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Psychological and Physiological Trauma Research
Seize Your Journeys
_______________________ Traumatic stress is found in many competent, healthy, strong, good people. No one can completely protect themselves from traumatic experiences. Many people have long-lasting problems following exposure to trauma. Up to 8% of persons will have PTSD at some time in their lives. People who react to traumas are not going crazy. What is happening to them is part of a set of common symptoms and problems that are connected with being in a traumatic situation, and thus, is a normal reaction to abnormal events and experiences. Having symptoms after a traumatic event is NOT a sign of personal weakness. Given exposure to a trauma that is bad enough, probably all people would develop PTSD. By understanding trauma symptoms better, a person can become less fearful of them and better able to manage them. By recognizing the effects of trauma and knowing more about symptoms, a person will be better able to decide about getting treatment. _______________________
FUNCTIONAL NEUROANATOMY In order to best understand this atlas it is important to have a sense of the functional neuroanatomy of the brain. Over the next several pages there is a brief summary of the 5 major brain systems that relate to behavior, along with the general location seen on SPECT of these areas.
The Deep Limbic System
Functions
Problems
The Basal Ganglia System
Functions
Problems
The Prefrontal Cortex
Functions
Problems
The Cingulate Gyrus
Problems
The Temporal Lobes
Functions
Problems
Non-dominant Side (usually the right)
Secure Attachments as a Defense Against Trauma “All people mature and thrive in a social context that has profound effects on how they cope with life’s stresses. Particularly early in life, the social context plays a critical role in fuffering an individual against stressful situations, and in building the psychological and biological capacities to deal with further stresses. The primary function of parents can be thought of as helping children modulate their arousal by attuned and well-timed provision of playing, feeding, comforting, touching, looking, cleaning, and resting—in short, by teaching them skills that will gradually help them modulate their own arousal. Secure attachment bonds serve as primary defenses against trauma-induced psychopathology in both children and adults (Finkelhor & Browne, 1984). In children who have been exposed to severe stressors, the quality of the parental bond is probably the single most important determinant of long-term damage (McFarlane, 1988).” van der Kolk, Bessel, Alexander C. McFarlane, and Lars Weisaeth, eds. 1996. Traumatic stress: The effects of overwhelming experience on mind, body, and society. New York and London: Guilford Press. .p. 185 _______________________
Sleep Disorders
“The sleep disorders are organized into four major sections according to presumed etiology. Primary Sleep Disorders are those in which none of the etiologies listed below (i.e., another mental disorder, a general medical condition, or a substance) is responsible. Primary Sleep Disorders are presumed to arise from endogenous abnormalities in sleep-wake generating or timing mechanisms, often complicated by conditioning factors. Primary Sleep Disorders in turn are divided into Dyssomnias (characterized by abnormalities in the amount, quality, or timing of sleep) and Parasomnias (characterized by abnormal behavioral or physiological events occurring in association with sleep, specific sleep stages, or sleep-awake transitions). Sleep Disorder Related to Another Mental Disorder involves a prominent complaint of sleep disturbance that results from a diagnosable mental disorder (often a Mood Disorder or Anxiety Disorder) but that is sufficiently severe to warrant independent clinical attention. Presumably, the pathophysiological mechanisms responsible for the mental disorder also affect sleep-awake regulation. Sleep Disorder Due to a General Medical Condition involves a prominent complaint of sleep disturbance that results from the direct physiological effects of a general medical condition on the sleep-wake system. Substance-Induced Sleep Disorder involves prominent complaints of sleep disturbance that result from the concurrent use, or recent discontinuation of use, of a substance (including medications). That systematic assessment in individuals who present with prominent complaints of sleep disturbance includes an evaluation of the specific type of sleep complaint and a consideration of concurrent mental disorders, general medical conditions, and substance (including medication) use that may be responsible for the sleep disturbance. Five distinct sleep stages can be measured by polysomnography: rapid eye movement (REM) sleep and four stages of non-rapid eye movement (NREM) sleep (stages 1, 2, 3, and 4). Stage 1 NREM sleep is a transition from wakefulness to sleep and occupies about 5% of time spent asleep in healthy adults. Stage 2 NREM sleep, which is characterized by specific EEG waveforms (sleep spindles and K complexes), occupies about 50% of time spent asleep. Stages 3 and 4 NREM sleep (also known collectively as slow-wave sleep) are the deepest levels of sleep and occupy about 10%-20% of sleep time. REM sleep, during which the majority of typical storylike dreams occur, occupies about 20%-25% of total sleep. These sleep stages have a characteristic temporal organization across the night. NREM stages 3 and 4 tend to occur in the first one-third to one-half of the night and increase in duration in response to sleep deprivation. REM sleep occurs cyclically throughout the night, alternating with NREM sleep about every 80-100 minutes. REM sleep periods increase in duration toward the morning. Human sleep also varies characteristically across the life span. After relative stability with large amounts of slow-wave sleep in childhood and early adolescence, sleep continuity and depth deteriorate across the adult age range. This deterioration is reflected by increased wakefulness and stage 1 sleep and decreased stages 3 and 4 sleep. Because of this, age must be considered in the diagnosis of a Sleep Disorder in any individual. Polysomnography is the monitoring of multiple electrophysiological parameters during sleep and generally includes measurement of EEG activity, electroculographic activity, and electromyographic activity. Additional polysomnographic measures may include oral or nasal airflow, respiratory effort, chest and abdominal wall movement, oxyhemoglobin saturation, or exhaled carbon dioxide concentration; these measures are used to monitor respiration during sleep and to detect the presence and severity of sleep apnea. Measurement of peripheral electromyographic activity may be used to detect abnormal movements during sleep. Most polysomnographic studies are conducted during the person’s usual sleeping hours—that is, at night. However, daytime polysomnographic studies also are used to quantify daytime sleepiness. The most common daytime procedure is the Multiple Sleep Latency Test (MSLT), in which the individual is instructed to lie down in a dark room and not resist falling asleep; this protocol is repeated fives times during the day. Sleep latency (the amount of time required to fall asleep) is measured on each trial and is used as an index of physiological sleepiness. The converse of the MSLT is also used: In the Repeated Test of Sustained Wakefulness (RTSW), the individual is placed in a quiet, dimly lit room and instructed to remain awake; this protocol is repeated several times during the day. Again, sleep latency is measured, but is it used here as an index of the individual’s ability to maintain wakefulness. Standard terminology for polysomnographic measures is used throughout the test in this section. Sleep continuity refers to the overall balance of sleep and wakefulness during a night of sleep. “Better” sleep continuity indicates consolidated sleep and wakefulness; “worse” sleep continuity indicates disrupted sleep with more wakefulness. Specific sleep continuity measures include sleep latency—the amount of time required to fall asleep (expressed in minutes); intermittent wakefulness—the amount of awake time after initial sleep onset (expressed in minutes); and sleep efficiency—the ratio of actual time spent asleep to time spent in bed (expressed as a percentage, with higher numbers indicating better sleep continuity). Sleep architecture refers to the amount and distribution of specific sleep stages. Sleep architecture measures include absolute amount of REM sleep and each NREM sleep stage (in minutes), relative amount of REM seep and NREM sleep stages (expressed as a percentage of total sleep time), and latency between sleep onset and the first REM period (REM latency). The text for each of the Sleep Disorders contains a section describing its relationship to corresponding disorders in The International Classification of Sleep Disorders: (ICSD) diagnostic and Coding Manual, published in 1990 by the American Sleep Disorders Association. _________________
Substance Dependence “Features The essential feature of Substance Dependence is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues use of the substance despite significant substance-related problems. There is a pattern of repeated self-administration that can result in tolerance, withdrawal, and compulsive drug-taking behavior. A diagnosis of Substance Dependence can be applied to every class of substances except caffeine. The symptoms of Dependence are similar across the various categories of substances, but for certain classes some symptoms are less salient, and in a few instances not all symptoms apply (e.g., withdrawal symptoms are not specified for Hallucinogenic Dependence). Although not specifically listed as a criterion item, “craving” (a strong subjective drive to use the substance) is likely to be experienced by most (if not all) individuals with Substance Dependence. Dependence is defined as a cluster of three or more of the symptoms listed below occurring at any time in the same 12-month-period. Tolerance (Criterion 1) is the need for greatly increased amounts of the substance to achieve intoxication (or the desired effect) or a markedly diminished effect with continued use of the same amount of the substance. The degree to which tolerance develops varies greatly across substances. Furthermore, for a specific drug, varied degrees of tolerance may develop for its different central nervous system effects. For example, for opioids, tolerance to respiratory depression and tolerance to analgesia develop at different rates. Individuals with heavy use of opioids and stimulants can develop substantial (e.g., 10-f0ld) levels of tolerance, often to a dosage that would be lethal to a nonuser. Alcohol tolerance can also be pronounced, but is usually less extreme than for amphetamine. Many individuals who smoke cigarettes consume more than 20 cigarettes a day, an amount that would have produced symptoms of toxicity when they first started smoking. Individuals with heavy use of cannabis or phencyclidine (PCP) are generally not aware of having developed tolerance (although it has been demonstrated in animal studies and in some individuals). Tolerance may be difficult to determine by history alone when the substance used is illegal and perhaps mixed with various diluents or with other substances. In such situations, laboratory tests may be helpful (e.g., high blood levels of the substance coupled with little evidence of intoxication suggest that tolerance is likely). Tolerance must also be distinguished from individual variability in the initial sensitivity to the effects of particular substances. For example, some first-time drinkers show very little evidence of intoxication with three or four drink, whereas others of similar weight and drinking histories had slurred speech and incoordination. Withdrawal (Criterion 2a) is a maladaptive behavioral change, with physiological and cognitive concomitants, that occurs when blood or tissue concentrations of a substance decline in an individual who had maintained prolonged heavy use of the substance. After developing unpleasant withdrawal symptoms, the persons is likely to take the substance to relieve or to avoid those symptoms (Criterion 2b), typically using the substance throughout the day beginning soon after awakening. Withdrawal symptoms, which are generally the opposite of the acute effects of the substance, vary greatly across the calluses of substances, and separate criteria sets for Withdrawal are provided for most of the classes. Marked and generally easily measured physiological signs of withdrawal are common with alcohol, opioids, and sedatives, hypnotics, and anxiolytics. Withdrawal signs and symptoms are often present, but may be less apparent, with stimulants such as amphetamines and cocaine, as well as with nicotine and cannabis. No significant withdrawal is seen even after repeated use of hallucinogens. Withdrawal from phencyclidine and related substances has not yet been described in humans (although it has been demonstrated in animals). Neither tolerance nor withdrawal is necessary or sufficient for a diagnosis of Substance Dependence. However, for most classes of substances, a past history of tolerance or withdrawals is associated with a more severe clinical course (i.e., an earlier onset of Dependence, higher levels of substance intake, and a greater number of substance-related problems). Some individuals (e.g., those with Cannabis Dependence) show a pattern of compulsive use without obvious signs of tolerance or withdrawal. Conversely, some general medical and postsurgical patients without Opioid Dependence may develop a tolerance to prescribed opioids and experience withdrawal symptoms without showing any signs of compulsive use. The specifiers With Physiological Dependence and Without Physiological Dependence are provided to indicate the presence or absence of tolerance or withdrawal. The following items describe the pattern of compulsive substance use that is characteristic of Dependence. The individual may take the substance in larger amounts or over a longer period than was originally intended (e.g., continuing to drink until severely intoxicated despite having set a limit of only one drink) (Criterion 3). The individual may express a persistent desire to cut down or regulate substance use. Often, there have been many unsuccessful efforts to decrease or discontinue use (Criterion 4). The individual may spend a great deal of time obtaining the substance, using the substance, or recovering from its effects (Criterion 5). In some instances of Substance Dependence, virtually all of the person’s daily activities revolve around the substance. Important social, occupational, ore recreational activities may be given up or reduced because of substance use (Criterion 6). The individual may withdraw from family activities and hobbies in order to use the substance in private or to spend more time with substance-using friends. Despite recognizing the contributing role of the substance to a psychological or physical problem (e.g., sever depressive symptoms or damage to organ systems), the person continues to use the substance (Criterion 7). The key issue in evaluating this criterion is not eh existence of the problem, but rather the individual’s failure to abstain from using the substance despite having evidence of the difficulty it is causing.
Specifiers Tolerance and withdrawal may be associated with a higher risk for immediate general medical problems and a higher relapse rate. Specifiers are provided to note their presence or absence: With Physiological Dependence. This specifier should be used when Substance Dependence is accompanied by evidence of tolerance (Criterion 1) or withdrawal (Criterion 2). Without Physiological Dependence. This specifier should be used when there is no evidence of tolerance (Criterion 1) or withdrawal (Criterion 2). In these individuals, Substance Dependence is characterized by a pattern of compulsive use (at least three items from Criteria 3-7).”
Diagnostic and Statistical Manual of Mental Disorders. 2000. 4th ed. Washington, D.C.: American Psychiatric Association. P. 193-195.
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PTSD, DID, and EMDR Posttraumatic Stress Disorder "The essential feature of Posttraumatic Stress Disorder us the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate (Criteria A1). The person's response to the event must involve intense fear, helplessness, or horror (or in children, the response must involve disorganized or agitated behavior) (Criterion A2). The characteristic symptoms resulting from the exposure to the extreme trauma include persistent reexperiencing of the traumatic event (Criterion E), and the disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion F). Traumatic events that are experienced directly include, but are not limited to, military combat, violent personal assault (sexual assault, physical attack, robbery, mugging), being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war or in a concentration camp, natural or manmade disasters, severe automobile accidents, or being diagnosed with a life-threatening illness. For children, sexually traumatic events may include developmentally inappropriate sexual experiences without threatened or actual violence or injury. Witnessed events include, but are not limited to, observing the serious injury or unnatural death of another person due to violent assault, accident, war, or disaster or unexpectedly witnessing a dead body or body parts. Events experienced by others that are learned about include, but are not limited to, violent personal assault, serious accident, or serious injury experienced y a family member or a close friend; learning about the sudden, unexpected death of a family member or a close friend; or learning that one's child has a life threatening disease. The disorder may be especially sever or long lasting when the stressor is of human design (e.g., torture, rape). the likelihood of developing this disorder may increase as the intensity of and physical proximity to the stressor increase. The traumatic event can be reexperienced in various ways. Commonly the person has recurrent and intrusive recollections of the event (Criterion B1) or recurrent distressing dreams during which the event can be replayed or otherwise represented (Criterion B2). In rare instances, the person experiences dissociative states that last from a few seconds to several hours, or even days, during which components of the event are relived and the person behaves as though experiencing the event at that moment (Criterion B3). These episodes, often referred to as "flashbacks," are typically brief but can be associated with prolonged distress and heightened arousal. Intense psychological distress (Criterion B4) or physiological reactivity (Criterion B5) often occurs when the person is exposed to triggering events that resemble or symbolize an aspect of the traumatic event (e.g., anniversaries of the traumatic event; cold, snowy weather or uniformed guards for survivors of death camps in cold climates; hot, humid weather for combat veterans of the South Pacific; entering any elevator for an woman who was reaped in an elevator). Stimuli associated with the trauma are persistently avoided. The person commonly makes deliberate efforts to avoid thoughts, feelings, or conversations about the traumatic event (Criterion C1) and to avoid activities, situations, or people who around recollections of it (Criterion C2). This avoidance of reminders may include amnesia for an important aspect of the traumatic event (Criterion C3). Diminished responsiveness to the external work, referred to as "psychic numbing" or "emotional anesthesia," usually begins soon after the traumatic event. The individual may complain of having markedly diminished interest or participation in previously enjoyed activities (Criterion C4), of feeling detached or estranged from other people (Criterion C5), or of having markedly reduced ability to feel emotions (especially those associated with intimacy, tenderness and sexuality) (Criterion C6). The individual may have a sense of a foreshortened future (e.g., not expecting to have a career, marriage, children, or a normal life span) (Criterion C7). The individual has persistent symptoms of anxiety or increased arousal that were not present before the trauma. these symptoms may include difficulty falling or staying asleep that may be to recurrent nightmares during which the traumatic event is relived (Criterion D1), hypervigilance (Criterion D4), and exaggerated startle response (Criterion D5). Some individuals report irritability or outburst of anger (Criterion D2) or difficulty concentrating or completing tasks (Criterion D3)."
Dissociative Identity Disorder (DID) "The essential feature of Dissociative identity Disorder is the presence of two or more distinct identities or personality states (Criterion A) that recurrently take control of behavior (Criterion B). There is an inability to recall important personal information, the extent of which is too great to be explained by ordinary forgetfulness (Criterion C). The disturbance is not due tot eh direct physiological effects of a substance or a general medical condition (Condition D.). In children, the symptoms cannot be attributed to imaginary playmates or other fantasy play. Dissociative Identity Disorder reflects a failure to integrate various aspects of identity, memory, and consciousness. Each personality state may be experienced as if it has a distinct personal history, self-image, and identity, including a separate name. Usually there is a primary identity that carries the individual's given name and is passive, dependent, guilty, and depressed. The alternate identities frequently have different names and characteristics that contrast with the primary identity (e.g., are hostile, controlling, and self-destructive). Particular identities may emerge in specific circumstances and may differ in reported age and gender, vocabulary, general knowledge, or predominant affect. Alternate identities are experienced as taking control in sequence, ore at the expense of the other, and may deny knowledge of one another, be critical of one another, or appear to be in open conflict. Occasionally, one or more powerful identities allocate time to the others. Aggressive or hostile identities may at times interrupt activities or place the others in uncomfortable situations. Individuals with this disorder experience frequent gaps in memory for personal history, both remote and recent. The amnesia is frequently asymmetrical. The more passive identities tend to have more constricted memories, whereas the more hostile, controlling, or "protector" identities have more complete memories. An identity that is not in control may nonetheless gain access to consciousness by producing auditory or visual hallucinations (e.g., a voice giving instructions). Evidence of amnesia may be uncovered by reports from others who have witnessed behavior that is disavowed by the individual or by the individual's own discoveries (e.g., finding items of clothing at home that the individual cannot remember having bought). There may be loss of memory not only for recurrent periods of time, but also an overall loss of biographical memory for some extended period of childhood, adolescence, or even adulthood. Transitions among identities are often triggered by psychosocial stress. The time required to switch from one identity to another is usually a matter of seconds, but, less frequently, may b gradual. Behavior that may be frequently associated with identity switches include rapid blinking, facial changes, changes in voice or demeanor, or disruption in the individual's train of thoughts. The number of identities reported ranges from 2 to more than 100. Half of reported cases include the individuals with 10 or fewer identities." Diagnostic and Statistical Manual of Mental Disorders. 2000. 4th ed. Washington, D.C.: American Psychiatric Association. EMDR Eye Movement Desensitization and Reprocessing "Eye Movement Desensitization and Reprocessing (EMDR)1 integrates elements of many effective psychotherapies in structured protocols that are designed to maximize treatment effects. These include psychodynamic, cognitive behavioral, interpersonal, experiential, and body-centered therapies2. EMDR is an information processing therapy and uses an eight phase approach. During EMDR1 the client attends to past and present experiences in brief sequential doses while simultaneously focusing on an external stimulus. Then the client is instructed to let new material become the focus of the next set of dual attention. This sequence of dual attention and personal association is repeated many times in the session. Eight Phases of Treatment The first phase is a history taking session during which the therapist assesses the client's readiness for EMDR and develops a treatment plan. Client and therapist identify possible targets for EMDR processing. These include recent distressing events, current situations that elicit emotional disturbance, related historical incidents, and the development of specific skills and behaviors that will be needed by the client in future situations. During the second phase of treatment, the therapist ensures that the client has adequate methods of handling emotional distress and good coping skills, and that the client is in a relatively stable state. If further stabilization is required, or if additional skills are needed, therapy focuses on providing these. The client is then able to use stress reducing techniques whenever necessary, during or between sessions. However, one goal is not to need these techniques once therapy is complete. In phase three through six, a target is identified and processed using EMDR procedures. These involve the client identifying the most vivid visual image related to the memory (if available), a negative belief about self, related emotions and body sensations. The client also identifies a preferred positive belief. The validity of the positive belief is rated, as is the intensity of the negative emotions. After this, the client is instructed to focus on the image, negative thought, and body sensations while simultaneously moving his/her eyes back and forth following the therapist's fingers as they move across his/her field of vision for 20-30 seconds or more, depending upon the need of the client. Athough eye movements are the most commonly used external stimulus, therapists often use auditory tones, tapping, or other types of tactile stimulation. The kind of dual attention and the length of each set is customized to the need of the client. The client is instructed to just notice whatever happens. After this, the clinician instructs the client to let his/her mind go blank and to notice whatever thought, feeling, image, memory, or sensation comes to mind. Depending upon the client's report the clinician will facilitate the next focus of attention. In most cases a client-directed association process is encouraged. This is repeated numerous times throughout the session. If the client becomes distressed or has difficulty with the process, the therapist follows established procedures to help the client resume processing. When the client reports no distress related to the targeted memory, the clinician asks him/her to think of the preferred positive belief that was identified at the beginning of the session, or a better one if it has emerged, and to focus on the incident, while simultaneously engaging in the eye movements. After several sets, clients generally report increased confidence in this positive belief. The therapist checks with the client regarding body sensations. If there are negative sensations, these are processed as above. If there are positive sensations, they are further enhanced. In phase seven, closure, the therapist asks the client to keep a journal during the week to document any related material that may arise and reminds the client of the self-calming activities that were mastered in phase two. The next session begins with phase eight, re-evaluation of the previous work, and of progress since the previous session. EMDR treatment ensures processing of all related historical events, current incidents that elicit distress, and future scenarios that will require different responses. The overall goal is produce the most comprehensive and profound treatment effects in the shortest period of time, while simultaneously maintaining a stable client within a balanced system. After EMDR processing, clients generally report that the emotional distress related to the memory has been eliminated, or greatly decreased, and that they have gained important cognitive insights. Importantly, these emotional and cognitive changes usually result in spontaneous behavioral and personal change, which are further enhanced with standard EMDR procedures." www.emdr.com __________________ Major Depressive Disorder “Diagnostic Features The essential feature of Major Depressive Disorder is a clinical course that is characterized by one or more Major Depressive Episodes without a history of Manic, Mixed, or Hypomanic Episodes (Criteria A and C). Episodes of Substance-Induced Mood Disorder (due to the direct physiological effects of a drug of abuse, a medication, or toxin exposure) or of Mood Disorder Due to a General Medical Condition do not count toward a diagnosis of Major Depressive Disorder. In addition, the episodes must not be better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified (Criterion B). The fourth digit in the diagnostic code for Major Depressive Disorder indicates whether it is a Single Episode (used only for first episodes) or Recurrent. It is sometimes difficult to distinguish between a single episode with waxing and waning symptoms and two separate episodes. For purposes of this manual, an episode is considered to have ended when the full criteria for eh Major Depressive Episode have not been met for at least 2 consecutive months. During this 2-month period, there is either complete resolution of symptoms or the presence of depressive symptoms that no longer meet the full criteria for a Major Depressive Episode (In Partial Remission). The fifth digit in the diagnostic code for Major Depressive Disorder indicates the current state of the disturbance. If the criteria for a Major Depressive Disorder are met, the severity of the episode is notes as Mild, Moderate, Severe Without Psychotic Features, or Severe With Psychotic Features. If the criteria for a Major Depressive Episode are not currently met, the fifth digit is used to indicate whether the disorder is In Partial Remission or In Full Remission. If Manic, Mixed, or Hypomanic Episodes develop in the course of Major Depressive Disorder, the diagnosis is changed to a Bipolar Disorder. However, if manic or hypomanic symptoms occur as a direct effect of antidepressant treatment, use of other medications, substance use, or toxin exposure, the diagnosis of Major Depressive Disorder remains appropriate and an addition diagnosis of Substance-induced Mood Disorder, With Manic features (or With Mixed Features), should be noted. Similarly, if manic or hypomanic symptoms occur as a direct effect of a general medical condition, the diagnosis of Major Depressive Disorder remains appropriate and an additional diagnosis of Mood Disorder Due to a General Medical Condition, With Manic Features (or With Mixed Features), should be noted.” p. 369 “Course Major Depressive Disorder may begin at any age, with an average age at onset in the mid-20s. Epidemiological data suggest that the age at onset is decreasing for those born more recently. The course of Major Depressive Disorder, Recurrent, is variable. Some people have isolated episodes that are separated by many years without any depressive symptoms, whereas others have clusters of episodes, and still others have increasingly frequent episodes as they grow older. Some evidence suggests that the periods of remission generally last longer early in the course of the disorder. The number of prior episodes predicts the likelihood of developing a subsequent Major Depressive Episode. At least 60% of individuals with Major Depresssive Disorder, Single Episode, can be expected to have a second episode. Individuals who have had tow episodes have a 70% chance of having a third, and individuals who have had three episodes have a 90% chance of having a fourth. About 5%-10% of individuals with Major Depressive Disorder, single Episode, subsequently develop a Manic Episode (i.e., develop Bipolar I Disorder). Major Depressive Episodes may end completely (in about two-thirds of cases), or only partially or not at all (in about one-third of cases). For individuals who have only partial remission, there is a greater likelihood of developing additional episodes and of continuing the pattern of partial interepisode recovery. The longitudinal course specifiers With Full Interepisode Recovery and Without Full Interepisode Recovery may therefore have prognostic value. A number of individuals have pre-existing Dysthymic Disorder prior to the onset of Major Depressive Disorder, single Episode. Some evidence suggests that these individuals are more likely to have additional Major Depressive Episodes, have poorer interepisode recovery, and may require additional acute-phase treatment and a longer period of continuing treatment to attain and maintain a more thorough and longer-lasting euthymic state. Follow-up naturalistic studies suggested that 1 year after the diagnosis of a major Depressive Episode, 40% of individuals still have symptoms that are sufficiently severe to meet criteria for a full Major Depressive Episode, roughly 20% continue to have some symptoms that no longer meet full criteria for a Major Depressive Episode (i.e., major Depressive Disorder, In Partial Remission), and 40% have no Mood Disorder. The severity of the initial Major Depressive Episode appears to predict persistence. Chronic general medical conditions are also a risk factor for more persistent episodes. Episodes of Major Depressive Disorder often follow a severe psychosocial stressor, such as the death of a loved one or divorce. Studies suggest that psychosocial events 9stressors) may play a more significant role in the precipitation of the first or second episodes of Major Depressive Disorder and may play less of a role in the onset of subsequent episodes. Chronic general medical conditions and Substance Dependence (particularly Alcohol or Cocaine Dependence) may contribute to the onset or exacerbation of Major Depressive Disorder. It is difficult to predict whether the first episode of a Major Depressive Disorder in a young person will ultimately evolve into a Bipolar Disorder. Some data suggest that the acute onset of severe depression, especially with psychotic features and psychomotor retardation, in a young person without prepubertal psychopathology is more likely to predict a bipolar disorder. A family history of Bipolar Disorder may also be suggestive of subsequent development of Bipolar Disorder.” p. 372-373
Diagnostic and statistical manual of mental disorders. 2000. 4th ed. Washington, D.C.: American Psychiatric Association.
________________ Major Depressive Disorder “Diagnostic Features The essential feature of Major Depressive Disorder is a clinical course that is characterized by one or more Major Depressive Episodes without a history of Manic, Mixed, or Hypomanic Episodes (Criteria A and C). Episodes of Substance-Induced Mood Disorder (due to the direct physiological effects of a drug of abuse, a medication, or toxin exposure) or of Mood Disorder Due to a General Medical Condition do not count toward a diagnosis of Major Depressive Disorder. In addition, the episodes must not be better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified (Criterion B). The fourth digit in the diagnostic code for Major Depressive Disorder indicates whether it is a Single Episode (used only for first episodes) or Recurrent. It is sometimes difficult to distinguish between a single episode with waxing and waning symptoms and two separate episodes. For purposes of this manual, an episode is considered to have ended when the full criteria for eh Major Depressive Episode have not been met for at least 2 consecutive months. During this 2-month period, there is either complete resolution of symptoms or the presence of depressive symptoms that no longer meet the full criteria for a Major Depressive Episode (In Partial Remission). The fifth digit in the diagnostic code for Major Depressive Disorder indicates the current state of the disturbance. If the criteria for a Major Depressive Disorder are met, the severity of the episode is notes as Mild, Moderate, Severe Without Psychotic Features, or Severe With Psychotic Features. If the criteria for a Major Depressive Episode are not currently met, the fifth digit is used to indicate whether the disorder is In Partial Remission or In Full Remission. If Manic, Mixed, or Hypomanic Episodes develop in the course of Major Depressive Disorder, the diagnosis is changed to a Bipolar Disorder. However, if manic or hypomanic symptoms occur as a direct effect of antidepressant treatment, use of other medications, substance use, or toxin exposure, the diagnosis of Major Depressive Disorder remains appropriate and an addition diagnosis of Substance-induced Mood Disorder, With Manic features (or With Mixed Features), should be noted. Similarly, if manic or hypomanic symptoms occur as a direct effect of a general medical condition, the diagnosis of Major Depressive Disorder remains appropriate and an additional diagnosis of Mood Disorder Due to a General Medical Condition, With Manic Features (or With Mixed Features), should be noted.” p. 369 “Course Major Depressive Disorder may begin at any age, with an average age at onset in the mid-20s. Epidemiological data suggest that the age at onset is decreasing for those born more recently. The course of Major Depressive Disorder, Recurrent, is variable. Some people have isolated episodes that are separated by many years without any depressive symptoms, whereas others have clusters of episodes, and still others have increasingly frequent episodes as they grow older. Some evidence suggests that the periods of remission generally last longer early in the course of the disorder. The number of prior episodes predicts the likelihood of developing a subsequent Major Depressive Episode. At least 60% of individuals with Major Depresssive Disorder, Single Episode, can be expected to have a second episode. Individuals who have had tow episodes have a 70% chance of having a third, and individuals who have had three episodes have a 90% chance of having a fourth. About 5%-10% of individuals with Major Depressive Disorder, single Episode, subsequently develop a Manic Episode (i.e., develop Bipolar I Disorder). Major Depressive Episodes may end completely (in about two-thirds of cases), or only partially or not at all (in about one-third of cases). For individuals who have only partial remission, there is a greater likelihood of developing additional episodes and of continuing the pattern of partial interepisode recovery. The longitudinal course specifiers With Full Interepisode Recovery and Without Full Interepisode Recovery may therefore have prognostic value. A number of individuals have pre-existing Dysthymic Disorder prior to the onset of Major Depressive Disorder, single Episode. Some evidence suggests that these individuals are more likely to have additional Major Depressive Episodes, have poorer interepisode recovery, and may require additional acute-phase treatment and a longer period of continuing treatment to attain and maintain a more thorough and longer-lasting euthymic state. Follow-up naturalistic studies suggested that 1 year after the diagnosis of a major Depressive Episode, 40% of individuals still have symptoms that are sufficiently severe to meet criteria for a full Major Depressive Episode, roughly 20% continue to have some symptoms that no longer meet full criteria for a Major Depressive Episode (i.e., major Depressive Disorder, In Partial Remission), and 40% have no Mood Disorder. The severity of the initial Major Depressive Episode appears to predict persistence. Chronic general medical conditions are also a risk factor for more persistent episodes. Episodes of Major Depressive Disorder often follow a severe psychosocial stressor, such as the death of a loved one or divorce. Studies suggest that psychosocial events 9stressors) may play a more significant role in the precipitation of the first or second episodes of Major Depressive Disorder and may play less of a role in the onset of subsequent episodes. Chronic general medical conditions and Substance Dependence (particularly Alcohol or Cocaine Dependence) may contribute to the onset or exacerbation of Major Depressive Disorder. It is difficult to predict whether the first episode of a Major Depressive Disorder in a young person will ultimately evolve into a Bipolar Disorder. Some data suggest that the acute onset of severe depression, especially with psychotic features and psychomotor retardation, in a young person without prepubertal psychopathology is more likely to predict a bipolar disorder. A family history of Bipolar Disorder may also be suggestive of subsequent development of Bipolar Disorder.” p. 372-373 Diagnostic and statistical manual of mental disorders. 2000. 4th ed. Washington, D.C.: American Psychiatric Association. ________________ DID-PTSD-EMDR Dissociative Identity Disorder (DID) "The essential feature of Dissociative identity Disorder is the presence of two or more distinct identities or personality states (Criterion A) that recurrently take control of behavior (Criterion B). There is an inability to recall important personal information, the extent of which is too great to be explained by ordinary forgetfulness (Criterion C). The disturbance is not due tot eh direct physiological effects of a substance or a general medical condition (Condition D.). In children, the symptoms cannot be attributed to imaginary playmates or other fantasy play. Dissociative Identity Disorder reflects a failure to integrate various aspects of identity, memory, and consciousness. Each personality state may be experienced as if it has a distinct personal history, self-image, and identity, including a separate name. Usually there is a primary identity that carries the individual's given name and is passive, dependent, guilty, and depressed. The alternate identities frequently have different names and characteristics that contrast with the primary identity (e.g., are hostile, controlling, and self-destructive). Particular identities may emerge in specific circumstances and may differ in reported age and gender, vocabulary, general knowledge, or predominant affect. Alternate identities are experienced as taking control in sequence, ore at the expense of the other, and may deny knowledge of one another, be critical of one another, or appear to be in open conflict. Occasionally, one or more powerful identities allocate time to the others. Aggressive or hostile identities may at times interrupt activities or place the others in uncomfortable situations. Individuals with this disorder experience frequent gaps in memory for personal history, both remote and recent. The amnesia is frequently asymmetrical. The more passive identities tend to have more constricted memories, whereas the more hostile, controlling, or "protector" identities have more complete memories. An identity that is not in control may nonetheless gain access to consciousness by producing auditory or visual hallucinations (e.g., a voice giving instructions). Evidence of amnesia may be uncovered by reports from others who have witnessed behavior that is disavowed by the individual or by the individual's own discoveries (e.g., finding items of clothing at home that the individual cannot remember having bought). There may be loss of memory not only for recurrent periods of time, but also an overall loss of biographical memory for some extended period of childhood, adolescence, or even adulthood. Transitions among identities are often triggered by psychosocial stress. The time required to switch from one identity to another is usually a matter of seconds, but, less frequently, may b gradual. Behavior that may be frequently associated with identity switches include rapid blinking, facial changes, changes in voice or demeanor, or disruption in the individual's train of thoughts. The number of identities reported ranges from 2 to more than 100. Half of reported cases include the individuals with 10 or fewer identities." Diagnostic and Statistical Manual of Mental Disorders. 2000. 4th ed. Washington, D.C.: American Psychiatric Association. PTSD, DID, and EMDR Posttraumatic Stress Disorder "The essential feature of Posttraumatic Stress Disorder us the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate (Criteria A1). The person's response to the event must involve intense fear, helplessness, or horror (or in children, the response must involve disorganized or agitated behavior) (Criterion A2). The characteristic symptoms resulting from the exposure to the extreme trauma include persistent reexperiencing of the traumatic event (Criterion E), and the disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion F). Traumatic events that are experienced directly include, but are not limited to, military combat, violent personal assault (sexual assault, physical attack, robbery, mugging), being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war or in a concentration camp, natural or manmade disasters, severe automobile accidents, or being diagnosed with a life-threatening illness. For children, sexually traumatic events may include developmentally inappropriate sexual experiences without threatened or actual violence or injury. Witnessed events include, but are not limited to, observing the serious injury or unnatural death of another person due to violent assault, accident, war, or disaster or unexpectedly witnessing a dead body or body parts. Events experienced by others that are learned about include, but are not limited to, violent personal assault, serious accident, or serious injury experienced y a family member or a close friend; learning about the sudden, unexpected death of a family member or a close friend; or learning that one's child has a life threatening disease. The disorder may be especially sever or long lasting when the stressor is of human design (e.g., torture, rape). the likelihood of developing this disorder may increase as the intensity of and physical proximity to the stressor increase. The traumatic event can be reexperienced in various ways. Commonly the person has recurrent and intrusive recollections of the event (Criterion B1) or recurrent distressing dreams during which the event can be replayed or otherwise represented (Criterion B2). In rare instances, the person experiences dissociative states that last from a few seconds to several hours, or even days, during which components of the event are relived and the person behaves as though experiencing the event at that moment (Criterion B3). These episodes, often referred to as "flashbacks," are typically brief but can be associated with prolonged distress and heightened arousal. Intense psychological distress (Criterion B4) or physiological reactivity (Criterion B5) often occurs when the person is exposed to triggering events that resemble or symbolize an aspect of the traumatic event (e.g., anniversaries of the traumatic event; cold, snowy weather or uniformed guards for survivors of death camps in cold climates; hot, humid weather for combat veterans of the South Pacific; entering any elevator for an woman who was reaped in an elevator). Stimuli associated with the trauma are persistently avoided. The person commonly makes deliberate efforts to avoid thoughts, feelings, or conversations about the traumatic event (Criterion C1) and to avoid activities, situations, or people who around recollections of it (Criterion C2). This avoidance of reminders may include amnesia for an important aspect of the traumatic event (Criterion C3). Diminished responsiveness to the external work, referred to as "psychic numbing" or "emotional anesthesia," usually begins soon after the traumatic event. The individual may complain of having markedly diminished interest or participation in previously enjoyed activities (Criterion C4), of feeling detached or estranged from other people (Criterion C5), or of having markedly reduced ability to feel emotions (especially those associated with intimacy, tenderness and sexuality) (Criterion C6). The individual may have a sense of a foreshortened future (e.g., not expecting to have a career, marriage, children, or a normal life span) (Criterion C7). The individual has persistent symptoms of anxiety or increased arousal that were not present before the trauma. these symptoms may include difficulty falling or staying asleep that may be to recurrent nightmares during which the traumatic event is relived (Criterion D1), hypervigilance (Criterion D4), and exaggerated startle response (Criterion D5). Some individuals report irritability or outburst of anger (Criterion D2) or difficulty concentrating or completing tasks (Criterion D3)."
EMDR Eye Movement Desensitization and Reprocessing "Eye Movement Desensitization and Reprocessing (EMDR)1 integrates elements of many effective psychotherapies in structured protocols that are designed to maximize treatment effects. These include psychodynamic, cognitive behavioral, interpersonal, experiential, and body-centered therapies2. EMDR is an information processing therapy and uses an eight phase approach. During EMDR1 the client attends to past and present experiences in brief sequential doses while simultaneously focusing on an external stimulus. Then the client is instructed to let new material become the focus of the next set of dual attention. This sequence of dual attention and personal association is repeated many times in the session. Eight Phases of Treatment The first phase is a history taking session during which the therapist assesses the client's readiness for EMDR and develops a treatment plan. Client and therapist identify possible targets for EMDR processing. These include recent distressing events, current situations that elicit emotional disturbance, related historical incidents, and the development of specific skills and behaviors that will be needed by the client in future situations. During the second phase of treatment, the therapist ensures that the client has adequate methods of handling emotional distress and good coping skills, and that the client is in a relatively stable state. If further stabilization is required, or if additional skills are needed, therapy focuses on providing these. The client is then able to use stress reducing techniques whenever necessary, during or between sessions. However, one goal is not to need these techniques once therapy is complete. In phase three through six, a target is identified and processed using EMDR procedures. These involve the client identifying the most vivid visual image related to the memory (if available), a negative belief about self, related emotions and body sensations. The client also identifies a preferred positive belief. The validity of the positive belief is rated, as is the intensity of the negative emotions. After this, the client is instructed to focus on the image, negative thought, and body sensations while simultaneously moving his/her eyes back and forth following the therapist's fingers as they move across his/her field of vision for 20-30 seconds or more, depending upon the need of the client. Athough eye movements are the most commonly used external stimulus, therapists often use auditory tones, tapping, or other types of tactile stimulation. The kind of dual attention and the length of each set is customized to the need of the client. The client is instructed to just notice whatever happens. After this, the clinician instructs the client to let his/her mind go blank and to notice whatever thought, feeling, image, memory, or sensation comes to mind. Depending upon the client's report the clinician will facilitate the next focus of attention. In most cases a client-directed association process is encouraged. This is repeated numerous times throughout the session. If the client becomes distressed or has difficulty with the process, the therapist follows established procedures to help the client resume processing. When the client reports no distress related to the targeted memory, the clinician asks him/her to think of the preferred positive belief that was identified at the beginning of the session, or a better one if it has emerged, and to focus on the incident, while simultaneously engaging in the eye movements. After several sets, clients generally report increased confidence in this positive belief. The therapist checks with the client regarding body sensations. If there are negative sensations, these are processed as above. If there are positive sensations, they are further enhanced. In phase seven, closure, the therapist asks the client to keep a journal during the week to document any related material that may arise and reminds the client of the self-calming activities that were mastered in phase two. The next session begins with phase eight, re-evaluation of the previous work, and of progress since the previous session. EMDR treatment ensures processing of all related historical events, current incidents that elicit distress, and future scenarios that will require different responses. The overall goal is produce the most comprehensive and profound treatment effects in the shortest period of time, while simultaneously maintaining a stable client within a balanced system. After EMDR processing, clients generally report that the emotional distress related to the memory has been eliminated, or greatly decreased, and that they have gained important cognitive insights. Importantly, these emotional and cognitive changes usually result in spontaneous behavioral and personal change, which are further enhanced with standard EMDR procedures." www.emdr.com _____________________ PTSD, DID, and EMDR Posttraumatic Stress Disorder "The essential feature of Posttraumatic Stress Disorder us the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate (Criteria A1). The person's response to the event must involve intense fear, helplessness, or horror (or in children, the response must involve disorganized or agitated behavior) (Criterion A2). The characteristic symptoms resulting from the exposure to the extreme trauma include persistent reexperiencing of the traumatic event (Criterion E), and the disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion F). Traumatic events that are experienced directly include, but are not limited to, military combat, violent personal assault (sexual assault, physical attack, robbery, mugging), being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war or in a concentration camp, natural or manmade disasters, severe automobile accidents, or being diagnosed with a life-threatening illness. For children, sexually traumatic events may include developmentally inappropriate sexual experiences without threatened or actual violence or injury. Witnessed events include, but are not limited to, observing the serious injury or unnatural death of another person due to violent assault, accident, war, or disaster or unexpectedly witnessing a dead body or body parts. Events experienced by others that are learned about include, but are not limited to, violent personal assault, serious accident, or serious injury experienced y a family member or a close friend; learning about the sudden, unexpected death of a family member or a close friend; or learning that one's child has a life threatening disease. The disorder may be especially sever or long lasting when the stressor is of human design (e.g., torture, rape). the likelihood of developing this disorder may increase as the intensity of and physical proximity to the stressor increase. The traumatic event can be reexperienced in various ways. Commonly the person has recurrent and intrusive recollections of the event (Criterion B1) or recurrent distressing dreams during which the event can be replayed or otherwise represented (Criterion B2). In rare instances, the person experiences dissociative states that last from a few seconds to several hours, or even days, during which components of the event are relived and the person behaves as though experiencing the event at that moment (Criterion B3). These episodes, often referred to as "flashbacks," are typically brief but can be associated with prolonged distress and heightened arousal. Intense psychological distress (Criterion B4) or physiological reactivity (Criterion B5) often occurs when the person is exposed to triggering events that resemble or symbolize an aspect of the traumatic event (e.g., anniversaries of the traumatic event; cold, snowy weather or uniformed guards for survivors of death camps in cold climates; hot, humid weather for combat veterans of the South Pacific; entering any elevator for an woman who was reaped in an elevator). Stimuli associated with the trauma are persistently avoided. The person commonly makes deliberate efforts to avoid thoughts, feelings, or conversations about the traumatic event (Criterion C1) and to avoid activities, situations, or people who around recollections of it (Criterion C2). This avoidance of reminders may include amnesia for an important aspect of the traumatic event (Criterion C3). Diminished responsiveness to the external work, referred to as "psychic numbing" or "emotional anesthesia," usually begins soon after the traumatic event. The individual may complain of having markedly diminished interest or participation in previously enjoyed activities (Criterion C4), of feeling detached or estranged from other people (Criterion C5), or of having markedly reduced ability to feel emotions (especially those associated with intimacy, tenderness and sexuality) (Criterion C6). The individual may have a sense of a foreshortened future (e.g., not expecting to have a career, marriage, children, or a normal life span) (Criterion C7). The individual has persistent symptoms of anxiety or increased arousal that were not present before the trauma. these symptoms may include difficulty falling or staying asleep that may be to recurrent nightmares during which the traumatic event is relived (Criterion D1), hypervigilance (Criterion D4), and exaggerated startle response (Criterion D5). Some individuals report irritability or outburst of anger (Criterion D2) or difficulty concentrating or completing tasks (Criterion D3)."
Dissociative Identity Disorder (DID) "The essential feature of Dissociative identity Disorder is the presence of two or more distinct identities or personality states (Criterion A) that recurrently take control of behavior (Criterion B). There is an inability to recall important personal information, the extent of which is too great to be explained by ordinary forgetfulness (Criterion C). The disturbance is not due tot eh direct physiological effects of a substance or a general medical condition (Condition D.). In children, the symptoms cannot be attributed to imaginary playmates or other fantasy play. Dissociative Identity Disorder reflects a failure to integrate various aspects of identity, memory, and consciousness. Each personality state may be experienced as if it has a distinct personal history, self-image, and identity, including a separate name. Usually there is a primary identity that carries the individual's given name and is passive, dependent, guilty, and depressed. The alternate identities frequently have different names and characteristics that contrast with the primary identity (e.g., are hostile, controlling, and self-destructive). Particular identities may emerge in specific circumstances and may differ in reported age and gender, vocabulary, general knowledge, or predominant affect. Alternate identities are experienced as taking control in sequence, ore at the expense of the other, and may deny knowledge of one another, be critical of one another, or appear to be in open conflict. Occasionally, one or more powerful identities allocate time to the others. Aggressive or hostile identities may at times interrupt activities or place the others in uncomfortable situations. Individuals with this disorder experience frequent gaps in memory for personal history, both remote and recent. The amnesia is frequently asymmetrical. The more passive identities tend to have more constricted memories, whereas the more hostile, controlling, or "protector" identities have more complete memories. An identity that is not in control may nonetheless gain access to consciousness by producing auditory or visual hallucinations (e.g., a voice giving instructions). Evidence of amnesia may be uncovered by reports from others who have witnessed behavior that is disavowed by the individual or by the individual's own discoveries (e.g., finding items of clothing at home that the individual cannot remember having bought). There may be loss of memory not only for recurrent periods of time, but also an overall loss of biographical memory for some extended period of childhood, adolescence, or even adulthood. Transitions among identities are often triggered by psychosocial stress. The time required to switch from one identity to another is usually a matter of seconds, but, less frequently, may b gradual. Behavior that may be frequently associated with identity switches include rapid blinking, facial changes, changes in voice or demeanor, or disruption in the individual's train of thoughts. The number of identities reported ranges from 2 to more than 100. Half of reported cases include the individuals with 10 or fewer identities." Diagnostic and Statistical Manual of Mental Disorders. 2000. 4th ed. Washington, D.C.: American Psychiatric Association. EMDR Eye Movement Desensitization and Reprocessing "Eye Movement Desensitization and Reprocessing (EMDR)1 integrates elements of many effective psychotherapies in structured protocols that are designed to maximize treatment effects. These include psychodynamic, cognitive behavioral, interpersonal, experiential, and body-centered therapies2. EMDR is an information processing therapy and uses an eight phase approach. During EMDR1 the client attends to past and present experiences in brief sequential doses while simultaneously focusing on an external stimulus. Then the client is instructed to let new material become the focus of the next set of dual attention. This sequence of dual attention and personal association is repeated many times in the session. Eight Phases of Treatment The first phase is a history taking session during which the therapist assesses the client's readiness for EMDR and develops a treatment plan. Client and therapist identify possible targets for EMDR processing. These include recent distressing events, current situations that elicit emotional disturbance, related historical incidents, and the development of specific skills and behaviors that will be needed by the client in future situations. During the second phase of treatment, the therapist ensures that the client has adequate methods of handling emotional distress and good coping skills, and that the client is in a relatively stable state. If further stabilization is required, or if additional skills are needed, therapy focuses on providing these. The client is then able to use stress reducing techniques whenever necessary, during or between sessions. However, one goal is not to need these techniques once therapy is complete. In phase three through six, a target is identified and processed using EMDR procedures. These involve the client identifying the most vivid visual image related to the memory (if available), a negative belief about self, related emotions and body sensations. The client also identifies a preferred positive belief. The validity of the positive belief is rated, as is the intensity of the negative emotions. After this, the client is instructed to focus on the image, negative thought, and body sensations while simultaneously moving his/her eyes back and forth following the therapist's fingers as they move across his/her field of vision for 20-30 seconds or more, depending upon the need of the client. Athough eye movements are the most commonly used external stimulus, therapists often use auditory tones, tapping, or other types of tactile stimulation. The kind of dual attention and the length of each set is customized to the need of the client. The client is instructed to just notice whatever happens. After this, the clinician instructs the client to let his/her mind go blank and to notice whatever thought, feeling, image, memory, or sensation comes to mind. Depending upon the client's report the clinician will facilitate the next focus of attention. In most cases a client-directed association process is encouraged. This is repeated numerous times throughout the session. If the client becomes distressed or has difficulty with the process, the therapist follows established procedures to help the client resume processing. When the client reports no distress related to the targeted memory, the clinician asks him/her to think of the preferred positive belief that was identified at the beginning of the session, or a better one if it has emerged, and to focus on the incident, while simultaneously engaging in the eye movements. After several sets, clients generally report increased confidence in this positive belief. The therapist checks with the client regarding body sensations. If there are negative sensations, these are processed as above. If there are positive sensations, they are further enhanced. In phase seven, closure, the therapist asks the client to keep a journal during the week to document any related material that may arise and reminds the client of the self-calming activities that were mastered in phase two. The next session begins with phase eight, re-evaluation of the previous work, and of progress since the previous session. EMDR treatment ensures processing of all related historical events, current incidents that elicit distress, and future scenarios that will require different responses. The overall goal is produce the most comprehensive and profound treatment effects in the shortest period of time, while simultaneously maintaining a stable client within a balanced system. After EMDR processing, clients generally report that the emotional distress related to the memory has been eliminated, or greatly decreased, and that they have gained important cognitive insights. Importantly, these emotional and cognitive changes usually result in spontaneous behavioral and personal change, which are further enhanced with standard EMDR procedures." www.emdr.com __________________ Major Depressive Disorder “Diagnostic Features The essential feature of Major Depressive Disorder is a clinical course that is characterized by one or more Major Depressive Episodes without a history of Manic, Mixed, or Hypomanic Episodes (Criteria A and C). Episodes of Substance-Induced Mood Disorder (due to the direct physiological effects of a drug of abuse, a medication, or toxin exposure) or of Mood Disorder Due to a General Medical Condition do not count toward a diagnosis of Major Depressive Disorder. In addition, the episodes must not be better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified (Criterion B). The fourth digit in the diagnostic code for Major Depressive Disorder indicates whether it is a Single Episode (used only for first episodes) or Recurrent. It is sometimes difficult to distinguish between a single episode with waxing and waning symptoms and two separate episodes. For purposes of this manual, an episode is considered to have ended when the full criteria for eh Major Depressive Episode have not been met for at least 2 consecutive months. During this 2-month period, there is either complete resolution of symptoms or the presence of depressive symptoms that no longer meet the full criteria for a Major Depressive Episode (In Partial Remission). The fifth digit in the diagnostic code for Major Depressive Disorder indicates the current state of the disturbance. If the criteria for a Major Depressive Disorder are met, the severity of the episode is notes as Mild, Moderate, Severe Without Psychotic Features, or Severe With Psychotic Features. If the criteria for a Major Depressive Episode are not currently met, the fifth digit is used to indicate whether the disorder is In Partial Remission or In Full Remission. If Manic, Mixed, or Hypomanic Episodes develop in the course of Major Depressive Disorder, the diagnosis is changed to a Bipolar Disorder. However, if manic or hypomanic symptoms occur as a direct effect of antidepressant treatment, use of other medications, substance use, or toxin exposure, the diagnosis of Major Depressive Disorder remains appropriate and an addition diagnosis of Substance-induced Mood Disorder, With Manic features (or With Mixed Features), should be noted. Similarly, if manic or hypomanic symptoms occur as a direct effect of a general medical condition, the diagnosis of Major Depressive Disorder remains appropriate and an additional diagnosis of Mood Disorder Due to a General Medical Condition, With Manic Features (or With Mixed Features), should be noted.” p. 369 “Course Major Depressive Disorder may begin at any age, with an average age at onset in the mid-20s. Epidemiological data suggest that the age at onset is decreasing for those born more recently. The course of Major Depressive Disorder, Recurrent, is variable. Some people have isolated episodes that are separated by many years without any depressive symptoms, whereas others have clusters of episodes, and still others have increasingly frequent episodes as they grow older. Some evidence suggests that the periods of remission generally last longer early in the course of the disorder. The number of prior episodes predicts the likelihood of developing a subsequent Major Depressive Episode. At least 60% of individuals with Major Depresssive Disorder, Single Episode, can be expected to have a second episode. Individuals who have had tow episodes have a 70% chance of having a third, and individuals who have had three episodes have a 90% chance of having a fourth. About 5%-10% of individuals with Major Depressive Disorder, single Episode, subsequently develop a Manic Episode (i.e., develop Bipolar I Disorder). Major Depressive Episodes may end completely (in about two-thirds of cases), or only partially or not at all (in about one-third of cases). For individuals who have only partial remission, there is a greater likelihood of developing additional episodes and of continuing the pattern of partial interepisode recovery. The longitudinal course specifiers With Full Interepisode Recovery and Without Full Interepisode Recovery may therefore have prognostic value. A number of individuals have pre-existing Dysthymic Disorder prior to the onset of Major Depressive Disorder, single Episode. Some evidence suggests that these individuals are more likely to have additional Major Depressive Episodes, have poorer interepisode recovery, and may require additional acute-phase treatment and a longer period of continuing treatment to attain and maintain a more thorough and longer-lasting euthymic state. Follow-up naturalistic studies suggested that 1 year after the diagnosis of a major Depressive Episode, 40% of individuals still have symptoms that are sufficiently severe to meet criteria for a full Major Depressive Episode, roughly 20% continue to have some symptoms that no longer meet full criteria for a Major Depressive Episode (i.e., major Depressive Disorder, In Partial Remission), and 40% have no Mood Disorder. The severity of the initial Major Depressive Episode appears to predict persistence. Chronic general medical conditions are also a risk factor for more persistent episodes. Episodes of Major Depressive Disorder often follow a severe psychosocial stressor, such as the death of a loved one or divorce. Studies suggest that psychosocial events 9stressors) may play a more significant role in the precipitation of the first or second episodes of Major Depressive Disorder and may play less of a role in the onset of subsequent episodes. Chronic general medical conditions and Substance Dependence (particularly Alcohol or Cocaine Dependence) may contribute to the onset or exacerbation of Major Depressive Disorder. It is difficult to predict whether the first episode of a Major Depressive Disorder in a young person will ultimately evolve into a Bipolar Disorder. Some data suggest that the acute onset of severe depression, especially with psychotic features and psychomotor retardation, in a young person without prepubertal psychopathology is more likely to predict a bipolar disorder. A family history of Bipolar Disorder may also be suggestive of subsequent development of Bipolar Disorder.” p. 372-373
Diagnostic and statistical manual of mental disorders. 2000. 4th ed. Washington, D.C.: American Psychiatric Association.
________________ Major Depressive Disorder “Diagnostic Features The essential feature of Major Depressive Disorder is a clinical course that is characterized by one or more Major Depressive Episodes without a history of Manic, Mixed, or Hypomanic Episodes (Criteria A and C). Episodes of Substance-Induced Mood Disorder (due to the direct physiological effects of a drug of abuse, a medication, or toxin exposure) or of Mood Disorder Due to a General Medical Condition do not count toward a diagnosis of Major Depressive Disorder. In addition, the episodes must not be better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified (Criterion B). The fourth digit in the diagnostic code for Major Depressive Disorder indicates whether it is a Single Episode (used only for first episodes) or Recurrent. It is sometimes difficult to distinguish between a single episode with waxing and waning symptoms and two separate episodes. For purposes of this manual, an episode is considered to have ended when the full criteria for eh Major Depressive Episode have not been met for at least 2 consecutive months. During this 2-month period, there is either complete resolution of symptoms or the presence of depressive symptoms that no longer meet the full criteria for a Major Depressive Episode (In Partial Remission). The fifth digit in the diagnostic code for Major Depressive Disorder indicates the current state of the disturbance. If the criteria for a Major Depressive Disorder are met, the severity of the episode is notes as Mild, Moderate, Severe Without Psychotic Features, or Severe With Psychotic Features. If the criteria for a Major Depressive Episode are not currently met, the fifth digit is used to indicate whether the disorder is In Partial Remission or In Full Remission. If Manic, Mixed, or Hypomanic Episodes develop in the course of Major Depressive Disorder, the diagnosis is changed to a Bipolar Disorder. However, if manic or hypomanic symptoms occur as a direct effect of antidepressant treatment, use of other medications, substance use, or toxin exposure, the diagnosis of Major Depressive Disorder remains appropriate and an addition diagnosis of Substance-induced Mood Disorder, With Manic features (or With Mixed Features), should be noted. Similarly, if manic or hypomanic symptoms occur as a direct effect of a general medical condition, the diagnosis of Major Depressive Disorder remains appropriate and an additional diagnosis of Mood Disorder Due to a General Medical Condition, With Manic Features (or With Mixed Features), should be noted.” p. 369 “Course Major Depressive Disorder may begin at any age, with an average age at onset in the mid-20s. Epidemiological data suggest that the age at onset is decreasing for those born more recently. The course of Major Depressive Disorder, Recurrent, is variable. Some people have isolated episodes that are separated by many years without any depressive symptoms, whereas others have clusters of episodes, and still others have increasingly frequent episodes as they grow older. Some evidence suggests that the periods of remission generally last longer early in the course of the disorder. The number of prior episodes predicts the likelihood of developing a subsequent Major Depressive Episode. At least 60% of individuals with Major Depresssive Disorder, Single Episode, can be expected to have a second episode. Individuals who have had tow episodes have a 70% chance of having a third, and individuals who have had three episodes have a 90% chance of having a fourth. About 5%-10% of individuals with Major Depressive Disorder, single Episode, subsequently develop a Manic Episode (i.e., develop Bipolar I Disorder). Major Depressive Episodes may end completely (in about two-thirds of cases), or only partially or not at all (in about one-third of cases). For individuals who have only partial remission, there is a greater likelihood of developing additional episodes and of continuing the pattern of partial interepisode recovery. The longitudinal course specifiers With Full Interepisode Recovery and Without Full Interepisode Recovery may therefore have prognostic value. A number of individuals have pre-existing Dysthymic Disorder prior to the onset of Major Depressive Disorder, single Episode. Some evidence suggests that these individuals are more likely to have additional Major Depressive Episodes, have poorer interepisode recovery, and may require additional acute-phase treatment and a longer period of continuing treatment to attain and maintain a more thorough and longer-lasting euthymic state. Follow-up naturalistic studies suggested that 1 year after the diagnosis of a major Depressive Episode, 40% of individuals still have symptoms that are sufficiently severe to meet criteria for a full Major Depressive Episode, roughly 20% continue to have some symptoms that no longer meet full criteria for a Major Depressive Episode (i.e., major Depressive Disorder, In Partial Remission), and 40% have no Mood Disorder. The severity of the initial Major Depressive Episode appears to predict persistence. Chronic general medical conditions are also a risk factor for more persistent episodes. Episodes of Major Depressive Disorder often follow a severe psychosocial stressor, such as the death of a loved one or divorce. Studies suggest that psychosocial events 9stressors) may play a more significant role in the precipitation of the first or second episodes of Major Depressive Disorder and may play less of a role in the onset of subsequent episodes. Chronic general medical conditions and Substance Dependence (particularly Alcohol or Cocaine Dependence) may contribute to the onset or exacerbation of Major Depressive Disorder. It is difficult to predict whether the first episode of a Major Depressive Disorder in a young person will ultimately evolve into a Bipolar Disorder. Some data suggest that the acute onset of severe depression, especially with psychotic features and psychomotor retardation, in a young person without prepubertal psychopathology is more likely to predict a bipolar disorder. A family history of Bipolar Disorder may also be suggestive of subsequent development of Bipolar Disorder.” p. 372-373 Diagnostic and statistical manual of mental disorders. 2000. 4th ed. Washington, D.C.: American Psychiatric Association. ________________ DID-PTSD-EMDR Dissociative Identity Disorder (DID) "The essential feature of Dissociative identity Disorder is the presence of two or more distinct identities or personality states (Criterion A) that recurrently take control of behavior (Criterion B). There is an inability to recall important personal information, the extent of which is too great to be explained by ordinary forgetfulness (Criterion C). The disturbance is not due tot eh direct physiological effects of a substance or a general medical condition (Condition D.). In children, the symptoms cannot be attributed to imaginary playmates or other fantasy play. Dissociative Identity Disorder reflects a failure to integrate various aspects of identity, memory, and consciousness. Each personality state may be experienced as if it has a distinct personal history, self-image, and identity, including a separate name. Usually there is a primary identity that carries the individual's given name and is passive, dependent, guilty, and depressed. The alternate identities frequently have different names and characteristics that contrast with the primary identity (e.g., are hostile, controlling, and self-destructive). Particular identities may emerge in specific circumstances and may differ in reported age and gender, vocabulary, general knowledge, or predominant affect. Alternate identities are experienced as taking control in sequence, ore at the expense of the other, and may deny knowledge of one another, be critical of one another, or appear to be in open conflict. Occasionally, one or more powerful identities allocate time to the others. Aggressive or hostile identities may at times interrupt activities or place the others in uncomfortable situations. Individuals with this disorder experience frequent gaps in memory for personal history, both remote and recent. The amnesia is frequently asymmetrical. The more passive identities tend to have more constricted memories, whereas the more hostile, controlling, or "protector" identities have more complete memories. An identity that is not in control may nonetheless gain access to consciousness by producing auditory or visual hallucinations (e.g., a voice giving instructions). Evidence of amnesia may be uncovered by reports from others who have witnessed behavior that is disavowed by the individual or by the individual's own discoveries (e.g., finding items of clothing at home that the individual cannot remember having bought). There may be loss of memory not only for recurrent periods of time, but also an overall loss of biographical memory for some extended period of childhood, adolescence, or even adulthood. Transitions among identities are often triggered by psychosocial stress. The time required to switch from one identity to another is usually a matter of seconds, but, less frequently, may b gradual. Behavior that may be frequently associated with identity switches include rapid blinking, facial changes, changes in voice or demeanor, or disruption in the individual's train of thoughts. The number of identities reported ranges from 2 to more than 100. Half of reported cases include the individuals with 10 or fewer identities." Diagnostic and Statistical Manual of Mental Disorders. 2000. 4th ed. Washington, D.C.: American Psychiatric Association. PTSD, DID, and EMDR Posttraumatic Stress Disorder "The essential feature of Posttraumatic Stress Disorder us the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate (Criteria A1). The person's response to the event must involve intense fear, helplessness, or horror (or in children, the response must involve disorganized or agitated behavior) (Criterion A2). The characteristic symptoms resulting from the exposure to the extreme trauma include persistent reexperiencing of the traumatic event (Criterion E), and the disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion F). Traumatic events that are experienced directly include, but are not limited to, military combat, violent personal assault (sexual assault, physical attack, robbery, mugging), being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war or in a concentration camp, natural or manmade disasters, severe automobile accidents, or being diagnosed with a life-threatening illness. For children, sexually traumatic events may include developmentally inappropriate sexual experiences without threatened or actual violence or injury. Witnessed events include, but are not limited to, observing the serious injury or unnatural death of another person due to violent assault, accident, war, or disaster or unexpectedly witnessing a dead body or body parts. Events experienced by others that are learned about include, but are not limited to, violent personal assault, serious accident, or serious injury experienced y a family member or a close friend; learning about the sudden, unexpected death of a family member or a close friend; or learning that one's child has a life threatening disease. The disorder may be especially sever or long lasting when the stressor is of human design (e.g., torture, rape). the likelihood of developing this disorder may increase as the intensity of and physical proximity to the stressor increase. The traumatic event can be reexperienced in various ways. Commonly the person has recurrent and intrusive recollections of the event (Criterion B1) or recurrent distressing dreams during which the event can be replayed or otherwise represented (Criterion B2). In rare instances, the person experiences dissociative states that last from a few seconds to several hours, or even days, during which components of the event are relived and the person behaves as though experiencing the event at that moment (Criterion B3). These episodes, often referred to as "flashbacks," are typically brief but can be associated with prolonged distress and heightened arousal. Intense psychological distress (Criterion B4) or physiological reactivity (Criterion B5) often occurs when the person is exposed to triggering events that resemble or symbolize an aspect of the traumatic event (e.g., anniversaries of the traumatic event; cold, snowy weather or uniformed guards for survivors of death camps in cold climates; hot, humid weather for combat veterans of the South Pacific; entering any elevator for an woman who was reaped in an elevator). Stimuli associated with the trauma are persistently avoided. The person commonly makes deliberate efforts to avoid thoughts, feelings, or conversations about the traumatic event (Criterion C1) and to avoid activities, situations, or people who around recollections of it (Criterion C2). This avoidance of reminders may include amnesia for an important aspect of the traumatic event (Criterion C3). Diminished responsiveness to the external work, referred to as "psychic numbing" or "emotional anesthesia," usually begins soon after the traumatic event. The individual may complain of having markedly diminished interest or participation in previously enjoyed activities (Criterion C4), of feeling detached or estranged from other people (Criterion C5), or of having markedly reduced ability to feel emotions (especially those associated with intimacy, tenderness and sexuality) (Criterion C6). The individual may have a sense of a foreshortened future (e.g., not expecting to have a career, marriage, children, or a normal life span) (Criterion C7). The individual has persistent symptoms of anxiety or increased arousal that were not present before the trauma. these symptoms may include difficulty falling or staying asleep that may be to recurrent nightmares during which the traumatic event is relived (Criterion D1), hypervigilance (Criterion D4), and exaggerated startle response (Criterion D5). Some individuals report irritability or outburst of anger (Criterion D2) or difficulty concentrating or completing tasks (Criterion D3)."
EMDR Eye Movement Desensitization and Reprocessing "Eye Movement Desensitization and Reprocessing (EMDR)1 integrates elements of many effective psychotherapies in structured protocols that are designed to maximize treatment effects. These include psychodynamic, cognitive behavioral, interpersonal, experiential, and body-centered therapies2. EMDR is an information processing therapy and uses an eight phase approach. During EMDR1 the client attends to past and present experiences in brief sequential doses while simultaneously focusing on an external stimulus. Then the client is instructed to let new material become the focus of the next set of dual attention. This sequence of dual attention and personal association is repeated many times in the session. Eight Phases of Treatment The first phase is a history taking session during which the therapist assesses the client's readiness for EMDR and develops a treatment plan. Client and therapist identify possible targets for EMDR processing. These include recent distressing events, current situations that elicit emotional disturbance, related historical incidents, and the development of specific skills and behaviors that will be needed by the client in future situations. During the second phase of treatment, the therapist ensures that the client has adequate methods of handling emotional distress and good coping skills, and that the client is in a relatively stable state. If further stabilization is required, or if additional skills are needed, therapy focuses on providing these. The client is then able to use stress reducing techniques whenever necessary, during or between sessions. However, one goal is not to need these techniques once therapy is complete. In phase three through six, a target is identified and processed using EMDR procedures. These involve the client identifying the most vivid visual image related to the memory (if available), a negative belief about self, related emotions and body sensations. The client also identifies a preferred positive belief. The validity of the positive belief is rated, as is the intensity of the negative emotions. After this, the client is instructed to focus on the image, negative thought, and body sensations while simultaneously moving his/her eyes back and forth following the therapist's fingers as they move across his/her field of vision for 20-30 seconds or more, depending upon the need of the client. Athough eye movements are the most commonly used external stimulus, therapists often use auditory tones, tapping, or other types of tactile stimulation. The kind of dual attention and the length of each set is customized to the need of the client. The client is instructed to just notice whatever happens. After this, the clinician instructs the client to let his/her mind go blank and to notice whatever thought, feeling, image, memory, or sensation comes to mind. Depending upon the client's report the clinician will facilitate the next focus of attention. In most cases a client-directed association process is encouraged. This is repeated numerous times throughout the session. If the client becomes distressed or has difficulty with the process, the therapist follows established procedures to help the client resume processing. When the client reports no distress related to the targeted memory, the clinician asks him/her to think of the preferred positive belief that was identified at the beginning of the session, or a better one if it has emerged, and to focus on the incident, while simultaneously engaging in the eye movements. After several sets, clients generally report increased confidence in this positive belief. The therapist checks with the client regarding body sensations. If there are negative sensations, these are processed as above. If there are positive sensations, they are further enhanced. In phase seven, closure, the therapist asks the client to keep a journal during the week to document any related material that may arise and reminds the client of the self-calming activities that were mastered in phase two. The next session begins with phase eight, re-evaluation of the previous work, and of progress since the previous session. EMDR treatment ensures processing of all related historical events, current incidents that elicit distress, and future scenarios that will require different responses. The overall goal is produce the most comprehensive and profound treatment effects in the shortest period of time, while simultaneously maintaining a stable client within a balanced system. After EMDR processing, clients generally report that the emotional distress related to the memory has been eliminated, or greatly decreased, and that they have gained important cognitive insights. Importantly, these emotional and cognitive changes usually result in spontaneous behavioral and personal change, which are further enhanced with standard EMDR procedures." www.emdr.com
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Psychological Trauma
Traumatic Brain Injury
Title: Self-awareness, distress, and postacute rehabilitation outcome. Author(s): Malec, James F. , Mayo Clinic, Dept of Psychiatry & Psychology, Rochester, MN, US
Moessner, Anne M. Source: Rehabilitation Psychology , Vol 45(3), Aug 2000. pp. 227-241. Journal URL: http://www.apa.org/journals/rep.html Publisher: US: American Psychological Assn/Educational Publishing Foundation. Publisher URL: http://www.apa.org ISSN: 0090-5550 (Print) Digital Object Identifier: http://dx.doi.org/10.1037//0090-5550.45.3.227 Language: English Key Concepts: participation in brain injury comprehensive day treatment program, impaired self-awareness & distress, 18-69 yr olds with brain injuries, 1-yr followup Abstract: Objective: To examine changes in impaired self-awareness (ISA) and distress with participation in a brain injury comprehensive day treatment program (CDTP) and their relationship to treatment outcomes at program end and 1-year follow-up. Study Design and Participants: Ratings of ISA and distress by rehabilitation staff and their relationship to other outcome measures were examined for 62 consecutive program graduates. Measures: Ratings of ISA and distress from the Mayo-Portland Adaptability Inventory (MPAI); outcome measures included Rasch-transformed MPAI score, goal attainment scaling T score, the Vocational Independence Scale, and the Independent Living Scale. Results: Nonparametric analyses of change scores showed that ISA and distress diminished after program participation. Nonparametric correlational analysis indicated that reduced ISA did not correlate with increased distress at program end. Linear and logistic regression analyses revealed that lower ISA and distress correlated with more positive outcomes on most measures (i.e., independent living, goal attainment scaling, and other ratings of disability on the MPAI) but did not predict vocational outcome. Conclusions: Participation in a CDTP reduces ISA and distress. Lower ISA and distress are associated with positive behavioral changes and more independent living but are neither necessary nor sufficient conditions for employment. _____
Record: 2
Title: Do neurocognitive ability and personality traits account for different aspects of psychosocial outcome after traumatic brain injury? Author(s): Schretlen, David J. , Johns Hopkins Hosp, Baltimore, MD, US Source: Rehabilitation Psychology , Vol 45(3), Aug 2000. pp. 260-273. Journal URL: http://www.apa.org/journals/rep.html Publisher: US: American Psychological Assn/Educational Publishing Foundation. Publisher URL: http://www.apa.org ISSN: 0090-5550 (Print) Digital Object Identifier: http://dx.doi.org/10.1037//0090-5550.45.3.260 Language: English Key Concepts: demographic & injury severity & neurocognitive & personality trait characteristics & social role engagement & behavioral adjustment, 23-53 yr olds who sustained traumatic brain injury 8 yrs earlier Abstract: Objective: To examine the contributions of demographic, injury, cognitive, and personality characteristics to psychosocial outcome 8 years after traumatic brain injury (TBI). Design: Multiple regression analyses were used to estimate the variance explained by putative "predictors" of psychosocial outcome. Participants: Thirty-nine TBI survivors and 39 family member informants. On the basis of Glasgow Coma Scale scores and Accident Injury Severity (head) ratings, the patients' brain injuries ranged from mild to critical in severity. Main Outcome Measures: One self-report measure combined putative markers of social role engagement, such as marital status and earned income. Another, based on informant ratings using the Katz Adjustment Scale, was conceptualized as reflecting behavioral adjustment. Results: Whereas cognitive functioning explained significant unique variation in social role engagement, it did not account for variance in behavioral adjustment. Conversely, whereas 3 personality trait ratings explained significant incremental variance in behavioral stability, only 1 did the same with respect to social role engagement. Conclusions: Social role engagement and behavioral adjustment appear to represent 2 related but distinguishable aspects of TBI outcome that are associated with different patient characteristics. _____
Record: 3
Title: Effect of music therapy on mood and social interaction among individuals with acute traumatic brain injury and stroke. Author(s): Nayak, Sangeetha , U of Medicine & Dentistry of New Jersey, New Jersey Medical School, Dept of Psychiatry, Newark, NJ, US
Wheeler, Barbara L.
Shiflett, Samuel C.
Agostinelli, Sandra Source: Rehabilitation Psychology , Vol 45(3), Aug 2000. pp. 274-283. Journal URL: http://www.apa.org/journals/rep.html Publisher: US: American Psychological Assn/Educational Publishing Foundation. Publisher URL: http://www.apa.org ISSN: 0090-5550 (Print) Digital Object Identifier: http://dx.doi.org/10.1037//0090-5550.45.3.274 Language: English Key Concepts: music therapy, mood & social interaction & participation in therapy, 31-84 yr olds with traumatic brain injury or stroke Abstract: Objective: To investigate the efficacy of music therapy techniques as an aid in improving mood and social interaction after traumatic brain injury or stroke. Design: Eighteen individuals with traumatic brain injury or stroke were assigned either standard rehabilitation alone or standard rehabilitation along with music therapy (3 treatments per week for up to 10 treatments). Measures: Pretreatment and posttreatment assessments of participant self-rating of mood, family ratings of mood and social interaction, and therapist rating of mood and participation in therapy. Results: There was a significant improvement in family members' assessment of participants' social interaction in the music therapy group relative to the control group. The staff rated participants in the music therapy group as more actively involved and cooperative in therapy than those in the control group. There was a trend suggesting that self-ratings and family ratings of mood showed greater improvement in the music group than in the control group. Conclusions: Results lend preliminary support to the efficacy of music therapy as a complementary therapy for social functioning and participation in rehabilitation with a trend toward improvement in mood during acute rehabilitation. _____
Record: 4
Title: Changes in orientation during acute rehabilitation after traumatic brain injury. Author(s): Israelian, Marlyne K. , U Alabama, Dept of Physical Medicine & Rehabilitation, Birmingham, AL, US
Novack, Thomas A.
Glen, Elizabeth T.
Alderson, Amy L. Source: Rehabilitation Psychology , Vol 45(3), Aug 2000. pp. 284-291. Journal URL: http://www.apa.org/journals/rep.html Publisher: US: American Psychological Assn/Educational Publishing Foundation. Publisher URL: http://www.apa.org ISSN: 0090-5550 (Print) Digital Object Identifier: http://dx.doi.org/10.1037//0090-5550.45.3.284 Language: English Key Concepts: validity of Orientation Log, assessment of progress in orientation to place & time & situation during acute rehabilitation, 16-93 yr olds with traumatic brain injury Abstract: Objective: To examine the profile of scores on a measure of orientation in a sample of patients with traumatic brain injury (TBI) during acute rehabilitation as a means of (a) assessing the extent of neural compromise, (b) assessing recovery of functioning, and (c) determining the relative difficulty of different indicators of orientation. Design: Repeated measures. Setting: Acute rehabilitation hospital. Participants: Forty-three patients with severe TBI interviewed daily throughout rehabilitation. Measures: The Orientation Log (O-Log) is a 10-item measure of orientation to place, time, and situation. Items are scored 0-3 on the basis of whether they are recalled spontaneously (3), with cueing (2), via recognition (1), or not at all (0). Results: O-Log score was correlated with severity of TBI. Return of orientation followed a consistent trajectory, with initial gains preceding a plateau effect. Patients had relatively more difficulty orienting to hospital name and date than to year, month, and city. Conclusions: The O-Log is sensitive to the severity of TBI. Progress in orientation, on average, occurs at a similar rate across patients, including those who present as severely disoriented, although those with severe disorientation may not achieve orientation by rehabilitation discharge. _____
Record: 5
Title: Rehabilitation treatment of sexuality issues due to acquired brain injury. Author(s): Dombrowski, Lisa K. , ReMed, Conshohocken, PA, US
Petrick, James D.
Strauss, David Source: Rehabilitation Psychology , Vol 45(3), Aug 2000. pp. 299-309. Journal URL: http://www.apa.org/journals/rep.html Publisher: US: American Psychological Assn/Educational Publishing Foundation. Publisher URL: http://www.apa.org ISSN: 0090-5550 (Print) Digital Object Identifier: http://dx.doi.org/10.1037//0090-5550.45.3.299 Language: English Key Concepts: issues in & treatment regarding sexual issues, clients with acquired brain injuries & their families Abstract: Brain injury can cause myriad deficits that affect an individual's sexuality. Sexuality has not been given much attention in the rehabilitation process. It is important for the rehabilitation team to treat psychosocial and sexual issues before the individual reenters the community. Treatments of psychosocial-sexual issues include sex education groups for survivors and families, social skills groups, individual and group psychotherapy, community skills training, and medication. These approaches can play an important role in helping survivors and their families cope with sexuality issues after brain injury and, thus, can increase self-awareness and decrease disinhibited behaviors. Three case studies describe sexuality issues and highlight the importance of awareness and the relationship between awareness and outcome. Treatment provides the survivor and family with information about how to discuss sexuality issues and teaches the survivor effective interaction skills so as to reduce unwanted sexual behaviors. _____
Record: 6
Title: Effects of coaching on detecting feigned cognitive impairment with the Category Test. Author(s): DiCarlo, Margaret A. , Roger Williams Medical Ctr, Dept of Psychiatry, Providence, RI, US
Gfeller, J. D.
Oliveri, M. V. Source: Archives of Clinical Neuropsychology , Vol 15(5), Jul 2000. pp. 399-413. Journal URL: http://www.elsevier.com/inca/publications/store/8/0/2/ Publisher: US: Elsevier Science/Pergamon. ISSN: 0887-6177 (Print) Language: English Key Concepts: coaching, detection of feigned cognitive impairment with Category Test, coached vs uncoached college student simulators of cognitive impairment vs traumatic brain injury patients Abstract: In a replication and extension of previous research (W. N. Tenhula and J. J. Sweet, 1996), the current study investigated the utility of the Category Test (CT) for detecting feigned cognitive impairment. 92 participants were randomly assigned to 1 of 3 groups and administered the CT. A Coached Simulator (CSL) group was instructed to simulate cognitive impairment and was provided test-taking strategies to avoid detection. An Uncoached Simulator (USL) group was simply instructed to feign impairment. A control group was instructed to perform optimally. In addition, the CT results of 30 traumatic brain injury (TBI) patients were analyzed. The results support the utility of 5 CT malingering indicators identified by Tenhula and Sweet: (a) number of errors on subtests I and II, (b) number of errors on subtest VII, (c) total CT errors, (d) number of errors on 19 easy items, and (e) number of criteria exceeded. Correct Classification rates of the 5 indicators for USLs and optimal performance controls ranged from 87% to 98%. Correct Classification rates for the TBI patients ranged from 70% to 100%. Significantly more CSLs were misclassified as nonsimulators on 4 of the CT malingering indicators. A decision rule of >1 error on subtests I and II was the most accurate malingering indicator. _____
Record: 7
Title: The neuropsychological similarities of mild and more severe head injury. Author(s): Reitan, Ralph M. , Reitan Neuropsychology Lab, Tuscon, AZ, US
Wolfson, Deborah Source: Archives of Clinical Neuropsychology , Vol 15(5), Jul 2000. pp. 433-442. Journal URL: http://www.elsevier.com/inca/publications/store/8/0/2/ Publisher: US: Elsevier Science/Pergamon. ISSN: 0887-6177 (Print) Language: English Key Concepts: similarities & differences in performance on Halstead-Reitan Neuropsychological Battery, patients with mild head injuries vs more severe traumatic brain injuries Abstract: Reports in the literature have suggested that the neuropsychological effects of mild head injury are selective, represented by impairment of attention, information processing, and memory, and that evaluations with comprehensive and standard test batteries are likely to miss such deficits. The present study compared 18 individuals with mild traumatic head injuries, 18 with more severe traumatic brain injuries, and 41 non-brain-damaged controls using 19 tests from the Halstead-Reitan Neuropsychological Battery. The results indicate that the group with mild head injuries performed significantly poorer than the controls, and that the group with more severe head injuries scored significantly more poorly than either of the other groups. Comparisons of the pattern of test scores for the 2 head-injured groups were remarkably similar across the 19 tests, yielding a rank difference correlation of 0.87. The findings yielded no evidence of selective or delimited impairment in the group with mild head injuries, but instead, showed them to have test results that were very similar, though showing less neuropsychological impairment, to the group of Ss with more severe head injuries. _____
Record: 8
Title: The experimental analysis of human operant behavior following traumatic brain injury. Author(s): Schlund, Michael W. , Kennedy Krieger Inst, Baltimore, MD, US
Pace, Gary M. Source: Behavioral Interventions , Vol 15(3), Jul-Sep 2000. pp. 155-168. Journal URL: http://www.interscience.wiley.com/jpages/1072-0847/ Publisher: United Kingdom: John Wiley & Sons. Publisher URL: ISSN: 1072-0847 (Print)
1099-078X (Electronic) Language: English Key Concepts: human operant behavior & discrimination & response to consequences, 23-39 yr olds with traumatic brain injury Abstract: Traumatic brain injury (TBI) may produce deficits in discriminating and responding appropriately to consequences. Commonly, insensitivity to consequences is attributed to deficits in cognitive processes, particularly executive functioning. The present investigation examined the hypothesis that TBI may reduce control exerted by reinforcers over behavior. Results of basic operant research on reinforcement processes with individuals with TBI may have clinical value for understanding and ultimately remediating deficits associated with TBI. In Exp 1, responding by 4 adults (aged 23-39 yrs) with TBI and 4 non-injured controls was investigated under reinforcement contingencies that differentially reinforced responding and the absence of responding within sessions. Results show that most TBI Ss obtained lower reinforcement rates than control Ss, especially under contingencies requiring the absence of responding. In Exp 2, results show that the addition of stimuli correlated with reinforcement improved one S's performance. Results suggest that TBI may differentially reduce sensitivity to response-reinforcer contingencies and some environmental changes may increase sensitivity. Results also suggest parallels between deficits in executive functioning and deficits in operant behavior. _____
Record: 9
Title: Cueing and logical problem solving in brain trauma rehabilitation: Frequency patterns in clinician and patient behaviors. Author(s): Merbitz, Charles T. , Illinois Inst of Technology, Inst of Psychology, Chicago, IL, US
Miller, Trudy K.
Hansen, Nancy K. Source: Behavioral Interventions , Vol 15(3), Jul-Sep 2000. pp. 169-187. Journal URL: http://www.interscience.wiley.com/jpages/1072-0847/ Publisher: United Kingdom: John Wiley & Sons. Publisher URL: ISSN: 1072-0847 (Print)
1099-078X (Electronic) Language: English Key Concepts: frequency patterns of clinician cueing during logical problem solving & other verbal tasks, 20 yr old male patient with severe traumatic brain injury Abstract: Frequencies (count per minute) of patient and therapist behaviors during rehabilitation sessions after traumatic brain injury were tracked in order to evaluate an intervention curriculum and the effects of cueing. Frequencies of correct solutions to logical problems and other verbal tasks during speech-language treatments were measured for a 20-yr-old male with memory impairments and impulsivity who underwent inpatient rehabilitation 14 mo after severe traumatic brain injury. Daily frequency of cues by the clinician during the patient's logic exercises also was measured. These behaviors were recorded each treatment session for 14 wks. The patient's performance in solving logical problems improved measurably but gradually. Day-to-day predictability of patient performance was seen, as was predictability in cueing by the clinician. Celerations (trends measured as changes in count per minute per week) in the clinician's cueing were inversely related to celerations in the patient's logical problem solving. Data suggest that, for clients with brain trauma, routine continuous measurement of frequencies of behavior may facilitate clinical application of experimental analysis and intervention techniques to improve performance. _____
Record: 10
Title: Helping one person at a time: Precision teaching and traumatic brain injury rehabilitation. Author(s): Kubina, Richard M. Jr. , Clarion U, Special Education & Rehabilitation Services, Clarion, PA, US
Ward, Marie C.
Mozzoni, Michael P. Source: Behavioral Interventions , Vol 15(3), Jul-Sep 2000. pp. 189-203. Journal URL: http://www.interscience.wiley.com/jpages/1072-0847/ Publisher: United Kingdom: John Wiley & Sons. Publisher URL: ISSN: 1072-0847 (Print)
1099-078X (Electronic) Language: English Key Concepts: precision teaching & rehabilitation, 44 yr old male with traumatic brain injury Abstract: The managed care movement has had a considerable effect in health care. Professionals and agencies in rehabilitation of traumatic brain injury (TBI) now have increased pressure to produce significant clinical outcomes in an abbreviated time frame. As the interest for effective treatment practices grows, a new resource, precision teaching, offers intriguing possibilities for practitioners and researchers. This article presents a case study illustrating precision teaching with a 44-yr-old male with TBI and provides suggestions for incorporating precision teaching into rehabilitative settings. _____
Record: 11
Title: Reducing aggression in adults with brain injuries. Author(s): O'Leary, Colleen A. , Timber Ridge-UMC NeuroRestorative(R) Ctr, Lebanon, TN, US Source: Behavioral Interventions , Vol 15(3), Jul-Sep 2000. pp. 205-216. Journal URL: http://www.interscience.wiley.com/jpages/1072-0847/ Publisher: United Kingdom: John Wiley & Sons. Publisher URL: ISSN: 1072-0847 (Print)
1099-078X (Electronic) Language: English Key Concepts: participation in anger-management sessions & coping skills groups, reduction of aggression, 21-42 yr olds with brain injuries participating in 10 wk curriculum at rehabilitation center Abstract: Five adult males (aged 21-42 yrs) with brain injuries participated in a 10-wk curriculum at a post-acute brain injury rehabilitation center to determine whether training could reduce their levels of verbal and physical aggression. During training, participants completed anger-management sessions and coping skills groups weekly. In addition, they tracked their performance through written "hassle logs" each time they experienced conflict or feelings of anger. Facility data collection on number of verbal and physical aggressions revealed clients reduced their number of aggressive outbursts and successfully generalized performance for 10 wks after the training period. _____
Record: 12
Title: Reversible memory loss following treatment with fluoxetine: A case study. Author(s): Hall, Thomas , Integrated Health Services, Middleboro, MA, US
Barrera, Ricardo D.
Randon, Michael Source: Behavioral Interventions , Vol 15(3), Jul-Sep 2000. pp. 217-224. Journal URL: http://www.interscience.wiley.com/jpages/1072-0847/ Publisher: United Kingdom: John Wiley & Sons. Publisher URL: ISSN: 1072-0847 (Print)
1099-078X (Electronic) Language: English Key Concepts: fluoxetine, short term & procedural memory, 51 yr old female patient with brain injury in addition to epileptic encephalopathy & seizure disorder & major depressive disorder Abstract: This case study reports on the unexpected effect of fluoxetine on short-term and procedural memory in a 51-yr-old brain-injured white female patient. The patient was admitted to the hospital's neurobehavioral unit for evaluation of seizures and to rule out the possible occurrence of pseudo-seizures. Her admitting diagnoses included epileptic encephalopathy, generalized non-convulsive seizure disorder, major depressive disorder recurrent, and status post closed-head injury. Observations revealed memory impairments, which appeared dose-related and dissipated as fluoxetine was titrated and discontinued. Results of this A-B-A reversal analysis, together with other reports in the literature, question whether this unexpected side-effect is related to a specific response from patients with acquired brain injury. _____
Record: 13
Title: Using self-monitoring procedures to increase on-task behavior with three adolescent boys with brain injury. Author(s): Selznick, Lisa , May Institute Inc, Boston, MA, US
Savage, Ronald C. Source: Behavioral Interventions , Vol 15(3), Jul-Sep 2000. pp. 243-260. Journal URL: http://www.interscience.wiley.com/jpages/1072-0847/ Publisher: United Kingdom: John Wiley & Sons. Publisher URL: ISSN: 1072-0847 (Print)
1099-078X (Electronic) Language: English Key Concepts: self-monitoring, task behavior & accuracy & productivity during completion of independent math assignments, 14 yr olds with brain injury Abstract: The effects of self-monitoring on-task behavior, accuracy, and productivity were assessed with three 14-yr-old boys with brain injury. A combined multiple baseline across Ss and alternating design schedule was used. Participants were taught to self-record the three dependent variables while they were completing independent math assignments. A tape-recorded audio tone was used as a cue to self-record. Research assistants recorded occurrence of on-task behavior using 10 sec interval recording. They also reported the percentage of problems completed accurately and the total duration of task engagement. The study expands on both the self-monitoring and brain injury rehabilitation literature by examining self-monitoring methods as an effective rehabilitative strategy for individuals with brain injuries. Findings are discussed in the context of prior self-monitoring studies and are interpreted from both a behavioral and cognitive perspective. This is done in an effort to bridge the gap between the theoretical orientations. By bridging this gap, the authors hope to facilitate the development of an integrative approach to brain injury rehabilitation with behavior analysts playing a primary role. _____
Record: 14
Title: The neuropathology of the vegetative state after an acute brain insult. Author(s): Adams, J. Hume , South Glasgow U Hosps, Southern General Hosp, Inst of Neurological Sciences, Dept of Neuropathology, Glasgow, Scotland
Graham, D. I.
Jennett, Bryan Source: Brain , Vol 123(7), Jul 2000. pp. 1327-1338. Journal URL: http://brain.oupjournals.org/ Publisher: England: Oxford Univ Press. Publisher URL: ISSN: 0006-8950 (Print)
1460-2156 (Electronic) Language: English Key Concepts: cerebral neuropathology & structure, 2-75 yr olds in vegetative states following acute brain insult Abstract: Examined the structural basis of the vegetative state through a detailed neuropathological study. Studied were the brains of 49 patients who remained vegetative until death, 1 mo-8 yrs after an acute brain insult; 35 (aged 7-75 yrs) had sustained a blunt head injury and 14 (aged 2-58 yrs) had some type of acute non-traumatic brain damage. Results show that in the traumatic cases the most common structural abnormalities were grades 2 and 3 diffuse axonal injury. The thalamus was abnormal in 80% of cases, and in 96% of Ss who survived for >3 mo. Other abnormalities included ischemic damage in the neocortex in 37% of cases and intracranial hematoma in 26%. In the non-traumatic cases there was diffuse ischemic damage in the neocortex in 64% of cases and focal damage in 29%; the thalamus was abnormal in every non-traumatic case. There were cases in both groups where the cerebral cortex, the cerebellum, and the brainstem appeared structurally normal. In every such case, however, there was profound damage to the subcortical white matter or to the major relay nuclei of the thalamus, or both. These lesions rendered any structurally intact cortex unable to function because connections between different cortical areas through the thalamic nuclei were no longer functional. _____
Record: 15
Title: Evidence for cellular damage in normal-appearing white matter correlates with injury severity in patients following traumatic brain injury: A magnetic resonance spectroscopy study. Author(s): Garnett, Matthew R. , Oxford Radcliffe Hosp, MRC Biochemical & Clinical Magnetic Resonance Unit, Oxford, England
Blamire, Andrew M.
Rajagopalan, Bheeshma
Styles, Peter
Cadoux-Hudson, Thomas A. D. Source: Brain , Vol 123(7), Jul 2000. pp. 1403-1409. Journal URL: http://brain.oupjournals.org/ Publisher: England: Oxford Univ Press. Publisher URL: ISSN: 0006-8950 (Print)
1460-2156 (Electronic) Language: English Key Concepts: cerebral white matter N-acetylaspartate & choline & creatine ratios, injury severity, 18-66 yr olds with traumatic brain injuries Abstract: Examined techniques using N-acetylaspartate (NAA) and choline-containing compounds to evaluate injury extent in traumatic brain injury (TBI) patients. 19 TBI patients (aged 18-66 yrs) in clinically stable condition 3-38 days following injury underwent magnetic resonance imaging (MRI) and proton magnetic resonance spectroscopy studies of frontal white matter that on conventional MRI appeared normal. Results show that brain NAA-creatine ratios were reduced and choline-creatine ratios were increased in TBI Ss compared with controls. NAA-choline ratio reduction correlated with severity of injury as measured by the Glasgow Coma Scale (G. Teasdale and B. Jennett, 1974) and the length of posttraumatic amnesia. It is concluded that there is an early reduction in NAA and an increase in choline compounds in normal-appearing white matter that correlates with head injury severity, and that this may provide a pathological basis for long-term neurological disability. _____
Record: 16
Title: Neurobehavioural outcomes of penetrating and tangential gunshot wounds to the head. Author(s): Hotz, Gillian A. , U Miami, School of Medicine, Miami, FL, US
Stewart, Kimberly J.
Petrin, David
Villanueva, Philip A.
Cohn, Stephen M.
Nedd, Kester J.
Puentes, Gisela
Duncan, Robert Source: Brain Injury , Vol 14(7), Jul 2000. pp. 649-657. Journal URL: http://www.tandf.co.uk/journals/tf/02699052.html Publisher: US: Taylor & Francis. Publisher URL: http://www.taylorandfrancis.com ISSN: 0269-9052 (Print)
1362-301X (Electronic) Language: English Key Concepts: neurobehavioral & clinical outcomes, patients with tangential vs penetrating gun shot wounds to head Abstract: Compared penetrating and tangential gunshot wounds to the head with regards to demographic, neurobehavioral and clinical outcome measures. Twenty-nine patients (mean age 20.3 yrs) with penetrating gunshot wounds (P-GSW) and 11 patients (mean age 32 yrs) with tangential gunshot wound (T-GSW) to the head admitted to an acute neurotrauma service were compared using standardized neurobehavioral and clinical outcome measures. The mean Glasgow Coma Scale score was 10.5 for the P-GSW group and 13.4 for the T-GSV group. The mean Abbreviated Injury Scale-CNS score for the P-GSW group was 5.00 and for the T-GSW group was 3.7. Significance was found on Digit Span and Block Design subtests. Outcomes between the 2 groups were similar, except for significant differences were found for acute length of stay (LOS) and for acute care charges. It was concluded that, initially, a penetrating gunshot wound is a more severe and costly injury than a tangential gunshot wound to the head, however T-GSW possess significant deficits and, if the patient survives past the acute phase of recovery, the two groups have similar functional outcomes. _____
Record: 17
Title: Factors associated with insomnia among post-acute traumatic brain injury survivors. Author(s): Fichtenberg, Norman L. , Rehabilitation Inst of Michigan, Novi, MI, US
Millis, Scott R.
Mann, Nancy R.
Zafonte, Ross D.
Millard, Anna E. Source: Brain Injury , Vol 14(7), Jul 2000. pp. 659-667. Journal URL: http://www.tandf.co.uk/journals/tf/02699052.html Publisher: US: Taylor & Francis. Publisher URL: http://www.taylorandfrancis.com ISSN: 0269-9052 (Print)
1362-301X (Electronic) Language: English Key Concepts: insomnia & demographic & psychosocial factors, 16-78 yr olds with post acute traumatic brain injury Abstract: Investigated the relationships between insomnia and select demographic, injury and psychosocial variables in post-acute, traumatic brain injury. Clinical assessment of sleep and mood was undertaken via objective measures and a diagnostic interview among 91 brain injury patients (aged 16-78) admitted to an outpatient neurorehabilitation clinic. No associations between insomnia and gender, education, age, and time since injury were found. A logistic regression model of insomnia prediction based upon the Beck Depression Inventory (BDI), self-reported pain disturbance, litigation and Glasgow Coma Score (GCS) correctly classified 87% of the sample with respect to the presence or absence of insomnia; however, depression and injury severity were the only variables that made a significant unique contribution to the prediction of insomnia. It is concluded that among post-acute traumatic brain injury patients, insomnia is linked with both the presence of depression and a history of milder brain injuries. This suggests that the determinants of insomnia may differ from the acute to the post-acute phase, with neurological factors playing a primary role early in the recovery process and psychosocial factors ascending later. _____
Record: 18
Title: Reliability of the relative's questionnaire for assessment of outcome after brain injury. Author(s): Hellawell, Deborah J. , Astley Ainslie Hosp, Rehabilitation Studies Unit, Edinburgh, Scotland
Signorini, David F.
Pentland, Brian Source: Disability & Rehabilitation: An International Multidisciplinary Journal , Vol 22(10), Jul 2000. pp. 446-450. Journal URL: http://www.tandf.co.uk/journals/tf/09638288.html Publisher: US: Taylor & Francis. Publisher URL: http://www.taylorandfrancis.com ISSN: 0963-8288 (Print)
1464-5165 (Electronic) Language: English Key Concepts: test-retest reliability of relative's questionnaire, outcomes following brain injury, brain injury patients & relatives Abstract: The relative's questionnaire (RQ) was developed to assess outcome after brain injury. The present study investigated its test-retest reliability when used in a postal survey. Hospital records were used to identify and contact surviving patients treated for brain injury 5-7 yrs earlier. Patients were sent a copy of the RQ (RQ1) and one month later a second copy (RQ2) was sent to those who returned RQ1. 128 patients returned RQ1, and 94 of these returned RQ2. The reliability of items was variable, with most having a kappa value of >0.6 suggesting "substantial agreement" or better. The data presented suggest that the RQ is a reliable instrument in collecting outcome information in brain-injured patients by postal survey. _____
Record: 19
Title: The relative validity of MMPI-2 interpretations based on standard and neurocorrected profiles for traumatic brain injury patients receiving rehabilitation services. Author(s): Barrett, Paul Theodore , Wayne State U., US Source: Dissertation Abstracts International: Section B: The Sciences & Engineering , Vol 61(1-B), Jul 2000. pp. 521. Publisher: US: Univ Microfilms International. ISSN: 0419-4217 (Print) Language: English Key Concepts: relative validity of MMPI-2 interpretations based on standard vs neurocorrected profiles, traumatic brain injury patients receiving rehabilitation services Abstract: The goal of administering and interpreting the MMPI is to gain increased understanding into an individual's psychopathology and emotional functioning. Because a neurologic patient's endorsement of items that are common sequelae of brain damage may lead to overestimating the extent of emotional distress, several authors have recommended correcting the MMPI profile prior to interpretation. Correcting MMPI/MMPI-2 profiles to adjust for such neurologically related items has become known as neurocorrection. In spite of the apparent popularity of neurocorrection and the number of published neurocorrection factors, there have been no published reports of differential accuracy or utility of the neurocorrected MMPI profiles of individual subjects relative to non-corrected profiles. This study was designed to redress that imbalance with patients who have sustained head injuries. Because of shortcomings in the development of existing neurocorrection scales, a more conceptually and psychometrically sound neurocorrection scale for was first developed using an adequate sample size and appropriate statistical treatments. The bulk of this study involved validation of the resulting neurocorrection factor and the other major neurocorrection factors designed specifically for patients with head injuries (Alfano, Paniak, & Finlayson, 1993; Gass, 1991). Based on Alfano, Finlayson, Steams, & Neilson's (1990) 44 item NC44 Scale, the scale developed for this study consisted of 30 MMPI-2 items that are used in scoring the clinical scales and were endorsed by at least 30% of the developmental subject pool. The results of the validation portion of this study provided no evidence for the validity of neurocorrection. None of the neurocorrection factors increased the correlation between the MMPI-2 clinical scales and corresponding adjective statement ratings. Furthermore, there was no significant difference between rehabilitation professionals' mean ratings of adjective statements associated with standard scoring and the mean ratings of statements associated with the neurocorrected scoring developed for this study. These results suggest that the neurocorrection factors proposed for increasing the accuracy of MMPI-2 interpretations are ineffective and probably only serve to reduce their validity. _____
Record: 20
Title: The determinants and correlates of outcome following traumatic brain injury: A prospective study. Author(s): Dawson, Deirdre Rose , U Toronto, Canada Source: Dissertation Abstracts International: Section B: The Sciences & Engineering , Vol 61(1-B), Jul 2000. pp. 526. Publisher: US: Univ Microfilms International. ISSN: 0419-4217 (Print) Language: English Key Concepts: prospective analysis of determinants & correlates of outcome following traumatic brain injury, patients & their friends & family members, Canada, 4 yr study Abstract: The determinants and correlates of outcome at one (Time 1) and four (Time 2) years posttraumatic brain injury (TBI) were investigated prospectively in patients (n = 92) recruited consecutively following admission to Canada's largest regional trauma centre. Friends and family members served as control subjects. Sixty-three percent of subjects who completed baseline testing completed follow-up interviews at Time 1. Of these, 72% completed neuropsychological testing. Fifty-three percent of subjects completed follow-up interviews and neuropsychological testing at Time 2. Demographic, injury-severity, acute imaging findings, and acute neuropsychological function (attention, orientation, memory) were investigated as determinants of outcome. Neuropsychological status (attention, memory, executive function) at Time 1 and 2, and psychological status (depression, locus of control, coping style) and social support at Time 2 were investigated as correlates of outcome. Outcomes evaluated at both time points included psychosocial outcome, and a measure of return to productivity (RTP) (work and/or school). At Time 2, quality of life (QOL) data were also reported. At both time points, TBI subjects reported considerable psychosocial distress relative to controls. At Time 1, 66% of TBI subjects had returned to productive activity, at Time 2, this increased to 78%. Determinants of outcome at Time 1 showed baseline memory status to be significantly associated with RTP (p le; 0.0007). Injury severity and measures of acute neuropsychological status showed a trend to be associated with psychosocial outcome and RTP (p le; 0.05). Determinants of outcome at Time 2 again showed acute memory status to be associated with RTP (p le; 0.003) and other measures of acute neuropsychological status to be associated with psychosocial status, RTP, and QOL at p le; 0.05. Psychological variables and social support were strongly correlated with psychosocial status, RTP, and QOL at Time 2. When included in hierarchical regression analyses with acute neuropsychological variables, they accounted for substantially more variance in each outcome. A small proportion of the neuropsychological test scores (measuring general slowing, memory and executive function) correlated with outcome at both time points. These data suggest that the influence of brain pathology on outcome is attenuated over time. Long-term outcome is explained by many factors: psychological factors and social support are particularly important. _____
Record: 21
Title: Exploratory study: Ten tasks used to evaluate or rehabilitate individuals with traumatic brain injury. Author(s): Merchant-Sullivan, Lillian , The Union Inst., US Source: Dissertation Abstracts International: Section B: The Sciences & Engineering , Vol 61(1-B), Jul 2000. pp. 558. Publisher: US: Univ Microfilms International. ISSN: 0419-4217 (Print) Language: English Key Concepts: tasks to evaluate or rehabilitate cognitive functioning, Ss with traumatic brain injury Abstract: Cognitive rehabilitation and assessment have long been based on the static approach to assessment. This approach is based on the standardized test and not on the significant amount of information gained during the learning process. This approach does not consider the individual's ability to generalize newly acquired knowledge to novel contexts. It does not measure practical intelligence which is a measurement of real life learning which is linked to daily cognitive processing. Most importantly static assessment does not tell family member where to start and what to expect. It has been observed that traumatic brain injured individuals need more work in real-life situations where learning potential is the key to success in daily living. The dynamic assessment approach which Is linked to practical intelligence allows the therapist and family members to utilize assessment which is linked to learning potential and receive critical feedback which motivates progress. This study examines 10 tasks, which are linked to the dynamic approach to assessment. These tasks are from various disciplines such as psychology, developmental psychology, education, occupational therapy, neuropsychology, neuro-linguistics, cognitive psychology and activities of daily living. The tasks can be used as a single unit of assessment or each task can be used separately as a measure of learning potential. From these 10 tasks 8 constructs were developed dealing with certain areas of cognitive functioning. These 8 constructs attempt to evaluate cognitive functioning in the areas of social judgment, perceptual organization, mental alertness, visual processing, memory, verbal processing, executive functioning, and sequencing skills. In I general, it was found that this assessment tool was able to distinguished traumatic brain injured individuals from normal controls and yielded statistically significant data in terms of theoretical research and practical application. These results suggest that this assessment tool, utilizing the dynamic method of assessment, maybe a useful tool to evaluate cognitive functioning and as an approach to cognitive rehabilitation. The focus of future research should include the range and limitation of the tasks and the constructs from the perspective of both the clinicians and family members of brain injured individuals. _____
Record: 22
Title: Speech disorders following severe traumatic brain injury: Kinematic analysis of syllable repetitions using electromagnetic articulography. Author(s): Jaeger, Marion , Kliniken Schmieder, Allensbach, Germany
Hertrich, Ingo
Stattrop, Ulrich
Schoenle, Paul-Walter
Ackermann, Hermann Source: Folia Phoniatrica et Logopaedica , Vol 52(4), Jul-Aug 2000. pp. 187-196. Journal URL: http://www.karger.ch/journals/fpl/fpl_jh.htm Publisher: Switzerland: S Karger AG. Publisher URL: ISSN: 1021-7762 (Print)
1421-9972 (Electronic) Language: English Key Concepts: orofacial gestures & pattern of articulation disorders secondary to traumatic brain injury, 21-58 yr old adults with dysarthria following severe traumatic brain injury Abstract: Investigated orofacial gestures in order to elucidate the pattern of articulation disorders secondary to traumatic brain injury. Using electromagnetic articulography, the lips, the tip of the tongue, and the tongue dorsum were tracked during repetitions of the syllables "pa", "ta", and "ka" in 10 speakers with dysarthria following severe traumatic brain injury (aged 21-58 yrs) and in 10 age-matched control Ss. When asked to produce the syllable trains as fast as possible, the patient group showed a rather homogeneous pattern of movement abnormalities including prolonged syllable durations and reduced peak velocity/amplitude ratios. Most presumably, limited speed generation gives rise to the impaired ability to increase speech rate. During the habitual speaking condition, reduced velocity/amplitude ratios were restricted to the tongue tip and tongue dorsum. The authors conclude that the tongue and the lips are differentially affected in dysarthria following severe traumatic brain injury. _____
Record: 23
Title: Cognitive rehabilitation: What is the problem? Author(s): Perna, Robert B. , Neuropsychological Services of the Southern Tier, Vestal, NY, US
Bekanich, Mary
Williams, Karren R.
Boozer, Richard H. Source: Journal of Cognitive Rehabilitation , Vol 18(4), Jul-Aug 2000. pp. 16-21. Publisher: US: NeuroScience Publishers. Publisher URL: http://www.neuroscience.cnter.com ISSN: 1062-2969 (Print) Language: English Key Concepts: techniques & efficacy of & research on cognitive rehabilitation, persons with mild to moderate traumatic brain injuries Abstract: Explores the question of why there is skepticism among health care professionals and insurance companies regarding the appropriateness of cognitive rehabilitation (CR) for persons with mild to moderate traumatic brain injuries (TBIs). CR is defined, and its potential uses are outlined. The authors then discuss the related issues of (1) physiological changes to brain in TBI, (2) intensity and duration of training needed in CR, (3) lack of knowledge about CR, (4) spontaneous recovery, and (5) outcomes and methodology for CR efficacy studies. _____
Record: 24
Title: TBI club: A psychosocial support group for adults with traumatic brain injury. Author(s): Vandiver, Vikki L. , Portland State U, Graduate School of Social Work, Portland, OR, US
Christofero-Snider, Carol Source: Journal of Cognitive Rehabilitation , Vol 18(4), Jul-Aug 2000. pp. 22-27. Publisher: US: NeuroScience Publishers. Publisher URL: http://www.neuroscience.cnter.com ISSN: 1062-2969 (Print) Language: English Key Concepts: community based psychosocial support group, self efficacy & quality of life, adults with traumatic brain injury Abstract: Describes the development of a community-based psychosocial support group (Club) for adults with traumatic brain injury (TBI). The development began with a community needs survey, and the club's conceptual foundation was from the area of psychosocial rehabilitation. An evaluation of the TBI Club's impact was planned using qualitative and quantitative methods. 49 Club members completed interviews conducted at 1st mo of attendance and 6 mo later. Ss showed positive changes on the Self-Efficacy Scale. Through their comments, Ss indicated need for opportunities for group affiliation, acceptance, vocational retraining, and employment opportunities. The Club directly addressed the quality of life domains by providing opportunities for social connections and education. _____
Record: 25
Title: Discussion of developmental plasticity: Factors affecting cognitive outcome after pediatric traumatic brain injury. Author(s): Chapman, Sandra Bond , U Texas, Callier Ctr for Communication Disorders, Brain Research & Treatment Ctr, Dallas, TX, US
McKinnon, Lyn Source: Journal of Communication Disorders , Vol 33(4), Jul-Aug 2000. pp. 333-344. Journal URL: http://www.elsevier.com/inca/publications/store/5/0/5/7/6/8/ Publisher: US: Elsevier Science. ISSN: 0021-9924 (Print) Digital Object Identifier: http://dx.doi.org/10.1016/S0021-9924(00)00029-0 Language: English Key Concepts: research on psychobiological factors in developmental plasticity, children & adolescents with traumatic brain injury Abstract: Notes that current research on plasticity has altered the over simplistic view of greater capacity in the developing brain after injury. This article argues that M. Dennis (2000; see also record 2000-02613-004) provides a model to elucidate the complexity of the multiple factors that influence recovery after brain injury in children. The authors present a brief summary of findings from their longitudinal research in neurobehavioral recovery after traumatic brain injury in children and adolescents that elaborates on the framework of Dennis. The discussion highlights the psychobiological factors that interact to define developmental plasticity and outlines directions for future research to elucidate and promote long-term recovery in pediatric brain-injured populations. _____
Record: 26
Title: Factors influencing outcome following mild traumatic brain injury in adults. Author(s): Ponsford, Jennie , Epworth Hosp, Bethesda Rehabilitation Unit, Dept of Psychology, Richmond, VIC, Australia
Willmont, Catherine
Rothwell, Andrew
Cameron, Peter
Kelly, Ann-Maree
Nelms, Robyn
Curran, Carolyn
Ng, Kim Source: Journal of the International Neuropsychological Society , Vol 6(5), Jul 2000. pp. 568-579. Journal URL: http://uk.cambridge.org/journals/ins/ Publisher: US: Cambridge Univ Press. ISSN: 1355-6177 (Print) Language: English Key Concepts: nature of cognitive & behavioral changes & factors associated with persisting problems at 1 wk & 3 mo postinjury, adults with mild traumatic brain injury Abstract: Investigated the nature of cognitive and behavioral changes associated with mild traumatic brain injury (TBI) at 1 wk and 3 mo postinjury and identified factors associated with persisting problems. A total of 84 adults (mean age 26.4 yrs) with mild TBI were compared with 53 adults (mean age 30.7 yrs) with other minor injuries as controls in terms of postconcussional symptomatology, behavior, and cognitive performance. A detailed history was taken and neuropsychological assessment performed. At 1 wk postinjury, adults with mild TBI were reporting symptoms, particularly headaches, dizziness, fatigue, visual disturbance, and memory difficulties. They exhibited slowing of information processing on neuropsychological measures, namely the Wechsler Adult Intelligence Scale--Revised Digit Symbol subtest and the Speed of Comprehension Test. By 3 mo postinjury, the symptoms reported at 1 wk had largely resolved, and no impairments were evident on neuropsychological measures. However, there was a subgroup of 24% of Ss who were still suffering many symptoms, who were highly distressed, and whose lives were still significantly disrupted. These individuals did not have longer posttraumatic amnesia duration. _____
Record: 27
Title: In-patient neuropsychiatric brain injury rehabilitation. Author(s): Lazaro, Fernando , Edgware Community Hosp, Brain Injury Rehabilitation Unit, London, England
Butler, Rob
Fleminger, Simon Source: Psychiatric Bulletin , Vol 24(7), Jul 2000. pp. 264-266. Journal URL: http://pb.rcpsych.org/ Publisher: England: Royal Coll of Psychiatrists. Publisher URL: ISSN: 0955-6036 (Print) Language: English Key Concepts: time since injury & reason for referral & symptomatic & demographic & diagnostic characteristics of clients admitted to neuropsychiatric rehabilitation center, inpatients with brain injury Abstract: Examined the service offered by an in-patient neuropsychiatric brain injury rehabilitation unit and the demographic details of patients admitted to the unit in order to find the most common reasons for referral. Seventy-three percent were male and the mean age of patients was 45 yrs. Seventy-five percent of admissions had a severe brain injury. Two-thirds of the patients were admitted within six months of the injury. The most common reasons for referral were memory difficulties (61 Ss), verbal aggression (31 Ss), and temper control (25 Ss). In-patient neuropsychiatric brain injury rehabilitation units offer management of patients referred with a wide range of cognitive, behavioural, functional, and physical problems. _____
Record: 28
Title: Impaired social response reversal. A case of 'acquired sociopathy'. Author(s): Blair, R. J. R. , U Coll London, Inst of Cognitive Neuroscience, London, England
Cipolotti, L. Source: Brain , Vol 123(6), Jun 2000. pp. 1122-1141. Journal URL: http://brain.oupjournals.org/ Publisher: England: Oxford Univ Press. Publisher URL: ISSN: 0006-8950 (Print)
1460-2156 (Electronic) Language: English Key Concepts: right frontal region & orbitofrontal cortex trauma, Antisocial Personality disorder acquisition, 56 yr old male, implications for neurocognitive systems involved in social cognition Abstract: Presents the case of a male patient with acquired sociopathy following trauma to the right frontal region, including the orbitofrontal cortex. J. S. (aged 56 yrs) fulfilled the criteria for Antisocial Personality Disorder and was rated at average or above on a number of intelligence measures. J. S. showed no reversal learning impairment, but showed severe difficulty in emotional expression recognition, autonomic responding, and social cognition. He displayed difficulty in identifying violations of social behavior. J. S.'s performance was contrasted with another patient who also presented with a grave dysexecutive syndrome but no socially aberrant behavior, and with 5 prison inmates with developmental psychopathy. Results show that acquired sociopathy is distinguishable from developmental psychopathy and need not be associated with general reversal learning impairments. It is not an inevitable result of executive dysfunction. It is concluded that multiple neurocognitive systems are involved in social cognition. _____
Record: 29
Title: Foreign accent syndrome following a catastrophic second injury: MRI correlates, linguistic and voice pattern analyses. Author(s): Carbary, Timothy J. , Michigan State U, East Lansing, MI, US
Patterson, Janet P.
Snyder, Peter J. Source: Brain & Cognition , Vol 43(1-3), Jun-Aug 2000. pp. 78-85. Journal URL: http://www.academicpress.com/b&c Publisher: US: Elsevier Science. ISSN: 0278-2626 (Print) Language: English Key Concepts: foreign accent syndrome & linguistic & phonetic & acoustic speech characteristics, 51 yr old male following head & throat trauma & previously injured left frontal cortex Abstract: Presents a case of foreign accent syndrome (FAS) following head and throat trauma from a physical assault, with discussion of anatomical localization of injury and comparisons of pre- and postinjury linguistic, phonetic, and acoustic speech characteristics. Because the 51 yr old male patient's injury and symptoms were unrelated to a previously injured left frontal cortex, the authors suggest that FAS has a primary subcortical involvement. This case was also accompanied by a deficit in linguistic, but not affective, prosodic expression. The foreign quality of the FAS speech is a perceptual impression of the listener and not inherent in the patient's vocalization. _____
Record: 30
Title: Signal-to-noise ratio sensitivity in ERPs to stimulus and task complexity: Different effects for early and late components. Author(s): Cudmore, Linda J. , U Waterloo, Waterloo, ON, Canada
Segalowitz, Sidney J. Source: Brain & Cognition , Vol 43(1-3), Jun-Aug 2000. pp. 130-134. Journal URL: http://www.academicpress.com/b&c Publisher: US: Elsevier Science. ISSN: 0278-2626 (Print) Language: English Key Concepts: tone discrimination stimulus difficulty with vs without working memory task, signal-to-noise ratio of early & late ERP components, college students with mild traumatic brain injury Abstract: Investigated signal-to-noise ratio of early and late event related potential (ERP) components and how well individual ERP trials correlated with overall averaged ERP. Continuous EEG activity was recorded from 57 university students during single- and dual-task conditions during easy and difficult tone discrimination and with vs without a verbal working memory task. 38 of the students had suffered mild traumatic brain injury. For early components, the addition of the 2nd task increased the correlations between the individual trials and the averaged ERPs. For the late components, both the addition of the 2nd task and an increase in stimulus difficulty decreased individual trial correlations. The results suggest that the signal-to-noise ratio analysis is a useful method for highlighting differences between early and late components associated with stimulus processing manipulations. _____
Record: 31
Title: Writing and rewriting numerals: A dissociation within the transcoding processes. Author(s): Grana, Alessia , U Trieste, Dept of Psychology, Trieste, Italy
Girelli, Luisa
Semenza, Carlo Source: Brain & Cognition , Vol 43(1-3), Jun-Aug 2000. pp. 224-228. Journal URL: http://www.academicpress.com/b&c Publisher: US: Elsevier Science. ISSN: 0278-2626 (Print) Language: English Key Concepts: errors in transcoding verbal to Arabic numerals, 24 yr old woman with traumatic brain injury Abstract: The case of A.B. is reported. A.B. is a 24 yr old female patient who had suffered a traumatic brain injury. She has a specific, though not isolated, deficit in transcoding verbal to Arabic numerals. Despite perfect production of Arabic numerals in a writing to dictation task, she frequently produced syntactic errors when the input was in written verbal form (e.g., duecentotrenta [two hundred and thirty] was written as "20030"). In absence of problems in the verbal comprehension system, A.B.'s performance is difficult to accommodate within current models of number processing. In the attempt to interpret the present findings, the authors suggest that different numerical codes, i.e., spoken and written verbal numerals, activate the transcoding algorithm with different efficiencies. _____
Record: 32
Title: Age effects on long-term neuropsychological outcome in paediatric traumatic brain injury. Author(s): Verger, K. , U Barcelona, Barcelona, Spain
Junque, Carme
Jurado, M. A.
Tresserras, P.
Bartumeus, F.
Nogues, P.
Poch, J. M. Source: Brain Injury , Vol 14(6), Jun 2000. pp. 495-503. Journal URL: http://www.tandf.co.uk/journals/tf/02699052.html Publisher: US: Taylor & Francis. Publisher URL: http://www.taylorandfrancis.com ISSN: 0269-9052 (Print)
1362-301X (Electronic) Digital Object Identifier: http://dx.doi.org/10.1080/026990500120411 Language: English Key Concepts: age at injury & long-term neuropsychological impairment, 6-23 yr olds who sustained traumatic brain injury at least 6 yrs prior Abstract: In order to investigate the relationship between age at injury and long-term neuropsychological impairment, 29 children and adolescents (aged 6-23 yrs) who sustained traumatic brain injury (TBI) were studied at least 6 years post-trauma. Tests of intellectual, memory, visuospatial, and frontal lobe functions were administered to patients and 29 normal matched control Ss. Correlations between performance on neuropsychological tests and age showed the following direction: the younger the child when TBI was sustained, the worse the cognitive outcome. After controlling for injury severity, visuospatial functions remained related to age. Patients' performance differed significantly from that of controls in half of the neuropsychological variables analyzed. To further investigate the effects of age at injury, the sample was divided into 2 groups (TBI before and after age of 8) and then compared with their respective controls. Patients damaged earlier presented impaired intellectual and visuopsatial functions. The results suggest that neuropsychological sequelae remain after at least 6 years of evolution, and there is an age at injury effect. _____
Record: 33
Title: Long-term mortality trends in patients with traumatic brain injury. Author(s): Baguley, Ian , Westmead Hosp, Brain Injury Rehabilitation, Westmead, NSW, Australia
Slewa-Younan, Shameran
Lazarus, Ross
Green, Alisa Source: Brain Injury , Vol 14(6), Jun 2000. pp. 505-512. Journal URL: http://www.tandf.co.uk/journals/tf/02699052.html Publisher: US: Taylor & Francis. Publisher URL: http://www.taylorandfrancis.com ISSN: 0269-9052 (Print)
1362-301X (Electronic) Digital Object Identifier: http://dx.doi.org/10.1080/026990500120420 Language: English Key Concepts: sex & age differences & level of functional independence, long term mortality trends, patients with traumatic brain injury, 10 yr study Abstract: Comparison of long-term mortality rates between patients with traumatic brain injury (TBI) and the general population has not been adequately investigated. This project aimed to obtain information on the long-term mortality rate of patients with TBI. Using a rehabilitation database of a major teaching hospital, the search identified 476 patents, of whom 27 were deceased. This mortality rate (5.7%) was compared with the expected mortality rate for an equivalent population without TBI (1.5%) using Australian Life Table data. Women were relatively under-represented in this subsample. Possible reasons for this finding are discussed. _____
Record: 34
Title: Psychiatric treatment outcome following traumatic brain injury. Author(s): Burg, Joanna S. , Northwestern U, Medical School, Dept of Psychiatry & Behavioral Sciences, Chicago, IL, US
Williams, R.
Burright, R. G. < |
