The aim of this study was to investigate the impact of brain injury survivors´ social cognition abilities on their working alliance with their therapist. Participants in this study were individuals who were enrolled in a vocational rehabilitation programme for acquired brain injury. Seventy-two individuals with complicated mild to severe acquired brain injury (49%TBI, 38% stroke, 14% other injury; mean age 44.9 years; 75% male) entered in the study between 1.5 and 31 years after their injury (Md=5 years). The therapeutic alliance was rated retrospectively at the time of study by the participants´ primary therapists on the Working Alliance Inventory (WAI). Social cognition measures (Reading the Mind in the Eyes Test, Recognition of Faux Pas Test, The Awareness of Social Inference Test, TASIT; Social Situations Task, Bangor Gambling Task) were administered as well as a standard neuropsychological test battery and the Hospital Anxiety and Depression Scale. Multilevel analyses revealed that both the TASIT and the Social Situations Task, but neither the standard neuropsychological tests nor the HADS were significantly related to WAI ratings. These findings indicate the impact that difficulties with emotions recognition and social rule violations can have on the formation of a therapeutic alliance.

The purpose of this study was to investigate the neurological correlates of both subjective fatigue as well as objective fatigability in individuals with traumatic brain injury (TBI). The study has a cross-sectional design. Participants (N = 53) with TBI (77% male, mean age at injury 38 years, mean time since injury 1.8 years) underwent a structural magnetic resonance imaging (MRI) scan and completed the Fatigue Severity Scale (FSS), while a subsample (N = 36) was also tested with a vigilance task. While subjective fatigue (FSS) was not related to measures of brain lesions, multilevel analyses showed that a change in the participants' decision time was significantly predicted by grey matter (GM) lesions in the right frontal lobe. The time-dependent development of the participants' error rate was predicted by total brain white matter (WM) lesion volumes, as well as right temporal GM and WM lesion volumes. These findings could be explained by decreased functional connectivity of attentional networks, which results in accelerated exhaustion during cognitive task performance. The disparate nature of objectively measurable fatigability on the one hand and the subjective experience of fatigue on the other needs further investigation.

OBJECTIVES:(1) To examine the relations between performance on cognitive tests and on-road driving assessment in a sample of persons with traumatic brain injury (TBI). (2) To compare cognitive predictors of the on-road assessment with demographic and injury-related predictors.PARTICIPANTS:Ninety-nine people with mild-severe TBI who completed an on-road driving assessment in an Australian rehabilitation setting.DESIGN:Retrospective case series.MAIN MEASURES:Wechsler Test of Adult Reading or National Adult Reading Test-Revised; 4 subtests from the Wechsler Adult Intelligence Scale-III; Rey Auditory Verbal Leaning Test; Rey Complex Figure Test; Trail Making Test; demographic factors (age, sex, years licensed); and injury-related factors (duration of posttraumatic amnesia; time postinjury).RESULTS:Participants who failed the driving assessment did worse on measures of attention, visual memory, and executive processing; however, cognitive tests were weak correlates (r values <0.3) and poor predictors of the driving assessment. Posttraumatic amnesia duration mediated by time postinjury was the strongest predictor of the driving assessment-that is, participants with more severe TBIs had later driving assessments and were more likely to fail.CONCLUSION:Cognitive tests are not reliable predictors of the on-road driving assessment outcome. Traumatic brain injury severity may be a better predictor of on-road driving; however, further research is needed to identify the best predictors of driving behavior after TBI.

Post-traumatic growth (PTG) is the experience of positive changes that can follow a traumatic event. The current study examined the factorial as well as the discriminant validity of the German version of the Post-traumatic Growth Inventory (PTGI-G) in stroke patients. A total of 188 adult stroke patients (63.3% male; median age 69 years) completed the PTGI-G and the German version of the Hospital Anxiety and Depression Scale (HADS-D) at the end of their inpatient rehabilitation. Confirmatory factor analyses indicate an acceptable model fit of both the original five-factor solution as well as a second-order factor model of the PTGI-G (CFI > .95; RMSEA < .01). Small and non-significant correlations between the PTGI-G subscales and the depression scale of the HADS-D support the discriminant validity of the PTGI-G. The PTGI-G appears to be a valid tool in the context of stroke research.

Objective:Fatigue is one of the most frequent sequelae of traumatic brain injury (TBI), although its causes are poorly understood. This study investigated the interrelationships between fatigue and sleepiness, vigilance performance, depression, and anxiety, using a structural equation modeling approach.Methods:Seventy-two participants with moderate to severe TBI (78% males) were recruited a median of 305 days postinjury. They completed the Fatigue Severity Scale, a vigilance task, the Epworth Sleepiness Scale, and Hospital Anxiety and Depression Scale. A model of the interrelationships between the study variables was developed, tested, and modified with path analysis.Results:The modified model had a good overall fit (chi(2)(2) = 1.3, P = .54; comparative fit index = 1.0; root-mean square error of approximation = 0.0; standardized root-mean square residual = 0.02). Most paths in this model were significant (P < .05). Fatigue predicted anxiety, depression, and daytime sleepiness. Depression predicted daytime sleepiness and poor vigilance, whereas anxiety tended to predict reduced daytime sleepiness.Conclusions:This model confirms the complexity of fatigue experience. It supports the hypothesis that fatigue after TBI is a cause, not a consequence, of anxiety, depression, and daytime sleepiness, which, in turn (especially depression), may exacerbate fatigue by affecting cognitive functioning. These findings suggest that to alleviate fatigue, it is important to address each of these factors. However, the findings need to be confirmed with a longitudinal research design.

The aim of the study was to describe the development and predictors of psychological adjustment during community-based traumatic brain injury (TBI) rehabilitation. Forty-two adolescent and adult individuals with TBI (mean age 32 years, 88% male, median post-traumatic amnesia 11 days) participated in a single-group, longitudinal design study. The main measures used were the Reactions to Impairment and Disability Inventory, Adjustment subscale; Sydney Psychosocial Reintegration Scale; Hospital Anxiety and Depression Scale; and Self-awareness of Deficits Interview. At rehabilitation start, individuals differed significantly from each other with respect to their level of psychological adjustment. Individual trajectories of psychological adjustment were highly variable. However, for the sample as a whole, psychological adjustment did not change during the course of rehabilitation (multilevel regression models; p > .05). Good psychological adjustment was related to low levels of emotional distress and a small discrepancy between current and aspired functional status. Poor functional status had a more minor impact on psychological adjustment in individuals with poor self-awareness than in individuals with high levels of self-awareness. The results confirm parts of theoretical models of psychological adjustment to acquired brain injury, especially the importance of goal refinement. However, the results need to be treated cautiously, given the limited sample size.

Background: Imagery rescripting (ImRS), i.e. changing intrusive mental images in imagery, is increasingly recognized as a helpful therapy technique. In ImRS exercises, patients sometimes suggest taking violent revenge on perpetrators. However, it is unclear whether vengeful phantasies can be particularly helpful in giving back feelings of power and control, or whether they rather increase aggressive feelings, with potentially harmful effects.Methods: Forty-six healthy participants watched 3 trauma movie segments depicting interpersonal violence. After each movie, one of 3 ImRS strategies (ImRS with violent revenge, ImRS without violence, safe place imagery) was applied. Dependent variables were subjective emotion ratings.Results: Aggressive and positive emotions changed most strongly with the safe place image, no differences between ImRS with and without violence were observed. Sad and anxious emotions were not differently influenced by different strategies.Limitations: Only a healthy sample with no previous display of aggression has been investigated. Crossover effects cannot be excluded due to the within-group design with repeated trauma movie segments.Conclusions: Using violent pictures in ImRS does not seem to be particularly risky as it does not increase aggressive emotions in the participants; however it has no added value. For the purpose of emotion regulation after an analog trauma, the safe place imagery does best. (C) 2013 Elsevier Ltd. All rights reserved.

Objectives: To examine the temporal relation between fatigue, depression, and daytime sleepiness after traumatic brain injury. Fatigue is a frequent and disabling consequence of traumatic brain injury (TBI). However, it is unclear whether fatigue is a primary consequence of the structural brain injury or a secondary consequence of injury-related sequelae such as depression and daytime sleepiness. Participants: Eighty-eight adults with complicated mild-severe TBI (69% male). Main Measures: Fatigue Severity Scale; depression subscale of the Hospital Anxiety and Depression Scale; Epworth Sleepiness scale at baseline and 6-month follow-up. Results: A cross-lagged path analysis computed within a structural equation modeling framework revealed that fatigue was predictive of depression (β = .20, P < .05) and sleepiness (β = .25, P < .05). However, depression and sleepiness did not predict fatigue (P > .05). Conclusions: The results support the view of fatigue after TBI as “primary fatigue”—that is, a consequence of the structural brain injury rather than a secondary consequence of depression or daytime sleepiness. A rehabilitation approach that assists individuals with brain injury in learning to cope with their neuropsychological and physical limitations in everyday life might attenuate their experience with fatigue.

Objective: To examine the direct, mediated, and moderated associations among cognition, coping, and emotional adjustment following traumatic brain injury (TBI). Design: Cross-sectional, single-group design. Participants: Ninety-seven participants with mild to severe TBI recruited from their rehabilitation hospital and assessed on average 19 months postinjury. Measures: The BIRT Memory and Information Processing Battery, Doors Test from the Doors and People Test, Hayling Sentence Completion Test, Controlled Oral Word Association Test, Trail Making Test, Digit Span, Symbol Digit Modalities Test-Oral Version, Hospital Anxiety and Depression Scale, and the Coping Scale for Adults. Results: Poorer performance on measures of memory, executive functions, and attention and information processing was associated with greater levels of self-reported depression and anxiety. No mediated relation was found between cognition and emotional adjustment. However, the use of adaptive coping strategies was found to moderate the relation between the Hayling A-a measure of information processing speed-and self-reported depression. Conclusions: Greater impairments in cognition directly predicted higher levels of anxiety and depression following TBI. In addition, the results suggest that the use of adaptive coping strategies has a greater effect on levels of depression for individuals with poor information processing speed.

A brief preparatory programme, based on the principles of motivational interviewing (MI), was developed as a way of engaging clients with traumatic brain injury (TBI) and preparing them for a cognitive behaviour therapy (CBT) programme for anxiety. The MI + CBT programme was delivered to a male client in his early 40s with severe TBI at four months post-injury, using a single-subject design with repeated measures pre- and post-treatment. The client received three sessions of manualised MI, followed by nine sessions of CBT. The MI sessions focused on helping the client to develop more realistic goals and supporting his self-efficacy about his ability to cope with anxiety. Specific strategies were used to accommodate the client's cognitive limitations, such as the use of personally meaningful metaphors and role plays. Re-assessments were conducted at the end of MI, CBT and nine weeks post-treatment, using a semi-structured clinical interview and self-report measures of anxiety, mood and change expectancy. The client showed significant improvement in anxiety following treatment and a significant reduction in subjective units of distress (SUDS) between the MI and CBT phases. The results suggest the potential utility of MI in people with TBI, and the need to evaluate treatment protocols in a controlled trial.

Background: CBT is a potentially effective treatment for anxiety disorders following TBI; however, empirical evidence has mainly come from clients with mild TBI. This paper describes a CBT-based anxiety treatment programme adapted for clients with more severe injuries. Two case studies are provided to illustrate the implementation of the programme, as a step toward larger scale testing of the programme's feasibility.Methods and procedures: A manualised adapted CBT treatment manual was used to deliver CBT in a standardised manner to two clients, one with severe and one with moderate TBI. Outcome was evaluated using a single-subject design with repeated measures of anxiety, mood and coping style at pre- and post-CBT.Results: The two clients demonstrated positive treatment response on either a measure of anxiety or a continuous measure of distress. Although neither demonstrated a clinically significant change according to the primary outcome measure (Hospital Anxiety and Depression Scale), they showed significant change in at least one corroborated measure of anxiety.Conclusions: This study suggests the potential utility of the adapted CBT programme for clients with moderate-severe TBI. Limitations of the single case studies were discussed, while noting how they would be addressed in a follow-up randomised controlled trial.

Levels of expressed emotion (EE) within the family, particularly criticism and emotional over-involvement, are associated with a patient's psychological outcome in a range of psychiatric and medical conditions. This study aimed to examine the relationship between levels of family EE and anxiety and depression in patients who have sustained a traumatic brain injury (TBI). A further aim was to examine whether family members' levels of psychological distress and attributions of patient symptom controllability, were related to their levels of patient-directed EE. Participants were 43 patients who had sustained a complicated mild to severe TBI three months to five years previously, and their nominated family members. Results indicated that family members' criticism and emotional over-involvement were associated with patients' levels of anxiety and depression. Moreover, family members' levels of anxiety and depression were associated with their levels of patient-directed criticism and emotional over-involvement, whilst their attributions of patient symptom control were not. These findings suggest that levels of EE within the family are associated with psychological adjustment following TBI. Consequently, interventions targeting EE in family members may help to reduce psychiatric difficulties following TBI.

Although cognitive-behavioural therapy (CBT) is the treatment of choice for anxiety, its delivery needs to be adapted for individuals with traumatic brain injury (TBI). It also requires clients' active engagement for maximum benefit. This study was a pilot randomised controlled trial involving an anxiety treatment programme adapted for people with TBI, based on CBT and motivational interviewing (MI). Twenty-seven participants with moderate/severe TBI (aged 21-73 years, 78% males) recruited from a brain injury rehabilitation hospital were randomly allocated to receive MI + CBT (n = 9), non-directive counselling (NDC) + CBT (n = 10) and treatment-as-usual (TAU) (n = 8). CBT and MI were manualised and delivered in 12 weekly individual sessions. Primary outcome was self-reported anxiety symptoms assessed at baseline, at the end of NDC/MI and immediately following CBT. Assessment was conducted by assessors blinded to group assignment. Intention-to-treat analyses showed that the two active treatment groups demonstrated significantly greater anxiety reduction than TAU. Participants receiving MI showed greater response to CBT, in terms of reduction in anxiety, stress and non-productive coping, compared to participants who received NDC. The results provided preliminary support for the adapted CBT programme, and the potential utility of MI as treatment prelude. Longer follow-up data are required to evaluate the maintenance of treatment effects.

OBJECTIVE:There is continuing controversy regarding predictors of poor outcome following mild traumatic brain injury (mTBI). This study aimed to prospectively examine the influence of preinjury factors, injury-related factors, and postinjury factors on outcome following mTBI. METHOD:Participants were 123 patients with mTBI and 100 trauma patient controls recruited and assessed in the emergency department and followed up 1 week and 3 months postinjury. Outcome was measured in terms of reported postconcussional symptoms. Measures included the ImPACT Post-Concussional Symptom Scale and cognitive concussion battery, including Attention, Verbal and Visual memory, Processing Speed and Reaction Time modules, pre- and postinjury SF-36 and MINI Psychiatric status ratings, VAS Pain Inventory, Hospital Anxiety and Depression Scale, PTSD Checklist-Specific, and Revised Social Readjustment Scale. RESULTS:Presence of mTBI predicted postconcussional symptoms 1 week postinjury, along with being female and premorbid psychiatric history, with elevated HADS anxiety a concurrent indicator. However, at 3 months, preinjury physical or psychiatric problems but not mTBI most strongly predicted continuing symptoms, with concurrent indicators including HADS anxiety, PTSD symptoms, other life stressors and pain. HADS anxiety and age predicted 3-month PCS in the mTBI group, whereas PTSD symptoms and other life stressors were most significant for the controls. Cognitive measures were not predictive of PCS at 1 week or 3 months. CONCLUSIONS:Given the evident influence of both premorbid and concurrent psychiatric problems, especially anxiety, on postinjury symptoms, managing the anxiety response in vulnerable individuals with mTBI may be important to minimize ongoing sequelae.

Psychiatric disorders are common and often debilitating following traumatic brain injury (TBI). However, there is little consensus within the literature regarding the risk factors for post-injury psychiatric disorders. A 1-year prospective study was conducted to examine which pre-injury, injury-related, and concurrent factors were associated with experiencing a psychiatric disorder, diagnosed using the Structured Clinical Interview for DSM-IV-TR Axis I Disorders, at 1 year post-injury. Participants were 122 adults with TBI and 88 proxy informants. Psychiatric disorders were common both pre-injury (54.1%) and at 12 months post-injury (45.9%). Results of regression analyses indicated individuals without a pre-injury psychiatric disorder or psychiatric symptomatology in the acute post-injury period were less likely to have a psychiatric disorder at 12 months post-injury. These findings confirm the importance of pre-injury history for the prediction of post-injury psychiatric disorders. Limb injury also emerged as a useful early indicator of later psychiatric disorder. Post-injury psychiatric disorders were associated with concurrent unemployment, pain, poor quality of life, and use of unproductive coping skills. The clinical implications of these findings are discussed.

BACKGROUND:Traumatic brain injury (TBI) can cause lasting functional changes and lead to unemployment. The purpose of this study was to create and test a structural equation model (SEM) of the prediction of functional and employment outcome after TBI.METHODS:Participants were 949 individuals with predominantly moderate to severe TBI (74% males, median age 25.7 years) who attended a follow-up interview 1 year post-injury. Outcome (employment and mood, cognitive and behavioural changes) was measured using the Structured Outcome Questionnaire. An SEM, based on existing research, was developed, tested and modified.RESULTS:A comparative fit index of 0.99 and a root mean square error of approximation of 0.03 supported the fit of the final model. Age, education, pre-injury employment, injury severity and limb injuries were direct predictors of employment outcome. Gender, pre-injury psychiatric disorders and limb injuries were related to employment outcome by their association with mood, cognitive and behavioural changes.CONCLUSIONS:The results demonstrate the complex interplay between various factors predicting outcome after TBI and provide evidence for the importance of tailoring rehabilitation to the individual's needs. Further research, including other conditions, can build on this model and include additional predictor and outcome measures.

Poor functional status and high rates of anxiety and depression have been reported in individuals who have sustained a traumatic brain injury (TBI). However, it is unclear whether psychiatric disorders after TBI are a cause or a consequence of functional limitations. The current study aimed to investigate the temporal relationship between anxiety, depression and functional impairment following TBI. The study has a prospective, longitudinal single-group design. Anxiety and depression, assessed using the Structured Clinical Interview for DSM-IV, and functional changes, assessed with the Glasgow Outcome Scale-Extended, were measured six and 12 months post-injury in 122 individuals who had sustained a TBI (79% male, mean age 35 years, mean duration of post-traumatic amnesia 24 days, mean Glasgow Coma Scale score 9.2). Cross-lagged analyses were conducted within a structural equation modelling framework. Functional changes six months post-injury predicted depression and anxiety one year after the injury. Anxiety and depression, in turn, were not predictive of later functional status. This study adds to our understanding of the temporal relationship between depression, anxiety and functional status after TBI. The results indicate the importance of supporting brain injured individuals in coping with the functional consequences of their injury in order promote psychological well-being. (JINS, 2011, 17, 781-787)

Traumatic brain injury (TBI) can result in significant disability, but outcome is variable. The impact of known predictors accounts for a limited proportion of the variance in outcomes. Apolipoprotein E (ApoE) genotype has been investigated as an additional source of variability in injury severity and outcome, with mixed findings reflecting variable methodology and generally limited sample sizes. This study aimed to examine whether possession of the ApoE ɛ4 allele was associated with greater acute injury severity and poorer long-term outcome in patients referred for rehabilitation following TBI. ApoE genotype was determined for 648 patients with TBI, who were prospectively followed up a mean of 1.9 years post-injury. Hypotheses that ɛ4 carriers would have lower Glasgow Coma Scale (GCS) scores and longer post-traumatic amnesia (PTA) duration were not supported. Prediction of worse Glasgow Outcome Scale-Extended (GOSE) scores for ɛ4 carriers was supported with greater susceptibility seen in females. These results indicate the ApoE ɛ4 allele may be associated with poorer long-term outcome, but not acute injury severity. Possible mechanisms include differential effects of the ɛ4 allele on inflammatory and cellular repair processes, and/or amyloid deposition.

BACKGROUND:High rates of depression have been reported in individuals with traumatic brain injury (TBI). The purpose of the current study was to investigate the relationship between structural MRI findings and the development of novel cases of post-injury depression in this populationMETHODS:The study has a cross-sectional design. Assessments were conducted on average 2.2 years post-injury. Participants were 54 individuals (76% male, mean age 35 years, median PTA duration 16 days) who had sustained a TBI. Depression was assessed with the Structured Clinical Interview for DSM-IV (SCID-IV). Structural MRI scans were performed with a 1.5 Tesla machine.RESULTS:The presence of lesions in the frontal, temporal, parietal and the sublobar regions was not related to depression. However, an imbalance of left vs right frontal and parietal viable brain volumes was related to the development of depression.DISCUSSION:These findings are in support of Heller's model of emotion processing, but should be replicated using larger samples. Potential clinical implications are discussed in the manuscript.

Background and Objective: Victoria's trauma management system provides acute care and rehabilitation following traumatic brain injury (TBI), with care of more complex injuries generally provided in specialist centres in metropolitan Melbourne. Little is known about how the outcomes of TBI survivors living in metropolitan Melbourne compare to those who reside in regional Victoria once they return to their community, where support services may be less available. The aim of the present study was to compare, in TBI individuals who have been treated at an inner-city rehabilitation centre in Melbourne, the long-term outcomes of those who live in metropolitan Melbourne (termed 'Metro') with those who reside in regional Victoria, termed 'Regional: Design and participants: Comparative study with quantitative outcome measures. A total of 959 patients, of whom 645 were designated 'metro' and 314 'regional', were followed-up routinely at 2 years post-injury. Outcome measures: Structured Outcome Questionnaire, Glasgow Outcome Scale - Extended, Sickness Impact Profile, Craig Handicap Assessment and Reporting Technique, Hospital Anxiety and Depression Scale, Alcohol Use Disorders Identification Test and Drug Abuse Screening Test. Results: Few differences in outcomes were found between groups. However, after controlling for group differences in age and injury severity, some non-significant trends were suggestive of better outcomes in terms of less social isolation and anxiety and fewer dysexecutive behaviours in regional dwellers. Conclusions: These findings suggest that outcomes in patients from regional areas are at least as good as those from metropolitan Melbourne.