The sensitivity and specificity of self-reported symptoms in individuals with traumatic brain injury.

In this study, self-reported symptoms (cognitive, physical, behavioural/affective) from the TIRR Symptom Checklist are compared across six panels: 135 individuals with mild TBI, 275 with moderate/severe TBI, 287 with no disability, 104 with spinal cord injury, 197 who are HIV positive and 107 who had undergone liver transplantation. Participants with TBI and SCI were at least 1 year post-injury. Individuals with TBI reported significantly more symptoms than other panels. Symptom reports in the TBI panels were independent of demographic variables (gender, education, income, ethnicity, age), as well as time since injury and depression. Five of the 67 symptoms were found to be sensitive/specific to TBI in general; 25 symptoms were sensitive/specific to mild TBI (23 were cognitive, one physical and one behavioural/affective). Implications of these results in terms of current debates about the 'reality' of symptom reports in individuals with mild TBI are discussed, as well as implications for using symptom checklists for TBI screening.

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. Personality 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.

Neuropsychologic outcome after deep hypothermic circulatory arrest in adults.

INTRODUCTION: Pediatric patients undergoing prolonged periods of deep hypothermic circulatory arrest have been found to experience long-term deficits in cognitive function. However, there is limited information of this type in adult patients who are undergoing deep hypothermic circulatory arrest for thoracic aortic repairs. METHODS: One hundred forty-nine patients undergoing elective cardiac or thoracic aortic operations were evaluated preoperatively; 106 patients were evaluated early in the postoperative period (EARLY), and 77 patients were evaluated late in the postoperative period (LATE) with a battery of neuropsychologic tests. Seventy-three patients had routine cardiac operations without deep hypothermic circulatory arrest, and 76 patients with deep hypothermic circulatory arrest were divided into 2 subgroups: those with 1 to 24 minutes of deep hypothermic circulatory arrest (n = 36 patients) and those with 25 minutes or more of deep hypothermic circulatory arrest (n = 40 patients). The neuropsychologic test battery consisted of 8 tests encompassing 5 domains: attention, processing speed, memory, executive function, and fine motor function. Data were normalized to baseline values, and changes from baseline were analyzed by analysis of covariance, multivariate logistic regression, and survival functions. RESULTS: In all domains, poor performance or inability to be tested EARLY were significant predictors of poor performance LATE (odds ratio, 5.27; P <.01). Deep hypothermic circulatory arrest of 25 minutes or more and advanced age were significant predictors of poor performance LATE for the memory and fine motor domains. Deep hypothermic circulatory arrest of 25 minutes or more (odds ratio, 4. 0; P =.02) was a determinant of prolonged hospital stay (>21 days). CONCLUSION: Deep hypothermic circulatory arrest of 25 minutes or more and advanced age were associated with memory and fine motor deficits and with prolonged hospital stay.

Axis I psychopathology in individuals with traumatic brain injury.

OBJECTIVES: To assess the incidence, comorbidity, and patterns of resolution of DSM-IV mood, anxiety, and substance use disorders in individuals with traumatic brain injury (TBI). DESIGN: The Structured Clinical Interview for DSM-IV Diagnoses (SCID) was utilized. Diagnoses were determined for three onset points relative to TBI onset: pre-TBI, post-TBI, and current diagnosis. Contrasts of prevalence rates with community-based 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 TBI 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 I 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.

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 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. PARTICIPANTS: 337 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 one"s 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.

The enigma of "hidden" traumatic brain injury.

OBJECTIVE: To examine individuals with "hidden" traumatic brain injury (TBI), 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-High 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.

The effect of parental traumatic brain injury on parenting and child behavior.

OBJECTIVES: To examine (1) the parenting skills of individuals with traumatic brain injury (TBI) and their spouses, (2) the effects of parental TBI on children, and (3) the effects of parental TBI on levels of depression for all family members. DESIGN: Independent two-tailed t tests and Pearson chi-square analyses were utilized to compare parents with TBI versus parents without TBI, spouses of parents with TBI versus spouses of parents without TBI, and children of parents with TBI versus children of parents without TBI. SETTING: Urban, suburban, and rural New York State. PARTICIPANTS: 32 families participated in the study; in 16 families one parent had a TBI and in the remaining 16 families, no parent had a TBI. Eighteen children from families with parental TBI and 26 children from families without TBI were interviewed. On average, parents with TBI were 9 years post-onset of injury at the time of interview. MAIN OUTCOME MEASURES: The parents' battery explored parents' perspectives of their own parenting skills (Parent Behavior Form, Parent Practices Questionnaire, Parenting Dimensions Inventory), their mood (Beck Depression Inventory), and the behaviors of their children (Children's Problem Checklist, Behavior Rating Profile). The child's battery tapped the children's perspective of their own behaviors (Behavior Rating Profile), their mood (Children's Depression Inventory), and the parental abilities of both parents (Parent Behavior Form, Parent Practices Questionnaire). RESULTS: Although parents with TBI and their spouses were similar to their comparison group in many parenting skills, parents with TBI reported less goal setting, less encouragement of skill development, less emphasis on obedience to rules and orderliness, less promotion of work values, less nurturing, and lower levels of active involvement with their children. Spouses of individuals with TBI, compared to their counterparts, reported less feelings of warmth, love, and acceptance toward their children. Children from families in which a parent had a TBI perceived both parents as more lax in their discipline, with the parent without TBI perceived as less actively involved in parenting roles. No differences in the frequency of behavioral problems were found between children of parents with TBI and children of parents without TBI. Parents with TBI and their children experienced more symptoms of depression relative to their respective comparison groups. CONCLUSION: Parental TBI has select consequences for all family members: individuals with TBI, their spouses, and their children. Prospective clinical evaluations of family members and proactive interventions to maximize family adjustment and minimize affective distress are indicated.

Poststroke depression: an examination of the literature.

OBJECTIVE: To examine literature on poststroke depression (PSD). DATA SOURCES: More than 200 articles related to stroke and depression were selected from a computer-based search spanning 1985 to 1995. STUDY SELECTION: All relevant articles on PSD. Articles in foreign languages, case studies, anecdotal reports, book chapters, and reviews were excluded. DATA EXTRACTION: Summary findings were independently reviewed by the authors. DATA SYNTHESIS: PSD remains a frequent sequela of stroke; its prevalence remains uncertain because of continued methodologic problems in defining subject groupings and in utilizing psychiatrically normed assessment tools with neurologically impaired individuals, and because of the poor specificity/sensitivity of neuroendocrine markers in determining a diagnosis. The etiology of PSD appears to be complex and not fully understood. Although there has been much research on PSD, this review highlights the sparsity of available literature on its treatment. CONCLUSION: The review points out the further need for more carefully designed studies of PSD that examine both assessment and treatment.

Utility of the dexamethasone suppression test in the diagnosis of poststroke depression.

The utility of the dexamethasone suppression test (DST) in the diagnosis of depression was examined in an outpatient sample of 29 stroke patients. Results indicated that the DST's sensitivity was 15%, its specificity was 67%, and its positive predictive value was 48%. These findings suggest that the DST yields no more information than would be gained from random assignment of the diagnosis of depression. Therefore, it is not a useful measure of mood in these patients.

Relationship among CT scans, neurological exam, and neuropsychological test performance in right-brain-damaged stroke patients.

Right-hemisphere stroke rehabilitation inpatients were assessed by: (1) CT scans; (2) neurological exam; and (3) cognitive and affective psychometric measures. Damage to temporal, parietal, and occipital regions was associated with visual-spatial impairments. Surprisingly, parietal damage was no more related than temporal and occipital damage to severity of visual inattention. While the neurologist's ratings of lability and depression were related to CT-scan measures, patients' self-report of depression was not so related. These findings support a less specific and probably greater interlobule organization of the right, as compared with left, hemisphere, and highlight the need for multifaceted affective assessment in such a brain-damaged group.

Perceptual remediation in patients with right brain damage: a comprehensive program.

This study provided a comprehensive program to treat visual perceptual disturbances associated with right brain damage (RBD). Three types of previously evaluated perceptual remediation were integrated into a sequentially administered remediation program: basic visual scanning, somatosensory awareness and size estimation training, and complex visual perceptual organization. The purpose of the study was to evaluate the immediate (at rehabilitation discharge) and long-term (four months after discharge) effects of this treatment program on patients with RBD. The effects of treatment on ADL and mood state were also examined. Seventy-seven RBD stroke rehabilitation inpatients were studied--including 48 Experimental (E) and 29 Control (C). At rehabilitation discharge, the E group relative to the C group showed greater gains in all three types of perceptual functioning. Four months after discharge from rehabilitation, the C group continued to show gains in perceptual functioning while the E group had reached a plateau. Longitudinal decreases in levels of self-reported anxiety and hostility, but not depression, were noted only for the E group.