Natural history of the long-term cognitive, affective, and physical sequelae of mild traumatic brain injury

Mild traumatic brain injury (MTBI) is associated with cognitive,affective, and physical sequelae. When symptoms persist for more than 3 months, a diagnosis of Post-Concussion Syndrome (PCS) is often given. The current study tracked symptom development to explore the natural sequelae of MTBI. Twenty-six MTBI patients received a comprehensive neuropsychological assessment at three intervals: within 1 week, at 4 months and at 7 months post-concussion. Based on DSMIV criteria and clinical judgment, two external raters diagnosed five MTBI participants with PCS. Results suggested that aspects of cognitive functioning of the symptomatic MTBI (i.e., PCS) participants were different from matched normal control (NC) subjects, and from the 21 MTBI patients who were asymptomatic, at 4 months. Asymptomatic MTBI participants improved in overall level of functioning from 4 to 7 months, but remained significantly different from NC participants in their reduced verbal fluency and working memory functioning.     

Amnesia, traumatic brain injury, and posttraumatic stress disorder: a methodological inquiry

This study explored the relationship between mild traumatic brain injury (MTBI), amnesia, and posttraumatic stress disorder (PTSD). MTBI status and amnesia for the event were assessed in 307 consecutive admissions to a Level 1 Trauma Center. Amnesia did not always occur concurrently with MTBI: 18% of those with MTBI had full recall and over half had partial recall of the event. Just over 10% of participants developed PTSD by 12 months post-injury, with prevalence comparable across MTBI and non-MTBI groups. Non-significant differences in incidence of PTSD were apparent between those with full recall (9%), partial recall (14%) and no recall (7%). These data highlight the fact that PTSD may develop following trauma despite amnesia for the event, and illustrate the importance in both clinical and research settings of carefully examining the extent of amnesia.     

Depression After Mild Traumatic Brain Injury: A Review of Current Research

Research pertaining to the occurrence of depression and/or depression symptomatology after a Mild Traumatic Brain Injury (MTBI) was reviewed. We found that methodological differences such as the criteria used to assess MTBI and depression, time that elapsed since brain injury, and control group variations confounded comparisons across studies. Nevertheless, the studies are consistent with at least a 35% prevalence of, and left frontal damage with depression after MTBI, an overlap of symptoms of depression and Postconcussion Syndrome (PCS), and indicate that depression can continue for many years following the injury. Our conclusion is that MTBI is the triggering event for a set of pathophysiological changes and a concomitant depressive episode in a vulnerable subset of the population. Due to a paucity of research, it cannot be definitively concluded that the underlying substrates of depression seen after MTBI and clinical depression are the same. Implications for future investigations are discussed.     

Mild Traumatic Brain Injury and Posttraumatic Stress Disorder in Returning Iraq and Afghanistan War Veterans: Implications for Assessment and Diagnosis

Mild traumatic brain injury (MTBI) and posttraumatic stress disorder (PTSD) are considered the “signature injuries” of combat soldiers returning from Iraq and Afghanistan. Both disorders can greatly affect the functioning of soldiers, yet the disorders often go undetected or are misdiagnosed by both military and civilian health care providers. This article provides information about MTBI and PTSD in returning combat soldiers along with implications for assessment and diagnosis.     

Assessment of performance validity in the Stroop Color and Word Test in mild traumatic brain injury patients: A criterion‐groups validation design

The current study assessed performance validity on the Stroop Color and Word Test (Stroop) in mild traumatic brain injury (TBI) using criterion‐groups validation. The sample consisted of 77 patients with a reported history of mild TBI. Data from 42 moderate–severe TBI and 75 non‐head‐injured patients with other clinical diagnoses were also examined. TBI patients were categorized on the basis of Slick, Sherman, and Iverson (1999) criteria for malingered neurocognitive dysfunction (MND). Classification accuracy is reported for three indicators (Word, Color, and Color–Word residual raw scores) from the Stroop across a range of injury severities. With false‐positive rates set at approximately 5%, sensitivity was as high as 29%. The clinical implications of these findings are discussed.     

Changes in coping style following traumatic brain injury and their relationship to productivity status

The use of maladaptive coping strategies following traumatic brain injury (TBI) is known to be associated with increased depression and a lower productivity status. What is not known is whether coping behaviours change following TBI and if they do change whether these changes account for significant variance in outcome. Seventy-three significant others of TBI survivors were recruited at the time their friend/family member was injured and followed prospectively. They reported on their friend/family member's pre-injury and 6-month coping behaviours using the Coping with Health Injuries and Problems Scale. The use of emotional pre-occupation coping (p = .02) increased significantly and approached significance for distraction coping(p = .08). These changes in coping also accounted for significant variance (22%, p = .02) in productivity status over and above that accounted for by demographics and injury severity. Whether maladaptive coping changes can be prevented with a view to improving outcomes is a question that now needs to be explored.     

Comprehensive driving assessment: neuropsychological testing and on-road evaluation of brain injured patients

The study investigates the correspondence between neuropsychological test results and on-road driving performance among 55 patients with a CT-verified brain damage or documented neurological disorder (cerebrovascular accident: 43, traumatic brain injury: 5, multiple sclerosis: 4, other: 3). 5 patients showed unimpaired test profiles and passed the on-road evaluation. 18 patients showed severe neuropsychological deficits contrary to driving and were not recommended for on-road evaluation. Of the remaining 32 patients with some neuropsychological deficits, all 100% in the minor impaired group (n = 8) passed the driving evaluation, compared to 69% in the mildly impaired (n = 16) and 38% in the moderately impaired group (n = 8). Measures of reduced visuoconstructive ability, reaction time, visual attention, and awareness of cognitive impairments, were found to discriminate between groups. It is concluded that neuropsychological assessment of targeted functions provide an ecological valid prediction of driving skill after brain damage, but that on-road evaluation is needed as supplement in cases with ambiguous test findings.     

Contribution of cognitive factors to the prediction of post-traumatic stress disorder, phobia and depression after motor vehicle accidents

Past research into the psychological consequences of traumatic events has largely focused on post-traumatic stress disorder (PTSD), although other anxiety disorders and depression are also common in the aftermath of trauma. Little is known about differential predictors of these conditions. The present study investigated the extent to which theoretically derived cognitive variables predict PTSD, phobias and depression after motor vehicle accidents. The cognitive predictors were compared to a set of established, mainly non-cognitive predictors. In addition, we tested how disorder-specific the cognitive predictors are. Participants (n=101) were interviewed within a year after having been injured in a motor vehicle accident. Diagnoses of PTSD, travel phobias and depression, symptom severities and predictor variables were assessed with self-report questionnaires and structured interviews. In multiple regression analyses, the sets of cognitive variables derived from disorder-specific models explained significantly greater proportions of the variance of the symptom severities than the established predictors (PTSD 76% vs. 45%, depression 72% vs. 46% and phobia 66% vs. 40%), and than cognitive variables derived from the models of the other disorders. In addition, the majority of individual cognitive variables showed the expected pattern of differences between diagnostic groups. The results support the hypothesis that disorder-specific sets of cognitive factors contribute to the development and maintenance of PTSD, phobias and depression following traumatic events.     

Behavioral Activation as an Early Intervention for Posttraumatic Stress Disorder and Depression Among Physically Injured Trauma Survivors

This paper describes an adaptation of behavioral activation (BA) for the early intervention of posttraumatic stress disorder (PTSD) and depression among physically injured survivors of traumatic injury, and presents pilot data on a small randomized effectiveness trial (N = 8). The application of BA to PTSD is based on the theory that increases in guided activity may break patterns of avoidance that can maintain PTSD. Compared to treatment as usual (TAU), those who received BA showed improvement in PTSD symptom severity from pre- to posttreatment, and there was a trend for the BA group to score better than the TAU group on physical functioning. Contrary to expectation, this brief adaptation did not have an impact on depression. Implications of these results for the effective early intervention after trauma are discussed.     

Lessons learned: the effect of prior technology use on Web-based interventions.

This study examined the role of regular prior technology use in treatment response to an online family problem-solving (OFPS) intervention and an Internet resource intervention (IRI) for pediatric traumatic brain injury (TBI). Participants were 150 individuals in 40 families of children with TBI randomly assigned to OFPS intervention or an IRI. All families received free computers and Internet access to TBI resources. OFPS families received Web-based sessions and therapist-guided synchronous videoconferences focusing on problem solving, communication skills, and behavior management. All participants completed measures of depression, anxiety, and computer usage. OFPS participants rated treatment satisfaction, therapeutic alliance, and Web site and technology comfort. With the OFPS intervention, depression and anxiety improved significantly more among technology using parents (n = 14) than nontechnology users (n = 6). Technology users reported increasing comfort with technology over time, and this change was predictive of depression at followup. Satisfaction and ease-of-use ratings did not differ by technology usage. Lack of regular prior home computer usage and nonadherence were predictive of anxiety at followup. The IRI was not globally effective. However, controlling for prior depression, age, and technology at work, there was a significant effect of technology at home for depression. Families with technology experience at home (n = 11) reported significantly greater improvements in depression than families without prior technology experience at home (n = 8). Although Web-based OFPS was effective in improving caregiver functioning, individuals with limited computer experience may benefit less from an online intervention due to increased nonadherence.     

Attention After Pediatric Traumatic Brain Injury: A Multidimensional Assessment

Attentional disturbance is a common complaint after TBI in children and adolescents, however, few studies have assessed post-traumatic attentional functions. The attentional constructs proposed by Mirsky, Anthony, Duncan, Ahearn, and Kellam (1991) provided a multidimensional framework for prospective assessment of late attentional disturbance after mild-moderate (n = 34) and severe (n = 57) traumatic brain injury (TBI). Attention was evaluated from 5 to 8 years after TBI in children ages 0 to 15 years at the time of injury. Children with severe TBI performed more poorly than children with mild-moderate TBI on tests comprising the focus/execute and shift constructs. Younger children scored below older children irrespective of injury severity on the Digit Span subtest and interstimulus interval scores from an adaptive rate continuous performance test reflecting the encode and sustain constructs of Mirsky et al. (1991). Age × Severity interaction effects were found for speeded perceptual-motor tests; scores were reduced following mild-moderate and severe TBI in younger children and following severe TBI in older patients. Results are discussed in terms of the vulnerability of skills in a rapid stage of development to disruption by acquired brain injury.     

Long‐Term Outcomes of Traumatic Brain Injury in Early Childhood

Mild traumatic brain injury (mTBI) is a leading cause of injury among children, with approximately 15% of children experiencing a TBI prior to 15 years of age. Acutely, mTBI has been associated with a range of cognitive, physical, emotional and behavioural impairments. However, few studies have examined outcomes beyond five years post injury, long before the developmental process is complete and the full extent of any deficits may manifest. Our group had the unique opportunity to use data from a longitudinal birth cohort of 1265 children (Christchurch Health and Development Study) to examine the long term outcomes of early injury (0–5 years). Information about these children, including mTBI events, had been collected at birth, 4 months and at yearly intervals until age 16, and again at ages 18, 21 and 25 years. We found that even after statistical control for a wide range of child and family confounds, children who had been hospitalized for an mTBI had increased inattention/hyperactivity and conduct as rated by mothers and teachers over ages 7–13 years. Increased rates of psychiatric disorders were over 14–16 years for those injured in the preschool, including symptoms consistent with Attention Deficit/Hyperactivity Disorder (ADHD), Odds Ratio = 4.6, Conduct Disorder (CD), Odds Ratio = 5.6 and Substance Abuse (Odds Ratio = 9.1). Over ages 21–25 ongoing behaviour problems were assessed using self‐reported arrests, violent offenses and property offenses. Compared to non‐injured individuals, mTBI groups were more likely to be arrested, involved in property, and violent offences. We controlled for a wide range of factors and there was still clear evidence of ongoing problems for individuals who had experienced a mTBI compared to their non injured counterparts. These findings provide compelling evidence of long term psychosocial and psychiatric outcomes following mTBI.     

Cognitive biases in processing infant emotion by women with depression,anxiety and post-traumatic stress disorder in pregnancy or after birth: A systematic review

Perinatal psychological problems such as post-natal depression are associated with poor mother–baby interaction, but the reason for this is not clear. One explanation is that mothers with negative mood have biased processing of infant emotion. This review aimed to synthesise research on processing of infant emotion by pregnant or post-natal women with anxiety, depression or post-traumatic stress disorder (PTSD). Systematic searches were carried out on 11 electronic databases using terms related to negative affect, childbirth and perception of emotion. Fourteen studies were identified which looked at the effect of depression, anxiety and PTSD on interpretation of infant emotional expressions (k = 10), or reaction times when asked to ignore emotional expressions (k = 4). Results suggest mothers with depression and anxiety are more likely to identify negative emotions (i.e., sadness) and less accurate at identifying positive emotions (i.e., happiness) in infant faces. Additionally, women with depression may disengage faster from positive and negative infant emotional expressions. Very few studies examined PTSD (k = 2), but results suggest biases towards specific infant emotions may be influenced by characteristics of the traumatic event. The implications of this research for mother–infant interaction are explored.     

Authenticity as a Mediator of the Relation Between Child Maltreatment and Negative Outcomes for College Women

The goal of this cross-sectional study was to determine if authenticity in relationships mediated the relation between early childhood maltreatment and negative outcomes (depression, low self-esteem, and traumatic symptoms). An ethnically diverse sample of female college students (N = 257, M age = 19.74) completed self-report questionnaires related to early childhood maltreatment, negative outcomes, and authenticity in relationships. Approximately 30% of participants experienced childhood maltreatment including physical maltreatment, emotional maltreatment, or both. Results from multiple mediation analyses indicated that, when controlling for physical maltreatment, authenticity in close relationships significantly partially mediated the relation between emotional maltreatment and depression, self-esteem, and traumatic symptoms (p < .05). However, when controlling for emotional maltreatment, physical maltreatment did not significantly predict any of the outcome variables, so physical maltreatment was not significantly mediated by authenticity in relationships. These results have important clinical implications for women who experience negative mental health outcomes as a result of childhood maltreatment.     

Stress and depression of facing death: Investigation of psychological symptoms in patients with mesothelioma

Cancer often results in psychological impairment, and lung cancer has been associated with greater morbidity and higher levels of psychological distress than any other form. Chronic exposure to asbestos is a significant risk factor for development of lung cancer, called mesothelioma. Few have studied the psychological consequences of chronic asbestos exposure and mesothelioma. This study investigated stress and depression symptoms in 49 men (M = 51.1 years, SD = 6.0) diagnosed with mesothelioma. Participants completed traumatic stress, depression and general psychological health questionnaires. All participants reported significant levels of traumatic stress symptoms, which was associated with increased symptoms of depression, anxiety, somatic complaints and social dysfunction. The results provide important suggestions for clinicians treating such terminally ill patients.     

Subjective improvement following treatment with carbamazepine (Tegretol) for a subpopulation of patients with traumatic brain injuries

Over a 3-yr period, 19 patients who had sustained brain traumas during motor vehicle incidents and who exhibited abnormal scores for a dichotic word-listening task and Roberts' Epileptic Spectrum Disorder Inventory more than one year after the injury were recommended for treatment with carbamazepine (Tegretol). The psychiatric profile of these patients, as defined by the Minnesota Multiphasic Personality Inventory, was similar to the profile of patients from other studies who had displayed more objective improvement following this treatment. Of the 14 patients 12 who followed the recommendation retrospectively reported that within a few weeks after treatment they experienced marked reductions in the incidence of sudden confusion and depression, increased attention and focus, and either elimination or attenuation of an aversive sensed presence. Such results suggest that many of the debilitating symptoms that persist for months to years after a traumatic brain injury may be electrical in nature rather than due to "psychological responses" and might be treatable by appropriate dosages of carbamazepine or other, e.g., Gabapentin (Neurontin) antiepileptic compounds.     

The Development of the Inventory of Problems–29: A Brief Self-Administered Measure for Discriminating Bona Fide From Feigned Psychiatric and Cognitive Complaints

This article describes the development of the Inventory of Problems–29 (IOP–29), a new, short, paper-and-pencil, self-administered measure of feigned mental and cognitive disorders. Four clinical comparison simulation studies were conducted. Study 1 (n = 451) selected the items and produced an index of potential feigning. Study 2 (n = 331) scaled this index to produce a probability score, and examined its psychometric properties. Study 3 tested the generalizability of Study 2's findings with 2 additional samples (ns = 128 and 90). Results supported the utility of the IOP–29 for discriminating bona fide from feigned psychiatric and cognitive complaints. Validity was demonstrated in feigning mild traumatic brain injury, psychosis, posttraumatic stress disorder, and depression. Within the independent samples of Studies 2 and 3, the brief IOP–29 performed similarly to the MMPI–2 and Personality Assessment Inventory, and perhaps better than the Test of Memory Malingering. Classifications within these samples with base rates of .5 produced sensitivity, specificity, positive predictive power, and negative predictive power statistics of about .80. Further research is needed testing the IOP–29 in ecologically valid field studies.     

Analgesia and other causes of amnesia that mimic post-traumatic amnesia (PTA): A cohort study

Objective. This study explores the possibility that a post-traumatic amnesia (PTA) like phenomenon is caused by the administration of drugs in hospital following injury and that this may be observed in patients who have not suffered a traumatic brain injury (TBI). This work also explored the possibility for an additional contribution to this phenomenon of demographic and psychological variables. Method. Sixty-three orthopaedic patients with no evidence of brain injury were recruited to a two-phase study. Medication records, demographic, and psychological data were obtained at the phase 1. At follow-up interviews (phase 2), psychological data (mood and post-traumatic stress disorder, PTSD) were again obtained and retrospective assessment of PTA using the Rivermead PTA protocol was carried out in 47 patients. Results. Thirty-eight per cent (N=18) of the total sample (N=47) reported a PTA-like phenomenon despite not having suffered TBI. A logistic regression model including the receipt of opioids, surgery, and anxiety-related variables, was significant in predicting this phenomenon (χ²=22.054, df=4, p≤.01) and accounted for up to 57.5% of variation in the data. Age, either alone or in interaction with opioid use, depression, and PTSD symptoms were not significant predictors. PTA-like phenomenon did not occur without at least one predictive factor. Conclusion. Receiving opioids, undergoing surgery, and suffering clinical levels of anxiety at an early stage following injury, can lead patients who have not suffered a TBI to report a PTA-like phenomenon at follow-up. This suggests that retrospective PTA assessment on actual brain injury patients may also be influenced by these factors.     

Sensitivity and specificity of reliable digit span in malingered pain-related disability

The reliable digit span (RDS) performance of chronic pain patients with unambiguous spinal injuries and no evidence of exaggeration or response bias (n = 53) was compared to that of chronic pain patients meeting criteria for definite malingered neurocognitive dysfunction (n = 35), and a group of nonmalingering moderate-severe traumatic brain injury (TBI) patients (n = 69). The results demonstrated that scores of 7 or lower were associated with high specificity (> .90) and sensitivity (up to .60) even when moderate to severe TBI are included. Multiple studies have demonstrated that RDS scores of 7 or lower rarely occur in TBI and pain patients who are not intentionally performing poorly on cognitive testing. This study supports the use of the RDS in detecting response bias in neuropsychological patients complaining of pain as well as in the assessment of pain-related cognitive impairment in patients whose primary complaint is pain.     

Depression Following Traumatic Brain Injury: The Validity of the CES-D as a Brief Screening Device

The validity, reliability, and factor structure of the Center for Epidemiological Studies-Depression Scale (CES-D) was examined with 253 patients seen for neuropsychological evaluation following traumatic brain injury (TBI). All patients completed the CES-D; 31 also completed the Beck Depression Inventory (BDI) and 17 completed the Minnesota Multiphasic Personality Inventory-II (MMPI-II). The CES-D demonstrated good concurrent, construct validity, significantly correlating with the BDI (r = .673, p < .0001) and the MMPI-II (Depression Scale T score r = .536, p = .027). The CES-D also demonstrated good internal consistency (coefficient alpha = .8195) and split-half reliability (Spearman–Brown r = .8284). Principal components factor analysis with varimax rotation resulted in a four-factor solution that accounted for 56.01% of the variance. The factor structure differed from the originally reported factor structure, and indicated that somatic difficulties were strongly associated with dysphoric affect in TBI patients. The CES-D is a valid and reliable screening instrument for use with TBI patients.