The impact of head injury neurobehavioural sequelae on personal relationships: Preliminary findings

Emotional, Behavioral, and Cognitive Symptom Associations With Community Participation in Chronic Traumatic Brain Injury

OBJECTIVES

To determine the association between self-reported emotional and cognitive symptoms and participation outcomes in chronic traumatic brain injury (TBI) and to explore the relative contribution of self-reported versus performance-based cognition to participation outcomes.

SETTING

Community.

PARTICIPANTS

Community-dwelling adults ( n = 135) with a lifetime history of mild to severe TBI.

DESIGN

Secondary analysis of a cross-sectional study on neurobehavioral symptoms in chronic TBI.

MAIN MEASURES

Behavioral Assessment Screening Tool (BAST) (Negative Affect, Fatigue, Executive Dysfunction, Impulsivity, Substance Abuse subscales) measured self-reported neurobehavioral symptoms; Participation Assessment with Recombined Tools (Productivity, Social Relations, and Out and About) measured self-reported participation outcomes; and Brief Test of Adult Cognition by Telephone (BTACT) measured performance-based cognition (Episodic Memory and Executive Function summary scores) in a subsample ( n = 40).

RESULTS

The BAST Executive Dysfunction was significantly associated with less frequent participation and had the strongest effect on participation in all participation domains. No other BAST subscales were associated with participation, after adjusting for all subscale scores and age, with the exception of BAST Impulsivity, which was associated with more frequent Social Relationships. Exploratory analysis in the sample including the BTACT revealed that, after accounting for subjective Executive Dysfunction using the BAST, performance-based Executive Function was associated with Productivity and Working Memory was associated with Social Relations, but neither was associated with being Out and About; the BAST Executive Dysfunction remained significant in all models even after including BTACT scores.

CONCLUSIONS

Self-reported Executive Dysfunction contributed to participation outcomes after mild to severe TBI in community-dwelling adults, whereas self-reported emotional and fatigue symptoms did not. Performance-based cognition measures may capture different variability in participation after injury.

(Re)constructing identity following acquired brain injury: The complex journey of recovery after stroke

INTRODUCTION

People with poststroke acquired brain injury (ABI) face a complex and often troubled identity reconstruction journey. The literature is rich with studies related to the psychological and neuropsychological components involved in rehabilitation, but it is lacking with respect to the investigation of the existential dimensions and the challenges associated with finding new senses and meanings for one's identity and future perspectives, body and interpersonal relationships.

METHODS

The aim of this study is to investigate the narrative processes of identity reconstruction after brain damage. Through a qualitative approach, 30 autobiographical narratives about self, body and the relationships with others were collected and analyzed. Semistructured interviews were used for the data collection. Narrative and positioning analysis were applied.

RESULTS

Four main positionings emerged: sanctioning a radical break with one's previous life; assuming a sense of salvation and compulsory as well as irreversible adaptation to the limitations associated with one's condition; feeling different and disabled; and considering new possibilities and active constructions of self-being in relationship with others. These results underline the narrative processes of construction of the injury and the identity and delineate possible resources and instruments to improve the clinical practice for health practitioners. They are also valuable for other professionals who deal with neurological services and rehabilitation, such as psychological counselling and support for persons who have experienced ABI and their families.

PATIENT OR PUBLIC CONTRIBUTION

This work resulted from a close collaboration between two universities and a hospital neurological rehabilitation department in the Veneto Region (Northern Italy). Three associations of people with stroke and their families living in the same area contributed to designing the research on the basis of the needs expressed by their members with the aim to identify strategies and devices to be implemented in the public service to improve the care pathway. They also participated in the interpretation of the data.

Calling on clinicians to get social and emotional

OBJECTIVE

Disorders of social cognition, such as difficulties with emotion perception, alexithymia, Theory of Mind (ToM), empathy and disorders of emotion regulation, are prevalent and pervasive problems across many neurological, neurodevelopmental and neuropsychiatric conditions. Clinicians are familiar with how these difficulties present but assessment and treatment has lagged behind other traditional cognitive domains, such as memory, language and executive functioning.

METHOD

In this paper, we review the prevalence and degree of impairment associated with disorders of social cognition and emotion regulation across a range of clinical conditions, with particular emphasis on their relationship to cognitive deficits and also real-world functioning. We reported effects sizes from published meta-analyses for a range of clinical disorders and also review test usage and available tests.

RESULTS

In general, many clinical conditions are associated with impairments in social cognition and emotion regulation. Effect sizes range from small to very large and are comparable to effect sizes for impairments in nonsocial cognition. Socio-emotional impairments are also associated with social and adaptive functioning. In reviewing prior research, it is apparent that the standardized assessment of social cognition, in particular, is not routine in clinical practice. This is despite the fact that there are a range of tools available and accruing evidence for the efficacy of interventions for social cognitive impairments.

CONCLUSION

We are using this information to urge and call for clinicians to factor social cognition into their clinical assessments and treatment planning, as to provide rigorous, holistic and comprehensive person-centred care.

Cannabinoids in traumatic brain injury and related neuropathologies: preclinical and clinical research on endogenous, plant-derived, and synthetic compounds

Traumatic brain injury is common, and often results in debilitating consequences. Even mild traumatic brain injury leaves approximately 20% of patients with symptoms that persist for months. Despite great clinical need there are currently no approved pharmaceutical interventions that improve outcomes after traumatic brain injury. Increased understanding of the endocannabinoid system in health and disease has accompanied growing evidence for therapeutic benefits of Cannabis sativa. This has driven research of Cannabis' active chemical constituents (phytocannabinoids), alongside endogenous and synthetic counterparts, collectively known as cannabinoids. Also of therapeutic interest are other Cannabis constituents, such as terpenes. Cannabinoids interact with neurons, microglia, and astrocytes, and exert anti-inflammatory and neuroprotective effects which are highly desirable for the management of traumatic brain injury. In this review, we comprehensively appraised the relevant scientific literature, where major and minor phytocannabinoids, terpenes, synthetic cannabinoids, and endogenous cannabinoids were assessed in TBI, or other neurological conditions with pathology and symptomology relevant to TBI, as well as recent studies in preclinical TBI models and clinical TBI populations.

Predictors of Functional School Outcome in Children With Pediatric Acquired Brain Injury

Objective

Among the variety of domains that may be impacted after pediatric acquired brain injury (pABI) are functional school outcomes. The purpose of this study was to identify demographic, medical, and psychological factors associated with impairments in functional school outcomes, defined as school absence, need of educational and psychological services, quality of life (QoL) in the school setting, and academic performance in children with pABI, with a specific emphasis on the significance of fatigue.

Materials and Method

We used baseline data from a randomized controlled trial. The sample consisted of seventy-six children aged 10 to 17 (M = 13 yrs) with pABI in the chronic phase (>1 year). All completed assessments of school-related QoL, academic performance, global functioning, fatigue, IQ, behavioral problems, and executive function.

Results

Fatigue, IQ, global functioning, behavioral problems, and sex emerged as potential predictors for functional school outcomes. Of note, overall fatigue emerged as the strongest potential predictor for parent-reported QoL in school (β = 0.548; p < 0.001) and self-reported QoL in school (β = 0.532; p < 0.001).

Conclusions

Following pABI, specific psychological, medical, and demographic factors are associated with functional school outcomes. Neither of the injury-related variables age at insult and time since insult were associated with functional school outcomes. Overall, our findings may suggest that a reintroduction to school with personalized accommodations tailored to the child's specific function and symptoms, such as fatigue, is recommended.

Factors related to the quality and stability of partner relationships after traumatic brain injury: A systematic literature review

OBJECTIVE

The latest literature review on partner relationships following traumatic brain injury (TBI), conducted a decade ago, discussed solely quantitative work and noted significant knowledge gaps. The current review updates and expands on this work by providing an overview of the current state of knowledge on factors related to relationship quality and stability following TBI.

DATA SOURCES

CINAHL, Embase, MEDLINE, Psychology and Behavioral Sciences Collection, APA PsycINFO, and PubMed were searched on April 23, 2020, for literature on factors associated with 1)relationship quality and 2)relationship stability following TBI.

STUDY SELECTION

English quantitative and qualitative studies investigating factors associated with relationship quality and/or stability following TBI were included. Two reviewers independently assessed eligibility. If consensus was not reached, a third reviewer's conclusion was decisive. Forty-three studies were included.

DATA EXTRACTION

Information regarding study objectives and characteristics, participant demographics, (in)dependent variables, and main findings was extracted. Study quality was rated using the JBI Checklist for Analytical Cross Sectional Studies and/or the CASP Checklist for Qualitative Research. Both were performed by the lead reviewer and checked by the second reviewer.

DATA SYNTHESIS

Thirty-eight factors related to relationship quality and/or stability were identified, covering injury characteristics (e.g., severity), body functions (e.g., personality changes), activities (e.g., communication), participation (e.g., social dependence), environment (e.g., children), and personal factors (e.g., coping strategies).

CONCLUSIONS

Relationship quality and stability following TBI are found to be related to a multitude of factors, including newly identified factors such as personality changes and dependence. Future research may wish to quantitatively investigate factors thus far only identified in qualitative research, explore possible positive effects of TBI on relationships, study the experiences of same-sex couples, and include the perspectives of both partners with and without the injury.

Marital Stability Over 10 Years Following Traumatic Brain Injury

OBJECTIVE

To examine the stability of marriage from the time of traumatic brain injury (TBI) to 10 years postinjury.

DESIGN

Retrospective cohort.

SETTING

TBI Model Systems centers.

PARTICIPANTS

In total, 1423 participants in the TBI Model Systems National Database who experienced TBI 10 years prior and were married at the time of injury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Remaining married to the same partner from the time of injury to 10-year follow-up.

RESULTS

At 10 years, 66% (938) remained married to the same person. Significant associations were found with age at injury (P < .0001), sex (P = .0028), and preinjury problematic substance use (P = .0092). Marital stability over the 10-year period was higher for those who were older, were female, and had no problematic substance use history. Marital instability was greatest in the first year postinjury.

CONCLUSIONS

Most married adults who received inpatient rehabilitation for TBI remained married to the same individual 10 years later. Those who were younger, were male, and had a history of problematic substance use were at a highest risk for relationship dissolution. Findings have implications for content, timing, and delivery of marital interventions. Substance use education and prevention appear to be important aspects of marital support.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Are spousal partner perceptions of continuity and discontinuity within the relationship linked to the symptoms of acquired brain injury?

PURPOSE

Some partners experience their relationship with a person with brain injury as the continuation of a loving pre-injury relationship (continuity), but others feel that the pre-injury relationship has been lost and replaced with something very different (discontinuity). This study provided a quantitative test of claims arising from qualitative research that certain symptoms of the injury might contribute to the experience of discontinuity - specifically, lack of emotional warmth, reduced social interaction and aggression.

METHODS

Fifty-three partners providing care to someone with brain injury completed questionnaires assessing continuity/discontinuity and a range of symptoms (emotional warmth, conversational ability, aggression, depression, somatic complaints, cognition, communication, aggression, and physical disability).

RESULTS

Discontinuity was significantly correlated with all symptom variables except physical disability but, in a multiple regression, only the measures of emotional warmth, conversation, aggression, and depression made a significant unique contribution.

CONCLUSIONS

Discontinuity has been linked with relationship dissatisfaction and dysfunction, greater burden and distress, and a less person-centred approach to the provision of care. Identifying which symptoms contribute to discontinuity may enable partners to be more effectively supported in terms of how they make sense of and react to those symptoms, so that a greater sense of continuity may be retained.Implications for rehabilitationIn a marriage/partnership after brain injury, some people struggle to maintain the loving relationship they shared with the person with the brain injury before the injury. This has an impact on the psychological wellbeing of the couple and on the quality of care provided.Certain symptoms of the brain injury may make it more difficult to maintain the loving pre-injury relationship.These include aggression, depression, a lack of emotional warmth within the relationship, and more general difficulties in making conversation.Caregivers dealing with these symptoms may need extra support in making sense of, and coming to terms with, these changes.

The effect of severe traumatic brain injury on social cognition, emotion regulation, and mood

This chapter provides a review of the emotional and psychosocial consequences of moderate to severe traumatic brain injury (TBI). Many of the disorders affecting socioemotional function arise from damage to frontotemporal systems, exacerbated by white matter injury. They include disorders of social cognition, such as the ability to recognize emotions in others, the ability to attribute mental states to others, and the ability to experience empathy. Patients with TBI also often have disorders of emotion regulation. Disorders of drive or apathy can manifest across cognitive, emotional, and behavioral domains. Likewise, disorders of control can lead to dysregulated emotions and behavior. Other disorders, such as loss of self-awareness, are also implicated in poor psychosocial recovery. Finally, this chapter overviews psychiatric disorders associated with TBI, especially anxiety and depression. For each kind of disorder, the nature of the disorder and its prevalence, as well as theoretical considerations and impact on every day functions, are reviewed.

Accepting what we do not know: A need to improve professional understanding of brain Injury in the UK

Acquired brain injury (ABI) can lead to life-long changes and disability. The complex and extensive nature of behavioural, cognitive, executive, physical and psychological difficulties mean ABI survivors and their families may come into contact with a range of health and social care services as part of their long-term care. This study aimed to understand the ABI knowledge base of professionals across a range of organisations within the UK, and to identify areas for improvement. This was achieved through a mixed methods approach using a mixed methods questionnaire (117 participants) and qualitative semi-structured interviews about service experiences (31 participants) of professionals and service users (families and individuals with ABI). Participants included UK health and social care professionals, ABI specialists, ABI survivors and family members. Data were collected from February 2017 to April 2018. The results of the study identified a lack of knowledge and understanding of ABI among health and social care professionals in the UK, from those involved in acute care through to long-term community services. Poor knowledge was associated with a lack of understanding of "hidden" disabilities associated with ABI, a lack of empathy and a lack of knowledge regarding specific safeguarding. Health and social care professionals across a range of services could benefit in ABI-specific training to improve their knowledge and improve the service currently being provided to individuals with ABI and their families.

Emotional Regulation Following Acquired Brain Injury: Associations With Executive Functioning in Daily Life and Symptoms of Anxiety and Depression

Objective: To examine whether a questionnaire measuring emotional regulation after acquired brain injury adds clinical information beyond what can be obtained with a comprehensive executive function questionnaire and an anxiety and depression measure.

Method: Seventy adult persons (age 19–66 years, M_age = 43, SD_age = 13) with acquired brain injury in the chronic phase and executive function complaints. All were recruited to participate in a randomized controlled trial (NCT02692352) evaluating the effects of cognitive rehabilitation. Traumatic brain injury was the dominant cause of injury (64%), and mean time since injury was 8 years. Emotional regulation was assessed with the Brain Injury Trust Regulation of Emotions Questionnaire (BREQ). Executive function was assessed with the Behavior Rating Inventory of Executive Function Adult Version (BRIEF-A). The Hopkins Symptom Checklist 25 (HCSL-25) was employed to measure anxiety and depression symptoms.

Results: Overall, significant correlations were found between reports of emotional regulation (BREQ) and executive function in daily life (BRIEF-A). Furthermore, our analyses revealed a significant relationship between self-reported scores of emotional regulation (BREQ) and symptoms of anxiety and depression (HSCL-25).

Conclusion: The significant associations between the BREQ and most of the other clinical measures indicate that, for patients with acquired brain injury, the BREQ does not add substantial information beyond what can be assessed with the BRIEF-A and the HSCL-25.

Training emotional recognition in a child with acquired brain injury: A single case study

Emotional processing is affected by childhood brain injury. Ineffective emotional processing and poor understanding of social cues affect the development of social relationships leading to social isolation and a poorer quality of life in the long-term. Facial expression recognition is a non-verbal social cue that is used to interpret the thoughts and feelings of others. Children with brain injury have shown deficits identifying even basic emotions from facial expression, yet few intervention studies have explored how to develop facial expression recognition in children with brain injury. Enhancing the ability to recognize and interpret facial expressions for these children would have implications for their emotional processing and social-emotional behavior. In this paper we report on a short single case study intervention to increase facial expression recognition using the Facial Affect Recognition training (FAR) for a 10-year-old-child with brain injury. Following intervention, there was not only an increase in facial expression recognition but also changes in social-emotional behavior indicating some generalization to other contexts. The results suggest that rehabilitation of emotional processing difficulties may indeed be possible, and further intervention studies aimed at developing these skills in children with brain injury are warranted.

The inter-relationship between acquired brain injury, substance use and homelessness; the impact of adverse childhood experiences: an interpretative phenomenological analysis study

PURPOSE

Acquired Brain Injuries, caused by a range of illnesses and injuries, can lead to long-term difficulties for individuals; mental health problems, cognitive and executive impairment and psychosocial problems including relationship breakdown, substance abuse and potentially homelessness. The study aimed to seek and gain a more definitive understanding of the inter-relationship of Acquired Brain Injury, substance abuse and homelessness by identifying key themes associated with the inter-relationship between these variables.

MATERIALS AND METHODS

The study recruited eight participants through homeless organisations and treatment centres. Participants were screened for suitability (Brain Injury Screening Index; Drug Abuse Screening Tool; Alcohol Use Disorders Identification Test and then participated in recorded semi-structured interviews, transcribed and analysed using Interpretative Phenomenological Analysis.

RESULTS

The study identified five master themes: Adverse Childhood Experiences and Trauma; Mental Health; Cognitive Decline and Executive Function; Services; Relationships.

CONCLUSION

Healthcare professionals need to engage with children, their families, and adults, who have been exposed to adverse childhood experiences and should employ routine screening tools for brain injury to ensure their presence is factored into developing appropriate models of intervention.IMPLICATIONS FOR REHABILITATIONNeed person-centred approaches to intervention for those with acquired brain injury who are homeless and have substance abuse issues.Need to screen for the presence of acquired brain injury when engaging with individuals who are homeless or have substance abuse.Need screening of acquired brain injury and adverse childhood experiences to improve access to services post-brain injury.

Evaluation of a Brief, Skill-Building, Supportive, and Educational Intervention for Couples After Brain Injury

OBJECTIVE

To examine the effectiveness of an intervention (Therapeutic Couples Intervention, TCI) designed to improve relationship quality for couples after acquired brain injury.

SETTING

Outpatient brain injury rehabilitation center.

PARTICIPANTS

Persons with brain injury (n = 75) and their intimate partners (n = 75).

DESIGN

Two-arm parallel, randomized, controlled trial with wait-listed control.

METHODS

Composed of 5 to 6 2-hour sessions, the TCI is a manualized, treatment program designed to enhance relationship quality by addressing issues and concerns most often identified by persons with brain injury and their partners.

MAIN MEASURE

Revised Dyadic Adjustment Scale completed by the persons with brain injury and their partners.

RESULTS

Persons with brain injury and their partners in the treatment group showed an improvement in relationship quality, both compared with their own baseline values and the control group.

CONCLUSIONS

Investigation provided evidence that a curriculum-based education, skill-building, and supportive intervention can benefit couples for up to 3 months after treatment. Additional research is needed to ascertain the long-term benefits of intervention and the efficacy of alternative delivery methods (eg, Internet, telephone, and group).

Relationship continuity and person-centred care: An exploratory mixed-methods investigation of spousal partners' responses to the challenging care needs of those with acquired brain injury

Some partners of people with an acquired brain injury experience the person with the injury and their relationship as continuous with the pre-injury person and relationship, but others experience the person and relationship as very different to what went before. Previous qualitative research has suggested that the experience of continuity may promote a more person-centred approach to how partners respond to challenging care needs. Given the value of triangulating evidence, this exploratory study used a mixed-methods design to investigate this suggestion. Twenty-six partners of people with an acquired brain injury completed the Birmingham Relationship Continuity Measure and a semi-structured interview about their response to challenging care needs. Interviews were coded and scored to provide a measure of the extent to which the participants' understanding, management and emotional responses showed a person-centred approach. The findings supported the hypothesis. Greater continuity was significantly correlated with a more person-centred approach. Associating relationship continuity and person-centred care is a novel approach to the issue of how family relationships may impact on care quality. Person-centred care can have important benefits for both the giver and receiver of care. Whether it can be promoted through fostering a sense of continuity in the relationship merits further investigation.

Relationship between late objective and subjective outcomes of holistic neurorehabilitation in patients with traumatic brain injury

OBJECTIVE

To explore the relation between objectively measured outcomes of neurorehabilitation and subjective self-appraisal of those outcomes in patients with traumatic brain injury (TBI).

METHODS

Forty-five adults (34 men; age at injury, mean ± SD, 30.1 ± 10.3 years) with chronic moderate-to-severe TBI (9.7 ± 5.5 years from injury; post-traumatic amnesia, 80% over one week) from two rehabilitation centres, in two countries. The subjects have had to resume working at various levels of competence following post-acute comprehensive neuropsychologically oriented neurorehabilitation, and experienced no functionally incapacitating, medical or psychological problems, for a minimum of six months after discharge. Objective outcome measure was the level of work competence attained post-rehabilitation transposed from the descriptions of the types of work attained by each subject into a number along a 10-point scale. Subjective outcome measure was the personal evaluations by ratings in six consequences of rehabilitation (effort during rehabilitation, meaning in life, productivity, acceptance, social life and intimate relationships) along a 10-point scale.

RESULTS

The attained work competence was statistically significantly related to the subjective self-appraisal of the ability to establish intimate relationships [odds ratio (OR), 1.79; 95% confidence interval (CI), 1.20-2.68; P = .005]. Otherwise, no association between subjective ratings and the levels of work was found. Of the patients, 67% attained competitive, 22% subsidized, and 11% volunteer or sheltered work. The subjective self-rated outcomes of the patients were relatively good [median, lower quartile (Q1) - upper quartile (Q3): 8 to 9, 7 to 8 - 8 to 9 out of 10]. The lowest ratings were observed for the ability to establish intimate relationships (8, 7-8 out of 10).

CONCLUSIONS

The results support the need to evaluate rehabilitation outcomes involving both objective measures and subjective appraisals of them. The findings suggest that community functioning and satisfaction with that are distinct aspects of the subjects´ experience that must be considered in the evaluation of rehabilitation. It seems that comprehensive neurorehabilitation improve outcome, and patients with TBI with tailored placements were largely satisfied with the areas of wellness in their life. Additional larger controlled studies are needed to clarify how composition of neurorehabilitation and individualization in outcomes assessment might enhance the outcome of TBI rehabilitation.

Neuropsychological correlates of self-reported impulsivity and informant-reported maladaptive behaviour among veterans with posttraumatic stress disorder and traumatic brain injury history

OBJECTIVE

Frontal lobe deficits resulting from traumatic brain injury (TBI) and/or posttraumatic stress disorder (PTSD) have been linked to impulsive behaviour. We sought to examine whether neuropsychological performance predicted self-reported impulsivity and informant-reported maladaptive behaviour.

METHOD

We administered the Delis-Kaplan Executive Function System (D-KEFS) to 116 Iraq/Afghanistan-era veterans diagnosed with a history of TBI and PTSD.

RESULTS

Poorer performance on D-KEFS Stroop Task (both colour and word, separately) and Trail making (letter sequencing and motor speed) tasks and higher PTSD symptom severity were associated with higher self-reported impulsivity. Trail making letter sequencing performance was negatively associated with informant-reported maladaptive behaviour. Regression analyses revealed PTSD symptom severity and Trail making letter sequencing best predicted self-reported impulsivity, even when accounting for age, sex, and education. Only Trail making letter sequencing predicted informant-reported maladaptive behaviour when accounting for other variables in the model.

CONCLUSIONS

Attention and processing speed impairments and PTSD symptom severity appear to be important predictors of impulsivity and problematic behaviour among veterans. Findings have implications for theoretical models of aggression and violence and inform the assessment and treatment of individuals with TBI and PTSD.

Reductions in Alexithymia and Emotion Dysregulation After Training Emotional Self-Awareness Following Traumatic Brain Injury: A Phase I Trial

OBJECTIVES

To examine the acceptability and initial efficacy of an emotional self-awareness treatment at reducing alexithymia and emotion dysregulation in participants with traumatic brain injury (TBI).

SETTING

An outpatient rehabilitation hospital.

PARTICIPANTS

Seventeen adults with moderate to severe TBI and alexithymia. Time postinjury ranged 1 to 33 years.

DESIGN

Within subject design, with 3 assessment times: baseline, posttest, and 2-month follow-up.

INTERVENTION

Eight lessons incorporated psychoeducational information and skill-building exercises teaching emotional vocabulary, labeling, and differentiating self-emotions; interoceptive awareness; and distinguishing emotions from thoughts, actions, and sensations.

MEASURES

Toronto Alexithymia Scale-20 (TAS-20); Levels of Emotional Awareness Scale (LEAS); Trait Anxiety Inventory (TAI); Patient Health Questionnaire-9 (PHQ-9); State-Trait Anger Expression Inventory (STAXI); Difficulty With Emotion Regulation Scale (DERS); and Positive and Negative Affect Scale (PANAS).

RESULTS

Thirteen participants completed the treatment. Repeated-measures analysis of variance revealed changes on the TAS-20 (P = .003), LEAS (P < .001), TAI (P = .014), STAXI (P = .015), DERS (P = .020), and positive affect (P < .005). Paired t tests indicated significant baseline to posttest improvements on these measures. Gains were maintained at follow-up for the TAS, LEAS, and positive affect. Treatment satisfaction was high.

CONCLUSION

This is the first study published on treating alexithymia post-TBI. Positive changes were identified for emotional self-awareness and emotion regulation; some changes were maintained several months posttreatment. Findings justify advancing to the next investigational phase for this novel intervention.

Relationship Stability After Traumatic Brain Injury Among Veterans and Service Members: A VA TBI Model Systems Study

OBJECTIVE

To explore stability of relationships and predictors of change in relationship status 2 years following TBI/polytrauma.

SETTING

Five Department of Veterans Affairs Polytrauma Rehabilitation Centers (VA PRCs).

PARTICIPANTS

A total of 357 active duty service members and Veterans enrolled in the Veterans Affairs Polytrauma Rehabilitation Centers Traumatic Brain Injury Model Systems database with complete marital status information at 2 years postinjury.

DESIGN

Prospective, longitudinal, multisite.

MAIN MEASURES

Relationship status change was defined as change in marital status (single/never married; married; divorced/separated) at 2-year follow-up, compared with status at enrollment.

RESULTS

At the time of enrollment, 134 participants (38%) were single/never married; 151 (42%) were married, and 72 (20%) were divorced/separated. Of those married at enrollment, 78% remained married at year 2 while 22% underwent negative change. Multivariable analyses revealed that age and education at the time of injury and mental health utilization prior to injury were significant predictors of relationship change. Among those who were single/divorced/separated at the time of enrollment, 87% remained so at year 2 while 13% underwent positive change. Injury during deployment significantly predicted positive relationship change.

CONCLUSIONS

The unmalleable, preinjury characteristics identified may be used as potential triggers for education, prevention, surveillance, and couples therapy, if needed.

Neurobehavioral Abnormalities Associated with Executive Dysfunction after Traumatic Brain Injury

Objective: This article will address how anomalies of executive function after traumatic brain injury (TBI) can translate into altered social behavior that has an impact on a person’s capacity to live safely and independently in the community.

Method: Review of literature on executive and neurobehavioral function linked to cognitive ageing in neurologically healthy populations and late neurocognitive effects of serious TBI. Information was collated from internet searches involving MEDLINE, PubMed, PyscINFO and Google Scholar as well as the authors’ own catalogs.

Conclusions: The conventional distinction between cognitive and emotional-behavioral sequelae of TBI is shown to be superficial in the light of increasing evidence that executive skills are critical for integrating and appraising environmental events in terms of cognitive, emotional and social significance. This is undertaken through multiple fronto-subcortical pathways within which it is possible to identify a predominantly dorsolateral network that subserves executive control of attention and cognition (so-called cold executive processes) and orbito-frontal/ventro-medial pathways that underpin the hot executive skills that drive much of behavior in daily life. TBI frequently involves disruption to both sets of executive functions but research is increasingly demonstrating the role of hot executive deficits underpinning a wide range of neurobehavioral disorders that compromise relationships, functional independence and mental capacity in daily life.

Is there a relationship between postural alignment and mobility for adults after acquired brain injury? A systematic review

PRIMARY OBJECTIVE

To examine the relationship between postural alignment and mobility skills for adults after acquired brain injury (ABI).

METHODS

Systematic review of the literature. Seven electronic databases, grey literature and reference lists of the shortlisted publications were searched. Studies were included if participants were adults with ABI, both postural alignment and mobility were measured and analysis included a relationship between alignment and mobility. Those that met the inclusion criteria were assessed with a critical appraisal tool. The review was registered with PROSPERO, registration number CRD42015019867.

RESULTS

Seven observational studies were included that had examined a relationship between postural alignment and mobility after ABI. Critical appraisal scores were moderate to strong. While some studies reported that improved postural alignment was related to improved mobility after ABI, results varied and there was insufficient evidence to answer the primary question. Heterogeneous study designs did not allow meta-regression.

CONCLUSIONS

A small amount of observational evidence exists for a relationship between postural alignment and mobility after ABI. Results vary, with some studies reporting that a more stable, upright trunk correlates with better mobility, and others providing conflicting or ambiguous results. Further research is needed to establish the relationship between postural alignment and mobility skills after ABI.

How Partners Experience Personality Change After Traumatic Brain Injury – Its Impact on Their Emotions and their Relationship

Objective: The aim of this qualitative study was to explore how spouses/partners experience social, emotional and behavioural changes in persons following traumatic brain injury (TBI), with a particular focus on their emotional impact and the effect on the couple relationship.

Method: Interpretative phenomenological analysis (IPA) of interview data explored five women's experiences of these changes in their partners following TBI.

Results: Themes describe the direct emotional impact of living with the changes as well as the emotional impact of attempts to manage and make sense of the changes (identity change, managing the changes and making sense of the changes). The impact on the couple relationship is described under the themes of feeling love and receiving love. Changes led three of the participants to experience their partner as having been replaced by a new person; they actively disliked this new person; they felt unable to love the new person in the same way as the old person; and their love was defined in terms of a caring relationship, rather than a spousal relationship.

Conclusions: The study provides insight into why social, emotional and behavioural changes might be so consistently associated with reduced emotional wellbeing and lower levels of relationship quality and satisfaction.

The impact of alexithymia on burnout amongst relatives of people who suffer from traumatic brain injury

BACKGROUND

Although previous research has provided some indication of the association of alexithymia and burnout, this is the first study exploring the association of these two variables in a sample of relatives of individuals who have sustained traumatic brain injury (TBI).

OBJECTIVE

To explore the degree to which relatives experience burnout and the extent to which alexithymia acts as a pre-disposing factor, controlling for depression and coping strategies.

METHOD

Toronto Alexithymia Scale-20, Maslach Burnout Inventory-Human Services, Estonian COPE Dispositional Inventory and Beck Depression Inventory-II were completed by 60 relatives of patients with TBI drawn from a tertiary head injury clinic population.

RESULTS

Levels of emotional exhaustion, reduced personal accomplishment and depression were significantly higher in the sub-group of relatives with alexithymia than in the sub-group of relatives without alexithymia. Difficulty describing feelings and externally oriented thinking style were significant predictors of emotional exhaustion, while difficulty identifying feelings and difficulty describing feelings were important predictors of depersonalization.

CONCLUSIONS

Relatives who present with alexithymia need to be identified at an early stage to minimize risks of burnout leading to adverse effects on patient-caregiver relationships.

Grief, Anger, and Relationality: The Impact of a Research-Based Theater Intervention on Emotion Work Practices in Brain Injury Rehabilitation

BACKGROUND

Therapeutic emotion work is performed by health care providers as they manage their own feelings as well as those of colleagues and patients as part of efforts to improve the physical and psychosocial health outcomes of patients. It has yet to be examined within the context of traumatic brain injury rehabilitation.

OBJECTIVE

To evaluate the impact of a research-based theater intervention on emotion work practices of neurorehabilitation staff.

RESEARCH DESIGN

Data were collected at baseline and at 3 and 12 months postintervention in the inpatient neurorehabilitation units of two rehabilitation hospitals in central urban Canada.

SUBJECTS

Participants (N = 33) were recruited from nursing, psychology, allied health, recreational therapy, and chaplaincy.

MEASURES

Naturalistic observations (N = 204.5 hr) of a range of structured and unstructured activities in public and private areas, and semistructured interviews (N = 87) were conducted.

RESULTS

Preintervention analysis indicated emotion work practices were characterized by stringent self-management of empathy, suppression of client grief, adeptness with client anger, and discomfort with reactions of family and spouses. Postintervention analysis indicated significant staff changes in a relationality orientation, specifically improvements in outreach to homosexual and heterosexual family care partners, and support for sexual orientation and intimacy expression. No improvements were demonstrated in grief support.

CONCLUSION

Emotion work has yet to be the focus of initiatives to improve neurorehabilitative care. Our findings suggest the dramatic arts are well positioned to improve therapeutic emotion work and effect cultures of best practice. Recommendations are made for interprofessional educational initiatives to improve responses to client grief and potential intimate partner violence.

Changes in sexual functioning from 6 to 12 months following traumatic brain injury: a prospective TBI model system multicenter study

OBJECTIVE

To investigate longitudinal changes in sexual functioning during the first year following moderate to severe traumatic brain injury (TBI).

DESIGN

Prospective cohort study.

SETTING

Community.

PARTICIPANTS

182 persons (53 women and 129 men) with moderate to severe TBI who were admitted to 1 of 6 participating TBI Model System centers and followed in the community at 6 and 12 months after injury.

MAIN MEASURES

Derogatis Interview for Sexual Functioning-Self-Report (DISF-SR); Global Sexual Satisfaction Index (GSSI).

RESULTS

Mean T-scores on the DISF-SR Arousal subscale demonstrated marginal improvement over time, with a 2.59-point increase (P = .05) from 6 to 12 months after injury. There were no significant differences over this 6-month period on the remaining DISF-SR subscales, including sexual cognition/fantasy, sexual behavior/experience, and orgasm. There was no significant change in satisfaction with sexual functioning on the GSSI from 6 months (72% satisfied) to 12 months (71% satisfied).

CONCLUSIONS AND IMPLICATIONS

Sexual function and satisfaction appears to be stable in those with moderate to severe TBI from 6 to 12 months after injury, with the exception of minimal improvement in arousal. These findings, to our knowledge, reflect the first evidence regarding prospective changes in sexual functioning in this population. Future research can go far to assist clinicians in treatment planning and managing patient expectations of recovery of sexual functioning after TBI.

Epilepsy and brain injury: a case report of a dramatic neuropsychiatric vicious circle

PRIMARY OBJECTIVE

Early treatment of epilepsy is warranted to avoid possible severe consequences. This study aimed to assess the value of treatment in a patient who developed epilepsy after major brain surgery.

DESIGN

Case description. A 51 years-old man had a history of putative petit mal seizures since adolescence and left frontotemporal lobectomy after a major traffic accident at age 17. He subsequently developed quickly generalizing partial complex seizures, associated with severe behavioural alterations and personality changes; the condition was left untreated. A further seizure-related loss of consciousness led to another traffic accident at age 47.

METHODS AND PROCEDURES

The patient was administered 200 mg/day topiramate, 600 mg/day quetiapine, 1000 mg/day valproate, 1200 mg/day gabapentin and 800 mg/day carbamazepine.

MAIN OUTCOMES AND RESULTS

The instituted anti-epileptic treatment reduced seizure frequency and severity, but did not affect psychiatric symptomatology, which even worsened. An association between anti-epileptic drugs with mood stabilizing properties and an atypical anti-psychotic dramatically improved psychiatric symptoms, but did not prevent the patient from needing long-term healthcare.

CONCLUSIONS

Long-term untreated epilepsy may expose to accident proneness and further psychiatric deterioration. Early diagnosis and treatment of epilepsy may help in avoiding a potentially lethal vicious circle.

Rehabilitation of executive function and social cognition impairments after brain injury

PURPOSE OF REVIEW

Brain injury is a major cause of long-term disability. Executive and social cognition sequelae are associated with poor outcome. This review examines recent evidence on the efficacy of rehabilitation in these areas.

RECENT FINDINGS

Accumulating evidence shows that interventions that work with patients on developing insight and strategies to offset executive impairments can produce significant benefits. Training of specific capacities, such as working memory, holds some promise, but more needs to be known about effect generalization. Evidence on social cognition rehabilitation following brain injury is sparse. Although there are some encouraging early results, more information on the clinical significance of change for everyday function is required.

SUMMARY

Rehabilitation in these areas is inherently difficult but vital if outcomes are to improve. Significant gains have been reported, and further work applying appropriate methods is urgently required.

Emotional regulation impairments following severe traumatic brain injury: an investigation of the body and facial feedback effects

The object of this study was to evaluate the combined effect of body and facial feedback in adults who had suffered from a severe traumatic brain injury (TBI) to gain some understanding of their difficulties in the regulation of negative emotions. Twenty-four participants with TBI and 28 control participants adopted facial expressions and body postures according to specific instructions and maintained these positions for 10 s. Expressions and postures entailed anger, sadness, and happiness as well as a neutral (baseline) condition. After each expression/posture manipulation, participants evaluated their subjective emotional state (including cheerfulness, sadness, and irritation). TBI participants were globally less responsive to the effects of body and facial feedback than control participants, F(1,50) = 5.89, p = .02, η(2) = .11. More interestingly, the TBI group differed from the Control group across emotions, F(8,400) = 2.51, p = .01, η(2) = .05. Specifically, participants with TBI were responsive to happy but not to negative expression/posture manipulations whereas control participants were responsive to happy, angry, and sad expression/posture manipulations. In conclusion, TBI appears to impair the ability to recognize both the physical configuration of a negative emotion and its associated subjective feeling.

Sexual functioning 1 year after traumatic brain injury: findings from a prospective traumatic brain injury model systems collaborative study

OBJECTIVE

To investigate the incidence and types of sexual difficulties in men and women with traumatic brain injury (TBI) 1 year after injury, as well as their comfort level in discussing problems with health care professionals.

DESIGN

Prospective cohort study.

SETTING

Community.

PARTICIPANTS

Persons with TBI (N=223; 165 men and 58 women) who had been treated at 1 of 6 participating TBI Model Systems inpatient rehabilitation units and were living in the community.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Derogatis Interview for Sexual Functioning-self-report (DISF-SR); Global Sexual Satisfaction Index (GSSI); structured interview regarding changes in sexual functioning; and comfort level discussing sexuality with health care professionals.

RESULTS

Women with TBI scored significantly below the normative sample for all subscales of the DISF-SR, including sexual cognition/fantasy, arousal, sexual behavior/experience, and orgasm. Men scored significantly below the normative sample on all scales except arousal. Women reported greater dysfunction than men for sexual cognition/fantasy and arousal. Twenty-nine percent of participants reported dissatisfaction with sexual functioning on the GSSI, with a greater percentage of men reporting dissatisfaction. Sixty-eight percent of participants indicated that they would spontaneously raise issues of sexual difficulties with health care professionals, while the remainder would either bring it up only if directly asked or would not discuss it at all.

CONCLUSIONS

Sexual difficulties were present in a substantial portion of community-dwelling people with TBI at 1 year after injury. Educational interventions to increase awareness among people with TBI and rehabilitation professionals are warranted, as well as interventions to improve sexual functioning.

The role of psychological symptoms and social group memberships in the development of post-traumatic stress after traumatic injury

OBJECTIVES

The costs associated with traumatic injury are often exacerbated by the development of post-traumatic stress symptoms. However, it is unclear what decreases the development of post-traumatic symptoms over time. The aim of the present research was to examine the role of psychological symptoms and social group memberships in reducing the development of post-traumatic stress symptoms after orthopaedic injuries (OIs) and acquired brain injuries (ABIs).

DESIGN AND METHODS

A longitudinal prospective study assessed self-reported general health symptoms, social group memberships, and post-traumatic stress symptoms among participants with mild or moderate ABI (n= 62) or upper limb OI (n= 31) at 2 weeks (T1) and 3 months (T2) after injury.

RESULTS

Hierarchical regressions revealed that having fewer T1 general health symptoms predicted lower levels of T2 post-traumatic stress symptoms after OI but forming more new group memberships at T1 predicted lower levels of T2 post-traumatic stress symptoms after ABI.

CONCLUSION

A focus on acquiring group memberships may be particularly important in reducing the development of post-traumatic stress symptoms after injuries, such as ABI, which result in long-term life changes.

The development of a measure of emotional regulation following acquired brain injury

Disturbances in emotional regulation following acquired brain injury have been found to be both prevalent and particularly disabling. Despite this, relatively little attention has been given to identifying characteristics of such deficits in a systematic way. We therefore describe the development of a new questionnaire measure of disturbances in emotional regulation that may occur following acquired brain injury. The measure demonstrates excellent psychometric properties, including high test-retest (.95) and split half (.96) reliability, high internal consistency (.96), and good concurrent validity (r = .64-.82). The questionnaire measures characteristics that are distinguishable from measures of cognitive ability and from other tests of affect. There was moderate overlap between self-report and relative versions of the questionnaire. Results suggest that the relative version has the stronger predictive value. The potential uses of the measure in relation to theory and practice are discussed.

Emergence of complex partial epilepsy-like experiences following closed head injuries: personality variables and neuropsychological profiles

To pursue Richard Roberts' epileptic spectrum disorder (ESD) and the emergence of complex partial epilepsy-like experiences, items and total scores for the ESD Inventory were examined for 185 patients who had sustained mechanical impacts (and were diagnosed with or without neuropsychological impairment) and a reference group (n=68) of university students. Results from neuropsychological, personality, neurological screening, and interview data supported the role of temporal lobe origins for these experiences. The incidences of these experiences were sufficient to adversely affect adaptation and to produce psychiatric profiles. Although only 70% of the patients who were impaired versus not impaired could be differentiated by items from the ESD Inventory, >95% of the patients with scores >100 on the ESD Inventory displayed abnormal scores on more than four Minnesota Multiphasic Personality Inventory scales. These results support Roberts' ESD concept and strongly suggest that persistent, subclinical occurrence of these experiences could be the cause or major correlate of neuropsychological impairment for these patients.