Relatives' reports of long term problems following traumatic brain injury or subarachnoid haemorrhage.

PURPOSE: To describe and compare the late outcome of traumatic brain injury (TBI) and subarachnoid haemorrhage (SAH) in terms of the carers' perspectives, and their symptoms' profiles. METHOD: Postal survey to surviving patients who had been discharged from a Regional Neurosurgical Unit five to seven years previously. There were 288 patients identified retrospectively from hospital records, of whom 209 (126 TBI and 83 SAH) were alive and traced at follow-up. The Glasgow Outcome Scale (GOS) and the Relative's Questionnaire (RQ) were used. RESULTS: Relative's questionnaires were returned by 128 patients; 70 TBI and 58 SAH, giving response rates of 56% and 70% respectively. In terms of outcome, there was a high degree of similarity between groups. On the GOS, approximately half of each group were classified as moderately disabled (49% and 48% of the TBI and SAH groups respectively); a quarter remained severely disabled (27% and 22%); and the remaining quarter were adjudged to have made a good recovery (24% and 29%). There was a considerable overlap in terms of the most commonly reported symptoms. Cognitive and physical problems tended to be more commonly reported by relatives of the TBI patients, whilst emotional and subjective symptoms were reported equally in both patient groups. CONCLUSIONS: The effects of TBI and SAH persist for many years post-injury, leading to considerable disability and increased dependency. Although the demographic details and mechanisms of injury in these two patient groups differ, there is a high degree of similarity in the pattern of sequelae reported by carers.

Reliability of the relative's questionnaire for assessment of outcome after brain injury.

PURPOSE: The relative's questionnaire (RQ) was developed to assess outcome after brain injury. The present study investigated its test-retest reliability when used in a postal survey. METHOD: Hospital records were used to identify and contact 288 surviving patients treated for brain injury five to seven years earlier. Patients were sent a copy of the RQ (RQ1) and one month later a second copy (RQ2) was sent to those who returned RQ1. RESULT: Two hundred and eleven patients were successfully contacted, of whom 128 (61%) returned RQ1, and 94 of these (73%) returned RQ2. The reliability of items was variable, with most having a kappa value of > 0.6 suggesting 'substantial agreement' or better. CONCLUSION: The data presented suggest that the RQ is a reliable instrument in collecting outcome information in brain-injured patients by postal survey. Further research is recommended to test the suitability of the RQ for the use as a telephone interview.

Simple assessment of outcome after acute brain injury using the Glasgow Outcome Scale.

To evaluate alternative methods of determining Glasgow Outcome Scale scores, a postal survey was made of 288 general practitioners and 128 relatives of patients who had sustained acute brain injuries 5-7 years previously. The Glasgow Outcome Scale score from the general practitioner and relative were compared with that calculated from questionnaire information by an experienced rater. There was poor agreement between general practitioner and rater (K = 0.17) and relative and rater (K = 0.35) scores. Both general practitioners and relatives indicated more favourable outcomes than the rater, with a higher level of agreement (K = 0.61) between them. When Glasgow Outcome Scale scores are used, the methods employed should be valid and reliable; failure to ensure this may be responsible for a considerable proportion of variability in reported studies of brain injury outcome.

Survey of the late consequences of polio in Edinburgh and the Lothians.

OBJECTIVE: This study aimed to identify the nature and frequency of new symptoms and associated disabilities experienced by people who suffered poliomyelitis many years ago, and their access to hospital services. DESIGN: Postal survey regarding symptoms, disability (Office of Population Censuses & Surveys (OPCS) disability questionnaire), and experience of services. SUBJECTS & SETTING: People known to the British Polio Fellowship and the regional rehabilitation service who had previously had polio and were resident in Edinburgh and the Lothians. RESULTS: The study population of 125 people had a median age of 59 years, and 60% were female. The most common symptoms, present in over 60%, were: cold intolerance, fatigue, increased and new muscle weakness, muscle and joint pain, and sleep disturbance. Motor disabilities, particularly of lower limbs, were prominent. Patient contact with hospital services in the preceding five years was: clinic (62%); physiotherapy (46%); occupational therapy (29%); speech therapy (2%); wheelchair service (42%); orthotics (40%). CONCLUSIONS: New problems are sufficiently frequent and severe to warrant a more detailed study to quantify the health care requirements of the post-polio population.

The Functional Assessment Measure (FIM + FAM) as part of the hospital discharge summary after brain injury rehabilitation.

OBJECTIVE: To assess the value of providing Functional Assessment Measure (FIM + FAM) data as part of the hospital discharge information after brain injury rehabilitation. DESIGN: Postal survey of general practitioners (GPs) and consultants. SUBJECTS: Consecutive discharges (n = 117) from an early brain injury rehabilitation unit over one year. RESULTS: Response rates were 81% from GPs and 54% from consultants. Eighty-four (89%) of GPs and 57 (82%) of consultants rated the information as useful; 87 (92%) and 51 (84%) respectively described the accompanying notes as easy to understand. CONCLUSIONS: The incorporation of FIM + FAM data in discharge summaries is worthwhile but the utility of this practice is still to be established.

Use of the functional assessment measure (FIM+FAM) in head injury rehabilitation: a psychometric analysis.

OBJECTIVES: The drive to measure outcome during rehabilitation after brain injury has led to the increased use of the functional assessment measure (FIM+FAM), a 30 item, seven level ordinal scale. The objectives of the study were to determine the psychometric structure, internal consistency, and other characteristics of the measure. METHODS: Psychometric analyses including both traditional principal components analysis and Rasch analysis were carried out on FIM+FAM data from 2268 assessments in 965 patients from 11 brain injury rehabilitation programmes. RESULTS: Two emergent principal components were characterised as representing physical and cognitive functioning respectively. Subscales based on these components were shown to have high internal consistency and reliability. These subscales and the full scale conformed only partially to a Rasch model. Use of raw item ratings, as opposed to transformed ratings, to produce summary scores for the two subscales and the full scale did not introduce serious distortion. CONCLUSION: The full FIM+FAM scale and two derived subscales have high internal reliability and the use of untransformed ratings should be adequate for most clinical and research purposes in comparable samples of patients with head injury.

Cognitive and psychosocial outcome following moderate or severe traumatic brain injury.

The outcome of 96 consecutive adult patients with moderate to severe head injury was sequentially measured at 6, 12 and 24 months post-injury. In addition to global outcome using the Glasgow Outcome Scale (GOS) and a battery of neuropsychological tests of cognitive function, the Head Injury Symptom Checklist (HISC) and Relative's Questionnaire (RQ) were used. Although poorer GOS scores and severe cognitive impairments were typically associated with greater severity of initial injury, relatives reported similar functional problems irrespective of injury severity. This illustrates the legacy of moderate head injury in influencing many aspects of everyday life, supporting the argument that the needs of this group should not be overlooked.

Persisting symptoms and carers' views of outcome after subarachnoid haemorrhage.

OBJECTIVE: To report the outcome of aneurysmal subarachnoid haemorrhage (SAH) in terms of subjective symptoms and carers' perspective over a period of two years. DESIGN: Forty-four consecutive patients admitted to a Regional Neurosurgical Unit and who survived aneurysmal SAH were invited for outpatient assessment at 6, 12 and 24 months post haemorrhage. MEASURES: The Glasgow Outcome Scale (GOS) was used to measure global outcome; the Hospital Anxiety and Depression Scale (HAD) to screen for affective symptoms; the Head Injury Symptom Checklist (HISC) to detect symptoms commonly reported after head trauma; and information was collected from a close friend or relative of the patient using the Relative's Questionnaire (RQ). RESULTS: GOS outcome was significantly related to the severity of the original haemorrhage, as classified by the World Federation of Neurological Surgeons (WFNS) Grading Scale, on admission to hospital. However, even in cases where patients had made a good recovery according to the GOS, a variety of problems were frequently reported by patients and relatives, and many of these persisted for the duration of the study. The three most common and persistent symptoms were tiredness (63%, 59% and 59% at 6, 12 and 24 months respectively), memory disturbance (50%, 52% and 56%) and passivity (61%, 47% and 46%). In contrast, the prevalence of disturbed mood, as reported using the HAD, was similar to that of the general population. CONCLUSIONS: Studies of outcome following SAH should address these subtle disturbances, and information pertaining to potential long-term problems should be provided to patients and relevant others.

Impaired auditory recognition of fear and anger following bilateral amygdala lesions.

The amygdalar complex is a medial temporal lobe structure in the brain which is widely considered to be involved in the neural substrates of emotion. Selective bilateral damage to the human amygdala is rare, offering a unique insight into its functions. There is impairment of social perception after amygdala damage, with defective recognition of facial expressions of emotion. Among the basic emotions, the processing of fear and anger has been shown to be disrupted by amygdala damage. Although it remains puzzling why this not found in all cases, the importance of the amygdala in negative emotion, and especially fear, has been confirmed by conditioning, memory and positron emission tomography (PET) experiments. Central to our understanding of these findings is the question of whether the amygdala is involved specifically in the perception of visual signals of emotion emanating from the face, or more widely in the perception of emotion in all sensory modalities. We report here a further investigation of one of these rare cases, a woman (D.R.) who has impaired perception of the intonation patterns that are essential to the perception of vocal affect, despite normal hearing. As is the case for recognition of facial expressions, it is recognition of fear and anger that is most severely affected in the auditory domain. This shows that the amygdala's role in the recognition of certain emotions is not confined to vision, which is consistent with its being involved in the appraisal of danger and the emotion of fear.

The Edinburgh Extended Glasgow Outcome Scale (EEGOS): rationale and pilot studies.

The Glasgow Outcome Scale (GOS) is the most widely used outcome measure in head injury research. However, it is a global and relatively insensitive measure, precluding any description of the types of impairments that lead to the disability. The Edinburgh Extended Glasgow Outcome Scale (EEGOS) was devised as a new outcome measure that retains the advantages of the existing GOS but allows comparison of patterns of recovery in different areas of function; behavioural, cognitive and physical. This report describes pilot studies of the EEGOS used retrospectively, and in 'live' face-to-face interviews. The results show raw percentage agreements of 45%, 60% and 70% in the retrospective study, and 83%, 78% and 83% in the 'live' study. These results demonstrate that the inter-rater reliability of the EEGOS is comparable to that of the GOS applied in similar situations.

Facial expression processing after amygdalotomy.

Facial expression processing impairments were studied in D.R., a 51-year-old woman with a partial bilateral amygdalotomy. D.R. was poor at recognising emotional facial expressions, both in static and moving stimuli. In identity matching tasks (same vs different person) and expression matching tasks (same vs different expression), D.R. was impaired at expression matching with simultaneously or successively presented faces; she experienced difficulties whenever the faces' identities were discrepant with their expressions. For identity matching, she also had problems when simultaneously presented images showed the same face with two different expressions; her deficit in interpreting facial expressions could lead her to mistake differences in expression for a difference in identity. In imagery tasks, D.R. was able to answer questions about the appearance of familiar people, yet she was very poor at imaging facial expressions of emotion. We suggest that her problems in processing facial expressions included impaired knowledge of the patterning of facial features in each emotion; without this, remembering or reconstructing what emotional facial expressions look like is as impaired as perceptual recognition. These findings are consistent with the hypothesis of a role for the amygdala in social behaviour.

Face processing impairments after amygdalotomy.

We report an investigation of face processing impairments in D.R., a 51-year-old woman with a partial bilateral amygdalotomy. D.R. was able to recognize pre-operatively familiar faces, but she showed generalized problems of name retrieval and a more circumscribed deficit affecting the recognition of faces learnt post-operatively. In contrast to her poor memory for new faces, D.R.'s ability to match simultaneously presented photographs of unfamiliar faces was unimpaired. However, D.R. also experienced deficits in expression processing which compromised the recognition of emotion from people's faces: she was poor both at matching and at identifying photographs of emotional facial expressions. In addition, her interpretation of eye gaze direction was defective, showing a more general problem in reading social signals from the face. The presence of impairments affecting the learning of new faces and the comprehension of gaze direction and facial expressions of emotion is consistent with the hypothesis of a role for the amygdala in learning and social behaviour.

The nature of semantic priming effects in the recognition of familiar people.

We report a series of experiments examining the nature of semantic priming effects in the recognition of familiar people. Experiment 1 showed that facilitation of the recognition of familiar target faces by related face primes occurs within the recognition system, since there is no equivalent priming when subjects are asked only to determine the sex of the target faces, rather than to recognize them as familiar. Experiments 2 and 3 examined the basis of the facilitatory effect of related primes, and showed that both for familiarity decision (Expt 2 and Expt 3) and face naming (Expt 3) tasks it is primarily based on close association of the prime and target people, rather than common membership of a semantic category. This associative component of semantic priming was further explored in Expt 4, which showed that cross-domain priming from face primes to target names was present for associated prime-target pairs, but was maximal when prime and target were the face (prime) and name (target) of the same person. The results of the experiments are consistent with the interactive activation simulation developed by Burton, Bruce & Johnston (1990), and set constraints which will have to be met by any other plausible account of semantic priming.

Recognition impairments and face imagery.

We investigated face imagery for H.J.A. and P.H., who experience profound difficulties in recognising familiar faces. H.J.A.'s problems involve a perceptual impairment that compromises the integration of features into a coherent representation, and he does not show covert recognition of faces in indirect tests. In contrast, P.H. has shown extensive covert recognition effects, leading to the suggestion that his deficit occurs at a higher level of visual processing than H.J.A.'s. H.J.A. and P.H. were given tasks intended to explore their ability to answer questions that depended on imaging single faces, and on configuration-based or feature-based comparisons of imaged sets of three faces. For all of these face imagery tasks, P.H.'s overall performance was severely impaired. H.J.A., though, showed preserved face imagery when imaging single faces and when making feature-based comparisons between imaged faces. However, when configuration-based comparisons were demanded H.J.A. also showed a severe and stable impairment of face imagery. These observations are inconsistent with the idea that face recognition impairments have a unitary underlying cause and vary only in severity. Instead, they imply multi-stage causation, with the nature of consequent impairments of face imagery being determined by the level at which the recognition deficit arises.

Reduplication of visual stimuli.

Investigation of P.T., a man who experienced reduplicative delusions, revealed significant impairments on tests of recognition memory for faces and understanding of emotional facial expressions. On formal tests of his recognition abilities, P.T. showed reduplication to familiar faces, buildings, and written names, but not to familiar voices. Reduplication may therefore have been a genuinely visual problem in P.T.'s case, since it was not found to auditory stimuli. This is consistent with hypotheses which propose that the basis of reduplication can lie in part in malfunction of the visual system.

Sequential Cotard and Capgras delusions.

We report sequential Cotard and Capgras delusions in the same patient, KH, and offer a simple hypothesis to account for this link. The Cotard delusion occurred when KH was depressed and the Capgras delusion arose in the context of persecutory delusions. We suggest that the Cotard and Capgras delusions reflect different interpretations of similar anomalous experiences, and that the persecutory delusions and suspiciousness that are often noted in Capgras cases contribute to the patients' mistaking a change in themselves for a change in others ('they are impostors'), whereas people who are depressed exaggerate the negative effects of the same change whilst correctly attributing it to themselves ('I am dead'). This explains why there might be an underlying similarity between delusions which are phenomenally distinct.

Face-processing impairments and the Capgras delusion.

Investigations of two cases of the Capgras delusion found that both patients showed face-processing impairments encompassing identification of familiar faces, recognition of emotional facial expressions, and matching of unfamiliar faces. In neither case was there any impairment of recognition memory for words. These findings are consistent with the idea that the basis of the Capgras delusion lies in damage to neuro-anatomical pathways responsible for appropriate emotional reactions to familiar visual stimuli. The delusion would then represent the patient's attempt to make sense of the fact that these visual stimuli no longer have appropriate affective significance.

Voice recognition impairment in a blind Capgras patient.

We report a case of a blind woman, M.N., who experienced the Capgras delusion. She thought that her pet cat had been replaced by a replica which was "ill-intentioned" towards her. M.N.'s case shows that the basis of the Capgras delusion cannot lie exclusively in damage to the visual system. However, testing of M.N.'s auditory recognition abilities revealed a deficit in the recognition of familiar voices. This impairment is consistent with the view that the Capgras delusion may arise in connection with damage to recognition mechanisms, and parallels findings of face processing impairments in sighted Capgras patients.