Mary R. Hibbard

Axis I Psychopathology in Individuals with Traumatic Brain Injury

Objectives:To assess the incidence, comorbiclity, and patterns of resolution of DSM-IV mood, anxiety, and substance use disorders in individuals with traumatic brain injury (TIM) Design:The Structured Clinical Interview for DSM-IV Diagnoses (SC1D) was utilized. Diagnoses were determined for three onset points relative to TBI onset: prc-TBI, post-TUI, and current diagnosis. Contrasts of prevalence rates with communitybased samples, as well as chi-square analysis and analysis of variance were used. Demographics considered in analyses included gender, marital status, severity of injury, and years since TIM onset Setting:Urban, suburban, and rural New York state. Participants: 100 adults with TBI who were between the ages of 18 and 65 years and who were, on average, 8 years post onset at time of interview Main Outcome Measures:SCID Axis I mood diagnoses of major depression, dysthymia, and bipolar disorder; anxiety diagnoses of panic disorder, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD), and phobia; and substance use disorders Results:Prior to TBI, a significant percentage of individuals presented with substance use disorders. After TBI, the most frequent Axis I diagnoses were major depression and select anxiety disorders (ie, PTSD, OCD, and panic disorder). Comorbidity was high, with 44% of individuals presenting with two or more Axis 1 diagnoses post TBI. Individuals without a pre-TBI Axis I disorder were more likely to develop post-TBI major depression and substance use disorders. Rates of resolution were similar for individuals regardless of previous psychiatric histories. Major depression and substance use disorders were more likely than were anxiety disorders to remit Conclusion:TBI is a risk factor for subsequent psychiatric disabilities. The need for proactive psychiatric assessment and timely interventions in individuals post TBI is indicated

The effect of employment on quality of life and community integration after traumatic brain injury

Objectives:To investigate the effect of employment on perceived quality of life (QOL), social integration, and home and leisure activities for individuals with traumatic brain injuries (TBIs). Design:A number of demographic and injury-related variables (age at injury, time since injury, severity of injury, education, gender, preinjury household income, and marital status) were analyzed for their association first with employment and then with the QOL, social integration, and home and leisure activities. Any of these variables showing significant associations were then included along with level of employment in three final multivariate analyses of variance (MANOVAs), again predicting QOL, social integration, and home and leisure activities. Setting:Urban, suburban, and rural New York state. Participants337 adults with TBI who resided in New York state and were between the ages of 18 and 65 years. Main Outcome Measures:The Craig Handicap Assessment Capacity Technique, the Bigelow Quality of Life Questionnaire, the Flanagan Scale of Needs (adapted), and a global QOL measure. Results:Employment showed a strong and consistent relationship with perceived QOL, social integration within the community, and home and leisure activities. Part-time employment may have been superior to full-time employment for individuals with TBI: part-time workers had fewer unmet needs, were more socially integrated, and were more engaged in home activities than full-time workers. Loss of consciousness, as a measure of severity, was unexpectedly predictive of diminished sense of QOL for individuals with less severe injuries. Conclusions:Being employed contributes to ones sense of well-being, social integration, and pursuit of leisure and home activities. Select advantages of working part-time for individuals with TBI were identified.

Peer support in the community: Initial findings of a mentoring program for individuals with traumatic brain injury and their families

Objectives:To evaluate the impact of a community-based peer support program for individuals and their family members following traumatic brain injury (TBI). Settings:Community-based sample of family members and individuals with traumatic brain injury. Participants:Twenty individuals who had participated in the peer support program (11 individuals with TBI and 9 family members). Main Outcome Measures:Quantitative and qualitative approaches were used: a retrospective structured interview assessing self-reported impacts of peer support on empowerment, quality of life, mood, skills and knowledge, and social supports; an in-depth qualitative interview with a subgroup of family members focused on the specific benefits/limitations of the peer support program. Results:Participants in the peer support program reported positive impacts of peer support on increasing their knowledge of TBI, enhancing their overall quality of life, improving their general outlook, and enhancing their ability to cope with depression post TBI. The peer support program was reported to have had a minimal impact on enhancing social support from families, friends, and the community, with varying impacts noted on levels of happiness, coping with anger and anxiety, communication with professionals, and control over ones life. Qualitative analysis suggests the merits of this type of community-based support and areas of improvement for the peer support program itself. Conclusions:Preliminary data suggest that peer support is a promising approach to enhancing coping for both individuals and their family members after TBI.

Axis II psychopathology in individuals with traumatic brain injury

Primary objectives:To determine the frequency and nature of post-TBI personality disorders (PDs) in a community-based sample of individuals with TBI. Research design:One hundred individuals with TBI were administered a structural clinical interview to determine Axis II psychopathology. Methods of procedures:The Structured Clinical Interview for DSM-IV Personality Disorders, Clinician Version (SCID II) was used to determine 12 Axis II personality disorders. SCID II questions were modified so that symptom onset could be rated as occurring pre-injury vs. post-TBI. Data were analysed using student T-tests, chi-square analysis and one way analyses of variance. Outcomes and results:Pre-TBI PDs were diagnosed in 24% of the sample; antisocial PD and obsessive–compulsive PD were the most common diagnoses. Post-TBI, 66% of the sample met criteria for at least one PD, with PDs independent of TBI severity, age at injury, and time since injury. The most common post-TBI PDs were: borderline, avoidant, paranoid, obsessive–compulsive and narcissistic. Men were more likely to be diagnosed with antisocial PD and narcissistic PD. Individuals with pre- TBI PDs were at greater risk of acquiring additional psychopathology post-TBI. Personalty traits endorsed by more than 30% of the sample post-TBI reflected loss of self-confidence, attempts to cope with cognitive and interpersonal failures and negative affect. Conclusion:These findings argue against a specific TBI personality syndrome, but rather a diversity of personality disorders reflective of the persistent challenges and compensatory coping strategies developed by individuals post-TBI. Prospective need for clinical assessment, pro-active education and focused treatment approaches are discussed.

The Role of Self-discrepancy Theory in Understanding Post–traumatic Brain Injury Affective Disorders: A Pilot Study

This pilot study examined the utility of self-discrepancy theory (SDT) in explaining post–traumatic brain injury (TBI) depression and anxiety. The SDT model was expanded to include the discrepancy between the postinjury self and the preinjury self. Study participants were 21 individuals with mild to severe TBI residing in the community, who completed the Selves Interview, the Selves Adjective Checklist, the Beck Depression Inventory–II and the Beck Anxiety Inventory. Strong correlations were found between affective distress and self-discrepancies, as measured by the checklist. Scores on the interview were not related to affective distress. The findings suggest that further research is merited to examine the utility of the SDT in addressing issues of post-TBI depression and anxiety.

Undiagnosed Health Issues in Individuals with Traumatic Brain Injury Living in the Community

Objectives:To examine the self-reported prevalence of long-term health issues in individuals with traumatic brain injury (TBI) living in the community Design:A structured health interview. For individuals with TBI, the presence of a specific health-related issue with onset post-TBI and currently a problem at the time of the interview was explored. For individuals without disability, a specific health-related issue was evaluated at time of interview. For each health issue, the proportion of individuals with TBI experiencing post-TBI onset but current symptoms was contrasted with symptom reports of individuals without disability. Chi-square statistical analyses were used to determine significance. For individuals with TBI, logistic regressions were used to model the probability of having a particular health difficulty when four covariates were examined, such as age, gender, time since onset of TBI, and duration of loss of consciousness (LOC) Setting:Urban, suburban, and rural New York State Participants:338 individuals with TBI and 273 individuals without disability between the ages of 18 and 65 years. Individuals with TBI were, on average, 10 years post-onset at the time of interview Main Outcome Measures:Self-reported health issues reflective of neuroendocrine, neurological, immunosuppression, and other health issues Results:Chronic health issues suggestive of ongoing neuroendocrine dysfunctions (ie, changes in hair/skin texture, body temperature changes), neurologic difficulties (ie, headaches, seizures, balance difficulties, spasticity, sleep disturbances, loss of urinary control), and arthritic complaints were significantly more common in individuals with TBI. The prevalence of many of these health-related difficulties was related to duration of LOC but not to time since injury. Age and gender effects were found, with older women with TBI more likely to report thyroid conditions, sleep disturbances, loss of urinary control, and arthritic changes. Women also reported greater frequency of headaches, colds, weight changes, and temperature changes post TBI Conclusion:Health issues reflective of neuroendocrine, neurological, and arthritic difficulties are common long-term health issues for individuals with TBI. Proactive patient education, ongoing health screening with appropriate medical follow-up, and timely interventions for individuals with TBI are indicated. Longitudinal studies are necessary to examine the natural course of post-TBI health difficulties

The enigma of "hidden" traumatic brain injury

Objective:To examine individuals with “hidden” traumatic brain injury (TBQ, defined in this study as those who sustained a blow to the head, with altered mental status, and experienced a substantial number of the cognitive, behavioral, and emotional sequelae typically associated with brain injury but did not make the causal connection between the injury and its consequences. Design:Comparison of four groups of individuals matched for age, gender, years of education, and duration of loss of consciousness. Setting:This study of hidden TBI followed the identification of 143 individuals who, within a larger study of people with TBI who live in the community, identified themselves as “nondisabled” (they were to be part of the comparison sample) but who had experienced a blow to the head that left them at minimum dazed and confused. Participants:21 of these 143 individuals also reported large numbers of symptoms (eg, headaches, memory problems) associated with TBI. This group (Hidden TBI-Hlgh Symptoms group) was compared to three other matched samples:one with known TBI (Known Mild TBI group) and one with no disability (No Disability group) (both of which were drawn from the larger study), and one group of individuals who identified themselves as having no disability but who had experienced a blow to the head that resulted in a few symptoms (Head Trauma-Low Symptoms group). Main Outcome Measures:All study participants were administered an interview that incorporated several existing instruments documenting levels of reported symptoms, emotional well-being/distress, and vocational/social handicaps. Results:The Hidden TBI-High Symptoms group was found to be similar to the Known Mild TBI group in terms of the number and types of symptoms experienced, whereas the Head Trauma-Low Symptoms group was similar in this respect to the No Disability group. The two former groups also evidenced high levels of emotional distress, whereas the two latter groups did not. However, on measures of handicap, the Hidden TBI-High Symptoms and Head Trauma-Low Symptoms groups were similar to the No Disability group and dissimilar from the Known Mild TBI group in that the last group experienced vocational handicap, in particular, whereas the other groups did not. Conclusions: We conclude that hidden TBI occurs at a nontrivial level (7% of our nondisabled sample). Also, individuals with hidden TBI (with persistent symptoms), unlike those with known mild TBI, are likely to experience emotional distress but not vocational handicap following injury.

Psychosocial aspects of living with cancer: a review of the literature.

Up until several years ago, little systematic effort was directed at developing an empirically based understanding of issues pertinent to psychosocial aspects of living with cancer. Recently, however, increased interest has been focused on this topic. This manuscript reviews over 100 articles, papers, and books written between 1960 and 1980 on the psychosocial impact of cancer on the adult patient and on methods of psychosocial treatment providing a “state of the art” appraisal of the area. A methodological critique of the research studies is provided as well.

Screening for substance abuse in individuals with traumatic brain injury

Primary objective: To determine the utility of the CAGE, the Brief Michigan Alcohol Screening Test (BMAST) and the Substance Abuse Subtle Screening Inventory (SASSI-3) with individuals with traumatic brain injury (TBI), two studies were conducted examining the accuracy, sensitivity and specificity of these instruments. Research design: Data from self-report instruments were compared to a clinical interview, Structured Clinical Interview for DSM-IV (SCID), to determine the accuracy, sensitivity and specificity. Methods and procedures: Two studies were conducted. In study I, 100 individuals with TBI were screened for alcohol abuse using the CAGE and the resulting classifications were compared with those derived from the SCID. In study II, 223 individuals were screened for alcohol abuse and drug abuse using the BMAST and SASSI-3 and the results of these screenings were compared with diagnoses obtained by the SCID. Main outcomes and results: The specificity of the self-report instruments was moderately high, ranging between 81–83%. The specificity of the CAGE for alcohol abuse both pre- and post-TBI was high, 96% and 86%, respectively. The sensitivity of the self-report instruments was most variable, ranging from 32–95%, with the SASSI face valid drug scale and the CAGE alcohol post-TBI indicating the most sensitivity, 95 and 91%, respectively. Conclusions: The findings suggest that the CAGE may be useful in screening for alcohol abuse and the face valid drug sub-scale of the SASSI-3 may be useful in screening for drug abuse in individuals with TBI.

The relationship of cognitive, personality, and academic measures to anesthesiology resident clinical performance

UNLABELLED Cognitive skills (including vigilance), personality factors, and standardized academic test performance may be associated with clinical competence in anesthesiology to varying degrees. Sixty-seven anesthesiology residents in training at one center between 1993 and 1995 were administered the modified Vigil (For Thought, Ltd., Nashua, NH), the Paced Auditory Serial Addition Test, the California Personality Inventory, the State-Trait Anxiety Inventory, and five standardized academic performance tests. The clinical performance of anesthesiology residents was rated on a quarterly basis by a clinical competence committee. A growth curve model indicated that there was significant variability in clinical competence at the start of residency and a statistically significant improvement over time, and that the relative ranking of the residents remained stable over the course of training. Of 46 potential variables, 7 were associated (P < 0.10) with poor clinical performance; these were subjected to a multivariate test (Mantel-Haenszel). Cognitive variables predicting poor clinical performance were difficulty performing a rapid mental arithmetic test requiring divided attention and commission errors during complex visual target detection. Personality variables predicting poor clinical performance were introversion and flexibility. A predictive academic variable was poor anesthesia knowledge as measured by using two different tests during the first month of training. There were varying levels of independence among these variables. IMPLICATIONS Early academic test performance and certain cognitive and personality tests were associated with the clinical performance of anesthesiology residents. The predictive value of these findings should be confirmed in a prospective, multicenter study.