Post-traumatic growth in adult survivors of brain injury: a qualitative study of participants completing a pilot trial of brief positive psychotherapy

Purpose: Post-traumatic growth (PTG) can occur following acquired brain injury (ABI). It has been proposed that people experiencing psychological distress following ABI may benefit from a positive psychotherapy intervention (PPT) aimed at increasing well-being; PPT may also influence PTG. We aimed to investigate PTG experiences in participants of a positive psychotherapy pilot trial. Methods: ABI survivors who had received PPT or treatment as usual (TAU) were interviewed individually after the end of the trial. Thematic analysis was conducted, to code transcripts for known themes from PTG literature as well as newly emerging themes. Results: Four participants (age = 46–62; n = 3 male; months since injury = 11–20) from the PPT group and three (age = 58–74; n = 2 male; months since injury = 9–22) from the TAU group were interviewed. Six themes were shared across both groups: personal strength, appreciation of life, relating to others, optimism/positive attitude, feeling fortunate compared to others, and positive emotional/behavioral changes. Two themes were expressed by PPT participants only: lifestyle improvements and new possibilities. One TAU participant reported spiritual change. Conclusions: A greater understanding of the development of PTG following ABI may help rehabilitation clinicians to promote better adjustment by focusing on clients’ potential for positive change and enhancing their capacity for growth

Towards validation of a new computerised test of goal neglect: preliminary evidence from clinical and neuroimaging pilot studies

Objective: Goal neglect is a significant problem following brain injury, and is a target for rehabilitation. It is not yet known how neural activation might change to reflect rehabilitation gains. We developed a computerised multiple elements test (CMET), suitable for use in neuroimaging paradigms. Design: Pilot correlational study and event-related fMRI study. Methods: In Study 1, 18 adults with acquired brain injury were assessed using the CMET, other tests of goal neglect (Hotel Test; Modified Six Elements Test) and tests of reasoning. In Study 2, 12 healthy adults underwent fMRI, during which the CMET was administered under two conditions: self-generated switching and experimenter-prompted switching. Results: Among the clinical sample, CMET performance was positively correlated with both the Hotel Test (r = 0.675, p = 0.003) and the Modified Six Elements Test (r = 0.568, p = 0.014), but not with other clinical or demographic measures. In the healthy sample, fMRI demonstrated significant activation in rostro-lateral prefrontal cortex in the self-generated condition compared with the prompted condition (peak 40, 44, 4; ZE = 4.25, p(FWEcorr) = 0.026). Conclusions: These pilot studies provide preliminary evidence towards the validation of the CMET as a measure of goal neglect. Future studies will aim to further establish its psychometric properties, and determine optimum pre- and post-rehabilitation fMRI paradigms

Cognitive function in people with psychiatric and neurological disorders in UK Biobank

Cognitive impairment is a major cause of disability for a large number of working-age adults living with chronic psychiatric and neurological conditions. Although well recognised in schizophrenia spectrum disorders and in neurological diseases such as multiple sclerosis (MS), cognitive impairment has historically received less attention in mood disorders. The relative prevalence of cognitive impairment in bipolar disorder (BD) and major depression compared with other conditions has not been clearly established, and the risk factors that drive cognitive variation within and across conditions are not well understood. The primary focus of this thesis was on BD, and the objectives were: (1) to investigate the prevalence of cognitive impairment in BD, compared with major depression, schizophrenia, MS and Parkinson’s disease (PD); and (2) to develop causal models to quantify and explain variation in cognitive function in BD and in other conditions. The methods encompassed a systematic literature review, a prevalence study using cross-sectional data from the UK Biobank cohort, and a series of multivariable analyses of UK Biobank data using graphical methods, regression- and matching-based estimation, and mediation models. The systematic review indicated that between 5% and 58% of adults with euthymic BD showed cognitive impairment. Prevalence was lower in the mania/BD group identified within the UK Biobank cohort, at around 7-10%, which was similar to rates seen in the MS and PD groups within the cohort. When causal models of cognitive performance in the mania/BD group took account of multiple potential confounders, performance on a short-term visuospatial memory test showed a small but reliable decrement. Mediation models provided evidence of indirect negative effects on cognitive performance via psychotropic medication, but not via cardiometabolic disease. A similar pattern of results was seen in the major depression group, though with smaller effect sizes. This thesis emphasises the importance of cognitive function as a fundamental phenotype in psychiatric and epidemiological research. There is scope to build on this work in future follow-up waves in UK Biobank, as well as in other UK and international cohort studies and through linkage with routine healthcare data

ForgetMeNot: Active Reminder Entry Support for Adults with Acquired Brain Injury

Smartphone reminding apps can compensate for memory impairment after acquired brain injury (ABI). In the absence of a caregiver, users must enter reminders themselves if the apps are going to help them. Poor memory and apathy associated with ABI can result in failure to initiate such configuration behaviour and the benefits of reminder apps are lost. ForgetMeNot takes a novel approach to address this problem by periodically encouraging the user to enter reminders with unsolicited prompts (UPs). An in situ case study investigated the experience of using a reminding app for people with ABI and tested UPs as a potential solution to initiating reminder entry. Three people with severe ABI living in a post-acute rehabilitation hospital used the app in their everyday lives for four weeks to collect real usage data. Field observations illustrated how difficulties with motivation, insight into memory difficulties and anxiety impact reminder app use in a rehabilitation setting. Results showed that when 6 UPs were presented throughout the day, reminder-setting increased, showing UPs are an important addition to reminder applications for people with ABI. This study demonstrates that barriers to technology use can be resolved in practice when software is developed with an understanding of the issues experienced by the user group

Vasoreactivity in CADASIL: comparison to structural MRI and neuropsychology

Impaired cerebrovascular reactivity precedes histological and clinical evidence of CADASIL in animal models. We aimed to more fully characterise peripheral and cerebral vascular function and reactivity in a cohort of adult CADASIL patients, and explore the associations of these with conventional clinical, imaging and neuropsychological measures. 22 adults with CADASIL gave informed consent to participate in an exploratorystudy of vascular function in CADASIL. Clinical assessment, comprehensive vascular assessment, MRI and neuropsychological testing were conducted. Transcranial Doppler and arterial spin labelling MRI with hypercapnia challenge both measured cerebral vasoreactivity. Number and volume of lacunes, subcortical hyperintensity volume, microbleeds and normalised brain volume were assessed on MRI scans. Analysis was exploratory and examined associations between different markers. The results showed that cerebrovascular reactivity measured by ASL correlated with peripheral vasoreactivity measured by flow mediated dilatation. Subjects with >5 lacunes were older, with evidence of atherosclerosis and had impaired cerebral and peripheral vasoreactivity. Subjects with depressive symptoms, disability or delayed processing speed, also had impaired vasoreactivity, as well as more lacunes and brain atrophy. Impaired vasoreactivity and vascular dysfunction may play a significant role in the pathophysiology of CADASIL and vascular tests may be important to include in both longitudinal and clinical trials

Technological memory aid use by people with acquired brain injury

Evans, Wilson, Needham, and Brentnall (2003) investigated memory aid use by people with acquired brain injury (ABI) and found little use of technological memory aids. The present study aims to investigate use of technological and other memory aids and strategies 10 years on, and investigate what predicts use. People with ABI and self-reported memory impairments (n = 81) completed a survey containing a memory aid checklist, demographic questions and memory questionnaires. Chi-square analysis showed that 10 of 18 memory aids and strategies were used by significantly more people in the current sample than in Evans et al. (2003). The most commonly used strategies were leaving things in noticeable places (86%) and mental retracing of steps (77%). The most commonly used memory aids were asking someone to remind you (78%), diaries (77%), lists (78%), and calendars (79%) and the most common technologies used were mobile phone reminders (38%) and alarms/timers (38%). Younger people who used more technology prior to their injury and who use more non-technological memory aids currently were more likely to use technology. Younger people who used more memory aids and strategies prior to their injury and who rated their memory as poorer were more likely to use all types of memory aids and strategies

Efficacy and cultural adaptations of narrative exposure therapy for trauma-related outcomes in refugees/asylum-seekers: a systematic review and meta-analysis

Refugees/asylum-seekers are more likely to have experienced traumatic events than the general population in high-income countries. Narrative Exposure Therapy (NET) was developed to treat trauma within this population. This review aimed to determine (1) the efficacy of NET and (2) if the interventions have been successfully culturally adapted. Databases were searched from January 2002 to September 2020, for peer-reviewed randomised controlled trials (RCT) of NET published in English, involving adult refugees/asylum-seekers with any trauma disorder, resettled in high-income countries. Data were extracted and risk of bias assessed using the Cochrane data collection forms, and meta-analyses were conducted for depression and trauma symptom change. Cultural adaptations were assessed using a structured framework. Six RCTs (total n = 272) met eligibility criteria. All reported significant reductions in trauma symptoms in the NET group but only two studies found a significant reduction in depression symptoms. Meta-analyses showed medium-large between-groups effect sizes in favour of NET (depression −0.59 [−1.07, −0.11]; trauma −0.75 [−1.19, −0.31]), with substantial heterogeneity. The most common cultural adaptations were in language and context. NET was shown to be a potentially beneficial intervention for treating trauma-related outcomes. However, studies should be more transparent regarding any attempts to make interventions more culturally appropriate

A systematic review of the effectiveness of machine learning for predicting psychosocial outcomes in acquired brain injury: which algorithms are used and why?

Clinicians working in the field of acquired brain injury (ABI, an injury to the brain sustained after birth) are challenged to develop suitable care pathways for an individual client’s needs. Being able to predict psychosocial outcomes after ABI would enable clinicians and service providers to make advance decisions and better tailor care plans. Machine learning (ML, a predictive method from the field of artificial intelligence) is increasingly used for predicting ABI outcomes. This review aimed to examine the efficacy of using ML to make psychosocial predictions in ABI, evaluate the methodological quality of studies, and understand researchers’ rationale for their choice of ML algorithms. Nine studies were reviewed from five databases, predicting a range of psychosocial outcomes from stroke, traumatic brain injury, and concussion. Eleven types of ML were employed with a total of 75 ML models. Every model was evaluated as having high risk of bias, unable to provide adequate evidence for predictive performance due to poor methodological quality. Overall, there was limited rationale for the choice of ML algorithms and poor evaluation of the methodological limitations by study authors. Considerations for overcoming methodological shortcomings are discussed, along with suggestions for assessing the suitability of data and suitability of ML algorithms for different ABI research questions