Noah Silverberg

BACKGROUND. Although objectively measurable memory impairments typically resolve within weeks after a concussion, many people continue to report memory symptoms for extended periods. The current standard of care, cognitive rehabilitation, addresses objective memory deficits by teaching compensatory strategies, but this traditional approach to treatment is likely ineffective and misdirected. I propose that treatment for persistent memory symptoms after concussion should not focus on improving memory ability but rather on addressing the psychological mechanisms that perpetuate excessively negative perceptions of memory ability. The primary aim of the study was to assess the feasibility of the trial methods, including the novel CBT intervention. A secondary aim was to find evidence of an efficacy signal for the novel CBT intervention.METHODS. I conducted a pilot randomized controlled trial to evaluate the feasibility of a new CBT-based treatment designed to improve persistent memory symptoms after concussion. I recruited 24 participants from a characterizing study for Functional Cognitive Disorder after concussion. Participants were randomized (1:1) stratified by memory concern severity into CBT or traditional cognitive rehabilitation. All individuals participated in 11 x 50-minute sessions delivered online by supervised clinical psychology graduate students. Prespecified feasibility criteria for a successful pilot were set for (1) recruitment, (2) patient-perceived credibility of treatment, (3) patient adherence to treatment, (4) therapists’ compliance with the treatment protocol, and (5) retention. For the secondary aim, I measured memory concern (primary efficacy outcome) as well as avoidance of normal memory use and catastrophizing (mechanistic outcomes).RESULTS AND IMPLICATIONS. The study is still ongoing. Of the 24 enrolled participants, 11 completed participation in the study. Data for recruitment and treatment credibility is fully collected, and both fall within the acceptable range. Data collection is ongoing for patient adherence, therapist compliance, and retention, with preliminary results looking promising. Given the lack of a full dataset, I did not estimate the efficacy signal of the CBT intervention. However, descriptive statistics are reported for primary and mechanistic outcomes. This pilot study is an essential step toward improving clinical care for patients with persistent memory symptoms after concussion. The results could support progression to an efficacy-focused clinical trial.

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People with mild traumatic brain injury (mTBI) are at elevated risk for developing mental health disorders, which in turn can lead to poorer recovery. This study aimed to identify risk factors and develop prognostic model(s) for mental health complications following mTBI. The study was a secondary data analysis of a randomized controlled trial, including 517 adults presenting to emergency departments/urgent care centers. Demographic, injury-related and health history information was collected during eligibility screening within a week of injury. At 2-weeks post-injury, participants completed online questionnaires assessing a range of social, psychological and behavioral factors. At 3- and 6-months post-mTBI, participants engaged in a structured psychodiagnostics interview to determine the presence/absence of new or worsened Major Depressive Disorder (MDD), anxiety-related disorders, and Post-Traumatic Stress Disorder (PTSD). The primary outcome in the current study was any vs. none of these mental health disorders. Logistic regression was used to assess the prognostic value of pre-, peri-, and early post-injury factors. Least Absolute Shrinkage Selection Operator (LASSO) was used for predictor selection. A comprehensive model (with LASSO selected predictors from all 22 predictors) and a basic (clinical) model were developed using logistic regression modelling, and compared. Being younger, identifying as a woman and a people of color, lower education level, having mTBI(s) history, maladaptive coping behaviors and illness perceptions, and greater PTSD symptom severity measured at 2-weeks post-injury were significant predictors for new/worsened mental health complications 3-6 months following mTBI. 14 predictors, including demographic, healthy history, injury-related, and early post-injury factors, were included in the comprehensive model. The comprehensive model showed strong discriminability for predicting mental health outcomes and significantly outperformed the basic model. The identified risk factors hold the potential to guide targeted screening and treatment in post-mTBI care. The basic model can identify at-risk patients as early as their emergency department visit, using data that is collected as part of usual clinical care. The comprehensive model, which incorporates self-report measures collected online at 2 weeks post-injury, can significantly improve prognostic accuracy. These models can serve as valuable tools for evidence-based screening and risk stratification, enabling selective referral and proactive management.

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Introduction: Subjective memory problems - forgetting names, leaving important objects at home - are a common post concussion symptom. Memory complaints after concussion are largely unrelated to injury severity, objective memory performance, or neuroimaging metrics of the brain’s structural integrity and may be a manifestation of a functional cognitive disorder (FCD). Several possible mechanisms for FCD have been proposed, including metacognitive bias or factors that interfere with attention, as well as anxiety-related explanations. This study aims to explore several theories as to why people develop persistent memory problems after concussion, despite having normal neuropsychological test scores. Methods: A cross-sectional study of 54 participants (n=34 with concussion and n=20 healthy controls). Subgroups were formed to compare participants suspected FCD after concussion (n=28) and healthy controls with no concerns about their memory (n=13). Independent sample t-tests compared these two subgroups on candidate predisposing/perpetuating factors in FCD theorical models. Simple linear regressions tested the relationship between these predisposing/perpetuating factors and FCD symptom severity in the full concussion sample. Results: Contrary to expectations, there was no evidence of a metacognitive deficit or bias associated with FCD symptoms after concussion. The healthy control group and suspected FCD after concussion subgroup differed on measures of somatization, depression, anxiety, memory perfectionism, and certain coping behaviours (checking to turn off electrical appliances and asking someone for reminders). However, within the full concussion sample, only asking for reminders, increased depression, and memory perfectionism, was significantly associated with FCD symptoms. Conclusions: The current study highlights some promising (e.g., memory perfectionism) and unlikely candidates (e.g., metacognitive bias towards underconfidence) to guide future research on the etiology of FCD after concussion, and possibly FCD in other clinical settings.

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