Psychiatric disorders after traumatic brain injury

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

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

Associations of Prior Head Injury With Mild Behavioral Impairment Domains

OBJECTIVE

This study investigated associations of prior head injury and number of prior head injuries with mild behavioral impairment (MBI) domains.

SETTING

The Atherosclerosis Risk in Communities (ARIC) Study.

PARTICIPANTS

A total of 2534 community-dwelling older adults who took part in the ARIC Neurocognitive Study stage 2 examination were included.

DESIGN

This was a prospective cohort study. Head injury was defined using self-reported and International Classification of Diseases, Ninth Revision ( ICD -9) code data. MBI domains were defined using the Neuropsychiatric Inventory Questionnaire (NPI-Q) via an established algorithm mapping noncognitive neuropsychiatric symptoms to the 6 domains of decreased motivation, affective dysregulation, impulse dyscontrol, social inappropriateness, and abnormal perception/thought content.

MAIN MEASURES

The primary outcome was the presence of impairment in MBI domains.

RESULTS

Participants were a mean age of 76 years, with a median time from first head injury to NPI-Q administration of 32 years. The age-adjusted prevalence of symptoms in any 1+ MBI domains was significantly higher among individuals with versus without prior head injury (31.3% vs 26.0%, P = .027). In adjusted models, a history of 2+ head injuries, but not 1 prior head injury, was associated with increased odds of impairment in affective dysregulation and impulse dyscontrol domains, compared with no history of head injury (odds ratio [OR] = 1.83, 95% CI = 1.13-2.98, and OR = 1.74, 95% CI = 1.08-2.78, respectively). Prior head injury was not associated with symptoms in MBI domains of decreased motivation, social inappropriateness, and abnormal perception/thought content (all P > .05).

CONCLUSION

Prior head injury in older adults was associated with greater MBI domain symptoms, specifically affective dysregulation and impulse dyscontrol. Our results suggest that the construct of MBI can be used to systematically examine the noncognitive neuropsychiatric sequelae of head injury; further studies are needed to examine whether the systematic identification and rapid treatment of neuropsychiatric symptoms after head injury is associated with improved outcomes.

Traumatic Brain Injury and Related Antisocial Behavioral Outcomes: A Systematic Review

Background and Objectives: Higher level of aggression and antisocial behavior have been found in the period following head trauma. These changes are attributable to specific brain alterations that generally involved frontal lobe, insula and limbic system. A descriptive review was conducted on the specificity of aggressive behavior in relation to traumatic brain injury by evaluating numerous variables, focusing on age at the time of trauma and neuroimaging studies. Materials and Methods: We searched on PubMed and the Web of Science databases to screen references of included studies and review articles for additional citations. From an initial 738 publications, only 27 met the search criteria of describing the relationship between aggression, brain alterations and traumatic brain injury. Results: These findings showed that traumatic brain injury (TBI) is related to changes in behavior, personality and mood. Conclusions: The development of aggressive and criminal behavior is associated with multiple factors, including the etiology of injury, environmental, psychosocial and personality factors and age at the time of trauma.

Cognitive functions and symptoms predicting later use of psychiatric services following mild traumatic brain injury in school-age

OBJECTIVE

To investigate whether neuropsychological test performance or presence of some specific injury symptoms at 1-3 months following pediatric mild traumatic brain injury (mTBI) can help to identify the children at risk for developing post-traumatic psychiatric symptoms.

METHODS

Data from 120 children and adolescents aged 7-15 years, treated at Turku University Hospital between 2010 and 2016 due to mTBI, and who had undergone neuropsychological evaluation at 1-3 months following injury, were enrolled from the hospital records. Neuropsychological test performancesand injury symptom reports were retrospectively retrieved from the patient files.

RESULTS

Slow information processing speed (p = 0.044), emotion regulation deficit (p = 0.014), impulsivity (p = 0.013), verbal processing difficulties (p = 0.042) and headache (p = 0.026) were independent predictors for having later contact in psychiatric care.

CONCLUSIONS

Neuropsychological examination containing measure of information processing speed, injury symptom interview, and parental questionnaires on behavioural issues of the child at 1-3 months following mTBI seems to be useful in detecting children with risk for post traumatic psychiatric symptoms. Targeted support and guidance for this group of children and adolescents and their families are recommended to prevent the development of an unfavorable psychosocial outcome.

Mania Following Traumatic Brain Injury: A Systematic Review

OBJECTIVE

Traumatic brain injury (TBI) is a leading cause of mortality and morbidity worldwide. Mania is an uncommon, but debilitating, psychiatric occurrence following TBI. The literature on mania following TBI is largely limited to case reports and case series. In the present review, the investigators describe the clinical, diagnostic, and treatment characteristics of mania following TBI.

METHODS

A systematic search of MEDLINE, EMBASE, and PsycINFO was conducted for English-language studies published from 1980 to July 15, 2021. The included studies provided the required individual primary data and sufficient information on clinical presentation or treatment of manic symptoms. Studies with patients who reported a history of mania or bipolar disorder prior to TBI and studies with patients who sustained TBI before adulthood were excluded.

RESULTS

Forty-one studies were included, which reported information for 50 patients (the mean±SD age at mania onset was 39.1±14.3 years). Patients were more frequently male, aged <50 years, and without a personal or family history of psychiatric disorders. Although 74% of patients reported mania developing within 1 year following TBI, latencies of up to 31 years were observed. Illness trajectory varied from a single manic episode to recurrent mood episodes. Rapid cycling was reported in six patients. Mood stabilizers and antipsychotics were most frequently used to improve symptoms.

CONCLUSIONS

Heterogeneity of lesion locations and coexisting vulnerabilities make causality difficult to establish. Valproate or a second-generation antipsychotic, such as olanzapine or quetiapine, may be considered first-line therapy in the absence of high-level evidence for a more preferred treatment. Early escalation to combined therapy (mood stabilizer and second-generation antipsychotic) is recommended to control symptoms and prevent recurrence. Larger prospective studies and randomized controlled trials are needed to refine diagnostic criteria and provide definitive treatment recommendations.

Psychotropic medication use among patients with a traumatic brain injury treated in the intensive care unit: a multi-centre observational study

BACKGROUND

Psychiatric sequelae after traumatic brain injury (TBI) are common and may impede recovery. We aimed to assess the occurrence and risk factors of post-injury psychotropic medication use in intensive care unit (ICU)-treated patients with TBI and its association with late mortality.

METHODS

We conducted a retrospective multi-centre observational study using the Finnish Intensive Care Consortium database. We included adult TBI patients admitted in four university hospital ICUs during 2003-2013 that were alive at 1 year after injury. Patients were followed-up until end of 2016. We obtained data regarding psychotropic medication use through the national drug reimbursement database. We used multivariable logistic regression models to assess the association between TBI severity, treatment-related variables and the odds of psychotropic medication use and its association with late all-cause mortality (more than 1 year after TBI).

RESULTS

Of 3061 patients, 2305 (75%) were alive at 1 year. Of these, 400 (17%) became new psychotropic medication users. The most common medication types were antidepressants (61%), antipsychotics (35%) and anxiolytics (26%). A higher Glasgow Coma Scale (GCS) score was associated with lower odds (OR 0.93, 95% CI 0.90-0.96) and a diffuse injury with midline shift was associated with higher odds (OR 3.4, 95% CI 1.3-9.0) of new psychotropic medication use. After adjusting for injury severity, new psychotropic medication use was associated with increased odds of late mortality (OR 1.19, 95% CI 1.19-2.17, median follow-up time 6.4 years).

CONCLUSIONS

Psychotropic medication use is common in TBI survivors. Higher TBI severity is associated with increased odds of psychotropic medication use. New use of psychotropic medications after TBI was associated with increased odds of late mortality. Our results highlight the need for early identification of potential psychiatric sequelae and psychiatric evaluation in TBI survivors.

Efficacy and Harms of Pharmacological Interventions for Anxiety after Traumatic Brain Injury: Systematic Review

After a traumatic brain injury (TBI), many persons experience significant and debilitating problems with anxiety. The aim of this systematic review was to critically evaluate the evidence regarding efficacy of pharmacological interventions for anxiety after TBI. We reviewed studies published in English before July 2020 and included original research on pharmacological interventions for anxiety after TBI in adults ≥16 years of age. MEDLINE, PubMed, CINAHL, EMBASE, PsycINFO, and CENTRAL databases were searched, with additional searching of key journals, clinical trials registries, and international drug regulators. The primary outcomes of interest were reduction in symptoms of anxiety and occurrence of harms. The secondary outcomes of interest were changes in depression, cognition, quality of life, and participation. Data were summarized in a narrative synthesis, and evidence quality was assessed using the Cochrane Risk of Bias tool. Only a single non-peer-reviewed, randomized controlled trial of 19 male military service members with mild TBI met inclusion criteria. This study found no significant effect of citalopram on anxiety symptoms over a 12-week intervention. The trial was stopped early because of poor recruitment, and much of the study detail was not included in the report. The methodological quality of the study was difficult to assess because of the lack of detail. No recommendations could be drawn from this review. There is a critical need for adequately powered and controlled studies of pharmacological interventions for anxiety after TBI across all severities that examine side-effect profiles and consider issues of comorbidity and effects of long-term pharmacotherapy.

Long-term follow-up of neurosurgical outcomes for adult patients in Uganda with traumatic brain injury

OBJECTIVE

Traumatic brain injury (TBI) is a major cause of mortality and morbidity in Uganda and other low- and middle-income countries (LMICs). Due to the difficulty of long-term in-person follow-up, there is a paucity of literature on longitudinal outcomes of TBI in LMICs. Using a scalable phone-centered survey, this study attempted to investigate factors associated with both mortality and quality of life in Ugandan patients with TBI.

METHODS

A prospective registry of adult patients with TBI admitted to the neurosurgical ward at Mulago National Referral Hospital was assembled. Long-term follow-up was conducted between 10.4 and 30.5 months after discharge (median 18.6 months). Statistical analyses included univariable and multivariable logistic regression and Cox proportional hazards regression to elucidate factors associated with mortality and long-term recovery.

RESULTS

A total of 1274 adult patients with TBI were included, of whom 302 (23.7%) died as inpatients. Patients who died as inpatients received surgery less frequently (p < 0.001), had more severe TBI at presentation (p < 0.001), were older (p < 0.001), and were more likely to be female (p < 0.0001). Patients presenting with TBI resulting from assault were at reduced risk of inpatient death compared with those presenting with TBI caused by road traffic accidents (OR 0.362, 95% CI 0.128-0.933). Inpatient mortality and postdischarge mortality prior to follow-up were 23.7% and 9%, respectively. Of those discharged, 60.8% were reached through phone interviews. Higher Glasgow Coma Scale score at discharge (continuous HR 0.71, 95% CI 0.53-0.94) was associated with improved long-term survival. Tracheostomy (HR 4.38, 95% CI 1.05-16.7) and older age (continuous HR 1.03, 95% CI 1.009-1.05) were associated with poor long-term outcomes. More than 15% of patients continued to suffer from TBI sequelae years after the initial injury, including seizures (6.1%) and depression (10.0%). Despite more than 60% of patients seeking follow-up healthcare visits, mortality was still 9% among discharged patients, suggesting a need for improved longitudinal care to monitor recovery progress.

CONCLUSIONS

Inpatient and postdischarge mortality remain high following admission to Uganda's main tertiary hospital with the diagnosis of TBI. Furthermore, posttraumatic sequelae, including seizures and depression, continue to burden patients years after discharge. Effective scalable solutions, including phone interviews, are needed to elucidate and address factors limiting in-hospital capacity and access to follow-up healthcare.

Depression and cognitive sequelae registered within the first year among young Danish TBI survivors

The aim of the study was to determine the proportion of depression and cognitive sequelae among young (15-30 years) Danish TBI survivors referred to interdisciplinary evaluation through a nationwide government-initiated health initiative. The cross-sectional study is based on data from the "Danish register for young adults with acquired brain injury" on TBI survivors included from October 2013 to December 2016. The main measures were Major depression inventory, Trail making test A and B, Fluency, Word learning with selective reminding, Matrix reasoning, Coding and Glasgow outcome scale - extended (GOS-E). During the study period, 131 young TBI survivors were referred to one of five national outpatient clinics. Ninety-six had complete data and of these 14.6% fulfilled the ICD-10 diagnostic criteria for depression and 34.4% had cognitive sequelae. An association was found between depression and cognitive sequelae (p = 0.004). Patients with both depression and cognitive sequelae (n = 10) had a significantly lower mean score on GOS-E (p = 0.0001). Depression and cognitive sequelae were frequent and associated with a poorer global functional outcome among young TBI survivors referred within a year after trauma. This finding and the notion that only 20% of the expected TBI population was referred to this nationwide health initiative indicate an unacknowledged need for interdisciplinary follow-up.

Measurement invariance of assessments of depression (PHQ-9) and anxiety (GAD-7) across sex, strata and linguistic backgrounds in a European-wide sample of patients after Traumatic Brain Injury

BACKGROUND

The Patient Health Questionnaire-9 (PHQ-9) and the Generalized Anxiety Disorder (GAD-7) are two widely used instruments to screen patients for depression and anxiety. Comparable psychometric properties across different demographic and linguistic groups are necessary for multiple group comparison and international research on depression and anxiety.

OBJECTIVES AND METHOD

We examine measurement invariance for the PHQ-9 and GAD-7 by: (a) the sex of the participants, (b) recruitment stratum, and (c) linguistic background. This study is based on non-randomized observational data six months after Traumatic Brain Injury (TBI) that were collected in 18 countries. We used multiple methods to detect Differential Item Functioning (DIF) including Item Response Theory, logistic regression, and the Mantel-Haenszel method.

RESULTS

At the 6-month post-injury, 2137 (738 [34.5%] women) participants completed the PHQ-9 and GAD-7 questionnaires: 885 [41.4%] patients were primarily admitted to the Intensive Care Unit (ICU), 805 [37.7%] were admitted to hospital ward, and 447 [20.9%] were evaluated in the Emergency Room and discharged. Results supported the invariance of PHQ-9 and GAD-7 across sex, patient strata and linguistic background. For different strata three PHQ-9 items and one GAD-7 item and for different linguistic groups only two GAD-7 items were flagged as showing differences in two out of four DIF tests. However, the magnitude of the DIF effect was negligible.

LIMITATION

Despite high number of participants from ICU, patients have mostly mild TBI.

CONCLUSION

The findings demonstrate adequate psychometric properties for PHQ-9 and GAD-7, allowing direct multigroup comparison across sex, strata, and linguistic background.

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

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

Peripheral Vestibular Organ Degeneration After Temporal Bone Fracture: A Human Otopathology Study

OBJECTIVES/HYPOTHESIS

Vestibular symptoms are a common sequela of temporal bone fractures (TBFs). The mechanisms of injury to the peripheral vestibular system following TBF, however, are not well described. Herein, we aimed to investigate the histopathology of the peripheral vestibular system in patients who sustained TBFs.

STUDY DESIGN

Retrospective human specimen analysis.

METHODS

Specimens from the National Temporal Bone Pathology Registry with (cases) and without (controls) TBFs were evaluated. Specimens were analyzed by light microscopy for vestibular hair cell and/or dendritic degeneration, presence of endolymphatic hydrops, blockage of the endolymphatic duct, and number of Scarpa ganglion cells (ScGCs) in the superior and inferior vestibular nerves.

RESULTS

Seven temporal bones (TBs) from five individuals with TBFs, and seven TBs from six age-matched individuals without a history of head injury met inclusion and exclusion criteria. All fractures involved the otic capsule. Severe degeneration of the cristae was identified in the semicircular canals in all TBF cases. The utricular and saccular maculae showed mild to severe degeneration in the TBF cases. Vestibular hydrops (n = 2 TBs) and blockage of the endolymphatic duct (n = 3 TBs) were also present in the TBF cases. There was a decrease of 52.6% in the mean total ScGC count in the TBF cases (n = 3 TBs) compared to age-matched controls (n = 7 TBs, P = .015). There was a mean loss of 53% of the ScGCs in the superior vestibular nerve and a mean loss of 52.3% of the ScGCs in the inferior vestibular nerve compared to age-matched controls (P = .033 and P = .021, respectively).

CONCLUSIONS

In a cohort of patients with TBFs, there were distinct peripheral vestibular changes including reduction of ScGCs.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:752-760, 2020.

Peripheral Vestibular System Histopathologic Changes following Head Injury without Temporal Bone Fracture

Objective

Vestibular symptoms such as dizziness and vertigo are common after head injury and may be due to trauma to the peripheral vestibular system. The pathophysiology of peripheral vestibular symptoms following head injury without temporal bone (TB) fracture, however, is not well understood. Herein, we investigate the histopathology of the peripheral vestibular system of patients who sustained head injury without a TB fracture.

Study Design

Otopathology study.

Setting

Otopathology laboratory.

Subjects and Methods

TB of subjects with a history of head injury without TB fractures were included and evaluated by light microscopy. Specimens were assessed for qualitative and quantitative characteristics, such as number of Scarpa’s ganglion cells in the superior and inferior vestibular nerves, vestibular hair cell and/or dendrite degeneration in vestibular end organs, presence of vestibular hydrops, and obstruction of the endolymphatic duct.

Results

Five cases (n = 5 TBs) had evidence of vestibular pathology. There was a decrease of 48.6% (range, 40%-59%) in the mean count of Scarpa’s ganglion cells as compared with that of normative historical age-matched controls. Moderate to severe degeneration of the vestibular membranous labyrinth was identified in the posterior, superior, and lateral canals in several cases (50%, n = 4 TBs). The maculae utriculi and sacculi showed mild to severe degeneration in 2 cases. Additional findings include vestibular hydrops (25%, n = 2 TBs) and blockage of the endolymphatic duct (n = 1 TB).

Conclusions

Otopathologic analysis of patients with a history of head injury without TB fracture demonstrated peripheral vestibular otopathology. Future studies are necessary to determine if otopathology findings are directly attributable to head injury.

Hemostatic nanoparticles increase survival, mitigate neuropathology and alleviate anxiety in a rodent blast trauma model

Explosions account for 79% of combat related injuries and often lead to polytrauma, a majority of which include blast-induced traumatic brain injuries (bTBI). These injuries lead to internal bleeding in multiple organs and, in the case of bTBI, long term neurological deficits. Currently, there are no treatments for internal bleeding beyond fluid resuscitation and surgery. There is also a dearth of treatments for TBI. We have developed a novel approach using hemostatic nanoparticles that encapsulate an anti-inflammatory, dexamethasone, to stop the bleeding and reduce inflammation after injury. We hypothesize that this will improve not only survival but long term functional outcomes after blast polytrauma. Poly(lactic-co-glycolic acid) hemostatic nanoparticles encapsulating dexamethasone (hDNPs) were fabricated and tested following injury along with appropriate controls. Rats were exposed to a single blast wave using an Advanced Blast Simulator, inducing primary blast lung and bTBI. Survival was elevated in the hDNPs group compared to controls. Elevated anxiety parameters were found in the controls, compared to hDNPs. Histological analysis indicated that apoptosis and blood-brain barrier disruption in the amygdala were significantly increased in the controls compared to the hDNPs and sham groups. Immediate intervention is crucial to mitigate injury mechanisms that contribute to emotional deficits.

Neuroplasticity of cognitive control networks following cognitive training for chronic traumatic brain injury

Cognitive control is the ability to coordinate thoughts and actions to achieve goals. Cognitive control impairments are one of the most persistent and devastating sequalae of traumatic brain injuries (TBI). There have been efforts to improve cognitive control in individuals with post-acute TBI. Several studies have reported changes in neuropsychological measures suggesting the efficacy of cognitive training in improving cognitive control. Yet, the neural substrates of improved cognitive control after training remains poorly understood. In the current study, we identified neural plasticity induced by cognitive control training for TBI using resting-state functional connectivity (rsFC). Fifty-six individuals with chronic mild TBI (9 years post-injury on average) were randomized into either a strategy-based cognitive training group (N = 26) or a knowledge-based training group (active control condition; N = 30) for 8 weeks. We acquired a total of 109 resting-state functional magnetic resonance imaging from 45 individuals before training, immediately post-training, and 3 months post-training. Relative to the controls, the strategy-based cognitive training group showed monotonic increases in connectivity in two cognitive control networks (i.e., cingulo-opercular and fronto-parietal networks) across time points in multiple brain regions (pvoxel < 0.001, pcluster < 0.05). Analyses of brain-behavior relationships revealed that fronto-parietal network connectivity over three time points within the strategy-based cognitive training group was positively associated with the trail making scores (pvoxel < 0.001, pcluster < 0.05). These findings suggest that training-induced neuroplasticity continues through chronic phases of TBI and that rsFC can serve as a neuroimaging biomarker of evaluating the efficacy of cognitive training for TBI.

Safe return to driving following severe acquired brain injury: role of a short neuropsychological assessment

BACKGROUND

Driving is a complex ability requiring a broad range of motor, cognitive-behavioral and visual skills that may be impaired after severe acquired brain injury (sABI). Resumption of driving is perceived as a major need by patients, being closely linked to personal autonomy, work and social activities.

AIM

The objective of this study was to identify a short battery of neuropsychological tests with predictive value with regard to safe return to driving after sABI.

DESIGN

Observational study.

SETTING

Outpatient of a rehabilitation center for sABI.

POPULATION

A continuous series of 127 patients with stable sABI, well-reintegrated at a family and social level, dismissed since at least one year from the end of their intensive rehabilitation, enrolled between 2006 and 2014.

METHODS

Patients underwent an extensive battery of neuropsychological tests (pencil and paper and specific PC programs), aimed at assessing cognitive functions, in performance and verbal tasks. The results were analyzed in relation to their on-road performance during the driving test conducted by the office of the Italian Government Authority (success or failure of the test).

RESULTS

No correlations were found between demographic data, etiology, driving experience, verbal competence and the decision of the competent authority. Significant correlation was found between attention, executive functions, overall visual-spatial exploration and driving performance.

CONCLUSIONS

Both "pencil and paper" and computerized tests in the cognitive domains of attentive functions, and those involving performance with visual-spatial material, are significantly correlated with the driving test outcome, even if there is not enough evidence of the relative value of off-road compared to direct on-road tests.

CLINICAL REHABILITATION IMPACT

We propose a small neuropsychological battery of tests with normative data for Italian population, predictive with respect to the ability to drive safely. We recommend to use it as first screening before submitting patients to more demanding and risky on-road driving tests.

Quantitative EEG Neurometric Analysis-Guided Neurofeedback Treatment in Postconcussion Syndrome (PCS): Forty Cases. How Is Neurometric Analysis Important for the Treatment of PCS and as a Biomarker?

Postconcussion syndrome (PCS) has been used to describe a range of residual symptoms that persist 12 months or more after the injury, often despite a lack of evidence of brain abnormalities on magnetic resonance imaging and computed tomography scans. In this clinical case series, the efficacy of quantitative EEG-guided neurofeedback in 40 subjects diagnosed with PCS was investigated. Overall improvement was seen in all the primary (Symptom Assessment-45 Questionnaire, Clinical Global Impressions Scale, Hamilton Depression Scale) and secondary measures (Minnesota Multiphasic Personality Inventory, Test of Variables for Attention). The Neuroguide Traumatic Brain Index for the group also showed a decrease. Thirty-nine subjects were followed up long term with an average follow-up length of 3.1 years (CI = 2.7-3.3). All but 2 subjects were stable and were off medication. Overall neurofeedback treatment was shown to be effective in this group of subjects studied.

Strategy-based reasoning training modulates cortical thickness and resting-state functional connectivity in adults with chronic traumatic brain injury

INTRODUCTION

Prior studies have demonstrated training-induced changes in the healthy adult brain. Yet, it remains unclear how the injured brain responds to cognitive training months-to-years after injury.

METHODS

Sixty individuals with chronic traumatic brain injury (TBI) were randomized into either strategy-based (N = 31) or knowledge-based (N = 29) training for 8 weeks. We measured cortical thickness and resting-state functional connectivity (rsFC) before training, immediately posttraining, and 3 months posttraining.

RESULTS

Relative to the knowledge-based training group, the cortical thickness of the strategy-based training group showed diverse temporal patterns of changes over multiple brain regions (pvertex < .05, pcluster < .05): (1) increases followed by decreases, (2) monotonic increases, and (3) monotonic decreases. However, network-based statistics (NBS) analysis of rsFC among these regions revealed that the strategy-based training group induced only monotonic increases in connectivity, relative to the knowledge-based training group (|Z| > 1.96, pNBS < 0.05). Complementing the rsFC results, the strategy-based training group yielded monotonic improvement in scores for the trail-making test (p < .05). Analyses of brain-behavior relationships revealed that improvement in trail-making scores were associated with training-induced changes in cortical thickness (pvertex < .05, pcluster < .05) and rsFC (pvertex < .05, pcluster < .005) within the strategy-based training group.

CONCLUSIONS

These findings suggest that training-induced brain plasticity continues through chronic phases of TBI and that brain connectivity and cortical thickness may serve as markers of plasticity.

Anxiety and comorbid depression following traumatic brain injury in a community-based sample of young, middle-aged and older adults

BACKGROUND

Anxiety is common following a traumatic brain injury (TBI), but who is most at risk, and to what extent, is not well understood.

METHODS

Longitudinal data from a randomly-selected community sample (Wave 1: 7397, Wave 2: 6621 and Wave 3: 6042) comprising three adult cohorts (young: 20-24 years of age, middle-aged: 40-44, older: 60-64), were analysed. The association between TBI history, anxiety and comorbid depression was assessed, controlling for age, sex, marital/employment status, medical conditions, recent life events, alcohol consumption, social support and physical activity.

RESULTS

Thirteen percent of the sample had sustained a TBI by Wave 3, 35% of whom had sustained multiple TBIs. Cross-sectional analyses revealed that clinically-significant anxiety was more common in people who had sustained a TBI. Longitudinal analyses demonstrated an increased risk of anxiety post-TBI, even after controlling for potential demographic, health and psychosocial confounds. Anxiety was more common than depression, although 10% of those with a TBI experienced comorbid anxiety/depression.

LIMITATIONS

TBIs were not medically confirmed and anxiety and depression were only assessed every four years by self-report, rather than clinical interview. Sample attrition resulted in the retention of healthier individuals at each wave.

CONCLUSIONS

TBIs are associated with a lifelong increased risk of experiencing clinically-significant anxiety, highlighting the chronic nature of TBI sequelae. Positive lifestyle changes (e.g., increasing physical activity, reducing alcohol consumption) may decrease the risk of anxiety problems in the early years after a TBI. Comorbid anxiety and depression was common, indicating that both should be monitored and treated.

Hyperbaric Oxygen Effects on Depression-Like Behavior and Neuroinflammation in Traumatic Brain Injury Rats

OBJECTIVE

The aim of this study was to determine whether hyperbaric oxygen (HBO) therapy causes attenuation of traumatic brain injury (TBI)-induced depression-like behavior and its associated anti-neuroinflammatory effects after fluid percussion injury.

METHODS

Anesthetized male Sprague-Dawley rats were divided into 3 groups: sham operation plus normobaric air (NBA) (21% oxygen at 1 absolute atmosphere [ATA]), TBI plus NBA, and TBI plus HBO (100% oxygen at 2.0 ATA). HBO was applied immediately for 60 min/d after TBI for 3 days. Depression-like behavior was tested by a forced swimming test, motor function was tested by an inclined plane test, and infarction volume was tested by triphenyltetrazolium chloride (TTC) staining on days 4, 8, and 15. Neuronal apoptosis (terminal deoxynucleotidyl transferase dUTP nick-end labeling assay), microglial (marker OX42) activation, and tumor necrosis factor (TNF)-α expression in microglia in the hippocampus CA3 were measured by immunofluorescence methods.

RESULTS

Compared with the TBI controls, without significant changes in TTC staining or in the motor function test, TBI-induced depression-like behavior was significantly attenuated by HBO therapy by day 15 after TBI. Simultaneously, TBI-induced neuronal apoptosis, microglial (marker OX42) activation, and TNF-α expression in the microglia in the hippocampus CA3 were significantly reduced by HBO.

CONCLUSIONS

Our results suggest that HBO treatment may ameliorate TBI-induced depression-like behavior in rats by attenuating neuroinflammation, representing one possible mechanism by which depression-like behavior recovery might occur. We also recommend HBO as a potential treatment for TBI-induced depression-like behavior if early intervention is possible.

Prevalence of and Risk Factors for Anxiety and Depressive Disorders after Traumatic Brain Injury: A Systematic Review

This review examined pre- and post-injury prevalence of, and risk factors for, anxiety disorders and depressive disorders after traumatic brain injury (TBI), based on evidence from structured diagnostic interviews. A systematic literature search was conducted in EMBASE, MEDLINE, Cochrane Central, PubMed, PsycINFO, and Google Scholar. We identified studies in civilian adults with TBI reporting on the prevalence of anxiety and depressive disorders using structured diagnostic interviews and assessed their quality. Pooled pre- and post-injury prevalence estimates of anxiety disorders and depressive disorders were computed. A total of 34 studies described in 68 publications were identified, often assessing anxiety disorders (n = 9), depressive disorders (n = 7), or a combination of disorders (n = 6). Prevalence rates of psychiatric disorders varied widely. Pooled prevalence estimates of anxiety and depressive disorders were 19% and 13% before TBI and 21% and 17% in the first year after TBI. Pooled prevalence estimates increased over time and indicated high long-term prevalence of Axis I disorders (54%), including anxiety disorders (36%) or depressive disorders (43%). Females, those without employment, and those with a psychiatric history before TBI were at higher risk for anxiety and depressive disorders after TBI. We conclude that a substantial number of patients encounter anxiety and depressive disorders after TBI, and that these problems persist over time. All health care settings should pay attention to the occurrence of psychiatric symptoms in the aftermath of TBI to enable early identification and treatment of these disorders and to enhance the recovery and quality of life of TBI survivors.

The emotional and behavioural consequences of traumatic brain injury

Recent published articles on emotional and behavioural consequences of trau matic brain injury (TBI) are reviewed. Database searches (Medline, Embase Psychiatry, CINAHL) for key terms (head injury, brain injury, adjustment, adapta tion, psychological, social, emotion, mood disorder) are used to identify relevant articles. The range of clinical problems reviewed include depression and anxiety, post-traumatic stress symptoms, apathy and anger. Comment is made on adjust ment to the effects of brain injury, including family adjustment and changes in presentation over the time course of recovery. Conclusions are drawn recognizing the importance of treatment for the psychological effects of TBI.

Manic Symptoms Due to Methylphenidate Use in an Adolescent with Traumatic Brain Injury

Almost one-fifth of children who sustain a traumatic brain injury (TBI) are under the risk of attention problems after injury. The efficacy and tolerability of methylphenidate (MPH) in children with a history of TBI have not been completely identified. In this case report, MPH-induced manic symptoms in an adolescent with TBI will be summarized. A male patient aged 17 years was admitted with the complaints of attention difficulties on schoolwork and forgetfullness which became evident after TBI. Long-acting MPH was administered with the dose of 18 mg/day for attention problems. After one week, patient presented with the complaints of talking to himself, delusional thoughts, irritability and sleeplessness. This case highlights the fact that therapeutic dose of MPH may cause mania-like symptoms in children with TBI. Close monitarization and slow dose titration are crucial when considering MPH in children with TBI.

Emotional Risk Factors and Postconcussional Disorder

Emotional risk factors were examined in 129 litigant and nonlitigant patients diagnosed with Postconcussional Disorder (PCD) following Mild Traumatic Brain Injury (MTBI). According to Millon Clinical Multiaxial Inventory (MCMI) criteria, four subgroups emerged: (a) 14.7% met criteria for an Axis I disorder, (b) 24.8% for an Axis II disorder, (c) 24.0% for bout Axis I and II disorders, and (d) 36.4% fell below threshold for psychopathology. Thus, 63.5% endorsed emotional pathology. Of the four groups, those with both Axis I and II psychopathology presented the greatest number of emotional complaints in a clinical interview and manifested the lowest neurocognitive test scores. Motor skills, verbal abilities, memory functioning, and IQ were primarily affected. With the exception of post-morbid emotional complaints, no significant differences were identified between litigants and nonlitigants. Our analysis suggests that the combination of both Axis I and II psychopathology is associated with greater impairment following MTBI.

Organic Bipolar Disorder: An Unusual Neuropsychiatric Sequelae following Right Frontotemporal Injury

Psychiatric disorders are common consequences of traumatic brain injury (TBI). But organic bipolar disorder is a rare entity when compared with other disorders. Here, we report this 49 year old patient with bipolar affective disorder following traumatic brain injury, its presentation and management. Though the pathophysiology of this disorder involves the interaction of factors that precede trauma (eg, genetic vulnerability and previous psychiatric history), factors that pertain to the traumatic injury itself (eg, type, extent, and location of brain damage), in our patient it showed an atypical presentation.

A prospective examination of Axis I psychiatric disorders in the first 5 years following moderate to severe traumatic brain injury

BACKGROUND

Psychiatric disorders commonly emerge during the first year following traumatic brain injury (TBI). However, it is not clear whether these disorders soon remit or persist for long periods post-injury. This study aimed to examine, prospectively: (1) the frequency, (2) patterns of co-morbidity, (3) trajectory, and (4) risk factors for psychiatric disorders during the first 5 years following TBI.

METHOD

Participants were 161 individuals (78.3% male) with moderate (31.2%) or severe (68.8%) TBI. Psychiatric disorders were diagnosed using the Structured Clinical Interview for DSM-IV, administered soon after injury and 3, 6 and 12 months, and 2, 3, 4 and 5 years post-injury. Disorder frequencies and generalized estimating equations were used to identify temporal relationships and risk factors.

RESULTS

In the first 5 years post-injury, 75.2% received a psychiatric diagnosis, commonly emerging within the first year (77.7%). Anxiety, mood and substance-use disorders were the most common diagnostic classes, often presenting co-morbidly. Many (56.5%) experienced a novel diagnostic class not present prior to injury. Disorder frequency ranged between 61.8 and 35.6% over time, decreasing by 27% [odds ratio (OR) 0.73, 95% confidence interval (CI) 0.65-0.83] with each year post-injury. Anxiety disorders declined significantly over time (OR 0.73, 95% CI 0.63-0.84), whilst mood and substance-use disorder rates remained stable. The strongest predictors of post-injury disorder were pre-injury disorder (OR 2.44, 95% CI 1.41-4.25) and accident-related limb injury (OR 1.78, 95% CI 1.03-3.07).

CONCLUSIONS

Findings suggest the first year post-injury is a critical period for the emergence of psychiatric disorders. Disorder frequency declines thereafter, with anxiety disorders showing greater resolution than mood and substance-use disorders.

Altered Amygdala Connectivity in Individuals with Chronic Traumatic Brain Injury and Comorbid Depressive Symptoms

Depression is one of the most common psychiatric conditions in individuals with chronic traumatic brain injury (TBI). Though depression has detrimental effects in TBI and network dysfunction is a "hallmark" of TBI and depression, there have not been any prior investigations of connectivity-based neuroimaging biomarkers for comorbid depression in TBI. We utilized resting-state functional magnetic resonance imaging to identify altered amygdala connectivity in individuals with chronic TBI (8 years post-injury on average) exhibiting comorbid depressive symptoms (N = 31), relative to chronic TBI individuals having minimal depressive symptoms (N = 23). Connectivity analysis of these participant sub-groups revealed that the TBI-plus-depressive symptoms group showed relative increases in amygdala connectivity primarily in the regions that are part of the salience, somatomotor, dorsal attention, and visual networks (p voxel < 0.01, p cluster < 0.025). Relative increases in amygdala connectivity in the TBI-plus-depressive symptoms group were also observed within areas of the limbic-cortical mood-regulating circuit (the left dorsomedial and right dorsolateral prefrontal cortices and thalamus) and the brainstem. Further analysis revealed that spatially dissociable patterns of correlation between amygdala connectivity and symptom severity according to subtypes (Cognitive and Affective) of depressive symptoms (p voxel < 0.01, p cluster < 0.025). Taken together, these results suggest that amygdala connectivity may be a potentially effective neuroimaging biomarker for comorbid depressive symptoms in chronic TBI.

Disadvantageous decision-making on a rodent gambling task is associated with increased motor impulsivity in a population of male rats

BACKGROUND

Impulsivity is understood as a range of behaviours, but the association between these behaviours is not well understood. Although high motor impulsivity is a key symptom of disorders like pathological gambling and addiction, in which decision-making on laboratory tasks is compromised, there have been no clear demonstrations that choice and motor impulsivity are associated in the general population. We examined this association in a large population of rodents.

METHODS

We performed a meta-analysis on behavioural data from 211 manipulation-naive male animals that performed a rodent gambling task in our laboratory between 2008 and 2012. The task measures an aspect of both impulsive decision-making and impulsive action, making it possible to evaluate whether these 2 forms of maladaptive behaviour are related.

RESULTS

Our meta-analysis revealed that motor impulsivity was positively correlated with poor decision-making under risk. Highly motor impulsive rats were slower to adopt an advantageous choice strategy and quicker to make a choice on individual trials.

LIMITATIONS

The data analyzed were limited to that produced by our laboratory and did not include data of other researchers who have used the task.

CONCLUSION

This work may represent the first demonstration of a clear association between choice and motor impulsivity in a nonclinical population. This lends support to the common practice of studying impulsivity in nonclinical populations to gain insight into impulse control disorders and suggests that differences in impulsive behaviours between clinical and nonclinical populations may be ones of magnitude rather than ones of quality.

The manifestation of anxiety disorders after traumatic brain injury: a review

The development of anxiety disorders after a traumatic brain injury (TBI) is a strong predictor of social, personal, and work dysfunction; nevertheless, the emergence of anxiety has been largely unexplored and poorly understood in the context of TBI. This article provides an overview of the limited published research to date on anxiety disorders that are known to develop after TBI, including post-traumatic stress disorder, generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, specific phobia, and social anxiety disorder. This review also examines diagnostic criteria, the epidemiology of each disorder, and the factors that influence the expression of these conditions, including injury-related and psychosocial variables. Putative neural correlates will be reviewed where known. A discussion of current treatment options and avenues for further research are explored.

Considerations for return to work following traumatic brain injury

Population-based studies have demonstrated that a history positive for traumatic brain injury (TBI) can result in cognitive impairment, behavioral alterations, and pain. These outcomes can and do influence occupational function, can affect others in the workplace, and raise concerns about workplace safety upon re-entry to the workplace. Risk for long-term impairment and disability can in some cases be mitigated by assessment of capabilities relative to job duties, conservative return-to-work schedules, and, in some cases, interventions to support that return. For those in occupations at high risk for brain injury, including first responders, soldiers, and construction workers, the long-term risk of brain injury as a risk factor for neurodegenerative disease must and should inform increased concern for those with repeated injuries to the brain over the course of their lifetime and career. This chapter reviews the risks of TBI, considers factors that optimize functional recovery, and discusses potential interventions and factors that aid in return to the workplace.

Long-term social integration and community support

TBI often results in reduced social participation. This decrease in social participation is independent of injury severity and time since injury. Thus, it is one of the many stable hallmarks of TBI. Changes in social participation have been related to many factors, including emotional dysregulation and disturbance and executive dysfunction. While there are evidenced-based treatments available to improve mood and executive functioning, none of the research has examined the impact of the various treatments on social participation or social integration. Therefore, while it is reasonable to expect that individuals who are feeling better about themselves and who improve their approach to day-to-day function will also experience increased social contact, there is no evidence to support this claim. This chapter reviews the literature on post-TBI social integration and its relationship to depression and executive dysfunction. In addition the intervention research in this area is briefly examined.

Mood disorders

Mood disturbances, especially depressive disorders, are the most frequent neuropsychiatric complication of traumatic brain injury (TBI). These disorders have a complex clinical presentation and are highly comorbid with anxiety, substance misuse, and other behavioral alterations such as impulsivity and aggression. Furthermore, once developed, mood disorders tend to have a chronic and refractory course. Thus, the functional repercussion of these disorders is huge, affecting the rehabilitation process and the long-term outcome of TBI patients. The pathophysiology of mood disorders involves the interplay of factors that precede trauma (e.g., genetic vulnerability and previous psychiatric history), factors that pertain to the traumatic injury itself (e.g., type, extent, and location of brain damage) and factors that influence the recovery process (e.g., family and social support). It is hardly surprising that mood disorders are associated with structural and functional changes of neural circuits linking brain areas specialized in emotional processing such as the prefrontal cortex, basal ganglia, and amygdala. In turn, the onset of mood disorders may contribute to further prefrontal dysfunction among TBI patients. Finally, in spite of the prevalence and impact of these disorders, there have been relatively few rigorous studies of therapeutic options. Development of treatment strategies constitutes a priority in this field of research.

Clinical and neuropsychological correlates of major depression following post-traumatic brain injury, a prospective study

OBJECTIVES

Major depression disorder (MDD) is the most frequent psychiatric complication after traumatic brain injury (TBI), with a prevalence of 14-77%. The aim of this study was to analyse the psychiatric sequelae of TBI, and to identify the neuropsychological and psychopathological correlates of post-TBI MDD in order to highlight their differences from those of primary MDD.

METHODS

This was a longitudinal, prospective, case-control study. Sixteen patients with closed brain injury, and a lesion revealed by computed tomography (CT), were recruited and were evaluated one (T1), three (T3) and six (T6) months after discharge from Neurosurgery Department; the controls were six patients with MDD. The psychiatric symptoms were evaluated using brief psychiatric rating scale (BPRS), Hamilton depression rating scale (HRSD), Beck depression inventory scale (BDI), Hamilton anxiety rating scale (HRSA), global assessment of functioning (GAF) and instrumental activity of daily living (IADL). Neuropsychological profiles were assessed by using neuropsychological tests, focused on memory and frontal-executive functioning.

RESULTS

At T1, MDD was observed in 10 cases (62.5%), a manic episode in 12.5%, and post-traumatic stress disorder in 6.5%. At T3 and T6, MDD was diagnosed in, respectively, eight (50%) and six cases (37.5%). Post TBI MDD had less severe depressive symptoms, showed greater social isolation and hostility and more cognitive deficits in comparison with the control group.

CONCLUSIONS

MDD is a frequent TBI complication. Patients with post-TBI MDD have a specific psychopathological profile characterised by a less severe depressive symptomatology and a neuropsychological pattern that is significantly associated with greater deficits in cognitive functions than those with primary MDD.

Relationship between employment status and sexual functioning after traumatic brain injury

OBJECTIVE

To determine if correlations exist between employment status and sexual functioning in persons with traumatic brain injury (TBI).

DESIGN

Descriptive cross-sectional.

SETTING

Community.

PARTICIPANTS

One hundred and forty-six English-speaking, community dwelling adults, without other neurological or psychiatric disorder that could impact outcome and (1) enrolled in TBI Model Systems sexuality study database or (2) admitted to Rehabilitation Institute of Chicago with primary diagnosis of TBI between 2004-2006.

MAIN OUTCOME MEASURES

Employment status, annual income, Derogatis Interview for Sexual Functioning Self Report (DISF-SR) sum and sub-scale scores, Global Sexual Satisfaction Index (GSSI).

RESULTS

No significant difference was found in GSSI scores between employed, unemployed or students/volunteers (p = 0.20); however, lower income marginally correlated with lower GSSI scores (p = 0.09). Marginally significant lower DISF-SR Sexual Cognition sub-group (p = 0.09) scores were found in unemployed vs. employed. Lower annual income also correlated with lower DISF-SR sum scores (p = 0.06), Sexual cognition/fantasy (p = 0.07), Orgasm/ejaculation (p = 0.003) and Sexual drive and relationship (p = 0.01) scores.

CONCLUSIONS

Lower quality sexual functioning and satisfaction was present in persons with TBI and concomitant unemployment or lower annual income. Efforts are needed to increase awareness amongst the TBI population and rehabilitation professionals of the potential impact unemployment or financial stress has on sexual functioning and satisfaction.

Family functioning, psychosocial stress, and goal attainment in brain injury rehabilitation

The study investigated the impact of family functioning (as measured by the Family Assessment Device) on goal attainment (as measured by a Goal Attainment Scale) and psychosocial distress (as measured by the Brief Symptom Inventory-18) among survivors of acquired brain injury in a community re-entry rehabilitation setting. The bivariate analysis suggests that participants had significantly greater goal attainment scores if they were members of families with stronger general functioning (r = .27, p < .05), stronger defined family roles (r = .28, p < .05), a greater capacity to respond emotionally to each other (r = .29, p < .05), and proactively solved family problems (r = .28, p < .05).

Patient Characterization Protocols for Psychophysiological Studies of Traumatic Brain Injury and Post-TBI Psychiatric Disorders

Psychophysiological investigations of traumatic brain injury (TBI) are being conducted for several reasons, including the objective of learning more about the underlying physiological mechanisms of the pathological processes that can be initiated by a head injury. Additional goals include the development of objective physiologically based measures that can be used to monitor the response to treatment and to identify minimally symptomatic individuals who are at risk of delayed-onset neuropsychiatric disorders following injury. Research programs studying TBI search for relationships between psychophysiological measures, particularly ERP (event-related potential) component properties (e.g., timing, amplitude, scalp distribution), and a participant's clinical condition. Moreover, the complex relationships between brain injury and psychiatric disorders are receiving increased research attention, and ERP technologies are making contributions to this effort. This review has two objectives supporting such research efforts. The first is to review evidence indicating that TBI is a significant risk factor for post-injury neuropsychiatric disorders. The second objective is to introduce ERP researchers who are not familiar with neuropsychiatric assessment to the instruments that are available for characterizing TBI, post-concussion syndrome, and psychiatric disorders. Specific recommendations within this very large literature are made. We have proceeded on the assumption that, as is typically the case in an ERP laboratory, the investigators are not clinically qualified and that they will not have access to participant medical records.

Involvement of extracellular signal regulated kinases in traumatic brain injury-induced depression in rodents

Traumatic brain injury (TBI) is the most common cause of death and acquired disability among children and young adults in the developed countries. In clinical studies, the incidence of depression is high after TBI, and the mechanisms behind TBI-induced depression remain unclear. In the present study, we subjected rats to a moderate fluid percussion into the closed cranial cavity to induce TBI. After 3 days of recovery, injured rats were given a forced swim test (FST) and novelty-suppressed feeding tests. We found that TBI rats exhibited increased duration of immobility and longer latency to begin chewing food in a new environment compared with sham-operated rats. Western blot analysis showed that TBI led to a decrease in the phosphorylated levels of extracellular signal regulated kinases (ERK1/2) and p38 mitogen-activated protein kinase (p38 MAPK). Fluoxetine, a selective serotonin reuptake inhibitor (SSRI), significantly reduced the duration of immobility when administered once per day for 14 days. Consistent with behavioral tests, fluoxetine treatment reversed TBI-induced decrease in p-ERK1/2 and p-p38 MAPK levels. Pre-treatment with a selective tryptophan hydroxylase inhibitor para-chlorophenylalanine (PCPA) blocked the antidepressant effect of fluoxetine. PCPA also prevented the effect of fluoxetine on ERK1/2 phosphorylation without affecting p38 MAPK phosphorylation. Pre-treatment with ERK inhibitor SL327 but not p38 MAPK inhibitor SB203580 prevented the antidepressant effect of fluoxetine. These results suggest that ERK1/2 plays a critical role in TBI-induced depression.