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Carmichael J, Ponsford J, Gould KR, Tiego J, Forbes MK, Kotov R, Fornito A, Spitz G. A Transdiagnostic, Hierarchical Taxonomy of Psychopathology Following Traumatic Brain Injury (HiTOP-TBI). J Neurotrauma 2024. [PMID: 38970424 DOI: 10.1089/neu.2024.0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2024] Open
Abstract
Psychopathology, including depression, anxiety, and post-traumatic stress, is a significant yet inadequately addressed feature of moderate-severe traumatic brain injury (TBI). Progress in understanding and treating post-TBI psychopathology may be hindered by limitations associated with conventional diagnostic approaches, specifically the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD). The Hierarchical Taxonomy of Psychopathology (HiTOP) offers a promising, transdiagnostic alternative to psychiatric classification that may more effectively capture the experiences of individuals with TBI. However, HiTOP lacks validation in the TBI population. To address this gap, we administered a comprehensive questionnaire battery, including 56 scales assessing homogeneous symptom components and maladaptive traits within HiTOP, to 410 individuals with moderate-severe TBI. We evaluated the reliability and unidimensionality of each scale and revised those with psychometric problems. Using a top-down, exploratory latent variable approach (bass-ackwards modeling), we subsequently constructed a hierarchical model of psychopathological dimensions tailored to TBI. The results showed that, relative to norms, participants with moderate-severe TBI experienced greater problems in the established HiTOP internalizing and detachment spectra, but fewer problems with thought disorder and antagonism. Fourteen of the 56 scales demonstrated psychometric problems, which often appeared reflective of the TBI experience and associated disability. The Hierarchical Taxonomy of Psychopathology Following Traumatic Brain Injury (HiTOP-TBI) model encompassed broad internalizing and externalizing spectra, splitting into seven narrower dimensions: Detachment, Dysregulated Negative Emotionality, Somatic Symptoms, Compensatory and Phobic Reactions, Self-Harm and Psychoticism, Rigid Constraint, and Harmful Substance Use. This study presents the most comprehensive empirical classification of psychopathology after TBI to date. It introduces a novel, TBI-specific transdiagnostic questionnaire battery and model, which addresses the limitations of conventional DSM and ICD diagnoses. The empirical structure of psychopathology after TBI largely aligned with the established HiTOP model (e.g., a detachment spectrum). However, these constructs need to be interpreted in relation to the unique experiences associated with TBI (e.g., considering the injury's impact on the person's social functioning). By overcoming the limitations of conventional diagnostic approaches, the HiTOP-TBI model has the potential to accelerate our understanding of the causes, correlates, consequences, and treatment of psychopathology after TBI.
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Affiliation(s)
- Jai Carmichael
- Monash-Epworth Rehabilitation Research Centre, School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Jennie Ponsford
- Monash-Epworth Rehabilitation Research Centre, School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Kate Rachel Gould
- Monash-Epworth Rehabilitation Research Centre, School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Jeggan Tiego
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Miriam K Forbes
- School of Psychological Sciences, Macquarie University, Sydney, Australia
| | - Roman Kotov
- Stony Brook University, New York, New York, USA
| | - Alex Fornito
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Gershon Spitz
- Monash-Epworth Rehabilitation Research Centre, School of Psychological Sciences, Monash University, Melbourne, Australia
- Department of Neuroscience, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
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Fraser EE, Downing MG, Haines K, Bennett L, Olver J, Ponsford JL. Experience of adapted cognitive behaviour therapy to address sexuality problems after traumatic brain injury: A qualitative study. Neuropsychol Rehabil 2024; 34:572-599. [PMID: 37306485 DOI: 10.1080/09602011.2023.2221858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 05/30/2023] [Indexed: 06/13/2023]
Abstract
Although sexuality has been shown to be negatively impacted in up to half of individuals who sustain traumatic brain injury (TBI), few studies have sought to evaluate the efficacy of targeted interventions. Gaining insight into the participant experience of undergoing treatment for post-TBI sexuality changes is a crucial aspect of intervention evaluation. This study aimed to investigate participants with TBI experience of undergoing eight sessions of a novel CBT intervention designed to help both couples and singles improve sexual wellbeing after TBI. Eight participants (50% male) with moderate-severe TBI, and a mean age of 46.38-years (SD = 13.54), completed a qualitative interview. A six-phase reflexive thematic analysis approach was used. Despite variability in participant characteristics, the findings suggested that participants with TBI experience reflected that of a positive treatment journey characterized by high levels of enjoyment and satisfaction. Key themes identified included contextual factors that preceded treatment, factors that facilitated treatment engagement, outcomes derived from the treatment experience, and feedback provided on reflection. The results not only provide an enriched understanding of the client experience of the intervention but provide corroborating preliminary evidence of efficacy for this novel CBT intervention in addressing complex and persistent sexuality problems after TBI.
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Affiliation(s)
- Elinor E Fraser
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Australia
- Epworth Healthcare, Monash-Epworth Rehabilitation Research Centre, Richmond, Australia
| | - Marina G Downing
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Australia
- Epworth Healthcare, Monash-Epworth Rehabilitation Research Centre, Richmond, Australia
| | - Kerrie Haines
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Australia
| | - Linda Bennett
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Australia
| | - John Olver
- Epworth HealthCare, Rehabilitation Medicine, Richmond, Australia
| | - Jennie L Ponsford
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Australia
- Epworth Healthcare, Monash-Epworth Rehabilitation Research Centre, Richmond, Australia
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Barua U, Ahrens J, Shao R, MacKenzie H, Wolfe D, Sequeira K, Teasell R, Loh E, Mehta S. Cognitive behavioral therapy for managing depressive and anxiety symptoms after brain injury: a meta-analysis. Brain Inj 2024; 38:227-240. [PMID: 38318855 DOI: 10.1080/02699052.2024.2309264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 01/19/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND Individuals with traumatic brain injury (TBI) are at increased risk of depression and anxiety, leading to impaired recovery. While cognitive-behavioral therapy (CBT) addresses anxiety and depression maintenance factors, its efficacy among those with TBI has not been clearly demonstrated. This review aims to bridge this gap in the literature. METHODS Several databases, including Medline, PsycInfo and EMBASE, were used to identify studies published between 1990 and 2021. Studies were included if: (1) trials were randomized controlled trials (RCT) involving CBT-based intervention targeting anxiety and/or depression; (2) participants experienced brain injury at least 3-months previous; (3) participants were ≥18 years old. An SMD ± SE, 95% CI and heterogeneity were calculated for each outcome. RESULTS Thirteen RCTs were included in this meta-analysis. The pooled-sample analyses suggest that CBT interventions had small immediate post-treatment effects on reducing depression (SMD ± SE: 0.391 ± 0.126, p < 0.005) and anxiety (SMD ± SE: 0.247 ± 0.081, p < 0.005). Effects were sustained at a 3-months follow-up for depression. A larger effect for CBT was seen when compared with supportive therapy than control. Another sub-analysis found that individualized CBT resulted in a slightly higher effect compared to group-based CBT. CONCLUSION This meta-analysis provides substantial evidence for CBT in managing anxiety and depression post-TBI.
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Affiliation(s)
- Ujjoyinee Barua
- Parkwood Research Institute, Parkwood Institute, London, Ontario, Canada
- St. Joseph's Health Care, Parkwood Institute, London, Ontario, Canada
- Faculty of Health Sciences, University of Western Ontario, London, Ontario, Canada
| | - Jessica Ahrens
- Parkwood Research Institute, Parkwood Institute, London, Ontario, Canada
- St. Joseph's Health Care, Parkwood Institute, London, Ontario, Canada
| | - Richard Shao
- Parkwood Research Institute, Parkwood Institute, London, Ontario, Canada
- St. Joseph's Health Care, Parkwood Institute, London, Ontario, Canada
| | - Heather MacKenzie
- Parkwood Research Institute, Parkwood Institute, London, Ontario, Canada
- St. Joseph's Health Care, Parkwood Institute, London, Ontario, Canada
- Department of Physical Medicine and Rehabilitation, University of Western Ontario, London, Ontario, Canada
| | - Dalton Wolfe
- Parkwood Research Institute, Parkwood Institute, London, Ontario, Canada
- St. Joseph's Health Care, Parkwood Institute, London, Ontario, Canada
- Faculty of Health Sciences, University of Western Ontario, London, Ontario, Canada
| | - Keith Sequeira
- Parkwood Research Institute, Parkwood Institute, London, Ontario, Canada
- St. Joseph's Health Care, Parkwood Institute, London, Ontario, Canada
- Department of Physical Medicine and Rehabilitation, University of Western Ontario, London, Ontario, Canada
| | - Robert Teasell
- Parkwood Research Institute, Parkwood Institute, London, Ontario, Canada
- St. Joseph's Health Care, Parkwood Institute, London, Ontario, Canada
- Department of Physical Medicine and Rehabilitation, University of Western Ontario, London, Ontario, Canada
| | - Eldon Loh
- Parkwood Research Institute, Parkwood Institute, London, Ontario, Canada
- St. Joseph's Health Care, Parkwood Institute, London, Ontario, Canada
- Department of Physical Medicine and Rehabilitation, University of Western Ontario, London, Ontario, Canada
| | - Swati Mehta
- Parkwood Research Institute, Parkwood Institute, London, Ontario, Canada
- St. Joseph's Health Care, Parkwood Institute, London, Ontario, Canada
- Department of Physical Medicine and Rehabilitation, University of Western Ontario, London, Ontario, Canada
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Stanton B, Chalder T, Carvalho C. Cognitive behavioural therapy for neurologists. Pract Neurol 2024; 24:22-27. [PMID: 37932039 DOI: 10.1136/pn-2023-003857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2023] [Indexed: 11/08/2023]
Abstract
In neurological practice, we take pride in accurate diagnosis and using neuroscience to develop novel disease-modifying therapies, but we sometimes neglect symptom management and the treatment of distress. Most patients with neurological disorders report that their mental health needs are not being met. Of the many forms of psychological therapy, cognitive behavioural therapy (CBT) is the most likely to be available to our patients. This article sets out to answer the following questions: (1) What is CBT? (2) What will patients experience if they have CBT? (3) Is CBT effective for people with neurological disorders? (4) Who is most suitable for CBT? (5) How and where can a neurologist refer their patients for CBT? (6) Can we as neurologists use aspects of the CBT model in our own consultations?
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Affiliation(s)
- Biba Stanton
- Department of Neurology, King's College Hospital NHS Foundation Trust, London, UK
| | - Trudie Chalder
- Department of Psychological Medicine, King's College London, London, UK
| | - Carolina Carvalho
- Department of Psychological Medicine, King's College London, London, UK
- School of Psychology, University of Surrey, Guildford, UK
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Carmichael J, Ponsford J, Gould KR, Spitz G. Characterizing depression after traumatic brain injury using a symptom-oriented approach. J Affect Disord 2024; 345:455-466. [PMID: 37879410 DOI: 10.1016/j.jad.2023.10.130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 10/20/2023] [Accepted: 10/21/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Progress in addressing depression after traumatic brain injury (TBI) has been limited. Traditional approaches to measuring depression classify individuals with diverse symptoms as having the same problem. We adopted a novel, symptom-oriented approach to characterize post-TBI depression, emphasizing specific symptoms rather than the number of symptoms. METHODS We assessed depressive symptoms cross-sectionally in 393 participants with moderate-severe TBI (range 0.4-35.4 years post-injury; M = 12.6) using the Inventory of Depression and Anxiety Symptoms - Expanded Version (IDAS-II). We analyzed symptoms of DSM-5 major depressive disorder (MDD), separating compound symptoms into sub-symptoms. We quantified depression heterogeneity across 16 specific symptoms and explored associations between each symptom and personal, injury-related, treatment, and functional/psychosocial outcome factors. RESULTS 28 % of participants self-reported a current depression diagnosis, and 35 % met DSM-5 symptom criteria for MDD. Depressed participants (according to either self-reported diagnosis or MDD symptom criteria) were more likely to endorse each specific depressive symptom, including those that overlap with TBI. Post-TBI depression was highly heterogeneous, with 84-91 % of depressed participants (depending on classification method) showing a unique symptom profile not shared with any other individual. The most common symptom profile was shared by only three individuals. This heterogeneity was meaningful, as specific depressive symptoms had distinct associations with personal, injury-related, treatment, and outcome factors. LIMITATIONS Cross-sectional design. We only analyzed DSM-5 MDD symptoms, and some symptoms were assessed using only one item. CONCLUSIONS A symptom-oriented approach to post-TBI depression captures the individual's unique profile of depressive symptoms, which relate differently to outcomes and other factors. We recommend future studies investigating post-TBI depression analyze specific symptoms alongside overall depression scores.
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Affiliation(s)
- Jai Carmichael
- Monash-Epworth Rehabilitation Research Centre, Epworth HealthCare, Melbourne, Australia; Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Australia.
| | - Jennie Ponsford
- Monash-Epworth Rehabilitation Research Centre, Epworth HealthCare, Melbourne, Australia; Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Australia
| | - Kate Rachel Gould
- Monash-Epworth Rehabilitation Research Centre, Epworth HealthCare, Melbourne, Australia; Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Australia
| | - Gershon Spitz
- Monash-Epworth Rehabilitation Research Centre, Epworth HealthCare, Melbourne, Australia; Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Australia; Department of Neuroscience, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
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Wong D, Pike K, Stolwyk R, Allott K, Ponsford J, McKay A, Longley W, Bosboom P, Hodge A, Kinsella G, Mowszowski L. Delivery of Neuropsychological Interventions for Adult and Older Adult Clinical Populations: An Australian Expert Working Group Clinical Guidance Paper. Neuropsychol Rev 2023:10.1007/s11065-023-09624-0. [PMID: 38032472 DOI: 10.1007/s11065-023-09624-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 10/16/2023] [Indexed: 12/01/2023]
Abstract
Delivery of neuropsychological interventions addressing the cognitive, psychological, and behavioural consequences of brain conditions is increasingly recognised as an important, if not essential, skill set for clinical neuropsychologists. It has the potential to add substantial value and impact to our role across clinical settings. However, there are numerous approaches to neuropsychological intervention, requiring different sets of skills, and with varying levels of supporting evidence across different diagnostic groups. This clinical guidance paper provides an overview of considerations and recommendations to help guide selection, delivery, and implementation of neuropsychological interventions for adults and older adults. We aimed to provide a useful source of information and guidance for clinicians, health service managers, policy-makers, educators, and researchers regarding the value and impact of such interventions. Considerations and recommendations were developed by an expert working group of neuropsychologists in Australia, based on relevant evidence and consensus opinion in consultation with members of a national clinical neuropsychology body. While the considerations and recommendations sit within the Australian context, many have international relevance. We include (i) principles important for neuropsychological intervention delivery (e.g. being based on biopsychosocial case formulation and person-centred goals); (ii) a description of clinical competencies important for effective intervention delivery; (iii) a summary of relevant evidence in three key cohorts: acquired brain injury, psychiatric disorders, and older adults, focusing on interventions with sound evidence for improving activity and participation outcomes; (iv) an overview of considerations for sustainable implementation of neuropsychological interventions as 'core business'; and finally, (v) a call to action.
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Affiliation(s)
- Dana Wong
- School of Psychology and Public Health, La Trobe University, Melbourne, Australia.
| | - Kerryn Pike
- School of Psychology and Public Health & John Richards Centre for Rural Ageing Research, La Trobe University, Melbourne, Australia
- School of Applied Psychology, Griffith University, Gold Coast, Australia
| | - Rene Stolwyk
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Australia
- Monash-Epworth Rehabilitation Research Centre, Melbourne, Australia
| | - Kelly Allott
- , Orygen, Parkville, Australia
- Centre for Youth Mental Health, The University of Melbourne, Parkville, Australia
| | - Jennie Ponsford
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Australia
- Monash-Epworth Rehabilitation Research Centre, Melbourne, Australia
| | - Adam McKay
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Australia
- MERRC, Rehabilitation and Mental Health Division, Epworth HealthCare, Richmond, Australia
| | - Wendy Longley
- Rehabilitation Studies Unit, Sydney Medical School, University of Sydney, Sydney, Australia
- The Uniting War Memorial Hospital, Waverley, Sydney, Australia
| | - Pascalle Bosboom
- MindLink Psychology, West Perth, Australia
- School of Psychological Science, University of Western Australia, Crawley, Australia
| | | | - Glynda Kinsella
- School of Psychology and Public Health, La Trobe University, Melbourne, Australia
| | - Loren Mowszowski
- Faculty of Science, School of Psychology & Brain and Mind Centre, The University of Sydney, Sydney, Australia
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Fletcher K, Wydera S, Thorpe N, Radford K, das Nair R, Booth V. A rapid realist review of clinical neuropsychology rehabilitation programmes to improve psychological wellbeing and quality of life for people with acquired brain injuries. Neuropsychol Rehabil 2023:1-36. [PMID: 37975854 DOI: 10.1080/09602011.2023.2273580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 10/03/2023] [Indexed: 11/19/2023]
Abstract
Approximately 20% of acquired brain injury (ABI) survivors experience reduced psychological wellbeing (PWB). Neuropsychological rehabilitation (NPR) is one approach supporting people with ABI to participate meaningfully in activities despite challenges. Although literature supports NPR effectiveness, little is known about change mechanisms. This systematic realist review identifies what NPR programmes have been designed, delivered, and evaluated for people with ABI to improve PWB and/or quality of life (QOL), as well as providing a context-relevant understanding of what NPR includes and how NPR might lead to positive outcomes. A rapid realist review was conducted in three phases: (1) structured retrieval and evidence extraction; (2) stakeholder consultation; (3) analysis and synthesis. Searches were completed, and findings from 35 publications and one stakeholder consultation were synthesized into a refined logic model. Six context-mechanism-outcome chains (CMOCs) were identified. Participants' relationships to internal experiences, and feelings of self-worth, mastery, and connection appeared to be mechanisms that led to improved PWB and QOL. Adaptation and individualized programmes were also key mechanisms to explain successful NPR. Embedding CMOCs into NPR could improve PWB and/or QOL for people with ABI. The logic model will inform ongoing development of a new online, group-based, NPR programme.
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Affiliation(s)
- K Fletcher
- Division of Rehabilitation & Ageing, University of Nottingham, Nottingham, UK
- Midlands Partnership NHS Foundation Trust, Stafford, UK
| | | | - N Thorpe
- Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, UK
| | - K Radford
- Division of Rehabilitation & Ageing, University of Nottingham, Nottingham, UK
| | - R das Nair
- Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, UK
- SINTEF, Trondheim, Norway
- Institute of Mental Health, University of Nottingham, Nottingham, UK
| | - V Booth
- Division of Rehabilitation & Ageing, University of Nottingham, Nottingham, UK
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Carmichael J, Hicks AJ, Gould KR, Spitz G, Ponsford J. Network analysis of anxiety and depressive symptoms one year after traumatic brain injury. Psychiatry Res 2023; 326:115310. [PMID: 37356251 DOI: 10.1016/j.psychres.2023.115310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 06/14/2023] [Accepted: 06/14/2023] [Indexed: 06/27/2023]
Abstract
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.
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Affiliation(s)
- Jai Carmichael
- Monash-Epworth Rehabilitation Research Centre, Epworth HealthCare, Melbourne, Australia; Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Australia.
| | - Amelia J Hicks
- Monash-Epworth Rehabilitation Research Centre, Epworth HealthCare, Melbourne, Australia; Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Australia
| | - Kate Rachel Gould
- Monash-Epworth Rehabilitation Research Centre, Epworth HealthCare, Melbourne, Australia; Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Australia
| | - Gershon Spitz
- Monash-Epworth Rehabilitation Research Centre, Epworth HealthCare, Melbourne, Australia; Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Australia; Department of Neuroscience, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Jennie Ponsford
- Monash-Epworth Rehabilitation Research Centre, Epworth HealthCare, Melbourne, Australia; Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Australia
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Brand J, McDonald SJ, Gawryluk JR, Christie BR, Shultz SR. Stress and traumatic brain injury: An inherent bi-directional relationship with temporal and synergistic complexities. Neurosci Biobehav Rev 2023; 151:105242. [PMID: 37225064 DOI: 10.1016/j.neubiorev.2023.105242] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/04/2023] [Accepted: 05/20/2023] [Indexed: 05/26/2023]
Abstract
Traumatic brain injury (TBI) and stress are prevalent worldwide and can both result in life-altering health problems. While stress often occurs in the absence of TBI, TBI inherently involves some element of stress. Furthermore, because there is pathophysiological overlap between stress and TBI, it is likely that stress influences TBI outcomes. However, there are temporal complexities in this relationship (e.g., when the stress occurs) that have been understudied despite their potential importance. This paper begins by introducing TBI and stress and highlighting some of their possible synergistic mechanisms including inflammation, excitotoxicity, oxidative stress, hypothalamic-pituitary-adrenal axis dysregulation, and autonomic nervous system dysfunction. We next describe different temporal scenarios involving TBI and stress and review the available literature on this topic. In doing so we find initial evidence that in some contexts stress is a highly influential factor in TBI pathophysiology and recovery, and vice versa. We also identify important knowledge gaps and suggest future research avenues that will increase our understanding of this inherent bidirectional relationship and could one day result in improved patient care.
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Affiliation(s)
- Justin Brand
- Division of Medical Sciences, University of Victoria, Victoria, British Columbia, Canada
| | - Stuart J McDonald
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Jodie R Gawryluk
- Department of Psychology, University of Victoria, Victoria, British Columbia, Canada
| | - Brian R Christie
- Division of Medical Sciences, University of Victoria, Victoria, British Columbia, Canada
| | - Sandy R Shultz
- Division of Medical Sciences, University of Victoria, Victoria, British Columbia, Canada; Department of Neuroscience, Monash University, Melbourne, Victoria, Australia; Faculty of Health Sciences, Vancouver Island University, Nanaimo, British Columbia, Canada.
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Silverberg ND, Mikolić A. Management of Psychological Complications Following Mild Traumatic Brain Injury. Curr Neurol Neurosci Rep 2023; 23:49-58. [PMID: 36763333 DOI: 10.1007/s11910-023-01251-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2023] [Indexed: 02/11/2023]
Abstract
PURPOSE OF REVIEW It has been clear for decades that psychological factors often contribute to mild traumatic brain injury (mTBI) outcome, but an emerging literature has begun to clarify which specific factors are important, when, for whom, and how they impact recovery. This review aims to summarize the contemporary evidence on psychological determinants of recovery from mTBI and its implications for clinical management. RECENT FINDINGS Comorbid mental health disorders and specific illness beliefs and coping behaviors (e.g., fear avoidance) are associated with worse recovery from mTBI. Proactive assessment and intervention for psychological complications can improve clinical outcomes. Evidence-based treatments for primary mental health disorders are likely also effective for treating mental health disorders after mTBI, and can reduce overall post-concussion symptoms. Broad-spectrum cognitive-behavioral therapy may modestly improve post-concussion symptoms, but tailoring delivery to individual psychological risk factors and/or symptoms may improve its efficacy. Addressing psychological factors in treatments delivered primarily by non-psychologists is a promising and cost-effective approach for enhancing clinical management of mTBI. Recent literature emphasizes a bio-psycho-socio-ecological framework for understanding mTBI recovery and a precision rehabilitation approach to maximize recovery. Integrating psychological principles into rehabilitation and tailoring interventions to specific risk factors may improve clinical management of mTBI.
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Affiliation(s)
- Noah D Silverberg
- Department of Psychology, University of British Columbia, 2136 West Mall, Vancouver, BC, V6T 1Z4, Canada.
- Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, BC, V5Z 1M9, Canada.
| | - Ana Mikolić
- Department of Psychology, University of British Columbia, 2136 West Mall, Vancouver, BC, V6T 1Z4, Canada
- Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, BC, V5Z 1M9, Canada
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11
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Rauwenhoff JCC, Bol Y, van Heugten CM, Batink T, Geusgens CAV, van den Hout AJHC, Smits P, Verwegen CRT, Visser A, Peeters F. Acceptance and commitment therapy for people with acquired brain injury: Rationale and description of the BrainACT treatment. Clin Rehabil 2023:2692155231154124. [PMID: 36750988 DOI: 10.1177/02692155231154124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND The treatment of anxiety and depressive symptoms following acquired brain injury is complex and more evidence-based treatment options are needed. We are currently evaluating the BrainACT intervention; acceptance and commitment therapy for people with acquired brain injury. RATIONALE This paper describes the theoretical underpinning, the development and content of BrainACT. Acceptance and commitment therapy focuses on the acceptance of feelings, thoughts and bodily sensations and on living a valued life, without fighting against what is lost. Since the thoughts that people with acquired brain injury can experience are often realistic or appropriate given their situation, this may be a suitable approach. THEORY INTO PRACTICE Existing evidence-based protocols were adapted for the needs and potential cognitive deficits after brain injury. General alterations are the use of visual materials, summaries and repetition. Acceptance and commitment therapy-specific adaptions include the Bus of Life metaphor as a recurrent exercise, shorter mindfulness exercises, simplified explanations, a focus on experiential exercises and the monitoring of committed actions. The intervention consists of eight one-hour sessions with a psychologist, experienced in acceptance and commitment therapy and in working with people with acquired brain injury. The order of the sessions, metaphors and exercises can be tailored to the needs of the patients. DISCUSSION Currently, the effectiveness and feasibility of the intervention is evaluated in a randomised controlled trial. The BrainACT intervention is expected to be a feasible and effective intervention for people with anxiety or depressive symptoms following acquired brain injury.
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Affiliation(s)
- Johanne C C Rauwenhoff
- School for Mental Health and Neuroscience, Faculty of Health, Medicine and Life Sciences, 5211Maastricht University, Maastricht, The Netherlands.,Limburg Brain Injury Centre, Maastricht, The Netherlands
| | - Yvonne Bol
- Department of Clinical and Medical Psychology, Zuyderland Medical Centre, Sittard-Geleen/Heerlen, The Netherlands
| | - Caroline M van Heugten
- School for Mental Health and Neuroscience, Faculty of Health, Medicine and Life Sciences, 5211Maastricht University, Maastricht, The Netherlands.,Limburg Brain Injury Centre, Maastricht, The Netherlands.,Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, 5211Maastricht University, Maastricht, The Netherlands
| | - Tim Batink
- Faculty of Psychology and Educational Sciences, Open University, Heerlen, The Netherlands
| | - Chantal A V Geusgens
- Department of Clinical and Medical Psychology, Zuyderland Medical Centre, Sittard-Geleen/Heerlen, The Netherlands
| | - Anja J H C van den Hout
- Department of Clinical and Medical Psychology, Zuyderland Medical Centre, Sittard-Geleen/Heerlen, The Netherlands
| | - Peter Smits
- Department of Rehabilitation Medicine, Sint Maartenskliniek, Nijmegen, The Netherlands
| | | | - Annemarie Visser
- Department of Rehabilitation Medicine, Center for Rehabilitation, University Medical Centre Groningen, Haren, The Netherlands
| | - Frenk Peeters
- Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience, 5211Maastricht University, Maastricht, The Netherlands
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12
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Monsour M, Borlongan CV. No one left behind: Inclusion of individuals experiencing homelessness in TBI stem cell therapy. Med Hypotheses 2023. [DOI: 10.1016/j.mehy.2022.111002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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13
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Neumann D, Juengst SB, Bombardier CH, Finn JA, Miles S, Zhang Y, Kennedy R, Rabinowitz AR, Thomas A, Dreer LE. Anxiety Trajectories the First 10 Years Following a Traumatic Brain Injury (TBI): A TBI Model Systems Study. Arch Phys Med Rehabil 2022; 103:2105-2113. [PMID: 35905772 DOI: 10.1016/j.apmr.2022.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 05/27/2022] [Accepted: 07/02/2022] [Indexed: 11/02/2022]
Abstract
OBJECTIVE Determine anxiety trajectories and predictors up to 10 years post-traumatic brain injury (TBI). DESIGN Prospective longitudinal, observational study. SETTING Inpatient rehabilitation centers. PARTICIPANTS 2,836 participants with moderate to severe TBI enrolled in the TBI Model Systems National Database who had ≥2 anxiety data collection points. MAIN OUTCOME MEASURE Generalized Anxiety Disorder-7 (GAD-7) at 1, 2, 5, and 10-year follow-ups. RESULTS Linear mixed models showed higher GAD-7 scores were associated with Black race (p<.001), public insurance (p<.001), pre-injury mental health treatment (p<.001), 2 additional TBIs with loss of consciousness (LOC) (p=.003), violent injury (p=.047), and more years post-TBI (p=.023). An interaction between follow-up year and age was also related to GAD-7 scores (p=.006). A latent class mixed model identified three anxiety trajectories: low-stable (n=2,195), high-increasing (n=289), and high-decreasing (n=352). The high-increasing and high-decreasing groups had ≥mild GAD-7 scores up to 10 years. Compared to the low-stable group, the high-decreasing group was more likely to be Black (OR=2.25), have public insurance (OR=2.13), have had pre-injury mental health treatment (OR=1.77), and have had 2 prior TBIs (OR=3.16). CONCLUSIONS A substantial minority of participants had anxiety symptoms that either increased (10%) or decreased (13%) over 10 years, but never decreased below mild anxiety. Risk factors of anxiety included indicators of socioeconomic disadvantage (public insurance) and racial inequities (Black race) as well as having had pre-injury mental health treatment and two prior TBIs. Awareness of these risk factors may lead to identifying and proactively referring susceptible individuals to mental health services.
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Affiliation(s)
- Dawn Neumann
- Associate Professor, Indiana University School of Medicine, Department of Physical Medicine and Rehabilitation, Indianapolis, IN; Research Director, Rehabilitation Hospital of Indiana, 4141 Shore Drive, Indianapolis, IN 46254.
| | - Shannon B Juengst
- University of Texas Southwestern Medical Center, Department of Physical Medicine & Rehabilitation
| | | | - Jacob A Finn
- Rehabilitation & Extended Care, Minneapolis VA Health Care System, Department of Psychiatry & Behavioral Sciences, University of Minnesota
| | - Shannon Miles
- James A. Haley Veterans' Hospital, Tampa, FL and Division of Psychiatry & Behavioral Sciences, Morsani College of Medicine, University of South Florida, Tampa, FL
| | - Yue Zhang
- University of Alabama at Birmingham, Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care
| | - Richard Kennedy
- University of Alabama at Birmingham, Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care
| | | | - Amber Thomas
- Spaulding Rehabilitation Hospital, Harvard Medical School, Department of Physical Medicine and Rehabilitation, Boston, MA
| | - Laura E Dreer
- University of Alabama at Birmingham, Departments of Ophthalmology & Visual Sciences & Physical Medicine & Rehabilitation
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14
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Fraser EE, Downing MG, Haines K, Bennett L, Olver J, Ponsford JL. Evaluating a Novel Treatment Adapting a Cognitive Behaviour Therapy Approach for Sexuality Problems after Traumatic Brain Injury: A Single Case Design with Nonconcurrent Multiple Baselines. J Clin Med 2022; 11:jcm11123525. [PMID: 35743597 PMCID: PMC9225377 DOI: 10.3390/jcm11123525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 06/08/2022] [Accepted: 06/14/2022] [Indexed: 02/04/2023] Open
Abstract
There has been little progress in development of evidence-based interventions to improve sexuality outcomes for individuals with traumatic brain injury (TBI). This study aimed to evaluate the preliminary efficacy of an individualised intervention using a cognitive behaviour therapy (CBT) framework to treat sexuality problems after TBI. A nonconcurrent multiple baseline single-case design with 8-week follow-up and randomisation to multiple baseline lengths (3, 4, or 6 weeks) was repeated across nine participants (five female) with complicated mild–severe TBI (mean age = 46.44 years (SD = 12.67), mean post-traumatic amnesia = 29.14 days (SD = 29.76), mean time post-injury = 6.56 years (median = 2.50 years, SD = 10.11)). Treatment comprised eight weekly, individual sessions, combining behavioural, cognitive, and educational strategies to address diverse sexuality problems. Clinical psychologists adopted a flexible, patient-centred, and goal-orientated approach whilst following a treatment guide and accommodating TBI-related impairments. Target behaviour was subjective ratings of satisfaction with sexuality, measured three times weekly. Secondary outcomes included measures of sexuality, mood, self-esteem, and participation. Goal attainment scaling (GAS) was used to measure personally meaningful goals. Preliminary support was shown for intervention effectiveness, with most cases demonstrating sustained improvements in subjective sexuality satisfaction and GAS goal attainment. Based on the current findings, larger clinical trials are warranted.
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Affiliation(s)
- Elinor E. Fraser
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, VIC 3800, Australia; (M.G.D.); (K.H.); (L.B.); (J.L.P.)
- Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Richmond, VIC 3121, Australia
- Correspondence:
| | - Marina G. Downing
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, VIC 3800, Australia; (M.G.D.); (K.H.); (L.B.); (J.L.P.)
- Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Richmond, VIC 3121, Australia
| | - Kerrie Haines
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, VIC 3800, Australia; (M.G.D.); (K.H.); (L.B.); (J.L.P.)
| | - Linda Bennett
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, VIC 3800, Australia; (M.G.D.); (K.H.); (L.B.); (J.L.P.)
| | - John Olver
- Rehabilitation Medicine, Epworth HealthCare, Richmond, VIC 3121, Australia;
| | - Jennie L. Ponsford
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, VIC 3800, Australia; (M.G.D.); (K.H.); (L.B.); (J.L.P.)
- Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Richmond, VIC 3121, Australia
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15
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Rauwenhoff JCC, Bol Y, Peeters F, van den Hout AJHC, Geusgens CAV, van Heugten CM. Acceptance and commitment therapy for individuals with depressive and anxiety symptoms following acquired brain injury: A non-concurrent multiple baseline design across four cases. Neuropsychol Rehabil 2022:1-31. [PMID: 35332849 DOI: 10.1080/09602011.2022.2053169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Patients with acquired brain injury (ABI) often experience symptoms of anxiety and depression. Until now, evidence-based treatment is scarce. This study aimed to investigate the effectiveness of Acceptance and Commitment Therapy (ACT) for patients with ABI. To evaluate the effect of ACT for people with ABI, a non-concurrent multiple baseline design across four cases was used. Participants were randomly assigned to a baseline period, followed by treatment and then follow-up phases. Anxiety and depressive symptoms were repeatedly measured. During six measurement moments over a year, participants filled in questionnaires measuring anxiety, depression, stress, participation, quality of life, and ACT-related processes. Randomization tests and NAP scores were used to calculate the level of change across phases. Clinically significant change was defined with the Reliable Change Index. Three out of four participants showed medium to large decreases in anxiety and depressive symptoms (NAP = 0.85 till 0.99). Furthermore, participants showed improvements regarding stress, cognitive fusion, and quality of life. There were no improvements regarding psychological flexibility, value-driven behaviour, or social participation. This study shows that ACT is possibly an effective treatment option for people experiencing ABI-related anxiety and depression symptoms. Replication with single case or large scale group studies is needed to confirm these findings.
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Affiliation(s)
- Johanne C C Rauwenhoff
- School for Mental Health and Neuroscience, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands.,Limburg Brain Injury Centre, Maastricht, Netherlands
| | - Yvonne Bol
- Department of Clinical and Medical Psychology, Zuyderland Medical Centre, Sittard-Geleen/Heerlen, Netherlands
| | - Frenk Peeters
- Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, Netherlands
| | - Anja J H C van den Hout
- Department of Clinical and Medical Psychology, Zuyderland Medical Centre, Sittard-Geleen/Heerlen, Netherlands
| | - Chantal A V Geusgens
- Department of Clinical and Medical Psychology, Zuyderland Medical Centre, Sittard-Geleen/Heerlen, Netherlands
| | - Caroline M van Heugten
- School for Mental Health and Neuroscience, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands.,Limburg Brain Injury Centre, Maastricht, Netherlands.,Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, Netherlands
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16
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Monsour M, Ebedes D, Borlongan CV. A review of the pathology and treatment of TBI and PTSD. Exp Neurol 2022; 351:114009. [PMID: 35150737 DOI: 10.1016/j.expneurol.2022.114009] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 12/25/2021] [Accepted: 02/05/2022] [Indexed: 02/07/2023]
Abstract
This literature review focuses on the underlying pathophysiology of TBI and PTSD symptoms, while also examining the plethora of stem cell treatment options to ameliorate these neuronal and functional changes. As more veterans return suffering from TBI and/or PTSD, it is vital that researchers discover novel therapies to mitigate the detrimental symptoms of both diagnoses. A variety of stem cell treatments have been studied and offer hopeful options for TBI and PTSD recovery.
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Affiliation(s)
- Molly Monsour
- Center of Excellence for Aging and Brain Repair, University of South Florida Morsani College of Medicine, 12901 Bruce B Downs Blvd, Tampa, FL 33612, USA
| | - Dominique Ebedes
- Center of Excellence for Aging and Brain Repair, University of South Florida Morsani College of Medicine, 12901 Bruce B Downs Blvd, Tampa, FL 33612, USA
| | - Cesario V Borlongan
- Center of Excellence for Aging and Brain Repair, University of South Florida Morsani College of Medicine, 12901 Bruce B Downs Blvd, Tampa, FL 33612, USA.
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17
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Support for Returning to Work for a Patient of Social Behavior Disorder with Impaired Self-awareness. JOURNAL OF CONTEMPORARY PSYCHOTHERAPY 2022. [DOI: 10.1007/s10879-021-09529-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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18
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Qubty D, Schreiber S, Rubovitch V, Boag A, Pick CG. No Significant Effects of Cellphone Electromagnetic Radiation on Mice Memory or Anxiety: Some Mixed Effects on Traumatic Brain Injured Mice. Neurotrauma Rep 2021; 2:381-390. [PMID: 34723249 PMCID: PMC8550818 DOI: 10.1089/neur.2021.0009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Current literature details an array of contradictory results regarding the effect of radiofrequency electromagnetic radiation (RF-EMR) on health, both in humans and in animal models. The present study was designed to ascertain the conflicting data published regarding the possible impact of cellular exposure (radiation) on male and female mice as far as spatial memory, anxiety, and general well-being is concerned. To increase the likelihood of identifying possible "subtle" effects, we chose to test it in already cognitively impaired (following mild traumatic brain injury; mTBI) mice. Exposure to cellular radiation by itself had no significant impact on anxiety levels or spatial/visual memory in mice. When examining the dual impact of mTBI and cellular radiation on anxiety, no differences were found in the anxiety-like behavior as seen at the elevated plus maze (EPM). When exposed to both mTBI and cellular radiation, our results show improvement of visual memory impairment in both female and male mice, but worsening of the spatial memory of female mice. These results do not allow for a decisive conclusion regarding the possible hazards of cellular radiation on brain function in mice, and the mTBI did not facilitate identification of subtle effects by augmenting them.
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Affiliation(s)
- Doaa Qubty
- Department of Anatomy and Anthropology, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shaul Schreiber
- Department of Psychiatry, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - Vardit Rubovitch
- Department of Anatomy and Anthropology, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amir Boag
- School of Electrical Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Chaim G Pick
- Department of Anatomy and Anthropology, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Psychiatry, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,The Dr. Miriam and Sheldon G. Adelson Center for the Biology of Addictive Diseases, Tel Aviv University, Tel Aviv, Israel.,Sylvan Adams Sports Institute, Tel Aviv University, Tel Aviv, Israel
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