Empathic Responses to Affective Film Clips Following Brain Injury and the Association with Emotion Recognition Accuracy

Objective To compare empathic responses to affective film clips in participants with traumatic brain injury (TBI) and Healthy controls (HCs), and examine associations with affect recognition. Design Cross sectional study using a quasi-experimental design. Setting Multi-site study conducted at a post-acute rehabilitation facility in the USA and a University in Canada. Participants A convenience sample of 60 adults with moderate to severe TBI and 60 HCs, frequency matched for age and sex. Average time post-injury was 14 years (range: .5-37) Main Outcome Measures Participants were shown affective film clips and asked to report how the main character in the clip felt and how they personally felt in response to the clip. Empathic responses were operationalized as participants feeling the same emotion they identified the character to be feeling. Results Participants with TBI had lower emotion recognition scores (p=.007) and fewer empathic responses than HCs (67% vs. 79%; p<.001). Participants with TBI accurately identified and empathically responded to characters’ emotions less frequently (65%) than HCs (78%). Participants with TBI had poorer recognition scores and fewer empathic responses to sad and fearful clips compared to HCs. Affect recognition was associated with empathic responses in both groups (p<.001). When participants with TBI accurately recognized characters’ emotions, they had an empathic response 71% of the time, which was more than double their empathic responses for incorrectly identified emotions. Conclusions Participants with TBI were less likely to recognize and respond empathically to others’ expressions of sadness and fear, which has implications for interpersonal interactions and relationships. This is the first study in the TBI population to demonstrate a direct association between an affect stimulus and an empathic response

Sex Differences in Emotion Recognition and Emotional Inferencing Following Severe Traumatic Brain Injury

The primary objective of the current study was to determine if men and women with traumatic brain injury (TBI) differ in their emotion recognition and emotional inferencing abilities. In addition to overall accuracy, we explored whether differences were contingent upon the target emotion for each task, or upon high- and low-intensity facial and vocal emotion expressions. A total of 160 participants (116 men) with severe TBI completed three tasks – a task measuring facial emotion recognition (DANVA-Faces), vocal emotion recognition (DANVA-Voices) and one measuring emotional inferencing (emotional inference from stories test (EIST)). Results showed that women with TBI were significantly more accurate in their recognition of vocal emotion expressions and also for emotional inferencing. Further analyses of task performance showed that women were significantly better than men at recognising fearful facial expressions and also facial emotion expressions high in intensity. Women also displayed increased response accuracy for sad vocal expressions and low-intensity vocal emotion expressions. Analysis of the EIST task showed that women were more accurate than men at emotional inferencing in sad and fearful stories. A similar proportion of women and men with TBI were impaired (≥ 2 SDs when compared to normative means) at facial emotion perception, χ2 = 1.45, p = 0.228, but a larger proportion of men was impaired at vocal emotion recognition, χ2 = 7.13, p = 0.008, and emotional inferencing, χ2 = 7.51, p = 0.006

Perspective training to treat anger problems after brain injury: Two case studies

BACKGROUND: People with acquired brain injury (ABI) often show increased anger and aggression. Anger has been linked to attributions of hostile intent. The more intentional and hostile the judgments of other’s behaviours are, the angrier the responses tend to be. Some people with ABI tend to make harsher attributions than healthy controls (negative attribution bias). Poor perspective-taking may distort assessment of others’ intentions, thereby contributing to this bias and subsequent anger responses. OBJECTIVE: Examine changes in anger and perspective-taking after a Perspectives Group in two participants with ABI. METHODS: This study is a case report exploring observational changes in anger, hostility, verbal and physical aggression and perspective-taking in two males with ABI and severe emotion dysregulation. Participants and their spouses also provided qualitative feedback through a semi-structured interview following perspectives training. The six-week “Perspectives Group” used hypothetical and real-life situations to teach participants to consider the perspectives of others when determining their intentions. RESULTS: Both participants showed post-treatment declines in aggression. Although only minimal changes occurred on the perspective-taking measure, spouses described important behavioural changes in their partners that indicated both decreased aggression and better perspective taking. CONCLUSIONS: These preliminary findings support further investigation of perspectives training for reducing anger after ABI

Negative Attribution Bias and Anger After Traumatic Brain Injury

Objectives: Negative attributions pertain to judgments of intent, hostility, and blame regarding others' behaviors. This study compared negative attributions made by people with and without traumatic brain injury (TBI) and examined the degree to which these negative attributions predicted angry ratings in response to situations. Setting: Outpatient rehabilitation hospital. Participants: Forty-six adults with moderate to severe TBI and 49 healthy controls. Design: Cross-sectional study using a quasi-experimental research design. Main Measures: In response to hypothetical scenarios, participants rated how irritated and angry they would be, and how intentional, hostile, and blameworthy they perceived characters' behaviors. There were 3 scenario types differentiated by the portrayal of characters' actions: benign, ambiguous, or hostile. All scenarios theoretically resulted in unpleasant outcomes for participants. Results: Participants with TBI had significantly higher ratings for feeling “irritated” and “angry” and attributions of “intent,” “hostility,” and “blame” compared with healthy controls for all scenario types. Negative attribution ratings accounted for 72.4% and 65.3% of the anger rating variance for participants with and without TBI, respectively. Conclusion: People with TBI may have negative attribution bias, in which they disproportionately judge the intent, hostility, and blameworthiness of others' behaviors. These attributions contributed to their ratings of feeling angry. This suggests that participants with TBI who have anger problems should be evaluated for this bias, and anger treatments should possibly aim to alter negative attributions. However, before implementing clinical practice changes, there is a need for replication with larger samples, and further investigation of the characteristics associated with negative attribution bias

Reductions in Alexithymia and Emotion Dysregulation After Training Emotional Self-Awareness Following Traumatic Brain Injury: A Phase I Trial

OBJECTIVES: To examine the acceptability and initial efficacy of an emotional self-awareness treatment at reducing alexithymia and emotion dysregulation in participants with traumatic brain injury (TBI). SETTING: An outpatient rehabilitation hospital. PARTICIPANTS: Seventeen adults with moderate to severe TBI and alexithymia. Time postinjury ranged 1 to 33 years. DESIGN: Within subject design, with 3 assessment times: baseline, posttest, and 2-month follow-up. INTERVENTION: Eight lessons incorporated psychoeducational information and skill-building exercises teaching emotional vocabulary, labeling, and differentiating self-emotions; interoceptive awareness; and distinguishing emotions from thoughts, actions, and sensations. MEASURES: Toronto Alexithymia Scale-20 (TAS-20); Levels of Emotional Awareness Scale (LEAS); Trait Anxiety Inventory (TAI); Patient Health Questionnaire-9 (PHQ-9); State-Trait Anger Expression Inventory (STAXI); Difficulty With Emotion Regulation Scale (DERS); and Positive and Negative Affect Scale (PANAS). RESULTS: Thirteen participants completed the treatment. Repeated-measures analysis of variance revealed changes on the TAS-20 (P = .003), LEAS (P < .001), TAI (P = .014), STAXI (P = .015), DERS (P = .020), and positive affect (P < .005). Paired t tests indicated significant baseline to posttest improvements on these measures. Gains were maintained at follow-up for the TAS, LEAS, and positive affect. Treatment satisfaction was high. CONCLUSION: This is the first study published on treating alexithymia post-TBI. Positive changes were identified for emotional self-awareness and emotion regulation; some changes were maintained several months posttreatment. Findings justify advancing to the next investigational phase for this novel intervention

The Relations of Self-Reported Aggression to Alexithymia, Depression, and Anxiety After Traumatic Brain Injury

Objectives: To compare self-reported aggression in people with and without traumatic brain injury (TBI) and examine the relations of aggression to alexithymia (poor emotional insight), depression, and anxiety. Setting: Rehabilitation hospital. Participants: Forty-six adults with moderate to severe TBI who were at least 3 months postinjury; 49 healthy controls (HCs); groups were frequency matched for age and gender. Design: Cross-sectional study using a quasi-experimental design. MainMeasures:Aggression (Buss-Perry Aggression Questionnaire); alexithymia (Toronto Alexithymia Scale-20); depression (Patient Health Questionnaire-9); and trait anxiety (State-Trait Anxiety Inventory). Results: Participants with TBI had significantly higher aggression scores than HCs. For participants with TBI, 34.2% of the adjusted variance of aggression was significantly explained by alexithymia, depression, and anxiety; alexithymia accounted for the largest unique portion of the variance in this model (16.2%). Alexithymia, depression, and anxiety explained 46% of the adjusted variance of aggression in HCs; in contrast to participants with TBI, depression was the largest unique contributor to aggression (15.9%). Conclusion: This was the first empirical study showing that poor emotional insight (alexithymia) significantly contributes to aggression after TBI. This relation, and the potential clinical implications it may have for the treatment of aggression, warrants further investigation

Exploration of a new tool for assessing emotional inferencing after traumatic brain injury

bjective: To explore validity of an assessment tool under development—the Emotional Inferencing from Stories Test (EIST). This measure is being designed to assess the ability of people with traumatic brain injury (TBI) to make inferences about the emotional state of others solely from contextual cues. Methods and procedures: Study 1: 25 stories were presented to 40 healthy young adults. From this data, two versions of the EIST (EIST-1; EIST-2) were created. Study 2: Each version was administered to a group of participants with moderate-to-severe TBI—EIST 1 group: 77 participants; EIST-2 group: 126 participants. Participants also completed a facial affect recognition (DANVA2-AF) test. Participants with facial affect recognition impairment returned 2 weeks later and were re-administered both tests. Main outcomes: Participants with TBI scored significantly lower than the healthy group mean for EIST-1, F(1,114) = 68.49, p < 0.001, and EIST-2, F(1,163) = 177.39, p < 0.001. EIST scores in the EIST-2 group were significantly lower than the EIST-1 group, t = 4.47, p < 0.001. DANVA2-AF scores significantly correlated with EIST scores, EIST-1: r = 0.50, p < 0.001; EIST-2: r = 0.31, p < 0.001. Test–re-test reliability scores for the EIST were adequate. Conclusions: Both versions of the EIST were found to be sensitive to deficits in emotional inferencing. After further development, the EIST may provide clinicians valuable information for intervention planning

Sex Differences in Emotional Insight After Traumatic Brain Injury

Objective To compare sex differences in alexithymia (poor emotional processing) in males and females with traumatic brain injury (TBI) and uninjured controls. Design Cross-sectional study. Setting TBI rehabilitation facility in the United States and a university in Canada. Participants Sixty adults with moderate to severe TBI (62% men) and 60 uninjured controls (63% men) (N=120). Interventions Not applicable. Main Outcome Measures Toronto Alexithymia Scale-20 (TAS-20). Results Uninjured men had significantly higher (worse) alexithymia scores than uninjured female participants on the TAS-20 ( P=.007), whereas, no sex differences were found in the TBI group (P=.698). Men and women with TBI had significantly higher alexithymia compared with uninjured same-sex controls (both P<.001). The prevalence of participants with scores exceeding alexithymia sex-based norms for men and women with TBI was 37.8% and 47.8%, respectively, compared with 7.9% and 0% for men and women without TBI. Conclusions Contrary to most findings in the general population, men with TBI were not more alexithymic than their female counterparts with TBI. Both men and women with TBI have more severe alexithymia than their uninjured same-sex peers. Moreover, both are equally at risk for elevated alexithymia compared with the norms. Alexithymia should be evaluated and treated after TBI regardless of patient sex

Neurobiological mechanisms associated with facial affect recognition deficits after traumatic brain injury

The neurobiological mechanisms that underlie facial affect recognition deficits after traumatic brain injury (TBI) have not yet been identified. Using functional magnetic resonance imaging (fMRI), study aims were to 1) determine if there are differences in brain activation during facial affect processing in people with TBI who have facial affect recognition impairments (TBI-I) relative to people with TBI and healthy controls who do not have facial affect recognition impairments (TBI-N and HC, respectively); and 2) identify relationships between neural activity and facial affect recognition performance. A facial affect recognition screening task performed outside the scanner was used to determine group classification; TBI patients who performed greater than one standard deviation below normal performance scores were classified as TBI-I, while TBI patients with normal scores were classified as TBI-N. An fMRI facial recognition paradigm was then performed within the 3T environment. Results from 35 participants are reported (TBI-I = 11, TBI-N = 12, and HC = 12). For the fMRI task, TBI-I and TBI-N groups scored significantly lower than the HC group. Blood oxygenation level-dependent (BOLD) signals for facial affect recognition compared to a baseline condition of viewing a scrambled face, revealed lower neural activation in the right fusiform gyrus (FG) in the TBI-I group than the HC group. Right fusiform gyrus activity correlated with accuracy on the facial affect recognition tasks (both within and outside the scanner). Decreased FG activity suggests facial affect recognition deficits after TBI may be the result of impaired holistic face processing. Future directions and clinical implications are discussed

Investigation of a New Couples Intervention for Individuals with Brain Injury: A Randomized Controlled Trial

d to (1) examine the efficacy of a treatment to enhance a couple’s relationship after brain injury (BI) particularly in relationship satisfaction and communication; and (2) determine couples’ satisfaction with this type of intervention. Design: Randomized Wait-list Controlled (WC) Trial. Setting: Midwestern outpatient BI rehabilitation center. Intervention: The Couples CARE intervention is a 16 week, 2-hour, manualized small group treatment utilizing psychoeducation, affect recognition and empathy training, cognitive and dialectical behavioral treatments (CBT, DBT), communication skills training, and Gottman’s theoretical framework for couples. Participants: Forty-four participants (22 persons with BI and their intimate partner) were randomized by couples to the intervention or WC group, with 11 couples in each group. Main Outcome Measures: Dyadic Adjustment Scale (DAS); Quality of Marriage Index (QMI); 4 Horsemen of the Apocalypse communication questionnaire. Measures were completed by the person with BI and their partner at 3 time points: baseline, immediate post-intervention, 3-month follow-up. Results The experimental group showed significant improvement at post-test and follow-up on the DAS and the Horsemen questionnaire compared to baseline and to the WC group which showed no significant changes on these measures. No significant effects were observed on the QMI for either group. Satisfaction scores were largely favorable. Conclusion suggest this intervention can improve couples’ dyadic adjustment and communication after BI. High satisfaction ratings suggest this small group intervention is feasible with couples following BI. Future directions for this intervention are discussed