The place of inner language in feeling: a commentary on “Revisiting the Left Convexity Hypothesis: Changes in the Mental Apparatus after Left Dorso-medial Prefrontal Damage” by Salas & Yuen

This paper provides a commentary on Salas and Yuen (this issue) who propose a revision to the ‘left convexity hypothesis’ of Kaplan-Solms and Solms, that there is no evidence for involvement of left hemisphere regions in the mental apparatus. Salas and Yuen provide a theoretical review and detailed clinical description that forms the basis for their argument that left dorso-medial frontal regions may be involved in ego regulation of emotion. In this commentary, the theoretical basis for Salas and Yuen’s argument is considered in light of cognitive and affective neuroscience models of emotion regulation. Whilst this commentary is supportive of Salas’ and Yuen’s position, the models discussed distinguish different roles of inner language associated with labeling and reappraisal, or with distancing or shifting of inner perspective. However this clinical, theoretical and empirical extension of Salas and Yuen’s position raises further questions regarding the role and nature of inner language with regard to the experience and regulation of emotion

Exploring domains of ‘frontal dysfunction’ relevant to everyday life following acquired brain injury.

Damage to the frontal areas of the brain is associated with alterations in cognitive, social, and emotional regulation abilities. These neuropsychological consequences present challenges to ecologically valid assessment (difficulties in everyday life being poorly predicted by traditional neuropsychological test performance) and far transfer of rehabilitation gains to everyday life. In this thesis, the literature on ‘cold’ and ‘hot’ cognitive, social and emotional frontal functions is discussed in relation to these challenges. Gaps in the research are identified relating to 1. Associations between specific ‘hot’ and ‘cold’ cognitive processes, 2. Association of ‘hot’ and ‘cold’ cognitive processes with everyday outcomes. Four studies are presented each addressing a different aspect of these gaps: ‘cold’ executive and ‘hot’ emotion regulation abilities and peer relationships following paediatric acquired brain injury (ABI); patterns and predictors of performance of people with traumatic brain injury (TBI) on a modified gamble task compared with healthy controls; interaction between coping style and specific executive functions in association with emotional outcomes after ABI; and the effect of brief goal management training (GMT) and periodic alerts on achievement of everyday intentions following ABI. Results indicate variation in the extent to which ‘hot’ and ‘cold’ frontal functions are associated with each other and everyday outcomes. A ‘frontal-contextual system’ model in which performance characteristics arise from the dynamic interaction between ‘hot’ and ‘cold’ frontal systems and everyday practical and social contexts is presented as a way of understanding everyday difficulties. Application of novel methodologies that can sample the interactions between system components and are sensitive to inter-individual variability may be useful for advancing understanding of the links between frontal dysfunction and everyday life. Implications for intervention that are similarly focused on the interactions between components and facilitation of social or physiological conditions that give rise to optimal adaptation in everyday life are discussed

What do kids with Acquired Brain Injury want? Mapping neuropsychological rehabilitation goals to the International Classification of Functioning, Disability and Health

Objective: To increase understanding of the community neuropsychological rehabilitation goals of young people with acquired brain injuries (ABIs). Method: Three hundred twenty-six neuropsychological rehabilitation goals were extracted from the clinical records of 98 young people with ABIs. The participants were 59% male, 2-19 years old, and 64% had a traumatic brain injury. Goals were coded using the International Classification of Functioning, Disability and Health: Children and Youth Version (ICF-CY). Descriptive statistical analysis was performed to assess the distribution of goals across the ICF-CY. Chi-squared and Cramer's V were used to identify demographic and injury-related associations of goal type. Results: The distribution of goals was 52% activities and participation (AP), 28% body functions (BF), 20% environmental factors (EF), and <1% body structures (BS). The number of EF goals increased with age at assessment (V =.14). Non-traumatic causes of ABIs were associated with more EF goals (V =.12). There was no association between sex or time post-injury and the distribution of goals across the ICF-CY. Conclusions: Young people with ABIs have a wide range of community neuropsychological rehabilitation goals that require an individualized, context-sensitive, and interdisciplinary approach. Community neuropsychological rehabilitation services may wish to ensure they are resourced to focus intervention on AP, with increasing consideration for EF as a young person progresses through adolescence. The findings of this research support models of community neuropsychological rehabilitation that enable wellness by combining direct rehabilitative interventions with attention to social context and systemic working across agencies

The nature of self-esteem and its relationship to anxiety and depression in adult acquired brain injury

Acquired brain injury (ABI) has a negative impact on self-esteem, which is in turn associated with mood disorders, maladaptive coping and reduced community participation. The aim of the current research was to explore self-esteem as a multi-dimensional construct and identify which factors are associated with symptoms of anxiety or depression. Eighty adults with ABI aged 17–56 years completed the Robson Self-Esteem Scale (RSES), of whom 65 also completed the Hospital Anxiety and Depression Scale; 57.5% of the sample had clinically low self-esteem. The RSES had good internal consistency (α = .89), and factor analysis identified four factors, which differed from those found previously in other populations. Multiple regression analysis revealed anxiety was differentially predicted by “Self-Worth” and “Self-Efficacy”, R2 = .44, F(4, 58) = 9, p < .001, and depression by “Self-Regard”, R2 = .38, F(4, 58) = 9, p < .001. A fourth factor, “Confidence”, did not predict depression or anxiety. In conclusion, the RSES is a reliable measure of self-esteem after ABI. Self-esteem after ABI is multidimensional and differs in structure from self-esteem in the general population. A multidimensional model of self-esteem may be helpful in development of transdiagnostic cognitive behavioural accounts of adjustment

Measuring coping style following acquired brain injury: a modification of the Coping Inventory for Stressful Situations Using Rasch analysis.

OBJECTIVE: The importance of coping style factors in the process of emotional adjustment following acquired brain injury (ABI) has been gaining increased attention. To assess ways of coping with distress accurately, clear conceptual definitions and measurement precision is vital. The purpose of this study was to investigate the psychometric properties of a well-known measure of coping, the Coping Inventory for Stressful Situations (CISS), for people who have experienced an ABI; and to modify the CISS, where necessary, to create a more reliable and valid measurement tool for this clinical group. METHODS: Psychometric properties were investigated using Rasch analysis of responses from a sample of adults with ABI (n = 207). The internal consistency reliability and construct validity of the scale were examined. RESULTS: All originally proposed subscales were not valid or reliable and, as such, were incapable of interval-level measurement within this sample - Task: χ(2) (32, N = 207) = 105.1, p < .001; Emotion: χ(2) (32, N = 204) = 121.9, p < .001; Avoidance: χ(2) (32, N = 207) = 66.7, p < .001. Three valid and reliable subscales were derived measuring emotion-, task-, and avoidance-oriented coping styles by removing items that provided the most unreliable information and exploring fit to the Rasch model. CONCLUSIONS: The original version of the CISS may not be a valid and reliable measure of coping style following ABI. Modified subscales of the three distinct coping domains have been proposed that would help to improve measurement of coping style following ABI in future research and clinical practice. PRACTITIONER POINTS: How people cope with difficulties following an ABI has been shown to impact upon emotional outcomes and functional recovery. The original version of the CISS was found to be an imprecise measure of coping following ABI. A modified version of the CISS was found to be a valid and reliable measure of three styles of coping (task-focused, emotion-focused, and avoidance-focused) that conforms to the properties of interval-level measurement as represented by the Rasch model. This structure is in keeping with previous theoretical models of coping. We advise caution about including items (1, 6, 7, 22, 24, 28, 29, 33, 34, and 46) that were found to diverge from the expectations of the Rasch measurement model in total subscale scores for measuring change in coping style. A conversion table for the three modified subscales is included in this paper to convert total raw scores into Rasch transformed logit values. Identifying strengths and weaknesses in coping style could be a means of guiding psychological intervention to promote good recovery following ABI. The sample included mainly people who had experienced non-traumatic brain injuries (e.g., a stroke). This research could be extended to include broader sample of people with differing brain injury aetiologies and neurological disorders.This is the author accepted manuscript. The final version is available from Wiley via http://dx.doi.org/10.1111/bjc.1207

Post-stroke emotionalism (PSE): A qualitative longitudinal study exploring individuals experience with PSE

Background: Post-stroke emotionalism (PSE) is a common emotional consequence of stroke characterised by episodes of crying or laughing. There is only one published qualitative study exploring the experience of emotionalism to date. Objectives: To explore individuals experience of PSE, describe how experience of living with PSE may change over time and develop a theoretical client-derived framework to shape future psychological interventions. Method: A qualitative secondary analysis of pseudonymised pre-collected semi-structured interview data was completed. Participants were recruited from nine acute stroke units in Scotland. Interviews were completed at two-weeks, six-months and 12-months post-stroke. Results: Data was analysed from 52 participants at two-weeks, 25 participants at six-months and 23 participants at 12-months. Three major themes were identified: ‘In the moment’, describing characteristics and triggers, ‘Ways of coping’, highlighted a variation of coping strategies including avoidance or acceptance and ‘Impact’, outlining the longer-term effects of PSE such as individuals’ beliefs. Analysis of changes over time highlighted increases in participants reporting of barriers to control, aspects of avoidance and wishing to hide emotional responses. Conclusion: The results indicate specific psychological aspects of PSE which could be viable targets in psychological interventions such as increasing adaptive coping strategies and challenging negatively held beliefs

'Putting a new perspective on life': A qualitative grounded theory of posttraumatic growth following acquired brain injury

Purpose: An acquired brain injury (ABI) is often described as a devastating experience and yet positive changes as a result of this event have been described. This study sought to understand the process of developing posttraumatic growth (PTG) following ABI.  Method: Semi-structured interviews were conducted with 10 adults with ABI, recruited from three sites of a community day service for people with ABI. Grounded theory was used to explore the development of positive changes experienced as a result of the injury.  Results: PTG appeared to occur in a non-linear way as participants negotiated processes captured in the following themes: “living with a life changing injury,” “trying to beat it and acceptance,” “identifying with a new you and others,” and “meaningful positive change.” Intra- and inter-personal comparisons emerged as important in accepting changes and reconnecting with pre-injury identity. This seemed to underpin accessing social and practical opportunities giving rise to connection with strengths and growth.  Conclusions: This study extends prior research into the process of adjustment and positive outcomes such as growth, although conclusions are limited to this specific sample and context. Further research and clinical practice development addressing acceptance and community engagement to develop positive change following ABI is required. Implications for rehabilitation: Experience of PTG develops over time and influenced by intra-and-inter-personal processes. Acceptance and shared experiences with others may contribute to positive psychological change. Interventions supporting pre-and-post injury comparisons with others could help acceptance. The focus on the management and expression of emotions associated with loss may be beneficial

The Bangor Gambling Task: Characterising the performance of survivors of traumatic brain injury

The Bangor Gambling Task (BGT, Bowman & Turnbull, 2004) is a simple test of emotion-based decision-making, with contingencies varying across five blocks of 20 trials. This is the first study to characterise BGT performance in survivors of traumatic brain injury (TBI) relative to healthy controls. The study also aimed to explore sub-groups (cluster analysis), and identify predictors of task performance (multiple regression). Thirty survivors of TBI and 39 controls completed the BGT and measures of premorbid IQ, working memory, and executive function. Results showed that survivors of TBI made more gamble choices than controls (total BGT score), although the groups did not significantly differ when using a cut-off score for ‘impaired’ performance. Unexpectedly, the groups did not significantly differ in their performance across the blocks, however, the cluster analysis revealed three subgroups (with survivors of TBI and controls represented in each cluster). Findings also indicated that age and group were significant predictors of overall BGT performance, but not gender, premorbid IQ, or working memory and executive function. In conclusion, the study findings are consistent with an individual differences account of emotion-based decision-making, and a number of issues need to be addressed prior to recommending the clinical use of the BGT

Detecting mental health problems after paediatric acquired brain injury: A pilot Rasch analysis of the strengths and difficulties questionnaire

The parent-reported Strengths and Difficulties Questionnaire (SDQ-P) is commonly used to assess for mental health problems, but its psychometric properties have not been studied in the paediatric Acquired Brain Injury (ABI) population. This study investigated the properties of the SDQ-P and its subscales in this population using Rasch analysis. One hundred and forty-three SDQ-Ps and 123 Impact Supplements were analyzed. Sixty-nine percent of SDQ-Ps were completed by female carers, 59% of young people were male, and 58% had Traumatic Brain Injury (TBI). In this population the SDQ-P Total Difficulties Scale and the Conduct Problems subscale showed questionable construct validity. The individual subscales and Impact Supplement did not meet the criteria for reliability. Two items had disordered thresholds. The individual subscales showed mistargeting and 13–24% person misfit. Two items were significantly underdiscriminating. There was differential item functioning with age and time post-injury, and local dependence between subscale items. The Total Difficulties scale was multidimensional. The most easily endorsed items were in keeping with common symptoms of brain injury. These findings suggest the SDQ-P in its current form may not be a reliable and valid assessment measure for mental health difficulties in the paediatric ABI population and requires further investigation