Diane L. Whiting

Suicide prevention after traumatic brain injury: A randomized controlled trial of a program for the psychological treatment of hopelessness

Objective:To evaluate the efficacy of a psychological treatment to reduce moderate to severe hopelessness after severe traumatic brain injury (TBI). Method:Randomized controlled trial. Participants were aged between 18 and 65 years, experienced posttraumatic amnesia more than 1day and moderate to severe hopelessness (Beck Hopelessness Scale [BHS]) and/or suicide ideation. Intervention comprised a 20-hour manualized group cognitive behavior therapy program. Participants were randomly allocated using concealed allocation (treatment n = 8; wait-list n = 9); all remained in their allocated group. Outcome variables were collected by assessors blind to group allocation. Results:No between-groups differences were observed on demographic, injury, cognitive, and psychosocial variables at baseline (time 1). A significant group-by-time interaction was found for BHS in the treatment group (F1,15 = 13.20, P = .002), reflecting a reduction in mean BHS scores between time 1 and time 2 (posttreatment) with no main effects for group or time. At 3-month follow-up (time 3), the treatment gains were maintained or improved for 75% (6/8) of participants. Secondary outcome variables (suicide ideation, depression, social problem solving, self-esteem, hopefulness) displayed no significant group-by-time interactions or main effects. Conclusions:This trial provides initial evidence for the efficacy of a psychological intervention in reducing hopelessness among long-term survivors with severe TBI.

A multi-tiered intervention to address behavioural and cognitive changes after diagnosis of primary brain tumour: A feasibility study

Purpose: Untreated behavioural and cognitive changes after primary brain tumour (PBT) can result in challenging behaviours (CBs), with limited documentation on treatment approaches. This study explored the feasibility of employing a Behavioural Consultancy approach to manage CBs, targeting individuals with PBT, family and treating staff. Methods: Participants were patients and families of two hospitals and health professionals from cancer/neurological services. A single-case experimental design piloted skill-based training and environmental changes in managing socio-behavioural impairments in a person with a low grade astrocytoma. A half-day workshop to train family members (n = 7) in compensatory strategy use to manage CBs after PBT was piloted. Finally, a 1-day workshop was provided to 43 health professionals in managing CBs after PBT. For both workshops, a pre–post impact evaluation was conducted employing a purpose-designed Strategies Use Measure. Results: All three interventions demonstrated positive results. The single case showed a 71% decrease in the target behaviour (time spent talking) post-intervention. Some attrition to these gains was observed at two follow-up time points (3 and 5 months). Participants from both workshops demonstrated significant post-intervention increases in perceived knowledge of Strategy Use (family members z = 2.03, p < 0.05; health professionals z = 4.95, p < 0.00; Wilcoxon signed-rank test). Conclusions: These initial studies highlight the potential of employing an integrated multi-tiered intervention based on a Behavioural Consultancy model to manage CBs after PBT.

Cognitive and psychological flexibility after a traumatic brain injury and the implications for treatment in acceptance-based therapies: A conceptual review.

This paper provides a selective review of cognitive and psychological flexibility in the context of treatment for psychological distress after traumatic brain injury, with a focus on acceptance-based therapies. Cognitive flexibility is a component of executive function that is referred to mostly in the context of neuropsychological research and practice. Psychological flexibility, from a clinical psychology perspective, is linked to health and well-being and is an identified treatment outcome for therapies such as acceptance and commitment therapy (ACT). There are a number of overlaps between the constructs. They both manifest in the ability to change behaviour (either a thought or an action) in response to environmental change, with similarities in neural substrate and mental processes. Impairments in both show a strong association with psychopathology. People with a traumatic brain injury (TBI) often suffer impairments in their cognitive flexibility as a result of damage to areas controlling executive processes but have a positive response to therapies that promote psychological flexibility. Overall, psychological flexibility appears a more overarching construct and cognitive flexibility may be a subcomponent of it but not necessarily a pre-requisite. Further research into therapies which claim to improve psychological flexibility, such as ACT, needs to be undertaken in TBI populations in order to clarify its utility in this group.

Validating measures of psychological flexibility in a population with acquired brain injury

This study presents preliminary validation data on both the Acceptance and Action Questionnaire-Acquired Brain Injury (AAQ-ABI) and the Acceptance and Action Questionnaire-II (AAQ-II). Data from 150 participants with ABI was subject to exploratory factor analysis on the AAQ-ABI (15 items). A subset of 75 participants with ABI completed a larger battery of measures to test construct validity for the AAQ-ABI and to undertake a confirmatory factor analysis (CFA) on the AAQ-II (7 items). Three meaningful factors were identified on the AAQ-ABI: Reactive Avoidance, Denial, and Active Acceptance. Reactive Avoidance demonstrated good internal and test-retest consistency (α = .89) and correlated in expected directions with other related measures including the AAQ-II. CFA of the AAQ-II did not provide a good fit but did have similar correlations with measures of psychological distress as found in prior non-ABI samples. The results suggest both measures can be used with individuals following an ABI but they index different facets of psychological flexibility. The AAQ-ABI appears to measure psychological flexibility about the thoughts and feelings relating to the brain injury itself while the AAQ-II measures psychological flexibility around general psychological distress. Future research could explore the additional 2 factors of the AAQ-ABI and use these measures in outcome studies that promote psychological flexibility in individuals with an ABI.

Frequency, clinical correlates, and ratings of behavioral changes in primary brain tumor patients: a preliminary investigation.

Purpose Few studies have addressed the specific behavioral changes associated with primary brain tumor (PBT). This paper will report on the frequency and demographic/clinical correlates of such behaviors, and the reliability of rating such behaviors among people with PBT, family informants, and clinicians. The association of behavioral changes and patient functional status will also be discussed. Methods A total of 57 patients with 37 family informants were recruited from two large Australian metropolitan hospitals. Each completed three neuro-behavioral self-report measures; the Emotional and Social Dysfunction Questionnaire, the Frontal Systems Behavior Scale, and the Overt Behavior Scale. Patients also completed a depression symptom measure. Functional status was defined by clinician-rated Karnofsky performance status. Results Patients were on average 52 years old, a median of 4 months (range 1–82) post-diagnosis, with high grade (39%), low grade (22%), or benign tumors (39%). Patients reported frequency rates of 7–40% across various behavioral domains including anger, inappropriate behavior, apathy, inertia, and executive impairment. The presence of epileptic seizures was associated with significantly higher levels of behavioral changes. Notably, behavior did not correlate with tumor grade or treatment modality. There was moderate agreement between patients and relatives on the presence or absence of behavioral changes, and substantial agreement between relative and clinician ratings. Depressed patients did not generally report more changes than non-depressed patients. Increases in the relative and clinician-rated behavior scores were significantly correlated with decreasing functional status in the patient. Conclusion Behavioral changes were a common sequela of both benign and malignant PBT. Larger scale studies are required to confirm these results. The results suggest the importance of including behavior in brain cancer psychosocial assessments and the need to develop interventions to treat these patients and reduce the burden of care on families.

Development and evaluation of information resources for patients, families, and healthcare providers addressing behavioral and cognitive sequelae among adults with a primary brain tumor.

ABSTRACT Behavioral and cognitive changes in patients with primary brain tumor (PBT) are common and may be distressing to patients and their family members. Healthcare professionals report a strong need for information, practical strategies, and training to assist consumers and better address management issues. A literature review by the current project found that 53% of the information resources currently available to consumers and health professionals contained minimal or no information about cognitive/behavioral changes after PBT, and 71% of the resources contained minimal or no information on associated strategies to manage these changes. This project aimed to develop an information resource for patients, carers, and health professionals addressing the behavioral and cognitive sequelae of PBT, including strategies to minimize the disabling impact of such behaviors. In consultation with staff and patient groups, 16 key information topics were identified covering cognitive and communication changes and challenging behaviors including executive impairment, behavioral disturbance, and social/emotional dysfunction. Sixteen fact sheets and 11 additional resource sheets were developed and evaluated according to established consumer communication guidelines. Preliminary data show that these resources have been positively received and well utilized. These sheets are the first of their kind addressing challenging behaviors in the neuro-oncology patient group and are a practical and useful information resource for health professionals working with these patients and their families. The new resource assists in reinforcing interventions provided to individual patients and their relatives who are experiencing difficulties in managing challenging behaviors after PBT.

Acceptance and Commitment Therapy delivered in a dyad after a severe traumatic brain injury: A feasibility study

Objective: There is a high prevalence of complex psychological distress after a traumatic brain injury but limited evidence of effective interventions. We examined the feasibility of Acceptance and Commitment Therapy after a severe traumatic brain injury using the criteria, investigating a therapeutic effect, and reviewing the acceptability of measures, treatment protocol, and delivery method (in a dyad of two clients and a therapist). Method: Two male outpatients with severe traumatic brain injury and associated psychological distress jointly engaged in a seven session treatment program based on Acceptance and Commitment Therapy principles. Pre- and post-treatment measures of mood, psychological flexibility, and participation were taken in addition to weekly measures. Results: The intervention showed a therapeutic effect with one participant, and appeared to be acceptable for both participants with regard to program content, measures, and delivery mode by in a dyad. One participant showed both significant clinical and reliable change across several outcome measures including measures of mood and psychological flexibility. The second participant did not show a reduction in psychological inflexibility, but did show a significant drop in negative affect. Significant changes pre- to post-treatment for measures of participation were not indicated. Qualitatively, both participants engaged in committed action set in accordance with their values. Conclusions: This study suggests that Acceptance and Commitment Therapy may be feasible to be delivered in a dyad with individuals who have a severe traumatic brain injury. A further test of its potential efficacy in a phase II clinical trial is recommended.

A prospective interrupted time series study of interventions to improve the quality, rating, framing and structure of goal-setting in community-based brain injury rehabilitation

Objective: To investigate whether the introduction of an electronic goals system followed by staff training improved the quality, rating, framing and structure of goals written by a community-based brain injury rehabilitation team. Design: Interrupted time series design. Intervention: Two interventions were introduced six months apart. The first intervention comprised the introduction of an electronic goals system. The second intervention comprised a staff goal training workshop. Methods: An audit protocol was devised to evaluate the goals. A random selection of goal statements from the 12 months prior to the interventions (Time 1 baseline) were compared with all goal statements written after the introduction of the electronic goals system (Time 2) and staff training (Time 3). All goals were de-identified for client and time-period, and randomly ordered. Results: A total of 745 goals (Time 1 n = 242; Time 2 n = 283; Time 3 n = 220) were evaluated. Compared with baseline, the introduction of the electronic goals system alone significantly increased goal rating, framing and structure (χ2 tests 144.7, 18.9, 48.1, respectively, p < 0.001). The addition of staff training meant that the improvement in goal quality, which was only a trend at Time 2, was statistically significant at Time 3 (χ2 15.0, p ≤ 001). The training also led to a further significant increase in the framing and structuring of goals over the electronic goals system (χ2 11.5, 12.5, respectively, p ≤ 0.001). Conclusion: An electronic goals system combined with staff training improved the quality, rating, framing and structure of goal statements.

Exploring the relationship between cognitive flexibility and psychological flexibility after acquired brain injury

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Take down policy If you believe that this document breaches copyright please contact us at vbn@aub.aau.dk providing details, and we will remove access to the work immediately and investigate your claim. • Provides the stakeholders with educational information to facilitate the process of working together on their joint assignment • May take many forms depending on the organizations presenting concerns, from defining and identifying tacit assumptions to understanding the impact of these cognitions • Involves the formal application of theoretical and empirically supported psychological principles to facilitate a desired development within ethical and professional practice standards • Is used most extensively during early sessions and may be supplemented with reading materials and other educational resourcesObjectives: The prevalence of sleep difficulties is high after head injury (HI). Previous research suggests that HI patients with sleep problems require longer stays in rehabilitation units and that disturbance of arousal disrupts engagement in rehabilitation activities. The present study explored the prevalence and types of sleep disorders in patients with severe HI undergoing inpatient rehabilitation and whether the presence of sleep problems affects their rehabilitation. Methods: Twenty-three (n = 23) severe HI patients responded to a semi-structured clinical screening interview about their sleep–wake patterns and wore an actiwatch (an activity monitor that is associated with sleep and wakefulness) for 7 days. Participants also completed self-report measures on sleep, mood, fatigue, pain and daytime sleepiness. Information on rehabilitation variables, including frequency of aggressive behaviour, engagement in rehabilitation and level of disability was collected retrospectively from staff and rehabilitation notes. Results: Fifteen participants (65.2%) had sleep problems. Of these, 10 (43.8%) met formal diagnostic criteria for a sleep disorder and in five (21.7%) no underlying cause for sleep problems was identified. Diagnosed sleep disorders in the sample comprised insomnia (21.7%), post-traumatic hypersomnia (8.7%), circadian rhythm disorder (8.7%), sleep apnoea (4.3%), periodic limb movement disorder (4.3%) and rhythmic movement disorder (4.3%). Senior rehabilitation therapists estimated sleep disturbance as interfering with the rehabilitation process in 26% of the overall research sample (n = 23). Sleep quality, assessed by self-report measures (Pittsburgh Sleep Quality Index; PSQI) was not significantly associated with rehabilitation variables (Hopkins Rehabilitation Engagement Rating Scale). Poor sleep quality (PSQI) was associated with greater anxiety (r = 0.611), fatigue (r = 0.683) and daytime sleepiness (r = 0.529). Conclusions: Consistent with previous studies, sleep disorder and disturbed sleep was common in HI patients undergoing rehabilitation and was associated with anxiety, fatigue and daytime sleepiness. These findings highlight the importance of assessing and treating sleep problems in HI patients undergoing rehabilitation.OBJECTIVESFatigue after an acquired brain injury is common, and is characterized by limited energy reserves to accomplish ordinary daily activities. A typical characteristic of mental fatigue is that the mental exhaustion becomes pronounced during sensory stimulation or when cognitive tasks are performed for extended periods without breaks. There is a drain of mental energy upon mental activity in situations in which there is an invasion of the senses with an overload of impressions, and in noisy and hectic environments. Another typical feature is a disproportionally long recovery time needed to restore the mental energy levels after being mentally exhausted. The mental fatigue is also dependent on the total activity level as well as the nature of the demands of daily activities. For many people, there is an increased risk of doing too much and becoming even more fatigued.METHODSWe have developed an application for Windows Phone for assessment of mental fatigue. The Mental Fatigue Scale is used. The MFS is a multidimensional questionnaire containing 15 questions. The questions included in the MFS are based on symptoms described following longitudinal studies of patients with TBI, brain tumours, infections or inflammations in the nervous system, vascular brain diseases, and other brain disorders. The app also includes information about mental fatigue. RESULTSThis application can help people determine the level of mental fatigue and it can also serve to provide an overall picture of the severity of the condition, and detect changes in mental fatigue over time. The scores will be added up and the results will be presented in the form of a rating scale and a diagram. People can then see their results for one week ago, one month ago or a whole year ago. Today, the most important recommendations are to adapt to the energy available by doing one thing at a time, resting regularly and not overdoing things. However, this is challenging for most people and it may take a long time, even years, to adapt to a sustainable level. It may also be difficult for the person to learn by himself/herself and it can take several years of considerable struggle, frustration, despair and depression, to find the right balance between rest and activity. This app can help people to be aware of mental fatigue. If they connect the results to daily activities, the app may also help them to be more aware about what may alleviate and what may make mental fatigue worse. CONCLUSIONSWith regular assessment of mental fatigue, this app may give feedback and support in order to achieve an enduring balance between activities and rest.The application can be downloaded without cost: http://www.windowsphone.com/en-us/store/app/mental-fatigue/87d4cb88-c9b5-4ac9-9a92-b63a5d8f4d82Abstract presented at the Tenth World Congress on Brain Injury, 19-22 March 2014, San Francisco, United StatesObjectives: Head injury (HI) patients report frequent problems with memory, concentration, fatigue, irritability, temper, dizziness and headaches. Sleep problems are reported in up to 70% of patients after head injury and insomnia symptoms can be found in up to 30% of HI patients; these rates are significantly higher than those found in the general population. This study has conducted the first qualitative analysis on the impact of sleep difficulties in the quality-of-life of HI patients. Methods: Two groups of therapists (n = 16) participated in focus group discussions. The groups included speech therapists, neuropsychologists, assistant psychologist, nurses and support workers that have been working in two local rehabilitation centres for at least 6 months prior to the study. Community patients were recruited from a local HI supporting network (Headway) and were invited to participate in the study. Three groups of community patients (n = 4 per group) with severe HI were facilitated to discuss their sleep problems after the injury in a group setting. Group discussions lasted ∼45–60 minutes per group until saturation was achieved. Thematic analysis was used to qualitatively explore the beliefs, experiences and expectations associated with sleep disturbances following head injury. Results: Therapists and support staff reported that sleep difficulties are common in HI patients and that in most cases sleep disturbance is related not only to the HI itself but also to mental health or environmental factors. Staff felt that little attention is routinely paid to these problems during rehabilitation unless specifically linked to challenging behaviour. Fatigue was thought to be highly relevant and to have a negative effect on engagement and participation in rehabilitation. Patients thought that sleep problems became persistent after injury and the areas that emerged as being more affected were: mood, cognition, everyday functioning, physical health, concentration and cognition. Most patients reported severe insomnia symptoms associated with worry about life and family during the night. Conclusions: To provide better management and improve their rehabilitation it is essential to understand the therapists’ and patients’ expectations and perceptions of sleep difficulties after head injury. Qualitative analysis shows that sleep difficulties have a significant impact on the cognitive, affective and behavioural difficulties that many patients experience following a head injury.