A longitudinal analysis of factors associated with post traumatic growth after acquired brain injury.

ABSTRACTPost-Traumatic Growth (PTG) is a form of positive psychological change that occurs for some individuals following traumatic experiences. High levels of PTG have been reported among survivors of acquired brain injury (ABI). Yet it remains unclear why some survivors of ABI develop PTG and others do not. The present study investigated early and late factors that are associated with long-term PTG in people with moderate to severe ABIs. Participants (n = 32, Mage = 50.59, SD = 12.28) completed self-report outcome measures at two time-points seven years apart (one-year and eight-years post-ABI). Outcome measures assessed emotional distress, coping, quality of life and ongoing symptoms of brain injury, as well as PTG at the later timepoint. Multiple regression analyses indicated that one-year post-ABI, fewer symptoms of depression, more symptoms of anxiety, and use of adaptive coping strategies accounted for a significant amount of variance in later PTG. At eight years post-ABI, fewer symptoms of depression, fewer ongoing symptoms of brain injury, better psychological quality of life and use of adaptive coping strategies explained a substantial amount of variance in PTG. For individuals with ABIs, PTG may be promoted by implementing long-term neuropsychological support which aims to facilitate use of adaptive coping strategies, supports psychological wellbeing and allows individuals to find meaning post-ABI.

Impaired metacognition and reduced neural signals of decision confidence in adults with traumatic brain injury.

OBJECTIVE: Metacognition reflects our capacity to monitor or evaluate other cognitive states as they unfold during task performance, for example, our level of confidence in the veracity of a memory. Impaired metacognition is seen in patients with traumatic brain injury (TBI) and substantially impacts their ability to manage functional difficulties during recovery. Recent evidence suggests that metacognitive representations reflect domain-specific processes (e.g., memory vs. perception) acting jointly with generic confidence signals mediated by widespread frontoparietal networks. The impact of neurological insult on metacognitive processes across different cognitive domains following TBI remains unknown. METHOD: To assess metacognitive accuracy, we measured decision confidence across both a perceptual and memory task in patients with TBI (n = 27) and controls (n = 28). During the metacognitive tasks, continuous electroencephalography was recorded, and event-related potentials (ERP) were analyzed. RESULTS: First, we observed a deficit in metacognitive efficiency across both tasks suggesting that patients show a loss of perceptual and memorial evidence available for confidence judgments despite equivalent accuracy levels to controls. Second, a late positive-going ERP waveform (500-700 ms) was greater in amplitude for high versus low-confidence judgements for controls across both task domains. By contrast, in patients with TBI, the same ERP waveform did not vary by confidence level suggesting a deficient or attenuated neural marker of decision confidence postinjury. CONCLUSIONS: These findings suggest that diffuse damage to putative frontoparietal regions in patients disrupts domain-general metacognitive accuracy and electrophysiological signals that accumulate evidence of decision confidence. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Life is about "constant evolution": the experience of living with an acquired brain injury in individuals who report higher or lower posttraumatic growth.

OBJECTIVE: To explore the experience of living with an Acquired Brain Injury (ABI) in individuals who report higher or lower posttraumatic growth (PTG). METHOD: A multi-method design was employed. Participant scores on the Posttraumatic Growth Inventory (PTGI) were used to identify groups for qualitative comparative analysis. Individual semi-structured interviews were conducted with fourteen individuals with ABI. Data were analysed thematically. RESULTS: Four themes emerged. The first two themes: "In my mind I was fine" surviving in aftermath of acquiring a brain injury and The everyday as "derailing" capture the transition process from an initial rehabilitation state characterised by neuropsychological and avoidance coping, towards active rebuilding for PTG. Internal building blocks for PTG and Growing in the social world: "you need to have that social connection" elaborate on the internal (e.g., acceptance, integration of the pre and post-injury self) and external (e.g., social relationships) factors seen to facilitate or obstruct PTG. CONCLUSIONS: Under certain conditions, individuals living with ABI may construe positive growth from their experiences. Practitioners can support PTG development by providing individual and family-based supports aimed at increasing acceptance, the integration of self, and social connection throughout all stages of ABI rehabilitation.IMPLICATIONS FOR REHABILITATIONInternal factors such as having a flexible and positive mindset and external factors such as one's social environment can affect how individuals living with an ABI construe positive growth.Individuals with ABI and their families require access to individualised longitudinal support for neuropsychological and social challenges that can result in increased distress and obstruct the development of PTG.Efforts to facilitate acceptance and support the integration of the pre and post-injury self through recognition of continuity of self and processing of new schematic beliefs can benefit PTG development.Rehabilitation providers should support individuals with ABI to develop or maintain a positive social identity within new or existing social groups.

Self-reported outcomes and patterns of service engagement after an acquired brain injury: a long-term follow-up study.

PRIMARY OBJECTIVE: To describe the clinical characteristics, self-reported outcomes in domains relating to activities of daily living and patterns of service engagement in the survivors of a moderate-to-severe acquired brain injury over seven years. RESEARCH DESIGN: A longitudinal research design was used. METHODS AND PROCEDURES: Thirty-two individuals who sustained a moderate-to-severe acquired brain injury completed a Sociodemographic and Support Questionnaire at one (t1) and seven years (t2) after completing a publicly funded inpatient neurorehabilitation program. MAIN OUTCOMES AND RESULTS: There were minimal changes in independent living, mobility, ability to maintain key relationships and in return to work in the interval between t1 and t2. Sixty-nine percent of participants engaged with two or more allied health professional services and 75% engaged with support services in the community over the seven years. CONCLUSIONS: There were minimal additional gains in outcomes relating to activities of daily-living and there was a high level of service need in the first decade postinjury. Young and middle-aged individuals who sustain an ABI may continue to live in the community for decades with some level of disability and may require ongoing access to services.

Rehabilitation of emergent awareness of errors post traumatic brain injury: A pilot intervention.

Impaired awareness of errors is common following traumatic brain injury (TBI) and can be a barrier to successful rehabilitation. The objective of this study was to develop and evaluate a computer-based intervention programme aimed at improving error awareness in individuals with TBI. A further aim was to explore its effects on metacognitive awareness and variability of performance. Participants were 11 individuals with TBI and impaired error awareness who performed a sustained attention task twice-weekly for four weeks. The intervention consisted of audio-visual feedback-on-errors during the sustained attention task. Six participants received audio-visual feedback-on-error, five did not receive feedback. Emergent and metacognitive awareness were measured pre- and post-intervention. Between-groups comparisons of emergent awareness from pre- to post-intervention showed that audio-visual feedback-on-error improved emergent awareness compared to no feedback-on-error. Some changes in metacognitive awareness of executive behaviours as a result of feedback were observed. Audio-visual feedback-on-error improved emergent awareness in individuals with TBI following a four-week/eight-session intervention. This improvement was not observed in the no-feedback group. This pilot intervention is not a stand-alone treatment but it has potential to be usefully incorporated into cognitive or clinical rehabilitation programmes to improve emergent awareness.

Connecting Self-Awareness and Error-Awareness in Patients with Traumatic Brain Injury.

Impaired self-awareness after traumatic brain injury (TBI) is often seen in stark contrast to the observations of significant-others, who are acutely aware of the difficulties experienced by patients. Our objective was to investigate the relationship between metacognitive knowledge in daily life and emergent awareness of errors during laboratory tasks, since the breakdown of error detection mechanisms may impose limitations on the recovery of metacognitive knowledge after TBI. We also examined the extent to which these measures of awareness can predict dysexecutive behaviors. A sample of TBI patients (n=62) and their significant-others, provided reports of daily functioning post injury. In addition, patients underwent a neuropsychological assessment and were instructed to signal their errors during go/no-go tests. Interrelationships between metacognitive and emergent levels of awareness were examined, after controlling for the influence of secondary cognitive variables. Significant-other ratings correlated with errors made by the patients on neuropsychological tests but not with their premorbid function. Patients who under-reported daily life difficulties or over-reported their competency, compared to significant-other reports, were less likely to show awareness of laboratory errors. Emergent awareness was also identified as the sole predictor of performance on the modified six-element test, an ecologically valid test of multitasking. The online breakdown of error awareness after brain injury is related to difficulties with metacognitive awareness as reported in daily life, and is also predictive of dysexecutive behaviors. These findings are discussed in the context of multidimensional and neural models of awareness and error monitoring.

Impaired self-awareness after traumatic brain injury: inter-rater reliability and factor structure of the Dysexecutive Questionnaire (DEX) in patients, significant others and clinicians.

AIMS: This study sought to address two questions: (1) what is the inter-rater reliability of the Dysexecutive Questionnaire (DEX) when completed by patients, their significant others, and clinicians; and (2) does the factor structure of the DEX vary for these three groups? METHODS: We obtained DEX ratings for 113 patients with an acquired brain injury from two brain injury services in the UK and two services in Ireland. We gathered data from two groups of raters-"significant others" (DEX-SO) such as partners and close family members and "clinicians" (DEX-C), who were psychologists or rehabilitation physicians working closely with the patient and who were able to provide an opinion about the patient's level of everyday executive functioning. Intra-class correlation coefficients and their 95% confidence intervals were calculated between each of the three groups (self, significant other, clinician). Principal axis factor (PAF) analyses were also conducted for each of the three groups. RESULTS: The factor analysis revealed a consistent one-factor model for each of the three groups of raters. However, the inter-rater reliability analyses showed a low level of agreement between the self-ratings and the ratings of the two groups of independent raters. We also found low agreement between the significant others and the clinicians. CONCLUSION: Although there was a consistent finding of a single factor solution for each of the three groups, the low level of agreement between significant others and clinicians raises a question about the reliability of the DEX.

A qualitative exploration of how individuals reconstruct their sense of self following acquired brain injury in comparison with spinal cord injury.

PRIMARY OBJECTIVE: The present study aimed to investigate the specific ways in which individuals reconstruct their sense of self following injury to the nervous system, by comparing individuals with acquired brain injury (ABI) and individuals with spinal cord injury (SCI), two groups that have experienced a sudden-onset injury with life-changing repercussions. RESEARCH DESIGN: Phenomenological qualitative research. METHODS AND PROCEDURES: Nine individuals with ABI and 10 individuals with SCI took part in an interview exploring the ways in which individuals reconstruct their sense of self following injury. Data were analysed using interpretative thematic analysis. MAIN OUTCOMES AND RESULTS: Findings showed similar themes identified within the interview data of the ABI and SCI groups. Both groups developed positive and negative self-narratives. Individuals employed strategies that facilitated the reconstruction of positive self-narratives. In addition, individuals described their sense of self as simultaneously continuous and changing. DISCUSSION: Findings are discussed in relation to proposed models of self-reconstruction post-injury to the nervous system.

The contribution of retrospective memory, attention and executive functions to the prospective and retrospective components of prospective memory following TBI.

PRIMARY OBJECTIVE: Despite the prevalence of prospective memory (PM) problems, relatively little is known about the processes underlying impairment following TBI. This study sought to examine PM performance, using a multiple-task, multiple-response video-based paradigm in which initial encoding of the cue-action associations was ensured (Video-Assessment of Prospective Memory; VAPM). RESEARCH DESIGN: VAPM was designed to allow easy identification of reasons for failure (i.e. cue detection and/or specific action retrieval). Patients with moderate/severe TBI (n = 32) and matched controls (n = 16) also completed standardized neuropsychological assessment including evaluation of episodic retrospective memory (RM), attention, information processing, executive functions and mood. MAIN OUTCOMES AND RESULTS: As a group, those with TBI were impaired on PM tasks with 50% failing to complete at least 2/6 required tasks despite near perfect performance by controls. Individual profile analyses revealed different reasons for impairment, with RM contributing significantly to both the prospective and retrospective components. This was supported by correlational analyses illustrating a significant relationship between cue detection and RM measures, in addition to measures of executive functions and attention. CONCLUSIONS: The contribution of RM to both components of PM, along with the finding of heterogeneity in performance among participants have important implications for theoretical understanding and clinical practice.

Emotional distress and awareness following acquired brain injury: an exploratory analysis.

BACKGROUND: Symptoms of depression and anxiety are commonly reported following brain injury, providing ongoing challenges to patients, clinicians and carers. There is increasing interest in the influence of impaired awareness on emotional distress, supported by psychological investigations. OBJECTIVE: To explore the relationship between awareness and time since injury on reported emotional distress. METHOD: Awareness was assessed by comparing the reports of persons with brain injury to the reports of their treating clinicians and significant others. Fifty-four participants with acquired brain injury (ABI) completed the Awareness Questionnaire, the Dysexecutive Questionnaire and the Hospital Anxiety and Depression Scales. Clinicians and significant others completed the Awareness Questionnaire and the Dysexecutive Questionnaire in relation to each participant. RESULTS: Analyses of variance identified a main effect of awareness, such that participants with better awareness of their difficulties had higher emotional distress, regardless of time since injury. CONCLUSION: Findings support psychological theories suggesting that emotional distress is a response to the stressor of a brain injury and denial of difficulty, manifesting as impaired awareness, may play a protective role. They highlight the importance of understanding a patient's level of awareness so as to provide support aimed at minimizing the impact of distress on the rehabilitation outcome.

Rehabilitation psychology: meeting the needs of individuals with acquired disabilities in Ireland.

PURPOSE: The current articles reviews the epidemiology of disability in Ireland, discusses the political and social factors which have increased focus on disability issues and offers training guidelines for rehabilitation psychology based on those of the APA's Rehabilitation Psychology Division. RATIONALE: With the growing number of individuals with acquired (vs developmental) disabilities in Ireland, there is increased recognition of the need to train psychologists to assist persons with acquired disabilities (e.g. spinal cord injury, acquired brain injury, stroke, etc.) in adjusting to their impairments, reintegrating back into their communities and reducing the long-term financial costs associated with disability. CONCLUSION: Social and political factors suggest that the time is right to develop rehabilitation psychology as a specialty in Ireland given the increased focus on disability in Ireland, including recently passed disability legislation (i.e. 2005 Disability Bill), international events (e.g. 2003 Dublin World Special Olympics) and increases in rehabilitation training programmes (i.e. medicine; physio, occupational and speech therapy).

Awareness of deficits in traumatic brain injury: a multidimensional approach to assessing metacognitive knowledge and online-awareness.

Recent models of impaired awareness in brain injury draw a distinction between metacognitive knowledge of difficulties and online awareness of errors (emergent and anticipatory). We examined performance of 31 Traumatic Brain Injury (TBI) participants and 31 healthy controls using a three-strand approach to assessing awareness. Metacognitive knowledge was assessed with an awareness interview and discrepancy scores on three questionnaires--Patient Competency Rating Scale, Frontal Systems Behavioral Scale and the Cognitive Failures Questionnaire. Online Emergent Awareness was assessed using an online error-monitoring task while participants performed tasks of sustained attention. Online anticipatory awareness was examined using prediction performance on two cognitive tasks. Results indicated that the TBI Low Self-Awareness (SA) group and High SA group did not differ in terms of severity, chronicity or standard neuropsychological tasks but those with Low SA were more likely to exhibit disinhibition, interpersonal problems and more difficulties in total competency. Sustained attention abilities were associated with both types of online awareness (emergent and anticipatory). There was a strong relationship between online emergent and online anticipatory awareness. Metacognitive knowledge did not correlate with the other two measures. This study highlights the necessity in adopting a multidimensional approach to assessing the multifaceted phenomenon of awareness of deficits.

Capture by misleading information and its false acceptance in patients with traumatic brain injury.

Exposure to misleading information, presented after a critical episode, can alter or impair memory reports about that episode. Here, we examine vulnerability to misleading information in patients with traumatic brain injury (TBI). The ability to initiate an effective retrieval strategy and inhibit irrelevant or interfering information requires participation from the prefrontal cortices, which are susceptible to damage following brain injury. We report that TBI patients are more prone to interference effects produced by misleading information during a cued-recall task and are more likely to accept this information as the product of 'remembering' compared with healthy controls. The results are consistent with a model proposing that patients are captured by highly accessible responses eliminating their opportunity to engage in recollection. Correlations between the cued-recall interference task and other executive measures helped elucidate the processes underlying 'capture'. In TBI patients, reduced recollection produced by a misleading prime was associated with impaired prospective remembering when engaged in a background task. A common functional deficit that may underlie poor performance on both tasks is the failure to inhibit previously relevant but currently irrelevant information. Subjective reports pertaining to the subject's cued-recall response were indexed by electrodermal activity. In control subjects, larger skin conductance responses (SCRs) were associated with a greater frequency of guess reports, suggesting that SCRs provide a marker for uncertainty regarding the candidacy of a selected response. TBI patients did not show this relationship, suggesting that impairments of post-retrieval evaluation might also underlie greater false acceptance of misinformation. Discussion focuses on the role of the prefrontal cortex and cognitive processes that mediate the selection and evaluation of memories.

Sustained attention in traumatic brain injury (TBI) and healthy controls: enhanced sensitivity with dual-task load.

Poor sustained attention or alertness is a common consequence of traumatic brain injury (TBI) and has a considerable impact on the recovery and adjustment of TBI patients. Here, we describe the development of a sensitive laboratory task in healthy subjects (Experiment 1) and its enhanced sensitivity to sustained attention errors in TBI patients (Experiment 2). The task involves withholding a key press to an infrequent no-go target embedded within a predictable sequence of numbers (primary goal) and detecting grey-coloured targets within the sequence (secondary goal). In Experiment 1, we report that neurologically healthy subjects are more likely to experience a lapse of attention and neglect the primary task goal, despite ceiling performance on the secondary task. Further, attentional lapses on the task correlated with everyday attentional failures and variability of response time. In Experiment 2, the task discriminates between TBI patients and controls with a large effect size. The dual-task yields more errors in both groups than a simple task involving only the primary goal that is commonly used to detect sustained attention deficits in neurologically impaired groups. TBI patients' errors also correlated with everyday cognitive failures and variability of response time. This was not the case in the simple version of the task. We conclude that the dual-task demand associated with this task enhances its sensitivity as a measure of sustained attention in TBI patients and neurologically healthy controls that relates to everyday slips of attention.

Non-epileptic seizures: patients' understanding and reaction to the diagnosis and impact on outcome.

RATIONALE: The study aim was to assess patients' understanding of and reaction to a diagnosis of non-epileptic attack disorder and to explore whether these factors contribute to outcome. METHOD: Eighty-four patients diagnosed with non-epileptic attack disorder participated in the study. Participants answered questions about their seizures and understanding and reaction to the diagnosis. Data were collected by semi-structured telephone interview. Questionnaires were sent to the patients' general practitioners (GPs) to gather information regarding the patient's seizure status, prescription of anti-epileptic drugs and opinion regarding the diagnosis. RESULTS: At the time of follow-up, a third of participants reported being seizure free. A total of 63% did not have a good understanding of the diagnosis, most were unclear about the precipitating factors and the most common reaction to the diagnosis was confusion. Many reported a negative impact of NES on everyday life. Sixty-five percent reported receiving psychological follow-up but the number of sessions attended was few (median 2). There was evidence that the reaction to the diagnosis contributed to the outcome in particular an angry outcome was associated with a poor prognosis. Ten GPs did not agree with the diagnosis. CONCLUSION: Patients understanding and reactions to a diagnosis of non-epileptic attacks are important factors that should contribute to the development of more tailored treatment approaches.