Psychiatry Research

Volume 113, Issue 3 , 30 December 2002, Pages 217-226

The association of preceding traumatic brain injury with mental disorders, alcoholism and criminality: the Northern Finland 1966 Birth Cohort Study

Markku Timonen, , a, b, Jouko Miettunena, Helinä Hakkoa, Paavo Zittingc, Juha Veijolaa, Lennart von Wendtd and Pirkko Räsänena

            The purpose of this study was to test the hypothesis that traumatic brain injury (TBI) during childhood and adolescence is associated with psychiatric disorders, heavy alcohol use and criminal offenses in adulthood. We made use of an unselected, general population birth cohort (n=12 058) in Northern Finland, which was followed up prospectively up to the age of 31. The data on TBIs of the cohort members were collected from the hospital case notes of the outpatient clinics of the hospitals in the region and from the Finnish Hospital Discharge Registers (FHDR). The data on mental disorders including alcohol diagnoses were also collected from the FHDR after a careful validation process. The Ministry of Justice provided information on criminal offenses for all subjects. The final number of subjects in our study was 5589 males and 5345 females. We found that after controlling for confounders, TBI during childhood or adolescence increased the risk of developing mental disorders two-fold (OR 2.1, 95% CI 1.1–3.6) and TBI was significantly related to later mental disorder with coexisting criminality in male cohort members (OR 4.1, 95% CI 1.2–13.6). The results support the TBI's association with psychiatric morbidity, which should not be overlooked when treating psychiatric patients, especially those with comorbid criminality.



Brain Inj. 2003 Jul;17(7):561-74.

Who knows best? Awareness of divided attention difficulty in a neurological rehabilitation setting.

Cock J, Fordham C, Cockburn J, Haggard P.

Department of Psychology, University of Reading, UK. josephine.cock@psy.unibe.ch

            OBJECTIVE: To explore whether patients relearning to walk after acquired brain injury and showing cognitive-motor interference were aware of divided attention difficulty; whether their perceptions concurred with those of treating staff. DESIGN: Patients and neurophysiotherapists (from rehabilitation and disabled wards) completed questionnaires. Factor analyses were applied to responses. Correlations between responses, clinical measures and experimental decrements were examined. RESULTS: Patient/staff responses showed some agreement; staff reported higher levels of perceived difficulty; responses conformed to two factors. One factor (staff/patients alike) reflected expectations about functional/motor status and did not correlate with decrements. The other factor (patients) correlated significantly with dual-task motor decrement, suggesting some genuine awareness of difficulty (cognitive performance prioritized over motor control). The other factor (staff) correlated significantly with cognitive decrement (gait prioritized over sustained attention). CONCLUSIONS: Despite some inaccurate estimation of susceptibility; patients and staff do exhibit awareness of divided attention difficulty, but with a limited degree of concurrence. In fact, our results suggest that patients and staff may be sensitive to different aspects of the deficit. Rather than 'Who knows best?', it is a question of 'Who knows what?'



J Head Trauma Rehabil. 2003 Mar-Apr;18(2):148-63.

Demographic, medical, and psychiatric factors in work and marital status after mild head injury.

Vanderploeg RD, Curtiss G, Duchnick JJ, Luis CA.

The James A. Haley Veterans Affairs Medical Center, Defense and Veterans Head Injury Program, Psychology Service 116B, Tampa, FL 33612, USA. Rodney.Vanderploeg@med.va.gov

            OBJECTIVE: To explore factors associated with long-term outcomes of work and marital status in individuals who had experienced a mild head injury (MHI), as well as those who had not. DESIGN: Population-based study using logistical regression analyses to investigate the impact of preinjury characteristics on work and marital status. PARTICIPANTS: Two groups of Vietnam-era Army veterans: 626 who had experienced a MHI an average of 8 years before examination, and 3,896 who had not. MAIN OUTCOME MEASURES: Demographic characteristics, concurrent medical conditions, early life psychiatric problems, loss of consciousness (LOC), and interactions among these variables were used to predict current work and marital status. RESULTS: Multiple variables were associated with work and marital status in the sample with MHI, accounting for approximately 23% and 17% of the variance in these two outcome variables, respectively. In contrast, the same factors accounted for significantly less variance in outcome in the sample without a head injury-13.3% and 9.4% for work and marital status, respectively. CONCLUSIONS: These findings suggest a more potent role for and increased vulnerability to the influence of demographic, medical, and psychiatric factors on outcomes after a MHI. That is, MHI itself moderates the influence of preinjury characteristics on work and marital status. In addition, in those who had a MHI, moderator relationships were found between education and LOC for both work and marital status. Similarly, complex moderator relationships among race, region of residence, and LOC were found for both work and marital status outcomes.


The Journal of Head Trauma Rehabilitation, March-April 2003 v18 i2 p201(3)

Traumatic brain injury: depression, neurogenesis, and medication management.

Robert B. Perna; Ann Rouselle; Patrick Brennan.

            Recent research suggests that depression and chronic stress may not only interfere with rehabilitation in the obvious ways, but also may cause further cerebral damage or slow the recovery process. Antidepressants not only effectively reduce depression, but may also protect against cell death and promote neurogenesis in that region of the brain linked to memory, a very common long-term deficit in brain injury. Reports of complications have been few, but future research needs to clarify the long term effects of antidepressants, particularly when used with individuals who sustained brain injury.



Mol Pathol. 2003 Jun;56(3):132-6.

Genetic vulnerability following traumatic brain injury: the role of apolipoprotein E.

Nathoo N, Chetty R, van Dellen JR, Barnett GH; nathoon@ccf.org



J Consult Clin Psychol. 2003 Aug;71(4):797-804.

Brain injury in battered women.

Valera EM, Berenbaum H.

Department of Psychology, University of Illinois at Urbana-Champaign, USA. eve_valera@hms.harvard.edu

The goals of the present study were to examine (a) whether battered women in a sample of both shelter and nonshelter women are sustaining brain injuries from their partners and (b) if so, whether such brain injuries are associated with partner abuse severity, cognitive functioning, or psychopathology. Ninety-nine battered women were assessed using neuropsychological, psychopathology, and abuse history measures. Almost three quarters of the sample sustained at least 1 partner-related brain injury and half sustained multiple partner-related brain injuries. Further, in a subset of women (n = 57), brain injury severity was negatively associated with measures of memory, learning, and cognitive flexibility and was positively associated with partner abuse severity, general distress, anhedonic depression, worry, anxious arousal, and posttraumatic stress disorder symptomatology.



J Athl Train. 2001 Sep;36(3):244-248.

Posttraumatic Retrograde and Anterograde Amnesia: Pathophysiology and Implications in Grading and Safe Return to Play.

Cantu RC.

Emerson Hospital, Concord, MA.

            The importance of not just PTA but all postconcussion signs and symptoms being absent at rest and exertion before allowing the athlete to return to play is emphasized.



J Athl Train. 2001 Sep;36(3):288-296.

Implementation of Neuropsychological Testing Models for the High School, Collegiate, and Professional Sport Settings.

Randolph C.

            The systematic model was designed to incorporate state-of-the-art techniques for the detection and tracking of neurocognitive deficits associated with concussion into recently formulated guidelines for the medical management of sport-related concussion. Current applications of the model are discussed, as well as ongoing studies designed to elaborate the empirical underpinnings of the model and refine clinical decision making in this area.





Volume 121, Issue 2, 315-325 (6 October 2003)

Apolipoprotein e4 decreases whereas apolipoprotein e3 increases the level of secreted amyloid precursor protein after closed head injury, 315-325

Y. Ezra, L. Oron, L. Moskovich, A. D. Roses, S. M. Beni, E. Shohami and D. M. Michaelson

SummaryPlus | Full Text + Links | PDF (466 K)

            Apolipoprotein E (apoE4) and head trauma are important genetic and environmental risk factors for Alzheimer's disease. Furthermore, apoE4 increases both the acute and chronic consequences of head trauma. The latter are associated with the deposition of amyloid-, which is particularly elevated in apoE4 subjects. The short-term effects of head injury are associated with transiently increased metabolism of amyloid precursor protein (APP) and its secreted fragment, APPs.

            In the present study, we examined the possibility that the acute, short-term pathological effects of apoE4 following head trauma and the corresponding neuroprotective effects of apoE3 are related to isoform-specific effects of apoE on APP metabolism. Accordingly, male transgenic mice expressing human apoE3 or apoE4 on a null mouse apoE background and apoE-deficient and control mice were subjected to closed head injury (CHI). The resulting effects on brain APP, and on its secreted products, APPs and secreted product of the -cleavage of APP (APPs) were then determined 24 h following injury. Immunoblotting revealed no significant differences between the basal APP, APPs and APPs levels of the hippocampus or the cortex of the control and the apoE3 and ApoE4 transgenic mice. The apoE-deficient mice also had similar cortical basal levels of APP and its metabolites, whereas their corresponding basal hippocampal APP and APPs levels were lower than those of the other groups. CHI lowered the hipppocampal APPs and APPs levels of the apoE4 transgenic mice, whereas those of the apoE3 transgenic mice and of the control and apoE-deficient mice were not affected by this insult. In contrast, CHI raised the cortical APP and APPs levels of the apoE3 transgenic mice but had no significant effect on those of the other mice groups. These animal model findings suggest that the acute, short-term pathological effects of apoE4 following CHI and the corresponding neuroprotective effects of apoE3 may be mediated by their opposing effects on the expression and cleavage of cortical and hippocampal APP. Similar isoform-specific interactions between apoE and APP may play a role in the acute, short-term effects of head trauma in humans.



Epilepsia, Volume 44 Issue s10 Page 2  - October 2003

The Epidemiology of Traumatic Brain Injury: A Review

John Bruns, Jr., and W. Allen Hauser; wahauser@optonline.net

            Summary: Purpose: Traumatic brain injury (TBI) not only has considerable morbidity and mortality, but it is a major cause of epilepsy. We wish to determine the frequency of TBI, special groups at risk for TBI, and mortality from TBI.



Clin Exp Neuropsychol. 2003 Oct;25(7):904-17.

Subtypes of emotional and behavioural sequelae in patients with traumatic brain injury.

Warriner E, Rourke B, Velikonja D, Metham L.

            This study examined patterns of emotional and behavioural sequelae in 300 individuals who sustained a traumatic brain injury (TBI). Participants were obtained through the Adult Acquired Brain Injury Program at Chedoke Hospital in Hamilton, Ontario, based on the following inclusionary criteria: (1) single incident of TBI; (2) no history of additional neurological diseases; (3) time postinjury </=8.5 years; (4) WAIS-R FSIQ >85 and/or estimated reading skills above grade 5 level; and (5) valid Minnesota Multiphasic Personality Inventory (MMPI) profiles (i.e., F<90, L<66, and K<66). MMPI profiles of these individuals, in randomly split samples of 150 per group, were subjected to a three-step cluster analytic approach. A six-cluster solution was adequately replicated across samples and across clustering techniques. The identified subtypes included profiles indicative of: (1) no concerns or normal functioning; (2) mild somatic and pain concerns; (3) mild internalizing difficulties; (4) marked disinhibition and externalizing behavioural difficulties; (5) marked internalizing difficulties; and (6) marked somatic, internalizing, and externalizing behavioural disturbances. Members of the Externalized subtype were significantly younger in age than those in the other five subtypes, and more likely to be single than those in the Internalized subtype. Individuals in the Internalized subtype tended to be married, have longer times postaccident, and lower WAIS-R Verbal Intelligence Quotients than those comprising the Normal subtype.



Inj Prev. 2003 Sep;9(3):257-260.

Effect of Italy's motorcycle helmet law on traumatic brain injuries.

Servadei F, Begliomini C, Gardini E, Giustini M, Taggi F, Kraus J.

            OBJECTIVES: To evaluate the impact of a revised Italian motorcycle-moped-scooter helmet law on crash brain injuries. DESIGN: A pre-post law evaluation of helmet use and traumatic brain injury (TBI) occurrence from 1999 to 2001. SETTING: Romagna region, northeastern Italy, with a 2000 resident population of 983 534 persons. PARTICIPANTS: Motorcycle-moped rider survey for helmet use compliance and all residents in the region admitted to the Division of Neurosurgery of the Maurizio Bufalini Hospital in Cesena, Italy for TBI. OUTCOME MEASURES: Helmet use compliance and change in TBI admissions and type(s) of brain lesions. RESULTS: Helmet use increased from an average of less than 20% to over 96%. A comparison of TBI incidence in the Romagna region shows that there was no significant variation before and after introduction of the revised helmet law, except for TBI admissions for motorcycle-moped crashes where a 66% decrease was observed. In the same area TBI admissions by age group showed that motorcycle mopeds riders aged 14-60 years sustained significantly fewer TBIs. The rate of TBI admissions to neurosurgery decreased by over 31% and epidural hematomas almost completely disappeared in crash injured moped riders. CONCLUSIONS: The revised Italian mandatory helmet law, with police enforcement, is an effective measure for TBI prevention at all ages.



J Neurol Neurosurg Psychiatry. 2003 Aug;74(8):1047-52.

Long term neuropsychological outcome after head injury: relation to APOE genotype.

Millar K, Nicoll JA, Thornhill S, Murray GD, Teasdale GM.

            BACKGROUND: Existing evidence suggests that some patients who sustain a head injury suffer cognitive decline many years later, and that head injury and possession of the APOE epsilon 4 allele are each risk factors for Alzheimer's disease. OBJECTIVE: To determine whether late cognitive decline after head injury is more prevalent among carriers of APOE epsilon 4. METHODS: A database of head injured patients was used. Initial assessment was at the time of their injury, between 1968 and 1985, and outcome data at six months were available. Their ages at the time of injury ranged between 2 and 70 years. A cohort of 396 subjects was reassessed at a mean of 18 years later, with determination of APOE genotype and detailed neuropsychological testing. RESULTS: Judging by the Glasgow outcome scale, twice as many patients had deteriorated as improved between six months after injury and the late assessment; 22.2% of APOE epsilon 4 carriers had a good late outcome compared with 30.5% of non-carriers (95% confidence interval for the difference, -0.7% to 17.2%; p = 0.084). There were no clear differences between epsilon 4 carriers and non-carriers in detailed neuropsychological assessments. CONCLUSIONS: Although this study provides additional evidence that a late decline may occur after head injury, there was no clear relation to APOE genotype. Despite the follow up interval of 15 to 25 years, the cohort is still too young (mean age 42.1 years) to assess the risk of Alzheimer's disease.



Psychiatry Research: Neuroimaging

Volume 124, Issue 3 , 30 November 2003, Pages 141-152

Cerebral blood flow in chronic symptomatic mild traumatic brain injury

Omer Bonne, Asaf Gilboa, Yoram Louzoun, Orli Kempf-Sherf, Maor Katz, Yeri Fishman, Zila Ben-Nahum, Yodphat Krausz, Moshe Bocher, Hava Lester, Roland Chisin and Bernard Lerer

            Patients with mild traumatic brain injury (MTBI) (Journal of Head Trauma and Rehabilitation, 8, 1993, 83–84) challenge physicians' skills and test their patience. Their manifold symptomatology is often not supported by objective neurological findings. We sought to compare regional cerebral blood flow (rCBF) between symptomatic subjects with longstanding MTBI and healthy controls, and to examine the correspondence between neuropsychological deficit and rCBF compromise. Twenty-eight clinically symptomatic male subjects with MTBI and twenty matched controls underwent neuropsychological testing and Tc-99m-HMPAO brain SPECT imaging. Neuropsychological test data were used to categorize subjects into sub-groups according to the presumed location of lesions based on their neurobehavioral deficits. Image subtraction comparisons were made between controls, all MTBI subjects and sub-groups. MTBI patients demonstrated regions of hypoperfusion in frontal, pre-frontal and temporal cortices, and sub-cortical structures. Hypoperfusion in `frontal', `left posterior' and to a lesser extent `sub-cortical' sub-groups was concordant with neuropsychological localization. This was not the case for the `right posterior' group, where no concordance was found. The rCBF is reduced in symptomatic patients with longstanding MTBI and unremarkable structural brain imaging. Although group analysis is appropriate for the generation of statistically significant differences, the clinical application of brain SPECT imaging in MTBI calls for a capability to associate clinical examination, neuropsychological assessment and cerebral perfusion at the individual subject level. Such competence is still to be attained.



Neuroscience Letters , Article in Press

Stimulus complexity enhances auditory discrimination in patients with extremely severe brain injuries

B. Kotchoubey, S. Lang, E. Herb, P. Maurer, D. Schmalohr, V. Bostanova and N. Birbaumera

    There is controversy as to what extent the processing of spectrally rich sounds in the human auditory cortex is related to the processing of singular frequencies. An informative index of the function of the auditory cortex, particularly important in neurological patients, is the mismatch negativity (MMN), a component of auditory event-related potentials. In the present study the MMN was recorded in 79 patients with extremely severe diffuse brain injuries, most of them in persistent vegetative state or minimal consciousness state. Both sinusoidal (`pure') and complex musical tones were used. Different statistical approaches converged in that musical tones elicited an MMN significantly more frequently, and of a larger amplitude, than simple sine tones. This implies that using simple stimuli in clinical populations may lead to a severe underestimation of the functional state of a patient's auditory system. The findings are also in line with behavioral and physiological data indicating independent processing of complex sounds in the auditory cortex.



Kortte, Kathleen Bechtold 1,2,3; Wegener, Stephen T. 2; Chwalisz, Kathleen 1

Anosognosia and Denial: Their Relationship to Coping and Depression in Acquired Brain Injury.

Rehabilitation Psychology. 48(3):131-136, August 2003.

            Objective: To evaluate relations among denial, anosognosia, coping strategies, and depression in persons with brain injury.  Study Design: Correlational.  Setting: A Midwest residential, post-acute brain injury rehabilitation center.  Participants: Twenty-seven adults with brain injury. Measures: Clinician's Rating Scale for Evaluating Impaired Self-Awareness and Denial of  Disability After Brain Injury, COPE, Beck Depression Inventory-II.  Results: Denial and anosognosia were related and co-occurred. Use of process coping strategies was associated with greater use of problem-focused coping strategies. Higher levels of denial were associated with greater use of avoidant coping strategies, and greater use of these coping strategies was related to higher levels of depression.  Conclusions: Individuals primarily in denial and individuals primarily anosognosic differ in the coping strategies they institute. Avoidant coping strategies are used more frequently by individuals in denial, and use of these strategies is associated with higher levels of clinical depression



The British Journal of Psychiatry (2003) 183: 276-278

EDITORIAL: Post-concussion syndrome: clarity amid the controversy?


            Post-concussion syndrome has presented clinicians with controversy and intrigue for at least 130 years. Its symptoms, which often follow uncomplicated mild head injury (post-traumatic amnesia <1h, Glasgow Coma Scale score 13–15, loss of consciousness <15 min) and moderate head injury (post-traumatic amnesia 1–24 h, Glasgow Coma Scale score 9–12, loss of consciousness 15 min to 6 h), commonly include headache, dizziness, fatigue, poor memory, poor concentration, irritability, depression, sleep disturbance, frustration, restlessness, sensitivity to noise, blurred vision, double vision, photophobia, nausea and tinnitus (King, 1997). Debate and argument have always plagued this syndrome, but research over the past decade or so has helped to clarify some of the areas of dispute and some interventions have been developed and evaluated. What follows is an attempt to illuminate the syndrome in the light of these developments.



Bruce, Jared M., Echemendia, Ruben J.

Delayed-Onset Deficits in Verbal Encoding Strategies Among Patients With Mild Traumatic Brain Injury.

Neuropsychology. 17(4):622-629, October 2003.

            Knowledge obtained from longitudinal animal models was used to predict the course of verbal memory deficits in 19 concussed patients and 19 control patients who were given versions of the Hopkins Verbal Learning Test-Revised at 2 hr, 48 hr, and 1 week postconcussion. The physiological literature suggests that concussed patients should exhibit a decline in performance from 2 hr to 48 hr postconcussion on a measure of complex memory strategies. Consistent with this hypothesis, mixed-factor analysis of covariance revealed that concussed patients used less semantic clustering strategies than control patients at 48 hr postconcussion, whereas minimal differences were found at 2 hr postinjury. Furthermore, a chi-square analysis showed that a significant number of concussed patients experienced a decline in the number of semantic clusters they used from 2 hr to 48 hr. No differences were found between the groups at the 1-week testing session.



How robust is performance on the National Adult Reading Test following traumatic brain injury?

Gerard A. Riley ; Lincoln V. Simmonds

British Journal of Clinical Psychology      Volume: 42 Part: 3 Page: 319 -- 328

            Objective. To investigate whether National Adult Reading Test (NART) performance may be impaired by severe traumatic brain injury (TBI).  Method. A sample of 26 people who had been given a NART within 12 months of a severe TBI was given a second NART at least 12 months after the first NART.  Results. Mean performance on the second NART was significantly better than performance on the first NART. Of the participants, 11 (42%) showed an improvement of more than 5 IQ points in respect of the verbal IQ estimates based on their NART scores, with three participants showing an improvement of 20 points. In applying the NART to determine the presence of an acquired intellectual impairment, use of the first NART scores alone would have resulted in such impairments being missed in at least 25% of a subsample of 16 participants for whom an actual verbal IQ had been obtained at the time of the first NART.  Conclusion. An NART given within 12 months of a severe TBI runs the risk of significantly underestimating pre-morbid IQ. If applied in this context, it is recommended that the NART score is used in conjunction with other methods of estimation, such as those based on demographic data.


Neuropsychologia, Article in Press

Deficits in facial emotion perception in adults with recent traumatic brain injury

Robin E. A. Green, , a, b, Gary R. Turnerb and William F. Thompsonb

            We examined whether facial emotion perception was compromised in adults with recent traumatic brain injury (TBI). Few studies have examined emotion perception in TBI; those that have, examined chronic patients only. Recent and chronic TBI populations differ according to degree of functional reorganization of the brain, use of compensatory strategies, and severity of cognitive impairments––any of which might differentially affect presentation of emotion perception deficits. A secondary aim of the study was to utilize the TBI population––in whom diffuse axonal injury (DAI) is a cardinal neurological feature––to examine the suggestion of Adolphs et al. [Journal of Neuroscience 20(7) (2000) 2683] suggestion that damage to white matter tracts should give rise to emotion perception deficits. Methods: Thirty TBI participants and 30 age-matched controls were tested. A 2×3 mixed design was employed. The dependent variable was accuracy on neutral and emotional face perception tests. Results: (1) The TBI group performed significantly less accurately than the matched controls on the facial emotion perception tasks, whereas the groups performed equivalently on a non-emotional face perception control task. (2) A sub-group of TBI participants without evidence of focal injury to areas of the brain most commonly implicated in facial emotion perception was as impaired on the emotion perception tasks as a second sub-group who had sustained focal lesions to these areas. This suggests an alternative neurological mechanism for deficits in the first sub-group, such as DAI. Conclusions: Patients with recently acquired TBI are impaired in their ability to perceive emotions in faces. DAI alone may cause can give rise to facial emotion perception deficits.



Archives of Clinical Neuropsychology, Article in Press

Cognitive factors in Postconcussion Syndrome symptom report

John Gunstad and Julie A. Suhr 

            Past studies suggest a variety of factors that influence the report of Postconcussion Syndrome (PCS) symptoms, including head injury, depression, pain, and subjective expectation. Participants included 190 undergraduates across 8 groups chosen to examine the relative contribution of these factors, as well as treatment-seeking behavior, in the report of both current and past PCS symptoms. Depressed persons, depressed persons receiving treatment, and headache sufferers receiving treatment reported elevated rates of PCS symptoms when compared to controls. Five of the eight groups reported experiencing more current than past symptoms. Head-injured persons and headache sufferers underestimated premorbid symptom rates relative to the baseline of controls. These findings are consistent with the growing number of studies that suggest non-neurologic factors may be more closely related to PCS symptom report than head injury status and raise further concern regarding use of self-reported PCS symptoms in the diagnosis of head injury.



Archives of Clinical Neuropsychology, In Press

Validation of the Meyers Short Battery on mild TBI patients

John E. Meyers, and Martin L. Rohling

            This manuscript reports the results of two studies focusing on patients with mild Traumatic Brain Injury (TBI). The first assesses the validity of the Meyers Short Battery (MSB) of neuropsychological tests. The second study reports on the reliability of the MSB. The groups consisted of normal controls, depressed, chronic pain patients, and patients with mild TBI. Validity was assessed using a discriminant function analysis comparing the non-TBI participants with the TBI participants, which showed a 96.1% correct classification rate. When patients were assessed at least 6 months post-injury and re-assessment 12–14 months later, an overall reliability of r=.86 was obtained. This indicates that the MSB has adequate psychometric properties for clinical use. The results are consistent with previous published research indicating that the MSB is sensitive not only to the presence of mild TBI but also to the degree of cognitive impairment based on loss of consciousness.

(Note: only 4% (7/160 total subjects (all noncompensation seekers) were excluded for flunking >=2 validity tests.


Major Depression Following Traumatic Brain Injury

Ricardo E. Jorge, MD; Robert G. Robinson, MD; David Moser, PhD; Amane Tateno, MD; Benedicto Crespo-Facorro, MD; Stephan Arndt, PhD

Arch Gen Psychiatry. 2004;61(1):42-50.

            Backgroud  Major depression is a frequent psychiatric complication among patients with traumatic brain injury (TBI). To our knowledge, however, the clinical correlates of major depression have not been extensively studied.  Objective  To determine the clinical, neuropsychological, and structural neuroimaging correlates of major depression occurring after TBI.  Design  Prospective, case-controlled, surveillance study conducted during the first year after the traumatic episode occurred.  Settings  University hospital level I trauma center and a specialized rehabilitation unit.  Methods  The study group consisted of 91 patients with TBI. In addition, 27 patients with multiple traumas but without evidence of central nervous system injury constituted the control group. The patients' conditions were evaluated at baseline and at 3, 6, and 12 months after the traumatic episode. Psychiatric diagnosis was made using a structured clinical interview and DSM-IV criteria. Neuropsychological testing and quantitative magnetic resonance imaging were performed at the 3-month follow-up visit.  Results  Major depressive disorder was observed in 30 (33%) of 91 patients during the first year after sustaining a TBI. Major depressive disorder was significantly more frequent among patients with TBI than among the controls. Patients with TBI who had major depression were more likely to have a personal history of mood and anxiety disorders than patients who did not have major depression. Patients with major depression exhibited comorbid anxiety (76.7%) and aggressive behavior (56.7%). Patients with major depression had significantly greater impairment in executive functions than their nondepressed counterparts. Major depression was also associated with poorer social functioning at the 6-and 12-month follow-up, as well as significantly reduced left prefrontal gray matter volumes, particularly in the ventrolateral and dorsolateral regions. Conclusions  Major depression is a frequent complication of TBI that hinders a patient's recovery. It is associated with executive dysfunction, negative affect, and prominent anxiety symptoms. The neuropathological changes produced by TBI may lead to deactivation of lateral and dorsal prefrontal cortices and increased activation of ventral limbic and paralimbic structures including the amygdala.




Psychiatric Illness Following Traumatic Brain Injury in an Adult Health Maintenance Organization Population

Jesse R. Fann, MD, MPH; Bart Burington, MS; Alexandra Leonetti, MS; Kenneth Jaffe, MD; Wayne J. Katon, MD; Robert S. Thompson, MD

Arch Gen Psychiatry. 2004;61:53-61.

            Background  Psychiatric illness after traumatic brain injury (TBI) has been shown to be prevalent in hospitalized and tertiary care patient populations.  Objective  To determine the risk of psychiatric illness after TBI in an adult health maintenance organization population.  Design  Prospective cohort study.  Setting  Large staff-model health maintenance organization.  Participants  Nine hundred thirty-nine health plan members diagnosed as having TBI in 1993 and enrolled in the prior year, during which no TBI was ascertained. Three health plan members per TBI-exposed subject were randomly selected as unexposed comparisons, matched for age, sex, and reference date.  Main Outcome Measure  Psychiatric illness in the 3 years after the TBI reference date, determined using computerized records of psychiatric diagnoses according to the International Classification of Diseases, Ninth Revision, Clinical Modification, prescriptions, and service utilization.  Results  Prevalence of any psychiatric illness in the first year was 49% following moderate to severe TBI, 34% following mild TBI, and 18% in the comparison group. Among subjects without psychiatric illness in the prior year, the adjusted relative risk for any psychiatric illness in the 6 months following moderate to severe TBI was 4.0 (95% confidence interval [CI], 2.4-6.8) and following mild TBI was 2.8 (95% CI, 2.1-3.7; P<.001) compared with those without TBI. Among subjects with prior psychiatric illness, the adjusted relative risk for any psychiatric illness in the 6 months following moderate to severe TBI was 2.1 (95% CI, 1.3-3.3) and following mild TBI was 1.6 (95% CI, 1.2-2.0; P = .005). Prior psychiatric illness significantly modified the relationship between TBI and subsequent psychiatric illness (P = .04) and was a significant predictor (P<.001). Persons with mild TBI and prior psychiatric illness had evidence of persisting psychiatric illness.  Conclusions  Both moderate to severe and mild TBI are associated with an increased risk of subsequent psychiatric illness. Whereas moderate to severe TBI is associated with a higher initial risk, mild TBI may be associated with persistent psychiatric illness.




Journal of Clinical and Experimental Neuropsychology

2003, Vol.25, No.8, pp. 1090-1101

Social Support Moderates Caregiver Life Satisfaction Following Traumatic Brain Injury

Tanya C. Ergh, Robin A. Hanks, Lisa J. Rapport and Renee D. Coleman

            Social support is an important determinant of adjustment following traumatic brain injury (TBI) sustained by a family member. The present study examined the extent to which social support moderates the influence of characteristics of the person with injury on caregiver subjective well-being. Sixty pairs of individuals who had sustained a moderate to severe TBI and their caregivers (N=120) participated. Years postinjury ranged from 0.3 to 9.9 (M=4.8, SD=2.6). Cognitive, functional, and neurobehavioral functioning of participants with TBI were assessed using neuropsychological tests and rating scales. Caregiver life satisfaction and perceived social support were assessed using self-report questionnaires. Results indicated that time since injury was unrelated to life satisfaction. Neurobehavioral disturbances showed an inverse relation with life satisfaction. Social support emerged as an important moderator of life satisfaction. Only among caregivers with low social support was cognitive dysfunction adversely related to life satisfaction. Similarly, a trend suggested that patient unawareness of deficit was associated with caregiver life dissatisfaction only among caregivers with low social support. In contrast, these characteristics were unrelated to life satisfaction among caregivers with adequate social support.



Am J Phys Med Rehabil. 2004 Jan;83(1):22-6.

Effect of co-morbid traumatic brain injury on functional outcome of persons with spinal cord injuries.

Macciocchi SN, Bowman B, Coker J, Apple D, Leslie D.

    OBJECTIVE: This study was undertaken to determine if persons who sustain a spinal cord injury (SCI) and co-morbid brain injury (dual diagnosis [DDS]) evidence smaller functional gains and experience significantly longer rehabilitation lengths of stay than persons with only an SCI. DESIGN: This retrospective comparison study was performed at a 100-bed rehabilitation hospital specializing in acute SCI and traumatic brain injury rehabilitation. Summary scale outcome data of persons who sustained an SCI were compared with outcome data of a group of persons with a DDS. Comparisons were established by matching groups principally on level of SCI and admission Motor FIM trade mark score and secondarily on education, sex, and age. Outcome measures included admission Motor and Cognitive FIM score, discharge Motor and Cognitive FIM score, Motor and Cognitive FIM change, length of stay, and rehabilitation charges. RESULTS: Persons with a DDS evidenced a significantly more impaired Cognitive FIM score at admission and discharge from rehabilitation. Persons with a DDS also achieved a significantly lower Motor FIM change than persons with SCI. There were no significant differences between DDS and SCI groups regarding Cognitive FIM change, length of stay, or rehabilitation charges. Injury severity as defined by the Glasgow Coma Scale or intracranial lesions did not predict response to treatment in the DDS group. CONCLUSION: Persons with a DDS achieved smaller functional gains during rehabilitation than peers with SCI. Brain injuries seem to limit functional gains, although the relationship between brain injury severity and functional change is not linear. Prospective studies are needed to identify factors limiting functional gains in rehabilitation and assist in developing specific treatment programs for persons with SCI and brain injury.





Retrieval Inhibition in Directed Forgetting FollowingSevere Closed-Head Injury

Maureen Schmitter-Edgecombe, William Marks, Matthew J. Wright, Matthew Ventura

Neuropsychology, 2004, Vol. 18, No. 1, 104–114, ©2004 American Psychological Association

            A variant of the list method directed forgetting procedure was used to examine the role of inhibition in memory performance following severe closed-head injury (CHI). Twenty-four participants with severe CHI and 24 controls studied picture and word stimuli in both forget and remember conditions. Memory testing for the to-be-forgotten and to-be-remembered items consisted of a free-recall test followed by a source-monitoring task. Despite poorer recall performance, the participants with CHI exhibited a directed forgetting effect similar to that in controls. Item recognition scores indicated that the inhibited items were not forgotten but rather were items whose accessibility had been lowered. These findings suggest that residual memory deficits in patients with severe CHI are unlikely to reflect inefficient retrieval inhibition.




Archives of Clinical Neuropsychology, in press (2004)

The construct of problem solving in higher level neuropsychological assessment and rehabilitation

Joseph F. Rath, Donna M. Langenbahn, Dvorah Simon, Rose Lynn Sherr, Jason Fletcher and Leonard Diller

            Three inter-related studies examine the construct of problem solving as it relates to the assessment of deficits in higher level outpatients with traumatic brain injury (TBI). Sixty-one persons with TBI and 58 uninjured participants completed measures of problem solving and conceptually related constructs, which included neuropsychological tests, self-report inventories, and roleplayed scenarios. In Study I, TBI and control groups performed with no significant differences on measures of memory, reasoning, and executive function, but medium to large between-group differences were found on timed attention tasks. The largest between-group differences were found on psychosocial and problem-solving self-report inventories. In Study II, significant-other (SO) ratings of patient functioning were consistent with patient self-report, and for both self-report and SO ratings of patient problem solving, there was a theoretically meaningful pattern of correlations with timed attention tasks. In Study III, a combination of self-report inventories that accurately distinguished between participants with and without TBI, even when cognitive tests scores were in the normal range, was determined. The findings reflect intrinsic differences in measurement approaches to the construct of problem solving and suggest the importance of using a multidimensional approach to assessment.



Archives of Clinical Neuropsychology, in press (2004)

A longitudinal, controlled study of patient complaints following treated mild traumatic brain injury

Shauna Kashluba, Chris Paniak, Treena Blake, Shawn Reynolds, Geraldine Toller-Lobe and Julianna Nagy

            This study provided 3-month follow-up data to a previous paper that compared symptom complaints of patients with mild traumatic brain injury (MTBI) with those of non-injured control participants within 1 month of injury. The 110 MTBI patients and 118 control participants were group-matched on age, gender, education level, and socioeconomic status. As a group, MTBI patients no longer endorsed significantly more symptoms (M=14.09, S.D.=10.77) than did the control group (M=12.56, S.D.=8.46, P=.232). Only 3 of the 43 queried symptoms were endorsed by significantly more (Bonferroni-corrected P<.00116) MTBI patients than controls. Using the same Bonferroni-corrected criteria, 10 of the 43 symptoms were endorsed at a significantly higher severity level by MTBI patients. Overall, the treated MTBI group's symptom complaints diminished from baseline to 3 months post-injury, with relatively few differences remaining between the two groups.