Kirsten V. Smith

Cerebral Microbleeds and Long-Term Cognitive Outcome: Longitudinal Cohort Study of Stroke Clinic Patients

Background: Vascular cognitive impairment causes significant disability in the elderly and is common following ischaemic stroke. Although the underlying mechanisms and prognostic factors remain unclear, small vessel diseases are known to contribute. Cerebral microbleeds (CMBs) are a magnetic resonance imaging (MRI) manifestation of small vessel diseases and may contribute to vascular cognitive impairment, particularly frontal-executive functions. We hypothesized that baseline CMBs would predict long-term cognitive outcome, specifically frontal-executive function. Methods: A cohort of consecutive patients found to have CMBs when first referred to a stroke clinic, together with a CMB-free control group matched for age, gender and clinicoradiological characteristics, were invited for follow-up cognitive assessment a median of 5.7 years later. MRI and detailed cognitive assessment (including current intellectual function, verbal memory, visual memory, naming skills, perceptual functions, frontal-executive functions; and speed and attention) were performed at baseline and follow-up. Patients were classified (blinded to MRI and clinical data) as impaired or unimpaired in each domain using predefined criteria. We compared the prevalence of cognitive impairments in each domain at baseline and follow-up and investigated clinical and radiological predictors [including baseline CMBs and white matter changes (WMCs)] of frontal-executive cognitive impairment. Results: Of the original cohort of 55 patients, 13 died without follow-up. Twenty-six of the surviving patients (9 with, 17 without baseline CMBs) agreed to follow-up neuropsychological assessment; 21 of these patients had a repeat MRI scan. The median number of cognitive domains impaired increased, regardless of the presence of baseline CMBs (with baseline CMBs: median 3, range 0–5 at follow-up vs. median 2, range 0–2 at baseline, p = 0.016; without CMBs: median 1.0, range 0–5 at follow-up vs. median 0, range 0–5 at baseline, p = 0.035). Frontal-executive impairment at follow-up was more prevalent in patients with baseline CMBs than in those without (78 vs. 29%, p = 0.038). The presence of baseline CMBs predicted frontal-executive impairment at follow-up (OR 8.40, 95% CI 1.27–55.39, p = 0.027). Fifty percent of patients with CMBs versus 8% of patients without baseline CMBs developed new CMBs (p = 0.047). The severity of WMCs increased; the difference was statistically significant only in patients without baseline CMBs (p = 0.027). There were no new cortical infarcts. Conclusion: In stroke clinic patients, CMBs are consistently associated with frontal-executive impairment; baseline CMBs are associated with frontal-executive impairment at follow-up after 5.7 years. The presence of CMBs has prognostic relevance for long-term cognitive outcome in stroke clinic patients, and may help to optimally target preventive strategies in individuals at highest risk of cognitive decline.

A prospective study of pre-trauma risk factors for post-traumatic stress disorder and depression.

Background It is unclear which potentially modifiable risk factors best predict post-trauma psychiatric disorders. We aimed to identify pre-trauma risk factors for post-traumatic stress disorder (PTSD) or major depression (MD) that could be targeted with resilience interventions. Method Newly recruited paramedics (n = 453) were assessed for history of mental disorders with structured clinical interviews within the first week of their paramedic training and completed self-report measures to assess hypothesized predictors. Participants were assessed every 4 months for 2 years to identify any episodes of PTSD and MD; 386 paramedics (85.2%) participated in the follow-up interviews. Results In all, 32 participants (8.3%) developed an episode of PTSD and 41 (10.6%) an episode of MD during follow-up. In all but nine cases (2.3%), episodes had remitted by the next assessment 4 months later. At 2 years, those with episodes of PTSD or MD during follow-up reported more days off work, poorer sleep, poorer quality of life, greater burn-out; and greater weight-gain for those with PTSD. In line with theories of PTSD and depression, analyses controlling for psychiatric and trauma history identified several pre-trauma predictors (cognitive styles, coping styles and psychological traits). Logistic regressions showed that rumination about memories of stressful events at the start of training uniquely predicted an episode of PTSD. Perceived resilience uniquely predicted an episode of MD. Conclusions Participants at risk of developing episodes of PTSD or depression could be identified within the first week of paramedic training. Cognitive predictors of episodes of PTSD and MD are promising targets for resilience interventions.

Impaired allocentric spatial processing in posttraumatic stress disorder

Highlights • PTSD sufferers/trauma controls completed tests of hippocampus-dependent processing.• The PTSD group were selectively impaired on allocentric spatial processing.• Other spatial and non-spatial measures were comparable across groups.• Multiple traumas resulted in poorer performance on all spatial measures.• Viewpoint alterations to the trauma memory may be implicated in cognitive therapy.

An adapted imaginal exposure approach to traditional methods used within Trauma-focused Cognitive Behavioural Therapy, trialled with a veteran population

Trauma-focused cognitive behavioural therapy (TF-CBT) is beneficial for individuals with post-traumatic stress disorder (PTSD); however, a subset of clients struggle to engage with traditional methods, due to high levels of avoidance and dissociation. This paper aims to describe an adapted approach to imaginal reliving and prolonged exposure, to facilitate subsequent cognitive updating. The paper demonstrates the technique with veterans, who are a client group that may struggle with some aspects of traditionally implemented TF-CBT. Two case studies are described, both with PTSD symptoms stemming from traumatic military experiences. An adapted exposure technique is utilized to address the barriers of high dissociation, poor access to trauma-related cognitions and fixed intrusive imagery. The approach involved three stages: (1) reliving the trauma outdoors, (2) manipulating the perspectives of the imagery, and (3) restructuring the narrative with new perspectives. Both clients showed decreased dissociation and improved toleration of their traumatic imagery. Improvement of PTSD symptoms and quality-of-life functioning was observed for both clients on objective measures. Adapting TF-CBT to have a stronger emphasis on grounding and allocentric processing may be helpful for a subset of patients with PTSD that present with high levels of dissociation and avoidance. Further research and investigation into alternative populations is needed.

PATH56 MRI correlates of vascular cognitive impairment: contribution of microbleeds, white matter changes and infarcts in a large hospital-based cross-sectional study

Background The mechanisms underlying vascular cognitive impairment remain poorly understood. Brain microbleeds may contribute, particularly to executive dysfunction. We investigated the cognitive effects of microbleeds and other neuroimaging markers for cerebrovascular disease in a large, hospital-based study. Methods Consecutive, unselected patients referred to the stroke unit or clinic underwent clinical assessment, detailed neuropsychological testing and vascular MRI. Microbleeds, white matter changes (WMC) and brain infarcts were identified and their effects on cognition assessed. Results 242 patients were included (N=60 with, N=182 without microbleeds). Executive impairment was more prevalent in patients with microbleeds than without (37% vs 20%; p=0.008). Patients with microbleeds were impaired in more cognitive domains than those without (p=0.007). The presence and number of lobar microbleeds, number of infarcts, and mean WMC score independently predicted executive impairment. The number of lobar microbleeds predicted impairment in multiple cognitive domains (OR 2.05, 95% CI 1.01 to 4.16, p=0.048), as did infarct number. Total microbleed count correlated with number of cognitive domains impaired (p=0.002). Conclusion Lobar microbleeds were independently associated with executive dysfunction and extent of cognitive impairment; number of infarcts and WMC score also contributed, suggesting an interaction between these different imaging markers of cerebrovascular disease.

13 Neuroimaging correlates of vascular cognitive impairment: prevalence and clinical relevance of mesial temporal lobe atrophy in a stroke service cohort

Objectives Vascular cognitive impairment and Alzheimers disease (AD) may interact and co-exist. We investigated the prevalence and impact of mesial temporal lobe atrophy (MTA), a radiological marker for AD, in a population of stroke patients. Methods Patients referred to a stroke service underwent detailed neuropsychological testing and standardised imaging, including GRE T2* MRI and FLAIR. We assessed MTA on FLAIR images using a newly developed and validated visual rating scale based on the Scheltens scale (scores 0 to 4; mild MTA <2 and severe ≥2). Microbleeds and white matter changes (WMC) were rated using validated scales. The effect of MTA on cognitive functions was tested using multivariate regression analyses. Findings 396 patients with full neuropsychological testing and complete MRI sequences were included (358 mild and 38 severe MTA). 171 patients (43%) showed some degree (score ≥1) of MTA. Patients with severe MTA were older (76 vs 64, p=0.000), more hypertensive (97% vs 66%, p=0.000), and had more severe WMC (median 9 vs 5.5, p=0.000) than patients with mild or no MTA. In adjusted multivariate analyses, MTA was a predictor of verbal memory impairment (OR 1.81, p=0.004) and frontal executive dysfunction (OR 1.48, p=0.023). Conclusions MTA is common in stroke patients and is independently associated with verbal memory and frontal executive deficits. Alzheimer pathology may play an important role in cognitive impairment in patients with cerebrovascular disease.

Treatment Efficacy for Veterans With Posttraumatic Stress Disorder: Latent Class Trajectories of Treatment Response and Their Predictors: Treatment Trajectories For Veterans With Ptsd

Abstract Evidence suggests that veterans with posttraumatic stress disorder (PTSD) have a poorer treatment response than nonveterans. In this study, we explored heterogeneity in treatment response for 960 veterans in the United Kingdom with PTSD who had been offered a residential intervention consisting of a mixture of group sessions and individual trauma‐focused cognitive behavioral therapy (TF–CBT). The primary outcome was PTSD score on the Impact of Event Scale–Revised (IES–R). Covariates included depression, anxiety, anger, alcohol misuse, functional impairment, and sociodemographic characteristics. Follow‐up occurred posttreatment at set time points for 12 months. We present predictors of PTSD severity at posttreatment and follow‐up obtained using a latent class growth analysis to identify different treatment trajectories. Multinomial logistic regression models were used to identify covariates predicting class membership, and five classes were identified. Of participants, 71.3% belonged to three classes showing positive treatment responses, and 1.2% showed initial improvement but later relapsed. Additionally, 27.5% of participants were identified within a treatment‐resistant class that showed little change in severity of presentation. Depression, anxiety, and having had a combat role during military service increased the likelihood of membership in the treatment‐resistant class, odds ratios (ORs) = 1.12–1.53, 1.16–1.32, and 2.89, respectively. Additionally, participants in the treatment‐resistant class had higher pretreatment PTSD scores for reexperiencing, avoidance, and hyperarousal symptoms, ORs = 5.24, 2.62, and 3.86, respectively. Findings suggest the importance of triaging individuals and offering interventions tailored to severity of presentation.

Conducting ethical internet-based research with vulnerable populations: a qualitative study of bereaved participants' experiences of online questionnaires.

ABSTRACT Background: Bereavement can be considered a potentially traumatic experience, and concerns have been raised about conducting grief research responsibly online. Objective: Given that online research introduces new methodological opportunities and challenges, we aimed to develop a greater understanding of how bereaved individuals experience participation in online research. Method: One day after participation in an online grief study, 876 participants, bereaved on average for 40 months, received a ‘check-in’ email to support well-being and offer further contact if needed. Although not explicitly asked to respond if no help was needed, 300 participants sent email replies, with only six requesting support. These responses were analysed qualitatively using content analysis. Results: Results suggested that participants found it acceptable to be asked about their grief and while difficult emotions were frequently described in response to the questionnaires, these reactions were temporary. A range of positive reactions was also reported, including new realizations arising from completing the research and changes in thinking related to grief. Participants also wrote about their appreciation for the study and how it was carried out, as well as a desire to contribute more to the study and to help others in a similar position. Conclusions: We suggest that the use of the check-in email to support well-being following study completion, along with advice on preparing to take part, contributed to positive experiences of participation and we recommend these strategies for future studies. These findings could allay clinical concerns about conducting online research with vulnerable populations, as well as raising questions about the possible therapeutic impact of measurement.

Conducting research in clinical psychology practice: Barriers, facilitators, and recommendations.

Objectives The combination of clinical psychologists’ therapeutic expertise and research training means that they are in an ideal position to be conducting high‐quality research projects. However, despite these skills and the documented benefits of research to services and service users, research activity in practice remains low. This article aims to give an overview of the advantages of, and difficulties in conducting research in clinical practice. Method We reviewed the relevant literature on barriers to research and reflected on our clinical and research experiences in a range of contexts to offer practical recommendations. Results We considered factors involved in the planning, sourcing support, implementation, and dissemination phases of research, and outline suggestions to improve the feasibility of research projects in post‐qualification roles. Conclusions We suggest that research leadership is particularly important within clinical psychology to ensure the professions continued visibility and influence within health settings. Practitioner points Clinical implications Emerging evidence suggests that clinical settings that foster research are associated with better patient outcomes. Suggestions to increase the feasibility of research projects in clinical settings are detailed. Limitations The present recommendations are drawn from the authors’ practical experience and may need adaptation to individual practitioners’ settings. This study does not attempt to assess the efficacy of the strategies suggested.