Posters presented at the annual meeting of the American Neuropsychiatric Association in Florida in February, 2000 and published in the Journal of Neuropsychiatry and Clinical Neurosciences.

Promoting Ethics and Objectivity: Recommendations for Experts.

Martelli, M.F., Zasler, N.D. & Grayson, R.L. (2000). Promoting Ethics and Objectivity: Recommendations for Experts. The Journal of Neuropsychiatry and Clinical Neuroscience, 12, 1, 152.

Specific training for medicolegal evaluation is not always obtained by professionals prior to performing such evaluations and most practitioners possess little training or expertise in identifying and coping with the various potential ethical conflicts that arise in this arena. A literature review resulted in generation of the following recommendations for promoting ethical conduct:

Protocol for Management of Emotional Incontinence Following Stroke and Neurologic Illness

Michael F. Martelli, Ph.D and Nathan D. Zasler, MD

Concussion Care Centre of Virginia and Pinnacle Rehabilitation

Martelli, M.F. & Zasler, N.D. (2000). Protocol for Management of Emotional Incontinence Following Stroke and Neurologic Disease. The Journal of Neuropsychiatry and Clinical Neuroscience, 12, 1, 152.

Emotional incontinence is a frequently observed phenomenon following stroke. Emotional incontinence is typically characterized by easy, frequent tearfulness and is usually triggered by relatively innocuous events that usually elicit only milder emotional reactions. The emotional expression associated with it is usually relatively superficial, is most often regarded as exaggerated and unintentional, and is often easily redirected. It is frequently experienced after neurologic insult, especially stroke, and especially early after insult, although it can also be quite persistent. It is thought to be accounted for by disconnection between temporolimbic emotional processing centers and bulbar centers that control gestural / emotional expression. It is contrasted with genuine grief and distress reactions where the releaser is significant and powerful and the emotional reactions strong and consistent (e.g., catastrophic reaction to inability to express an important need or recent discovery of paralytic limb). Importantly, emotional incontinence can be disruptive socially and vocationally and can be accompanied by significant anticipatory and reactive embarassment that can lead to social avoidance. In working with patients to increase control of emotional incontinence, we have developed a 4 step self-control procedure called Re-L.I.F.E.. The general outline for the procedure is as follows: Re: L-Label: feelings as illegitimate, hyper-intensified emotions (e.g., Pseudo (inflated) Bulbar Emotion!; Re I - Interpret: them as Emotional Incontinence in which nerves connecting the brain's emotional experience centers to emotional expression muscles are weakened - resulting in decreased control & exaggerated release of emotion!; Re F- Focus: on anything less distressing, more pleasant, different, for attention redirection, disrupting intensified emotional expression & restoring control!; Re E - Evaluate: Decide that the involuntary crying (or laughing) is Illegitimate, False Information. Dismiss it and Restore Control through re-focusing attention!

Notably, personalized posters & graphic representations are typically employed to assist with learning and application of this intervention. Case study efficacy data are presented that show that when this"self-talk" self-control procedure was employed consistently, especially with reminders from others, it developed into an effective control mechanism that greatly reduced expressions of emotional incontinence.

MacMillan, P.J., Martelli, M.F., Hart, R.P. & Zasler, N.D. (2000). Vulnerability to Disability Following Traumatic Brain Injury. Presented at the 11th Annual Meeting of the American Neuropsychiatric Association, Fort Myers, Florida.

Adaptation Following Traumatic Brain:

A Vulnerability, Stress and Coping Model

Pamela J. MacMillan 1,4, Michael F. Martelli2,3, Robert P. Hart3 and Nathan D. Zasler2

1Sheltering Arms Physical Rehabilitation

2Concussion Care Centre of Virginia, Ltd. and Tree of Life,

3Virginia Commonwealth University / Medical College of Virginia

4 The College of William and Mary in Virginia

Abstract

There an estimated 2 million Traumatic Brain Injuries (TBI) each year in the United States and psychosocial and neurobehavioral disorders, versus physical impairments, are the most disabling condsequences. Variability in outcome following TBI is more often the rule than the exception, and this phenomenon is not well understood. Overwhelmingly, outcome studies have focused on the effect of post-injury variables and generally employed gross measures of physical and cognitive status versus quality of life and adaptation to disability. Many studies have excluded persons with psychiatric and substance abuse histories. There is increasing appreciation, however, that pre-injury characteristics such as coping history may influence outcome and contribute to individual variability in terms of vulnerablity to persistent disability. This vulnerability likely reflects a complex combination of both premorbid and post-injury variables. This formulation was the framework for the present study of outcome following moderate and severe. Forty-five adults at least two years post moderate or severe TBI were evaluated. Pre-injury psychiatric and pre-injury substance abuse histories, in addition to levels of social support after TBI, were measured for each subject. It was hypothesized that persons with more severe premorbid psychiatric and substance abuse histories in addition to less social support following their brain injuries would demonstrate poorer adaptation. Subjects were rated on the following four outcome measures: employment status, independent living status, self-assessment of neurobehavioral functioning, and a significant others's assessment of their neurobehavioral functioning. Pre-injury psychiatric and substance abuse histories predicated employment status. Pre-injury substance history predicted independent living status. Social support following TBI predicted signficant other's assessment of patient's neurobehavioral status. None of the independent variables were found to predict patient assessment of his or her neurobehavioral functioning.

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Introduction

Traumatic brain Injury (TBI) constitutes a major health and societal problem in the United States of America. Traumatic Brain injuries occur in a tri-modal distributaiton with the highest incidence in children (i.e. younger than 5 years old), young adults (i.e. 16 to 34 years), and adults (i.e. 65 years and older, Cifu, et. al., 1996). TBI rates are highest for males age 15 to 24 years and for both sexes after the age 70 (Reeder, et al., 1996). In general, adult men represent two-thirds of the brain injuries sustained between ages 15 to 70. It is well-known that reovery from brain injury is a long term process and that there significant patient diveristy in long-term outcome. TBI outcomes range from subtle changes in personality to profound physical, cognitive, and psychosocial disability. It is also widely accepted that neurobehavioral, cognitive, and adjustment difficulties, versus physical impairments, represent the most disabling long-term effects of TBI (Schalen, 1994).

Outcome Following Traumatic Brain Injury

Outcome from moderate to severe brain injury is difficult to prognosticate precisely. There is a great deal of individual variability in patient recovery. Persons with TBI represent a diverse group. To some extent, this observed diversity is a a function of pr-injury differences in personality, social roles, and intellect (Mayer, Kearting, & Rapp, 1986). Additionally, diverisity in patient outcome arises from post-injury differences in pathophysiology and associated sequelae (Levin, Benton, & Grossmanm, 1982). Furthermore, outcome, at least in the survivor's view can be subjective. What one patient and family may consider "positive" may be viewed as an insurmountable loss by another individual and his or her family.

Previous research has demonstrated that post-injury variables impact outcome. Variables such as length of coma, duration, of post-traumatic amnensia, the presence of seizures, and type of brain injury as well documented and known to influence outcome from traumatic brain injury (Alexandre, 1983; Johnston & Hall, 1994; Ruffm Marshall, Crouchm, Klauber, Levin, Barth, Kreutzer, Blunt, Foukles, Eisenbergm Jane, & Mamarou, 1993, Zasler, 1997). In addition, pre-injury status appears to influence otucome and may be particularly important when evaluating long-term outciome and adaptation following brain injury (Martelli, Zasler, & Braith, 1996).

In limitied studies, is has been found that persons with a pre-injury history of substance abuse, psychiatric disorder, low intelliegence, and poor occupational adjustment tend to have more complicated recoveries than similarly injured patients without such histories (Dawson & Chipman, 1995; Thomsen, 1992). Researchers, however, have paid less attention to the premorbid factors that might influence outcome, possibly in part, because of the difficulty in obtaining reliable information and the vast aray of characteristics and events from which to choose (Dikmen, Machamer, Donovan, Wirm, & Terakin, 1995).

It is intuitively appealing to acknowledge that when a traumatically brain injured person is confronted with the long-term outcome of TBI, premorbid psychological coping characteristics appear quite important. The impact of the interaction between premorbid and post-injury personality variables and long-term outcome has not yet been determined but given the variability in patient recovery, investigation is warranted (Prigatano, 1986).

It is widely accepted, however, that premorbid intellectual personality, and sociocultural interact with acquired brain injury to produce a complex symptom picture (Prigatano, 1986). Statements attributing post-injury behavioral disturbances soley to cerebral inslut are "probably simplistic explanations" (Ewing-Cobb, Fletcher, & Levin, 1985, p. 74). Clinicians involved in the rehabilitation of persons with TBI are frequently impressed that personality variables, both pre- and post-injury, contribute greatly to long-term outcome (Gans, 1983).

Stress and Coping Models of Adaptation Following Injury

Increasingly sophisticated models of behavior are emerging in the fields of medicine and psychology that assist with conceptualizing and designing treatment interventions for challenging health care situations. Biopsychosocial models represent alternative theoretical approaches to dualistic and reductionistic biomedical models that explain disease and health primarily in terms of measurable biological variables. A stress, coping and vulnerability formulation of brain injury postulates that the injury results in multiple cognitive, emotional, social and neurophysical demands which constitute, singularly and in combination, severe stressors which not only challenge the coping capabilities of the individual, but directly diminish available resources through loss of premorbid skills and a combination of reductions in social and financial supports (Martelli, Braith and MacMillan, 1992). This formulation includes a complex interaction of factors surrounding brain injury, the history the individual brings to the injury, and the environment that the individual confronts afterwards.

In 1992, Kay proposed a concept of individual vulnerability suggests that a large number of variables, ranging from biological to psychosocial, influence the impact and outcome of a brain injury for any given individual. Individual differences in brain structure, hormonal and neurotransmitter balances and other biologic systems represent preinjury differences that may render one brain more susceptible to, or magnify, neurologic impairment. Subsequently, a wide variety of personality and psychosocial variables interact to with the particular impairments to produce a unique functional outcome.

Satz (1993), after reviewing the clinical literature proposed a "threshold factor" to account for instances of protection from, or vulnerability to, clinical symptoms when the central nervous system is diseased. The concept of "brain reserve capacity", as espoused by Satz, offers a useful explanation of threshold differences in the onset of clinical symptoms or the expression of disabilities after brain injury. Psychosocial factors, intelligence and educational level, represent indirect, albeit imprecise, measures of this construct.

When an individual sustains a brain injury, a dramatic imbalance in psychological, biological and environmental function occurs. The observed diversity in individual outcome certainly reflects the influence of pre-injury differences in neurologic status, personality and coping skills, intellect, and social resources and roles (Mayer, Keating, & Rapp, 1986) interacting with post-injury differences in pathophysiology and associated sequelae (e.g., Levin, Benton, & Grossman, 1982), and changing environmental demands. Neurologic disease occurs within a multiaxial matrix of a person's physiologic, psychologic and social history and environment to produce a complex presentation where diversity in outcome is expected. In conceptualizing adaptation and outcome from a "demands versus resources" model, Satz argues that an individual's unique history is critical in determining what vulnerabilities and resources he or she brings to the injury, as these resources act as "deposits" in a resource "bank" that enhance future adaptation (Satz, 1993).

When confronted with managing the long term impact of brain injury, an individual's premorbid personality and coping resources, including premorbid intellectual, personality and sociocultural factors, interact with the sequelae of acquired brain injury to produce a complex symptom picture (e.g., Prigatano, 1986). This conceptualization is consistent with the stress and coping literature (Lazarus & Folkman, 1984), which conceptualizes coping as an individual's cognitive and behavioral efforts to master demands and conflicts, including the sequelae of neurologic disease, and where an individual's traditional mastery of coping is expected to influence his or her responses to injury.

In one of the few empirical investigations of a theoretical model derived from the cerebral reserve/individual vulnerability and stress and coping literature, Martelli, et al. (1996) investigated the hypothesis that individuals possess adaptational reserve for meeting neurologic and other demands. They posited that greater degrees of reserve would be associated with higher levels of resilience and improved adaptation and recovery from neurologic trauma, and that, to the extent that the adaptational reserve is limited, or previously depleted, individuals can be expected to demonstrate increased vulnerability and poorer response to the adaptational demands of brain injury. Their preliminary investigation defined vulnerability in terms of the sum and degree of negative prognostic indicators, and employed a composite rating in order to evaluate their collective effect on disability status and vocational outcome following cerebral trauma.

These findings offer strong preliminary support for the utility of a composite prognostic indicator approach to predicting outcome following traumatic brain injury, as measured by vocational and disability status. The finding that a simple, linear combination score was highly reliable in predicting outcome variables further suggests that this combination of variables is relatively robust.

More importantly, the study results offer strong preliminary support for the utility of a vulvulnerability theory of adaptation following brain injury that includes both neurologic and psychosocial variables. This study, which represents one of the few to investigate the specific concepts of individual vulnerability and cerebral reserve, and multifactorial, biopsychosocial interactive models for assessing impact of injury and illness on adaptation, coping, and disability, appears to offer promising utility and additional investigation is warranted

Previous research has provided a more than adequate foundation for understanding functional oucome following TBI. Additional research is indicated to evalualte the combined effects of multiple variables upon an individual's residual level of disability. Evaluating the influence of premorbid and post-injury variables should result in better predictions with increased understanding of the risk factors associated with TBI and the design of more appropriate intervention programs.

Current Study

The following study is a partial extension of Martelli's and others' 1996 investigation narrowed the focus on the investigation to evalluate the combined influence of psychological factors (i..e. premoribd psychiatric history, social (i.e. perceived level of social support after injury) and biological (i.e. substance abuse history ) following TBI. This study looks at pre-injury psychological status, substance abuse history which includes a strong biological component, and social support which evaluates the survivor's social environment. The purpose of this study is to answer the following research question: What is the influence of pre-injury psychiatric history and substance abuse history coupled with post-injury social support upon long-term outcome after moderate and severe traumatic brain injury?

Subjects and Methods

The sample consisted of 45 adults receiving both follow-up rehabilitation medicine or neurpsychological services at least two years post moderate or severe TBI. Ages ranged from 24 to 63 years old, with a mean age of 43 years. Twenty-nine participatants were male and 116 were female. Time since TBI ranged from two to twenty-nine years. Mean number of years since brain injury was ten years. Median time since injury was two years; mode was ten years.

Brain injury survivors and as significant other such as a family member, friend, or caregiver were requested to meet with the researcher for a brief interview and completion of several questionnaires. Notably, no persons declined participation in the study. Based on the patient's and significant others' report in conjunction iwth medical records, the reseacher rated the patient in terms of the following variables: premorbid psychiatric history and premorbid substance abuse history. The researcher rated psychiatairc and substance histories as none, mild, moderae and severe based on a scale created for this study to avoid using dicochotomous categories such as present or absent. Medical records were thoroughly reviewed to ascertain type of injury, premorbid psychiatric and substance histories. Current employment and independent living status were ascertained by consensus of medical record review with significant other and patient report. Employment status was rated as follows: disabled, unemployed, sheltered work shop, supported employment, full-time competive employment, homemaker, full time student, or volunteer. Living satus was rated as: nursing home, assisted living facility/adult home, home with assistance in activities of daily living such as dressing and bathing, home with supervision in medications/finances, or independent living.

The Neurobehavioral Functioning Inventory (Kreutzer, et. al., 1996) was utilized to measure current cognitive, physical, and emotional functioning. The Lubben Social Network Scale (1988) was employed to measure the brain injured participant's current social support system. Brain injured participants were requested to complete the patient form of the Neurobehavioral Functioning Inventory as well as The Lubben Social Network Scale. A significant other or family member identified by the patient was requested to complete the family form of the Neurobehavioral Functioning Inventory to glean their assessment of the patient's functioning.

Procedure

Informed consent for participation in the study was obtained from patients on arrival for their regularly scheduled appointment. The purpose of the investigation and the nature of the questionnaire were described both verbally and in writing. Each eligible patient was given a packet and asked to complete the questionnaires and ask a significant other to complete the family form of the Neurobehavioral Functioning Inventory at home. Completed questionnaires were returned either by mail or duing the patient's next appointment. Those persons who did nto return for an appointment or mail their packets were contacted by the examiner, yield ing a statisfactory overall completion rate of 89%.

Results

Correlation analysis fiollowed by a stepwise linear regression procedure was employed to examine the combined efffects of premorbid psychiatric history and substance abuse history and post-injury social support on employment status. Premorbid psychiatric status and substance abuse history were significantly positively correlated with lower employment status following TBI (r=.69 and .54 respectively, p < .01) while post-injury social support was not (r=-.15, p> .16), showing only a weak trend toward a negative association with lower employment status. With regard to the interrelationship of subject (i.e. vulnerability variables premorbid psychiatric and substance abuse history had a strong postive association (r=.46, p<.01) while neither was correlated with post-injury social support (r approximately 0 fir both, with P>.5). Premorbid psychiatraic history and substance abuse history and post injury social support proecuded a two variable model with premorbid psychiatric and substance abuse history predicting, and accounting for 54% of the variation in employment status. As hypothesized, more severe history of psychiatric difficulties and substance abuse.

The utility of employing a simple, linear combination of predictor variables (i.e. simple addition of rating scores for premorbid psychiatric and substance abuse histories were employed using a chi square analysis. Subjects were spilt into low and high vulnerability groups. Only 2 of the 20 persons in the high vulnerability grup were working and this was in only a part time capacity. In contrast, only 17% (4 of 23) of the low vulnerability subjects were not employed (X2 [2, N=45, p<.001] =25.3).

Both premorbid psychiatric status and substance abuse were significantly positively correlated with lower independent living status (r=.38 and .57 respectively and p <.01, respectively) while post-injury social support demonstrated no assocation (r=.06, p>.5). Premorbid psychiatric and substance abuse history and post- injury social support on living status produced a one variable model with premorbid substance abuse history showing moderate prediction and accounting for 33% of the variance, for living status (F(1,43)= 20.97, p<.001; R2=.33).

In order to facilitate this analysis, premorbid substance abuse history was spilt into low and high risk groups. Ninety percent of persons with no significant premorbid substance abuse were living independently, while only a small minority (i.e. 23 or 3 of 13) of those with premorbid substance abuse were living independently, while only a small minority (i.e. 23% or 3 of 13) of those with premorbid substance abuse were living independently. Pre-injury substance abuse was found to moderately predict independent living status after brain injury, while pre-injury psychiatric history and post-injury social support did not add to the prediction.

None of the predictor variables were significantly correlated with patient rated assessment of neurobehavioral status (absolute values of r's <.15, p's > = .2). No combination of the variables significantly predicted self-rated neurobehavioral status. Forcing the three variables into a simple linear regression analysis demonstrated this non-significant relationship.

Initial correlation analysis followed by a stepwise linear regression procedure was employed to examine the combined effects of premorbid psychiatric and substance abuse histories in addition to less social support following injury will demonstrate poorer post-injury as measured by a family member's or significant other's rating of their post-injury adjustment on family rated patient neurobehavioral funtioning showed that only social support on the Lubben measure was significantly correlated with family rated pagtient neurobehavioral status (r=-36, p < .01). This negative association indicates that higher patient perceived social support is associated with less family rated neurobehavioral dysfunction (or higher levels of neurobehavioral functioning). Examing the combined effects of premorbid psychiatric and substance abuse history and post-injury social support on family rated patient neurobehavioral status revealed s single variable model that significantly predicted, and accounted for 12.7% of the variance for family rated patient neurobehavioral status (F (1,43)=6.2, p <.05; R2=.127). Post-injury social support was found to significantly predict family or significant other's rating of subject functioning on the Family Form of the Neurobehavioral Functioning Inventory. Pre-injury psychiatric history and substance abuse hsigtory did not add to the prediction.

Discussion

Results of this exploratory research are promising. Clearly premorbid psychiatric and substance abuse histories exert a strong influence on how well an individual will cope with and adapt to additional life challenges such as TBI. It is notable to social support did not offer additional perdictive valude in employment, living status or self-assessment of neurobehavioral functioning. The finding that social support following injury predicted family member's evaluation of subject functioning may reflect the significant other's investment in the brain injury survivor's functioning. That is, perhaps the significant other is invested in viewing the brain injured person as functioning more adaptively given his or her involved in the patient's life.

The results of this study offer information for brain injury survivors, their families, health care professionals, and managed care. It seems apparent that individuals with premorbid coping liabilities will require more assistance and support in order to achieve maximal functioning. These persons should not be thought of as treatment failures, but rather, additional or pehaps qualitatively different rehabilitative services should be provided for them in order to promote independent functioning. Insurance companies have been known to deny brain injured persons treatment for psychiatric problems based on the belief that these difficulties were not related to or influenced by the brain injury. Clearly this appears to be a simplistic or reductionistic formulation of an indiviudal's functioning and does nto adequately address the whole person. Hopefully, the results of this study will add support to the premise that some persons are simply more vulnerable to disability than others, and therefore, require either different or additional post-injury assistance that might increase reimbursement for services.

Limitations

This is a correlational study with the goal of prediction; therefore one cannot infer causality. Caution is appropriate in interpretation. In addition, methodological limitations, including a lack of well accepted and established rating scales for rating psychiatric and substance abuse hstisory represent potenional compromises of internal validity. To counter balance this threat, the researcher utilized multiple data sources including family and patient report with thorough medical record review. Any inconsistencies triggered resulted in seeking clarification and additinal information. If a high confidence could not be achieved with regard to accuracy of information, then that data point was to be excluded. Fortunately, there were no such inaccuracies or conflicts in the patient information obtained.

The extent to which the results of this study can be generalized from the convenience sample to the population of traumatically brain injured adults is limited by the fact that these subjects were not randomly chosen. Furthermore, one of the sites, is a non-profit hospital tha acccepts all patients regardless fo ability to pay; the private practive facility only accepts insured patients. Therefore, this study may include more persons who possess fewer social and financial resources than other similarly brain injured adults. Efforts to balance the number of subjects from each site were made in order to minimize the possibility of overrepresentation of poorly insured persons who have fewer resources in general and would hence limit variablity.

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Table 1: TBI Vulnerability Scale

Vulnerability Indicator Information Source
___Length of PTA
  • 1 < 20Min
  • 2 > 20Min <24Hrs
  • 3 < 24Hrs < 1Week
  • 4 > 1Week < 4Weeks
  • 5 > 4Weeks
  • ___Premorbid Neurologic Status
  • 0 = No Neuro Involvement;
  • 1 = Mild Neuro Involvement
  • 2 = Signif. Neuro Involvement
  • ___Premorbid Psychiatric Status
  • 0 = No Psychiatric History
  • 1 = Mild
  • 2 = Moderate
  • 3 = Severe
  • ___Estimated Premorbid IQ
  • 0 = SUPERIOR
  • 1 = HIGH AVG
  • 2 = AVERAGE
  • 3 = LOW AVG
  • 4 = BORDERLINE
  • ___Post-Traumatic Seizures
  • 0 = No Seizures
  • 1 = Seizures in Past
  • 2 = Current Seizures and Past
  • ___Marital Status
  • 0 = Married/Cohabitating
  • 1 = Steady Romance
  • 2 = No Romantic Relationship
  • ___Type of Injury
  • 1 = Gun Shot/Penetrating Missile
  • 2 = Fall
  • 3 = Motor Vehicle Accident
  • ___Victim/No Fault
  • 0 = No Fault
  • 1 = Victim
  • ___Collateral Injuries
  • 0 = None/nonsignificant
  • 1 = Mild or Singular
  • 2 = Multiple or Severe
  • 3 = Severe, Multiple
_____Vulnerability Score (sum)
Available medical records;

Secondary 'reliable' collaborative report if required

Consensual ratings from available medical records; Secondary 'reliable' collaborative reports

Consensual ratings based on available medical records, sefl-report, and family interview

Consensual rating based primarily on Barona et al (1984) formula Available medical records;

Secondary 'reliable' collaborative report

Medical Records; Self-report; Collaborative report

Self-report; Collaborative report

Available medical records and 'reliable' collaborative report

Structured interview, review of available medical records, and collaborative report

Consensual ratings of available medical records, examination, and/or 'reliable' collaborative report

Composite score produced by summation

Table 2. Current Work Status for High and Low Vulnerability Groups

Current Work Status By Vulnerability Code
CURRENT WORK

STATUS

  HI-RISK

LOW-RISK Total
  Not Working / No School 7 6 13
  Part-Time Work/ School 1 6 7
  Full-Time Work/ School 0 8 8
  Total 8 20  
  p < .01

Table 3. Current Disability Status for High and Low Vulnerability Groups

Current Disability Status By Vulnerability Code
CURRENT

DISABILITY

STATUS

  HI-RISK LOW-RISK Total
  No Disability 2 14 16
  Receiving Disability 6 6 12
  Total 8 20  
  p < .05