Michael Schonberger

Functional outcome 10 years after traumatic brain injury: Its relationship with demographic, injury severity, and cognitive and emotional status

Previous investigations of long-term outcome following traumatic brain injury (TBI) have yielded mixed results regarding the predictive power of injury severity and demographic factors. Furthermore, there has been limited investigation of the association between long-term outcome and current cognitive functioning and psychiatric state. The aim of this study was to investigate the association of injury severity, demographic factors, and concurrent cognitive and psychiatric functioning with functional outcome 10 years following mild to severe TBI. Outcome was rated using the Extended Glasgow Outcome Scale (GOSE) for 60 participants, who also completed neuropsychological measures of attention, speed of processing, memory and executive function and the Hospital Anxiety and Depression Scale (HADS). Outcome on the GOSE ranged from upper good recovery (32%) to lower severe disability (2%). Participants showing poorer outcome on the GOSE had significantly longer posttraumatic amnesia duration; less education; performed more poorly on cognitive measures of information processing speed, attention, memory, and executive function; and showed higher levels of anxiety on the HADS.

Predictors of Postconcussive Symptoms 3 Months After Mild Traumatic Brain Injury

OBJECTIVE There is continuing controversy regarding predictors of poor outcome following mild traumatic brain injury (mTBI). This study aimed to prospectively examine the influence of preinjury factors, injury-related factors, and postinjury factors on outcome following mTBI. METHOD Participants were 123 patients with mTBI and 100 trauma patient controls recruited and assessed in the emergency department and followed up 1 week and 3 months postinjury. Outcome was measured in terms of reported postconcussional symptoms. Measures included the ImPACT Post-Concussional Symptom Scale and cognitive concussion battery, including Attention, Verbal and Visual memory, Processing Speed and Reaction Time modules, pre- and postinjury SF-36 and MINI Psychiatric status ratings, VAS Pain Inventory, Hospital Anxiety and Depression Scale, PTSD Checklist-Specific, and Revised Social Readjustment Scale. RESULTS Presence of mTBI predicted postconcussional symptoms 1 week postinjury, along with being female and premorbid psychiatric history, with elevated HADS anxiety a concurrent indicator. However, at 3 months, preinjury physical or psychiatric problems but not mTBI most strongly predicted continuing symptoms, with concurrent indicators including HADS anxiety, PTSD symptoms, other life stressors and pain. HADS anxiety and age predicted 3-month PCS in the mTBI group, whereas PTSD symptoms and other life stressors were most significant for the controls. Cognitive measures were not predictive of PCS at 1 week or 3 months. CONCLUSIONS Given the evident influence of both premorbid and concurrent psychiatric problems, especially anxiety, on postinjury symptoms, managing the anxiety response in vulnerable individuals with mTBI may be important to minimize ongoing sequelae.

Psychosocial and emotional outcomes 10 years following traumatic brain injury.

ObjectivesTo investigate the association of psychosocial outcome 10 years following traumatic brain injury (TBI) with demographic variables, injury severity, current cognitive functioning, emotional state, aggression, alcohol use, and fatigue. SettingCommunity-based follow-up. ParticipantsFifty-three participants with mild to very severe TBI sustained 10 years previously and significant others. MeasuresSydney Psychosocial Reintegration Scale, Extended Glasgow Outcome Scale, Hospital Anxiety and Depression Scale, NFI Aggression scale, Fatigue Severity Scale, Alcohol Use Disorders Identification Test, neuropsychological tests of attention/processing speed, memory, and executive function. ResultsPsychosocial functioning was lowest in the occupational activity domain and highest in the living skills domains. Variables including education, posttraumatic amnesia duration, numerous cognitive measures, concurrent fatigue, aggression, anxiety, and depression were all significantly associated with psychosocial outcome, although the strength of correlations varied between ratings of participants with TBI and relatives. Posttraumatic amnesia duration was most strongly associated with psychosocial outcome measured by relatives; anxiety, aggression, and depression were the strongest predictors when ratings were assigned by participants with TBI. Self-reported fatigue, depression, and alcohol use were the strongest predictors of aggression. ConclusionsIt is important to address problems with anxiety, depression, fatigue, and alcohol use as a possible means of improving long-term psychosocial outcome following TBI.

The nature, frequency and course of psychiatric disorders in the first year after traumatic brain injury: a prospective study

BACKGROUND Psychiatric disorders are common following traumatic brain injury (TBI). However, few studies have examined the course of disorder development and the influence of pre-injury psychiatric history. The present study aimed to examine the frequency of, and association between, psychiatric disorders occurring pre- and post-injury, and to examine the post-injury course of disorders. METHOD Participants were 102 adults (75.5% male) with predominantly moderate-severe TBI. Participants were initially assessed for pre-injury and current disorders, and reassessed at 3, 6 and 12 months post-injury using the Structured Clinical Interview for DSM-IV Disorders (SCID). RESULTS Over half of the participants had a pre-injury psychiatric disorder; predominantly substance use, mood, and anxiety disorders. In the first year post-injury, 60.8% of participants had a psychiatric disorder, commonly anxiety and mood disorders. Post-injury disorders were associated with the presence of a pre-injury history (p<0.01), with 74.5% of participants with a pre-injury psychiatric history experiencing a post-injury disorder, which commonly presented at initial assessment or in the first 6 months. However, 45.8% of participants without a pre-injury history developed a novel post-injury disorder, which was less likely to emerge at the initial assessment and generally developed later in the year. CONCLUSIONS Despite evidence that most post-injury psychiatric disorders represent the continuation of pre-existing disorders, a significant number of participants developed novel psychiatric disorders. This study demonstrates that the timing of onset may differ according to pre-injury history. There seem to be different trajectories for anxiety and depressive disorders. This research has important implications for identifying the time individuals are most at risk of psychiatric disorders post-injury.

Impact of age on long-term cognitive function after traumatic brain injury.

OBJECTIVE To examine the association of age and time postinjury with cognitive outcome 5-22 years following traumatic brain injury (TBI), in relation to matched uninjured controls. METHODS One hundred twelve participants with mild to very severe TBI, aged 16-81 years at the time of injury, were cognitively assessed on measures of processing speed and attention, verbal and visual memory, executive function, and working memory. Results were compared with those of 112 healthy controls individually matched for current age, gender, education, and estimated IQ. RESULTS Older injured individuals performed worse than did younger injured individuals across all cognitive domains, after controlling for the performance of controls. In relation to matched controls, long-time survivors performed disproportionately worse than did more recently injured individuals, irrespective of age. CONCLUSIONS After maximum spontaneous recovery from TBI, poorer cognitive functioning appears to be associated with both older age at the time of injury and increased time postinjury. These findings have implications for prognosis, early treatment recommendations, and long-term issues of differential diagnosis and management planning.

Predictors of psychiatric disorders following traumatic brain injury.

Objective:To investigate predictors of posttraumatic brain injury psychiatric disorders. Design:Retrospective, cross-sectional design with stratified random sampling of groups of patients on average 1 to 5 years postinjury. DSM-based diagnostic interviews of both traumatic brain injury (TBI) participant and informant. Participants:One hundred community-based participants, aged 19–74 years, with traumatic brain injury sustained 0.05–5.5 years previously. Setting:Community-based patients previously treated at a rehabilitation hospital. Main measure:The Structured Clinical Interview for DSM-IV diagnosis. Results:A psychiatric history was a high-risk factor for having the same disorder postinjury. However, the majority of cases of depression and anxiety were novel, suggesting that significant factors other than pre-TBI psychiatric status contribute to post-TBI psychiatric outcome. Female gender, lower education, and pain were also associated with postinjury depression and unemployment and older age with anxiety. Conclusion:Findings suggest that long-term screening and support are important for individuals with TBI, regardless of preinjury psychiatric status.

The development of the therapeutic working alliance, patients' awareness and their compliance during the process of brain injury rehabilitation.

Purpose: To examine the development and interaction of the therapeutic alliance, patients’ compliance and awareness during the process of brain injury rehabilitation and the role of demographic and injury related variables in this process. Subjects were 86 patients who underwent a holistic neuropsychological outpatient rehabilitation programme. Patients had suffered a traumatic brain injury (n = 27), a cerebrovascular accident (n = 49) or another neurological insult (n = 10). Measures: The therapeutic alliance between clients and their primary therapists, clients’ awareness and their compliance were rated four times during the 14-week rehabilitation programme. The therapeutic alliance was rated by both clients and therapist using the Working Alliance Inventory (WAI), awareness and compliance were rated by the therapists. Results: The development of the process measures over time is described in the article. Clients’ and therapists’ perspectives on their alliance tended to converge over time. Clients’ experience of their emotional bond with their therapist added as much to the prediction of clients’ awareness as the localization of their brain injury. Clients’ awareness was related to their compliance and mediated the impact of the therapeutic alliance on their compliance. Discussion: A good working alliance is the basis of successful rehabilitative work. The article discusses therapeutic implications of the results.

The factor structure of the Hospital Anxiety and Depression Scale in individuals with traumatic brain injury

There is a lack of validated scales for screening for anxiety and depression in individuals with traumatic brain injury (TBI). The purpose of this study was to examine the factor structure of the Hospital Anxiety and Depression Scale (HADS) in individuals with TBI. A total of 294 individuals with TBI (72.1% male; mean age 37.1 years, S.D. 17.5, median post-traumatic amnesia (PTA) duration 17 days) completed the HADS 1 year post-injury. A series of confirmatory factor analyses was conducted to examine the fit of a one-, two- and three-factor solution, with and without controlling for item wording effects (Multi-Trait Multi-Method approach). The one-, two- or three-factor model fit the data only when controlling for negative item wording. The results are in support of the validity of the original anxiety and depression subscales of the HADS and demonstrate the importance of evaluating item wording effects when examining the factor structure of a questionnaire. The results would also justify the use of the HADS as a single scale of emotional distress. However, even though the three-factor solution fit the data, alternative scales should be used if the purpose of the assessment is to measure stress symptoms separately from anxiety and depression.

The association between Apolipoprotein E and traumatic brain injury severity and functional outcome in a rehabilitation sample

Traumatic brain injury (TBI) can result in significant disability, but outcome is variable. The impact of known predictors accounts for a limited proportion of the variance in outcomes. Apolipoprotein E (ApoE) genotype has been investigated as an additional source of variability in injury severity and outcome, with mixed findings reflecting variable methodology and generally limited sample sizes. This study aimed to examine whether possession of the ApoE ɛ4 allele was associated with greater acute injury severity and poorer long-term outcome in patients referred for rehabilitation following TBI. ApoE genotype was determined for 648 patients with TBI, who were prospectively followed up a mean of 1.9 years post-injury. Hypotheses that ɛ4 carriers would have lower Glasgow Coma Scale (GCS) scores and longer post-traumatic amnesia (PTA) duration were not supported. Prediction of worse Glasgow Outcome Scale-Extended (GOSE) scores for ɛ4 carriers was supported with greater susceptibility seen in females. These results indicate the ApoE ɛ4 allele may be associated with poorer long-term outcome, but not acute injury severity. Possible mechanisms include differential effects of the ɛ4 allele on inflammatory and cellular repair processes, and/or amyloid deposition.

Factors contributing to attentional impairments after traumatic brain injury.

The aim of the present study was to investigate the contribution of impaired information processing speed and strategic control of attention to performance on attentional tasks after traumatic brain injury (TBI). Forty moderately to severely injured rehabilitation inpatients and 40 healthy controls completed a selection of attentional tasks. Slowed processing speed in the TBI group was identified on the Symbol Digit Modalities Test (SDMT), 2&7 Selective Attention Test (2&7), Selective Attention (SAT), and Four Choice Reaction Time (4CRT) tasks. Impaired working memory was evident on the Letter Number Sequencing (LNS) task. Structural equation modeling revealed that the group difference in RT on the complex SAT was accounted for by slowed speed of processing on the simple SAT, and not working memory. TBI participants made more errors and missed responses on the complex version of the SAT, suggesting impairment in some aspects of strategic control of attention, and appeared unable to benefit from the automatic condition of the 2&7 Test. There was little evidence of deficit on the Sustained Attention to Response Task (SART). The present study provides evidence for a significant contribution of slowed processing speed to impaired performance on attentional tasks after TBI.