George P. Prigatano

Personality Disturbances Associated with Traumatic Brain Injury.

Personality disturbances associated with traumatic brain injury are reviewed. The varied structural pathology of the brain in this patient group makes it difficult to specify how different brain lesions may result in specific emotional and motivational disturbances. However, an attempt to clarify terms and review empirical findings is made. Longitudinal prospective studies that utilize appropriate control groups are needed. Future research may especially benefit by considering the long-term effects of early agitation following traumatic brain injury as well as the problem of aspontaneity and impairment of self-awareness.

Disturbances of self-awareness and rehabilitation of patients with traumatic brain injury: a 20-year perspective.

Over the last 20 years, numerous papers that are relevant to understanding the problem of impaired self-awareness after moderately severe to severe traumatic brain injury have appeared. This article reviews many of these papers and summarizes salient findings relevant to rehabilitation and future research.

Cognitive and affective sequelae in complicated and uncomplicated mild traumatic brain injury.

This study examined cognitive and affective disturbances in patients with complicated (presence of space occupying lesion) vs uncomplicated (absence of space occupying lesion) mild traumatic brain injury (TBI). It was predicted that the complicated group would perform worse in both domains compared to the uncomplicated group. Participants were 28 patients admitted to an inpatient neurorehabilitation unit with mild TBI and assessed within 40 days of their injury. The complicated group (n = 14) was matched to the uncomplicated group (n = 14) on Glasgow Coma Scale score and compared to 14 normal controls on the BNI Screen for Higher Cerebral Functions (BNIS). The complicated group showed greater cognitive disturbances than the uncomplicated and control groups, while both TBI groups performed worse on affective measures. These findings document the role of affective disturbances in mild TBI. They also highlight the importance of early intervention strategies for improving affective communication in patients with mild TBI.

Behavioral Limitations TBI patients tend to underestimate: A replication and extension to patients with lateralized cerebral dysfunction

Abstract Patients with moderate to severe traumatic brain injury (TBI), as well as patients with lateralized cerebral dysfunction, completed the Patient Competency Rating Scale (PCRS) along with a neuropsychological control group. Relatives or significant others for each patient also rated the patients abilities on the PCRS. A previous finding that TBI patients overestimate social interaction and emotional control skills was replicated. Patients with right versus left hemisphere lesions also tended to show this same pattern, while the neuropsychological control group did not. Brain dysfunction may increase the tendency to overstate certain behavioral characteristics irrespective of the location of the lesion. Nonneurological factors, however, may also contribute to this phenomenon. In this regard, it may be useful to distinguish between impaired self-awareness versus denial of disability after brain injury.

Friends after traumatic brain injury in children.

ObjectiveTo determine whether a dose-response relation exists between the number of reported close friends and traumatic brain injury (TBI) severity in the postacute phase in school-age children. DesignA retrospective relational study. Setting and ParticipantsPrimary care hospital/medical center–based study on parental perspectives of recovery following TBI in school-age children (14 with severe TBI; 10 with moderate TBI; 36 with mild TBI; and 16 trauma controls). Main Outcome MeasuresParental ratings on the Child Behavior Checklist and selected neuropsychological test findings and ratings of academic performance. ResultsSeventy-five percent of trauma controls but only 38.9% of children with mild and 20% of children with moderate TBI reportedly had 4 or more friends. Only 14.3% of children with severe TBI reportedly had 4 or more friends. Glasgow Coma Scale score at admission correlated with the number of friends postacutely (by parental reports) (r = +0.307, N = 76, P = .007). Conclusion: More severe brain injury is associated with fewer friends in the postacute phase following TBI. The relation, however, was not purely linear and the hypothesis was supported only partially. Broadening the social network of children with moderate and severe TBI should be a major goal of neuropsychological rehabilitation.

Digit memory test: Unequivocal cerebral dysfunction and suspected malingering

The Digit Memory Test (DMT) (Hiscock & Hiscock, 1989), a forced-choice test for detecting malingering, was administered to 27 patients with unequivocal cerebral dysfunction, 5 patients with postconcussional syndrome, 6 suspected malingerers and 10 normal controls. Results indicate that, even in patients with severe, but static cerebral dysfunction and unequivocal memory disorder, DMT performance is between 95% to 100% correct. By contrast, the 6 patients in whom malingering was seriously considered performed at a level much below the other three groups (74% correct) but not significantly below chance. The DMT may be helpful in evaluating patients suspected of malingering even when they do not score significantly below chance.

Cognitive and affective improvement in brain dysfunctional patients who achieve inpatient rehabilitation goals

OBJECTIVE To evaluate whether improvements in specific cognitive and affective functions are associated with achieving inpatient rehabilitation goals after the acute onset of brain dysfunction. DESIGN Retrospective analysis of data obtained in a prospective inception cohort study. STUDY SETTING Medical center and neurological institute. SUBJECTS Ninety-five heterogeneous brain dysfunctional patients who participated in an interdisciplinary inpatient neurorehabilitation program. Subjects were classified as having achieved their rehabilitation goals (Group 1) or not (Group 2) at time of discharge. MAIN OUTCOME MEASURE Number of treatment goals attained. RESULTS Although overall level of performance on the BNI Screen (BNIS) for Higher Cerebral Functions distinguished patients who later achieved their inpatient rehabilitation goals, on admission only performance on the visual spatial subtest was associated with later goal attainment. In contrast, at discharge, patients who showed greater improvement in awareness, affect, visual spatial skills, memory, and attention/concentration were likely to obtain their rehabilitation goals. This was true when the initial level of performance was taken into account. CONCLUSIONS Measurement of overall neuropsychological status and specific visual spatial abilities at time of admission may help determine which brain dysfunctional patients will obtain inpatient rehabilitation goals. Improvement in a variety of cognitive and affective functions was associated with goal attainment. Early cognitive rehabilitation should focus on both cognitive and affective disturbances to facilitate recovery and rehabilitation outcome.

Disordered mind, wounded soul: The emerging role of psychotherapy in rehabilitation after brain injury

The traditional pessimism over attempting psychotherapy with brain dysfunctional individuals is being challenged. Symbols that can guide the psychotherapeutic process with these individuals are discussed and presented. The role of various art forms to enhance a better understanding of the brain dysfunctional patients phenomenologic experiences are also considered. Establishing a sense of meaning after brain injury becomes the center point around which psychotherapeutic efforts are developed.

Edwin A. Weinstein's Contributions to Neuropsychological Rehabilitation

Disorders of self awareness following various brain injuries can greatly impede efforts at neuropsychological rehabilitation. Understanding and managing these disorders requires perspectives from neuropsychology, behavioural neurology and neuropsychiatry. This paper attempts to clarify Edwin A. Weinsteins pioneering work in this area and its impact on neuropsychological rehabilitation.

Cognitive retraining after traumatic brain injury and its role in facilitating awareness

This article explores the nature and rationale of cognitive retraining activities in a neuropsychologically oriented outpatient rehabilitation program. Daily performance on tasks of speed of information processing, memory, language, flexibility, and visuospatial problem solving provide valuable quantitative and qualitative data. Individualized compensatory strategies are developed. Patients learn about residual strengths and weaknesses and their impact on work performance. In this way cognitive retraining activities promote greater self-awareness, which facilitates better psychosocial functioning and return to productive work.