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A Randomised Controlled Trial of a Cognitive-Behavioural Therapy Program for Managing Social Anxiety After Acquired Brain Injury
Abstract
Despite the prevalence of psychiatric illness in people with acquired brain injury (ABI), there are very few empirically validated studies examining the efficacy of treatments targeting commonly occurring disorders such as depression and anxiety. Using a randomised controlled trial, this study evaluated the efficacy of a cognitive behavioural intervention specifically designed for managing social anxiety following ABI. Twelve brain-injured participants were screened, randomly allocated to either treatment group (TG) or a wait list group (WLG), and proceeded through to the final stages of therapy. The TG received between 9 and 14 hourly, individual sessions of cognitive behavioural therapy. Repeated measures analyses revealed significant improvements in general anxiety, depression and a transient mood measure, tension-anxiety, for the TG when compared to the WLG at posttreatment. These treatment gains were maintained at one-month follow-up. Although in the predicted direction, postintervention improvements in social anxiety and self-esteem for the TG were not significant in comparison with the WLG. This study lends support to the small body of literature highlighting the potential of cognitive behavioural interventions for managing the psychological problems that serve as a barrier to rehabilitation following ABI.
... Although pharmacological interventions such as piracetam, creatine, monoaminergic stabilizer OSU6162, and methylphenidate can alleviate fatigue, adverse effects limit their usage and further research is needed to clarify their effects [Hakkarainen and Hakamies, 1978;Sakellaris et al. 2008;Johansson et al. 2012bJohansson et al. , 2014. Therefore, many researchers have attempted to identify complementary and alternative interventions to relieve PTBIF [Bateman et al. 2001;Hodgson et al. 2005;Gemmell and Leathem, 2006;Hassett et al. 2009;Johansson et al. 2012a;Björkdahl et al. 2013;Sinclair et al. 2014]. In this study, we aimed to systematically review randomized controlled trials (RCTs) that evaluated treatment of PTBIF using complementary and alternative medicine (CAM) to provide practical recommendations for this syndrome. ...
... Among these interventions, there were four types of physical interventions: fitness-center-based exercise [Hassett et al. 2009], Tai Chi [Gemmell and Leathem, 2006], aquatic physical activity [Dijkers and Bushnik, 2008], and aerobic training [Bateman et al. 2001]. The three types of cognitive and behavioral interventions (CBIs) were cognitive behavioral therapy (CBT) [Hodgson et al. 2005], mindfulness-based stress reduction (MBSR) [Johansson et al. 2012a], and computerized working-memory training [Björkdahl et al. 2013]. The two types of biofeedback therapy were the Flexyx Neurotherapy System (FNS) [Schoenberger et al. 2001] and cranial electrotherapy [Smith et al. 1994], and blue-light therapy was the only included light therapy [Sinclair et al. 2014]. ...
... A summary of quality assessment scores for the included trials is shown in Table 2. Of the 10 RCTs, only three studies were high-quality RCTs (3-5 points) based on the Jadad scale [Smith et al. 1994;Bateman et al. 2001;Hodgson et al. 2005], and the other studies were low-quality RCTs (0-2 points) [Schoenberger et al. 2001;Gemmell and Leathem, 2006;Driver and Ede, 2009;Hassett et al. 2009;Johansson et al. 2012a;Björkdahl et al. 2013;Sinclair et al. 2014]. The quality of this evidence was judged to be low/very low using the GRADE system (Table 1). ...
Background:
We systematically reviewed randomized controlled trials (RCTs) of complementary and alternative interventions for fatigue after traumatic brain injury (TBI).
Methods:
We searched multiple online sources including ClinicalTrials.gov, the Cochrane Library database, MEDLINE, CINAHL, Embase, the Web of Science, AMED, PsychINFO, Toxline, ProQuest Digital Dissertations, PEDro, PsycBite, and the World Health Organization (WHO) trial registry, in addition to hand searching of grey literature. The methodological quality of each included study was assessed using the Jadad scale, and the quality of evidence was evaluated using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. A descriptive review was performed.
Results:
Ten RCTs of interventions for post-TBI fatigue (PTBIF) that included 10 types of complementary and alternative interventions were assessed in our study. There were four types of physical interventions including aquatic physical activity, fitness-center-based exercise, Tai Chi, and aerobic training. The three types of cognitive and behavioral interventions (CBIs) were cognitive behavioral therapy (CBT), mindfulness-based stress reduction (MBSR), and computerized working-memory training. The Flexyx Neurotherapy System (FNS) and cranial electrotherapy were the two types of biofeedback therapy, and finally, one type of light therapy was included. Although the four types of intervention included aquatic physical activity, MBSR, computerized working-memory training and blue-light therapy showed unequivocally effective results, the quality of evidence was low/very low according to the GRADE system.
Conclusions:
The present systematic review of existing RCTs suggests that aquatic physical activity, MBSR, computerized working-memory training, and blue-light therapy may be beneficial treatments for PTBIF. Due to the many flaws and limitations in these studies, further controlled trials using these interventions for PTBIF are necessary.
... Evaluating a five-session CBT program for acute stress disorder following mild TBI, Bryant et al. (2003) reported a lower percentage of cases receiving CBT (n = 12) showing clinically significant post-traumatic stress disorder at therapy completion and 6-month follow-up than those receiving treatment as usual (n = 12). In a waitlist-controlled trial of CBT in 12 individuals with social anxiety (nine with TBI), Hodgson et al. (2005) reported a significant reduction in depression and anxiety on the Hospital Anxiety and Depression Scale (HADS), though not social phobia at post-treatment and 1-month follow-up. Tiersky et al. (2005) found that CBT combined with neurorehabilitation reduced anxiety on the Symptom Checklist -90R in 20 individuals with mild-moderate TBI. ...
... The previous study by Hodgson et al. (2005) ...
... The finding of a reduction in HADS-Anxiety is consistent with findings from two previous studies demonstrating reduced anxiety in response to CBT intervention in samples with less severe TBI (Bryant et al. 2003;Hodgson et al. 2005). The present study has shown that aCBT can also achieve significant reduction in anxiety in individuals with predominantly severe TBI. ...
Background:
Anxiety and depression are common following traumatic brain injury (TBI), often co-occurring. This study evaluated the efficacy of a 9-week cognitive behavioral therapy (CBT) program in reducing anxiety and depression and whether a three-session motivational interviewing (MI) preparatory intervention increased treatment response.
Method:
A randomized parallel three-group design was employed. Following diagnosis of anxiety and/or depression using the Structured Clinical Interview for DSM-IV, 75 participants with mild-severe TBI (mean age 42.2 years, mean post-traumatic amnesia 22 days) were randomly assigned to an Adapted CBT group: (1) MI + CBT (n = 26), or (2) non-directive counseling (NDC) + CBT (n = 26); or a (3) waitlist control (WC, n = 23) group. Groups did not differ in baseline demographics, injury severity, anxiety or depression. MI and CBT interventions were guided by manuals adapted for individuals with TBI. Three CBT booster sessions were provided at week 21 to intervention groups.
Results:
Using intention-to-treat analyses, random-effects regressions controlling for baseline scores revealed that Adapted CBT groups (MI + CBT and NDC + CBT) showed significantly greater reduction in anxiety on the Hospital Anxiety and Depression Scale [95% confidence interval (CI) -2.07 to -0.06] and depression on the Depression Anxiety and Stress Scale (95% CI -5.61 to -0.12) (primary outcomes), and greater gains in psychosocial functioning on Sydney Psychosocial Reintegration Scale (95% CI 0.04-3.69) (secondary outcome) over 30 weeks post-baseline relative to WC. The group receiving MI + CBT did not show greater gains than the group receiving NDC + CBT.
Conclusions:
Findings suggest that modified CBT with booster sessions over extended periods may alleviate anxiety and depression following TBI.
... The idea to offer CBT to patients with neurological impairment is not new but studies investigating its effectiveness for this patient group showed mixed results. CBT can be suitable for treating post-brain-injury depression, anxiety and emotional distress and is also applicable to different groups of patients with cognitive deficits (Bradbury et al., 2008;Exner et al., 2021;Gallagher et al., 2019;Hodgson et al., 2005;Khan-Bourne & Brown, 2003;Waldron et al., 2013). Although CBT can be effective after acquired brain injury, psychological distress could not be decreased in all cases (Hodgson et al., 2005;Rasquin et al., 2009) and even worsened in some (Lincoln & Flannaghan, 2003;Ramaratnam et al., 2008). ...
... CBT can be suitable for treating post-brain-injury depression, anxiety and emotional distress and is also applicable to different groups of patients with cognitive deficits (Bradbury et al., 2008;Exner et al., 2021;Gallagher et al., 2019;Hodgson et al., 2005;Khan-Bourne & Brown, 2003;Waldron et al., 2013). Although CBT can be effective after acquired brain injury, psychological distress could not be decreased in all cases (Hodgson et al., 2005;Rasquin et al., 2009) and even worsened in some (Lincoln & Flannaghan, 2003;Ramaratnam et al., 2008). However, altogether the evidence is encouraging: the majority of published studies report positive effects. ...
Background
Over the last decades, brain surgery became a more frequently applied treatment for temporal lobe epilepsy (TLE). Despite its success, several studies found de-novo post-operative psychiatric symptoms in TLE surgery patients. Cognitive behavioural therapy is effective to treat brain healthy psychiatric patients but might not be translatable to patients with resections in emotion regulating networks as these areas seem to be essentially involved in successful psychotherapeutic treatment.
Methods
Here we report the case of a female patient with medically refractory medial temporal lobe epilepsy resulting in left anterior temporal lobectomy at age 35. Post operation she did not show adequate fearful response but at the same time manifested symptoms of a severe panic disorder. We investigated if this patient, despite lesions in emotion-behaviour brain circuits, can benefit from cognitive behavioural therapy.
Results
The intervention, customized to the specific resources and difficulties of the patient, was effective in stopping panic attacks and improving social functioning.
Conclusions
This case shows that MTL brain surgery patients may benefit from CBT and demonstrates the important and if yet still somewhat mysterious role of the amygdala in emotion regulation processes.
... ES = −0.08 CI: −1.06 to 0.90 Hodgson et al. (2005), Australia (1) IG = 6, CG = 6; ...
... Findings derived from randomized control trials provide support for the empirical validity of CBT demonstrating that CBT is as effective for the treatment of depression as pharmacotherapy [e.g., (46)]. CBT has been shown to be efficacious for the treatment of a variety of psychological consequences but despite the vast literature demonstrating this, relatively few studies have focused on the development of a specific CBT intervention for improving mood and coping after brain injury (47)(48)(49). Nevertheless, in addition To complicate matters, previous research has found that issues of self-criticism and shame are frequent after ABI (52) and may interfere with the treatment. ...
A moderate-to-severe acquired brain injury (ABI) can have tremendous lifelong consequences for ABI-survivors and their families. Despite rehabilitation practice since the 1980s aspiring to a dynamic, coherent and holistic approach, the psychological dimension still seems to be a challenge and research has revealed persisting psychosocial impairments after ABI. Therefore, we developed BackUp©, a manual based short term psychological intervention for adults with ABI. This study explores the effect of the intervention though a small feasibility study, employing a single case design. One client received the intervention. Self-report measures were collected, and a semi structured interview was conducted. While results from pre, post and follow-up measures do not show clear positive results, the interview reveals positive experiences and the participant reported achieving his therapy goal. This case study provides support for a psychological intervention to support the psychological rehabilitation after an ABI.
... If patients suffer mainly from persistent affective and cognitive symptoms, a copy of the questionnaire with persistent symptoms is sent to the division of neuropsychology for them to contact the patient for an ambulant visit based on principles from cognitive behavioural therapy. Several studies showed that cognitive behavioural therapy in sessions of 50 to 60 minutes led to significant improvement compared to waiting list controls, and we hope this effect can be replicated with the new concept of aftercare in the Cantonal Hospital St.Gallen (Hodgson, McDonald, Tate, & Gertler, 2005;Mittenberg, Tremont, Zielinski, Fichera, & Rayls, 1996;Tiersky et al., 2005). The evaluation of this new concept for aftercare should be content of future research. ...
... Over recent years, CBT has been increasingly used as a treatment within TBI populations. It has been argued that its highly structured and goal-oriented approach, in addition to a focus on concrete thoughts and behaviours, means that it is an appropriate intervention for individuals with cognitive impairments (Hodgson, McDonald, Tate, & Gertler, 2005;Doering & Exner, 2011). Additional adaptations may also be beneficial to ensure that CBT is accessible to the TBI population. ...
Background:
Anxiety is a common neuropsychological sequela following traumatic brain injury (TBI). Cognitive Behaviour Therapy (CBT) is a recommended, first-line intervention for anxiety disorders in the non-TBI clinical population, however its effectiveness after TBI remains unclear and findings are inconsistent.
Objective:
There are no current meta-analyses exploring the efficacy of CBT as an intervention for anxiety symptoms following TBI, using controlled trials. The aim of the current study, therefore, was to systematically review and synthesize the evidence from controlled trials for the effectiveness of CBT for anxiety, specifically within the TBI population.
Method:
Three electronic databases (Web of Science, PubMed and PsycInfo) were searched and a systematic review of intervention studies utilising CBT and anxiety related outcome measures in a TBI population was performed through searching three electronic databases. Studies were further evaluated for quality of evidence based on Reichow's (2011) quality appraisal tool. Baseline and outcome data were extracted from the 10 controlled trials that met the inclusion criteria, and effect sizes were calculated.
Results:
A random effects meta-analysis identified a small overall effect size (Cohen's d) of d = -0.26 (95%CI -0.41 to -0.11) of CBT interventions reducing anxiety symptoms following TBI.
Conclusions:
This meta-analysis tentatively supports the view that CBT interventions may be effective in reducing anxiety symptoms in some patients following TBI, however the effect sizes are smaller than those reported for non-TBI clinical populations. Clinical implications and limitations of the current meta-analysis are discussed.
... Single-case-studies in ABI have documented maintenance of CBT benefits at follow-up timescales of 1 to 6 months [28][29][30][31]. Group studies in ABI have shown similar maintenance of benefits, where the clinical range in which a group mean score lay, remained unchanged at 1 to 12 month follow-up [32][33][34][35]. Our findings imply that over longer timespans services need to plan for a proportion of service-users accessing specialist Clinical Psychology services more than once or intermittently. ...
... Based on the hypothesis test, it is known that there is an effect of expressive writing on cognitive state anxiety in badminton athletes. The results of this study are consistent with the studies of Scott, et al.(2003) and Hudson and Day (2012) who found that expressive writing has positive benefits on the psychological condition of athletes[24]. This study is also following the results of research by Park, et al. (2014) and the opinion of Pennebaker (2012) that expressive writing is useful in reducing the intensity of anxiety felt by someone. ...
The purpose of this study was designed to examine the effect of expressive writing on cognitive state anxiety on the student-athletes of badminton. This study uses an experimental research method with one group pre and posttest design. The treatment in this study was expressive writing given for 3 consecutive days. The participants of this study were 7 badminton athletes from the East Java Student Education and Training Center. The instrument in this study used cognitive state anxiety. Data were analyzed using the Wilcoxon test and a significance value of 0.042 <0.05 was obtained. Thus it can be said that there is an effect of expressive writing on cognitive state anxiety on badminton student-athletes.
... Given the frequency of these problems, there has been relatively limited research evaluating treatments. Several randomized controlled trials (RCTs) have demonstrated the efficacy of Cognitive Behavior Therapy (CBT) adapted to accommodate the specific needs of brain-injured clients (Hodgson et al. 2005;Hsieh et al. 2012;Ponsford et al. 2016), but the specific processes that may enhance treatment efficacy have not been examined. ...
Traumatic Brain Injury (TBI) associated cognitive impairments may pose an obstacle to homework engagement in Cognitive Behavior Therapy (CBT) for depression and anxiety. The current study examined the association of demographic, injury-related and CBT process variables with homework engagement in CBT adapted for TBI -related cognitive impairments (CBT-ABI). The audio-recordings of 177 CBT-ABI sessions, representing 31 therapist-client dyads, were assessed from the independent observer perspective. Client homework engagement, therapist competence in assigning and reviewing homework, and working alliance strength, were measured. Multi-level mixed model regressions showed that older client age, more time since injury, stronger working alliance and greater therapist competence in homework review, were significantly associated with higher levels of homework engagement. The findings highlight how CBT-ABI therapists can possibly enhance homework engagement for clients with TBI.
... However, injury-related cognitive impairments of memory, attention and executive function (Klonoff, 2010;Ponsford, Sloan, & Snow, 2012) may limit potential for gains from CBT. While the structured nature of CBT makes it relatively well suited for a brain-injured client, modifications (e.g., inclusion of a co-therapist, note-taking and visual aids) are likely to be required in order to address specific cognitive impairments (Hodgson, McDonald, Tate, & Gertler, 2005;Ponsford et al., 2016). Several RCTs of adapted CBT (Bédard et al., 2014;Bryant, Moulds, Guthrie, & Nixon, 2003;Ponsford et al., 2016) have shown a clinically significant improvement in depression and/or anxiety symptoms compared to control groups. ...
Cognitive Behaviour Therapy (CBT) has the strongest preliminary support for treatment of depression and anxiety following traumatic brain injury (TBI). TBI associated cognitive impairments may pose an obstacle to development of a strong working alliance, on which therapeutic gains depend. The current study examined the association of demographic (i.e., gender, age at study entry, years of education and premorbid IQ) and injury-related (i.e., years since injury, post-trauma amnesia duration, memory and executive functioning test performance) variables with alliance in CBT adapted for TBI (CBT-ABI). The audio-recordings of 177 CBT-ABI sessions from 31 participants were assessed with an observer version of the Working Alliance Inventory at nine time-points. Multi-level mixed model regressions showed that participants and therapists maintained a relatively strong alliance across all sessions. Pre-intervention symptom severity was considered as a confounder variable and was found to have no statistically significant influence on the models. None of the demographic variables were significantly associated with alliance scores. More years since injury was associated with a stronger alliance. These findings demonstrate that TBI associated cognitive impairments do not necessarily pose an obstacle to development and maintenance of a strong working alliance, which is more likely to develop with more time post-brain injury.
... In relation to the heterogeneity of the study samples, some studies included acquired brain injury with a mix of aetiologies (Bradbury et al., 2008;Hodgson, McDonald, Tate, & Gertler, 2005;Medd & Tate, 2000). While reflective of clinical practice, this mix makes it difficult to partial out the specific effect for people with TBI. ...
This study investigated if an Acceptance and Commitment Therapy (ACT) intervention (ACT-Adjust) can facilitate psychological adjustment and reduce psychological distress following severe traumatic brain injury (TBI). The study design comprised a single centre, two-armed, Phase II pilot randomized controlled trial. Nineteen individuals with severe TBI (PTA ≥7 days) who met a clinical threshold for psychological distress (Depression Anxiety Stress Scales-21; DASS > 9) were randomly allocated to either ACT-Adjust (n = 10) or an active control, Befriending Therapy (n = 9), in conjunction with a holistic rehabilitation programme. Primary (psychological flexibility, rehabilitation participation) and secondary (depression, anxiety & stress) outcomes were measured at three-time points (pre, post and follow up). Significant decreases were found for DASS-depression (group by time interaction, F1,17 = 5.35, p = .03) and DASS-stress (group by time interaction, F1,17 = 5.69, p = .03) in comparison to the Befriending group, but not for the primary outcome measures. The reduction in stress post-treatment was classed as clinically significant, however interaction differences for stress and depression were not maintained at one month follow up. Preliminary investigations indicate potential for ACT in decreasing psychological distress for individuals with a severe TBI with further sessions required to maintain treatment gains. The pilot results suggest further investigation is warranted in a larger scale clinical trial.
... [122][123][124] All of these showed indications of effects on fatigue, but the effects were generally weak, and difficult to interpret due to the study designs. Other CBT studies for social anxiety, 125 post-concussion symptoms, 126 and depression after TBI, 127 also revealed effects on fatigue, although this was not the primary target. Johansson and colleagues performed two studies 128,129 examining the effects of Mindfulness-based stress reduction aimed at reducing fatigue after stroke or TBI. ...
Background: Traumatic brain injury (TBI) is one of the most common causes of disability and mortality. While some patients recover quickly, especially at the mild side of the injury severity continuum, many will experience symptoms for years to come. In this chronic phase, patients report a wide array of symptoms, where fatigue is one the most common. This fatigue makes huge impact in several areas of these patients’ lives. Despite the prevalence of fatigue after TBI, the underlying mechanisms are unclear. Further, there are no standardized way for assessment and diagnosis, and there are no treatments with satisfying empirical support. The aim of this thesis was to examine the effects of the novel compound OSU6162 on fatigue in patients with TBI, and to explore functional and structural brain imaging correlates of fatigue after TBI.
Methods: Studies I and III were based on a placebo-controlled, double-blinded clinical trial examining the effects of the monoaminergic stabilizer OSU6162 on fatigue in patients in the chronic phase of traumatic brain injury. In study I, self-assessment scales of fatigue and neuropsychological tests were used as outcomes, while functional magnetic resonance imaging (fMRI) blood-oxygen-level dependent (BOLD) signal was the primary outcome in study III. Studies II and IV used cross-sectional designs, comparing patients with TBI with age- and gender matched healthy controls. Study II examined whether fMRI BOLD signal could be used to detect and diagnose fatigue in patients with TBI, and study IV whether white matter hyperintensities (WMH) contribute to lower cognitive functioning and presence of fatigue after TBI.
Results: Study I revealed no effects of OSU6162 during 28 days of treatment at maximum doses of 15 mg twice daily on measures of fatigue or any other outcome. The results from study II indicated that fatigue after TBI is linked to alterations in striato-thalamic-cortical loops, and suggested that fMRI could be a promising technique to use in the diagnosis of fatigue after TBI. In study III the results revealed effects of treatment in the right occipitotemporal and orbitofrontal cortex. In these areas, the BOLD response was normalized in the OSU6162 group as compared to healthy controls, while the placebo group showed a steady low activity in these areas. The regional effects were located outside the network shown to be linked to fatigue in study II, which might explain why there were no effects on fatigue after treatment with OSU6162 in study I. Study IV showed that WMH lesions increased with increased TBI severity, but the presence and extent of lesions did not explain lower neuropsychological functioning or fatigue in subjects with previous TBI.
Conclusions: In summary, although no effects on fatigue after treatment with OSU6162 were seen, the results provide support to the theory that fatigue after TBI is linked to alterations in striato-thalamic-cortical loops, and on how fatigue after TBI could be assessed or diagnosed using fMRI. Structural damage within white matter was however not related to fatigue.
... When used in TBI population, CT has been both administered in individual and group formats, attempting to address a wide range of symptoms. There are a couple of randomized control trials suggesting that CT is effective in reducing depression (Ashman et al., 2014), anxiety (Bryant et al., 2003;Hodgson et al., 2005) and hopelessness (Simpson et al., 2011). Group studies using a pre-post treatment design have reported a decreased in post-traumatic headaches (Gurr & Coetzer, 2005), anger problems (Medd & Tate, 2000), depression symptoms (Topolovec-Vranic et al., 2009), post-traumatic stress disorder problems (Chard et al., 2011) and changes in coping style (Anson & Ponsford, 2006). ...
Introduction: During the last decades, psychological interventions have become central components of rehabilitation programs for Traumatic Brain Injury (TBI). Nevertheless, due to a wide variability of therapeutic approaches there is little agreement regarding which approach is more suitable, or whether key elements from different psychotherapies should be integrated. This article critically reviews several contemporary approaches that are dominant in the literature. Methods: In order to accomplish such goal, an all-time search on Web of Science and Google Scholar was carried, using TBI and Psychotherapy as key words (n = 72). Results: The main finding of this paper is that theoretical and technical variability among psychotherapies reflects differences in the ‘level of care’ that is targeted: symptom reduction, behavioral problem reduction, quality of life and meaning reconstruction. Four contemporary approaches to psychotherapy [cognitive behavioral, third wave cognitive behavioral, narrative and psychodynamic] are then briefly described, by presenting their main theoretical tenets, the level of care they target, and the existing evidence that supports their efficacy. Finally, the implications of using a ‘levels of care’ perspective when addressing the ‘effectiveness’ debate is considered, as well as the need to familiarize future clinicians with more integrative models of psychological support after TBI.
... Subjective sensation of apprehension of danger and dread that may be accompanied by signs of restlessness, tension, tachycardia and shortness of breath that are part of the fight or flight response. (Hodgson et al., 2005) Music Listening (Forsblom et al., 2009) Biofeedback-assisted relaxation training (Holland et al., 1999) Challenging behaviors Agitation and Aggression, inappropriate behaviours, restlessness, lack of control (Kim et al., 2002) Specific Behavioural Techniques: teach new skills, socially appropriate behaviour and improve independent functioning. (Eames and Wood, 1985) Multi-intervention Training Programs (Bornhofen and McDonald, 2008) Music Therapy (Hitchen et al., 2010) Choice-making interventions (Kern et al., 1998) Touch and massages (Hegarty and Gale, 1996) Community reintegration Independence and Social Integration ...
One of the latest approaches in the rehabilitation of a wide range of deficits of the nervous system is based on the use of virtual reality (VR), which combines training scenarios with dedicated interface devices. It must be emphasized, however, that so far little work exists on the quantitative assessment of the clinical impact of VR based approaches. In this dissertation, we present a number of studies that investigate the potential of VR technologies for motor recovery after stroke.
First, we explore the transfer of VR-based rehabilitation systems from clinic-based training to at home applications, and we compare the effects of different rehabilitation approaches. Our results reveal that the development of compensatory behaviors, such as learned non-use, can greatly interfere with the recovery dynamics and prevent the retention of motor improvements.
Grounded in our observations, we introduce a novel rehabilitation strategy based on the sensorimotor augmentation of goal-oriented movements, that aims to correct these compensatory behaviors. We establish the principles behind this intervention using a computational model of recovery, and we validate its efficacy through a set of behavioral experiments that combine observational studies and a randomized controlled trial. This thesis work advances our understanding of the key mechanisms influencing motor recovery after stroke and provides a new perspective on how to maximize the retention of functional improvements.
... There is some evidence to suggest that cognitive behavioral therapy (CBT), alone or in conjunction with other treatments, may be helpful in reducing postinjury fatigue and is worthy of further study [85,87,[101][102][103]. Ponsford et al. point out the need to help patients to regulate their lifestyle 'to live within cognitive and physical limitations' (p. ...
Nearly 2 million traumatic brain injuries occur annually, most of which are mild (mTBI). One debilitating sequela of mTBI is cognitive fatigue: fatigue following cognitive work. Cognitive fatigue has proven difficult to quantify and study, but this is changing, allowing models to be proposed and tested. Here, we review evidence for four models of cognitive fatigue, and relate them to specific treatments following mTBI. The evidence supports two models: cognitive fatigue results from the increased work/effort required for the brain to process information after trauma-induced damage; and cognitive fatigue results from sleep disturbances. While there are no evidence-based treatments for fatigue after mTBI, some pharmacological and nonpharmacological treatments show promise for treating this debilitating problem. Future work may target the role of genetics, neuroinflammation and the microbiome and their role in complex cognitive responses such as fatigue.
... In addition to PTSD symptom reduction, both depressive symptoms [28,30,31] and postconcussive symptoms [32] decrease following PTSD-focused CBT interventions in patients with history of TBI. Likewise, CBT has been successfully applied to targeted treatment of a range of other emotional and behavioural sequelae of TBI such as insomnia [33], social anxiety [34,35] and depression [34]. ...
Management of symptoms following traumatic brain injury (TBI) can be complex and remains a high priority for Department of Defense (DoD) and Department of Veteran Affairs (VA). Concurrently, awareness of TBI in the public has increased. VA convened a State of the Art (SOTA) Conference to identify priorities for future research and promote best practices for TBI care. Scientific evidence of effective management of symptoms following TBI is expanding, and this evidence has been synthesized into Clinical Practice Guidelines (CPGs) and Clinical Practice Recommendations (CPRs). Knowledge gaps still exist and research efforts to address these gaps should include leveraging large administrative data sets and existing registries to determine effective treatments, investigate compliance of existing clinical care with CPGs and study limitations to determine modifiable vs. non-modifiable core tenants of the evidence-based treatments.
... No guidance is available specific to the management of SA after TBI, but empiricallybased guidance for generic SA interventions in the UK (NICE, 2013) recommends cognitive behavioural therapy (CBT) as a first-line intervention (i.e., before pharmacological interventions), underpinned by a specifically developed theoretical model (e.g., Clark & Wells, 1995). However, a randomised controlled trial of a CBT programme for SA after acquired brain injury (ABI) found that although SA did reduce, treatment effects were not statistically significant (Hodgson, McDonald, Tate, & Gertler, 2012). However, a small sample size (n = 12) and variability in the ABI group (people who had experienced stroke, hypoxic brain injury and cerebral oedema were included alongside those who had experienced TBI) limits the usefulness of this study in understanding management of SA after TBI. ...
Social anxiety (SA) following traumatic brain injury (TBI) has the potential to affect an individual’s general psychological well-being and social functioning, however little research has explored factors associated with its development. The present study used hierarchical multiple regression to investigate the demographic, clinical and psychological factors associated with SA following TBI. A sample of 85 people who experienced TBI were recruited through social media websites and brain injury services across the North-West of England. The overall combined biopsychosocial model was significant, explaining 52–54.3% of the variance in SA (across five imputations of missing data). The addition of psychological variables (self-esteem, locus of control, self-efficacy) made a significant contribution to the overall model, accounting for an additional 12.2–13% of variance in SA above that explained by demographic and clinical variables. Perceived stigma was the only significant independent predictor of SA (B = .274, p = .005). The findings suggest that psychological variables are important in the development of SA following TBI and must be considered alongside clinical factors. Furthermore, the significant role of stigma highlights the need for intervention at both an individualised and societal level.
Objectives: We tested the feasibility and efficacy of a brief mindfulness-based intervention (bMBI) for adult brain tumor (BT) survivors experiencing elevated depressive symptoms. Specifically, we examined whether there are improvements in mental health symptoms (i.e. depressive symptoms, quality of life (QOL),mental wellbeing, perceived stress) among participants at post-intervention. Methods: Nineteen BT survivors participated in a five-session, in-person, group-based bMBI intervention. Data on attendance, depressive symptoms, QOL, mental well-being, and perceived stress were collected at three timepoints. Findings: The preliminary analysis supports that this bMBI: (a) was efficacious in decreasing depressive symptoms and perceived stress, as well as increasing mental well-being and QOL, and (b) was feasible, with a retention rate greater than 70% and an attendance rate greater than 80% for adult BT survivors.Conclusions: These findings lend support for a feasible and efficacious sintervention for adult BT survivors experiencing elevated depressive symptomsImplications: With the paucity of psychosocial interventions targeting adult BTsurvivorship, future empirically rigorous studies for this population are warranted. The uptake/adoption of this bMBI by psychosocial providers may play an important role in improving the mental health and QOL of adult BT survivors.
The aim of this randomized controlled trial was to evaluate an adapted cognitive behavioural therapy (CBT) programme for treating anxiety in adolescents with acquired brain injury (ABI). Participants with ABI (12-19 years, N = 36) recruited from two sites were randomly allocated into either the intervention receiving 11 sessions of CBT (n = 19) or a wait-list control group (n = 17). The primary outcome was participants' anxiety and secondary outcomes were participants' depression, self-perception, and participation in daily activities, and parental stress, measured at (i) pre-intervention, (ii) immediately post-intervention, (iii) 2 months post-intervention and (iv) 6 months post-intervention. Repeated measures ANOVAs revealed significant treatment effects with the intervention group demonstrating greater improvements in self-reported anxiety, as well as self- and parent-reported depression from pre- to immediately post-treatment, compared to wait-list controls. Little evidence of treatment effects was found for the remaining outcomes (parent-reported anxiety, self-perception, daily participation, and parental stress). Significant improvement in self-reported anxiety found immediately post-treatment was maintained at two- and six-month follow-up. Findings provide support for adapted CBT as an effective means of reducing anxious and depressive symptomatology in adolescents with ABI compared to waitlist controls, and offer support for the use of these techniques to manage anxiety in this population..
Traumatic Brain and Spinal Cord Injury comprehensively covers the medical and pathological issues related to neurotrauma and its often devastating consequences. Written by globally renowned experts in the field, both clinicians and researchers will find this book invaluable to update their knowledge. This volume is divided into two sections, one covering the brain, the other the spinal cord. Each section discusses the following topics: • The demographic in the developed and developing world where neurotrauma is witnessing a massive expansion • Major clinical issues including advanced semi-experimental monitoring techniques utilized by neurosurgeons and intensivists and the potential use of identifying markers of tissue injury • Overview of major pathophysiological changes • The development of animal models; successes and limitations • Past, current and future therapeutic strategies including rehabilitative opportunities. Presenting the most up-to-date clinical and experimental research in neurotrauma, this volume is essential reading for neurologists, neurosurgeons, intensive care physicians and rehabilitative physicians.
Traumatic Brain and Spinal Cord Injury comprehensively covers the medical and pathological issues related to neurotrauma and its often devastating consequences. Written by globally renowned experts in the field, both clinicians and researchers will find this book invaluable to update their knowledge. This volume is divided into two sections, one covering the brain, the other the spinal cord. Each section discusses the following topics: • The demographic in the developed and developing world where neurotrauma is witnessing a massive expansion • Major clinical issues including advanced semi-experimental monitoring techniques utilized by neurosurgeons and intensivists and the potential use of identifying markers of tissue injury • Overview of major pathophysiological changes • The development of animal models; successes and limitations • Past, current and future therapeutic strategies including rehabilitative opportunities. Presenting the most up-to-date clinical and experimental research in neurotrauma, this volume is essential reading for neurologists, neurosurgeons, intensive care physicians and rehabilitative physicians.
Traumatic Brain and Spinal Cord Injury comprehensively covers the medical and pathological issues related to neurotrauma and its often devastating consequences. Written by globally renowned experts in the field, both clinicians and researchers will find this book invaluable to update their knowledge. This volume is divided into two sections, one covering the brain, the other the spinal cord. Each section discusses the following topics: • The demographic in the developed and developing world where neurotrauma is witnessing a massive expansion • Major clinical issues including advanced semi-experimental monitoring techniques utilized by neurosurgeons and intensivists and the potential use of identifying markers of tissue injury • Overview of major pathophysiological changes • The development of animal models; successes and limitations • Past, current and future therapeutic strategies including rehabilitative opportunities. Presenting the most up-to-date clinical and experimental research in neurotrauma, this volume is essential reading for neurologists, neurosurgeons, intensive care physicians and rehabilitative physicians.
Traumatic Brain and Spinal Cord Injury comprehensively covers the medical and pathological issues related to neurotrauma and its often devastating consequences. Written by globally renowned experts in the field, both clinicians and researchers will find this book invaluable to update their knowledge. This volume is divided into two sections, one covering the brain, the other the spinal cord. Each section discusses the following topics: • The demographic in the developed and developing world where neurotrauma is witnessing a massive expansion • Major clinical issues including advanced semi-experimental monitoring techniques utilized by neurosurgeons and intensivists and the potential use of identifying markers of tissue injury • Overview of major pathophysiological changes • The development of animal models; successes and limitations • Past, current and future therapeutic strategies including rehabilitative opportunities. Presenting the most up-to-date clinical and experimental research in neurotrauma, this volume is essential reading for neurologists, neurosurgeons, intensive care physicians and rehabilitative physicians.
Traumatic Brain and Spinal Cord Injury comprehensively covers the medical and pathological issues related to neurotrauma and its often devastating consequences. Written by globally renowned experts in the field, both clinicians and researchers will find this book invaluable to update their knowledge. This volume is divided into two sections, one covering the brain, the other the spinal cord. Each section discusses the following topics: • The demographic in the developed and developing world where neurotrauma is witnessing a massive expansion • Major clinical issues including advanced semi-experimental monitoring techniques utilized by neurosurgeons and intensivists and the potential use of identifying markers of tissue injury • Overview of major pathophysiological changes • The development of animal models; successes and limitations • Past, current and future therapeutic strategies including rehabilitative opportunities. Presenting the most up-to-date clinical and experimental research in neurotrauma, this volume is essential reading for neurologists, neurosurgeons, intensive care physicians and rehabilitative physicians.
Traumatic Brain and Spinal Cord Injury comprehensively covers the medical and pathological issues related to neurotrauma and its often devastating consequences. Written by globally renowned experts in the field, both clinicians and researchers will find this book invaluable to update their knowledge. This volume is divided into two sections, one covering the brain, the other the spinal cord. Each section discusses the following topics: • The demographic in the developed and developing world where neurotrauma is witnessing a massive expansion • Major clinical issues including advanced semi-experimental monitoring techniques utilized by neurosurgeons and intensivists and the potential use of identifying markers of tissue injury • Overview of major pathophysiological changes • The development of animal models; successes and limitations • Past, current and future therapeutic strategies including rehabilitative opportunities. Presenting the most up-to-date clinical and experimental research in neurotrauma, this volume is essential reading for neurologists, neurosurgeons, intensive care physicians and rehabilitative physicians.
Traumatic Brain and Spinal Cord Injury comprehensively covers the medical and pathological issues related to neurotrauma and its often devastating consequences. Written by globally renowned experts in the field, both clinicians and researchers will find this book invaluable to update their knowledge. This volume is divided into two sections, one covering the brain, the other the spinal cord. Each section discusses the following topics: • The demographic in the developed and developing world where neurotrauma is witnessing a massive expansion • Major clinical issues including advanced semi-experimental monitoring techniques utilized by neurosurgeons and intensivists and the potential use of identifying markers of tissue injury • Overview of major pathophysiological changes • The development of animal models; successes and limitations • Past, current and future therapeutic strategies including rehabilitative opportunities. Presenting the most up-to-date clinical and experimental research in neurotrauma, this volume is essential reading for neurologists, neurosurgeons, intensive care physicians and rehabilitative physicians.
Traumatic Brain and Spinal Cord Injury comprehensively covers the medical and pathological issues related to neurotrauma and its often devastating consequences. Written by globally renowned experts in the field, both clinicians and researchers will find this book invaluable to update their knowledge. This volume is divided into two sections, one covering the brain, the other the spinal cord. Each section discusses the following topics: • The demographic in the developed and developing world where neurotrauma is witnessing a massive expansion • Major clinical issues including advanced semi-experimental monitoring techniques utilized by neurosurgeons and intensivists and the potential use of identifying markers of tissue injury • Overview of major pathophysiological changes • The development of animal models; successes and limitations • Past, current and future therapeutic strategies including rehabilitative opportunities. Presenting the most up-to-date clinical and experimental research in neurotrauma, this volume is essential reading for neurologists, neurosurgeons, intensive care physicians and rehabilitative physicians.
Traumatic Brain and Spinal Cord Injury comprehensively covers the medical and pathological issues related to neurotrauma and its often devastating consequences. Written by globally renowned experts in the field, both clinicians and researchers will find this book invaluable to update their knowledge. This volume is divided into two sections, one covering the brain, the other the spinal cord. Each section discusses the following topics: • The demographic in the developed and developing world where neurotrauma is witnessing a massive expansion • Major clinical issues including advanced semi-experimental monitoring techniques utilized by neurosurgeons and intensivists and the potential use of identifying markers of tissue injury • Overview of major pathophysiological changes • The development of animal models; successes and limitations • Past, current and future therapeutic strategies including rehabilitative opportunities. Presenting the most up-to-date clinical and experimental research in neurotrauma, this volume is essential reading for neurologists, neurosurgeons, intensive care physicians and rehabilitative physicians.
Traumatic Brain and Spinal Cord Injury comprehensively covers the medical and pathological issues related to neurotrauma and its often devastating consequences. Written by globally renowned experts in the field, both clinicians and researchers will find this book invaluable to update their knowledge. This volume is divided into two sections, one covering the brain, the other the spinal cord. Each section discusses the following topics: • The demographic in the developed and developing world where neurotrauma is witnessing a massive expansion • Major clinical issues including advanced semi-experimental monitoring techniques utilized by neurosurgeons and intensivists and the potential use of identifying markers of tissue injury • Overview of major pathophysiological changes • The development of animal models; successes and limitations • Past, current and future therapeutic strategies including rehabilitative opportunities. Presenting the most up-to-date clinical and experimental research in neurotrauma, this volume is essential reading for neurologists, neurosurgeons, intensive care physicians and rehabilitative physicians.
Traumatic Brain and Spinal Cord Injury comprehensively covers the medical and pathological issues related to neurotrauma and its often devastating consequences. Written by globally renowned experts in the field, both clinicians and researchers will find this book invaluable to update their knowledge. This volume is divided into two sections, one covering the brain, the other the spinal cord. Each section discusses the following topics: • The demographic in the developed and developing world where neurotrauma is witnessing a massive expansion • Major clinical issues including advanced semi-experimental monitoring techniques utilized by neurosurgeons and intensivists and the potential use of identifying markers of tissue injury • Overview of major pathophysiological changes • The development of animal models; successes and limitations • Past, current and future therapeutic strategies including rehabilitative opportunities. Presenting the most up-to-date clinical and experimental research in neurotrauma, this volume is essential reading for neurologists, neurosurgeons, intensive care physicians and rehabilitative physicians.
Traumatic Brain and Spinal Cord Injury comprehensively covers the medical and pathological issues related to neurotrauma and its often devastating consequences. Written by globally renowned experts in the field, both clinicians and researchers will find this book invaluable to update their knowledge. This volume is divided into two sections, one covering the brain, the other the spinal cord. Each section discusses the following topics: • The demographic in the developed and developing world where neurotrauma is witnessing a massive expansion • Major clinical issues including advanced semi-experimental monitoring techniques utilized by neurosurgeons and intensivists and the potential use of identifying markers of tissue injury • Overview of major pathophysiological changes • The development of animal models; successes and limitations • Past, current and future therapeutic strategies including rehabilitative opportunities. Presenting the most up-to-date clinical and experimental research in neurotrauma, this volume is essential reading for neurologists, neurosurgeons, intensive care physicians and rehabilitative physicians.
Traumatic Brain and Spinal Cord Injury comprehensively covers the medical and pathological issues related to neurotrauma and its often devastating consequences. Written by globally renowned experts in the field, both clinicians and researchers will find this book invaluable to update their knowledge. This volume is divided into two sections, one covering the brain, the other the spinal cord. Each section discusses the following topics: • The demographic in the developed and developing world where neurotrauma is witnessing a massive expansion • Major clinical issues including advanced semi-experimental monitoring techniques utilized by neurosurgeons and intensivists and the potential use of identifying markers of tissue injury • Overview of major pathophysiological changes • The development of animal models; successes and limitations • Past, current and future therapeutic strategies including rehabilitative opportunities. Presenting the most up-to-date clinical and experimental research in neurotrauma, this volume is essential reading for neurologists, neurosurgeons, intensive care physicians and rehabilitative physicians.
Traumatic Brain and Spinal Cord Injury comprehensively covers the medical and pathological issues related to neurotrauma and its often devastating consequences. Written by globally renowned experts in the field, both clinicians and researchers will find this book invaluable to update their knowledge. This volume is divided into two sections, one covering the brain, the other the spinal cord. Each section discusses the following topics: • The demographic in the developed and developing world where neurotrauma is witnessing a massive expansion • Major clinical issues including advanced semi-experimental monitoring techniques utilized by neurosurgeons and intensivists and the potential use of identifying markers of tissue injury • Overview of major pathophysiological changes • The development of animal models; successes and limitations • Past, current and future therapeutic strategies including rehabilitative opportunities. Presenting the most up-to-date clinical and experimental research in neurotrauma, this volume is essential reading for neurologists, neurosurgeons, intensive care physicians and rehabilitative physicians.
Traumatic Brain and Spinal Cord Injury comprehensively covers the medical and pathological issues related to neurotrauma and its often devastating consequences. Written by globally renowned experts in the field, both clinicians and researchers will find this book invaluable to update their knowledge. This volume is divided into two sections, one covering the brain, the other the spinal cord. Each section discusses the following topics: • The demographic in the developed and developing world where neurotrauma is witnessing a massive expansion • Major clinical issues including advanced semi-experimental monitoring techniques utilized by neurosurgeons and intensivists and the potential use of identifying markers of tissue injury • Overview of major pathophysiological changes • The development of animal models; successes and limitations • Past, current and future therapeutic strategies including rehabilitative opportunities. Presenting the most up-to-date clinical and experimental research in neurotrauma, this volume is essential reading for neurologists, neurosurgeons, intensive care physicians and rehabilitative physicians.
Traumatic Brain and Spinal Cord Injury comprehensively covers the medical and pathological issues related to neurotrauma and its often devastating consequences. Written by globally renowned experts in the field, both clinicians and researchers will find this book invaluable to update their knowledge. This volume is divided into two sections, one covering the brain, the other the spinal cord. Each section discusses the following topics: • The demographic in the developed and developing world where neurotrauma is witnessing a massive expansion • Major clinical issues including advanced semi-experimental monitoring techniques utilized by neurosurgeons and intensivists and the potential use of identifying markers of tissue injury • Overview of major pathophysiological changes • The development of animal models; successes and limitations • Past, current and future therapeutic strategies including rehabilitative opportunities. Presenting the most up-to-date clinical and experimental research in neurotrauma, this volume is essential reading for neurologists, neurosurgeons, intensive care physicians and rehabilitative physicians.
Traumatic Brain and Spinal Cord Injury comprehensively covers the medical and pathological issues related to neurotrauma and its often devastating consequences. Written by globally renowned experts in the field, both clinicians and researchers will find this book invaluable to update their knowledge. This volume is divided into two sections, one covering the brain, the other the spinal cord. Each section discusses the following topics: • The demographic in the developed and developing world where neurotrauma is witnessing a massive expansion • Major clinical issues including advanced semi-experimental monitoring techniques utilized by neurosurgeons and intensivists and the potential use of identifying markers of tissue injury • Overview of major pathophysiological changes • The development of animal models; successes and limitations • Past, current and future therapeutic strategies including rehabilitative opportunities. Presenting the most up-to-date clinical and experimental research in neurotrauma, this volume is essential reading for neurologists, neurosurgeons, intensive care physicians and rehabilitative physicians.
Traumatic Brain and Spinal Cord Injury comprehensively covers the medical and pathological issues related to neurotrauma and its often devastating consequences. Written by globally renowned experts in the field, both clinicians and researchers will find this book invaluable to update their knowledge. This volume is divided into two sections, one covering the brain, the other the spinal cord. Each section discusses the following topics: • The demographic in the developed and developing world where neurotrauma is witnessing a massive expansion • Major clinical issues including advanced semi-experimental monitoring techniques utilized by neurosurgeons and intensivists and the potential use of identifying markers of tissue injury • Overview of major pathophysiological changes • The development of animal models; successes and limitations • Past, current and future therapeutic strategies including rehabilitative opportunities. Presenting the most up-to-date clinical and experimental research in neurotrauma, this volume is essential reading for neurologists, neurosurgeons, intensive care physicians and rehabilitative physicians.
Traumatic Brain and Spinal Cord Injury comprehensively covers the medical and pathological issues related to neurotrauma and its often devastating consequences. Written by globally renowned experts in the field, both clinicians and researchers will find this book invaluable to update their knowledge. This volume is divided into two sections, one covering the brain, the other the spinal cord. Each section discusses the following topics: • The demographic in the developed and developing world where neurotrauma is witnessing a massive expansion • Major clinical issues including advanced semi-experimental monitoring techniques utilized by neurosurgeons and intensivists and the potential use of identifying markers of tissue injury • Overview of major pathophysiological changes • The development of animal models; successes and limitations • Past, current and future therapeutic strategies including rehabilitative opportunities. Presenting the most up-to-date clinical and experimental research in neurotrauma, this volume is essential reading for neurologists, neurosurgeons, intensive care physicians and rehabilitative physicians.
Traumatic Brain and Spinal Cord Injury comprehensively covers the medical and pathological issues related to neurotrauma and its often devastating consequences. Written by globally renowned experts in the field, both clinicians and researchers will find this book invaluable to update their knowledge. This volume is divided into two sections, one covering the brain, the other the spinal cord. Each section discusses the following topics: • The demographic in the developed and developing world where neurotrauma is witnessing a massive expansion • Major clinical issues including advanced semi-experimental monitoring techniques utilized by neurosurgeons and intensivists and the potential use of identifying markers of tissue injury • Overview of major pathophysiological changes • The development of animal models; successes and limitations • Past, current and future therapeutic strategies including rehabilitative opportunities. Presenting the most up-to-date clinical and experimental research in neurotrauma, this volume is essential reading for neurologists, neurosurgeons, intensive care physicians and rehabilitative physicians.
Traumatic Brain and Spinal Cord Injury comprehensively covers the medical and pathological issues related to neurotrauma and its often devastating consequences. Written by globally renowned experts in the field, both clinicians and researchers will find this book invaluable to update their knowledge. This volume is divided into two sections, one covering the brain, the other the spinal cord. Each section discusses the following topics: • The demographic in the developed and developing world where neurotrauma is witnessing a massive expansion • Major clinical issues including advanced semi-experimental monitoring techniques utilized by neurosurgeons and intensivists and the potential use of identifying markers of tissue injury • Overview of major pathophysiological changes • The development of animal models; successes and limitations • Past, current and future therapeutic strategies including rehabilitative opportunities. Presenting the most up-to-date clinical and experimental research in neurotrauma, this volume is essential reading for neurologists, neurosurgeons, intensive care physicians and rehabilitative physicians.
Traumatic Brain and Spinal Cord Injury comprehensively covers the medical and pathological issues related to neurotrauma and its often devastating consequences. Written by globally renowned experts in the field, both clinicians and researchers will find this book invaluable to update their knowledge. This volume is divided into two sections, one covering the brain, the other the spinal cord. Each section discusses the following topics: • The demographic in the developed and developing world where neurotrauma is witnessing a massive expansion • Major clinical issues including advanced semi-experimental monitoring techniques utilized by neurosurgeons and intensivists and the potential use of identifying markers of tissue injury • Overview of major pathophysiological changes • The development of animal models; successes and limitations • Past, current and future therapeutic strategies including rehabilitative opportunities. Presenting the most up-to-date clinical and experimental research in neurotrauma, this volume is essential reading for neurologists, neurosurgeons, intensive care physicians and rehabilitative physicians.
This chapter provides a review of the emotional and psychosocial consequences of moderate to severe traumatic brain injury (TBI). Many of the disorders affecting socioemotional function arise from damage to frontotemporal systems, exacerbated by white matter injury. They include disorders of social cognition, such as the ability to recognize emotions in others, the ability to attribute mental states to others, and the ability to experience empathy. Patients with TBI also often have disorders of emotion regulation. Disorders of drive or apathy can manifest across cognitive, emotional, and behavioral domains. Likewise, disorders of control can lead to dysregulated emotions and behavior. Other disorders, such as loss of self-awareness, are also implicated in poor psychosocial recovery. Finally, this chapter overviews psychiatric disorders associated with TBI, especially anxiety and depression. For each kind of disorder, the nature of the disorder and its prevalence, as well as theoretical considerations and impact on every day functions, are reviewed.
After a traumatic brain injury (TBI), many persons experience significant and debilitating problems with anxiety. The aim of this systematic review was to critically evaluate the evidence regarding efficacy of pharmacological interventions for anxiety after TBI. We reviewed studies published in English before July 2020 and included original research on pharmacological interventions for anxiety after TBI in adults ≥16 years of age. MEDLINE, PubMed, CINAHL, EMBASE, PsycINFO, and CENTRAL databases were searched, with additional searching of key journals, clinical trials registries, and international drug regulators. The primary outcomes of interest were reduction in symptoms of anxiety and occurrence of harms. The secondary outcomes of interest were changes in depression, cognition, quality of life, and participation. Data were summarized in a narrative synthesis, and evidence quality was assessed using the Cochrane Risk of Bias tool. Only a single non-peer-reviewed, randomized controlled trial of 19 male military service members with mild TBI met inclusion criteria. This study found no significant effect of citalopram on anxiety symptoms over a 12-week intervention. The trial was stopped early because of poor recruitment, and much of the study detail was not included in the report. The methodological quality of the study was difficult to assess because of the lack of detail. No recommendations could be drawn from this review. There is a critical need for adequately powered and controlled studies of pharmacological interventions for anxiety after TBI across all severities that examine side-effect profiles and consider issues of comorbidity and effects of long-term pharmacotherapy.
Background:
Given the high frequency and significance of anxiety and depression following traumatic brain injury (TBI), there is a need to evaluate the efficacy of psychological interventions and to understand factors influencing response to such interventions. The present study investigated factors associated with positive response to cognitive behavioral therapy adapted for cognitive impairments (CBT-ABI) for individuals with anxiety and depression following TBI, including demographic and injury-related factors, pretreatment levels of anxiety and depression, working alliance, and change expectancy as predictors.
Methods:
Participants were 45 individuals enrolled in an active treatment condition within a randomized controlled trial, examining the efficacy of a 9-session CBT-ABI program for anxiety and depression following TBI. These participants completed all CBT sessions.
Results:
Mixed-effects regressions controlling for baseline anxiety and depression indicated that for anxiety, older age at injury, as well as higher level of baseline anxiety, was associated with greater symptom reduction. For depression, longer time since injury and higher expectancy for change, as well as higher baseline level of depression, were significantly associated with a greater reduction in depression symptoms.
Conclusions:
This study paves the way for more detailed studies of the therapeutic processes involved in alleviating anxiety and depression following TBI.
Objective: Examine a psychoeducational and skill-building intervention’s effectiveness for individuals after traumatic brain injury (TBI), using a two-arm, parallel, randomized, controlled trial with wait-listed control.
Methods: The Resilience and Adjustment Intervention (RAI) targets adjustment challenges and emphasizes education, skill-building and psychological support. Overall, 160 outpatients were randomly assigned to a treatment or wait-list control (WLC) group. The manualized treatment was delivered in seven 1-h sessions. The Connor-Davidson Resilience Scale (CD-RISC) was the primary outcome measure. Secondary measures included the Mayo Portland Adaptability Inventory-4 (MPAI-4), Brief Symptom Inventory-18 (BSI-18) and 13-Item Stress Test.
Results: After adjusting for injury severity, education and time postinjury, the RAI group (N = 75) demonstrated a significantly greater increase in resilience (effect size = 1.03) compared to the WLC group (N = 73). Participants in the RAI group demonstrated more favourable scores on the MPAI-4 Adjustment and Ability Indices, BSI-18 and the 13-item Stress Test. However, only the CD-RISC and BSI-18 demonstrated a clinically significant difference. In addition, RAI participants demonstrated maintenance of gains from pre-treatment to 3-month follow-up; however, only the BSI-18 maintained a clinically significant difference.
Conclusions: Investigation provided evidence that a resilience-focused intervention can improve psychological health and adjustment after TBI. Additional research is needed to ascertain the longer term benefits of intervention and the efficacy of alternative delivery methods (e.g., via telephone, Internet).
Anxiety, aggression/agitation, apathy and disinhibition are common neuropsychiatric consequences of acquired brain injury (ABI); these consequences can cause functional impairment and lead to reduced social integration. This systematic review aims to provide an examination of the current evidence on psychological interventions for treating these consequences. Two reviewers selected potential relevant articles, retrieved from five literature databases; methodological quality was assessed and appraised. A total of 5207 studies were found, of which 43 were included: 21 studies for anxiety, 18 for aggression, two studies for apathy, and six for disinhibition. Three studies addressed multiple consequences. Four high-quality (i.e., Class I and II) studies showed significant decreases in anxiety after cognitive behavioural therapy (CBT). In total, 14 studies consistently showed significant decreases in aggression/agitation after behavioural management techniques or anger management sessions. Substantial variability existed in the examined interventions and in their effects on apathy and disinhibition. Unfortunately, firm conclusions and recommendations for clinical practice are considered premature, due to concerns about the methodology used. However, this review yielded new evidence on the effectiveness of CBT for anxiety symptoms post-ABI and there has been some response to the ongoing call for studies with high methodological quality.
Due to diverse cognitive, emotional and interpersonal changes that can follow brain injury, psychological therapies often need to be adapted to suit the complex needs of this population. The aims of the study were to synthesise published recommendations for therapy modifications following brain injury from non- progressive traumatic, vascular, or metabolic causes and to determine how often such modifications have been applied to cognitive behavioural therapy (CBT) for post-injury emotional adjustment problems. A systematic review and narrative synthesis of therapy modifications recommended in review articles and reported in intervention studies was undertaken. Database and manual searches identified 688 unique papers of which eight review articles and 16 intervention studies met inclusion criteria. The review articles were thematically analysed and a checklist of commonly recommended modifications composed. The checklist items clustered under themes of: therapeutic education and formulation; attention; communication; memory; and executive functioning. When this checklist was applied to the intervention studies, memory aids and an emphasis on socialising patients to the CBT model were most frequently reported as adaptations. It was concluded that the inconsistent reporting of psychological therapy adaptations for people with brain injury is a barrier to developing effective and replicable therapies. We present a comprehensive account of potential modifications that should be used to guide future research and practice.
This study used a qualitative design with the objective of identifying concrete and practical solutions to optimize mental health care service delivery to persons with moderate-to-severe traumatic brain injury (TBI). Eighty provincial service providers, decision-makers, and community representatives participated. Qualitative analysis software (DRAP), developed by Boudreault and Kalubi (2007), was used to collect and analyze the statements emerging from the provincial workshop discussions. To summarize, 341 statements were collected during the workshop; 70.3% of these relating to clinical practice were considered essential, as were 63.2% that addressed policies, 50.7% that dealt with service reorganization, and 66.6% that were related to training. This workshop identified important strategies and priority actions considered essential for implementation in the Quebec health network for persons with moderate-to-severe TBI.
Problems with anger management after traumatic brain injury are one of the most frequent changes in the long term reported by relatives of injured people. In spite of their impact there have been few reports either describing therapy procedures for this disorder or examining their efficacy. The present study evaluated a cognitive-behavioural intervention for anger management difficulties following acquired brain injury. Participants were screened and randomly allocated to either a Treatment Group (TREAT) or Waiting List Group (WAIT). Each participant in TREAT received approximately six, hourly individual sessions of anger-management therapy while those in WAIT monitored their anger daily. Sixteen participants proceeded through to the final stages of the study. A significant decrease in anger on the State-Trait Anger Expression Inventory (STAXI) was found for TREAT in comparison with WAIT at post-treatment. Repeated-measures analyses for TREAT showed significant improvements between pre-treatment and post-treatment measures (immediate and 2-month follow-up) on the STAXI. No significant generalisation of treatment effects to self-esteem, anxiety, depression, or degree of self-awareness were found.
Cognitive Rehabilitation: Emerging Issues and Paradigm Shifts - Volume 4 Issue 1 - Robyn Tate, Jacinta Douglas
This study reports Auditory Verbal Learning Test (AVLT) data for 153 adults in age groups spanning seven decades, with approximately equal numbers of males and females and matched for intelligence, education, and occupation. Overall performance deteriorated with increased age, females performing better than males. Older subjects recalled fewer words, were more susceptible to information overload during input, showed diminished retrieval efficiency, and had a decline in memory for the source of items. In contrast, rate of learning, forgetting over 20-min, monitoring of recall, and interference effects remained stable across the age range.
Brain injury may produce impairments in self awareness. The magnitude of impairment is often determined by comparing patient self reports with self reports of others (report-report) or with patient performance (report-performance). This paper presents data on the pattern of a self-awareness deficit in memory functioning exhibited by a brain injury survivor 5 years post-injury. The effects of practice and feedback on reporting-recall differences was examined using single case methodology. Several prospective and retrospective self reports were obtained, to allow an examination of reporting about past or future recall. Results showed that recall improved and the magnitude of report-recall differences were reduced with practice and feedback.
The development, reliability, and discriminative ability of a new instrument to assess social phobia are presented. The Social Phobia and Anxiety Inventory (SPAI) is an empirically derived instrument incorporating responses from the cognitive, somatic, and behavioral dimensions of social fear. The SPAI high test–retest reliability and good internal consistency. The instrument appears to be sensitive to the entire continuum of socially anxious concerns and is capable of differentiating social phobics from normal controls as well as from other anxiety patients. The utility of this instrument for improved assessment of social phobia and anxiety and its use as an aid for treatment planning are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Community norms are reported for the Beck Anxiety Inventory (BAI; A. T. Beck, N. Epstein, G. Brown, & R. A. Steer, 1988), Fear Questionnaire (FQ; I. M. Marks & A. Mathews, 1979), Penn State Worry Questionnaire (PSWQ; T. J. Meyer, M. L. Miller, R. L. Metzger, & T. D. Borkovec, 1990), and Social Phobia and Anxiety Inventory (SPAI; S. M. Turner, D. C. Beidel, C. V. Dancu, & M. A. Stanley, 1989). The demographic profile of the samples closely matched the 1990 U.S. national census. On the SPAI, women scored higher than men on the Agoraphobia subscale, and the lowest income group scored higher than higher income participants on the Difference and Social Phobia subscales. Participants under 45 years of age exceeded those aged 45–65 on the BAI, the PSWQ, and FQ Social Phobia, Blood/Injury, and Total Phobia scores. Percentile scores are provided for all measures, as well as discussion of their usefulness for assessing clinical significance of therapy outcomes. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
We conducted a meta-analysis using all available controlled treatment outcome studies of cognitive-behavioral and pharmacological treatments for social phobia (N= 24 studies, N= 1079 subjects). The mean social anxiety effect size for cognitive-behavioral treatments was .74 and for pharmacological treatments was .62. Both were significantly different from zero and the difference between them was not significant. Among cognitive-behavioral treatments, exposure-interventions yielded the largest effect size (ES) whether alone (ES = .89) or combined with cognitive restructuring (ES = .80). Selective serotonin reup-take inhibitors (ES = 1.89) and benzodiazepines (ES = .72) yielded the largest effect sizes for pharmacotherapy. According to cost projections, group cognitive-behavioral treatment offered the most cost-effective intervention.
Post-traumatic stress disorder (PTSD) is described following a road traffic accident in which the patient suffered a severe head injury. The stress reaction was associated with intrusive thoughts and avoidance of cognitive and physical events associated with consequences of the accident. The condition was successfully treated by behavioural intervention. It seems clear that PTSD can occur even where there is loss of consciousness and organic amnesia for the event and its immediate sequelae.
The Drug Abuse Screening Test (DAST) was designed to provide a brief instrument for clinical screening and treatment evaluation research. The 28 self-report items tap various consequences that are combined in a total DAST score to yield a quantitative index of problems related to drug misuse. Measurement properties of the DAST were evaluated using a clinical sample of 256 drug/alcohol abuse clients. The internal consistency reliability estimate was substantial at .92, and a factor analysis of item intercorrelations suggested an unidimensional scale. With respect to response style biases, the DAST was only moderately correlated with social desirability and denial. Concurrent validity was examined by correlating the DAST with background variables, frequency of drug use during the past 12 months, and indices of psychopathology. Although these findings support the usefulness of the DAST for quantifying the extent of drug involvement within a help-seeking population, further validation work is needed in other populations and settings.
A current conceptual conundrum is the question of whether it is possible to have a co-occurrence of both Posttraumatic Stress Disorder and head trauma. The current report describes the results of behavior therapy and a series of neuropsychological tests for a man who suffered Posttraumatic Stress Disorder and neuropsychological deficits after an automobile accident. A series of neuropsychological test batteries documented considerable improvement. The patient was also treated for Posttraumatic Stress Disorder with behavior therapy so symptoms abated much earlier than the neuropsychological deficits.
Feedback is a commonly used technique in neurorehabilitation. It functions to strengthen or weaken select relations between individuals' behaviour and their environment. The study of behaviour-environment relations is a focus of operant psychology, commonly referred to as behaviour analysis. Central to behaviour analysis is the analysis of interrelations among stimuli, behaviour, and consequences. The focus on behaviour-environment relations may have considerable benefits for designing clinical treatments and accounting for successful and unsuccessful treatments, especially psychological interventions for maladaptive behaviour. In the present investigation, three persons with traumatic brain injuries, diagnosed with depression and presenting mild cognitive impairments, received feedback about their maladaptive behaviour. Weekly feedback resulted in general reductions in the variability and frequency of maladaptive behaviour. The results support the utility of giving equal consideration to relations between persons with traumatic brain injury and their environment, despite existing psychological or cognitive impairments. Future research on variables that influence the development and maintenance of behaviour-environment relations, and more generally operant behaviour, may provide a unique perspective on the effects of traumatic brain injury.
Patients who had suffered traumatic brain injury were evaluated to determine the occurrence of psychiatric disorders during a 30-year follow-up.
Sixty patients were assessed on average 30 years after traumatic brain injury. DSM-IV axis I disorders were diagnosed on a clinical basis with the aid of the Schedules for Clinical Assessment in Neuropsychiatry (version 2.1), and axis II disorders were diagnosed with the Structured Clinical Interview for DSM-III-R Personality Disorders. Cognitive impairment was measured with a neuropsychological test battery and the Mini-Mental State Examination.
Of the 60 patients, 29 (48.3%) had had an axis I disorder that began after traumatic brain injury, and 37 (61.7%) had had an axis I disorder during their lifetimes. The most common novel disorders after traumatic brain injury were major depression (26.7%), alcohol abuse or dependence (11.7%), panic disorder (8.3%), specific phobia (8.3%), and psychotic disorders (6.7%). Fourteen patients (23.3%) had at least one personality disorder. The most prevalent individual disorders were avoidant (15.0%), paranoid (8.3%), and schizoid (6.7%) personality disorders. Nine patients (15.0%) had DSM-III-R organic personality syndrome.
The results suggest that traumatic brain injury may cause decades-lasting vulnerability to psychiatric illness in some individuals. Traumatic brain injury seems to make patients particularly susceptible to depressive episodes, delusional disorder, and personality disturbances. The high rate of psychiatric disorders found in this study emphasizes the importance of psychiatric follow-up after traumatic brain injury.
Acute stress disorder permits early identification of trauma survivors who are at risk of developing chronic posttraumatic stress disorder (PTSD). This study aimed to prevent PTSD in people who developed acute stress disorder after a mild brain injury by early provision of cognitive behavior therapy.
Twenty-four civilian trauma survivors with acute stress disorder were given five individually administered sessions of either cognitive behavior therapy or supportive counseling within 2 weeks of their trauma.
Fewer patients receiving cognitive behavior therapy than supportive counseling met criteria for PTSD at a posttreatment evaluation (8% versus 58%, respectively). There were also fewer cases of PTSD at a 6-month follow-up evaluation among those receiving cognitive behavior therapy (17%) than among those receiving supportive counseling (58%). Patients in the cognitive behavior therapy condition displayed less reexperiencing and avoidance symptoms at the follow-up evaluation than patients receiving supportive counseling.
These findings suggest that PTSD following mild brain injury can be effectively prevented with early provision of cognitive behavior therapy.
Research into the rehabilitation of individuals following Traumatic Brain Injury (TBI) in the past 15 years has resulted in greater understanding of the condition. The second edition of this book provides an updated guide for health professionals working with individuals recovering from TBI.
Theoretical accounts of post-traumatic stress disorder (PTSD) suggest that memory for a precipitating event is crucial for its development. Indeed, Sbordone and Liter (1995) have recently argued that mild traumatic brain injury and PTSD are mutually exclusive disorders. A case is described who sustained a severe head injury in a road traffic accident. He had a retrograde amnesia of two days and a post-traumatic amnesia of four weeks. Six months after his accident he was found to be suffering from a number of anxiety symptoms, including nightmares and intrusive thoughts, consistent with a diagnosis of PTSD. The implications of this case for theories of PTSD are discussed.
Contemporary psychological literature as well as the preceding papers (Mateer & Sohlberg, 2003; Wilson, 2003; Ylvisaker, 2003) emphasise the individual patient's personal ecological context as a crucial factor in the delivery of cognitive rehabilitation services. Testing and assessment procedures in neuropsychology have been enjoined to take increasing notice of the patient's historical, cultural and social background in providing services (American Psychological Association, 2003). Similarly, the design and delivery of treatment services must take into account how and where patients are living their lives post-injury. This has the benefit of moving cognitive rehabilitation from an emphasis on the more obvious or face-valid concerns about sterile “cognitive” models to individual ways of facilitating learning and information transfer improvement in the real world. In this way of approaching the problem, the patient's cultural and demographic context as well as their emotional adaptations are not confounding variables but critical design variables. The challenge now in delivering these paradigms of care is to show that they are appropriate and effective in some place in healthcare delivery systems, whether traditional or alternative. Questions of effectiveness of cognitive rehabilitation treatments and cost should be balanced in an equation relating to the probability of objective and demonstrable patient enhancement in living. Goals set and achieved must have consensual value that cannot be captured by traditional cost-benefit analysis in preventive or curative healthcare economic methodology. Cognitive rehabilitation as a family of interventions has little to no chance of being evaluated as efficacious using traditional treatment designs, using traditional neuropsychological measures as dependent variables, and involving research designs with crossover, sham or placebo conditions.
A case of post-traumatic stress disorder and minor head injury following a road traffic accident is reported. Significant, persisting, and disabling cognitive deficits were reported by the patient and confirmed on neuropsychological testing. A magnetic resonance imaging scan showed no evidence of cerebral damage. A cognitive behavioural treatment approach to the problem is described. The relative contribution of emotional and organic factors to the cognitive and behavioural sequelae of head injury is discussed.
Recent innovations in behavior modification have, for the most part, detoured around the role of cognitive processes in the production and alleviation of symptomatology. Although self-reports of private experiences are not verifiable by other observers, these introspective data provide a wealth of testable hypotheses Repeated correlations of measures of inferred constructs with observable behaviors have yielded consistent findings in the predicted direction.Systematic study of self-reports suggests that an individual's belief systems, expectancies, and assumptions exert a strong influence on his state of well-being, as well as on his directly observable behavior. Applying a cognitive model, the clinician may usefully construe neurotic behavior in terms of the patient's idiosyncratic concepts of himself and of his animate and inanimate environment. The individual's belief systems may be grossly contradictory; i.e., he may simultaneously attach credence to both realistic and unrealistic conceptualizations of the same event or object. This inconsistency in beliefs may explain, for example, why an individual may react with fear to an innocuous situation even though he may concomitantly acknowledge that this fear is unrealistic.Cognitive therapy, based on cognitive theory, is designed to modify the individual's idiosyncratic, maladaptive ideation. The basic cognitive technique consists of delineating the individual's specific misconceptions, distortions, and maladaptive assumptions, and of testing their validity and reasonableness. By loosening the grip of his perseverative, distorted ideation, the patient is enabled to formulate his experiences more realistically. Clinical experience, as well as some experimental studies, indicate that such cognitive restructuring leads to symptom relief.
Clinical experience and research indicate that the outcome of psychotherapy is in part determined by the degree to which patient and therapist can form a strong working alliance. Four interrelated factors can collectively shape brain-injured patients' reactions to the psychotherapy process and predicate the conditions under which a working alliance can be cultivated. Assessment of these factors can help the therapist anticipate how each patient will relate during psychotherapy as well as tailor the therapy process in a way that will optimize the patient's capacity to make meaningful use of it. The four factors include the neurologic syndrome and associated cognitive deficits, the psychologic impact of the deficits, the patient's psychologic make-up independent of the brain injury, and the patient's social context.
(C) Williams & Wilkins 1991. All Rights Reserved.
A substantial literature now exists that indicates that cognitive-behaviour therapies are effective for a wide range of psychological problems (See Hawton, Salkovskis, Kirk, & Clark, 1989). However, it is only very recently that cognitive-behaviour therapists have considered people with learning disabilities as suitable clients for this particular approach. The present paper describes some of the challenges that are encountered when applying cognitive-behaviour therapy to this client group.
ABSTRACT– A self-assessment scale has been developed and found to be a reliable instrument for detecting states of depression and anxiety in the setting of an hospital medical outpatient clinic. The anxiety and depressive subscales are also valid measures of severity of the emotional disorder. It is suggested that the introduction of the scales into general hospital practice would facilitate the large task of detection and management of emotional disorder in patients under investigation and treatment in medical and surgical departments.
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).
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.
Urban, suburban, and rural New York state.
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.
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.
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.
TBI is a risk factor for subsequent psychiatric disabilities. The need for proactive psychiatric assessment and timely interventions in individuals post TBI is indicated.
A meta-analytic comparison of studies testing cognitive behavior therapy (CBT; n = 12) and exposure treatment (n = 9) for social phobia indicates that the treatment modalities are equally effective. Compared to exposure, CBT did not lead to greater pretest-posttest or pretest-follow-up improvement on self-report measures of social anxiety, cognitive symptoms, or depressed/anxious mood. Length of treatment was generally unrelated to outcome, although a larger number of exposure sessions produced better results on measures of social anxiety at posttest.
Survivors of acquired brain injury (ABI) are at risk of a range of neuropsychiatric and behavioural disorders. Emotional disturbance, with reactive elements of mood disorder, such as depression and anxiety, appear particularly common. Specific anxiety disorders, such as post-traumatic stress disorder (PTSD) have also been identified. Pain syndromes are also common-particularly in those who have suffered Traumatic Brain Injuries (TBI). Survivors of ABI are often atrisk of substance misuse and of irritability states. Their relationships may suffer from the stresses triggered by the aftermath of injury. Intimate, in particular, sexual relationships may be particularly affected. These effects are not, necessarily, only consequent of severe injuries, as mild TBI can also have, for some, significant neuropsychiatric effects. Assessment and management of such conditions are compromised by survivors of injury often having a limited insight into the sequelae of their injuries. Interventions for such disorders and forms of distress are increasingly available. This paper introduces the special issue of Neuropsychological Rehabilitation on biopsychosocial approaches in neurorehabilitation. A range of papers provide overviews for assessing and managing such neuropsychiatric, mood and behavioural (health and habit) disorders.
Survivors of acquired and traumatic brain injuries may often experience anxiety states. Psychological reactions to neurological trauma may be caused by a complex interaction of a host of factors. We explore how anxiety states may be understood in terms of a biopsychosocial formulation of such factors. We also review the current evidence for the presence of specific anxiety disorders after brain injury. We then describe how cognitive-behaviour therapy (CBT), a treatment of choice for many anxiety disorders, may be integrated with cognitive rehabilitation (CR), for the management of anxiety disorders in brain injury. We illustrate how CBT and CR may be delivered with a case of a survivor of traumatic brain injury (TBI) who had developed obsessive compulsive disorder and health anxiety. We show how CBT plus CR allows a biopsychosocial formulation to be developed of the survivor's concerns for guiding a goal-based intervention. The survivor made significant gains from intervention in terms of goals achieved and changes on clinical measures. We argue that large-scale research is needed for developing an evidence base for managing emotional disorders in brain injury.
This article focuses on depression and its psychological management following brain injury or stroke in the adult population. The presentation of depression in the context of brain injury is discussed and a summary of the psychosocial aetiological factors for the development of depression in this context is provided. The links between depression and neuropsychological functioning are explored and the significant impact of depression on neurorehabilitation outcome highlights the need for the development of effective interventions in this area. Cognitive behaviour therapy (CBT) is presented as a potentially suitable treatment: The model is described with ideas for the clinician on how to adapt the delivery of CBT for clients with neuropsychological impairment. To date, there have been a very small number of studies evaluating CBT for the treatment of depression in brain injury, however their results have been promising. It is concluded that further research is necessary.
This paper describes an holistic approach to the psychotherapy of the brain injured individual in which the biological, intrapsychic, family, social and spiritual systems are taken into account. By acknowledging that the patient's innate goodness has not been destroyed, technical issues are addressed that enable the patient to deal with his losses and achieve higher levels of adjustment.
The social adjustment of 11 severely head injured patients was assessed using the KATZ adjustment scale. The result suggested that the group had poor social adjustment, and on many dimensions was similar to a psychiatric population. The head-injured patients also had social interaction difficulties as assessed by a range of observational and self-report measures. When compared to an out-patient and non-clinical group they had poor social performance, high social anxiety and low self-esteem. The implications of this for rehabilitation are discussed.
A self-assessment scale has been developed and found to be a reliable instrument for detecting states of depression and anxiety in the setting of an hospital medical outpatient clinic. The anxiety and depressive subscales are also valid measures of severity of the emotional disorder. It is suggested that the introduction of the scales into general hospital practice would facilitate the large task of detection and management of emotional disorder in patients under investigation and treatment in medical and surgical departments.
This study examined psychiatric sequelae of traumatic brain injuries in outpatients and their relation to functional disability.
Fifty consecutive outpatients with traumatic brain injuries who came to a brain injury rehabilitation clinic for initial evaluation were examined for DSM-III-R diagnoses with the use of the National Institute of Mental Health Diagnostic Interview Schedule. The patients completed the Medical Outcomes Study Health Survey to assess functional disability and a questionnaire to assess postconcussion symptoms and self-perceptions of the severity of their brain injuries and cognitive functioning.
Thirteen (26%) of the patients had current major depression, and an additional 14 (28%) reported a first-onset major depressive episode after the injury that had resolved. Twelve (24%) had current generalized anxiety disorder, and four (8%) reported current substance abuse. The group with depression and/or anxiety was significantly more impaired than the nondepressed/nonanxious patients according to the Medical Outcomes Study Health Survey measures of emotional role functioning, mental health, and general health perceptions. The depressed/anxious group also rated their injuries as significantly more severe and their cognitive functioning as significantly worse, despite the lack of significant differences in objective measures of severity of injury and Mini-Mental State examination scores. The depressed patients reported significantly more postconcussion symptoms that were increasing in severity over time.
Depression and anxiety are common in outpatients with traumatic brain injuries. Patients with depression or anxiety are more functionally disabled and perceive their injury and cognitive impairment as more severe. Depressed patients report more increasingly severe postconcussion symptoms.
The Alcohol Use Disorders Identification Test (AUDIT) has been developed from a six-country WHO collaborative project as a screening instrument for hazardous and harmful alcohol consumption. It is a 10-item questionnaire which covers the domains of alcohol consumption, drinking behaviour, and alcohol-related problems. Questions were selected from a 150-item assessment schedule (which was administered to 1888 persons attending representative primary health care facilities) on the basis of their representativeness for these conceptual domains and their perceived usefulness for intervention. Responses to each question are scored from 0 to 4, giving a maximum possible score of 40. Among those diagnosed as having hazardous or harmful alcohol use, 92% had an AUDIT score of 8 or more, and 94% of those with non-hazardous consumption had a score of less than 8. AUDIT provides a simple method of early detection of hazardous and harmful alcohol use in primary health care settings and is the first instrument of its type to be derived on the basis of a cross-national study.
A meta-analysis was conducted using 42 treatment-outcome trials for social phobia. Six conditions were compared: Waiting-list control, placebo, EXP (within-session exposure and homework exposure), CT (cognitive restructuring without exposure exercises), CT + EXP, and SST (social skills training). All interventions, including placebo, had larger effect sizes than that of the waiting-list control, and the interventions did not differ in drop-out proportions. Only CT + EXP yielded a significantly larger effect size than placebo. Effects of treatments tended to increase during the follow-up period. These results support the use of cognitive-behavioral treatments for social phobia, especially the use of CT + EXP.
Individuals that may be especially susceptible to panic attacks in the rehabilitation setting are patients who have suffered traumatic brain injuries, post-concussion syndrome, lesions, or encephalopathy. An individual is described who suffered a traumatic brain injury and was determined to have suffered a panic attack during his rehabilitation stay. The manifestations of panic attacks are described, using the case report as an example. The psychological aetiology of panic disorders is also reviewed, and treatment options using four major classes of neuropharmacologic agents: benzodiazepines, tricyclic antidepressants, monoamide oxidase inhibitors, and serotonin reuptake inhibitors, are discussed. Given the increasing incidence and survival of patients with traumatic brain injuries, the complications of panic attacks and disorders will become more important; they are a serious condition that can affect an individual's lifestyle, employment, and relationships, and increase the risk of suicide. Rehabilitation specialists should be aware of the manifestations and management of panic attacks and come to appreciate that recognition of this treatable condition is important during all stages of rehabilitation.
The aim of this study was to investigate the influence of posttraumatic stress disorder (PTSD) on rehabilitation after severe traumatic brain injury (TBI). Ninety-six patients with severe TBI patients were assessed 6 months after hospital discharge with the Posttraumatic Stress Disorder Interview, the Functional Assessment Measure (FAM), the Community Integration Questionnaire (CIQ), the Overt Aggression Scale (OAS), the General Health Questionnaire (GHQ), the Beck Depression Inventory (BDI), and the Satisfaction with Life Scale (SWL). PTSD was diagnosed in 27% of patients. Patients with PTSD reported higher scores on the GHQ and BDI, and lower scores on the FAM, CIQ, OAS, and SWLS than those without PTSD. Effective rehabilitation after severe TBI may be enhanced by management of PTSD.
A meta-analysis of psychological and pharmacological treatments for social phobia was conducted to evaluate whether the various treatments differ in their efficacy for treating social phobia, whether they are more effective than wait-list and placebo controls, whether rates of attrition differ, and whether treatment gains are maintained at follow-up. A total of 108 treatment-outcome trials for social phobia met inclusion/exclusion criteria for the meta-analysis. Eleven treatment conditions were compared: wait-list control, pill placebo, benzodiazepines (BDZs), selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors, attention placebo, exposure (EXP), cognitive restructuring (CR), EXP plus CR, social skills training, and applied relaxation. The most consistently effective treatments for social phobia were pharmacotherapies. BDZs and SSRIs were equally effective and more effective than control conditions. Dropout rates were similar among all the active treatment conditions. Assessment of the durability of treatment gains for pharmacotherapies was not possible because an insufficient number of drug studies included follow-up data. The treatment gains of psychological therapies, although moderate, continued during the follow-up period. BDZs and SSRIs seem to be effective treatments for social phobia, at least in the short term. Recommendations for future research include assessing the long-term outcome for pharmacotherapies and evaluating the inclusion of a cognitive-behavioral treatment during the drug tapering period.
Cognitive-behavioral therapy (CBT) is the most thoroughly studied nonpharmacologic approach to the treatment of social anxiety disorder, and its efficacy has been demonstrated in a large number of investigations. This article summarizes the data on the efficacy of CBT for the treatment of the symptoms of social anxiety disorder and impaired quality of life. The relative efficacy of various CBT approaches, both in the short-term and over extended follow-up periods, is reviewed. Factors associated with more or less positive response to CBT among patients with social anxiety disorder are examined. Special attention is given to the comparison of CBT with pharmacologic approaches to the treatment of social anxiety disorder and the potential utility of combining these approaches. Future directions in the application of combinations of CBT and pharmacotherapy to the treatment of social anxiety disorder are discussed.
Social anxiety disorder is fairly prevalent among alcohol abusing/dependent subjects. The objective of the present study was to investigate: (a) the incidence of social anxiety symptoms in inpatient alcoholics, (b) the effect of alcohol detoxification on these symptoms, and (c) whether a combined psychotherapeutic/mirtazapine treatment during the post-detoxification phase of alcoholism has a greater impact on the aforementioned symptoms than a non-pharmacological approach.
Social anxiety symptoms were assessed through the Liebowitz Social Anxiety Scale (LSAS) following a 4-5-week detoxification period in two groups: group A (n=21) that followed a detoxification protocol of cognitive-behavioral orientation and group B (n=33) that was assigned to mirtazapine in addition to the standard protocol. Concomitant psychopathology was monitored through the HARS and HDRS, and level of functioning through the GAS.
A marked reduction of social anxiety symptoms was evidenced in both groups. However, patients on mirtazapine improved significantly more compared to controls.
A single measure of social anxiety, i.e., the LSAS was used. Also, a longer follow-up period is needed to ascertain remission of social anxiety symptoms.
The present study found a rather high incidence of social anxiety symptoms in inpatient alcoholics which subsided following alcohol detoxification; moreover, it provides preliminary evidence that a combined psychotherapeutic/mirtazapine treatment (30-60 mg/daily) has a greater impact on the aforementioned symptoms than non-pharmacological treatment alone.
We present two cases to illustrate the assessment and management of post-traumatic stress disorder (PtSD) in the context of traumatic brain injury (TBI). Case KE suffered a TBI in a road traffic accident (RTA) in which his girlfriend was killed. Case CM survived a penetrating neurological injury from a severe knife attack. Both suffered cognitive difficulties, primarily in attention and memory, and selective visual impairments, and had endured significant losses of social role.
Within a neurorehabilitation programme, goals were set regarding management of their cognitive difficulties for regaining social roles and for the management of their PtSD symptoms. Cognitive behavioural therapy (CBT) was provided for managing PtSD symptoms, which included use of a stress inoculation and graduated exposure to avoided situations and trauma re-experiences.
Both survivors reported significant improvements in managing mood state, and in redeveloping social roles. Objective measures confirmed significant gains from intervention.
CBT, set within a neurorehabilitation programme, can lead to improvement in PtSD symptoms and psychosocial outcome in TBI survivors.
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- R Crino
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Anxiety disorders and phobias: A cognitive perspective
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Axis I and II psychiatric disorders after traumatic brain injury: A 30 year follow-up study
- S Koponen
- T Taiminen
- R Porten
- L Himanen
- H Isoneimi
- H Heinonen
- S Hinkka
- O Tenovou
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