Annemarie C. Visser-Keizer

Speed of information processing after unilateral stroke

Speed of information processing in the subacute stage after stroke was studied in 88 first ever, unilateral, ischemic stroke patients. The patient group included 42 right and 46 left hemisphere patients. Seventy-one control subjects were also examined. Four reaction time tasks with different levels of complexity were used: two visuomotor, and two semantic categorisation tasks. The results showed that stroke causes a decrease in decision making speed, but that the effect is different for right and left hemisphere patients. The right hemisphere group were slower than the control group on all reaction time tasks, and slower than the left hemisphere patients on the visuomotor tasks. The left hemisphere patients were slower than the healthy controls, only on the most complex tasks, the categorisation tasks.

Deficits in facial emotion recognition indicate behavioral changes and impaired self-awareness after moderate to severe traumatic brain injury.

Traumatic brain injury (TBI) is a leading cause of disability, specifically among younger adults. Behavioral changes are common after moderate to severe TBI and have adverse consequences for social and vocational functioning. It is hypothesized that deficits in social cognition, including facial affect recognition, might underlie these behavioral changes. Measurement of behavioral deficits is complicated, because the rating scales used rely on subjective judgement, often lack specificity and many patients provide unrealistically positive reports of their functioning due to impaired self-awareness. Accordingly, it is important to find performance based tests that allow objective and early identification of these problems. In the present study 51 moderate to severe TBI patients in the sub-acute and chronic stage were assessed with a test for emotion recognition (FEEST) and a questionnaire for behavioral problems (DEX) with a self and proxy rated version. Patients performed worse on the total score and on the negative emotion subscores of the FEEST than a matched group of 31 healthy controls. Patients also exhibited significantly more behavioral problems on both the DEX self and proxy rated version, but proxy ratings revealed more severe problems. No significant correlation was found between FEEST scores and DEX self ratings. However, impaired emotion recognition in the patients, and in particular of Sadness and Anger, was significantly correlated with behavioral problems as rated by proxies and with impaired self-awareness. This is the first study to find these associations, strengthening the proposed recognition of social signals as a condition for adequate social functioning. Hence, deficits in emotion recognition can be conceived as markers for behavioral problems and lack of insight in TBI patients. This finding is also of clinical importance since, unlike behavioral problems, emotion recognition can be objectively measured early after injury, allowing for early detection and treatment of these problems.

Subjective changes in emotion, cognition and behaviour after stroke: Factors affecting the perception of patients and partners

The presence and severity of changes in emotion and cognition experienced by left- and right-sided stroke patients and observed by their partners were compared at 3 months poststroke. The results showed that, regardless of the side of stroke, several changes were reported by half of the stroke patients and their partners. It appeared that while left hemisphere stroke patients agreed with their partners on the number and severity of most changes, partners of right hemisphere patients reported more frequent and more severe changes than the patients themselves. The level of observability of the altered behaviour, distress of the partner, distress of left-sided stroke patients and hemispatial neglect of right-sided stroke patients emerged as factors related to disagreement between stroke patient and partner.

Performance of healthy subjects on an ecologically valid test for social cognition: The short, Dutch Version of The Awareness of Social Inference Test (TASIT)

The present paper addresses the psychometric quality of the shortened Dutch version of The Awareness of Social Inference Test (TASIT), a social cognition task comprising dynamic social interactions. Because the original TASIT required a rather long administration time, two shortened parallel forms were developed. Results showed that TASIT–short was feasible and that the two alternate forms were reasonably comparable in a group of neurologically healthy individuals (N = 98). Also, the results confirmed the ecological validity of TASIT–short in this healthy group. The test appeared sensitive to brain injury as it differentiated between the healthy subjects and a group of patients with acquired brain injury (N = 16). On the basis of the present study we conclude that TASIT–short has added value to the assessment of social cognition in patients with acquired brain injury.

Effectiveness of a Treatment for Impairments in Social Cognition and Emotion Regulation (T-ScEmo) After Traumatic Brain Injury: A Randomized Controlled Trial

Objective: To evaluate the effects of a multifaceted Treatment for Social cognition and Emotion regulation (T-ScEmo) in patients with a traumatic brain injury. Participants: Sixty-one patients with moderate to severe traumatic brain injury randomly assigned to an experimental T-ScEmo intervention or a Cogniplus control condition. Interventions: T-ScEmo is a compensatory strategy training for impairments in emotion recognition, theory of mind, and social behavioral skills. Cogniplus is a computerized cognitive function training. Both interventions were given in 16 to 20 weekly 1-hour sessions. Main Measures: Social cognition tests and questionnaires for social behavior (self- and proxy-rated) administered at baseline, immediately posttreatment, and at 3 to 5 months of follow-up. Results: Compared with the Cogniplus group, the T-ScEmo group improved significantly on facial affect recognition, theory of mind, proxy-rated empathic behavior, societal participation, and treatment goal attainment, which lasted up to 5 months after treatment. At follow-up, the T-ScEmo group also reported higher quality of life and their life partners rated relationship quality to be higher than the Cogniplus group. Conclusion: This study shows that impairments in social cognition can be effectively dealt with by using a comprehensive treatment protocol, leading to improvements in everyday life social functioning.

To Fear is to Gain? The Role of Fear Recognition in Risky Decision Making in TBI Patients and Healthy Controls

Fear is an important emotional reaction that guides decision making in situations of ambiguity or uncertainty. Both recognition of facial expressions of fear and decision making ability can be impaired after traumatic brain injury (TBI), in particular when the frontal lobe is damaged. So far, it has not been investigated how recognition of fear influences risk behavior in healthy subjects and TBI patients. The ability to recognize fear is thought to be related to the ability to experience fear and to use it as a warning signal to guide decision making. We hypothesized that a better ability to recognize fear would be related to a better regulation of risk behavior, with healthy controls outperforming TBI patients. To investigate this, 59 healthy subjects and 49 TBI patients were assessed with a test for emotion recognition (Facial Expression of Emotion: Stimuli and Tests) and a gambling task (Iowa Gambling Task (IGT)). The results showed that, regardless of post traumatic amnesia duration or the presence of frontal lesions, patients were more impaired than healthy controls on both fear recognition and decision making. In both groups, a significant relationship was found between better fear recognition, the development of an advantageous strategy across the IGT and less risk behavior in the last blocks of the IGT. Educational level moderated this relationship in the final block of the IGT. This study has important clinical implications, indicating that impaired decision making and risk behavior after TBI can be preceded by deficits in the processing of fear.

Description of an early cognitive behavioral intervention (UPFRONT-intervention) following mild traumatic brain injury to prevent persistent complaints and facilitate return to work:

Purpose: Many patients with mild traumatic brain injury do not fully return to work owing to persistent posttraumatic complaints. Research suggests that preventing chronic complaints might be prevented by giving cognitive behavioral therapy early after injury. Therefore, a new cognitive behavioral intervention (UPFRONT-intervention) was developed to not only prevent chronic complaints but to also establish a more successful return to work. The intervention is currently being evaluated in a multicenter randomized controlled trial design (trial number ISRCTN86191894) in mild traumatic brain injury patients who are at-risk of negative outcomes (patients with high numbers of early complaints). Two case examples are presented to demonstrate the application of the intervention. Rationale: Psychological factors, like cognitive appraisal and coping, play an important role in the persistence of posttraumatic complaints. Some patients are less able to adapt and thus to cope with the injury and its initial consequences than others. Dealing with the injury in a passive, avoidant way, focusing on negative feelings, will hamper recovery and is therefore a valuable target for an intervention. Theory into practice: The UPFRONT intervention is a short cognitive behavioral therapy intervention for patients that are at-risk of developing persistent posttraumatic complaints. Patients will undergo five sessions of cognitive behavioral therapy within 4–10 weeks after trauma. The intervention aims to enhance patients’ feeling of competency of dealing with the consequences of mild traumatic brain injury by providing psycho-education, identifying and challenging unrealistic illness perceptions and improving coping style (decreasing maladaptive coping and enhancing adaptive coping).

Fatigue in patients 3-10 years after aneurysmal and angiographically negative subarachnoid haemorrhage

Background: Acquired brain injury (ABI) is often a lifelong disability that entails a marked change in a person’s life. It involves biopsychosocial levels and return to work (RTW) is one of the mai ...Accepted Abstracts from the International Brain Injury Association’s Eleventh World Congress on Brain InjuryObjective: To investigate whether: 1) traumatic brain injury (TBI) reduces striatal dopamine transporter (DAT) levels; 2) TBI causes structural changes to the substantia nigra and/or nigrostriatal tract; 3) DAT levels following TBI correlate with substantia nigra or nigrostriatal tract damage; 4) DAT levels relate to behavioural measures of apathy and/or speed of processing. Background: Persistent cognitive problems following TBI are common. The heterogeneous nature of TBI means that the basis of cognitive dysfunction is likely to be multi-factorial. Animal and human studies have shown dopaminergic disruption following TBI. However, the cause of this disruption is unclear and may relate to damage to the dopaminergic nuclei or their ascending projections. Design/Methods: 32 moderate/severe TBI patients with persistent cognitive problems and 15 healthy controls had an ioflupane ( 123 I) SPECT scan (DaTscan), MRI and full neuropsychological assessment. DAT levels in the striatum were measured. MRI was used to calculate substantia nigra volumes and nigrostriatal tract diffusion metrics. Results: Quantitative assessment showed reduced DAT levels in TBI patients. Patients had substantia nigra atrophy, as well as increased mean diffusivity in the nigrostriatal tract. There was a significant relationship between (1) DAT levels and substantia nigra volumes in patients and (2) mean diffusivity in the nigrostriatal tract and anterior striatal DAT levels. DAT levels showed a significant relationship with apathy measures but not speed of processing. Conclusions: A proportion of TBI patients with persistent cognitive problems have reduced striatal DAT levels implying a disruption to their dopaminergic system. DAT levels are correlated with structural changes in the substantia nigra and nigrostriatal tract. This supports a causal relationship between damage to these regions by TBI and functional dopaminergic dysfunction. Reduced DAT levels also relate to apathy. Dopaminergic therapies may therefore benefit those patients with evidence of disruption to their dopaminergic systems. Study Supported by: Guarantors of Brain NIHR Disclosure: Dr. Jenkins has nothing to disclose. Dr. De Simoni has nothing to disclose. Dr. Bourke has nothing to disclose. Dr. Cole has nothing to disclose. Dr. Sharp has nothing to disclose.Objectives: The majority of patients with traumatic brain injury (TBI) sustain a mild TBI, of which the prognosis isgenerally favourable. However, patients with moderate-to-severe TBI can experience long-lasting cognitive, emotional and behavioural deficits that interfere with functioning in daily life and the resumption of work. Current literature suggests that executive functioning and coping style are important factors affecting outcome. Moreover, it is suggested that intact executive functioning is a pre-requisite for the use of adaptive coping; as executive processes such as foresight, planning and initiation seem essential for the employment of active coping strategies. So far, the exact association between executive functioning and coping remains unclear, as literature has pro-vided us with mixed results. The aim of the present study is 2-fold. First, we aim to assess the association between executive functioning and coping among patients with TBI at different levels of severity. Second, we aim to investigate to what extent injury severity influences the association between executive ability and coping as a moderating factor.Methods: We included 109 TBI patients from two prospective follow-up studies, of which 53 patients were classified as mild TBI, 19 patients as moderate and 37 patients as severe. Additionally, 33 healthy controls were included. Executive functioning and coping style were assessed by neuropsycho-logical examination in the post-acute and chronic phase after TBI. Results: Greater self-reported executive dysfunction was related to greater use of passive coping styles in all separate levels of severity and in the mixed TBI group (β= 0.591,p<0.001). Additionally, a lower amount of self-reported executive dysfunction was related to higher levels of active coping in the mixed TBI group (β=–0.457,p< 0.001) and the mild and severe TBI groups. Additionally, better performance on an executive test for response inhibition was related to greater use of active coping in the total TBI group (β=–0.178,p=0.047). No evidence for a moderating effect of injury severity on the association between executive functioning and coping was found. Conclusions: Self-reported executive functioning was a significant predictor of coping style at all levels of injury severity inpatients with TBI. Individuals who reported greater executive problems were predisposed to rely on a maladaptive passive coping style. Furthermore, these results suggest that less self-reported executive dysfunction was related to a higher use of an active coping style.Libra Rehabilitation & Audiology Dept. of Neurorehabilitation PO Box 1355, 5602 BJ Eindhoven E info@libranet.nl I www.libranet.nl Correspondence to Ingrid Brands, MD, PhD i.brands@libranet.nl Introduction  Self-efficacy refers to the belief in one’s ability to achieve goals. In patients with acquired brain injury (ABI) higher levels of general self-efficacy and self-efficacy for managing brain injury-specific symptoms have shown to be associated with better quality of life (QoL).1  Being highly self-efficacious in managing one’s health issues is assumed to be a key factor in successful chronic disease selfmanagement.2  Neuropsychological rehabilitation programmes focus on teaching patients to compensate for and manage their cognitive deficits and the social and emotional consequences of ABI. Yet, do these programmes lead to higher levels of self-efficacy in managing brain injury-specific symptoms? Results  QoL and brain injury-specific self-efficacy increased significantly after neuropsychological rehabilitation. Table 2  Both general and brain injury-specific self-efficacy were positively associated with QoL after neuropsychological rehabilitation. Table 3  A lower initial level of cognitive functioning predicted worse QoL after neuropsychological rehabilitation (β = −.63, p = .05).  Cognitive functioning was not significantly associated with initial brain injury-specific self-efficacy (r = .13, p = .60). Objective We examined:  the influence of neuropsychological rehabilitation on general and brain injury-specific self-efficacy and on QoL,  whether initial levels of general and brain injury-specific selfefficacy and cognitive functioning would predict QoL after neuropsychological rehabilitation,  whether cognitive functioning was associated with initial selfefficacy for managing brain injury-related symptoms.Objectives: Disability research as an academic field was established in the 1960s and 1970s in the Nordic countries and in the Anglo-Saxon world. Disability research was studied within the medical model, e.g. in medical and rehabilitation studies, while disability studies became a part of the social model, e.g. in social and psychological studies. It has been a lack of theoretical perspective in disability research and according to that a discussion of theoretical approaches in disability studies that has been raised during recent years. The aim of the study is to describe and illustrate conceptually how vertical and horizontal knowledge integration appear in disability research, exemplified within a case from a person with acquired brain injury.Methods: The study adopted a qualitative approach to answer the research aim, undertaking a literature review to accompany an analysis of the concepts, vertical and horizontal. The concepts were thereafter analysed within theories from disability research and exemplified with a case from brain injury rehabilitation.Results: Tentatively the conceptions, vertical and horizontal, are described and, in addition, a bio-psycho-social perspective is mentioned andtwo theoretical approaches within disability research are described: human functioning sciences and interdisciplinary research. Vertical knowledge integration can be seen as a stratification between differentlevels on a biological, psychological and social level. Horizontal knowledge integration can be understood across varying disabilities. The study indicates that vertical and horizontal knowledge integration in disability research are useful for a broader and deeper understanding of disability and functional impairment where, over the last few years, different theoretical perspectives have become increasingly common. Furthermore, the study shows that acquired brain injury, in a scientific context, has been studied within different levels of society. For example:●On a biological level, e.g. within biochemical bloodanalysis;●On a psychological level, e.g. within neuropsychologicaldiagnostics; and●On a social level, e.g. as a changeover process duringrecovery.Conclusions: The study indicates that a variety of scientific contributions are needful in our understanding of the phenomenon of living withacquired brain injuryin the contemporary society.