final paper

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Measurement and Assessment of Post-Traumatic Brain Injury (TBI) Anxiety

Martha Ramsey

Saint Leo University

Tests & Measures: PSY 625

Instructor Lara Ault

October 7, 2023

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Measurement and Assessment of Post-Traumatic Brain Injury (TBI) Anxiety

Introduction

Post-traumatic brain injury anxiety poses major public health concerns in the United

States and other developed economies. Both mild and severe post-traumatic brain injury

anxiety adversely affect patients’ mental and socioeconomic well-being. According to

Gaudette et al. (2022), persons with such conditions are predisposed to unemployment,

poverty, and depression. Thus, the development of anxiety disorders after a traumatic brain

injury is a critical indicator of social, personal, and work dysfunction. The burden of

psychiatric ailments after a head injury also has implications on the disease prognosis.

Traumatic brain injury (TBI) may also stem from a wide range of symptoms that affect

patients’ cognition and psychological well-being (Al-Kader et al., 2022). A significant

fraction of TBI cases globally and within the United States culminate in the development of

either mild or severe symptoms, also referred to as concussions. The symptoms that develop

after TBI are often temporary, including neurological conditions such as mood disorders,

depression, irritability, and anxiety (Al-Kader et al., 2022). Persons with TBI anxiety are also

vulnerable to sensory and somatic complaints, which include sleep-related disorders,

headaches, blurred vision, and dizziness. TBI anxiety is an anxiety disorder that arises from

an acquired disruption of the normal functioning or structure of the brain caused by a head

impact or external force (Tucker & McCabe, 2021). While many tools for measuring,

diagnosing, and assessing TBI anxiety exist, there are still major literature gaps in the studies

that attempt to evaluate their reliability and accuracy. Therefore, this systematic literature

aims to seal the existing knowledge gaps by investigating the measures, reliability, validity,

and timing of TBI anxiety.

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Measures for Assessing Post-TBI Anxiety

Accurate post-TBI anxiety is critical in developing evidence-based interventions for

reversing its adverse impact on individuals’ psychosocial well-being. Numerous scholars

propose different tools, strategies, and instruments for evaluating the level of severity of this

psychological condition. The State-Trait Anxiety Inventory (STAI) and the Hospital Anxiety

Depression Scale (HADS) are some of the leading metrics for assessing post-TBI anxiety

(Knowles & Olatunji, 2020). STAI is a 40-item self-reporting scale that evaluates separately

the dimensions of state and trait anxiety. Some of the anxiety indicators that it measures

include feelings of apprehension, tension, nervousness, and worry. It also evaluates the extent

to which an individual feels ‘right now’ or in the present (Knowles & Olatunji, 2020). It

requires respondents to rate the intensity of their nervousness in terms of not at all,

somewhat, moderately so, or very much so. This anxiety metric also addresses the degree to

which individuals generally feel by rating themselves using a four-point Likert scale: almost

never, sometimes, often, or almost always. Since its adoption in 1966, STAI has been

translated into more than 48 languages and has been broadly researched in many clinical and

institutional contexts (Knowles & Olatunji, 2020). Most significantly, the evidence of its

construct validity stems from a wide range of sources, including correlations with anxiety

metrics.

HADS is an instrument that is widely utilized to measure psychological distress

among post-TBI patients. It has been translated into many languages, including French,

German, Dutch, Chinese, and Arabic (Stern, 2014). It generates clinically meaningful results

as a psychological screening instrument, particularly in group comparisons and studies with

different aspects of disease or quality of life. It is a 14-item questionnaire that comprises

seven questions for anxiety and seven for depression (Stern, 2014). Due to its ease of use, it

takes only two to five minutes to fill out and generate outcomes. While the anxiety and

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depression questions are interspersed within the questionnaire, they must be scored

separately. In that respect, cut-off scores are available for estimation. For instance, scores of 8

or more for anxiety have a specificity of 0.78 and a sensitivity of 0.9 (Stern, 2014). Those for

depression have a specificity of 0.79 and a sensitivity of 0.83.

Reliability and Pre-Post Assessment

Assessing the reliability and validity of the selected post-TBI anxiety instruments is

important in understanding their accuracy. Reliability refers to the extent to which

measurements are repeatable when different people perform them on different occasions

under different conditions supposedly with alternative instruments (Kubai, 2019). A reliable

instrument should capture accurately the intended construct under investigation and ensure

the meaningfulness of the study findings (Kubai, 2019). Reliable measurement instruments

increase the believability and trustworthiness of the findings, particularly if the investigations

are repeated by different researchers within similar conditions or different research

instruments that assess the same construct (Kubai, 2019). This study will use a systematic

review method to evaluate the reliability of the two post-TBI anxiety measurement

instruments. Most specifically, articles that examine the reliability of the selected instruments

will be searched, analyzed, and synthesized.

Literature Review

STAI and Hospital Anxiety and HADS as Assessment Tools

Investigations into the reliability, accuracy, and validity of post-TBI anxiety

measuring instruments have attracted significant scholarly attention. Knowles and Olatunji

(2020), for instance, utilize a meta-analysis to compare STAIT scores among individuals with

depressive and anxiety disorders. The researchers also analyze the correlations with measures

of anxiety and depressive symptom severity to determine the discriminant and convergent

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validity. After searching identifying and analyzing 388 published peer-reviewed journal

articles, they found that individuals with anxiety disorders and those with depressive

symptoms showcased significantly elevated scores on the STAIT tool compared to the non-

clinical comparison groups. The results further demonstrate that anxiety and depressive

symptoms severity were strongly correlated with the STAIT scores (mean- 0.59, r =0.61).

However, people persons with depressive disorders reported significantly higher STAIT

scores than their counterparts with an anxiety disorder. Owing to these outcomes, the

researchers propose the consideration of STAIT as a non-specific metric for evaluating

negative affectivity rather than trait anxiety.

While anxiety and depressive symptoms are widely experienced after TBI, studies

that validate the instruments of anxiety and depression are scarce. Carmichael et al. (2023)

utilize an empirical research design to evaluate the effectiveness of HADS in measuring post-

TBI anxiety. Using novel indices drawn from symmetrical bi-factor modeling, they examine

whether HADS reliably differentiated anxiety and depression among 874 adult participants

with moderate and severe TBI anxiety. The results demonstrate a dominantly general distress

factor that accounts for 84% of the systematic variance in HADS total scores. Additionally,

the researchers find that the specific anxiety and depression factors account for minimal

residual variance in the respective subscale scores (12% and 20%, respectively). From these

findings, clinicians and researchers should exercise caution when interpreting the individual

HADS subscales and instead consider adopting the totals cores as a more valid,

transdiagnostic measure of general distress in persons with TBI. In the assessment of post-

TBI anxiety, studies such as those conducted by Anderson et al. (2023) and Chen et al.

(2020) have utilized measurement tools such as the State-Trait Anxiety Inventory (STAI) and

the Hospital Anxiety and Depression Scale (HADS). These measures are designed to assess

anxiety symptoms specifically related to TBI.

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TBI represents 80 to 90% of all traumatic brain injury cases that are widely treated in

healthcare institutions or emergency departments. Lamontagne et al. (2021) explore the

prevalence of anxiety-related disorders and anxiety symptoms among 4, 8, and 12 months

post-injury in individuals with mild traumatic brain injury. They also consider pre-injury

history of anxiety disorders and verify whether the presence of anxiety in the first months

after TBI is connected to more symptoms a year later. The researchers utilized HADS to

evaluate 120 participants hospitalized after an accident and having sustained TBI. The

findings reveal that after four months, 23.8 respondents presented with at least one anxiety-

related disorder compared with 15.2% at 8 months. Most significantly, 32.5% of the

participants presented with at least one anxiety disorder over the first 12 months postinjury

compared with their non-anxious peers.

Empirical Studies

Studies that adopt experimental research design also recommend the standards that

occupational therapists should follow to treat or manage adults with post-TBI anxiety.

Wheeler and Acord-Vira (2023) provide valuable insights into occupational therapy practice

guidelines for adults with traumatic brain injury. Occupational therapy often involves

assessing the cognitive and functional abilities of individuals post-TBI to develop tailored

rehabilitation plans. The guidelines underscore the significance of measuring cognitive and

functional outcomes to facilitate the recovery and reintegration of TBI survivors into their

daily lives. This highlights the importance of post-TBI assessments in guiding therapeutic

interventions and optimizing patient outcomes.

Post-TBI measurement and assessments are essential components of understanding

and addressing the challenges faced by TBI survivors. The research by Wheeler and

AcordVira (2023) emphasizes the need for comprehensive assessment strategies that

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encompass cognitive, neuroinflammatory, and functional domains. Such assessments not only

provide a clear picture of the post-TBI landscape but also serve as the foundation for

evidence-based interventions that aim to enhance the well-being and quality of life of the

individuals involved.

Reliability and Pre-Post Assessment in Anxiety Measurement

One crucial aspect of anxiety measurement in the context of TBI assessment is the

reliability of the chosen measures. Researchers, including Smithson et al. (2023), have

employed quantitative research methods to evaluate the pre-post reliability of anxiety

assessments. This involves assessing the consistency of anxiety scores before and after TBI

interventions, ensuring the robustness of the measurements. Boxley et al. (2016) also

examine the reliability of HADS for assessing post-TBI anxiety using internal consistency

and external factor structure of the scale among veterans in a polytrauma brain injury clinic.

They selected 312 participants using a stratified random sampling procedure and adopted the

tool to measure their level of anxiety. A confirmatory factor analysis of the depression and

anxiety subscales revealed that the two factors were highly correlated. In that respect, the

goodness of fit for the two-factor model was also acceptable, with a root mean square error of

approximation of 0.006 and a comparative fit index of 0.94. Therefore, their findings

reinforce the hypothesis that HADS is an effective tool for screening depression and anxiety

among patients with mild or severe traumatic brain injury in veteran population settings.

Inquiries into the reliability of STAIT for measuring post-TBI anxiety have also

surged phenomenally in the last decades. Pretorious (2023), for example, analyzes the

reliability of the tool and the effectiveness of its psychometric properties. They selected 322

participants using a convenient sampling procedure that encompasses the student population.

The respondents were instructed to fill out the five-item version of the trait scale of the

STAIT and a nine-item version of the Beck Hopelessness Scale. The results revealed that the

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five-item metric of anxiety had satisfactory levels of reliability and validity. The results also

indicated that the measuring scale encompassed a unidimensional metric instrument that

captures virtually all the key aspects of anxiety. Given these findings, STAI continues to

demonstrate sound internal consistency reliability and construct validity. It can discriminate

between psychiatric patients and healthy control subjects, making it efficacious in assessing

changes in anxiety over time. It has also been successfully correlated with other metrics of

anxiety, which reveal high levels of reliability.

Validity and Correlations with Timing of TBI Diagnosis

Validity is a fundamental consideration in the measurement of post-TBI anxiety.

Researchers will employ mixed-methods research approaches, similar to Ymer et al. (2021),

to establish the validity of measures. This will include quantitative analyses to assess the

convergent and discriminant validity of the selected measures in relation to the timing of TBI

diagnosis. Qualitative interviews will also be conducted to gather in-depth insights and

enhance the validity of the assessment. One of the earliest studies that analyzed the validity

and timing of TBI measurements was performed by Whelan-Goodison et al. (2008).

According to these researchers, rating scales are widely adopted to evaluate depression and

anxiety in traumatic brain injuries. However, only a few have been validated for adoption in

different populations. Overlap of symptoms between these disorders and TBI may, for

instance, result in under or over-diagnosis of depression and anxiety. After selecting 100

participants with mild and severe TBI and 87 informatics, the researchers interviewed this

population using SCID-IV and administered them with HADS. The findings suggest that

HADS scores were linked to a high likelihood of depression and anxiety. However, the

clinical categories of the HADS did not strongly correspond with the clinical diagnoses of

depression and anxiety. Therefore, while HADS was a validated measure of emotional

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distress in the selected sample, the cut-off scores and categories were not effective in

forecasting the caseness of depression and anxiety.

Timing of TBI Diagnosis in Anxiety Assessment

Investigating the timing of TBI diagnosis holds significant relevance in the

assessment of post-TBI anxiety. Utilizing a longitudinal research design, this project will

track individuals with TBI over time to gather data on when TBI diagnoses were made. This

data will be correlated with anxiety assessments, providing a nuanced understanding of how

the timing of diagnosis impacts anxiety levels. Wang et al. (2021) observe that depression

and anxiety are common occurrences after TBI. Therefore, determining their prevalence and

interplay within the first year after TBI with different severity levels may enhance patients’

outcomes after the traumatic experience. Wang et al. (2021) select participants with a clinical

diagnosis of TBIn for a large European collaborative longitudinal survey. They assess the

socio-demographic, premorbid, and injury-related factors as risk factors. The findings

indicate that 14.1-15.5 percent of patients reported generalized anxiety disorder. Finally,

depression and anxiety after TBI also presented high within-domain persistency and cross-

domain concurrent associations.

Assessing Post-TBI Mental Health Insights from Research

In alignment with the project's focus on assessing and measuring post-TBI anxiety

and its broader impact on mental health, it is important to explore research such as the pilot

randomized trial conducted by Ymer et al. (2021). This trial compares the effectiveness of 6

Cognitive Behavioral Therapy (CBT) to health education in addressing sleep disturbance and

fatigue among individuals who have experienced traumatic brain injuries (TBI). While the

primary outcome in this study is related to sleep disturbances and fatigue, it provides valuable

insights into the broader context of post-TBI mental health. By exploring the measures,

reliability, and validity used in this trial, we can draw relevant conclusions about their

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applicability in assessing various aspects of TBI-related mental health challenges, including

anxiety (Gómez-de-Regil et al, 2019). This study serves as an exemplar of research

methodology that can inform the assessment and measurement of post-TBI mental health in

our project, contributing to a more comprehensive understanding of the psychological well-

being of TBI survivors.

Conclusion

Post-TBI anxiety is one of the leading psychological disorders in the United States

and beyond. Individuals who face these problems report low quality of life, unemployment,

and poor psychosocial well-being. Understanding the process of measuring and diagnosing

this ailment is critical in designing pharmacological and non-pharmacological interventions

for preventing and managing this health crisis. This study aims to explore the reliability,

validity, accuracy, and timing of instruments for measuring anxiety among post-TBI patients.

The findings from the existing body of literature demonstrate a high validity, reliability, and

timing of both HADS and STAIT anxiety measurement scales.

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