Emotional distress is highly prevalent in the years following an acquired brain injury (ABI). Yet, there is a lack of research examining the long-term psychological outcomes and potential influencing factors, among individuals with ABIs. In this study, we trace longitudinal changes in neuropsychological outcomes in 32 individuals with moderate-to-severe ABI who engaged in neurorehabilitation in a post-acute hospital. Outcomes assessed at one- and eight-years post-ABI include emotional distress, coping, subjective experience of injury-related difficulties, and quality of life (QOL). Almost half of all participants reported clinically elevated symptoms of anxiety and depression at eight-years post-ABI (t2). There was minimal variation in neuropsychological outcomes between one- and eight-years post-ABI. Greater use of maladaptive coping responses was associated with greater symptoms of anxiety and depression at t1. As the subjective experiences of injury-related difficulties increased, so too did the symptoms of anxiety and depression at both timepoints. Higher levels of depression were associated with lower psychological and social QOL at t1 and lower levels of psychological, physical, social, and environmental QOL at t2. This study offers a unique insight into the intricate links that exist longitudinally between coping responses, subjective experiences of injury-related difficulties, QOL, and emotional distress following an ABI. It also highlights the need to conceptualize ABI as a chronic health condition that requires long term psychological support.

Experiences of loss and change following acquired brain injury (ABI) are frequent and multi-contextual, yet the long-term experiences of people with ABI are not well understood. This study explored the experiences of intrapersonal loss, grief and change in people with ABI, a decade after their injury. Twelve adults with ABI were interviewed 10-13 years post-injury. Using interpretative phenomenological analysis, we identified four overarching themes: a dawning realization of the impact of injury; loss of personhood; loss and liminality; and learning to live with loss and grief. Our findings indicate that in the decade following ABI, people continue to develop awareness of the impact of their injury and experience oscillating acceptance towards enforced changes. Participants reported a diminished sense of agency and autonomy in how they were perceived by and interacted with following injury. Additionally, identity may be lost, suspended, and renegotiated. Findings suggest dynamic, active, and flexible coping strategies that continue to be present over the long term. Considering the persistent nature of the injury and the evolving needs of the individual, a longer term view of rehabilitation outcomes may be required, contextualised by relational and intrapersonal challenges that may present over the longer term.

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.

Abstract 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 REHABILITATION Internal 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.

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).

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.

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.

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.

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.

Impaired self-awareness (ISA) is common following acquired brain injury (ABI) and is related to functional outcome variables. This study examines two questionnaires currently used in clinical and research settings, which measure ISA by comparing patient reports with those of clinicians and significant others. This study also attempts to identify sensitive neuropsychological tests which may be used to predict ISA. A multivariate cross-sectional design is employed, including regression analyses and correlations. Fifty-four participants with ABI completed the Awareness Questionnaire (AQ), the Dysexecutive Questionnaire (DEX) and a battery of neuropsychological tests. Clinicians and significant others of each participant completed the AQ and the DEX. Findings support convergent validity of the two questionnaires; however, there were differences in the response patterns on each questionnaire. Regression analyses indicated that estimated IQ and in particular verbal IQ scores accounted for a greater amount of the variance in awareness than executive functioning test scores. The variance accounted for by executive functioning test scores was low and only partial support for current cognitive neuropsychological models of self-awareness was observed. The value of obtaining multiple informant reports when assessing patient self-awareness is highlighted.

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.

Prospective memory (PM), persisting and disabling problem following acquired brain injury (ABI). It is widely accepted that compensatory strategies are the treatment of choice in the rehabilitation of PM deficits. The advent of new technologies has broadened the array of external memory aids to include potentially useful personal digital assistants (PDAs) in alleviating PM deficits. This study aimed to investigate the effectiveness of an unmodified off-the-shelf PDA (Palm IIIe®) in compensating for everyday PM problems. Five participants with ABI were trained to programme the PDA to prompt them with an audible cue and on-screen message at appropriate times. Seven personally relevant PM tasks were set up weekly to measure the usefulness of the PDA as compared to relying on memory alone. An A-B quasi-experimental design was employed which consisted of two phases: the A (memory only) baseline phase and the B (PDA strategy) intervention phase. Task performance was compared between phases A and B. All participants performed significantly better during the two weeks in which they used the PDA (Z = –2.02, p<0.05) demonstrating its efficacy in reducing PM failures. The limitations of the PDA and a range of possible solutions to improve its efficiency are discussed including strategies around delayed-execute PM tasks.

Acquired brain injury/illness (ABI) can lead to a range of cognitive, physical, emotional, social and behavioural sequelae. Unawareness of these deficits and of errors made in activities of everyday living can be a significant barrier for successful outcomes in rehabilitation following ABI. This review presents several theories and clinical models that propose multiple psychological, neuropsychological and biopsychosocial underpinnings of impaired self-awareness (ISA). Current knowledge regarding neuropathology of awareness is discussed, highlighting the widespread locations and connections within the brain that are implicated in awareness. Clinical practice promotes a client-centred approach to rehabilitation that acknowledges the multiple contributing factors of ISA post-ABI. This review discusses the merits of theories and clinical models in providing a useful framework for assessing and treating the multifaceted and complex phenomenon of ISA following ABI.

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.

In a cognitive perspective, repression is defined as a coping strategy whose objective is to extinguish awareness of subjective emotional experience, leading to restriction of subjective experience. It is characterized by avoidance of threatening and distressing information, minimization of negative affects and low tendency to anxiety. Several measures of repressive coping style have been developed and the Weinberger Adjustment Inventoty (WAI) appears to be the most psychometrically sound measure of repression.Objectives. - The main aim of this study was to translate and validate a French version of the WAI in non-clinical individuals on general population. The secondary objectives were to investigate its relationship to independent measures of anxiety, depression and alexithymia.Materials and methods. - Subjects (n = 159) were asked to complete the WAI questionnaire. A principal component analysis was carried out. The internal consistency was measured by the Cronbach alpha coefficients, and discriminant validity was assessed by examining correlations between the scales of the WAI. Because there is no other French validated instrument assessing repression, convergent validity was studied with alexithymia (Bermond-Vorst Alexithymia Questionnaire), anxiety and depression (Hospital Anxiety Depression Scale).Results. - Our factorial structure of the French WAI resembles the Weinberger's one. The "Consideration for Others" subscale does not belong to the Self-Restraint dimension: this is consistent with literature findings. The others results show solid metrological properties. Cronbach alpha reliabilities for principal and secondary factors were ranged from 0.80 to 0.93 (from 0.65 to 0.85 for the subscales) and the intercorrelations were low. Correlations were found between the WAI, the HAD and the Bvaq-b. Anxiety and Depression (HAD) are positively correlated to Distress and negatively correlated to Restraint, Defensiveness and Composite score. The repressive style, characterized by high scores on Defensiveness and Composite score, is positively correlated to affective component of alexithymia and negatively correlated to the cognitive score of alexithymia.Conclusion. - Globally, findings replicate earlier findings obtained in the Anglo-American context. The French version of the WAI thus appears to be valid and will help studying repression in France, especially in its complex relationships to alexithymia. (C) 2010 Published by Elsevier Masson SAS.

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).

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.