Umberto Bivona

Neuropsychiatric Disorders in Persons With Severe Traumatic Brain Injury: Prevalence, Phenomenology, and Relationship With Demographic Clinical and Functional Features

Objective:To characterize neuropsychiatric symptoms in a large group of individuals with severe traumatic brain injury (TBI) and to correlate these symptoms with demographic, clinical, and functional features. Methods:The Neuropsychiatric Inventory (NPI), a frequently used scale to assess behavioral, emotional, and motivational disorders in persons with neurological diseases, was administered to a sample of 120 persons with severe TBI. Controls were 77 healthy subjects. Results:A wide range of neuropsychiatric symptoms was found in the population with severe TBI: apathy (42%), irritability (37%), dysphoria/depressed mood (29%), disinhibition (28%), eating disturbances (27%), and agitation (24%). A clear relationship was also found with other demographic and clinical variables. Conclusion:Neuropsychiatric disorders constitute an important part of the comorbidity in populations with severe TBI. Our study emphasizes the importance of integrating an overall assessment of cognitive disturbances with a specific neuropsychiatric evaluation to improve clinical understanding and treatment of persons with TBI.

Executive function and metacognitive self-awareness after Severe Traumatic Brain Injury

The objective of this study is to identify the clinical, neuropsychological, neuropsychiatric, and functional variables that correlate with metacognitive self-awareness (SA) in severe traumatic brain injury (TBI) outpatients and to assess the influence of the same variables on the sensory-motor, cognitive, and behavioral-affective indicators of SA. This cross-sectional observational study evaluated 37 outpatients from May 2006 to June 2007 in a neurorehabilitation hospital on the basis of the following inclusion criteria: (1) age 8); (3) posttraumatic amnesia (PTA) resolution; (4) capacity to undergo formal psychometric evaluation despite cognitive and sensory-motor deficits; (5) absence of aphasia; (6) availability of informed consent. A neuropsychological battery was used to evaluate attention, memory, and executive functions. SA was assessed by the awareness questionnaire (AQ), administered to both patients and relatives. Decreased metacognitive self-awareness is significantly correlated with increased problems in some components of executive system, even when the AQ subscales were considered separately. The significant correlation found between some components of executive system and metacognitive self-awareness confirmed the importance of addressing this issue to treat SA contextually in the rehabilitation of executive functions.

A preliminary investigation of road traffic accident rate after severe brain injury

Primary objective: to investigate the road traffic accident rate in patients who have resumed driving after severe brain injury. Research design: a retrospective study conducted by means of telephone interviews. Methods and procedures: The caregivers of 90 patients suffering from severe brain injury were included. All of the patients had sustained severe brain injury and prolonged coma, i.e. lasting for at least 48 hours. The caregivers were interviewed by means of a Questionnaire that investigated several aspects of driving competence after coma and the incidence of road traffic accidents. Main outcomes and results: All patient outcomes were evaluated by means of the Glasgow Outcome Scale (GOS). The 90 caregivers reported that 29 patients (32%) had resumed driving and that 11 of the 29 (38%) were subsequently involved in road traffic accidents. During the total duration of our patient population risk exposure, we found 11 cases in our study group, against the 4.7 expected cases calculated in the normal population. The relative risk of road traffic accidents in severe brain injury patients versus uninjured individuals was 2.3. Conclusions: Our preliminary data show that a subject who has suffered from severe brain injury and coma lasting for at least 48 hours has a statistically significant higher risk of being involved in a road traffic accident.

Metacognitive unawareness correlates with executive function impairment after severe traumatic brain injury.

UNLABELLED The aim of this study was to evaluate clinical, neuropsychological, and functional differences between severe traumatic brain injury (TBI) outpatients with good and/or heightened metacognitive self-awareness (SA) and those with impaired metacognitive SA, assessed by the Patient Competency Rating Scale (PCRS). Fifty-two outpatients were recruited from a neurorehabilitation hospital based on the following inclusion criteria: 1) age > or = 15 years; 2) diagnosis of severe TBI; 3) availability of neuroimaging data; 4) post-traumatic amnesia resolution; 5) provision of informed consent. MEASURES A neuropsychological battery was used to evaluate attention, memory and executive functions. SA was assessed by the PCRS, which was administered to patients and close family members. Patients were divided into two groups representing those with and without SA. Patients with poor SA had more problems than those with good SA in some components of the executive system, as indicated by the high percentage of perseverative errors and responses they made on the Wisconsin Card Sorting Test. Moreover, a decrease in metacognitive SA correlated significantly with time to follow commands (TFC). This study suggests the importance of integrating an overall assessment of cognitive functions with a specific evaluation of SA to treat self-awareness and executive functions together during the rehabilitation process.

Low Self-Awareness of Individuals With Severe Traumatic Brain Injury Can Lead to Reduced Ability to Take Another Person's Perspective

Aims of this study were (i) to verify whether a deficit or a lack of self-awareness can lead to difficulties in assuming another persons perspective after a severe traumatic brain injury (TBI); (ii) to verify whether perspective-taking deficits emerge more from performance-based tasks than self-reports; and (iii) to evaluate the possible relationships between perspective-taking difficulties and some clinical, neuropsychological, neuropsychiatric, and neuroimaging variables. The Interpersonal Reactivity Index, Empathy Quotient, first-order false-belief, and faux pas written stories were administered to 28 patients with severe TBI and 28 healthy controls. The Awareness Questionnaire was also administered to TBI patients and their caregivers. Patients were split into 2 groups (impaired self-awareness vs adequate self-awareness) on the basis of the discrepancy Awareness Questionnaire score. Both TBI groups obtained lower scores than healthy controls on the Fantasy subscale of the Interpersonal Reactivity Index, the reality question of the false-belief stories, and the memory questions of the faux pas test. Only impaired self-awareness patients tended to obtain lower scores in first-order false-belief detection. Impaired self-awareness patients also performed significantly worse than both healthy controls and adequate self-awareness patients on the faux pas tasks. The analysis suggests a causal relationship between low self-awareness and perspective-taking difficulties in this population of patients.

Return to Driving After Severe Traumatic Brain Injury: Increased Risk of Traffic Accidents and Personal Responsibility

Objective:To determine the frequency of road traffic accidents among individuals who start or resume driving after severe traumatic brain injury (TBI) and to investigate their responsibility for these accidents. Design:Observational/retrospective study. Participants:Sixty adults with severe TBI and their caregivers. Measures:Return to Driving Questionnaire and Glasgow Outcome Scale. Results:Thirty of the 60 participants started to drive or resumed driving after TBI. Nineteen (63%) of them were involved in traffic accidents, with personal responsibility in 26 of 36 after return to driving. Participants caused a significantly higher number of accidents after TBI than before. Conclusions:The ability to drive is frequently compromised after severe TBI. Specific rehabilitation of this complex activity should be a main goal of social reintegration programs in this population.

Memory and anatomical change in severe non missile traumatic brain injury: ∼1 vs. ∼8 years follow-up

In previous studies, we investigated a group of subjects who had suffered from a severe non missile traumatic brain injury (nmTBI) without macroscopic focal lesions and we found brain atrophy involving the hippocampus, fornix, corpus callosum, optic chiasm, and optic radiations. Memory test scores correlated mainly with fornix volumes [37,38]. In the present study, we re-examined 11 of these nmTBI subjects approximately 8 yr later. High-spatial resolution T1 weighted magnetic resonance images of the brain (1mm(3)) and standardised memory tests were performed once more in order to compare brain morphology and memory performance originally assessed 3-13 months after head injury (first study) and after 8-10 yr (present study). An overall improvement of memory test performance was demonstrated in the latest assessment, indicating that cognitive recovery in severe nmTBI subjects had not been completed within 3-13 months post-injury. It is notable that the volumes of the fornix and the hippocampus were reduced significantly from normal controls, but these volumes do not differ appreciatively between nmTBI subjects at first (after ∼1 yr) and at second (after ∼8 yr) scans. On the contrary, a clear reduction in the volume of the corpus callosus can be observed after ∼1 yr and a further significant reduction is evident after ∼8 yr, indicating that the neural degeneration in severe nmTBI continues long after the head trauma and relates to specific structures and not to the overall brain.

Prospective memory in patients with severe closed-head injury: Role of concurrent activity and encoding instructions.

Objectives: To assess the sensitivity of patients who suffered a severe closed-head injury to the manipulation of attentional resources and encoding instructions during the execution of prospective memory tasks. Material and Methods: A group of patients with chronic sequelae of severe closed-head injury and a group of matched normal controls were given an experimental procedure for the assessment of time-based and event-based prospective memory. Availability of attentional resources at the time of intention recall and encoding conditions at the time of giving instructions were varied across experimental sessions. Results: The simultaneous execution of a concurrent task was more detrimental to accuracy in the spontaneous recall of the prospective intention in the post-traumatic than in the normal control group. Moreover, the instruction to encode more extensively by rehearsing aloud and mentally imaging the actions to be performed at the time of the study improved recall accuracy more in the post-traumatic than in the normal control group. Conclusions: Based on these data, we suggest that a prospective memory deficit in post-traumatic patients is due, among other things, to reduced availability of attentional resources and to poor encoding of actions to be performed.

A biopsychosocial analysis of sexuality in adult males and their partners after severe traumatic brain injury

Abstract Purpose: The primary aim of this study was to investigate changes in sexual function in males and their partners following severe TBI. Secondary aims of the study were to explore the relationship between selected sociodemographic, emotional/behavioural and sexual function variables. Methods: Twenty males with a history of severe TBI and 20 healthy controls (HC) and their respective partners were recruited. Sexual life was assessed with the Sexuality Evaluation Schedule Assessment Monitoring (SESAMO). Study participant level of self-awareness was evaluated by the Awareness Questionnaire, whereas their neuropsychiatric and psychopathological statuses were assessed by the NPI, the HAM-D and STAI. Results: A reduction in desire and frequency of sexual intercourse was found in all survivors and their partners. Moreover, higher levels of survivor depression correlated with lower partner harmony. Survivor feelings toward their partners gradually decreased over time, as did the ability to make decisions as a couple. The comparison with HC couples revealed that both survivors’ and their partners’ exaggerated the extent of disease. Conclusions: After male severe TBI, men appear to have a reduced quality of their sexual life, which may be more a result of relationship dysfunction than a sexual performance deficit related to their brain injury history.

Selective Cognitive Dysfunction Is Related to a Specific Pattern of Cerebral Damage in Persons With Severe Traumatic Brain Injury.

Objective:Cognitive dysfunction is a common sequela of traumatic brain injury (TBI); indeed, patients show a heterogeneous pattern of cognitive deficits. This study was aimed at investigating whether patients who show selective cognitive dysfunction after TBI present a selective pattern of cerebral damage. Setting:Post-Coma Unit, IRCCS Santa Lucia Foundation, Rome, Italy. Participants:We collected data from 8 TBI patients with episodic memory disorder and without executive deficits, 7 patients with executive function impairment and preserved episodic memory capacities, and 16 healthy controls. Design:We used 2 complementary analyses: (1) an exploratory and qualitative approach in which we investigated the distribution of lesions in the TBI groups, and (2) a hypothesis-driven and quantitative approach in which we calculated the volume of hippocampi of individuals in the TBI and control groups. Main Measures:Neuropsychological scores and hippocampal volumes. Results:We found that patients with TBI and executive functions impairment presented focal lesions involving the frontal lobes, whereas patients with TBI and episodic memory disorders showed atrophic changes of the mesial temporal structure (hippocampus). Conclusion:The complexity of TBI is due to several heterogeneous factors. Indeed, studying patients with TBI and selective cognitive dysfunction should lead to a better understanding of correlations with specific brain impairment and damage, better follow-up of long-term outcome scenarios, and better planning of selective and focused rehabilitation programs.