Abstract
Introduction
The non pharmacological approach is an important issue in the treatment of psychological and behavioural disorders in traumatic brain injury (TBI) patients. It remains nevertheless insufficiently known and defined. The objective of this work was to develop precise recommendations for caregivers and relatives.
Method
The elaboration of these guidelines followed the procedure validated by the French health authority for good practice recommendations, close to the Prisma statement, involving a systematic, critical review of the literature and the expert opinions of the French Society of Physical Medicine and Rehabilitation (SOFMER) group.
Results
458 articles were identified, among which 98 were selected for their relevance to the theme of the research. None of the studies reached the highest level of evidence. Fifteen controlled studies reached a relatively high level of evidence (level 2); other studies were case series or expert opinions, and other articles again were reviews of the literature and theoretical points of view. The holistic approach structured into programmes, cognitive-behavioural therapy, and family and systemic therapy, despite the low levels of proof, are recommended in first intention at all stages in the evolution of TBI. Relational and adaptive approaches, rehabilitation and vocational approaches, and psychoanalytical therapies may be useful, provided that therapists are familiar with and trained in traumatic brain injury.
Conclusion
Despite the small number of publications and a low level of proof, a number of recommendations for the non-pharmacological approach to psychological and behavioural disorders in TBI is proposed by the consensus conference of experts. Scientific research in this domain is needed to confirm and complete these first recommendations.
1
Introduction
The non-pharmacological approach to psycho-behavioural disturbances among brain-damaged individuals is a major issue for patients, families, and healthcare and social worker teams, who often experience difficulty coping with disturbances defined as “excesses”: irritability, impulsiveness, de-inhibition, anger, or disturbances that reflect “deficits”: lack of initiative, lack of energy, apathy, depression. The aim of this therapeutic approach is to improve psychological and behavioural disturbances, reduce pharmacological treatments that are damaging to brain function, avoid the exhaustion of families or care teams, restrict excessive hospitalisations in psychiatric care, not well suited to brain-damaged individuals, and combat social and professional exclusion. This type of approach requires considerable means, which are not always available once the person has left the rehabilitation unit , and it is often not well known, and is little documented despite a certain number of articles centred on interpersonal approaches ( Table 1 ), holistic approaches ( Table 2 ), cognitive-behavioural approaches ( Table 3 ), systemic approaches ( Table 4 ) or psychodynamic approaches ( Table 5 ).
Recently, there has been renewed interest for the instatement of new psychotherapies ( Table 6 ) suited to behavioural disorders . To date there has been only one review of the literature on the subject , and no official recommendations.
This article sums up the work conducted under the auspices of the Haute Autorité de la Santé (HAS the French health authority) and the Société Française de Médecine Physique et de Réadaptation (SOFMER) to produce good practice recommendations in the area of “behavioural disturbances in brain-damaged individuals”, also broaching the theme of “care provision techniques and non-pharmacological interventions”. After summing up the methods implemented, we will present the results of literature analysis, the recommendation concerning each of the approaches, and a general synthesis.
2
Methods
A bibliographic search was performed on Medline from 1999 to 2012 using the following keywords: “Brain Injuries” or “Craniocerebral Trauma” or Brain injur* or Brain trauma or Head injur* or Head trauma* AND “Complementary Therapies” or “Behavior Therapy” or “Cognitive Therapy” or “Feedback” or “Holistic Nursing” or “Psychoanalysis” or “Psychotherapy” or “Family Therapy” or “psychological treatment” or “psychological therap” or “behaviour management” or “group psychotherapy” or “family intervention” or “music therapy”. Title NOT “Critical Care” or “Child” or “Infant” or “Pediatrics” or “Adolescent” or “Critical care” or “child” or “infan” or “paediatr” or “pediatr or adolescent”.
Complementary searches were performed on the articles perused and on documents from earlier periods or not referenced. After the abstracts had been read the research that did not correspond to the exact theme of the review were removed. The final update was performed in July 2015 prior to publication of the work. Once perused, all the articles retained were classified according to level of proof (ranging from level 1 – randomised comparative trials with good power – to level 4 – retrospective studies, case studies), and according to a recommendation grade (ranging from grade A – established scientific proof – to grade C – low level of proof). They were then divided into two categories according to the techniques described: global approaches (interpersonal and adaptive, holistic, rehabilitational and occupational) and specific therapies (cognitive behavioural therapies, systemic family therapies, psychoanalytical therapies, others).
Recommendations were drafted by a group of experts following the HAS protocol: ( http://www.has-sante.fr/portail/jcms/c_431294/recommandations-pour-la-pratique-clinique-rpc ). This protocol uses several of the PRISMA criteria (criteria 1, 2, 3, 5, 6, 7, 13, 15).
2
Methods
A bibliographic search was performed on Medline from 1999 to 2012 using the following keywords: “Brain Injuries” or “Craniocerebral Trauma” or Brain injur* or Brain trauma or Head injur* or Head trauma* AND “Complementary Therapies” or “Behavior Therapy” or “Cognitive Therapy” or “Feedback” or “Holistic Nursing” or “Psychoanalysis” or “Psychotherapy” or “Family Therapy” or “psychological treatment” or “psychological therap” or “behaviour management” or “group psychotherapy” or “family intervention” or “music therapy”. Title NOT “Critical Care” or “Child” or “Infant” or “Pediatrics” or “Adolescent” or “Critical care” or “child” or “infan” or “paediatr” or “pediatr or adolescent”.
Complementary searches were performed on the articles perused and on documents from earlier periods or not referenced. After the abstracts had been read the research that did not correspond to the exact theme of the review were removed. The final update was performed in July 2015 prior to publication of the work. Once perused, all the articles retained were classified according to level of proof (ranging from level 1 – randomised comparative trials with good power – to level 4 – retrospective studies, case studies), and according to a recommendation grade (ranging from grade A – established scientific proof – to grade C – low level of proof). They were then divided into two categories according to the techniques described: global approaches (interpersonal and adaptive, holistic, rehabilitational and occupational) and specific therapies (cognitive behavioural therapies, systemic family therapies, psychoanalytical therapies, others).
Recommendations were drafted by a group of experts following the HAS protocol: ( http://www.has-sante.fr/portail/jcms/c_431294/recommandations-pour-la-pratique-clinique-rpc ). This protocol uses several of the PRISMA criteria (criteria 1, 2, 3, 5, 6, 7, 13, 15).
3
Results: the international recommendations
Of the 458 articles identified, 98 were retained for their relevance to the research theme. Among these 93 articles were classified according to level, 15 were classified as level 2, 2 as level 3, and 56 as level 4; the remaining articles were 11 reviews of the literature and 9 theoretical articles. Grade recommendation B was allocated to 17 articles, and C to 44. No research was classified level 1 or grade A.
It was not possible to reach any scientific grade A recommendation on account of the low levels of proof across the research overall. However 37 recommendations were drafted on the basis of expert opinion (EO), among which 33 (89%) obtained a consensus of over 90% of the experts involved.
The general recommendations are as follows:
- •
Non-pharmacological treatment for behavioural disturbances among brain-damaged patients and for distress in their families is recommended in first intention, whatever the stage in the condition. This treatment should be implemented by therapists who are acquainted with neuropsychological disorders related to traumatic brain injury (TBI), in collaboration with professional teams and the patient’s close circle (EO).
- •
The non-pharmacological treatment of behavioural disturbances includes different approaches: holistic (planned care itineraries, occupational activities, social activity, professional activity), cognitive-behavioural, systemic familial, and in some cases psychoanalytical. It also involves the adjustment of behaviours in the patient’s close circle and in the care and follow-up teams (EO).
- •
Different approaches can be combined depending on the predominance of certain symptoms or comorbidities, and if necessary backed up by specific treatments (post-traumatic distress syndrome, addictions etc.) (EO).
3.1
Global approaches
3.1.1
The interpersonal and adaptive approach
Even if this is not a structured approach corresponding to a targeted therapy, the expert group considered it important to start this article with the interpersonal (relational) and adaptive approach, one of the foundations of any care provision for psycho-behavioural disturbances among brain-damaged individuals. The relational approach consists, as far as possible, in adjusting the behaviours of the patient’s close circle and adapting the environment so as to avoid behavioural disturbances triggered by outside factors such as noise, hustle, annoyance, excessive demands etc.. There is frequently a degree of misunderstanding of the needs of a brain-damaged individual in his or her immediate circle, social circle and above all professional circle, which is why C. Croisiaux and the team in the La Braise centre in Anderlecht, Belgium, recognised for their European expertise in the medical and social care for behavioural disturbances, have drafted a document providing advice and recommendations, systematically incorporating the notion of the “non-visible” disability, i.e. cognitive and psycho-behavioural disturbances, into the relationship with the patient. The working group drew on this work to a considerable extent to propose 8 recommendations based on expert agreement (EO). Further to this, 3 recent research articles ( Table 1 ), 2 classified level 2, and 1 level 4, back up the interpersonal and adaptive approach more specifically.
- •
Avoid stressful situations and interference; allow for the cognitive difficulties (avoiding having to do two things at once, avoiding distractions, or tasks that take too long, etc.); allow for fatigue, and the person’s psychological state; avoid major changes and unexpected events – the person needs as much stability as possible. It should be borne in mind that things that may have been learned may not be fully acquired; a change or an upset can compromise the work achieved, and require new adjustments (EO).
- •
Remain structured, clear and precise, talk slowly suiting language to any understanding problems (short sentences, simple words, but avoid infantilising the person so that he/she does not feel devalued). Accompany the person step by step in different tasks, even those that may appear straightforward (EO).
- •
Maintain respect for the person and his or her need for autonomy: avoid thinking or acting too hastily in his or her place, provide scope for him/her to take life in hand (EO).
- •
Note down in writing any important information, using whatever form is best suited to the cognitive or sensory deficits of the patient – paper or electronic diary, notice board, memo stickers (EO).
- •
Go along with the tools and strategies set up, and encourage their use on a daily basis. Circulate the information among the different people involved – the brain-damaged individual, the person of trust, the family, the professionals, the helpers etc. – taking care to comply with confidentiality requirements (EO).
- •
Avoid feeling targeted by any irritation or aggressiveness. Set a distance, and resort to professionals or assistance services, avoid responding to aggressiveness by more aggressiveness in return (EO).
- •
For the patient, practice in controlling aggression consists in trying to detect the sensation of increasing tension and knowing how to cut off from other people in these situations. For the family, the training consists in trying to identify the run-up to bouts of aggressiveness, and to analyse and prevent triggering and aggravating factors; there also needs to be a reference person who can soothe bouts of anger, adapt his or her behaviour and style of communication, and use verbal signals to tell the patient he or she is behaving aggressively. This person can also recall pleasant moments (EO).
- •
For the families, encourage encounters with other families of people who have sustained TBIs, or with relevant associations, so as to share experiences (EO).
| References | Type of study | Level of proof | Conclusion |
|---|---|---|---|
| Hanks et al., 2012 | Randomised study with control group, 92 subjects and 62 spouses | 2 | 80% improvement in behavioural disturbances and social integration when family had accompaniment and therapeutic education. |
| Sim et al., 2013 | Case study with control group, 29 patients with spouses | 4 | Training in conversation with spouses/partners of TBI patients improved productivity of discourse and quality of exchanges. |
| Wade et al., 2014 | Randomised study 132 relatives of TBI patients | 2 | Teaching programme on TBI on website more efficient for behavioural adaptation of families than leaving relatives to seek their own information on the internet. |
3.1.2
Holistic approaches, rehabilitation and occupational therapy
The holistic approach, derived from holism in the 1920s, sees human functioning in complex, global manner within the framework of a recently described model in the medical and bio-psycho-social fields. Holistic psychotherapy is not derived from a technique already in existence, it was specially developed for TBI patients. The principle underpinning this method targets the need to gain awareness of the disability and to accept it, with a view to better social and professional rehabilitation. It sets out to obtain this in global, coordinated and progressive manner, in individual psychotherapy sessions, group psychotherapies, and cognitive rehabilitation. The patient advances stage by stage according to the following classic pattern: implication, awareness, malleability, control of compensation phenomena, acceptance, identity, social rehabilitation.
In the USA, these programmes are intensive, reaching as many as 20 hours a week over 4 to 6 months. Among proponents of this type of care for brain-damaged individuals, the most long-standing instance is Goldstein among TBI patients in the First World War, followed by Ben Yshai and Prigatano in the 1980s, and then in the 1990s by Teasdale and Christensen in Europe and North in France. Even if these care techniques may not be implemented in their entirety for reasons of cost cost, they are often integrated today into follow-up care programmes and specialised rehabilitation procedures for TBI patients . More recent work has confirmed the positive impact of cognitive rehabilitation activities and of the level of social integration on psycho-behavioural disturbances. Eighteen articles were retrieved ( Table 2 ) among which 4 reached level 2, and 9 reached level 4, along with 2 literature reviews with favourable conclusions.
| References | Type of study | Level of proof | Conclusion |
|---|---|---|---|
| Prigatano et al., 1984 | Randomised study with control group, 35 patients | 2 | Significant improvement in emotional disturbances and rates of return to work (75% vs 36%) compared to control group |
| Teasdale and Christensen 1993 | Prospective study without control group, 22 patients | 4 | Improvement in emotional, social and professional situation |
| Delmonico 1998 | Descriptive article | None | Group psychotherapy programme among TBI patients centred on behavioural disturbances, management of frustration and addictions, combining educational, cognitive and occupational approaches, within coordinated team |
| Burg JS 2000 | Case-control study comparing 42 TBI cases in psychiatric sector with 25 non-TBI controls | 4 | TBI patients exhibited lesser improvement on Brief Symptom Inventory than non-TBI patients. |
| Soderback I 2004 | Prospective study with no control group, 46 patients | 4 | Institutional therapy programme centred on gardening, improving sensory-motor abilities, cognitive function, social integration and feelings of well-being |
| Marin RS 2005 | Descriptive article | None | Presentation of bio-psycho-social approach to assess and improve motivation disturbances among TBI patients |
| Judd D et Wilson SL 2005 | Retrospective study, 21 psychologists | None | Combined use of educational, psycho-social and cognitive treatments to instate a therapeutic alliance with TBI patients |
| Schonberg M 2006 | Prospective study with no control group, 86 patients including 27 TBI and 49 AV | 4 | The level of the therapeutic alliance in a holistic 14-week programme was correlated with the reduction in depressive syndrome and the degree of implication in the programme. |
| Le Gall C, Mazaux JMM 2007 | Retrospective study, 75 patients | 4 | Programme for social and professional integration, holistic type (UEROS). At 5 years, patients exhibited significantly improved autonomy (+27%), professional activity (37%) and satisfaction with life. |
| Dahlberg CA 2007 | Randomised study with control group, 52 patients | 2 | 12 group sessions 1h30/week, centred on social communication disorders, improvement in communication and satisfaction with life, results maintained at 6 months |
| Martelli MF 2008 | Review of the literature | None | Holistic programme integrating classic psychotherapeutic approach entailing learning and adapting social skills |
| Mc Donald S 2008 | Randomised multi-centre study with control group, 39 patients | 2 | Holistic programme centred on improvement of behavioural disturbances, comparing 3 groups of 13 patients over 12 weeks: holistic group, social activity group, waiting list group. Improvement in holistic group for social interaction, no improvement in social cognition nor in self-evaluation of behavioural disturbances. No improvement in the other two groups |
| Cicerone KD en 2008 | Randomised study with control group, 68 patients | 2 | Comparison of two groups of 34 patients – holistic neuropsychological and rehabilitation group, with group and individual treatment 15h/week for 16 weeks, and neurological rehabilitation group. Improvement in cognitive performances in both groups. Significant improvement in holistic group for social integration and quality of life. Benefit maintained at 6 months |
| Hofer H 2010 | Prospective study without control group, 11 patients | 4 | Psychotherapeutic and neuropsychological rehabilitation programme centred on adjustment strategies, with improvement in depression and adaptation of behaviours. |
| Nilson 2011 | Prospective study without control group, 10 patients | 4 | Holistic programme centred on self-assessment of disturbances, information, physical activity and behavioural adaptation |
| Driscoll DM 2011 | Review of the literature | None | Different psycho-social programmes, interest and limitations in the area of psychiatric pathology and brain injury. |
| Saout V 2011 | Clinical case | 4 | Description of an agitated, violent TBI patient in rehabilitation unit despite medication, benefit of psychiatric hospitalisations alternating with rehabilitation unit |
| Cogné M, Mazaux JMM, Wiart L 2014 | Retrospective study, 57 patients | 4 | Resumed work by Legall (UEROS), 10 years on, improvement in autonomy, professional activity, psychological disturbances and quality of life. |
Remark : The holistic approach is thought to improve emotional disturbances, integration and social interactions.
- •
The holistic approach, although restricted by the material available means for its implementation, is in particular recommended for patients with social integration difficulties (EO).
- •
Efforts should be made at national level to assess feasibility and develop national holistic programmes (EO).
- •
Rehabilitation and occupational therapies have an important place in the improvement of behavioural disturbances among brain-damaged individuals on account of their structuring, socialising and valorising role on individual level. There is no detailed study on this aspect determining the relative usefulness of one or other type of occupation (sporting, artistic, cultural, volunteer work etc.) nor on determining any particular approach to professional activity (return to previous employment, sheltered workshop, change of jobs etc.), but feedback from the holistic approach strongly suggest that activities of this type are beneficial. The activities should be coordinated by medical-social structures, if possible specialised in TBI. These activities also provide important back-up for psychotherapies, because they confront the patients with social and/or professional realities that explore identity, grieving for loss and other difficulties linked to their disability (EO).
Remark : Occupational and rehabilitation activities could contribute to improving psychological and behavioural disturbances among TBI patients.
- •
Rehabilitation and remediation activities (neuropsychology, speech therapy, physiotherapy, occupational therapy) should be specific and tailored to each person. These activities contribute to the improvement of behavioural disturbances, and are recommended within the care itinerary of TBI patients (EO).
- •
A programme of occupational activities (sporting, artistic, cultural, volunteer work etc.) or where possible a professional project, with the collaboration health or medico-social structures, are recommended on account of their structuring, socialising, and valorising role for individuals. These programmes should be integrated into the overall care plan for the patient (EO).
3.2
Specific approaches
3.2.1
Behavioural and cognitive-behavioural therapies (BT, CBT)
The cognitive-behavioural approach is one of the main trends in contemporary clinical psychology, initially developed in English-speaking countries in the 1940s. The basic hypothesis is that the interpretation of subjective experience is biased by the influence of maladaptive thinking that can generate observable disturbances and symptoms. The patterns involved are mainly implicit, but what they produce (mental images, so-called “automatic” thoughts) is accessible to consciousness. They can then be identified, and if appropriate altered. The aim of therapy is thus to help the subject alter beliefs, thoughts and behaviours on two different levels:
- •
On the cognitive level:, by way of a process of “cognitive restructuring” in which the idea is to identify malfunctioning thoughts, identify cognitive distortions, test the validity of these findings, and develop more rational alternatives with the help of a therapeutic alliance. The methodology is strict, entailing systematic evaluations and the establishment of progressive objectives in the form of a contract, which are self- and hetero-evaluated (feedback).
- •
On behavioural level, we can quote for instance the gradual exposure to problem-situations, the establishment of behavioural experiments, the development of an “interior dialogue”, the use of therapeutic notes and diaries, the use of role play, training in problem-solving, or the use of relaxation techniques.
CBT was used in the 1980s and 1990s among TBI patients under the particular influence of R. Wood and J. Ponsford and it is today recommended and used in first intention in English-speaking countries. In the face of a combination of disturbances that are behavioural, emotional and cognitive, CBT appears well suited. There is for example the highly structured nature of the therapy (the attitude of the practitioner is empathetic, but he or she remains very active), the setting of precise, concrete objectives, and the focus on the “here and now”. Paradoxically, this widely used approach is not well developed in certain European countries, partly on account of psychotherapeutic orientations that have differed over time. There are 26 articles in this area, 3 reaching level 2, two others level 3, and three level 4, the other nine articles being literature reviews ( Table 3 ).
| Reference | Type of study | Level of proof | Conclusions |
|---|---|---|---|
| Wood R et Burgess 1988 | Retrospective study, 30 patients | 4 | Improvement in aggressiveness for patients receiving positive reinforcement techniques – verbal or material rewards, and “time out” procedures, reduction in need for time-out from 8 to 2 per 5 weeks at 6 months |
| Zencius A 1990 | Case study | 4 | Description of 3 cases of sexual de-inhibition improved via combined bio-feedback and behavioural adjustment |
| Pickett E 1991 | Case study | None | Interest of mental imagery in psychotherapy to help patients adapt better to their deficits and adopt new behaviours. |
| Uomoto JM 1992 | Case study | None | Presentation of positive reinforcement and time-out techniques in the case of an aggressive patient and his family |
| Ponsford J 1995 Manchester 1997 | Case studies | 4 | Description of time-out and positive reinforcement, consisting, in case of aggressive reaction, of looking away, leaving the room without comment, and resuming action as if nothing had happened, alongside reward strategies and positive biofeedback if reaction is suited. |
| Alderman N 1999 | Case study | None | Presentation of aggressiveness scale: OAS-MNR (Overt Aggression Scale Modified for Neuro Rehabilitation) to assess the origins of aggressiveness and provide the patient with feedback |
| Yody B 2000 | Case study | None | Description of a case of de-inhibition and aggressiveness in institution requiring precise assessment of the disturbances and specific training for the team. |
| Demark 2002 | Review of the literature | None | Looks at difficulties for application of behavioural methods to aggressive behaviours among TBI patients, requiring adaptation |
| Bedard M 2003 | Case-control study, 13 patients | 3 | Evaluation of MBCT (Mindfulness-Based Cognitive Therapy) centred on meditation, breathing, mental imagery and acceptance. Comparison of 10 mild to moderate TBI who followed a 12-week group therapy, with 3 controls, significant improvement in quality of life, depression and stress. |
| Anson K et Ponsford J 2006 | Case-control study, 30 patients | 3 | Comparison group of 30 patients following CBT programme, 10 sessions twice weekly/5 weeks, based on coping skills for emotional disturbances (Coping skills group) and a control group (waiting list). Improvement in understanding of emotional disturbances and strategies, no improvement in depression, anxiety, self-esteem or psycho-social functioning. |
| Carnevale GJ 2006 | Randomised prospective study, 37 patients | 2 | Comparison of 3 groups of TBI patients, one following a NBSM programme (Natural Setting Behaviour Management), one following an educational programme, and the third being a control group. The treated group was significantly improved at 3 months after the end of the programme, reduction in behavioural disturbances, but no reduction in stress or carer burden. |
| Mateer CA 2006 | Case study | 4 | The authors underline the need to combine cognitive drilling with CBT to improve cognitive and emotional disturbances restricting return to work. |
| Manchester D 2007 | Case study | 4 | Presentation of CBT group programme (EQUIP), for 3 aggressive TBI patients, 4 30-minute group sessions /week for 6 weeks, centred on acquiring appropriate social conduct, mood improvement and correction of aggressive behaviours. 2 patients had improved at the end of the programme, and 3 months later the 3 patients were less aggressive. |
| Soo C et Tate R 2007 | Review of the literature | 4 | Three studies on small samples, of which two on mild to moderate TBI, observed an improvement in anxiety in CBT treated groups compared to control groups. Numbers of patients and heterogeneity prevented meta-analysis. The authors recommended further research. |
| Arco L 2008 | Case study | 4 | For a serious TBI patient, describes improvement in compulsive disorders by CBT at home, results maintained at 6 months |
| Bradbury CL 2008 | Prospective randomised study, 20 patients | 2 | Compared 20 serious TBI patients at home presenting anxiety or depressive disorders, one group following 10 sessions of CBT, the other an educational programme. The CBT group improved for anxious-depressive symptoms, but not for social skills nor adaptation to disability. No improvement with the educational programme. |
| Fann JR 2009 | Review of the literature | None | Of 27 studies on the treatment of post-TBI depression, no specific study of psychotherapeutic care. The authors conclude to the sparseness of the literature, and recommend CBT in first intention, and further research |
| Walker AJ 2010 | Retrospective study, 52 patients | 4 | Analysis of serious TBI patients presenting bouts of anger treated with group CBT once weekly for 12 weeks. In all 9 groups were followed from 1998 to 2006. Improvement in feelings and expression of anger after the sessions, and maintenance of effects in the long term for 31. |
| Topolovec-Vranic J 2010 | Case series, 21 patients | 4 | CBT website (MoodGym), 1 session/week for 6 weeks, evaluated for 21 mild to moderate TBI depressive patients at home. Programme completed by 64%, 43% re-contacted by phone at 1 year. Attenuation of depression. Level of participation restricted by severity of memory and attention deficits |
| Lundqvist A 2010 | Case series, 21 patients | 4 | Among 21 TBI patients who followed group CBT an improvement was noted in awareness of the disturbances, behavioural strategies, life satisfaction, professional situation and self-confidence. |
| Doering B 2011 | Review of the literature | None | Review of the efficacy of CBT combined with cognitive drilling for behavioural disturbances among TBI patients, underlining, despite the probable interest of the technique, the methodological weaknesses of the studies and the need for further research |
| Kangas M 2011 | Review of the literature | None | Suggests the interest among different CBTs of acceptance and commitment therapies and the scientific evaluation of their efficacy for mild to moderate TBI patients |
| Schmidt J 2011 | Review of the literature | None | Reviews the interest of feedback to improve awareness of the disability among brain-damaged patients. Of 12 studies, only 3 presented satisfactory methodologies, amounting to 62 patients in all. The result are only moderately conclusive for awareness of functional improvement. |
| Hsieh MY, Ponsford en 2012 | Comparative randomised trial 27 patients | 2 | Evaluation of a 12-week CBT programme on anxiety among TBI patients in two groups: one with a programme of motivational interviews and the other a programme of non-directive interviews. Anxiety improved in the first group, but the results were not as good in case of memory deficits. |
| Waldron 2013 | Review of the literature | None | Analysis of 24 articles (11 case studies, 13 group studies of which 9 with control group). For the group comparisons, the results are generally favourable (pre/post intervention differences in comparisons, or in favour of treated group vs control group). Raises the relevant questions of “dose” (dose-response relationship) and of format (individual or group treatment). |
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