Joseph J. Fins calls for a reconsideration of severe brain injury treatment, including discussion of public policy and physician advocacy.

IntroductionEspecially in the chronic phase, individuals with traumatic brain injury may still have impairments at the discourse level, even if these remain undetected by conventional aphasia tests. As a consequence, IwTBI may be impaired in conversational behavior and disadvantaged in their socio-communicative participation. Even though handling discourse is thought to be a basic requirement for participation and quality of life, only a handful of test procedures assessing discourse disorders have been developed so far. The MAKRO Screening is a (...) recently developed screening tool designed to assess discourse impairments. The test construction is based on psycholinguistic frameworks and the concept of macro-rules, which refer to cognitive functions responsible for organizing and reducing complex information in discourse.AimThe aim of our study was to investigate discourse processing in IwTBI in different tasks and to assess problems in communicative participation in the post-acute and chronic phase. In this context, we also aimed to analyze the influence of the severity of the initial impairment and the verbal executive abilities on the discourse performance. Additionally, the impact of macrolinguistic discourse impairments and verbal fluency on perceived communicative participation was targeted in our analysis.MethodsData from 23 IwTBI and 23 healthy control subjects have been analyzed. They completed two subtests of the MAKRO screening: Text production and Inferences. Discourse performance was examined in relation to measures of semantic fluency and verbal task-switching. Socio-communicative problems were evaluated with the German version of the La Trobe Communication Questionnaire.ResultsIwTBI showed lower test results than the control group in the two subtests of the MAKRO-Screening. Difficulties in picture-based narrative text production also indicated greater perceived difficulties in communicative participation. We also found that the subject’s performance on the MAKRO-Screening subtests can partly be explained by underlying dysexecutive symptoms and the severity of their injury. The preliminary results of our study show that cognitive-linguistic symptoms in IwTBI are also evident in the chronic phase. These can be detected with procedures referring to the discourse level, such as the MAKRO-Screening. The assessment of discourse performance should be an integral part in the rehabilitation of IwTBI in order to detect cognitive-linguistic communication disorders and to evaluate their impact on socio-communicative participation. (shrink)

Individuals with Acquired Brain Injury (ABI) suffer chronic impairment across cognitive, physical and psycho-social domains, and the experience of anxiety, isolation and apathy has been amplified by the COVID-19 pandemic. A qualitative evaluation was conducted of 14 individuals with ABI who had participated in series of COVID adapted group-based intervention(s) that had been designed to improve wellbeing. Eight themes were identified: Facilitating Safety, Fostering Positive Emotion, Managing and Accepting Difficult Emotions, Promoting Meaning, Finding Purpose and Accomplishment, Facilitating Social (...) Ties, (Re)Connecting to Nature, and Barriers to Efficacy. Findings are discussed with respects to recent theoretical developments in positive psychology and wellbeing science and support the use of online and outdoor interventions to enhance wellbeing in individuals living with ABI during the COVID-19 pandemic. This paper makes a unique contribution to second wave positive psychology (PP2.0) through the application of recent advances in wellbeing science to an ABI population during the COVID-19 pandemic. In doing so, this paper lays the foundation for new interventions that not only reduce impairment and distress, but also create opportunities for meaning and enhanced wellbeing in people living with chronic conditions and those individuals living with ABI in particular. (shrink)

Circumscribed delusional beliefs can follow brain injury. We suggest that these involve anomalous perceptual experiences created by a deficit to the person's perceptual system, and misinterpretation of these experiences due to biased reasoning. We use the Capgras delusion (the claim that one or more of one's close relatives has been replaced by an exact replica or impostor) to illustrate this argument. Our account maintains that people voicing this delusion suffer an impairment that leads to faces being perceived as drained (...) of their normal affective significance, and an additional reasoning bias that leads them to put greater weight on forming beliefs that are observationally adequate rather than beliefs that are a conservative extension of their existing stock. We show how this position can integrate issues involved in the philosophy and psychology of belief, and examine the scope for mutually beneficial interaction. (shrink)

Background: People with traumatic brain injury face a range of mental health challenges during the adjustment process post-injury, but access to treatment can be difficult, particularly for those who live in regional and remote regions. eHealth provides the potential to improve access to evidence-based psychological therapy for people with a severe TBI. The aim of the current study is to assess the efficacy of a psychological intervention delivered via video consulting to reduce psychological distress in people with TBI.Methods: This (...) paper outlines the protocol for a multi-center, three-arm, parallel, non-inferiority randomized controlled trial of an evidence-based manualized psychological intervention, ACT-Adjust. ACT-Adjust provides nine sessions for adults with a moderate to severe TBI experiencing clinical levels of psychological distress. Fifty-six participants referred from Brain Injury Rehabilitation Units across New South Wales and the NSW icare scheme will be randomly allocated to three conditions; video consulting, face-to-face and, a waitlist control.Discussion: This is the first RCT to evaluate the efficacy of a psychological therapy delivered via video consulting for individuals with a moderate to severe TBI.Trial Registration:www.anzctr.org.au, Australian New Zealand Clinical Trials Registry ANZCTRN2619001602112. (shrink)

Circumscribed delusional beliefs can follow brain injury. We suggest that these involve anomalous perceptual experiences created by a deficit to the person's perceptual system, and misinterpretation of these experiences due to biased reasoning. We use the Capgras delusion (the claim that one or more of one's close relatives has been replaced by an exact replica or impostor) to illustrate this argument. Our account maintains that people voicing this delusion suffer an impairment that leads to faces being perceived as drained (...) of their normal affective significance, and an additional reasoning bias that leads them to put greater weight on forming beliefs that are observationally adequate rather than beliefs that are a conservative extension of their existing stock. We show how this position can integrate issues involved in the philosophy and psychology of belief, and examine the scope for mutually beneficial interaction. (shrink)

In this paper, we explore the issue of the elimination of sports, or elements of sports, that present a high risk of brain injury. In particular, we critically examine two elements of Angelo Corlett’s and Pam Sailors’ arguments for the prohibition of football and Nicholas Dixon’s claim for the reformation of boxing to eliminate blows to the head based on the empirical assumption of an essential or causal connection between brain injuries incurred in football and the development of (...) a degenerative brain disease known as chronic traumatic encephalopathy ; and John Stuart Mill’s rejection of consensual domination. We present four arguments to contest the validity of Corlett, Dixon’s and Sailor’s positions. Specifically, we argue that certain autonomy-based arguments undermine paternalist arguments for reform; the nature of the goods people pursue in their lives might justify their foregoing future autonomy; Mill’s argument against consensual domination draws on ambiguous and arbitrary distinctions; the lack of consensus and empirical evidence regarding CTE arising from brain injuries in sport underdetermines calls for reform. We conclude that these proposals for reforming or eliminating sports with high risks of brain injuries are not well founded. (shrink)

Tilbe Göksun and Anjan Chatterjee Dept. of Psychology, Koç University, Turkey Center for Cognitive Neuroscience, University … Read More →.

This essay addresses the question: What is the probative value of including neuroscience data in court cases where the defendant might have had a traumatic brain injury? That is, this essay attempts to articulate how well we can connect scientific data and clinical test results to the demands of the Daubert standard in the United States’ court system, and, given the fact that neuroimaging is already being used in our courts, what, if anything, we should do about this fact. (...) Ultimately, I am not sure that there are completely satisfactory answers to this query at this particular time in our legal history. I briefly rehearse the recent use of brain research in our legal system, summarize how neuroscience data regarding TBI and its relation to poor behavioral outcomes are currently used in the courtroom, review challenges with using these data, and highlight fundamental tensions between how the legal system views the causes of behavior and how medicine, neuroscience, and psychology do. Until these tensions are resolved, it is unclear the place neuroscience data should have in courts. (shrink)

It is well documented that people with moderate-to-severe traumatic brain injury (TBI) can undergo personality changes, including becoming more impulsive in terms of how they behave. Legal guidance and academic commentary support the view that impulsiveness can render someone decisionally incompetent as defined by English and Welsh law. However, impulsiveness is a trait found within the healthy population. Arguably, impulsiveness is also a trait that gives rise to behaviours that should normally be tolerated even when they cause harm to (...) the person enacting the behaviours. The purpose of this paper is to show why both of these considerations present as significant challenges to the law in England and Wales. (shrink)

Owen, Freyenhagen, and Martin should be lauded for bringing the complexities of competence assessment and acquired brain injury to light. This discussion is often a difficult and vexed exercise for an array of conditions including ABI, and is usually a judgment that is critically important for determining whether or not a patient has the right to make their own decisions. There are a number of themes in their article that chime with ideas developed by Fulford about the nature of (...) illness, and I suggest that, in addition to teasing out some subtleties of competence assessment, they have also explained, in a phenomenologically grounded way, why it is that we should consider ABI an illness.Tests of... (shrink)

After years of skepticism and denials regarding the significance of concussions in sport, the issue is now front and center. This is fitting, given that the impact of concussions in sport is profound. Thus, it is with trepidation that one ventures to direct some attention onto brain injuries other than concussions incurred through sport. Given a closer look, however, it may be that considering various kinds of brain injuries, with different causes, will help us better understand the range (...) and seriousness of brain injuries in sport. My focus is on emotional trauma in sport. I argue that severe emotional pathology is evidence of underlying brain injury. Any attempt to minimize the significance of emotional disturbance that results from emotional trauma as ‘merely’ psychological in nature is thus misguided. (shrink)

Traumatic brain injuries to the frontal lobes are associated with many maladaptive forms of behavior. We investigated the association between brain damage and impulsivity, as measured by the rate of delay discounting. The main aim of this study was to test the hypothesis of steeper discounting of different amounts in a group of patients with frontal lobe damage. We used a delay discounting task in the form of a structured interview. A total of 117 participants were divided into (...) five groups: three neurological groups and two groups without brain damage. Our analyses showed that patients with focal damage to the frontal lobes demonstrated steeper delay discounting than other participants. Other clinical groups demonstrated similar discounting rates. The data pattern related to the magnitude effect on the group level suggested that the magnitude effect is absent in the group of patients with damage to the frontal lobes; however, results were less consistent on an individual level. Amount-dependent discounting was observed in only two groups, the healthy control group and the neurological group with other cortical areas damaged. (shrink)

Chronic back pain (CBP) is a leading cause of disability and results in considerable socio-economic burdens worldwide. Although CBP patients are commonly diagnosed and treated with a focus on the ‘end organ dysfunction’ (i.e., peripheral nerve injuries or diseases), the evaluation of CBP remains flawed and problematic with great challenges. Given that the peripheral nerve injuries or diseases are insufficient to define the etiology of CBP in some cases, the evaluation of alterations in the central nervous system becomes particularly (...) necessary and important. With the development of advanced neuroimaging techniques, extensive studies have been carried out to identify the cortical abnormalities in CBP patients. Here, we provide a comprehensive overview on a series of novel findings from these neuroimaging studies to improve our understanding of the cortical abnormalities originated in the disease. First, CBP patients normally exhibit central sensitization to external painful stimuli, which is indexed by increased pain sensitivity and brain activations in pain-related brain regions. Second, long-term suffering from chronic pain leads to emotional disorders, cognitive impairments, and the abnormalities of the relevant brain networks among CBP patients. Third, CBP is associated with massive cortical reorganization, including structural, functional, and metabolic brain changes. Overall, a deep insight into the neural mechanisms underlying the development and outcome of CBP through more sophisticated neuroimaging investigations could not only improve our current understanding of the etiology of CBP but also facilitate the diagnosis and treatment of CBP based on precision medicine. (shrink)

Assessment of decision-making capacity (DMC) can be difficult in acquired brain injury (ABI) particularly with the syndrome of organic personality disorder (OPD) (the “frontal lobe syndrome”). Clinical neuroscience may help but there are challenges translating its constructs to the decision-making abilities considered relevant by law and ethics. An in-depth interview study of DMC in OPD was undertaken. Six patients were purposefully sampled and rich interview data were acquired for scrutiny using interpretative phenomenological analysis. Interview data revealed that awareness of (...) deficit and thinking about psychological states can be present. However, the awareness of deficit may not be “online” and effectively integrated into decision-making. Without this online awareness of deficit the ability to appreciate or use and weigh information in the process of deciding some matters appeared absent. We argue that the decision-making abilities discussed are: (1) necessary for DMC, (2) threatened by ABI, and (3) assessable at interview. Some advice for practically incorporating these abilities within assessments of DMC in patients with OPD is outlined. (shrink)

Metabolic dysfunction is a ubiquitous underlying feature of many neurological conditions including acute traumatic brain injuries and chronic neurodegenerative conditions. A central problem in neurological patients, in particular those with traumatic brain injuries, is an impairment in the utilization of glucose, which is the predominant metabolic substrate in a normally functioning brain. In such patients, alternative substrates including ketone bodies and lactate become important metabolic candidates for maintaining brain function. While the potential neuroprotective benefits of (...) ketosis have been recognized for up to almost a century, the majority of work has focused on the use of ketogenic diets to induce such a state, which is inappropriate in cases of acute disease due to the prolonged periods of time (i.e., weeks to months) required for the effects of a ketogenic diet to be seen. The following review seeks to explore the neuroprotective effects of exogenous ketone and lactate preparations, which have more recently become commercially available and are able to induce a deep ketogenic response in a fraction of the time. The rapid response of exogenous preparations makes their use as a therapeutic adjunct more feasible from a clinical perspective in both acute and chronic neurological conditions. Potentially, their ability to globally moderate long-term, occult brain dysfunction may also be relevant in reducing lifetime risks of certain neurodegenerative conditions. In particular, this review explores the association between traumatic brain injury and contusion-related dementia, assessing metabolic parallels and highlighting the potential role of exogenous ketone and lactate therapies. (shrink)

As improvements in neuroscience have enabled a better understanding of disorders of consciousness as well as methods to treat them, a hurdle that has become all too prevalent is the denial of coverage for treatment and rehabilitation services. In 2011, a settlement emerged from a Vermont District Court case, Jimmo v. Sebelius, which was brought to stop the use of an “improvement standard” that required tangible progress over an identifiable period of time for Medicare coverage of services. While the use (...) of this standard can have deleterious effects on those with many chronic conditions, it is especially burdensome for those in the minimally conscious state, where improvements are unpredictable and often not manifested through repeatable overt behaviors. Though the focus of this paper is on the challenges of brain injury and the minimally conscious state, which an estimated 100,000 to 200,000 individuals suffer from in the United States, the post-Jimmo arguments presented can and should have a broad impact as envisioned by the plaintiffs who brought the case on behalf of multiple advocacy groups representing patients with a range of chronic care conditions. (shrink)

Over 40 years of research have shown that traumatic brain injury affects brain volume. However, technical and practical limitations made it difficult to detect brain volume abnormalities in patients suffering from chronic effects of mild or moderate traumatic brain injury. This situation improved in 2006 with the FDA clearance of NeuroQuant®, a commercially available, computer-automated software program for measuring MRI brain volume in human subjects. More recent strides were made with the introduction of NeuroGage®, (...) commercially available software that is based on NeuroQuant® and extends its utility in several ways. Studies using these and similar methods have found that most patients with chronic mild or moderate traumatic brain injury have brain volume abnormalities, and several of these studies found—surprisingly—more abnormal enlargement than atrophy. More generally, 102 peer-reviewed studies have supported the reliability and validity of NeuroQuant® and NeuroGage®. Furthermore, this updated version of a previous review addresses whether NeuroQuant® and NeuroGage® meet the Daubert standard for admissibility in court. It concludes that NeuroQuant® and NeuroGage® meet the Daubert standard based on their reliability, validity, and objectivity. Due to the improvements in technology over the years, these brain volumetric techniques are practical and readily available for clinical or forensic use, and thus they are important tools for detecting signs of brain injury. (shrink)

Differential tractography and correlation tractography are new tractography modalities to study neuronal changes in brain diseases, but their performances in detecting neuronal injuries are yet to be investigated in patients with mild traumatic brain injury. Here we investigated the white matter injury in mTBI patients using differential and correlation tractography. The diffusion MRI was acquired at 33 mTBI patients and 31 health controls. 7 of the mTBI patients had one-year follow-up scans, and differential tractography was used to evaluate (...) injured fiber bundles on these 7 patients. All subjects were evaluated using digital symbol substitution test and trail making test A, and the correlation tractography was performed to explore the exact pathways related to the cognitive performance. Our results showed that differential tractography revealed neuronal changes in the corpus callosum in all 7 follow-up mTBI patients with FDR between 0.007 and 0.17. Further, the correlation tractography showed that the splenium of the corpus callosum, combined with the right superior longitudinal fasciculus and right cingulum, were correlated with DSST in the acute mTBI patients. The cognitive impairment findings in the acute stage and the longitudinal findings in the corpus callosum in the chronic stage of mTBI patients suggest that differential tractography and correlation tractography are valuable tools in the diagnostic and prognostic evaluation of neuronal injuries in mTBI patients. (shrink)

Uncontrollable anger is common following an acquired brain injury, with impaired emotion regulation being one of the main contributors. Existing psychological interventions appear moderately effective, though studies typically include limitations such as small sample sizes, issues of long-term efficacy, and standardization of content. While ER has been a popular research field, the study of ER for anger management after ABI is less well investigated, and contains few interventions based on the widely used Process Model of ER. This review surveys (...) the efficacy of ER strategies in individuals with ABI, and proposes a novel research design for future interventions. Recommendations are made about: strategy number and type, shared decision-making, approaches to data analysis, and mode of delivery. (shrink)

Thanks to Barton Palmer and John McMillan for these thoughtful commentaries. We found much to agree with and it is striking how so many of the issues relating to decision-making capacity assessment find resonances outside of an English jurisdiction. California and New Zealand are clearly grappling with a very similar set of issues and the commentaries speak to the international nature of these discussions.We will pick up on some main points the commentaries raise.As Palmer notes, DMC law is vulnerable to (...) the criticism that it does not attend to the authenticity of a decision. In ordinary language, this is the idea that someone is deciding while “not their self” or that it is the “illness speaking.” There is a... (shrink)

This is an observational exploratory study assessing self-concept and its association with depression, anxiety, satisfaction with life, and quality of life 6 months after experiencing a traumatic brain injury. Participants were 33 patients who suffered a traumatic brain injury 6 months before the assessment. The measures used in this study were the Repertory Grid Technique, Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, Satisfaction With Life Scale, and the Quality of Life after Brain Injury. We calculated Euclidean distances to (...) assess differences in pre-and post-injury self-perception, as well as the proportion of opposed pole construct rating and polarization to understand how they are associated with the scores of the other offered measures. We found that the distance between the present and ideal self, as well as the distance between the present self and the self before the lesion showed moderate positive correlations with depression, and negative correlations with satisfaction with life and quality of life. Also, for the present and self before the lesion, the proportion of opposed pole ratings was correlated with depression symptoms, quality, and satisfaction with life, while for the present self and the ideal self this proportion was correlated with all the measures. The proportion of polarization of the present self and the total polarization was negatively correlated with symptom measures. The repertory grid might facilitate a greater understanding of self-concept after traumatic brain injury. This information could be used to guide treatments that address the emotions related to distances observed in the perception of the self. (shrink)

In this article, I argue that as we learn more about how we might intervene in the brain in ways that impact human behavior, the scope of what counts as “moral behavior” becomes smaller and smaller because things we successfully manipulate using evidence-based science are often things that fall outside the sphere of morality. Consequently, the argument that we are morally obligated to morally enhance our neighbors starts to fall apart, not because humans should be free to make terrible (...) choices, but because morality is not something subject to such manipulation. To illustrate my argument, I shall use the rise of veteran diversion courts in the United States as a putative instance of an intervention designed to change human behavior for the better. Part of my purpose in working my way through this case study is to demonstrate that many philosophers have the psychology of immoral action wrong. (shrink)

As infancy is characterized by rapid physical growth and critical periods of development, disruptions due to illness or disease reveal vulnerability associated with this period. Spinal cord injury has devastating consequences at any age, but its onset neonatally, at birth, or within the first year of life multiplies its impact. The immediate physical and physiological consequences are obvious and immense, but the effects on the typical trajectory of development are profound. Activity-based restorative therapies capitalize on activity-dependent plasticity of the neuromuscular (...) system below the lesion and when provided to children with SCI aim to improve the child’s neuromuscular capacity, health and quality of life. This is a report of an infant with a cervical SCI at birth resulting in paralysis of leg and trunk muscles and paresis of arm and hands who was enrolled in an ABRT program at 3 years of age. After 59 sessions of ABRT, the child demonstrated significant improvements in trunk control and arm function, as well as social and emotional development. Despite the chronicity of injury and low expectations for improvement with therapeutic interventions, ABRT had a positive impact on the child’s physical capacity and provided benefits across multiple developmental domains. (shrink)

ArgumentThis essay considers the metaphors of projection in Hugo Münsterberg's theory of cinema spectatorship. Münsterberg (1863–1916), a German born and educated professor of psychology at Harvard University, turned his attention to cinema only a few years before his untimely death at the age of fifty-three. But he brought to the new medium certain lasting preoccupations. This account begins with the contention that Münsterberg's intervention in the cinema discussion pursued his well-established strategy of pitting a laboratory model against a clinical one, (...) in this case the “master-trope” of early cinema a spectatorship drawn from hysteria, hypnosis, and related phenomena like double-consciousness. Münsterberg's laboratory-oriented account also flowed from his account of cinema technology as an outgrowth of the apparatus of his own discipline of experimental psycho-physiology, which entailed a model of cinema spectatorship continuous with the epistemological setting of laboratory relations. I argue that inThe Photoplayand related writings projection functioned in three registers: material, psychological, and philosophical. Münsterberg's primary concern was with psychological projection, where he drew upon his own work in experimental aesthetics to articulate an account of how the basic automatisms of cinema produce a state of oscillation between immersion and distraction. I show how Münsterberg's experimental aesthetics drew upon German doctrines of aesthetic empathy, orEinfühlung, which Münsterberg sought to modify in accordance with the dynamic and temporal characteristics of psycho-physiological experiment. Finally, I argue that Münsterberg's cinema theory was enfolded in his action or double-standpoint theory, in which the transcendental self posits the material, objective conditions of laboratory experience as a means to know itself. This philosophical projection explained cinema's uncanny ability to suspend ordinary perceptions of space, time, and causality. It also made cinema uniquely suited for the philosophical emancipation of a popular mass audience. (shrink)