Rael T. Lange

Examination of "Postconcussion-Like" Symptoms in a Healthy Sample

The post-concussion syndrome (PCS) is relatively common following mild traumatic brain injury (MTBI). However, the factors that cause and maintain this syndrome continue to be debated. The purpose of this investigation was to examine the prevalence of postconcussion-like symptoms in a sample of healthy individuals. Participants (N = 104) completed the British Columbia Postconcussion Symptom Inventory-Short Form (BC-PSI-Sf), a test designed to measure both the frequency and intensity of ICD-10 criteria for PCS, and the Beck Depression Inventory (2nd ed.). Specific endorsement rates of postconcussion-like symptoms ranged from 35.9% to 75.7% for any experience of the symptoms in the past 2 weeks, and from 2.9% to 15.5% for the experience of more severe symptoms. Symptoms reported on the BC-PSI-Sf also showed a moderately high correlation with self-reported depressive symptoms [r (102) = .76, p < .01]. This study illustrates that the presence of postconcussion-like symptoms: (a) are not unique to mild head injury and are commonly found in healthy individuals, and (b) are highly correlated with depressive symptoms.

“Good Old Days” Bias Following Mild Traumatic Brain Injury

A small percentage of people with a mild traumatic brain injury (MTBI) report persistent symptoms and problems many months or even years following injury. Preliminary research suggests that people who sustain an injury often underestimate past problems (i.e., “good old days” bias), which can impact their perceived level of current problems and recovery. The purpose of this study was to examine the influence of the good old bays bias on symptom reporting following MTBI. The MTBI sample consisted of 90 referrals to a concussion clinic (mean time from injury to evaluation = 2.1 months, SD = 1.5, range = 0.8–8.1). All were considered temporarily fully disabled from an MTBI and they were receiving financial compensation through the Workers Compensation system. Patients provided post-injury and pre-injury retrospective ratings on the 16-item British Columbia Post-concussion Symptom Inventory (BC-PSI). Ratings were compared to 177 healthy controls recruited from the community and a local university. Consistent with the good old bays bias, MTBI patients retrospectively endorsed the presence of fewer pre-injury symptoms compared to the control group. Individuals who failed effort testing tended to retrospectively report fewer symptoms pre-injury compared to those patients who passed effort testing. Many MTBI patients report their pre-injury functioning as better than the average person. This can negatively impact their perception of current problems, recovery from injury, and return to work.

Depression strongly influences postconcussion symptom reporting following mild traumatic brain injury.

Objective:To examine the influence of depression on postconcussion symptom reporting in patients following mild traumatic brain injury (MTBI). Participants:Sixty patients referred to a specialty clinic following MTBI, 58 outpatients with Structured Clinical Interview for DSM-diagnosed depression, and 72 healthy community control participants. Procedure:Participants with MTBI were divided into 2 subgroups on the basis of self-reported symptoms of depression (23 MTBI-depressed, 37 MTBI-not depressed). All participants completed a postconcussion symptom questionnaire. Main outcome measure:British Columbia Post-concussion Symptom Inventory. Results:There were significant differences in total reported postconcussion symptoms among all 4 groups (all P < .002; Cohens d = 0.68–3.24, large to very large effect sizes; MTBI-depressed > depressed outpatients > MTBI-no depression > healthy controls). There were significant differences in the number of symptoms endorsed (P < .05), with the highest number of symptoms endorsed by the MTBI-depressed group, followed by depressed outpatients, MTBI-no depression, and healthy controls. Conclusions:Patients who experience MTBIs and who have a postinjury recovery course complicated by significant depression report more postconcussion symptoms, and more severe symptoms, than (a) outpatients with depression, and (b) patients with MTBIs who do not have significant symptoms of depression.

Detecting exaggeration and malingering with the trail making test.

The purpose of this study was to examine whether unusual performance on the Trail Making Test could be indicative of deliberate exaggeration. Participants were 571 patients seen as part of a hospital trauma service who had acute traumatic brain injuries, and 228 patients involved in head injury litigation. As expected, the hospital patients with more severe traumatic brain injuries performed more poorly than the patients with less severe brain injuries on Trails A and Trails B. Cutoff score tables were developed for the patients with acute traumatic brain injuries for the total sample and by injury severity groups. Scores falling at or below the 5th percentile were considered suspicious for possible exaggeration. The performances of the head injury litigants who exaggerated on at least one well-validated symptom validity test were compared to these cutoffs. Very high positive predictive values for individuals with very mild head injuries on Trails A and B were identified (i.e., both 100%); lower positive predictive values were obtained for individuals with more severe head injuries (55.6-60%). The negative predictive values were only moderate (range=66.4-78.2%), and the sensitivity was very low (range=7.1-18.5%) for all groups. Scores that fall in the range of possible biased responding should be considered “red flags” for the clinician because they likely do not make biological or psychometric sense. However, the sensitivity of the test for deliberate exaggeration is very low, so clinicians who rely on this test in isolation to identify deliberately poor performance will fail to identify the vast majority of cases.

Interview versus questionnaire symptom reporting in people with the postconcussion syndrome.

ObjectiveTo compare spontaneous, interview-based, postconcussion symptom reporting to endorsement of symptoms on a standardized questionnaire. ParticipantsSixty-one patients referred to a concussion clinic following mild traumatic brain injury. ProcedurePatients recalled their current symptoms and problems via open-ended interview and then completed a structured postconcussion checklist. Main Outcome MeasuresOpen-ended interview and the British Columbia Postconcussion Symptom Inventory (BC-PSI). ResultsOn average, patients endorsed 3.3 symptoms (SD = 1.9) during open-ended interview and 9.1 symptoms (SD = 3.2) on the BC-PSI (P < .001). Approximately 44% endorsed 4 or more symptoms during interview compared with 92% on the BC-PSI. The percentage of patients endorsing items on the BC-PSI compared with interview was significantly greater on all 13 items. It was common for patients to endorse symptoms as moderate-severe on the BC-PSI, despite not spontaneously reporting those symptoms during the interview. ConclusionsClinicians need to be cautious when interpreting questionnaires and be aware of the possibility of nonspecific symptom endorsement, symptom overendorsement, symptom expectations influencing symptom endorsement, and the nocebo effect.

Influence of poor effort on neuropsychological test performance in U.S. military personnel following mild traumatic brain injury

The purpose of this study was to examine the influence of poor effort on neuropsychological test performance in military personnel following mild traumatic brain injury (MTBI). Participants were 143 U.S. service members who sustained a TBI, divided into three groups based on injury severity and performance on the Word Memory Test and four embedded markers of poor effort: MTBI-pass (n = 87), MTBI-fail (n = 21), and STBI-pass (n = 35; where STBI denotes severe TBI). Patients were evaluated at the Walter Reed Army Medical Center on average 3.9 months (SD = 3.4) post injury. The majority of the sample was Caucasian (84.6%), was male (93.0%), and had 12+ years of education (96.5%). Measures included the Personality Assessment Inventory (PAI) and 13 common neurocognitive measures. Patients in the MTBI-fail group performed worse on the majority of neurocognitive measures, followed by the Severe TBI-Pass group and the MTBI-pass group. Using a criterion of three or more low scores <10th percentile, the MTBI-fail group had the greatest rate of impairment (76.2%), followed by the Severe TBI-Pass group (34.3%) and MTBI-pass group (16.1%). On the PAI, the MTBI-fail group had higher scores on the majority of clinical scales (p < .05). There were a greater number of elevated scales (e.g., 5 or more elevated mild or higher) in the MTBI-fail group (71.4%) than in the MTBI-pass group (32.2%) and Severe TBI-Pass group (17.1%). Effort testing is an important component of postacute neuropsychological evaluations following combat-related MTBI. Those who fail effort testing are likely to be misdiagnosed as having severe cognitive impairment, and their symptom reporting is likely to be inaccurate.

Diffusion Tensor Imaging Findings Are Not Strongly Associated With Postconcussional Disorder 2 Months Following Mild Traumatic Brain Injury

Objective:To examine the relation between diffusion tensor imaging (DTI) of the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI). Participants:Sixty patients with MTBI and 34 patients with orthopedic/soft-tissue injuries (Trauma Controls) prospectively enrolled from consecutive admissions to a level 1 trauma center. Procedure:Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury. Participants also completed a postconcussion symptom checklist. The MTBI group was divided into 2 subgroups based on the International Classification of Diseases, Tenth Revision symptom criteria for postconcussion disorder (PCD): PCD Present (n = 21), PCD Absent (n = 39). Main Outcome Measures:Measures of fractional anisotropy and mean diffusivity for the genu, body, and splenium of the corpus callosum. Participants also completed the British Columbia Post-Concussion Symptom Inventory. Results:The MTBI group reported more postconcussion symptoms than the trauma controls. There were no significant differences between MTBI and trauma control groups on all DTI measures. In the MTBI sample, there were no significant differences on all DTI measures between those who did and did not meet the International Classification of Diseases, Tenth Revision research criteria for postconcussion disorder. Conclusions:These data do not support an association between white matter integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI.

Neuropsychological functioning following complicated vs. uncomplicated mild traumatic brain injury

Objective: It would be logical to assume that patients with intracranial abnormalities (i.e. complicated MTBIs) would have worse outcome than patients without these abnormalities (i.e. uncomplicated MTBIs). However, the literature is limited and somewhat mixed regarding outcome in patients with complicated mild TBIs. The purpose of this study is to employ a carefully controlled research design to compare the acute neuropsychological functioning of patients following complicated and uncomplicated MTBI. Method: Participants were 20 patients with complicated MTBI and 20 patients with uncomplicated MTBI selected from an archival database of 465 patients. Patients were carefully matched on age, education, gender, ethnicity, days assessed post-injury and mechanism of injury. Patients were assessed an average of 3.5 days (SD = 1.9) post-injury with 13 common cognitive variables. Results: There were significant group differences on only three of the 13 cognitive measures (complicated mild TBI worse than uncomplicated mild TBI). There were no significant differences in the proportion of impaired scores between groups on all measures, with the exception of Hopkins Verbal Learning Test Delayed Recall. Conclusion: Patients with complicated MTBIs performed more poorly only on a small number of tests during the acute recovery period.

Interpreting the trail making test following traumatic brain injury: comparison of traditional time scores and derived indices.

The purpose of this study was to examine the clinical application of traditional time scores and various derived indices from the Trail Making Test (TMT) in a sample of 571 patients with acute traumatic brain injury (TBI). Participants were classified into four injury severity groups. A clear linear relation between injury severity and TMT performance was demonstrated, with the more severely brain injured patients performing more poorly on most measures. Hierarchical logistic regression analysis of TMT time scores across binary extreme groups based on injury severity resulted in high classification rates for patients with very mild TBI (93.0% correctly classified) and low classification rates for patients with moderate to severe TBI (50.0% correctly classified). However, TMT derived indices did not provide a unique contribution to test interpretation beyond what is already available from Part A and B separately. Portions of these data were presented at the American Psychological Association conference in August, 2001, San Francisco.

Outcome from Complicated versus Uncomplicated Mild Traumatic Brain Injury

Objective. To compare acute outcome following complicated versus uncomplicated mild traumatic brain injury (MTBI) using neurocognitive and self-report measures. Method. Participants were 47 patients who presented to the emergency department of Tampere University Hospital, Finland. All completed MRI scanning, self-report measures, and neurocognitive testing at 3-4 weeks after injury. Participants were classified into the complicated MTBI or uncomplicated MTBI group based on the presence/absence of intracranial abnormality on day-of-injury CT scan or 3-4 week MRI scan. Results. There was a large statistically significant difference in time to return to work between groups. The patients with uncomplicated MTBIs had a median of 6.0 days (IQR = 0.75–14.75, range = 0–77) off work compared to a median of 36 days (IQR = 13.5–53, range = 3–315) for the complicated group. There were no significant differences between groups for any of the neurocognitive or self-report measures. There were no differences in the proportion of patients who (a) met criteria for ICD-10 postconcussional disorder or (b) had multiple low scores on the neurocognitive measures. Conclusion. Patients with complicated MTBIs took considerably longer to return to work. They did not perform more poorly on neurocognitive measures or report more symptoms, at 3-4 weeks after injury compared to patients with uncomplicated MTBIs.