the Personality Assessment Inventory (PAI; Anxiety, Anxiety-Related Disorders, and Depression) in 88 participants 1 year after they suffered a moderate-severe traumatic brain injury (TBI). Participants were all enrolled in the federally funded Traumatic Brain Injury Model System project at Carolinas Rehabilitation. The following variables were assessed at the time of injury: age, sex, employment and marital status, and length of loss of consciousness. Disability status, using the Disability Rating Scale (DRS), was assessed at the time of discharge from the rehabilitation hospital. A series of three linear regression analyses found that these variables significantly predicted scores on the Anxiety and Anxiety-Related Disorders scales, which accounted for 14% and 17.7% of the variance, respectively. The variables did not significantly predict scores on the Depression scale. Within each regression analysis, DRS was consistently and negatively related to each PAI scale, such that greater disability was associated with better psychological functioning. Such seemingly paradoxical findings are discussed in terms of anosognosia or poor awareness of psychological functioning among those with greater disability 1 year after TBI.

Neurosurgery three times over: a psychiatrist's insider perspective

The author, a practicing psychiatrist, describes his own experience in becoming a neurosurgical patient, three times in quick succession, for a recurring subdural hematoma. In addition to a brief review of the literature, he observes his own experience, including reaction to the diagnosis and to the surgical, postsurgical, and intensive-care experience. Suggestions are made to neurosurgeons and their staff to help patients during this experience and in recovery, from the vantage point of a psychiatrist who specializes in dealing with psychological issues arising from illness.

Examining health status of women in rural, peri-urban and urban areas in Jamaica

BACKGROUND

A comprehensive review of the literature revealed that less information is available in literature on health status of women, and health status of women in 3 geographical zones in Jamaica.

AIMS

This study examined data on the health status of women in Jamaica in order to provide some scientific explanation of those factors that account for their health status; and differences based on area of residence.

MATERIALS AND METHODS

The sub-sample for the current study was 8,541 women ages of 15 and 100 years extracted from a national survey of 25,018 respondents. Stratified random sampling technique was used to draw the sample. Data were stored, retrieved and analyzed using SPSS 16.0. Descriptive statistics were used to provide background information on the subsample, and logistic regressions were utilized to model health statuses.

RESULTS

Rural women had the lowest health status (OR = 0.819, 95% CI = 0.679-0.989) among all women (peri-urban OR = 1.054, 95% CI = 0.842-1.320; urban OR = 1.00) and that they were the least likely to have health insurance coverage. Health insurance was the critical predictor of good health status of women in Jamaica, and this was equally the same across the 3 geographic areas; and that married women were 1.3 times more likely (OR 1.3, 95 CI = 1.036-1.501) to report good health compared to those who were never married.

CONCLUSION

This study provides an understanding of women's health status in Jamaica as well as the disparity which correlates based on the different geographical regions.

Changes in coping strategies, social support, optimism and health-related quality of life following traumatic brain injury: A longitudinal study

PRIMARY OBJECTIVE

To study longitudinal changes in psychological coping strategies, social support, life orientation and health-related quality of life in the late period after traumatic brain injury (TBI).

SUBJECTS

Thirty-one patients with TBI who were first investigated on average 2.3 years after injury and were prospectively followed on average 5.7 years later.

METHODS

Estonian versions of the COPE-D Test, the Brief Social Support Questionnaire, the Life Orientation Test and the RAND-36 questionnaire.

RESULTS

During the late follow-up period health-related quality of life and resuming work did not improve significantly. Persons with TBI reported an increase in seeking social/emotional support (p<0.05), frequent use of avoidance-oriented styles and reduced use of task-oriented styles. This was accompanied by low social support and low satisfaction with support, both of which were associated with health-related quality of life and resuming work after TBI. Although the patients had become more optimistic (p<0.05), this did not correlate with their health status and social well-being.

CONCLUSIONS

This prospective study revealed maladaptive changes in the profile of coping strategies and an increase in optimism. As social support, satisfaction with support and health-related quality of life did not improve, then rehabilitation, social and psychological support are continuously needed.

Psychological adjustment and marital satisfaction following head injury. Which critical personal characteristics should both partners develop?

PRIMARY OBJECTIVE AND RESEARCH DESIGN: Using a correlational design, this study verifies the relationships between personal characteristics of individuals with TBI and their spouses and their level of psychological and marital adjustment.

METHODS AND PROCEDURE

Seventy individuals with TBI and their spouses in the post-acute rehabilitation phase completed self-report questionnaires assessing the predictive variables (coping and social problem-solving strategies; perceived communication skills) and the criteria variables of psychological and marital adjustment.

MAIN OUTCOMES AND RESULTS

In the target group, the characteristics most strongly related to adjustment variables were an effective attitude towards problems, infrequent use of avoidance coping strategies, and a positive perception of one's spouse's communication skills. Individuals with TBI and their spouses report significantly lower scores on some of these personal characteristics, compared to those of a matched control group of 70 couples from the general population.

CONCLUSIONS

Specific personal characteristics are critical for psychological and marital adjustment following TBI. This knowledge may be of relevance for detecting couples at risk for developing difficulties in the post-acute rehabilitation phase. Rehabilitation interventions targeting the personal characteristics identified as critical for the adjustment process could help to prevent these difficulties.

In the line of fire: traumatic brain injury among Iraq War veterans

Soldiers returning home from Iraq are experiencing an increased number of head injuries related to blasts and explosions compared to soldiers of previous conflicts. These injuries are often undetected until the soldiers return home and have difficulty functioning as they did prior to the war. It is therefore important for occupational health nurses to understand blast injury, its pathophysiology, methods for detecting traumatic brain injury, and how these soldiers can be treated.

In the Line of Fire

Soldiers returning home from Iraq are experiencing an increased number of head injuries related to blasts and explosions compared to soldiers of previous conflicts. These injuries are often undetected until the soldiers return home and have difficulty functioning as they did prior to the war. It is therefore important for occupational health nurses to understand blast injury, its pathophysiology, methods for detecting traumatic brain injury, and how these soldiers can be treated.

Community integration, social support and life satisfaction in relation to symptoms 3 years after mild traumatic brain injury

PRIMARY OBJECTIVE

To investigate the relation between psychosocial functioning (community integration, life satisfaction and social support) and symptoms (post-concussion, post-traumatic stress and depression) in persons with mild traumatic brain injury (MTBI) 3 years after the trauma.

METHODS

Population-based follow-up study of 163 patients. At follow-up, an assessment of community integration, social support, life satisfaction and symptoms was made.

RESULTS

Total score of Community Integration Questionnaire (CIQ) was negatively correlated to total score of the Rivermead Post-Concussion Symptoms Questionnaire (RPQ, r = -0.270, p < 0.001) and to total score of the Beck Depression Inventory (BDI, r = -0.332, p < 0.001). Life satisfaction (LiSat-11) was negatively correlated to the RPQ (r = -0.459, p < 0.001), to total score of the Impact of Event Scale (IES, r = -0.365, p < 0.001) and to the BDI (r = -0.642, p < 0.001). Low levels of life satisfaction were common at follow-up.

CONCLUSIONS

A large proportion of the individuals with MTBI experienced both psychosocial difficulties, with low levels of life satisfaction in particular and symptoms (post-concussion, post-traumatic stress and depression) 3 years after trauma. Since the possibility of pre-injury factors contributing to the condition at follow-up cannot be ruled out, the study indicates that all these factors should be taken into consideration in the management of persons with MTBI.

Perceived self-efficacy and life satisfaction after traumatic brain injury

OBJECTIVE

To investigate the contribution of activity-related satisfaction and perceived self-efficacy to global life satisfaction after traumatic brain injury (TBI).

PARTICIPANTS

Convenience sample of 97 adults who were living in their community at least 6 months after sustaining a TBI.

MEASURES

Community Integration Questionnaire, Quality of Community Integration Questionnaire, Self-Efficacy Questionnaire for TBI, Perceived Quality of Life Scale, Satisfaction with Life Scale.

RESULTS

Among demographic and injury-related variables, gender and time since injury made significant contributions to the prediction of global life satisfaction. Productivity made a modest, significant contribution to life satisfaction. Satisfaction with productivity and with leisure/social activities both contributed to global life satisfaction. The greatest contribution to the prediction of global life satisfaction was made by the person's perceived self-efficacy, particularly perceived self-efficacy for the management of cognitive symptoms. Perceived cognitive self-efficacy also appeared to mediate the relation between community integration and global life satisfaction.

CONCLUSION

Community integration, activity-related satisfaction, and global life satisfaction represent distinct constructs, and dissociable aspects of psychosocial outcome after TBI. Perceived self-efficacy for the management of cognitive symptoms may mediate the relation between the individual's expectations and achievements and thereby contribute to overall subjective well-being.

Unawareness of illness in neuropsychiatric disorders: phenomenological certainty versus etiopathogenic vagueness

Awareness of illness is a form of self-knowledge concerning information about the pathological state, its functional consequence, and the way it affects the patient and his interaction with the environment. Unawareness of illness has raised much interest for its consequences on compliance with treatment, prognosis, and the patient's quality of life. This review highlights the great complexity of this phenomenon both at phenomenological and etiopathogenic levels in stroke, traumatic brain injury, psychosis, dementias, and mood disorders. In particular, the clinical expression is characterized by failure to acknowledge being ill, misattribution of symptoms, and noncompliance with treatment. Unawareness of illness may also be linked with characteristics that are peculiar to each individual disturbance, such as symptom duration and cognitive impairment. Despite a long-lasting interest in the clinical characteristics of unawareness, only recently has the focus of research investigated pathogenic mechanisms, with sometimes controversial results. The vast majority of studies have pointed out a remarkable involvement of the right hemisphere. Specifically, functional and structural changes of the dorso-lateral prefrontal cortex and some other frontal areas have often been found to be associated with awareness deficit, as well as parieto-temporal areas and the thalamus, although to a lesser extent. These data indicate the present difficulty of localizing a specific cerebral area involved in unawareness and suggest the existence of possible brain circuits responsible for awareness. In conclusion, phenomenological manifestations of poor awareness are well outlined in their complexity, whereas neuroanatomic and neuropsychological findings are still too vague and sparse and need further, greater efforts to be clarified.

Evaluation of the Neurobehavioral Functioning Inventory as a Depression Screening Tool After Traumatic Brain Injury

OBJECTIVE

To examine the utility of the Neurobehavioral Functioning Inventory (NFI) for diagnosing depression in a rehabilitation setting.

DESIGN

In a prospective study, a structured clinical interview (Structured Clinical Interview for DSM-IV-TR) was used to identify DSM-IV-defined major depressive disorder (MDD) symptoms among patients with traumatic brain injury (TBI). NFI Depression scale items were compared with DSM-IV diagnosis obtained by the Structured Clinical Interview for DSM-IV Axis I Disorders.

SETTING

Outpatient neuropsychology clinic at a university hospital, private outpatient physical medicine and rehabilitation clinic, and a long-term specialized living assistance program.

PARTICIPANTS

Participants consisted of 78 patients with TBI who were at least 3 months postinjury and 18 years of age or older.

MAIN OUTCOME MEASURES

Structured Clinical Interview for DSM-IV Axis I Disorders and the NFI.

RESULTS

Psychiatric diagnostic interview with the Structured Clinical Interview for DSM-IV Axis I Disorders indicated that 50% of patients with TBI in our sample had at least one of the following in their lifetime: MDD, MDD due to general medical condition, dysthymia, or adjustment disorder with depressed mood. Thirty percent met diagnostic criteria for current MDD with or without general medical condition. Analyses of the NFI items revealed that individuals with depression endorsed greater levels of problems than did those without depression on 14 of the 32 items related to the DSM-IV symptom domains for depression (P < .00156 with Bonferroni correction). In predicting the diagnosis of depression using individual NFI items, the classification rate based on the Random Forests estimate was 83%.

CONCLUSION

Findings indicate that the NFI items differentiated between depressed and nondepressed patients with TBI. Imposing minimal burden on patients and staff, the NFI appears to have good predictive value in diagnosing major depression. In clinical practice and research, the NFI is a potentially valuable screening tool for identifying major depression in persons with TBI.