Cheryl L. Bradbury

Measuring premorbid IQ in traumatic brain injury: An examination of the validity of the Wechsler Test of Adult Reading (WTAR)

Estimation of premorbid IQ in traumatic brain injury (TBI) is clinically and scientifically valuable because it permits the quantification of the cognitive impact of injury. This is achieved by comparing performances on tests of current ability to estimates of premorbid IQ, thereby enabling current capacity to be interpreted in light of preinjury ability. However, the validity of premorbid IQ tests that are commonly used for TBI has been questioned. In the present study, we examined the psychometric properties of a recently developed test, the Wechsler Test of Adult Reading (WTAR), which has yet to be examined for TBI. The cognitive performance of a group of 24 patients recovering from TBI (with a mean Glasgow Coma Scale score in the severely impaired range) was measured at 2 and 5 months postinjury. On both occasions, patients were administered three tests that have been used to measure premorbid IQ (the WTAR and the Vocabulary and Matrix Reasoning subtests of the Wechsler Adult Intelligence Scale 3rd Edition, WAIS-III) and three tests of current ability (Symbol Digit Modalities Test–Oral and Similarities and Block Design subtests of the WAIS-III). We found that performance significantly improved on tests of current cognitive ability, confirming recovery. In contrast, stable performance was observed on the WTAR from Assessment 1 (M = 34.25/50) to Assessment 2 (M = 34.21/50; r = .970, p < .001). Mean improvement across assessments was negligible (t = −0.086, p = .47; Cohens d = −0.005), and minimal individual participant change was observed (modal scaled score change = 0). WTAR scores were also highly similar to scores on a demographic estimate of premorbid IQ. Thus, converging evidence—high stability during recovery from TBI and similar IQ estimates to those of a demographic equation—suggests that the WTAR is a valid measure of premorbid IQ for TBI. Where word pronunciation tests are indicated (i.e., in patients for whom English is spoken and read fluently), these results endorse the use of the WTAR for patients with TBI.

The Efficacy of Cognitive Behavior Therapy in the Treatment of Emotional Distress After Acquired Brain Injury

OBJECTIVE To evaluate the efficacy of cognitive behavior therapy (CBT), adapted to meet the unique needs of individuals with acquired brain injury (ABI), and modified for both group and telephone delivery. DESIGN Matched-controlled trial, with multiple measurements across participants, including pretreatment baseline assessment plus posttreatment and 1-month follow-up. SETTING Outpatient community brain injury center. PARTICIPANTS Participants (N=20) with chronic ABI. Ten were assigned to the CBT treatment group and 10 to education control. All were experiencing significant emotional distress at the onset of the study. INTERVENTION Eleven sessions of CBT (or education control), including 1 introductory individual session plus 10 further sessions administered in either group format or by telephone. The CBT was designed to decrease psychologic distress and improve coping. Specific adaptations were made to the CBT in order to better accommodate individuals with cognitive difficulties. MAIN OUTCOME MEASURES Primary outcome measures included the Symptom Checklist-90-Revised (SCL-90-R) and the Depression Anxiety Stress Scales (DASS-21). Secondary outcome measures included the Community Integration Questionnaire (CIQ) and the Ways of Coping Scale, Revised. RESULTS Significant CBT treatment effects (in both group and telephone formats) were observed on the SCL-90-R and the DASS-21, whereas no significant effects were observed in the education control group. No significant effects of treatment were observed on the CIQ or Ways of Coping Scale, Revised. CONCLUSIONS Results suggest that adapted CBT-administered by telephone or in a face-to-face group setting-can significantly improve emotional well-being in chronic ABI.

Traumatic Brain Injury in Patients With Traumatic Spinal Cord Injury: Clinical and Economic Consequences

OBJECTIVE To evaluate the clinical and economic burden of traumatic brain injury (TBI) in people with traumatic spinal cord injury (SCI). DESIGN Prospective, case-matched control study. SETTING Inpatient spinal cord rehabilitation program. PARTICIPANTS Patients (n=10) diagnosed with traumatic SCI and concomitant TBI matched to an SCI only control group. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Inpatient rehabilitation length of stay, health care costs (patient care hours), clinician resource allocation, behavioral and critical incidents, FIM, Personality Assessment Inventory, and neuropsychological assessment findings. RESULTS Prolonged loss of consciousness, increased rehabilitation costs, and greater demands on clinician recourses (trend) were found in the SCI with TBI group relative to the SCI-only group. Neuropsychological test performance was significantly worse in the SCI with TBI group, while the FIM cognition score did not discriminate because of ceiling effects. Greater evidence of psychopathology was observed in the SCI with TBI group. CONCLUSIONS The presence of TBI in SCI has a range of clinical and economic consequences. This dual diagnosis has the potential to affect SCI rehabilitation negatively, as well as quality of life and reintegration in the community. Specialized care appears to be needed to improve outcomes and to minimize clinical and economic burden, but further research is required.

Cognitive behavior therapy after acquired brain injury: maintenance of therapeutic benefits at 6 months posttreatment.

Objectives:To examine whether 6-month posttreatment acquired brain injury (ABI) patients receiving cognitive behavior therapy (CBT) adapted for ABI would demonstrate (1) maintenance of psychological benefits, (2) better community integration, and (3) commensurate benefits for both teletherapy and face-to-face group therapy. A secondary objective was to examine the relationship between coping strategies and mood and community integration. Participants:Seventeen chronic ABI patients with elevated psychological distress. Outcome Measures:Symptom Checklist-90-Revised (SCL-90-R), Depression Anxiety Stress Scales-21 (DASS-21), Community Integration Questionnaire, and the Ways of Coping questionnaire, revised. Procedures:Eleven CBT sessions provided either in a face-to-face group format or individually by telephone with outcomes measured pretreatment, posttreatment, and at 6-month follow-up. Results:At 6-month follow-up, full-group scores were significantly better than pretreatment for psychological distress (t16 = 6.22, P < .01, SCL-90-R; t16 = 7.32, P < .01, DASS-21) and for community integration (t16 = −6.15, P < .01), with negligible decrements from immediately posttreatment. Subgroup scores were comparable. Coping also improved but was uncorrelated with mood or community integration. Conclusion:The CBT adapted for ABI shows enduring benefits for mood and community integration. The efficacy of teletherapy obviates service access problems related to geographical remoteness and mobility restrictions. A larger, randomized, control trial that examines underlying mechanisms of efficacy is needed.

Obsessive beliefs and neurocognitive flexibility in obsessive-compulsive disorder☆

A substantial proportion of individuals with obsessive-compulsive disorder (OCD) do not endorse the dysfunctional beliefs proposed by cognitive models of OCD to be important in the onset and maintenance of symptoms. Previous research has attempted to characterize Low and High obsessive beliefs groups in terms of cognitive and symptom correlates to distil potential etiological differences in these subgroups of OCD patients. The current study sought to further examine potential neurocognitive differences between obsessive beliefs subgroups. Performance on the Wisconsin Card Sorting Test (WCST) was compared between a Low Beliefs OCD subgroup, a High Beliefs OCD subgroup, and two anxious control groups: Panic Disorder with Agoraphobia (PDA) and Social Phobia (SP). The High Beliefs OCD subgroup performed significantly poorer on WCST subscales compared to the other diagnostic groups. These findings were not accounted for by severity of OCD or depressive symptoms. The Low Beliefs OCD subgroup performed similar to the anxiety disorder control groups. The results suggest a potential interplay between heightened obsessive beliefs and neurocognitive inflexibility.

Missed diagnosis of traumatic brain injury in patients with traumatic spinal cord injury.

OBJECTIVE To determine the frequency of missed acute care traumatic brain injury diagnoses in patients with traumatic spinal cord injury, and to examine risk factors for missed traumatic brain injury diagnosis. DESIGN Prospective magnetic resonance imaging and neuro-psychological assessment plus retrospective medical record review, including computed tomography. SUBJECTS Ninety-two adults with traumatic spinal cord injury recruited from a large, tertiary spinal cord injury program, initially referred from urban teaching hospitals with neurotrauma facilities. METHODS Diagnosis of traumatic brain injury made with clinical neurological indices (i.e., Glasgow Coma Scale, post-traumatic amnesia, and loss of consciousness), neuroimaging (computed tomography and structural magnetic resonance imaging), and neuropsychological tests of attention and speed of processing, memory, and executive function; all measures were validated on a case-by-case basis to rule out confounds. Missed traumatic brain injury diagnoses were made via acute care medical record review and were corroborated by patient/family report where possible. RESULTS The frequency of missed traumatic brain injury diagnoses in our sample was 58.5%. Missed traumatic brain injury diagnoses were more frequent in injuries sustained outside of a motor vehicle collision (MVC), with 75.0% of acute care traumatic brain injury diagnoses missed in non-MVC patients vs. 42.9% missed in MVC patients. Among patients with non-MVC injuries, a comparable percentage of missed traumatic brain injury diagnoses were observed in patients with cervical (79%) and sub-cervical injuries (80%). CONCLUSION In more than half of the traumatic spinal cord injury patients referred for in-patient rehabilitation, acute care diagnoses of traumatic brain injury were missed. A risk factor for missed diagnosis was an injury caused by a mechanism other than an MVC (e.g., falls, assaults), perhaps due to reduced expectations of traumatic brain injury in non-MVC patients. In our research study, we employed multiple assessments to aid diagnosis, which is particularly important for detecting the milder traumatic brain injuries often associated with spinal cord injury; unfortunately, limited resources may preclude a comprehensive diagnostic approach in clinical settings. Our findings point to the need to examine current acute care diagnostic protocols, and to increase vigilance in patients with traumatic injuries sustained outside of an MVC setting.

Use of Diffusion-Tensor Imaging in Traumatic Spinal Cord Injury to Identify Concomitant Traumatic Brain Injury

OBJECTIVE To characterize and differentiate cerebral white matter (WM) changes related selectively to traumatic brain injury (TBI) or spinal cord injury (SCI) in patients with SCIs in order to improve diagnostic accuracy of TBI in people with SCI. DESIGN Diffusion-tensor imaging (DTI)-derived fractional anisotropy (FA) data in WM tracts were compared between a healthy control and 2 patient groups. Between-subject comparisons of FA were performed using region of interest (ROI) analysis and tract-based spatial statistics. SETTING A large, urban inpatient SCI program. PARTICIPANTS Three groups: SCI and concomitant TBI (SCI with TBI, n=7); SCI without TBI (SCI only, n=15); and healthy control subjects (n=12). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE FA was used as a measure of cerebral WM integrity. RESULTS ROI analyses showed reduced FA in the genu and splenium of the corpus callosum and forceps minor in patients with SCI with TBI compared with both healthy controls and patients with SCI only. ROI analyses did not show evidence of FA differences in patients with SCI only compared with controls. Tract-based spatial statistics did not demonstrate between-group differences in FA. CONCLUSIONS DTI is a sensitive tool to detect TBI-related WM damage in patients with SCI who have suffered concomitant TBI. No WM abnormalities on DTI could be attributed to SCI alone, although this finding should be further explored in future studies. Therefore, DTI may be a valuable tool to identify TBI in the SCI population. Further research to produce normative FA values is needed to allow identification of TBI in individual patients with SCI.

Disgust recognition in obsessive-compulsive disorder: diagnostic comparisons and posttreatment effects.

Objective: To examine whether disgust recognition deficits are present and specific to obsessive-compulsive disorder (OCD), and the extent to which this deficit, if present, can be reduced in cognitive-behavioural therapy (CBT). Method: Responses to the Pictures of Facial Affect (POFA) were examined in patients with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnosed OCD (n = 20), panic disorder with agoraphobia (PDA; n = 15), and generalized social phobia (GSP; n = 15) and a second, independent OCD sample of treatment responders to CBT (n = 11). Results: There were signifcant and statistically large disgust recognition differences between the OCD group and comparison PDA and GSP groups. However, patients with OCD treated with CBT showed disgust recognition scores that were equivalent to the PDA and GSP groups, significantly better than the untreated OCD sample, and equivalent to scores from the original POFA nonaffected standardization sample. Conclusions: These results provide support for the presence of disgust recognition impairment in OCD, and provide preliminary evidence that disgust recognition impairments may improve with treatment.

Traumatic Brain Injury in Spinal Cord Injury: Frequency and Risk Factors.

Background:The frequency of traumatic brain injury (TBI) co-occurring with traumatic spinal cord injury (tSCI) is unclear despite a number of past studies; as well, limited research has examined predictors of co-morbid TBI in tSCI patients. Objectives:(1a) To summarize past literature on comorbid diagnosis of TBI in tSCI in order to reexamine the frequency of dual diagnosis in a study designed to obviate past methodological limitations; (1b) to compare dual-diagnosis frequency with vs without the inclusion of diagnostically ambiguous cases; and (2) to measure risk factors for tSCI and comorbid TBI. Methods:Ninety-one of 135 eligible adults with tSCI, 3 to 6 months postinjury, were prospectively recruited from a tertiary inpatient tSCI rehabilitation program. TBI diagnosis was based on comprehensive, validated clinical neurological and neuroimaging measures. Results:Objective 1: 39.6% of the tSCI patients sustained a concomitant TBI, but when ambiguous cases were removed from analysis, frequency rose to 58.1%. Objective 2: Motor vehicle collisions were most likely to yield a comorbid TBI diagnosis, but 31.6% of falls also resulted in TBI. Patients with cervical and thoracic injuries showed a very similar frequency of comorbid TBI. Conclusions:Varied methodological approaches, particularly the decision to include/exclude ambiguous cases, likely explain disparate past estimates of TBI in tSCI. However, even this studys lower frequency estimate, at nearly 40%, is clinically important. The prevailing assumption that dual diagnosis is less common in thoracic than cervical spine injuries was not supported. Finally, while comorbid TBI most frequently occurred in motor vehicle collisions, nearly a third of tSCIs sustained in falls resulted in comorbid TBI in our sample.