Self- and Informant-Ratings on the Patient Competency Rating Scale in Patients with Traumatic Brain Injury

The Patient Competency Rating Scale (PCRS) provides self- and informant-ratings of everyday memory and gives a guide to patients' awareness of their difficulties. Research using the PCRS has focussed on groups with severe TBI and little is known about ratings of functioning in other severity groups or in a non-TBI population. In the current study the TBI group (n = 53) overrated their pre-accident competency compared to controls (n = 131). Patients with severe TBI (n = 25) underestimated their difficulties, while ratings of those with moderate (n = 14) and mild (n = 14) TBI were consistent with their informants, that is, in areas of cognition and emotion. Controls reported difficulty in interpersonal functioning and emotional control that their informants were unaware of.     

Neural correlates of self-evaluative accuracy after traumatic brain injury

Individuals who have sustained a traumatic brain injury (TBI) often exhibit an array of cognitive deficits, yet perhaps most maladaptive of these sequelae is the frequent occurrence of reduced insight into one's own condition. In such cases, TBI individuals may overestimate their post-injury level of socio-cognitive functioning, leading to disparities between how they perceive themselves and what others observe. This functional MRI (fMRI) investigation examined the relationship between level of insight into one's post-injury condition (i.e. trait/ability status) and neural activation evoked during an fMRI task involving self-appraisal of one's traits and abilities. Twenty TBI patients (8-12 weeks post-injury, ER Glasgow Coma Scale Average = 10.9+/-2.8) were selected on the criterion that they overestimate their current trait/abilities (as detected on the patient competency rating scale, PCRS). fMRI activation on the self-appraisal task was compared between the TBI patients and 20 matched controls. For both groups, the fMRI task evoked activation at mid-line prefrontal and retrosplenial cortices. TBI patients exhibited greater signal change in the anterior cingulate, precuneus and right temporal pole. Subsequently, a linear regression analysis was conducted for the TBI group, with the PCRS and a measure of cognitive speed entered as predictor variables to determine the selective effect of insight on self-evaluative brain activation. A more accurate level of trait/ability-based insight was related to increased signal change in the right anterior dorsal prefrontal cortex (PFC). The results suggest that one's post-injury level of self-referential insight is related to a network inclusive of the medial and right dorsal PFC.     

Awareness of activity limitations and prediction of performance in patients with brain injuries and orthopedic disorders.

The aim of this study was to compare the accuracy of performance predictions in experimental tasks with patients' awareness of activity limitations. Participants were 24 patients with brain injuries (i.e., traumatic brain injury and cerebrovascular disorders) and 22 patients with orthopedic disorders. Prediction of performance was examined in a memory task (word list learning) and a motor task (finger tapping). Awareness of activity limitations was measured by comparing patients' self-ratings and staff ratings in the Patient Competency Rating Scale (PCRS). Results for the PCRS showed that patients with orthopedic disorders underestimated and patients with brain injuries (i.e., patients with TBI) overestimated their level of functioning in the total scale and the social/emotional subscale in comparison to staff ratings. Both patient groups agreed with staff ratings in physical/basic self-care items. In the predicted performance tasks a similar pattern could be observed: None of the groups showed an overestimation of performance in the motor task, whereas patients with brain injuries overestimated their competency in the memory task. However, the agreement between both awareness measures (PCRS, predicted performance) was only low, which indicates that they might measure different aspects or levels of self-awareness.     

African American acculturation and neuropsychological test performance following traumatic brain injury.

The present study examined the influence of African American acculturation on the performance of neuropsychological tests following traumatic brain injury (TBI). Seventy one participants already enrolled in a larger-scale study assessing the impact of TBI (i.e., the South Eastern Michigan Traumatic Brain Injury Model Systems project) completed a self-report measure of African American acculturation (African American Acculturation Scale-Short Form; Landrine & Klonoff, 1995) in addition to a standardized battery of neuropsychological tests. Hierarchical regression analyses were conducted to evaluate the relationship between level of acculturation and test performance after controlling for injury-related (initial Glasgow Coma Scale score, time since injury) and demographic variables (age, sex, years of education, and socioeconomic status). Lower levels of acculturation were associated with significantly poorer performances on the Galveston Orientation & Amnesia Test, MAE Tokens test, WAIS-R Block Design, Rey Auditory Verbal Learning Test, and Symbol Digit Modalities Test. Decreased levels of acculturation were also significantly related to lower scores on a composite indicator of overall neuropsychological test performance. In addition, the examiner's ethnicity (Black or White) was related with scores on a few of the tests (i.e., Block Design, Trail Making Test), but was not significantly associated with the overall neuropsychological test performance. Overall, these findings suggest that differences in cultural experience may be an important factor in the neuropsychological assessment of African Americans following TBI, and provide additional support for the hypothesis that cultural factors may partially account for the differences among ethnic/cultural groups on neuropsychological tests.     

Self- and informant-ratings on the patient competency rating scale in patients with traumatic brain injury

The Patient Competency Rating Scale (PCRS) provides self- and informant-ratings of everyday memory and gives a guide to patients' awareness of their difficulties. Research using the PCRS has focussed on groups with severe TBI and little is known about ratings of functioning in other severity groups or in a non-TBI population. In the current study the TBI group (n = 53) overrated their pre-accident competency compared to controls (n = 131). Patients with severe TBI (n = 25) underestimated their difficulties, while ratings of those with moderate (n = 14) and mild (n = 14) TBI were consistent with their informants, that is, in areas of cognition and emotion. Controls reported difficulty in interpersonal functioning and emotional control that their informants were unaware of.     

Assessing connectivity related injury burden in diffuse traumatic brain injury

Many of the clinical and behavioral manifestations of traumatic brain injury (TBI) are thought to arise from disruption to the structural network of the brain due to diffuse axonal injury (DAI). However, a principled way of summarizing diffuse connectivity alterations to quantify injury burden is lacking. In this study, we developed a connectome injury score, Disruption Index of the Structural Connectome (DISC), which summarizes the cumulative effects of TBI‐induced connectivity abnormalities across the entire brain. Forty patients with moderate‐to‐severe TBI examined at 3 months postinjury and 35 uninjured healthy controls underwent magnetic resonance imaging with diffusion tensor imaging, and completed behavioral assessment including global clinical outcome measures and neuropsychological tests. TBI patients were selected to maximize the likelihood of DAI in the absence of large focal brain lesions. We found that hub‐like regions, with high betweenness centrality, were most likely to be impaired as a result of diffuse TBI. Clustering of participants revealed a subgroup of TBI patients with similar connectivity abnormality profiles who exhibited relatively poor cognitive performance. Among TBI patients, DISC was significantly correlated with post‐traumatic amnesia, verbal learning, executive function, and processing speed. Our experiments jointly demonstrated that assessing structural connectivity alterations may be useful in development of patient‐oriented diagnostic and prognostic tools. Hum Brain Mapp 38:2913–2922, 2017. © 2017 Wiley Periodicals, Inc.     

Frequency of behavioural problems at one year following traumatic brain injury: Correspondence between patient and caregiver reports

A group of 62 adults with significant (i.e., ventilation required for > 24 hours) traumatic brain injury (TBI) were assessed approximately one year following their injury. The people with TBI and their primary caregivers completed the patient and relative/friend versions respectively, of the 20-item Head Injury Behaviour Rating Scale (HIBS). Responses by the patient and caregiver groups were compared for the total number of problems reported and the frequency of specific problem behaviours. The caregiver group reported a greater total number of problem behaviours and a higher frequency for 19 of the 20 specific behaviours. These differences between the patients' and caregivers' reports were statistically significant for seven of the 19 problem behaviours. The majority (86%) of these significant differences were on items from the Behavioural Regulation, rather than the Emotional Regulation, subscale of the HIBS. The implications of these findings for the practice of neuropsychological rehabilitation are presented.     

S-100B concentration is not related to neurocognitive performance in the first month after mild traumatic brain injury

The serum concentration of S-100B is reported to reflect the severity of brain damage. The purpose of this study was to determine whether elevated serum S-100B concentrations were related to neuropsychological test performance of patients in the subacute phase of recovery from mild traumatic brain injury (TBI). S-100B concentrations were measured in blood samples taken within 6 h after TBI. Serum S-100B was estimated using an immunoluminometric assay. Cognitive speed and memory were assessed with neuropsychological tests at a median of 13 days (range 7-21 days) after injury. The two groups, formed on a median split of initial serum S-100B concentrations (>or<0.22 microg/l) did not differ in age or education. The neuropsychological performance of the TBI patients was also compared with that of a healthy control group. Cognitive speed and memory performance of mild TBI patients were inferior compared to those of healthy subjects. There were no significant differences within the TBI group when serum S-100B concentration was taken into consideration. The findings suggest that serum S-100B levels after mild TBI are not predictive of neuropsychological performance in the subacute stage of recovery.     

Community treatment orders: the experiences of Non-Maori and Maori within mainstream and Maori mental health services

Purpose

Community treatment orders (CTOs) are sometimes used to coerce patients into treatment on the basis that such treatment is in their best interest. The experiences of Maori, New Zealand’s indigenous ethnic minority are less well known and this paper compares the views of Maori and non-Maori about CTOs.

Methods

Patients with experience of CTOs for greater than 6 months participated. Self-report measures were used to identify patients’ views of compulsory treatment. Demographic data, heath service characteristics, the experience of coercion, views of compulsory community treatment, satisfaction with care, social functioning, and psychopathology were assessed.

Results

There were few differences in demographic or clinical characteristics between Maori and non-Maori. There were no differences in the views of Maori compared to non-Maori patients with respect to compulsory community treatment. There were no differences in the views of Maori cared for by mainstream compared to culturally specialist Maori mental health service.

Conclusions

In a well-established system of compulsory treatment, there is no evidence of greater negative impact of CTOs in an indigenous minority population. The opportunity for Maori to self-select between mainstream and specialist Maori mental health services may minimize the negative aspects of compulsory community treatment for Maori.     

Patient compliance in brain injury rehabilitation in relation to awareness and cognitive and physical improvement

The purpose of the present study was to investigate the relationship between patients' compliance and awareness and outcome of brain injury rehabilitation. Subjects were 98 patients who underwent a holistic neuropsychological outpatient rehabilitation programme. Patients had suffered a traumatic brain injury (n = 26), a cerebrovascular accident (n = 58), or another neurological insult (n = 14). Measures: Two staff members, a neuropsychologist and a physiotherapist, retrospectively and separately rated patients' awareness and their compliance. Outcome was measured with the d2 test of concentration, measures of oxygen uptake, strength endurance, running speed, and patients' and relatives' ratings of patients' cognitive, physical, and overall problems on the European Brain Injury Questionnaire (EBIQ). The discrepancy between patients' and relatives' ratings on the EBIQ was incorporated as a second measure of patients' awareness. Results: The neuropsychologist's compliance ratings were significantly related to measures of insight, improvement of d2 performance accuracy and stability, improvement of oxygen uptake, and reduction of cognitive and overall problems as reported by the patients, while the physiotherapist's compliance ratings were related to measures of insight, improvement of d2 performance speed, improvement of oxygen uptake and strength endurance, and all three EBIQ patient scales. Discussion: The results suggest a differential relationship between situation-specific compliance and outcome.     

Neuropsychological assessment and employment outcome after traumatic brain injury: a review

While there may be many reasons for obtaining neuropsychological assessment after traumatic brain injury (TBI), prediction of real world functioning is generally a key goal. The present paper reviews 23 studies concerning the relationship between neuropsychological test results and employment outcome after TBI. The review was conducted in accordance with guidelines developed by the Committee on Empirically Supported Practice of Division 40 (Neuropsychology) of the American Psychological Association. Results of the review support a Category A (strongly supported) recommendation for the use of early neuropsychological assessment to predict late employment outcome. Studies of late neuropsychological assessment and subsequent employment outcome and studies of concurrent neuropsychological assessment and employment outcome were inconclusive regarding either support or contraindication for neuropsychological assessment to predict employment outcome. Almost all studies conducted at these late or concurrent time points had significant limitations with regard to study type or adequacy of methodology. However, there is no conceptual basis for believing that neuropsychological findings obtained closer in time to assessment of employment outcome should be less predictive of this outcome than neuropsychological findings obtained at an earlier time.     

The contributions of culture and ethnicity to New Zealand mental health research findings

BACKGROUND AND MATERIAL: In the last five years a number of studies have been conducted in specialist psychiatric and primary care populations in New Zealand which have allowed comparisons in terms of clinical phenomena and therapeutic experiences between Maori (the indigenous people of New Zealand) and non-Maori. These studies were reviewed in terms of the methodology used, their major findings and their implications. DISCUSSION: In specialist psychiatric services Maori were more likely to present with hallucinations and/or aggression and less likely to present with depression and/or episodes of self-harm. They were overly represented in those with schizophrenia. Maori were more likely to be involved in acts of aggression and to be secluded, and an equivalent episode of care for Maori appeared to be significantly more costly than for non Maori. Other studies, conducted in prison and community-based samples, suggested that Maori were less likely to access care and, when given a diagnosis of depression, less likely to be prescribed anti-depressant medication.The rates of depression were significantly higher in Maori (women) and Maori were also overly represented in those with anxiety and substance misuse disorders. These differences remained even after the sample was standardised for socio-economic status. Further exploration of the genesis and implications of these findings, derived from a strong and relatively well-defined indigenous people, may usefully inform the more general issues of culture and its significance for diagnosis, classification and service use. CONCLUSIONS: While the methodologies used and the actual results gained differed across studies, there do seem to be differences in phenomenological profiles at presentation, in the diagnostic patterns, the cost of care, and the therapeutic experiences between Maori and non-Maori New Zealanders. These differences may reflect actual differences between certain ethnic groups, which then explain the differences in the experiences of those users, or they may reflect inadequacies on the parts of non-MAori clinicians, their diagnostic tools and the services in which they operate, in catering for Maori patients.     

Gambling task performance in traumatic brain injury: relationships to injury severity, atrophy, lesion location, and cognitive and psychosocial outcome.

OBJECTIVE: To determine the sensitivity of the Gambling Test (GT) to the neurocognitive effects of traumatic brain injury (TBI) and to examine the cognitive, neural, and psychosocial correlates of impaired GT performance in patients with TBI. BACKGROUND: The GT is sensitive to behavioral deficits in patients with prefrontal brain damage, especially in ventral regions. Patients with TBI and behavioral deficits often have focal ventral prefrontal damage as well as diffuse damage. Analysis of the correlates of the GT in this population has implications for interpretation of the GT in other groups. METHOD: Seventy-one TBI patients were administered the GT, neuropsychological tests, and psychosocial outcome questionnaires. Patients also had high-resolution structural magnetic resonance imaging analyzed for both lesion location and tissue compartment volumes. RESULTS: The GT was sensitive to TBI in general, but not to TBI severity or quantified chronic phase atrophy. Marked impairment was observed in (but not limited to) patients with large frontal lesions. There were modest correlations between the GT and tests of working memory and executive functioning as well as between self- and other-rated real-life memory, executive, and emotional problems. CONCLUSIONS: The GT can be a useful adjunct to assessment of patients with TBI. Interpretation of GT performance in patients with complex neuropsychological deficits such as TBI should consider the influence of domain-general resources in addition to specific ventral prefrontal function.     

Executive functioning and the application of social skills following traumatic brain injury

Many adults with a traumatic brain injury (TBI) are less competent conversationalists following their injury. Reduced conversational competency is a clinically significant problem. It is associated with a variety of adverse psychosocial outcomes following TBI. Unfortunately, direct attempts to improve the conversational competency of adults with TBI using social skills training has had limited success. This article applies McFall's (1982) social skills model to conversational competency following TBI. This social skills model is based on two critical assumptions. First, in order to be judged socially competent, a person needs to possess the social skills required in a given social context. Second, that social competence requires the ability to apply social skills flexibly according to the rules of social interaction. It is argued that the inability to flexibly apply behaviour according to rules (executive dysfunction) could account for many characteristics of conversation following TBI. This argument is illustrated through the detailed application of Norman and Shallice's (1986) theory of executive functioning to research on conversational behaviour following TBI. It is concluded that fostering appropriate social environments, and providing support are more likely to be effective than remedial social skills training.     

Quantitative proton MRS predicts outcome after traumatic brain injury

OBJECTIVE: To determine whether proton MRS (1H-MRS) neurochemical measurements predict neuropsychological outcome of patients with traumatic brain injury (TBI). BACKGROUND: Although clinical indices and conventional imaging techniques provide critical information for TBI patient triage and acute care, none accurately predicts individual patient outcome. METHODS: The authors studied 14 patients with TBI soon after injury (45+/-21 days postinjury) and again at 6 months (172+/-43 days) and 14 age-, sex-, and education-matched control subjects. N-acetylaspartate (NAA), creatine, and choline were measured in normal-appearing occipitoparietal white and gray matter using quantitative 1H-MRS. Outcome was assessed with the Glasgow Outcome Scale (GOS) and a battery of neuropsychological tests. A composite measure of neuropsychological function was calculated from individual test z-scores probing the major functional domains commonly impaired after head trauma. RESULTS: Early NAA concentrations in gray matter predicted overall neuropsychological performance (r = 0.74, p = 0.01) and GOS (F = 11.93, p = 0.007). Other metabolite measures were not related to behavioral function at outcome. CONCLUSION: 1H-MRS provides a rapid, noninvasive tool to assess the extent of diffuse injury after head trauma, a component of injury that may be the most critical factor in evaluating resultant neuropsychological dysfunction. 1H-MRS can be added to conventional MR examinations with minimal additional time, and may prove useful in assessing injury severity, guiding patient care, and predicting patient outcome.     

Neuropsychological and Behavioral Measures of Attention Assess Different Constructs in Children With Traumatic Brain Injury

Neuropsychological and behavioral measures are used to assess attention, but little convergence has been found between these two assessment methods. However, many prior studies have not considered attention as a multicomponent system, which may contribute to this lack of agreement between neuropsychological and behavioral measures. To address this the current study examined the relationship between the neuropsychological measures that comprise a four-component model of attention and parent-report behavioral ratings of attention problems and hyperactivity. A total of 65 children and adolescents who had sustained a traumatic brain injury (TBI) were included in the study. Principal components analysis identified the four attention components in this sample, which accounted for 80.9% of the variance. However, correlations between the neuropsychological measures of attention and behavioral ratings of attention and hyperactivity were low and non-significant. This minimal correspondence suggests that neuropsychological and behavioral measures assess different aspects of attentional disturbances in children with TBI.     

Neuropsychological and behavioral measures of attention assess different constructs in children with traumatic brain injury

Neuropsychological and behavioral measures are used to assess attention, but little convergence has been found between these two assessment methods. However, many prior studies have not considered attention as a multicomponent system, which may contribute to this lack of agreement between neuropsychological and behavioral measures. To address this the current study examined the relationship between the neuropsychological measures that comprise a four-component model of attention and parent-report behavioral ratings of attention problems and hyperactivity. A total of 65 children and adolescents who had sustained a traumatic brain injury (TBI) were included in the study. Principal components analysis identified the four attention components in this sample, which accounted for 80.9% of the variance. However, correlations between the neuropsychological measures of attention and behavioral ratings of attention and hyperactivity were low and non-significant. This minimal correspondence suggests that neuropsychological and behavioral measures assess different aspects of attentional disturbances in children with TBI.     

Capacity for Delivering Culturally Competent Mental Health Services in New Mexico: Results of a Statewide Agency Survey

The Federal government has promoted National Standards for Culturally and Linguistically Appropriate Services (CLAS) to reduce mental health disparities among Hispanic and Native American populations. In 2005, the State of New Mexico embarked upon a comprehensive reform of its behavioral health system with an emphasis on improving cultural competency. Using survey methods, we examine which language access services (i.e., capacity for bilingual care, interpretation, and translated written materials) and organizational supports (i.e., training, self-assessments of cultural competency, and collection of cultural data) mental health agencies in New Mexico had at the onset of a public sector mental health reform (Office of Minority Health 2001). This work was presented at the nineteenth National Institute of Mental Health Conference on Mental Health Services, Washington, DC, July 2007. An erratum to this article can be found at     

Influence of Angiotensin-converting enzyme polymorphism on neuropsychological subacute performance in moderate and severe traumatic brain injury

Traumatic brain injury (TBI) frequently results in cerebrovascular lesions that may increase secondary damage and cause neuropsychological impairment. Previous studies suggest an association among the insertion/deletion (I/D) polymorphism of the angiotensin-converting enzyme (ACE), cardiovascular disease, and cognitive performance. Clinical and experimental studies have demonstrated the beneficial effects of ACE inhibitor treatment on vascular injury, hypertension, brain ischemia, and cognitive functioning. In a sample of 73 moderate and severe TBI patients, the authors assessed whether cognitive sequelae differed in relation to the ACE I/D polymorphism. D allele carrier patients performed worse than those with I/I polymorphism on tests involving attention and processing speed. Findings suggest that the physiopathological changes associated with TBI may have greater consequences in ACE D allele carriers.     

Attention following traumatic brain injury: Neuropsychological and driving simulator data,and association with sleep,sleepiness, and fatigue

The objectives of this study were to compare individuals with traumatic brain injury (TBI) and healthy controls on neuropsychological tests of attention and driving simulation performance, and explore their relationships with participants’ characteristics, sleep, sleepiness, and fatigue. Participants were 22 adults with moderate or severe TBI (time since injury ≥ one year) and 22 matched controls. They completed three neuropsychological tests of attention, a driving simulator task, night-time polysomnographic recordings, and subjective ratings of sleepiness and fatigue. Results showed that participants with TBI exhibited poorer performance compared to controls on measures tapping speed of information processing and sustained attention, but not on selective attention measures. On the driving simulator task, a greater variability of the vehicle lateral position was observed in the TBI group. Poorer performance on specific subsets of neuropsychological variables was associated with poorer sleep continuity in the TBI group, and with a greater increase in subjective sleepiness in both groups. No significant relationship was found between cognitive performance and fatigue. These findings add to the existing evidence that speed of information processing is still impaired several years after moderate to severe TBI. Sustained attention could also be compromised. Attention seems to be associated with sleep continuity and daytime sleepiness; this interaction needs to be explored further.