Multilevel modeling of self-esteem change during acute inpatient stroke rehabilitation.

OBJECTIVE: To explore self-esteem change during inpatient stroke rehabilitation and moderators of change. RESEARCH METHOD: One hundred twenty survivors of stroke serially completed the State Self-Esteem Scale (SSES) during inpatient rehabilitation, as well as measures of mood and perceived recovery as potential moderators of change. Age, gender, prior stroke, prestroke depression, stroke laterality, and admission Functional Independence Measure (FIM) self-care, mobility, and cognitive scores were also included as moderators. RESULTS: Multilevel modeling of the repeated administrations of the SSES indicated that self-esteem significantly improved during rehabilitation. Female gender, left hemisphere stroke, prior stroke, and lower admission FIM cognitive scores were associated with lower self-esteem ratings at admission, but only age and admission FIM self-care and mobility scores were associated with self-esteem change. Older individuals showed less self-esteem improvement than younger individuals, and higher self-care and mobility scores at admission were associated with greater self-esteem improvement. While mood change significantly covaried with self-esteem, the rate of mood change did not appear to influence rate of self-esteem change. Greater improvement in self-esteem over time was related to lower levels of perceived recovery, but this was likely because of the relationship between perceived recovery and self-esteem at rehabilitation admission. IMPLICATIONS: These results suggest that self-esteem improves during inpatient rehabilitation, and this change may be partially dependent on functional status. Implications for facilitating self-esteem change by the clinician are discussed, as well as future research directions.

Self-esteem level and stability, admission functional status, and depressive symptoms in acute inpatient stroke rehabilitation.

OBJECTIVES: Explore the relationship of self-esteem level, self-esteem stability, and admission functional status on discharge depressive symptoms in acute stroke rehabilitation. RESEARCH METHOD: One hundred twenty stroke survivors serially completed a measure of state self-esteem during inpatient rehabilitation and completed a measure of depressive symptoms at discharge. Functional status was rated at admission using the Functional Independence Measure (FIM). Regressions explored main effects and interactions of self-esteem level and stability and admission FIM self-care, mobility, and cognitive functioning on discharge depressive symptoms. RESULTS: After controlling for potential moderating variables, self-esteem level interacted with FIM self-care and cognitive functioning to predict discharge depressive symptoms, such that survivors with lower self-rated self-esteem and poorer functional status indicated higher levels of depressive symptoms. Self-esteem stability interacted with FIM mobility functioning, such that self-esteem instability in the presence of lower mobility functioning at admission was related to higher depressive symptoms at discharge. IMPLICATIONS: These results suggest that self-esteem variables may moderate the relationship between functional status and depressive symptoms. Self-esteem level and stability may differentially moderate functional domains, although this conclusion requires further empirical support.

Self-esteem stability and depressive symptoms in acute stroke rehabilitation: methodological and conceptual expansion.

OBJECTIVES: Explore the relationship of self-esteem level, self-esteem stability, and other moderating variables with depressive symptoms in acute stroke rehabilitation. MEASURES: One hundred twenty participants completed measures of state self-esteem, perceived recovery, hospitalization-based hassles, impairment-related distress, and tendency to overgeneralize negative self-connotations of bad events. Self-report of depressive symptoms was collected at admission and on discharge. Four regression analyses explored the relationship of self-esteem level and stability and each of 4 moderating variables (perceived recovery, hassles, impairment-related distress, and overgeneralization) with depressive symptoms at discharge. RESULTS: Analyses indicated significant 3-way interactions in the 4 regression models. In general, individuals with unstable high self-esteem endorsed greater depressive symptoms under conditions of vulnerability (e.g., lower perceived recovery) than did individuals with stable high self-esteem. Under conditions of vulnerability, participants with stable low self-esteem indicated the highest levels of depressive symptoms. IMPLICATIONS: Self-esteem level and stability interact with psychological, environmental, and stroke-specific variables to predict depressive symptoms at discharge from stroke rehabilitation. This suggests the viability of self-esteem stability in exploring depressive symptoms in this setting and the complexity of emotional adjustment early after stroke.

Relationships among premorbid alcohol use, acute intoxication, and early functional status after traumatic brain injury.

OBJECTIVE: To investigate the relationships among intoxication at time of injury, preinjury history of problem drinking, and early functional status in patients with traumatic brain injury (TBI). DESIGN: Prospective cohort study. SETTING: Acute inpatient TBI rehabilitation. PARTICIPANTS: Participants were 1748 persons with TBI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Blood alcohol levels (BALs) were obtained at admission to the emergency department, and a history of problem drinking was obtained through interview. Study outcomes, Disability Rating Scale (DRS), and FIM instrument scores were gathered at admission to inpatient rehabilitation. RESULTS: Multivariate regression analysis revealed that BAL and a history of binge drinking were predictive of DRS, but not FIM, scores. A higher BAL was associated with poorer functional status on the DRS. Paradoxically, a history of binge drinking was associated with more intact functional status on the DRS. CONCLUSIONS: The relationships among intoxication at time of injury, history of problem drinking, and early outcome after TBI were modest. Injury severity had a more significant association with TBI functional status.

Self-esteem in an acute stroke rehabilitation sample: a control group comparison.

OBJECTIVE: To compare ratings of self-esteem and depressive mood in a sample of stroke survivors in an acute inpatient rehabilitation setting to those of a matched control group. DESIGN: Stroke survivors (n = 80) were matched on age and education to a group of neurologically intact community-dwelling control participants. Between-group analysis compared mean ratings of self-esteem and depressive measures. Within-group correlational analyses explored the relationship between self-esteem and mood. Between-group comparison of the correlations between self-esteem and mood explored differences in the strength of association between these constructs. Regression analyses explored the relationship of self-esteem measures after controlling for depressive mood. MAIN MEASURES: Visual Analogue Self-Esteem Scale, Rosenberg Self-Esteem Scale, Geriatric Depression Scale. RESULTS: Stroke survivors rated significantly lower mean levels of self-esteem on the Visual Analogue Self-Esteem Scale (37 versus 41) and the Rosenberg Self-Esteem Scale (21 versus 24) than the control group. Stroke survivors also rated higher mean levels of depressive mood on the Geriatric Depression Scale (9 versus 6). Significantly higher correlations between self-esteem and mood ratings were noted in the stroke group than in the control group. Lower self-esteem ratings do not appear to be a byproduct of depressive mood. CONCLUSIONS: Self-esteem is negatively impacted by stroke and is strongly, but independently, associated with depressive mood. Clinicians may better facilitate the emotional adjustment of the survivor by considering this facet of psychological impact and intervening to address self-esteem.

Assessment and correlates of self-esteem following stroke using a pictorial measure.

OBJECTIVE: To describe the characteristics of a non-verbal measure of self-esteem in a sample of individuals in the acute phase following stroke. DESIGN: Acute-phase stroke survivors (n=156) were administered measures of self-esteem, depression, anxiety, general emotional distress and cognitive functioning during admission to an inpatient stroke rehabilitation unit. MAIN MEASURES: Visual Analogue Self-Esteem Scale (VASES), Geriatric Depression Scale, Adult Manifest Anxiety Scale, Visual Analog Mood Scales, measures of neuropsychological functioning. RESULTS: VASES performance was not related to demographic variables, cognitive functioning, visual acuity, prior stroke or severe visuoperceptual impairment/left visual neglect. The VASES was most related to emotional functioning, with lower self-esteem ratings associated with higher levels of depressive symptoms and general emotional distress. Individuals with right hemisphere stroke tended to endorse lower self-esteem ratings, while aphasic individuals may have misunderstood the intent of the task. CONCLUSIONS: The non-verbal VASES appears to be minimally impacted by potentially invalidating patient factors (e.g. visual acuity, left visual neglect), although its use with patients with severe communication deficits is cautioned. The VASES may prove useful in identifying acute stroke survivors most at risk for emotional dysfunction, and may be useful as a research tool in this population.

Detection of feigned head injury symptoms on the MMPI-2 in head injured patients and community controls.

MMPI-2 results from 39 moderately to severely head injured (HI) and 44 community volunteer (CV) participants given instructions to feign symptoms or answer honestly during an analog forensic neuropsychological examination were compared. No significant effects for HI or the interaction between the HI and instruction set (IS) factors were noted on either clinical or selected validity scales (F, Fb, Fp, Ds2, FBS). However, the main effect of IS was significant for both clinical and validity scales (median Cohen's d=1.34 and 1.39, respectively). Most validity scales were characterized by perfect specificity rates but low to modest sensitivity, whereas FBS had both moderate sensitivity and specificity. Logistic regressions showed that the F and Ds2 scales made a significant contribution independent of motivational tests to the identification of feigning during neuropsychological examination.

Construct validity of the 7/24 spatial recall test.

This investigation was conducted to examine the construct validity of the 7/24 Spatial Recall Test (7/24). Participants were 64 outpatients who met criteria for clinically definite multiple sclerosis (MS). Data obtained from administration of a fixed neuropsychological assessment battery were analyzed to evaluate the relation between demographic, physical, and emotional factors and performance on the 7/24, to examine the measure's convergent/discriminant validity, to determine which variables account for the greatest proportion of variance in 7/24 scores, and to assess further the test's sensitivity to the cognitive sequelae of MS. Findings suggest that 7/24 scores are significantly explained by the constructs of visual-spatial perception/analysis, memory, reasoning, and/or processing speed. The proportion of variance in 7/24 performances accounted for by cognitive and demographic variables, however, was quite low. Relative to the measure's normative sample, participants in this investigation performed significantly poorer on number of responses recalled across Set A learning trials but not on Set A long-delay recall. Results of this investigation indicate some level of sensitivity of the 7/24 to the cognitive impairments associated with MS but offer only weak support for the 7/24 as a valid measure of visuospatial learning/memory.

Head injury and the ability to feign neuropsychological deficits.

This study investigated the possibility that head-injured patients, by virtue of their exposure to medical and legal evaluations, are better able to feign deficits than controls. Both internal and external validity issues were addressed in a malingering simulation using 46 moderately to severely head injured and 46 matched control subjects who were administered a battery of neuropsychological and motivational tests under standard or malingering instructions. Results showed no significant interaction between malingering instructions and head injury status on commonly used motivational tests or neuropsychological tests, nor were the head injured malingerers better able to avoid detection using established cutting scores on motivational tests. These results suggest that head injured individuals are no more able to feign neuropsychological deficits successfully than non-head injured individuals.