Anger is a very common problem after brain injuries. When someone with a brain injury has a problem with anger, there are usually several causes acting in combination.
Some people are angry about the injury or problems that may have come with it, such as disabilities and loss of job, friends, money and control over one’s life. Some people were angry people before their injuries and still have that problem. People who have always been angry may need psychotherapy to help them learn to cope, and in some cases medication is required. (In our experience, people unfamiliar with the person or with brain injury are often too quick to assume that personality alone is to blame.)
But many people also develop impulsive anger as a direct effect of the damage to the brain. In other words, the parts of the brain that normally inhibit angry feelings and behavior have been damaged and do not do their jobs as well. This means that the person’s anger threshold is lowered so that he or she becomes angry more easily and more intensely. We can tell that this impulsive anger is directly due to the brain injury when:
The anger begins with the brain injury or is made much worse by it
Angry feelings come and go relatively suddenly
Anger episodes may be in response to minor events
The person having the angry episodes is surprised and embarrassed or distressed by them
The anger is made worse by physiological stress such as fatigue, pain or low blood sugar
This was the problem Joe had. Joe was a quiet man, an accountant; active in his church and an assistant little league coach. He never drank or used street drugs; he was healthy; and he had never been in a fight or in trouble with the law. He was well liked in the community. His wife said that he rarely got angry, and when he did he usually sulked.
When his car was hit by a drunk driver and Joe hit his head on the window, all that changed. He had been knocked out for five minutes but after he was checked out at the Emergency Room they sent him home. He went back to work a week later but had trouble concentrating and remembering. Worse, he started yelling at his wife and children, often for little things like laughing loudly at the TV.
One day at work, he broke a computer keyboard by hitting it with a stapler; and he sometimes tore up papers he was working on. After each of these episodes, he would be very embarrassed and apologetic. He came for help after loudly cursing at his daughter because she was playing with her program at a Wednesday evening church service.
With Joe, it was clear that he was having impulsive anger resulting from his head injury. When other more familiar causes of anger are also present, such as difficult personality, alcohol abuse, or anger at the injury itself, the impulsive anger resulting directly from the brain injury can get overlooked. It is important to try to identify and treat that part of the anger too.
Dealing with Impulsive Anger Resulting from Brain Injury
When a person with a brain injury first wakes up from a coma, they are usually disoriented and confused and often they are agitated. They do not understand what is going on around them, and they are not truly responsible for their own actions. It is up to the people taking care of then to keep them safe, even if this means restraining them or using medications when absolutely necessary. As they recover, they gradually come to be able to control their actions. Their staff and families can then gradually teach them about the best ways to manage their angry feelings. Because a person with a brain injury’s “anger thresholds” or “flashpoints” have been lowered, they need to relearn how to manage the changed reactions.
They need emotional rehabilitation in addition to physical and cognitive rehabilitation.
Understanding the Anger
The brain injury survivor is, in some ways, a different person. What makes him or her angry may be different. We need to learn what those things are. Here are some common factors that contribute to anger after brain injury.
High noise or activity level
Lack of structure
Fear or anxiety
Embarrassment, shame or guilt
Discovery or confrontation of problems
Cognitive impairments – especially memory deficits and confabulation (remembering things that did not happen)
Hypoglycemia (low blood sugar)
Medications (levels low or high?)
Alcohol or drugs
Anger Warning Signs
Loud high voice
Increased movement and fidgeting
Moving towards the object of anger
Searching for or picking up weapons
Hitting, kicking and other forms of violence
Fantasies of doing any of the speech or behavioral signs
Negative thoughts about others
Feelings of frustration
Feelings of fear or anxiety
Feelings of embarrassment, shame or guilt
Feelings of hurt
These strategies are for staff and families to use when the person with brain injury is too confused to be responsible for his or her actions. It is important for staff and families to remember during this time that the anger is due to the injury, and they should not take it personally.
Make the environment safe
Remove potential weapons
Keep alcohol and drugs inaccessible
Keep vehicles and dangerous tools inaccessible
Regulate Level of Stimulation
Some need to avoid over stimulation
Some need to be kept busy and distracted
Provide Appropriate Level of Supervision
Provide the least restrictive environment possible
Provide Reorientation as Needed
Much of the anger in an agitated confused and disoriented person can come from misperceiving and misunderstanding the situation
Staff and families should frequently remind the person of where they are, what is happening and why
Leave the person alone for a short period of time if this can be done safely. As you leave, tell them briefly what you are doing and why. “You are beginning to get upset. We are going to leave you alone for a few minutes so you can calm down.”
Change the subject, the focus of activity or the location
Use a concrete object as a focus when possible
Reorient and Reassure
Remind the person of where they are, what is going on and why
Try to clear up misunderstandings when this can be done without renewing argument
Direct the person in activities that may reduce agitation, such as guided relaxation
These strategies are to be phased in when the brain injury survivor has recovered enough learning abilities and awareness to begin to cooperate in learning to control anger.
“Back Off, Calm Down, Try Again”
Because the impulsive anger resulting from brain injury often comes and goes suddenly, an effective way to deal with it is for the angry person to back off, calm down and try again. This strategy can be phrased in the individual’s own words or whatever expression is comfortable such as “retreat, relax, return” or “take a break” or “time out”.
When warning signs appear, the person should leave the situation and go to a safe place. Others will have to cue him or her to leave. If the person will not leave, the other people present should leave instead, if possible.
Practicing backing off when not angry (like a fire drill) will help this go more smoothly when it is really needed.
When the person has backed off to a safe place, he or she should work on claming down. Many techniques can be used to calm down including:
Preparing to Return
Once calm, the person may need to rethink the situation and prepare to return.
Reviewing a list of questions is a possible preparation;
Do I need to apologize?
Do I need to explain why I left?
Do I need to tell anyone my feelings?
What can I do to avoid this next time?
Here are some statements to encourage rethinking the situation;
“I don’t hate my mother; I’m just angry with her”
“Maybe she had a point I should listen to”
“He’s not wrong, we just disagree”
When the person returns from backing off and calming down he or she may need to
talk through the issue,
explain the backing off and feelings
resume what he or she was doing.
Once a person has learned to back off, calm down and try again successfully, he or she can work on calming down in the situation without leaving.
Anger Cue Cards
Anger cue cards can be used to remind the brain injury survivor of their warning signs such as Loud Voice, Tense Muscles, Confusion, or Thoughts of Hitting. These cards should be carried by the person with a brain injury and optional copies can be placed where anger incidents often happen or where backing off takes place.
A Back Off card might say:
“I’m feeling angry, I need to back off”
Leave the room
Angry Reactions to Brain Injury
Anger at the cause of injury: The victim of an injury may be angry at the cause of the injury such as a drunk driver, an assailant, a corporation or a government. Such people often need help finding effective and satisfying channels for their anger. Often, they can talk this out with a trusted friend or family member.
It is part of human nature to grieve when we lose something, not just when someone dies, but also when we suffer an injury or illness. We try to find reasons for our losses. One part of a grief reaction is anger at what we think caused it. This anger can also get displaced onto any handy target. People can work through these reactions by talking out their feelings. This is such a human experience that it usually does not require a psychologist, just a trusted and understanding person. However, poor memory or judgment or emotional or personality problems can complicate grief reactions and psychotherapy may be needed.
When frustration contributes to angry reactions, the person needs to be trying easier things. Specific preparation can also be given before difficult tasks. For example,
“Now it’s time to go shopping. I know this is sometimes frustrating for you. How will you know if you are starting to get frustrated, and what will you do about it?”
Normal, Legitimate Anger
People with brain injury still have legitimate reasons to get angry. If their legitimate anger is discounted, ignored or “treated”, they may get angrier. If they have expressed their anger inappropriately, their angry actions should be dealt with separately from their legitimate complaint. They should not get their way just because they made a fuss, but the complaint should not be ignored.
Brain injury survivors often have impaired judgment which can contribute to anger problems. Cognitive rehabilitation for judgment can help. People with these difficulties need to check their judgments with caregivers or people they trust. Alcohol and drugs can contribute to anger problems. The clearest solution is abstinence but abuse programs or counseling may be needed. Not taking prescribed medications can also contribute to anger problems. The doctor should be told if the medications have not been taken as directed and if there have been any problems.
Anger is a common problem following brain injury. It has many causes, and there are many solutions to be tried. The rehabilitation team, the family and friends and the brain injury survivor can all work together to understand and manage the problem to help the person with brain injury to work towards recovering self control.
In response to the need to better define the natural history of emerging consciousness after traumatic brain injury (TBI) and to better describe the characteristics of the condition commonly labeled Post-traumatic Amnesia, a case definition and diagnostic criteria for the Post- traumatic Confusional State (PTCS) were developed. This project was completed by the Confusion Workgroup of the American Congress of Rehabilitation Medicine Brain Injury Interdisciplinary Special Interest group. The case definition was informed by an exhaustive literature review and expert opinion of workgroup members from multiple disciplines. The workgroup reviewed 2,466 abstracts and extracted evidence from 44 articles. Consensus was reached through teleconferences, face-to-face meetings, and three rounds of modified Delphi voting. The case definition provides detailed description of PTCS (1) core neurobehavioral features, (2) associated neurobehavioral features, (3) functional implications, (4) exclusion criteria, (5) lower boundary, and (6) criteria for emergence. Core neurobehavioral features include disturbances of attention, orientation, and memory as well as excessive fluctuation. Associated neurobehavioral features include emotional and behavioral disturbances, sleep-wake cycle disturbance, delusions, perceptual disturbances and confabulation. The lower boundary distinguishes PTCS from the minimally conscious state while upper boundary is marked by significant improvement in the four core and five associated features. Key research goals are establishment of cut-offs on assessment instruments and determination of levels of behavioral function that distinguish persons in PTCS from those who have emerged to the period of continued recovery.
To investigate the efficacy of telehealth-based and in-person social communication skills training (TBIconneCT) for people with moderate to severe traumatic brain injury (TBI) based on outcomes reported by the survivor and a close communication partner.
Australia. Two telehealth dyads were located outside Australia.
Adults (n = 51) at least 6 months after moderate-severe TBI with social communication skills deficits, and their usual communication partners (family members, friends, or paid carers).
Partially randomized controlled trial, with a telehealth intervention group, in-person intervention group, and a historical control group.
La Trobe Communication Questionnaire (LCQ) (total score, and number of items with perceived positive change). Both self- and other-reports.
Trained participants had significantly more items with perceived positive change than did historical controls. A medium effect size in the sample was observed for improvements in total score reported by trained communication partners after treatment. Comparisons between telehealth and in-person groups found medium to large effect sizes in the sample, favoring the telehealth group on some LCQ variables.
Whether delivered via telehealth or in-person, social communication skills training led to perceived positive change in communication skills. It was unexpected that outcomes for the telehealth group were better than for the in-person group on some variables.
TRAINING COMMUNICATION PARTNERS is best practice in providing intervention for cognitive communication impairments after traumatic brain injury (TBI).1 Providing communication partners with skills to enable effective conversations creates a more positive daily communication environment for people with a TBI. Training focuses on addressing negative patterns that communication partners may use in conversations with people with TBI, such as failing to follow up on the person’s contributions, not giving enough information to support the person’s comprehension, using questions designed to test the person’s memory rather than asking for meaningful information, and querying the person’s accuracy.2 The aim of training is to facilitate collaborative interactions between people with TBI and communication partners.3 The TBI communication partner training program with the highest level of evidence is TBI Express.4 This program has been shown to improve the quality of conversations5,6 and self-reported communication outcomes.7
TBI Express is an intensive program, involving 35 hours of intervention consisting of a combination of group sessions and dyad sessions (attended by both the person with TBI and their communication partner). This makes it difficult to implement TBI Express in full, given limitations on clinician time.8 Availability of families is a further barrier to accessing training, given factors of distance from rehabilitation services9 and competing time demands.10 The TBIconneCT program is a reduced-intensity version of TBI Express involving 15 hours of intervention over 10 sessions with the option for in-person or telehealth delivery. Each session involves the person with TBI and their communication partner attending together. TBIconneCT has shown positive outcomes using telehealth delivery with 2 participants in a single case experimental design study.11 To further investigate the effectiveness of TBIconneCT, a clinical trial was conducted. This trial had 3 arms: in-person TBIconneCT training, telehealth TBIconneCT training, and a historical control group.
The current study reports on a secondary outcome measure from this previously reported trial of TBIconneCT.12 The previous report addressed the primary outcome measure of conversational quality using the Adapted Measure of Support in Conversation (Reveal Competence scale)13 based on ratings from a blinded assessor. The secondary outcome measure reported in the current study evaluated the impact of the training on communication problems from the perspectives of the most important stakeholders: people with TBI and their usual communication partners.14 The La Trobe Communication Questionnaire (LCQ)15 is the secondary measure analyzed in the current article. Although level of insight will affect participants’ reporting, the LCQ has been shown to be a valuable tool that is sensitive to change, and it has been recommended as a supplemental outcome measure in TBI research.16
The research questions for the current study were:
(1) Is TBIconneCT training more efficacious than no training in improving LCQ outcomes as rated by people with TBI and their usual communication partners?
For the purposes of this question, the group of trained participants (formed by combining in-person and telehealth participants into a single group) was compared with the group of historical control participants.
(2) What is the magnitude of any difference in LCQ outcomes between telehealth and in-person training?
The sample size of this trial was not large enough for a noninferiority design. This question is therefore exploratory in nature.[…]
Whether at work or at school, people these days are under tremendous pressure to perform, perform and perform! Stress and pressure can have adverse affects on the well-being of a person, and need to be controlled.
Now, this doesn’t mean you make a dash to your nearest therapist. There are a number of wonderful and smart apps that you can use on your phone. These brain training apps have been scientifically designed to target specific areas of the human mind and control harmful emotions such as anxiety, as well as to improve memory and sharpness of the brain.
Here are 11 iPhone apps that you will not only enjoy but also find useful in keeping your mental health balanced at all times.
This app consists of games that focus on improving the user’s memory, problem-solving capability, attention span, and thinking. There are three games in each session, and they challenge the brain by changing every time. The user has to complete the games while playing against a clock.
Free of trial. $15 per month for the full version.
This brain training app has 10 sets of games that work on different areas of the brain and improve memory as well as concentration. A user is required to finish a particular task from each category on a daily basis and the app tracks the progress by a color coded graph.
Developed with the help of neuroscientists, this fun app improves a person’s cognitive abilities, which includes memory and concentration. The progress made by the user over a period of time can be tracked. Users can also play challenge rounds with their friends. The app also modifies the difficulty level to suit the profile of the user and provide recommendations based on the results. Spending 20–30 minutes a few times every week can give measurable improvement in the performance of a user.
The makers of this app claim that it can improve the IQ of a user, and improve intelligence and memory. The app is fun and is user friendly, and 30 minutes a day can fetch you results in less than three weeks.
If nothing else makes you happy in life, this app will. Well, this is what the developers claim at least. This app comes loaded with lots of quizzes, polls and gratitude journals, which work on the fundamentals of positive psychology. The app also helps to control stress and emotions to make you feel better.
You will like the little gold robot that comes in every time to explain the next game you are going to play. While the games are not much different to those offered in apps such as Luminosity, the look and feel reminds me of a workshop from old times.
Initially created as an app for suicide prevention, it has found its use as a great app for tracking the mood of the user by taking measure of all things relevant to the user’s mental health. In case the user experiences high emotional stress, the app has a coping mechanism that includes voice-recorded mindfulness, exercises and music for relaxation. There is also a map that informs the user of the nearest therapist and medical facilities for mental health treatment.
Eidetic is a memory enhancement app and uses a ‘spaced repetition’ technique to help users memorize information such as important phone numbers, words, credit card details or passwords. It also notifies you when it’s time to take a test to see what you remember, so that you retain information in your long-term memory.
Braingle helps to maintain the sharpness of the brain and improve the reasoning ability of a person through riddles and optical illusions. It is different from other brain training apps that employ memory and reaction based tests. You can also compete with your friends and family members in figuring out the fun riddles.
If you have a penchant for solving hard riddles, then this app is a must-have for you. Filled with exclusive riddles along with a simple-to-use interface, the app gives you riddles that you have to solve through a book. You will be given hints along the way, and when you give up, the answers will be revealed. This app will encourage you to broaden your thinking and put your mind to a challenging test.
This fun brain training app follows the journey of two animated characters who travel through a field of grass. Personal Zen is a nice app meant for reducing anxiety and trains the brain to focus on the positive aspects. The developer’s advice is to use the app for 10 minutes a day to see the best results.
To systematically evaluate the efficacy of exergames in individuals with major neurocognitive disorder.
Materials and methods
PubMed, EMBASE and PEDro were systematically searched from inception until October 2019 for randomised and clinical controlled trials. Methodological quality of the trials was assessed with the PEDro rating scale or Risk of Bias in Nonrandomised Studies of Interventions-I (ROBINS-I), when appropriate. Grading of Recommendations Assessments, Development and Evaluation (GRADE) was used to assess the overall quality of the evidence.
Eight trials, all of moderate to high methodological quality (i.e., PEDro score of 6 or higher or a Robins-I moderate quality score) were included. The overall quality of evidence was moderate to high according to the GRADE criteria. Improvements in gait, mobility and balance and beneficial effects on activities of daily living performance, cognitive function, fear of falls, quality of life and mood following exergaming were reported. Heterogeneity in outcome measures, intervention characteristics and included participants precluded a meta-analysis.
The current literature is of moderate to high quality and demonstrates that exergames have a wide range of physical and mental benefits in people with major neurocognitive disorder. More controlled trials are however needed to confirm the existing evidence before exergames can be recommended in treatment guidelines for people with major neurocognitive disorder.
Implications for rehabilitation
Exergames have many physical and mental benefits in people with major neurocognitive disorder
Exergaming can enhance gait, mobility and balance in people with major neurocognitive disorder
Evidence for beneficial cognitive effects of exergaming is emerging
Many pharmacological treatments were proved effective in the treatment of panic disorder (PD), generalized anxiety disorder (GAD), social anxiety disorder (SAD), post-traumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD); still many patients do not achieve remission with these treatments. Neurostimulation techniques have been studied as promising alternatives or augmentation treatments to pharmacological and psychological therapies. The most studied neurostimulation method for anxiety disorders, PTSD, and OCD was repetitive transcranial magnetic stimulation (rTMS). This neurostimulation technique had the highest level of evidence for GAD. There were also randomized sham-controlled trials indicating that rTMS may be effective in the treatment of PTSD and OCD, but there were conflicting findings regarding these two disorders. There is indication that rTMS may be effective in the treatment of panic disorder, but the level of evidence is low. Deep brain stimulation (DBS) was most studied for treatment of OCD, but the randomized sham-controlled trials had mixed findings. Preliminary findings indicate that DBS could be affective for PTSD. There is weak evidence indicating that electroconvulsive therapy, transcranial direct current stimulation, vagus nerve stimulation, and trigeminal nerve stimulation could be effective in the treatment of anxiety disorders, PTSD, and OCD. Regarding these disorders, there is no support in the current literature for the use of neurostimulation in clinical practice. Large high-quality studies are warranted.
Zugliani MM, Cabo MC, Nardi AE, Perna G, Freire RC. Pharmacological and neuromodulatory treatments for panic disorder: clinical trials from 2010 to 2018. Psychiatry Investig. 2019;16(1):50–8.PubMedPubMedCentralCrossRefGoogle Scholar
Freire RC, Nardi AE. The effect of neurostimulation in depression. In: Kim YK, editor. Understanding depression: contemporary issues, vol. 1. Singapore: Springer Singapore; 2018. p. 177–87.CrossRefGoogle Scholar
Freire RC, Cirillo PC, Nardi AE. Clinical application of neurostimulation in depression. In: Kim YK, editor. Understanding depression: contemporary issues, vol. 2. Singapore: Springer Singapore; 2018. p. 271–82.Google Scholar
Li H, Wang J, Li C, Xiao Z. Repetitive transcranial magnetic stimulation (rTMS) for panic disorder in adults. Cochrane Database Syst Rev. 2014;9:CD009083.Google Scholar
Koek RJ, Roach J, Athanasiou N, Van ‘t Wout-Frank M, Philip NS. Neuromodulatory treatments for post-traumatic stress disorder (PTSD). Prog Neuro-Psychopharmacol Biol Psychiatry. 2019;92:148–60.CrossRefGoogle Scholar
D’Urso G, Mantovani A, Patti S, Toscano E, de Bartolomeis A. Transcranial direct current stimulation in obsessive-compulsive disorder, posttraumatic stress disorder, and anxiety disorders. J ECT. 2018;34(3):172–81.PubMedCrossRefPubMedCentralGoogle Scholar
Milev RV, Giacobbe P, Kennedy SH, Blumberger DM, Daskalakis ZJ, Downar J, et al. Canadian network for mood and anxiety treatments (CANMAT) 2016 clinical guidelines for the Management of Adults with major depressive disorder: section 4. Neurostimul Treat Can J Psychiat. 2016;61(9):561–75.CrossRefGoogle Scholar
Cirillo PC, Gold AK, Nardi AE, Ornelas AC, Nierenberg AA, Campodron J, et al. Transcranial magnetic stimulation in anxiety and trauma-related disorders: a systematic review and meta-analysis. Brain Behav. 2019; https://doi.org/10.1002/brb3.1284.
Diefenbach GJ, Bragdon LB, Zertuche L, Hyatt CJ, Hallion LS, Tolin DF, et al. Repetitive transcranial magnetic stimulation for generalised anxiety disorder: a pilot randomised, double-blind, sham-controlled trial. Br J Psychiatry. 2016;209(3):222–8.PubMedCrossRefPubMedCentralGoogle Scholar
Dilkov D, Hawken ER, Kaludiev E, Milev R. Repetitive transcranial magnetic stimulation of the right dorsal lateral prefrontal cortex in the treatment of generalized anxiety disorder: a randomized, double-blind sham controlled clinical trial. Prog Neuro-Psychopharmacol Biol Psychiatry. 2017;78:61–5.CrossRefGoogle Scholar
White D, Tavakoli S. Repetitive transcranial magnetic stimulation for treatment of major depressive disorder with comorbid generalized anxiety disorder. Ann Clin Psychiatry. 2015;27(3):192–6.PubMedPubMedCentralGoogle Scholar
Bystritsky A, Kaplan JT, Feusner JD, Kerwin LE, Wadekar M, Burock M, et al. A preliminary study of fMRI-guided rTMS in the treatment of generalized anxiety disorder. J Clin Psychiatry. 2008;69(7):1092–8.PubMedCrossRefPubMedCentralGoogle Scholar
Diefenbach GJ, Assaf M, Goethe JW, Gueorguieva R, Tolin DF. Improvements in emotion regulation following repetitive transcranial magnetic stimulation for generalized anxiety disorder. J Anxiety Disord. 2016;43:1–7.PubMedCrossRefPubMedCentralGoogle Scholar
Huang Z, Li Y, Bianchi MT, Zhan S, Jiang F, Li N, et al. Repetitive transcranial magnetic stimulation of the right parietal cortex for comorbid generalized anxiety disorder and insomnia: a randomized, double-blind, sham-controlled pilot study. Brain Stimul. 2018;11(5):1103–9.PubMedCrossRefPubMedCentralGoogle Scholar
Bystritsky A, Kerwin LE, Feusner JD. A preliminary study of fMRI-guided rTMS in the treatment of generalized anxiety disorder: 6-month follow-up. J Clin Psychiatry. 2009;70(3):431–2.PubMedCrossRefPubMedCentralGoogle Scholar
Isserles M, Shalev AY, Roth Y, Peri T, Kutz I, Zlotnick E, et al. Effectiveness of deep transcranial magnetic stimulation combined with a brief exposure procedure in post-traumatic stress disorder – a pilot study. Brain Stimul. 2013;6(3):377–83.PubMedCrossRefPubMedCentralGoogle Scholar
Nam DH, Pae CU, Chae JH. Low-frequency, repetitive Transcranial magnetic stimulation for the treatment of patients with posttraumatic stress disorder: a double-blind, sham-controlled study. Clin Psychopharmacol Neurosci. 2013;11(2):96–102.PubMedPubMedCentralCrossRefGoogle Scholar
Watts BV, Landon B, Groft A, Young-Xu Y. A sham controlled study of repetitive transcranial magnetic stimulation for posttraumatic stress disorder. Brain Stimul. 2012;5(1):38–43.PubMedCrossRefPubMedCentralGoogle Scholar
Cohen H, Kaplan Z, Kotler M, Kouperman I, Moisa R, Grisaru N. Repetitive transcranial magnetic stimulation of the right dorsolateral prefrontal cortex in posttraumatic stress disorder: a double-blind, placebo-controlled study. Am J Psychiatry. 2004;161(3):515–24.PubMedCrossRefPubMedCentralGoogle Scholar
Osuch EA, Benson BE, Luckenbaugh DA, Geraci M, Post RM, McCann U. Repetitive TMS combined with exposure therapy for PTSD: a preliminary study. J Anxiety Disord. 2009;23(1):54–9.PubMedCrossRefPubMedCentralGoogle Scholar
Boggio PS, Rocha M, Oliveira MO, Fecteau S, Cohen RB, Campanha C, et al. Noninvasive brain stimulation with high-frequency and low-intensity repetitive transcranial magnetic stimulation treatment for posttraumatic stress disorder. J Clin Psychiatry. 2010;71(8):992–9.PubMedCrossRefPubMedCentralGoogle Scholar
Shivakumar V, Dinakaran D, Narayanaswamy JC, Venkatasubramanian G. Noninvasive brain stimulation in obsessive-compulsive disorder. Indian J Psychiatry. 2019;61(Suppl 1):S66–76.PubMedPubMedCentralGoogle Scholar
Shiozawa P, Leiva AP, Castro CD, da Silva ME, Cordeiro Q, Fregni F, et al. Transcranial direct current stimulation for generalized anxiety disorder: a case study. Biol Psychiatry. 2014;75(11):e17–8.PubMedCrossRefPubMedCentralGoogle Scholar
Saunders N, Downham R, Turman B, Kropotov J, Clark R, Yumash R, et al. Working memory training with tDCS improves behavioral and neurophysiological symptoms in pilot group with post-traumatic stress disorder (PTSD) and with poor working memory. Neurocase. 2015;21(3):271–8.PubMedCrossRefPubMedCentralGoogle Scholar
Van’t Wout M, Longo SM, Reddy MK, Philip NS, Bowker MT, Greenberg BD. Transcranial direct current stimulation may modulate extinction memory in posttraumatic stress disorder. Brain Behav. 2017;7(5):e00681.PubMedPubMedCentralCrossRefGoogle Scholar
Shiozawa P, Enokibara da Silva M, Cordeiro Q. Transcranial direct current stimulation (tDCS) for panic disorder: a case study. J Depress Anxiety. 2014;3(3):158.CrossRefGoogle Scholar
Heeren A, Billieux J, Philippot P, De Raedt R, Baeken C, de Timary P, et al. Impact of transcranial direct current stimulation on attentional bias for threat: a proof-of-concept study among individuals with social anxiety disorder. Soc Cogn Affect Neurosci. 2017;12(2):251–60.PubMedCrossRefPubMedCentralGoogle Scholar
Alonso P, Cuadras D, Gabriels L, Denys D, Goodman W, Greenberg BD, et al. Deep brain stimulation for obsessive-compulsive disorder: a meta-analysis of treatment outcome and predictors of response. PLoS One. 2015;10(7):e0133591.PubMedPubMedCentralCrossRefGoogle Scholar
Sousa MB, Reis T, Reis A, Belmonte-de-Abreu P. New-onset panic attacks after deep brain stimulation of the nucleus accumbens in a patient with refractory obsessive-compulsive and bipolar disorders: a case report. Revista brasileira de psiquiatria (Sao Paulo, Brazil: 1999). 2015;37(2):182–3.CrossRefGoogle Scholar
Shapira NA, Okun MS, Wint D, Foote KD, Byars JA, Bowers D, et al. Panic and fear induced by deep brain stimulation. J Neurol Neurosurg Psychiatry. 2006;77(3):410–2.PubMedPubMedCentralCrossRefGoogle Scholar
Okun MS, Mann G, Foote KD, Shapira NA, Bowers D, Springer U, et al. Deep brain stimulation in the internal capsule and nucleus accumbens region: responses observed during active and sham programming. J Neurol Neurosurg Psychiatry. 2007;78(3):310–4.PubMedCrossRefPubMedCentralGoogle Scholar
Langevin JP, Koek RJ, Schwartz HN, Chen JWY, Sultzer DL, Mandelkern MA, et al. Deep brain stimulation of the Basolateral amygdala for treatment-refractory posttraumatic stress disorder. Biol Psychiatry. 2016;79(10):e82–e4.PubMedCrossRefPubMedCentralGoogle Scholar
Daban C, Martinez-Aran A, Cruz N, Vieta E. Safety and efficacy of Vagus nerve stimulation in treatment-resistant depression. A systematic review. J Affect Disord. 2008;110(1–2):1–15.PubMedCrossRefPubMedCentralGoogle Scholar
George MS, Ward HE Jr, Ninan PT, Pollack M, Nahas Z, Anderson B, et al. A pilot study of vagus nerve stimulation (VNS) for treatment-resistant anxiety disorders. Brain Stimul. 2008;1(2):112–21.PubMedCrossRefPubMedCentralGoogle Scholar
Cook IA, Abrams M, Leuchter AF. Trigeminal nerve stimulation for comorbid posttraumatic stress disorder and major depressive disorder. Neuromodulation. 2016;19(3):299–305.PubMedCrossRefPubMedCentralGoogle Scholar
Trevizol AP, Shiozawa P, Albuquerque Sato I, da Silva ME, de Barros Calfat EL, Alberto RL, et al. Trigeminal nerve stimulation (TNS) for Post-traumatic stress disorder: a case study. Brain Stimul. 2015;8(3):676–8.PubMedCrossRefPubMedCentralGoogle Scholar
Trevizol AP, Shiozawa P, Sato IA, Calfat EL, Alberto RL, Cook IA, et al. Trigeminal nerve stimulation (TNS) for generalized anxiety disorder: a case study. Brain Stimul. 2015;8(3):659–60.PubMedCrossRefPubMedCentralGoogle Scholar
Trevizol AP, Taiar I, Malta RC, Sato IA, Bonadia B, Cordeiro Q, et al. Trigeminal nerve stimulation (TNS) for social anxiety disorder: a case study. Epilepsy Behav. 2016;56:170–1.PubMedCrossRefPubMedCentralGoogle Scholar
Trevizol AP, Sato IA, Cook IA, Lowenthal R, Barros MD, Cordeiro Q, et al. Trigeminal nerve stimulation (TNS) for panic disorder: an open label proof-of-concept trial. Brain Stimul. 2016;9(1):161–2.PubMedCrossRefPubMedCentralGoogle Scholar
Ahmadi N, Moss L, Simon E, Nemeroff CB, Atre-Vaidya N. Efficacy and long-term clinical outcome of comorbid posttraumatic stress disorder and major depressive disorder after electroconvulsive therapy. Depress Anxiety. 2016;33(7):640–7.PubMedCrossRefPubMedCentralGoogle Scholar
Margoob MA, Ali Z, Andrade C. Efficacy of ECT in chronic, severe, antidepressant- and CBT-refractory PTSD: an open, prospective study. Brain Stimul. 2010;3(1):28–35.PubMedCrossRefPubMedCentralGoogle Scholar
Rosenquist PB, Youssef NA, Surya S, McCall WV. When all else fails: the use of electroconvulsive therapy for conditions other than major depressive episode. Psychiatr Clin North Am. 2018;41(3):355–71.PubMedCrossRefPubMedCentralGoogle Scholar
Fontenelle LF, Coutinho ES, Lins-Martins NM, Fitzgerald PB, Fujiwara H, Yucel M. Electroconvulsive therapy for obsessive-compulsive disorder: a systematic review. J Clin Psychiatry. 2015;76(7):949–57.PubMedCrossRefPubMedCentralGoogle Scholar
Garrido A. Electroconvulsive therapy in severe obsessive-compulsive disorder. Eur Psychiatry. 1998;13(Suppl 4):236s–7s.CrossRefGoogle Scholar
Dubois JC. Obsessions and mood: apropos of 43 cases of obsessive neurosis treated with antidepressive chemotherapy and electroshock. Ann Med Psychol (Paris). 1984;142(1):141–51.Google Scholar
Fontani V, Mannu P, Castagna A, Rinaldi S. Social anxiety disorder: radio electric asymmetric conveyor brain stimulation versus sertraline. Patient Prefer Adherence. 2011;5:581–6.PubMedPubMedCentralGoogle Scholar
Kuhn J, Lenartz D, Huff W, Lee S, Koulousakis A, Klosterkoetter J, Sturm V. Remission of alcohol dependency following deep brain stimulation of the nucleus accumbens: valuable therapeutic implications? J Neurol Neurosurg Psychiatry. 2007;78(10):1152–3.CrossRefGoogle Scholar
Cognitive:deficits often occur in people with epilepsy (PWE). However, in Brazil, PWE might not undergo neurocognitive evaluation due to the low number of validated tests available and lack of multidisciplinary teams in general epilepsy outpatient clinics.
Objective: To correlate Brief Cognitive Battery-Edu (BCB-Edu) scores with epilepsy characteristics of 371 PWE.
Methods: Clinical and cognitive assessment (MMSE, BCB-Edu) of 371 PWE aged >18 years was performed. The clinical aspects of epilepsy were correlated with BCB-Edu data. Cognitive data of PWE were compared against those of 95 healthy individuals (NC), with p-<0.05.
Results: People with epilepsy had lower cognitive performance than individuals in the NC group. Cognitive aspects also differed according to epilepsy characteristics. Predictive factors for impairment in multiple cognitive domains were age and use of more than one antiepileptic drug (logistic regression; R2 Nagelkerke=0.135).
Conclusion: Worse cognitive performance was found in PWE on different domains. There was a relationship between cognitive impairment and the aspects of epilepsy. BCB-Edu proved to be effective as a cognitive assessment screening test for epilepsy in adults. Key words: epilepsy, Brief Cognitive Battery-Edu, cognition[…]
The rehabilitation of cognitive and behavioral abnormalities in individuals with stroke is essential for promoting patient’s recovery and autonomy. The aim of our study is to evaluate the effects of robotic neurorehabilitation using Lokomat with and without VR on cognitive functioning and psychological well-being in stroke patients, as compared to traditional therapy.
Ninety stroke patients were included in this randomized controlled clinical trial. The patients were assigned to one of the three treatment groups, i.e. the Robotic Rehabilitation group undergoing robotic rehab with VR (RRG+VR), the Robotic Rehabilitation Group (RRG-VR) using robotics without VR, and the Conventional Rehabilitation group (CRG) submitted to conventional physiotherapy and cognitive treatment.
The analysis showed that either the robotic training (with and without VR) or the conventional rehabilitation led to significant improvements in the global cognitive functioning, mood, and executive functions, as well as in activities of daily living. However, only in the RRG+VR we observed a significant improvement in cognitive flexibility and shifting skills, selective attention/visual research, and quality of life, with regard to the perception of the mental and physical state.
Our study shows that robotic treatment, especially if associated with VR, may positively affect cognitive recovery and psychological well-being in patients with chronic stroke, thanks to the complex interation between movement and cognition.
VR environments help improve rehabilitation of impaired complex cognitive functions
Combining neuroimaging and VR boosts ecological validity, generates practical gains
These are the first neurofunctional predictive biomarkers of VR cognitive training
As Virtual reality (VR) is increasingly used in neurological disorders such as stroke, traumatic brain injury, or attention deficit disorder, the question of how it impacts the brain’s neuronal activity and function becomes essential. VR can be combined with neuroimaging to offer invaluable insight into how the targeted brain areas respond to stimulation during neurorehabilitation training. That, in turn, could eventually serve as a predictive marker for therapeutic success. Functional magnetic resonance imaging (fMRI) identified neuronal activity related to blood flow to reveal with a high spatial resolution how activation patterns change, and restructuring occurs after VR training. Portable and quiet, electroencephalography (EEG) conveniently allows the clinician to track spontaneous electrical brain activity in high temporal resolution. Then, functional near-infrared spectroscopy (fNIRS) combines the spatial precision level of fMRIs with the portability and high temporal resolution of EEG to constitute an ideal measuring tool in virtual environments (VEs). This narrative review explores the role of VR and concurrent neuroimaging in cognitive rehabilitation.
Introduction: This pilot study analyzes the effect of a cognitive training program in adults with intellectual disability (ID).
Method: Twenty subjects (mean age 52.7 ± 9.77 years) with mild and moderate ID were divided in control and experimental group. Only the experimental group received the training program. This program was applied through the GNPT® (Guttmann, NeuroPersonalTrainer®) platform for people with ID.
Results: The results revealed a significant improvement in the Kaufman Brief Intelligence Test-2 scores (Matrices subtest) in the experimental group [Z = 2.12; p = .03] after the intervention, indicating an enhancement in fluid ability due to effect of cognitive training program.
Conclusion: Findings provide evidence of the importance of applying these programs in a systematized way in adults with ID.