Relationship between social cognition and social behaviour following traumatic brain injury

ENGAGE-TBI: adaptation of a community-based intervention to improve social participation after brain injury

BACKGROUND

Social isolation is prevalent after traumatic brain injury (TBI) and has negative implications for health and well-being. Interventions targeting social participation show promise for reducing social isolation. We adapted a social participation intervention, ENGAGE, to meet the needs of people with TBI. ENGAGE relies on social learning and guided problem-solving to achieve social participation goals.

METHODS

This study was conducted in two phases. First, we conducted focus groups with 12 participants with TBI to inform adaptations. We then tested the adapted protocol (n = 6). Post-intervention interviews informed additional refinements. We collected preliminary data on feasibility and effects on social participation (Activity Card Sort, PROMIS Ability to Participate in Social Roles, PROMIS Satisfaction with Participation in Social Roles) and social isolation (PROMIS Social Isolation).

RESULTS

Intervention adaptations included simplified processes for developing goals and plans, simplified workbook materials, greater time for reflection on lessons learned, and expanded peer mentorship. ENGAGE-TBI resulted in high satisfaction for 80% of participants and high engagement in intervention for 100% of participants. Attendance and retention benchmarks were achieved. Improvements in social participation exceeded the minimal clinically important difference on all measures.

CONCLUSIONS

The promising preliminary data support further investigation into the feasibility and effects of ENGAGE-TBI.

Interoception after frontal brain injury: A systematic review

OBJECTIVE

Interoception is crucial for emotional processing. It relies on the bidirectional connections between the insula, a crucial structure in interoception, and the frontal lobe, which is implicated in emotional experiences. Acquired frontal brain injury often leads to emotional disorders. Our goal was to explore the interoceptive profiles of patients with frontal lesions with or without insular involvement.

METHOD

Given the neuroanatomical links between interoception and emotions, we conducted a systematic Preferred Reporting Items for Systematic Reviews and Meta-analyses guided review of studies assessing at least one dimension of interoception in adults with acquired frontal injuries, with or without associated insular lesions.

RESULTS

Seven articles were included. The review indicated that interoceptive accuracy declines after frontal injuries. The two studies that investigated interoceptive sensitivity found lower scores in patient groups. Finally, inconsistent results were found for interoceptive metacognition after frontal damage.

CONCLUSIONS

This review is the first to explore interoceptive disorders after acquired frontal brain injury. The findings reveal deficits in cardiac interoceptive accuracy and interoceptive sensitivity following frontal damage. Inconsistent results were observed for interoceptive metacognition. Further research is needed to confirm the presence of interoceptive deficits following a frontal lesion. Additionally, the relationship between interoceptive deficits and emotional disorders, often reported after frontal brain injury, should be investigated.

Leukemia Inhibitory Factor as a late-stage treatment for delayed white matter loss in concussive head injury

Background

Leukemia Inhibitory Factor (LIF) is an injury-induced cytokine that peaks 48 hours after a traumatic brain injury (TBI). Juvenile LIF haplodeficient mice exhibit desynchronized glial responses, increased neurodegeneration, decreased axonal conductivity and behavioral deficits after a concussive head injury. Given the necessity of LIF during the acute recovery phase after injury, we hypothesized that intranasal (IN) LIF treatment would prevent neurodegeneration when administered during the chronic recovery period from a mild TBI (mTBI).

Methods

Young adult male CD1 mice were subjected to a midline, closed-head frontal cortex injury using a flat metal impactor with a 3mm tip to induce a mTBI. In the 6-8 weeks post-mTBI, known to precede axonal atrophy in this mTBI model, two doses of 40 ng and 100 ng of LIF were administered twice daily, 5 days/week for two consecutive weeks. Sensorimotor functions were assessed at 4 and 8 weeks post mTBI, followed by ex-vivo brain magnetic resonance imaging at 9.4T and histopathology.

Findings

mTBI mice showed sensorimotor deficits at 4 weeks, which worsened by 8 weeks post-injury. IN-LIF treatment prevented the progressive sensorimotor loss seen in the vehicle-treated controls. Increased mean diffusivity (MD) and decreased fractional anisotropy (FA) were observed in the corpus callosum and prefrontal cortex of mTBI brains. In a dose-dependent manner, IN-LIF prevented the mTBI-induced MD increase and FA decrease. Histologically, there was significantly less astrogliosis, microgliosis and axonal injury in the IN-LIF treated mice vs. controls.

Interpretation

These results support the therapeutic potential of IN-LIF to reduce delayed neurodegeneration and improve neurological outcomes after mTBIs.

Funding

Supported by R21 NS125201, which was awarded to SWL, SK, and FH, and Rutgers Busch Biomedical Grant IRES 21-002946 to SWL and SK.

Research in context

Evidence before this study: Earlier studies had shown that LIF haplodeficient mice sustained worse outcomes after brain injury, which supported the hypothesis that LIF was an essential neuroprotective injury induced cytokine. Other studies had shown that acutely administered LIF was neuroprotective and glioprotective in mouse models of multiple sclerosis, neonatal hypoxia-ischemia and pediatric TBI. However, to date most pre-clinical studies for TBI have tested the efficacy of therapeutics delivered during the acute (primary) or sub-acute (secondary) recovery period. Few studies have focused on the mechanisms of delayed neurodegeneration (tertiary neurodegeneration) and therapeutics are entirely lacking. Therefore, we decided to test IN LIF during the chronic recovery period from TBI. With preliminary data, we submitted an NIH exploratory grant (R21) that was awarded to the senior investigators of this manuscript in October of 2021. That grant supported the majority of the studies contained in this submission.A pubmed search performed on Feb. 9th, 2025 using the search string "(traumatic brain injury) AND (axonal damage) AND (magnetic resonance imaging) AND intranasal AND neuroprotection" returned no references.Added value of this study: The standard of care for individuals who have sustained head injuries is to treat their symptoms. They are provided medications to reduce seizures, decrease anxiety, reduce depression and reduce pain and other symptoms. However, none of these medications will prevent tertiary neurodegeneration. Given the number of individuals who have sustained head injuries, new therapeutics, especially therapeutics that can be easily administered, are needed. With the Superbowl having just taken place, there is once again increasing concern that many of these athletes who have sustained head injuries during the course of their careers will go on to develop chronic traumatic encephalopathy, for which there is no treatment.The studies we described herein are innovative as no other group has evaluated any of the cytokines related to LIF for their neuroprotective properties for mTBI and certainly not during the tertiary injury period. Moreover, a Pubmed database search that covered the period from 1966 to 2025 reveals that only a handful of other studies have used intranasal delivery of any compound to treat TBI, and all of these studies administered their therapeutic within 6 hours after an injury. Developing a long-lasting, CNS-targeted therapeutic that can be delivered as a simple nose spray will have a lasting impact on clinical medicine. Our studies presage future clinical trials to assess the therapeutic efficacy of intranasal LIF for individuals who have sustained mild TBIs.

A Combination of Low Doses of Lithium and Valproate Improves Cognitive Outcomes after Mild Traumatic Brain Injury

The prevalence of mild traumatic brain injury (mTBI) is high compared with moderate and severe TBI, comprising almost 80% of all brain injuries. mTBI activates a complex cascade of biochemical, molecular, structural, and pathological changes that can result in neurological and cognitive impairments. These impairments can manifest even in the absence of overt brain damage. Given the complexity of changes triggered by mTBI, a combination of drugs that target multiple TBI-activated cascades may be required to improve mTBI outcomes. It has been previously demonstrated that cotreatment with the U.S. Food and Drug Administration (FDA)-approved drugs lithium plus valproate (Li + VPA) for 3 weeks after a moderate-to-severe controlled cortical impact injury reduced cortical tissue loss and improved motor function. Since both lithium and valproate can exhibit toxicity at high doses, it would be beneficial to determine if this combination treatment is effective when administered at low doses and for a shorter duration, and if it can improve cognitive function, after a mild diffuse TBI. In the present study, we tested if the combination of low doses of lithium (1 mEq/kg or 0.5 mEq/kg) plus valproate (20 mg/kg) administered for 3 days after a mild fluid percussion injury can improve hippocampal-dependent learning and memory. Our data show that the combination of low-dose Li + VPA improved spatial learning and memory, effects not seen when either drug was administered alone. In addition, postinjury Li + VPA treatment improved recognition memory and sociability and reduced fear generalization. Postinjury Li + VPA also reduced the number of anti-ionized calcium binding adaptor molecule 1 (Iba1)-positive microglia counted using a convolutional neural network, indicating a reduction in neuroinflammation. These findings indicate that low-dose Li + VPA administered acutely after mTBI may have translational utility to reduce pathology and improve cognitive function.

Social cognition in acquired brain injury: adaptation and validation of the Brief Assessment of Social Skills (BASS)

BACKGROUND

Acquired brain injury (ABI) is associated with social cognitive impairments, yet these impairments are often overlooked during clinical assessments. There are few validated and clinically appropriate measures of social cognition in ABI. The current study examined the validity of the Brief Assessment of Social Skills (BASS) in measuring social cognition following ABI.

METHOD

Twenty-eight people with ABI were recruited from local brain injury rehabilitation and support services and completed measures of social cognition, general intellectual ability, and social functioning. Twenty-eight controls demographically matched for age, gender, and years of education also performed these measures.

RESULTS

A diagnosis of ABI was significantly associated with poorer performance on five subtests of the BASS. The BASS had moderate correlations with established measures of social cognition and measures characteristics that are distinguishable from general cognition. There was minimal evidence of a relationship between performance on the BASS and social functioning, with a significant relationship between a BASS subscale and informant-reported living skills and total social functioning. Using a series of case studies, the clinical utility of the BASS was emphasized by the development of unique social cognitive profiles across ABI individuals, including impairments in areas not significant at a group level.

DISCUSSION

The BASS is a brief and comprehensive measure that is able to detect social cognition impairments in ABI patients. Given the prevalence of impairment in social cognition following ABI and the implications of these abilities on social functioning, this measure can be used in comprehensive neuropsychological assessment to guide and monitor progress toward rehabilitation goals.

Social face processing in chronic severe traumatic brain injury: Altered decoding of emotions and mental states but preserved gaze cueing of attention

The processing of social information transmitted by facial stimuli is altered in individuals with traumatic brain injury (TBI). This study investigated whether these alterations also affect the mechanisms underlying the orienting of visual attention in response to eye-gaze signals. TBI patients and a control group of healthy individuals matched on relevant criteria completed a spatial cueing task. In this task, a lateral visual target was presented along with a task-irrelevant face, with the gaze averted to the left or right. Arrows pointing towards the left or right were also used as non-social control stimuli. Social cognition abilities were further investigated through tests based on decoding emotional expressions and mental states conveyed by facial stimuli. The decoding of emotions and mental states was worse in the TBI group than in the control group. However, both groups demonstrated reliable and comparable orienting of attention to both eye-gaze and arrow stimuli. Despite impairments in certain aspects of social face processing among TBI patients, gaze cueing of attention appears to be preserved in this neuropsychological population.

Evidence-Based Review of Randomized Controlled Trials of Interventions for the Management of Behavioral Issues in Individuals With Moderate to Severe Traumatic Brain Injury

OBJECTIVE

To present an evidence-based review of randomized controlled trials (RCTs) evaluating interventions for the management of behavioral issues post moderate to severe traumatic brain injury (MSTBI), as part of an extensive database that has been conceptualized as a living systematic review.

METHODS

Systematic searches were conducted in MEDLINE, PubMed, Scopus, CINAHL, EMBASE and PsycINFO, up to and including December 2022, for articles published in the English language, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The quality of RCT was assessed using the Physiotherapy Evidence Database (PEDro) scale, and level of evidence was assigned using a modified Sackett scale.

RESULTS

Forty-six RCTs examining interventions and outcome measures related to behavioral issues post-MSTBI were included. These studies collectively enrolled 3,267 participants. The majority of RCTs were conducted in the United States (n = 27; 58.7%) and 28 (60.9%) were conducted after 2010. Of these, 27 RCTs examined non-pharmacological interventions and 19 examined pharmacological interventions. Effective pharmacological treatments included amantadine and dexmedetomidine. Effective non-pharmacological interventions included sensory stimulation in the acute phase, anger self-management programs, peer mentoring, problem-solving, and emotional regulation. Psychotherapy showed conflicting evidence.

CONCLUSION

This evidence-based review provides a comprehensive overview of the research landscape of RCTs addressing behavior post-MSTBI. The findings from these RCTs may be valuable for health care professionals, researchers, and policymakers involved in the field of TBI and behavior.

Computerized social cognitive training in the subacute phase after traumatic brain injury: A quasi-randomized controlled trial

OBJECTIVES

To assess the usefulness of a computerized tasks module designed for the rehabilitation of social cognition (SC) in acquired brain injury.

METHODS

Quasi-randomized controlled trial (ClinicalTrials.gov:NCT03479970) involving 45 patients with moderate-severe traumatic brain injury (TBI) in a subacute inpatient rehabilitation hospital. The experimental group (n = 28) received treatment with a computerized SC module in combination with a non-SC module. The control group (n = 26) only received a treatment with non-SC module.

RESULTS

Intragroup comparisons showed that the experimental group had better results for all SC measures, except for International Affective Picture System (IAPS). The control group improved for Facial Expressions of cEmotion-Stimuli and Tests (FEEST) and Moving Shapes Paradigm (MSP), showing no changes with respect to pretreatment in IAPS, MSP and Reading the Mind in the Eyes Test (RMET). Intergroup comparisons did not present differences between the two groups for pretreatment measures. Post-treatment comparison showed that the experimental group obtained better results for RMET than the control group.

CONCLUSION

The computerized SC module was useful for the rehabilitation of SC in patients with moderate-severe TBI in the subacute phase. The group that received combined rehabilitative treatment (SC + non-SC) obtained better results for SC than the group that received treatment intended only for non-SC.

Ongoing Challenges Related to the COVID-19 Pandemic Among People With Brain Injury

The COVID-19 pandemic exacerbated social isolation among people with traumatic brain injury (TBI). Yet, little is known about how changes in personal factors, environmental factors, or the characteristics of activities affected social participation. We examined experiences with social isolation and barriers to social participation using the person-environment-occupation-performance model as a framework. Twelve adults with TBI participated in a series of three focus groups. Data were analyzed using thematic analysis. We identified two primary themes with sub-themes: (1) social isolation experiences: (1a) emotional impact and (1b) managing personal risk; and (2) greater barriers but a lack of strategies to address them: (2a) access and opportunities and (2b) social and societal factors. New environmental barriers and task demands affected occupational performance, and participants identified few successful strategies to overcome these barriers. Occupational therapy can develop new strategies to re-balance the person-environment fit and enhance social participation.

Factors related to social inferencing performance in moderate-severe, chronic TBI

OBJECTIVE

Following traumatic brain injury (TBI), deficits in social cognition are common. Social inferencing is a crucial component of social cognition that enables an individual to understand the thoughts, feelings, and intentions of a communication partner when this information is not explicitly stated. Existing literature suggests a variety of factors contribute to social inferencing success (e.g. biological sex, executive functioning), yet findings are not conclusive, largely because these factors have been examined in isolation.

METHOD

In this cross-sectional study, stepwise regression with cross validation was used to examine the extent that several theoretically motivated factors were associated with social inferencing (measured by performance on The Awareness of Social Inference Test [TASIT]) in adult participants with TBI (n = 105). Demographic information, executive functioning, aggression, emotional functioning measures, and participation in society were all examined in relation to social inferencing performance.

RESULTS

The findings confirm the importance of higher-level cognitive skills (i.e. executive functioning) in social inferencing, and advance the literature by underlining the potential importance of productive participation in social inferencing performance.

CONCLUSION

This study innovatively highlights factors linked with social inferencing skills and, in doing so, how deficits in social inferencing might manifest in the lives of individuals with TBI.

Dynamic and/or multimodal assessments for social cognition in neuropsychology: Results from a systematic literature review

Objective: Despite the prevalence of socio-cognitive disturbances, and their important diagnostic/therapeutic implications, the assessment of these disturbances remains scarce. This systematic review aims to identify available social cognition tools for adult assessment that use multimodal and/or dynamic social cues, specifying their strengths and limitations (e.g. from a methodological, psychometric, ecological, and clinical perspective). Method: An electronic search was conducted in Pubmed, PsychINFO, Embase and Scopus databases for articles published up to the 3th of January 2023 and the first 200 Google Scholar results on the same date. The PRISMA methodology was applied, 3884 studies were screened based on title and abstract and 329 full texts were screened. Articles using pseudo-dynamic methodologies (e.g. morphing), reported only subjective or self-reported measures, or investigated only physiological or brain activity responses were excluded. Results: In total, 149 works were included in this review, representing 65 assessment tools (i.e. 48% studying emotion recognition (n = 31), 32% Theory of Mind (n = 21), 5% empathy (n = 3), 1.5% moral cognition/social reasoning (n = 1), and 14% being multimodal (n = 9)). For each study, the tool's main characteristics, psychometric properties, ecological validity indicators and available norms are reported. The tools are presented according to social-cognitive process assessed and communication channels used. Conclusions: This study highlights the lack of validated and standardized tools. A few tools appear to partially meet some clinical needs. The development of methodologies using a first-person paradigm and taking into account the multidimensional nature of social cognition seems a relevant research endeavour for greater ecological validity.

Microbiome depletion prior to repeat mild TBI differentially alters social deficits and prefrontal cortex plasticity in adolescent and adult rats

Although aging, repeat mild traumatic brain injury (RmTBI), and microbiome modifications independently change social behavior, there has been no investigation into their cumulative effects on social behavior and neuroplasticity within the prefrontal cortex. Therefore, we examined how microbiome depletion prior to RmTBI affected social behavior and neuroplasticity in adolescent and adult rats. Play, temperament analysis, elevated plus maze, and the hot/cold plate assessed socio-emotional function. Analyses of perineuronal nets (PNNs) and parvalbumin (PV) interneurons was completed. Social-emotional deficits were more pronounced in adults, with microbiome depletion attenuating social behavior deficits associated with RmTBI in both age groups. Microbiome depletion increased branch length and PNN arborization within the PFC but decreased the overall number of PNNs. Adults and males were more vulnerable to RmTBI. Interestingly, microbiome depletion may have attenuated the changes to neuroplasticity and subsequent social deficits, suggesting that the microbiome is a viable, but age-specific, target for RmTBI therapeutics.

Social cognition in adult survivors of brain tumors: studying the relationship between theory of mind and quality of life

OBJECTIVE

The present study is the first to examine theory of mind (ToM) sequelae in a sample of adult survivors of primary brain tumors, and to investigate the assumed relationship between ToM and health-related quality of life (HRQoL).

METHOD

Participants were 40 long-term adult survivors of primary brain tumors and 40 matched healthy controls. They completed ToM tests (Faux-Pas test and Advanced ToM task) and two questionnaires assessing HRQoL (36-Item Short-Form Health Survey and EORTC QLQ-C30/QLQ-BN20). Their relatives also completed an observer-rated version of the SF-36 questionnaire.

RESULTS

Survivors performed worse than controls only on the Advanced ToM task. Overall, patients and caregivers reported more problems than healthy controls and their relatives regarding both global HRQoL and its social/emotional aspects. No relationship was found between ToM and HRQoL scores.

CONCLUSION

Adult survivors of primary brain tumors may exhibit ToM deficits several years after treatment and report more problems on social/emotional HRQoL components. Our findings highlight the need to consider these late effects in survivors' long-term follow-up, even if the clinical involvement of ToM deficits still needs to be elucidated. The assessment of ToM deficits and their potential impact on survivors' everyday life is thoroughly discussed.

Sex and Age-at-Injury as Determinants of Social Behavior Outcomes After TBI

While our understanding of long-term disability after traumatic brain injury (TBI) has habitually focused on cognitive and sensorimotor functioning, it is increasingly appreciated that changes in social function for survivors of a brain injury are common and have a profound impact on one's quality of life. In this chapter, we highlight the consequences of TBI on social behavior, taking into account evidence from studies of patient populations as well as from preclinical animal models. After first considering the protracted nature of the development of social behavior across the lifespan, including the neurobiological networks that underlie social functioning, we discuss how TBI results in social behavior impairments and how these manifest. We focus particularly on how age-at-injury influences TBI-induced social impairments, with most of the evidence suggesting age-dependent vulnerability after injury at a younger age. In addition, we explore how biological sex is a key determinant of social behavior impairments after TBI, while gender in humans may also influence the nature and extent of social outcomes. Finally, we identify key knowledge gaps and emphasize the need for further research in the field.

Mediating effects of impulsivity and alexithymia in the association between traumatic brain injury and aggression in incarcerated males

Studies suggest both alexithymia and impulsivity (partially) explain aggressive behavior in traumatic brain injury (TBI) patients, but none of these studies use both questionnaire and performance-based measures as recommended, nor simultaneously investigate both impulsivity and alexithymia. The available studies therefore likely miss part of the constructs of alexithymia and impulsivity, and do not comprehensively assess the mediating effects of both constructs in the relationship between TBI and aggression. A sample of N = 281 incarcerated individuals were recruited from Dutch penitentiary institutions, and completed the Buss Perry Aggression Questionnaire (aggression), BIS-11 (impulsivity) and Toronto Alexithymia Scale-20 (alexithymia) questionnaires, as well as a stop-signal task and an emotion recognition paradigm. Several multiple mediation analyses were conducted using structural equation modelling, to assess the viability of a causal theoretical model of aggression. The final planned models were the original models with a good fit with the data (comparative fit index > 0.95, root mean square error of approximation and Standardized root mean square residual < 0.05), and results indicate that only questionnaire-based impulsivity mediated the relationship between TBI and aggression. TBI was unrelated to alexithymia, stop-signal or emotion recognition performance. Aggression was predicted by both alexithymia and impulsivity, but not by the performance measures. Post hoc analyses shows that alexithymia moderates the relationship between impulsivity and aggression. These results imply that aggressive incarcerated individuals showing impulsive behavior should be screened for TBI, since TBI is often overlooked or misdiagnosed, and indicate that both impulsivity and alexithymia are potential focus points for aggression reduction treatment in TBI patients.

Dynamic Emotion Recognition and Social Inference Ability in Traumatic Brain Injury: An Eye-Tracking Comparison Study

Emotion recognition and social inference impairments are well-documented features of post-traumatic brain injury (TBI), yet the mechanisms underpinning these are not fully understood. We examined dynamic emotion recognition, social inference abilities, and eye fixation patterns between adults with and without TBI. Eighteen individuals with TBI and 18 matched non-TBI participants were recruited and underwent all three components of The Assessment of Social Inference Test (TASIT). The TBI group were less accurate in identifying emotions compared to the non-TBI group. Individuals with TBI also scored lower when distinguishing sincere and sarcastic conversations, but scored similarly to those without TBI during lie vignettes. Finally, those with TBI also had difficulty understanding the actor's intentions, feelings, and beliefs compared to participants without TBI. No group differences were found for eye fixation patterns, and there were no associations between fixations and behavioural accuracy scores. This conflicts with previous studies, and might be related to an important distinction between static and dynamic stimuli. Visual strategies appeared goal- and stimulus-driven, with attention being distributed to the most diagnostic area of the face for each emotion. These findings suggest that low-level visual deficits may not be modulating emotion recognition and social inference disturbances post-TBI.

The Pathogenesis of Disinhibition in Patients with Traumatic Brain Injury: A Two Patient Case Report

Higher brain dysfunction commonly occurs following traumatic brain injury (TBI), and may manifest in a social behavioral impairment which can significantly impede active social participation. We report two cases, one of voyeurism and the second of alcohol abuse, which might have been caused by TBI resulting in disinhibition, a type of social behavioral impairment. We discuss the underlying pathophysiological mechanisms to raise awareness of such cases and aid the development of effective interventions. Patient 1 suffered a TBI at 18 years of age, 2 years after which he presented repeated episodes of sexually deviant behavior (voyeurism). At 28, he committed suicide, since he was unable to control his aberrant behavior. Patient 2 suffered a TBI at the age of 13. He first displayed problematic behavior 7 years later, which included drinking excessive amounts of alcohol and stealing while inebriated. Despite both patients having sound moral judgment, they had irrational and uncontrollable impulses of desire. Imaging findings could explain the possible causes of impulse control impairments. Damage to the basal ganglia and limbic system, which are involved in social behavior, presumably led to desire-dominated behavior, leading to the patients conducting unlawful acts despite intact moral judgment. It is crucial to educate society about the prevalence of these disorders, explain how these disinhibitions start, and develop effective interventions.

Facial affect recognition in context in adults with and without TBI

Introduction

Several studies have reported impaired emotion recognition in adults with traumatic brain injury (TBI), but studies have two major design features that limit application of results to real-world contexts: (1) participants choose from among lists of basic emotions, rather than generating emotion labels, and (2) images are typically presented in isolation rather than in context. To address these limitations, we created an open-labeling task with faces shown alone or in real-life scenes, to more closely approximate how adults with TBI label facial emotions beyond the lab.

Methods

Participants were 55 adults (29 female) with moderate to severe TBI and 55 uninjured comparison peers, individually matched for race, sex, and age. Participants viewed 60 photographs of faces, either alone or in the pictured person's real-life context, and were asked what that person was feeling. We calculated the percent of responses that were standard forced-choice-task options, and also used sentiment intensity analysis to compare verbal responses between the two groups. We tracked eye movements for a subset of participants, to explore whether gaze duration or number of fixations helped explain any group differences in labels.

Results

Over 50% of responses in both groups were words other than basic emotions on standard affect tasks, highlighting the importance of eliciting open-ended responses. Valence of labels by participants with TBI was attenuated relative to valence of Comparison group labels, i.e., TBI group responses were less positive to positive images and the same was true for negative images, although the TBI group responses had higher lexical diversity. There were no significant differences in gaze duration or number of fixations between groups.

Discussion

Results revealed qualitative differences in affect labels between adults with and without TBI that would not have emerged on standard forced-choice tasks. Verbal differences did not appear to be attributable to differences in gaze patterns, leaving open the question of mechanisms of atypical affect processing in adults with TBI.

Behavioral and Psychiatric Symptoms in Patients with Severe Traumatic Brain Injury: A Comprehensive Overview

Traumatic brain injury (TBI) is defined as an altered brain structure or function produced by an external force. Adults surviving moderate and severe TBI often experience long-lasting neuropsychological and neuropsychiatric disorders (NPS). NPS can occur as primary psychiatric complications or could be an exacerbation of pre-existing compensated conditions. It has been shown that changes in behavior following moderate to severe TBI have a prevalence rate of 25-88%, depending on the methodology used by the different studies. Most of current literature has found that cognitive behavioral and emotional deficit following TBI occurs within the first six months whereas after 1-2 years the condition becomes stable. Identifying the risk factors for poor outcome is the first step to reduce the sequelae. Patients with TBI have an adjusted relative risk of developing any NPS several-fold higher than in the general population after six months of moderate-severe TBI. All NPS features of an individual's life, including social, working, and familiar relationships, may be affected by the injury, with negative consequences on quality of life. This overview aims to investigate the most frequent psychiatric, behavioral, and emotional symptoms in patients suffering from TBI as to improve the clinical practice and tailor a more specific rehabilitation training.

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.

Use of Technologies in the Therapy of Social Cognition Deficits in Neurological and Mental Diseases: A Systematic Review

Objective: This article systematically reviews the effects of technology-based (TB) treatments on impaired social cognition (SC) in neurological and mental disorders. Methods: Strictly adhering to the PRISMA guidelines, a systematic search was carried out in PsycINFO, PubMed, and Web of Science (last search: April 22, 2021) to identify studies that, implementing a control group design, evaluated TB treatments targeting deficits in emotion recognition, Theory of Mind (ToM) and social behavior in adult patients with nondevelopmental and nonprogressive neurological or mental disorders. Risk of bias was assessed using the PEDro Scale, certainty assessment followed the GRADE approach. Results: Sixteen studies involving 857 patients, all focusing on psychotic disorders, were retrieved. The most pronounced effects were observed concerning emotion recognition with all studies revealing overall improvements. Regarding ToM and social behavior, results were mixed. However, the number of studies including outcome measures for these domains, is significantly lower compared to the domain of emotion recognition, limiting the validity of the results. Risk of bias and certainty assessment revealed further limitations of evidence. Conclusion: TB treatment achieves positive effects especially with regard to emotion recognition impairments, at least for patients with schizophrenia. Future research should expand the evaluation of TB training of other SC domains, ought to be carried out in more diverse patient populations, rely on different devices, and include follow-up measurements.

Physiological reactivity at rest and in response to social or emotional stimuli after a traumatic brain injury: A systematic review

Numerous studies have shown that alterations in physiological reactivity (PR) after traumatic brain injury (TBI) are possibly associated with emotional deficits. We conducted a systematic review of these studies that evaluated PR in adults with moderate-to-severe TBI, either at rest or in response to emotional, stressful, or social stimuli. We focused on the most common measures of physiological response, including heart rate (HR), heart rate variability (HRV), respiratory sinus arrhythmia (RSA), electrodermal activity (EDA), salivary cortisol, facial electromyography (EMG), and blink reflex.

Methods

A systematic literature search was conducted across six databases (PsycINFO, Psycarticles, SciencDirect, Cochrane Library, PubMed, and Scopus). The search returned 286 articles and 18 studies met the inclusion criteria.

Results

Discrepancies were observed according to the type of physiological measure. Reduced physiological responses in patients with TBI have been reported in most EDA studies, which were also overrepresented in the review. In terms of facial EMG, patients with TBI appear to exhibit reduced activity of the corrugator muscle and diminished blink reflex, while in most studies, zygomaticus contraction did not show significant differences between TBI and controls. Interestingly, most studies measuring cardiac activity did not find significant differences between TBI and controls. Finally, one study measured salivary cortisol levels and reported no difference between patients with TBI and controls.

Conclusion

Although disturbed EDA responses were frequently reported in patients with TBI, other measures did not consistently indicate an impairment in PR. These discrepancies could be due to the lesion pattern resulting from TBI, which could affect the PR to aversive stimuli. In addition, methodological differences concerning the measurements and their standardization as well as the characteristics of the patients may also be involved in these discrepancies. We propose methodological recommendations for the use of multiple and simultaneous PR measurements and standardization. Future research should converge toward a common methodology in terms of physiological data analysis to improve inter-study comparisons.

Reference Values of the Quality of Life after Brain Injury (QOLIBRI) from a General Population Sample in Italy

Traumatic brain injury (TBI) may affect the lives of the individuals concerned and their relatives negatively in many dimensions. Health-related quality of life (HRQoL) is a comprehensive and complex concept that can assess one's satisfaction with a broad range of areas of life and health. The Quality of Life after Traumatic Brain Injury (QOLIBRI) questionnaire is a TBI-specific measure for HRQoL which is used in research and health services worldwide. When evaluating self-reported HRQoL after TBI, reference values from a general population are helpful to perform clinically relevant evaluations and decisions about the condition of an affected person by comparing the patient scores with reference values. Despite the widespread use of the QOLIBRI, reference values have until now only been available for the Netherlands and the United Kingdom. The aim of this study was to validate the QOLIBRI for the general population in Italy and to provide reference values. An adapted form of the QOLIBRI was administered to 3298 Italians from a healthy general population using an online survey. Their scores were compared with those of 298 individuals post-TBI recruited within the international longitudinal observational cohort CENTER-TBI study in Italian hospitals, who completed the original questionnaire. The psychometric characteristics and the measurement invariance of the QOLIBRI were assessed. A regression analysis was performed to identify predictors relevant for HRQoL in the general population. Reference values were provided using percentiles. Measurement invariance analysis showed that the QOLIBRI captures the same HRQoL constructs in an Italian general population and Italian TBI sample from the observational Center-TBI study. Higher age, higher education and the absence of a chronic health condition were associated with higher QOLIBRI scores, suggesting better HRQoL. Reference values were provided for a general Italian population adjusted for age, sex, education and presence of chronic health conditions. We recommend using these for a better interpretation of the QOLIBRI score in clinical practice and research in Italy.

INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury, Part IV: Cognitive-Communication and Social Cognition Disorders

INTRODUCTION

Moderate to severe traumatic brain injury causes significant cognitive impairments, including impairments in social cognition, the ability to recognize others' emotions, and infer others' thoughts. These cognitive impairments can have profound negative effects on communication functions, resulting in a cognitive-communication disorder. Cognitive-communication disorders can significantly limit a person's ability to socialize, work, and study, and thus are critical targets for intervention. This article presents the updated INCOG 2.0 recommendations for management of cognitive-communication disorders. As social cognition is central to cognitive-communication disorders, this update includes interventions for social cognition.

METHODS

An expert panel of clinicians/researchers reviewed evidence published since 2014 and developed updated recommendations for interventions for cognitive-communication and social cognition disorders, a decision-making algorithm tool, and an audit tool for review of clinical practice.

RESULTS

Since INCOG 2014, there has been significant growth in cognitive-communication interventions and emergence of social cognition rehabilitation research. INCOG 2.0 has 9 recommendations, including 5 updated INCOG 2014 recommendations, and 4 new recommendations addressing cultural competence training, group interventions, telerehabilitation, and management of social cognition disorders. Cognitive-communication disorders should be individualized, goal- and outcome-oriented, and appropriate to the context in which the person lives and incorporate social communication and communication partner training. Group therapy and telerehabilitation are recommended to improve social communication. Augmentative and alternative communication (AAC) should be offered to the person with severe communication disability and their communication partners should also be trained to interact using AAC. Social cognition should be assessed and treated, with a focus on personally relevant contexts and outcomes.

CONCLUSIONS

The INCOG 2.0 recommendations reflect new evidence for treatment of cognitive-communication disorders, particularly social interactions, communication partner training, group treatments to improve social communication, and telehealth delivery. Evidence is emerging for the rehabilitation of social cognition; however, the impact on participation outcomes needs further research.

Psychiatric disorders in post-traumatic brain injury patients: A scoping review

Background

Traumatic Brain Injury (TBI) is an important antecedent in the evaluation of patients with psychiatric disorders. The association between TBI and the subsequent appearance of psychiatric disorders has been documented, however, the findings found in the literature are diverse and controversial.

Objective

To identify the most prevalent psychiatric disorders after head trauma.

Design

An exploratory review (SCOPING) was carried out using the PRISMA extension protocol. Articles published between the years 2010-2022 were used to identify and describe the most prevalent psychiatric disorders after a TBI. Psychiatric disorders were classified according to clinical characteristics in neurotic syndromes, psychotic syndromes, cognitive disorders, among others.

Results

A total of 32 articles were included. In the framework of neurotic syndromes, depression is the most prevalent psychiatric alteration after a TBI, becoming a sequel that shows a higher incidence in the first year after the traumatic event. The findings found in relation to post-traumatic stress disorder are controversial, showing great variability regarding the degree of severity of the injury. The prevalence of psychotic syndromes is relatively low because it is difficult to determine if the psychosis is a direct consequence of a TBI. In the cognitive sphere, it was found that people with TBI presented alterations in cognitive functions.

Conclusions

The findings found in the review respond to the hypothesis initially raised, which assumes that head trauma is an important etiological factor in the appearance of psychiatric disorders.

Perceived care partner burden at 1-year post-injury and associations with emotional awareness, functioning, and empathy after TBI: A TBI model systems study

BACKGROUND

People with traumatic brain injury (TBI) can lack awareness of their own emotions and often have problems with emotion dysregulation, affective disorders, and empathy deficits. These impairments are known to impact psychosocial behaviors and may contribute to the burden experienced by care partners of individuals with TBI.

OBJECTIVE

To examine the associations of emotional awareness, emotional functioning, and empathy among participants with TBI with care partner burden.

METHOD

This multisite, cross-sectional, observational study used data from 90 dyads (participants with TBI and their care partner) 1-year post-injury. Participants with TBI completed the Difficulty with Emotional Regulation Scale (DERS; Awareness, Clarity, Goals, Impulse, Nonacceptance, and Strategies subscales); PTSD Checklist-Civilian Version; NIH Toolbox Anger-Affect, Hostility and Aggression Subdomains; PHQ-9; GAD-7; and the Interpersonal Reactivity Index (empathic concern and perspective taking subscales). Care partners completed the Zarit Burden Inventory (ZBI) and provided demographic information.

RESULTS

Care partners were predominately female (77%), and most were either a spouse/partner (55.2%) or parent (34.4%). In an unadjusted model that included assessments of emotional awareness, emotional functioning, and empathy of the participant with TBI, the DERS-Awareness and NIH-Hostility subscales accounted for a significant amount of variance associated with care partner burden. These findings persisted after adjusting for care partner age, relationship, education, and the functional status of the participant with TBI (β= 0.493 and β= 0.328, respectively).

CONCLUSION

These findings suggest that high levels of hostility and low emotional self-awareness can significantly affect the burden felt by TBI care partners.

Facebook Experiences of Users With Traumatic Brain Injury: A Think-Aloud Study

BACKGROUND

A critical gap in our knowledge about social media is whether we can alleviate accessibility barriers and challenges for individuals with traumatic brain injury (TBI), to improve their social participation and health. To do this, we need real-time information about these barriers and challenges, to design appropriate aids.

OBJECTIVE

The aim of this study was to characterize the ways people with TBI accessed and used social media websites and understand unique challenges they faced.

METHODS

We invited 8 adults with moderate to severe TBI to log onto their own Facebook page and use it as they regularly would while thinking aloud. Their comments were recorded and transcribed for qualitative analysis. We first analyzed participants' utterances using a priori coding based on a framework proposed by Meshi et al to classify adults' motives for accessing social media. We next used an open coding method to understand the challenges that people with TBI faced while using Facebook. In other words, we analyzed participants' needs for using Facebook and then identified Facebook features that made it challenging for them to meet those needs.

RESULTS

Participants used all categories of codes in the framework by Meshi et al and provided detailed feedback about the Facebook user interface. A priori coding revealed 2 dimensions that characterized participants' Facebook use: whether they were active or passive about posting and self-disclosure on Facebook and their familiarity and fluency in using Facebook. The open coding analysis revealed 6 types of challenges reported by participants with TBI, including difficulty with language production and interpretation, attention and information overload, perceptions of negativity and emotional contagion, insufficient guidance to use Facebook, concerns about web-based scams and frauds, and general accessibility concerns.

CONCLUSIONS

Results showed that individuals with TBI used Facebook for the same reasons typical adults do, suggesting that it can help increase social communication and reduce isolation and loneliness. Participants also identified barriers, and we propose modifications that could improve access for individuals with brain injury. On the basis of identified functions and challenges, we conclude by proposing design ideas for social media support tools that can promote more active use of social media sites by adults with TBI.

Working Memory for Emotions in Adolescents and Young Adults with Traumatic Brain Injury

This preliminary study investigated the interaction between working memory and social cognition in adolescents and young adults with traumatic brain injury (TBI). It was hypothesized that participants with or without TBI would better recognize social information when working memory or social cognitive load was low, and that adolescents and young adults with TBI would be more affected by increased cognitive demand than their uninjured peers. Eight adolescents and young adults with complicated mild-severe TBI (aged 14-22 years) and eight age- and sex-matched typically developing (TD) adolescents completed computer-based n-back tasks requiring recognition of either face identity or facial affect, with 0-back, 1-, and 2-back conditions. The TBI group had lower scores overall than the TD group, and scores for both groups were lower for affect recognition than identity recognition. Scores for both groups were lower in conditions with a higher working memory load. There was a significant group-by-working memory interaction, with larger group differences in high-working memory conditions. Study results and their potential implications for social outcomes are discussed.

Interaction of discourse processing impairments, communicative participation, and verbal executive functions in people with chronic traumatic brain injury

Introduction

Especially in the chronic phase, individuals with traumatic brain injury (TBI) (IwTBI) may still have impairments at the discourse level, even if these remain undetected by conventional aphasia tests. As a consequence, IwTBI may be impaired in conversational behavior and disadvantaged in their socio-communicative participation. Even though handling discourse is thought to be a basic requirement for participation and quality of life, only a handful of test procedures assessing discourse disorders have been developed so far. The MAKRO Screening is a recently developed screening tool designed to assess discourse impairments. The test construction is based on psycholinguistic frameworks and the concept of macro-rules, which refer to cognitive functions responsible for organizing and reducing complex information (e.g., propositional content) in discourse.

Aim

The aim of our study was to investigate discourse processing in IwTBI in different tasks and to assess problems in communicative participation in the post-acute and chronic phase. In this context, we also aimed to analyze the influence of the severity of the initial impairment and the verbal executive abilities on the discourse performance. Additionally, the impact of macrolinguistic discourse impairments and verbal fluency on perceived communicative participation was targeted in our analysis.

Methods

Data from 23 IwTBI (moderate to severe) and 23 healthy control subjects have been analyzed. They completed two subtests of the MAKRO screening: Text production and Inferences. Discourse performance was examined in relation to measures of semantic fluency and verbal task-switching. Socio-communicative problems were evaluated with the German version of the La Trobe Communication Questionnaire (LCQ).

Results

IwTBI showed lower test results than the control group in the two subtests of the MAKRO-Screening. Difficulties in picture-based narrative text production also indicated greater perceived difficulties in communicative participation (LCQ). We also found that the subject's performance on the MAKRO-Screening subtests can partly be explained by underlying dysexecutive symptoms (in terms of verbal fluency and verbal task switching) and the severity of their injury. The preliminary results of our study show that cognitive-linguistic symptoms in IwTBI are also evident in the chronic phase. These can be detected with procedures referring to the discourse level, such as the MAKRO-Screening. The assessment of discourse performance should be an integral part in the rehabilitation of IwTBI in order to detect cognitive-linguistic communication disorders and to evaluate their impact on socio-communicative participation.

Altered Serotonin 2A (5-HT2A) Receptor Signaling Underlies Mild TBI-Elicited Deficits in Social Dominance

Various forms of traumatic brain injury (TBI) are a leading cause of disability in the United States, with the generation of neuropsychiatric complications such as depression, anxiety, social dysfunction, and suicidality being common comorbidities. Serotonin (5-HT) signaling is linked to psychiatric disorders; however, the effects of neurotrauma on normal, homeostatic 5-HT signaling within the central nervous system (CNS) have not been well characterized. We hypothesize that TBI alters specific components of 5-HT signaling within the CNS and that the elucidation of specific TBI-induced alterations in 5-HT signaling may identify novel targets for pharmacotherapies that ameliorate the neuropsychiatric complications of TBI. Herein, we provide evidence that closed-head blast-induced mild TBI (mTBI) results in selective alterations in cortical 5-HT_2A receptor signaling. We find that mTBI increases in vivo cortical 5-HT_2A receptor sensitivity and ex vivo radioligand binding at time points corresponding with mTBI-induced deficits in social behavior. In contrast, in vivo characterizations of 5-HT_1A receptor function revealed no effect of mTBI. Notably, we find that repeated pharmacologic activation of 5-HT_2A receptors post-injury reverses deficits in social dominance resulting from mTBI. Cumulatively, these studies provide evidence that mTBI drives alterations in cortical 5-HT_2A receptor function and that selective targeting of TBI-elicited alterations in 5-HT_2A receptor signaling may represent a promising avenue for the development of pharmacotherapies for TBI-induced generation of neuropsychiatric disorders.

Traumatic brain injury-induced submissive behavior in rats: link to depression and anxiety

Traumatic brain injury (TBI) affects millions of people worldwide, many of whom are affected with post-TBI mood disorders or behavioral changes, including aggression or social withdrawal. Diminished functionality can persist for decades after TBI and delay rehabilitation and resumption of employment. It has been established that there is a relationship between these mental disorders and brain injury. However, the etiology and causal relationships behind these conditions are poorly understood. Rodent models provide a helpful tool for researching mood disorders and social impairment due to their natural tendencies to form social hierarchies. Here, we present a rat model of mental complications after TBI using a suite of behavioral tests to examine the causal relationships between changes in social behavior, including aggressive, hierarchical, depressive, and anxious behavior. For this purpose, we used multivariate analysis to identify causal relationships between the above post-TBI psychiatric sequelae. We performed statistical analysis using principal component analysis, discriminant analysis, and correlation analysis, and built a model to predict dominant-submissive behavior based on the behavioral tests. This model displayed a predictive accuracy of 93.3% for determining dominant-submissive behavior in experimental groups. Machine learning algorithms determined that in rats, aggression is not a principal prognostic factor for dominant-submissive behavior. Alternatively, dominant-submissive behavior is determined solely by the rats' depressive-anxious state and exploratory activity. We expect the causal approach used in this study will guide future studies into mood conditions and behavioral changes following TBI.

An Examination of Social Inferencing Skills in Males and Females Following Traumatic Brain Injury

OBJECTIVE

This study examines sex differences in social inferencing deficits after traumatic brain injury (TBI), and examines the odds of males and females being impaired while controlling for potential confounders.

DESIGN

Cross-sectional survey.

SETTING

Outpatient.USA and a University in Canada.

PARTICIPANTS

One hundred five participants with TBI (60 males, 45 females) and 105 healthy controls (HC; 57 males, 48 females).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The Awareness of Social Inference Test (TASIT), which includes 1) Emotional Evaluation Test (EET), 2) Social Inference-Minimal (SI-M) test, and 3) Social Inference-Enriched (SI-E) test.

RESULTS

Within the HC sample, males and females performed similarly on all three TASIT subtests. Within the TBI group, males had significantly lower scores than females on EET (P = 0.03), SI-M (P=0.01) and SI-E (P=0.04). Using impairment cutoffs derived from the HC sample, significantly more males with TBI (30%) were impaired on the EET than females(16.7%); impairment was similar between males and females on SI-M and SI-E. When adjusting for executive functioning and education, the odds of being impaired on the EET did not significantly differ for males and females (OR = 0.47; 95% CI: 0.16 - 1.40; P = 0.18).

CONCLUSIONS

While more males with TBI have emotion perception deficits than females, the difference appears to be driven by education and executive functioning. Research is needed in larger samples with more definitive norms to better understand social inferencing impairments in males and females with TBI, and translation to interpersonal behaviors.

Visual scanpath training to emotional faces following severe traumatic brain injury: A single case design

The visual scanpath to emotional facial expressions was recorded in BR, a 35-year-old male with chronic severe traumatic brain injury (TBI), both before and after he underwent intervention. The novel intervention paradigm combined visual scanpath training with verbal feedback and was implemented over a 3-month period using a single case design (AB) with one follow up session. At baseline BR's scanpath was restricted, characterised by gaze allocation primarily to salient facial features on the right side of the face stimulus. Following intervention his visual scanpath became more lateralised, although he continued to demonstrate an attentional bias to the right side of the face stimulus. This study is the first to demonstrate change in both the pattern and the position of the visual scanpath to emotional faces following intervention in a person with chronic severe TBI. In addition, these findings extend upon our previous work to suggest that modification of the visual scanpath through targeted facial feature training can support improved facial recognition performance in a person with severe TBI.

Examining the bidirectional association between emotion recognition and social autistic traits using observational and genetic analyses

BACKGROUND

There is mixed evidence for an association between autism spectrum disorder (ASD) and emotion recognition deficits. We sought to assess the bidirectionality of this association using phenotypic and genetic data in a large community sample.

METHODS

Analyses were conducted in three stages. First, we examined the bidirectional association between social autistic traits at age 8 years and emotion recognition task (ERT) responses at age 24 years (Study 1; N = 3,562); and between Diagnostic Analysis of Non-Verbal Accuracy (DANVA) emotion recognition responses at age 8 years and social autistic traits at age 10 years (Study 2; N = 9,071). Next, we used genetic analyses (Study 3) to examine the association between polygenic risk scores for ASD and outcomes for the ERT and DANVA. The genetic correlation between ASD and ERT responses at age 24 was also estimated. Analyses were conducted in the Avon Longitudinal Study of Parents and Children.

RESULTS

Social autistic traits at age 8 years were negatively associated with later total correct responses on ERT in Study 1 (b = -0.18; 95% CI: -0.27 to -0.09). We also found evidence of an association in Study 2 (b = -0.04; 95% CI: -0.05 to -0.03). We found the opposite association, that is positive, between the ASD polygenic risk score and ERT (b = 0.40; 95% CI: 0.10 to 0.70); however, this association varied across different p-value thresholds and would not survive multiple testing, so should be interpreted with caution. We did not find evidence of a genetic correlation between ASD and ERT.

CONCLUSION

We found an observational association between poorer emotion recognition and increased social autistic traits. Our genetic analyses may suggest a shared genetic aetiology between these or a potential causal pathway; however, future research would benefit from using better powered GWAS to examine this further. Our results may inform interventions targeting emotion recognition.

Sleep disturbances following traumatic brain injury are associated with poor neurobehavioral outcomes in U.S. military service members and veterans

STUDY OBJECTIVES

This study examined whether sleep disturbances were associated with neurobehavioral outcome following a traumatic brain injury (TBI) in a well characterized group of service members and veterans.

METHODS

Six-hundred and six participants were enrolled into the Defense and Veterans Brain Injury Center, 15-Year Longitudinal TBI study. All participants completed a battery of tests measuring self-reported sleep disturbances, neurobehavioral symptoms, and Posttraumatic Stress Disorder PTSD symptoms. Data were analyzed using analysis of variance with post-hoc comparisons. Four groups were analyzed separately: uncomplicated mild TBI (MTBI); complicated mild, moderate, severe, or penetrating - combined TBI (CTBI); injured controls (IC, i.e., orthopedic or soft-tissue injury without TBI); and non-injured controls (NIC).

RESULTS

A higher proportion of the MTBI group reported moderate-severe sleep disturbances (66.5%) compared to the IC (54.9%), CTBI (47.5%), and NIC groups (34.3%). Participants classified as having Poor Sleep had significantly worse scores on the majority of TBI-QOL scales compared to those classified as having Good Sleep, regardless of TBI severity or the presence of TBI. There was a significant interaction between sleep disturbances and PTSD. While sleep disturbances and PTSD by themselves were significant factors associated with worse outcome, both factors combined resulted in worse outcome than either singularly.

CONCLUSIONS

Regardless of group (injured or NIC), sleep disturbances were common and were associated with significantly worse neurobehavioral functioning. When experienced concurrently with PTSD, sleep disturbances pose significant burden to service members and veterans.

The relationship between vocal affect recognition and psychosocial functioning for people with moderate to severe traumatic brain injury: a systematic review

The purpose of this review was to explore how vocal affect recognition deficits impact the psychosocial functioning of people with moderate to severe traumatic brain injury (TBI). A systematic review following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines was conducted, whereby six databases were searched, with additional hand searching of key journals also completed. The search identified 1847 records after duplicates were removed, and 1749 were excluded through title and abstract screening. After full text screening of 65 peer-reviewed articles published between January 1999 and August 2019, only five met inclusion criteria. The methodological quality of selected studies was assessed using the Mixed Methods Appraisal Tool (MMAT) Version 2018 with a fair level of agreement reached. A narrative synthesis of the results was completed, exploring vocal affect recognition and psychosocial functioning of people with moderate to severe TBI, including aspects of social cognition (i.e., empathy; Theory of Mind) and social behaviour. Results of the review were limited by a paucity of research in this area, a lack of high-level evidence, and wide variation in the outcome measures used. More rigorous study designs are required to establish more conclusive evidence regarding the degree and direction of the association between vocal affect recognition and aspects of psychosocial functioning. This review is registered with Prospero.

Correlates of the personality change judgments of individuals who have MS

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

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.

Cognitive-communication difficulties following traumatic brain injury sustained in older adulthood: a scoping review

BACKGROUND

Older adults are a peak incidence group for traumatic brain injury (TBI). However, empirical evidence on TBI in older adults is often limited to extrapolated findings from studies involving younger adults. While cognitive-communication deficits are an established consequence of TBI with substantial impact on social outcome for younger adults, little is known about the nature of cognitive-communication changes experienced by older adults following a new-onset TBI. In order to inform evidence-based service delivery and support older adults who sustain TBI, it is important to understand how these difficulties manifest in older adults.

AIMS

To review the empirical literature to determine the nature and breadth of research that has addressed the influence of older age on cognitive-communication outcomes following TBI sustained in older adulthood.

METHODS & PROCEDURES

A scoping review framework was used. Five electronic databases (Medline, PsycINFO, Embase, CINAHL and Scopus) were searched to locate peer-reviewed studies addressing cognitive-communication following TBI sustained at ≥ 55 years. Given the absence of dedicated investigations within the search yield, studies were included where at least 30% of participants were aged ≥ 55 years at injury, and age was a stated focus of the investigation.

OUTCOMES & RESULTS

A total of 2468 unique records were identified and reduced to 225 after title and abstract screening. Full-text review revealed only three studies that met the criteria. Collectively these studies included adults aged 55-93 years at injury. Two studies focused on age as a predictor for acute cognitive-communication difficulty, and one on the impact of age on facial emotion recognition in the chronic stages of injury. None of the studies had a dedicated focus on cognitive-communication outcomes for older adults who sustained a TBI within the defined period of older adulthood.

CONCLUSIONS & IMPLICATIONS

This scoping review produced limited results and insufficient evidence to inform rehabilitation for older adults. Indeed, very little is known about cognitive-communication outcomes for older adults who sustain a TBI. This review highlights the need, in the context of an ageing population, for research within this area to be prioritized. What this paper adds What is already known on the subject Empirical evidence to support the management of post-TBI cognitive-communication difficulties in adults predominantly stems from studies with young adults. However, the broader TBI literature suggests that outcome for older adults requires specific consideration due to its distinct nature and occurrence during a stage of life when there is the potential for subtle change to the processes of cognition and communication as part of typical ageing. What this paper adds to existing knowledge This scoping review identifies that research related to cognitive-communication outcomes for older adults who have sustained a TBI is very much in its infancy. Overarching statements about post-TBI cognitive-communication outcomes for older adults cannot be drawn, nor can it be determined if outcomes for older adults differ from younger adults. What are the potential or actual clinical implications of this work? The lack of research in this area means that tangible guidance cannot be provided to clinicians working with older adults following TBI to support evidence-based practice for cognitive-communication. This scoping review strongly supports the need for further research in this area.

Surviving the "silent epidemic": A qualitative exploration of the long-term journey after traumatic brain injury

Previous studies examining life after traumatic brain injury (TBI) have taken a predominantly short-term and quantitative perspective, with generally narrow focus, and have not specifically investigated changes in experience over time post-injury to gain a uniquely long-term perspective. This study therefore aimed to qualitatively explore the broad long-term experience of living for 10 years or more with TBI. Thirty participants completed semi-structured interviews investigating the impact of TBI on various life domains, the rehabilitation experience and support received, and overall perspectives of the long-term journey after TBI. Results demonstrated that: (a) although some participants reported full recovery, several experienced persistent physical, cognitive and emotional problems that impacted their independence, employment and interpersonal relationships; (b) early rehabilitation was very helpful, but some participants experienced difficulties accessing ongoing services; (c) family and social support were important to recovery; (d) most participants drew upon inner strength to find positives in their experience. These findings have identified factors that facilitate and impede long-term recovery from TBI, which may inform better support and care for injured individuals over the years after injury to improve their quality of life.

An Emotional Agent for Moral Impairment Rehabilitation in TBI Patients

The ability to identify the emotions of others is a key component of what is known as social cognition. Narratives exploit this mechanism to create an emotional bond with the characters and to maintain the engagement of the audience throughout the story. In this paper, we illustrate a case study in emotion understanding in stories that exploits a computational agent to explore emotion impairment in a group of traumatic brain injured people. The study focuses on moral emotions, aiming to investigate the differences in moral functioning that characterize traumatic brain injured patients. After comparing the understanding of the moral and emotional facets of the agent's behavior in traumatic brain injured patients and in neurologically intact controls, slight-yet meaningful-differences were observed between the two groups. We describe the test methodology and results, highlighting their implications for the design of rehabilitation applications based on virtual agents.

Sex Differences in Emotional Insight After Traumatic Brain Injury

OBJECTIVE

To compare sex differences in alexithymia (poor emotional processing) in males and females with traumatic brain injury (TBI) and uninjured controls.

DESIGN

Cross-sectional study.

SETTING

TBI rehabilitation facility in the United States and a university in Canada.

PARTICIPANTS

Sixty adults with moderate to severe TBI (62% men) and 60 uninjured controls (63% men) (N=120).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Toronto Alexithymia Scale-20 (TAS-20).

RESULTS

Uninjured men had significantly higher (worse) alexithymia scores than uninjured female participants on the TAS-20 (P=.007), whereas, no sex differences were found in the TBI group (P=.698). Men and women with TBI had significantly higher alexithymia compared with uninjured same-sex controls (both P<.001). The prevalence of participants with scores exceeding alexithymia sex-based norms for men and women with TBI was 37.8% and 47.8%, respectively, compared with 7.9% and 0% for men and women without TBI.

CONCLUSIONS

Contrary to most findings in the general population, men with TBI were not more alexithymic than their female counterparts with TBI. Both men and women with TBI have more severe alexithymia than their uninjured same-sex peers. Moreover, both are equally at risk for elevated alexithymia compared with the norms. Alexithymia should be evaluated and treated after TBI regardless of patient sex.

Social cognition in patients with acquired brain lesions: An overview on an under-reported problem

Social cognition (SC) consists of mental representations of interpersonal relationships, which are used flexibly by the individual to promote functional social behaviors and achieve the goals. SC is a multidimensional construct and is supported by the activity of distributed neural networks in which different cortical and subcortical regions of the brain are involved. The review aims to evaluate the current literature on SC taking into account how it is compromised in acquired brain injury. Studies performed between 2010 and 2019 and fulfilling the selected criteria were searched on PubMed, Scopus, Cochrane and Web of Sciences databases. Impairment of SC is a neglected but common consequence of ABI, often leading to disordered interpersonal functioning and poor regulation of personal behavior with impaired social adaptation and quality of life of both the patient and his/her family. This review supports the idea that SC could have an important role in the management of neurological patients by both clinicians and caregivers.

The Psychosocial Impact of Neurobehavioral Disability

Neurobehavioral disability (NBD) comprises elements of executive and attentional dysfunction, poor insight, problems of awareness and social judgement, labile mood, altered emotional expression, and poor impulse control, any or all of which can have a serious impact upon a person's decision-making and capacity for social independence. The aim of this narrative review is to explore some of the more intrusive forms of NBD that act as obstacles to psychosocial outcome to act as a frame of reference for developing effective rehabilitation interventions. Special consideration is given to the psychosocial impact of three core forms of NBD: a failure of social cognition, aggressive behavior, and problems of drive/motivation. Consideration is also given to the developmental implications of sustaining a brain injury in childhood or adolescence, including its impact on maturational and social development and subsequent effects on long-term psychosocial behavior.

Sex and Gender Differences in Emotion Recognition and Theory of Mind After TBI: A Narrative Review and Directions for Future Research

A growing body of literature has examined sex differences in a variety of outcomes from moderate-severe traumatic brain injury (TBI), including outcomes for social functioning. Social functioning is an area in which adults with TBI have significant long-term challenges (1-4), and a better understanding of sex and gender differences in this domain may have a significant clinical impact. This paper presents a brief narrative review of current evidence regarding sex differences in one aspect of social functioning in adults with TBI: social cognition, specifically affect recognition and Theory of Mind (ToM). Data from typical adults and adults with TBI are considered in the broader context of common stereotypes about social skills and behaviors in men vs. women. We then discuss considerations for future research on sex- and gender-based differences in social cognition in TBI, and in adults more generally.

Theory of Mind Impairments Highlighted With an Ecological Performance-Based Test Indicate Behavioral Executive Deficits in Traumatic Brain Injury

Background: In view of the recent literature, the negative impact of traumatic brain injury (TBI) on social cognition remains a debated issue. On one hand, a considerable number of studies reported significant impairments in emotion recognition, empathy, moral reasoning, social problem solving, and mentalizing or theory of mind (ToM) abilities in patients with TBI. On the other hand, the ecological validity of social cognition tasks is still a matter of concern and debate for clinicians and researchers.

Objectives: The objectives of the present study were 2-fold: (1) to assess social cognition in TBI with an ecological performance-based test which focuses on ToM ability, and (2) to study the relationship between performances on this task and behavioral disorders. To this end, 47 patients with moderate to severe TBI in the chronic stage were assessed with a ToM task, the Movie for the Assessment of Social Cognition (MASC), a film displaying social interactions in natural settings and asking for an evaluation of the emotions, thoughts, and intentions of the characters. Behavioral disorders were assessed with the Behavioral Dysexecutive Syndrome Inventory (BDSI), a structured interview of an informant in assessing changes compared with previous behavior in 12 domains.

Results: Patients were significantly less accurate in mental state attribution than a demographically matched group of 38 healthy control subjects. Significant others of patients also reported more behavioral executive problems than controls' relatives on most of the domains of the BDSI. In addition, social cognition performance in the MASC was significantly correlated with behavioral dysexecutive problems rated by proxies on the BDSI.

Conclusions: This study is the first to find association between impairments in mentalizing abilities in the MASC and behavioral impairments in patients with TBI, confirming the added value of this ecological task and that the recognition of social signals is a key element for adequate behavioral functioning.

Default Mode Network Connectivity Predicts Emotion Recognition and Social Integration After Traumatic Brain Injury

Moderate-severe traumatic brain injury (TBI) may result in difficulty with emotion recognition, which has negative implications for social functioning. As aspects of social cognition have been linked to resting-state functional connectivity (RSFC) in the default mode network (DMN), we sought to determine whether DMN connectivity strength predicts emotion recognition and level of social integration in TBI. To this end, we examined emotion recognition ability of 21 individuals with TBI and 27 healthy controls in relation to RSFC between DMN regions. Across all participants, decreased emotion recognition ability was related to increased connectivity between dorsomedial prefrontal cortex (dmPFC) and temporal regions (temporal pole and parahippocampal gyrus). Furthermore, within the TBI group, connectivity between dmPFC and parahippocampal gyrus predicted level of social integration on the Community Integration Questionnaire, an important index of post-injury social functioning in TBI. This finding was not explained by emotion recognition ability, indicating that DMN connectivity predicts social functioning independent of emotion recognition. These results advance our understanding of the neural underpinnings of emotional and social processes in both healthy and injured brains, and suggest that RSFC may be an important marker of social outcomes in individuals with TBI.