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Mild traumatic brain injury (mTBI) accounts for most cases of TBI, and many patients show incomplete long-term functional recovery. We aimed to create a prognostic model for functional outcome by combining demographics, injury severity, and psychological factors to identify patients at risk for incomplete recovery at 6 months. In particular, we investigated additional indicators of emotional distress and coping style at 2 weeks above early predictors measured at the emergency department. The UPFRONT study was an observational cohort study done at the emergency departments of three level-1 trauma centres in the Netherlands, which included patients with mTBI, defined by a Glasgow Coma Scale score of 13–15 and either post-traumatic amnesia lasting less than 24 h or loss of consciousness for less than 30 min. Emergency department predictors were measured either on admission with mTBI—comprising injury severity (GCS score, post-traumatic amnesia, and CT abnormalities), demographics (age, gender, educational level, pre-injury mental health, and previous brain injury), and physical conditions (alcohol use on the day of injury, neck pain, headache, nausea, dizziness)—or at 2 weeks, when we obtained data on mood (Hospital Anxiety and Depression Scale), emotional distress (Impact of Event Scale), coping (Utrecht Coping List), and post-traumatic complaints. The functional outcome was recovery, assessed at 6 months after injury with the Glasgow Outcome Scale Extended (GOSE). We dichotomised recovery into complete (GOSE=8) and incomplete (GOSE≤7) recovery. We used logistic regression analyses to assess the predictive value of patient information collected at the time of admission to an emergency department (eg, demographics, injury severity) alone, and combined with predictors of outcome collected at 2 weeks after injury (eg, emotional distress and coping). Between Jan 25, 2013, and Jan 6, 2015, data from 910 patients with mTBI were collected 2 weeks after injury; the final date for 6-month follow-up was July 6, 2015. Of these patients, 764 (84%) had post-traumatic complaints and 414 (45%) showed emotional distress. At 6 months after injury, outcome data were available for 671 patients; complete recovery (GOSE=8) was observed in 373 (56%) patients and incomplete recovery (GOSE ≤7) in 298 (44%) patients. Logistic regression analyses identified several predictors for 6-month outcome, including education and age, with a clear surplus value of indicators of emotional distress and coping obtained at 2 weeks (area under the curve [AUC]=0·79, optimism 0·02; Nagelkerke R2=0·32, optimism 0·05) than only emergency department predictors at the time of admission (AUC=0·72, optimism 0·03; Nagelkerke R2=0·19, optimism 0·05). Psychological factors (ie, emotional distress and maladaptive coping experienced early after injury) in combination with pre-injury mental health problems, education, and age are important predictors for recovery at 6 months following mTBI. These findings provide targets for early interventions to improve outcome in a subgroup of patients at risk of incomplete recovery from mTBI, and warrant validation. Dutch Brain Foundation.

Cognitive deficits are frequently found after subarachnoid hemorrhage (SAH), but their influence on return to work is largely unknown. To improve identification of those patients at-risk for long-term return to work problems, we aimed to examine the value of cognitive deficits in the prediction of long-term return to work after subarachnoid hemorrhage. SAH patients (N = 71) who were employed before SAH and were able to undergo neuropsychological assessment, were included. Demographic characteristics and acute SAH-related variables (SAH-type and external cerebrospinal fluid drainage) were taken into account. Neuropsychological tests for memory, speed, attention, executive function, and emotion recognition and a questionnaire for executive functions were used. Return to work was assessed using the Role Resumption List. Results showed that patients with incomplete return to work had significantly lower scores on neuropsychological measures for complex attention and executive functions (p < 0.05) compared to patients with complete return to work. Return to work could not be significantly predicted using only demographic characteristics and acute SAH-related variables, but adding measures of complex attention and executive functions resulted in a prognostic model that could reliably distinguish between complete and incomplete return to work. Statistically significant predictors in the final model were cerebrospinal fluid drainage and scores on a questionnaire for executive functions: patients with cerebrospinal fluid drainage and higher scores on the a questionnaire for executive functions were less likely to return to work. Together, these findings show that neuropsychological measures, especially for complex attention and executive functions, have added value to acute SAH-related and demographic variables in the prediction of long-term return to work after SAH.

Traumatic brain injury (TBI) is a leading cause of disability, specifically among younger adults. Behavioral changes are common after moderate to severe TBI and have adverse consequences for social and vocational functioning. It is hypothesized that deficits in social cognition, including facial affect recognition, might underlie these behavioral changes. Measurement of behavioral deficits is complicated, because the rating scales used rely on subjective judgement, often lack specificity and many patients provide unrealistically positive reports of their functioning due to impaired self-awareness. Accordingly, it is important to find performance based tests that allow objective and early identification of these problems. In the present study 51 moderate to severe TBI patients in the sub-acute and chronic stage were assessed with a test for emotion recognition (FEEST) and a questionnaire for behavioral problems (DEX) with a self and proxy rated version. Patients performed worse on the total score and on the negative emotion subscores of the FEEST than a matched group of 31 healthy controls. Patients also exhibited significantly more behavioral problems on both the DEX self and proxy rated version, but proxy ratings revealed more severe problems. No significant correlation was found between FEEST scores and DEX self ratings. However, impaired emotion recognition in the patients, and in particular of Sadness and Anger, was significantly correlated with behavioral problems as rated by proxies and with impaired self-awareness. This is the first study to find these associations, strengthening the proposed recognition of social signals as a condition for adequate social functioning. Hence, deficits in emotion recognition can be conceived as markers for behavioral problems and lack of insight in TBI patients. This finding is also of clinical importance since, unlike behavioral problems, emotion recognition can be objectively measured early after injury, allowing for early detection and treatment of these problems.

Facial expressions have a communicatory function and the ability to read them is a prerequisite for understanding feelings and thoughts of other individuals. Impairments in recognition of facial emotional expressions are frequently found in patients with neurological conditions (e.g. stroke, traumatic brain injury, frontotemporal dementia). Hence, a standard neuropsychological assessment should include measurement of emotion recognition. However, there is debate regarding which tests are most suitable. The current study evaluates and compares three different emotion recognition tests. 84 healthy participants were included and assessed with three tests, in varying order: a. Ekman 60 Faces Test (FEEST) b. Emotion Recognition Task (ERT) c. Emotion Evaluation Test (EET). The tests differ in type of stimuli from static photographs (FEEST) to more dynamic stimuli in the form of morphed photographs (ERT) to videos (EET). Comparing performances on the three tests, the lowest total scores (67.3% correct answers) were found for the ERT. Significant, but moderate correlations were found between the total scores of the three tests, but nearly all correlations between the same emotions across different tests were not significant. Furthermore, we found cross-over effects of the FEEST and EET to the ERT; participants attained higher total scores on the ERT when another emotion recognition test had been administered beforehand. Moreover, the ERT proved to be sensitive to the effects of age and education. The present findings indicate that despite some overlap, each emotion recognition test measures a unique part of the construct. The ERT seemed to be the most difficult test: performances were lowest and influenced by differences in age and education and it was the only test that showed a learning effect after practice with other tests. This highlights the importance of appropriate norms.

Certain subtypes of young onset dementia (YOD), such as the behavioural variant of FTD or the behavioural variant of AD (bvYOD), present with changes in social behaviour instead of memory impairments. These symptoms are often under-recognized, delaying the diagnosis and contributing to psychosocial problems. Impairments in social cognition (SC), an important affected domain in bvYOD, underlie these social behavioural changes. Especially emotional blunting and a lack of empathy in patients with bvYOD might be related to problematic social behaviour, such as risk-taking behaviour, which may potentially harm others. However, despite the importance of SC impairments in the diagnosis of YOD and the impact of SC impairments on social behaviour, there is a lack of valid and well normed measures for certain aspects of SC, such as emotion experience and empathy. The YOD-RiSoCo study is an observational prospective cohort study, consisting of two separate, but related, studies. Study 1 includes 64 patients with bvYOD and 64 healthy controls to assess the sensitivity and validity of newly developed SC instruments for measuring emotion experience and empathy, by comparing their average group performance. Furthermore, validity of the new instruments will be assessed by analysing the associations of performances on these new tests with those on more traditional SC and other neurocognitive tests. Study 2 focuses on assessing to which extent SC measures relate to risk-taking behaviour. This study includes 20 patients with bvYOD and 20 healthy controls from Study 1, in addition to 20 patients with non-bvYOD (e.g. Alzheimer's dementia or vascular dementia) and 20 patients with serious brain injury affecting frontal networks. A specific question is whether the relationship between SC and risk-taking behaviour is generic (for all groups with SC impairments), or specific (not in dementia without SC impairments). Results of the YOD-RiSoCo study will yield new, sensitive neuropsychological tests for aspect of social cognition, which may contribute to a more timely diagnosis of YOD, allowing earlier provision of appropriate counselling and care for patients and their close others. Furthermore, the study will contribute to a better identification of those social behavioural symptoms that negatively affect functioning and social relations. The trial is registered at www.clinicaltrials.gov with identifier NCT06286293.

Behavioural changes after stroke might be explained by social cognition impairments. The aim of the present study was to investigate whether performances on social cognition tests (including emotion recognition, Theory of Mind (ToM), empathy and behaviour regulation) were associated with behavioural deficits (as measured by proxy ratings) in a group of patients with relatively mild stroke. Prospective cohort study in which 119 patients underwent neuropsychological assessment with tests for social cognition (emotion recognition, ToM, empathy, and behaviour regulation) 3-4 years post stroke. Test scores were compared with scores of 50 healthy controls. Behavioural problems were assessed with the Dysexecutive Questionnaire (DEX) self rating and proxy rating scales. Pearson correlations were used to determine the relationship between the social cognition measures and DEX scores. Patients performed significantly worse on emotion recognition, ToM and behaviour regulation tests than controls. Mean DEX-self score did not differ significantly from the mean DEX-proxy score. DEX-proxy ratings correlated with tests for emotion recognition, empathy, and behavioural regulation (lower scores on these items were associated with more problems on the DEX-proxy scale). Social cognition impairments are present in the long term after stroke, even in a group of mildly affected stroke patients. Most of these impairments also turned out to be associated with a broad range of behavioural problems as rated by proxies of the patients. This strengthens the proposal that social cognition impairments are part of the underlying mechanism of behavioural change. Since tests for social cognition can be administered in an early stage, this would allow for timely identification of patients at risk for behavioural problems in the long term.

To investigate the impact of frontal macro-structural lesions on intrinsic network measures, we examined brain network function during resting-state fMRI in patients with frontal lesions in the subacute phase after mild to moderate traumatic brain injury. Additionally, network function was related to neuropsychological performances. 17 patients with frontal lesions, identified on admission CT after mild to moderate trauma, were compared to 30 traumatic brain injury patients without frontal lesions and 20 healthy controls. Three months post-injury, we acquired fMRI scans and neuropsychological assessments (measuring frontal executive functions and information processing speed). Using independent component analysis, the activity of and connectivity between network components (largely located in the prefrontal cortex) and relations with neuropsychological measures were examined and compared across groups. The analysis yielded five predominantly frontal components: anterior and posterior part of the default mode network, left and right frontoparietal network and salience network. No significant differences concerning fMRI measures were found across groups. However, the frontal lesions group performed significantly worse on neuropsychological tests than the other two groups. Additionally, the frontal lesions group showed a significant positive association of stronger default mode network–salience network connectivity with better executive performances. Our findings suggest that, on fMRI level, frontal network measures are not largely affected by frontal lesions following a mild to moderate traumatic brain injury. Yet, patients with damage to the frontal structures did show poorer executive abilities which might to some degree be related to altered frontal network connectivity between the default mode network and salience network.

Cortisol is released through activation of the hypothalamic-pituitary-adrenal axis by physiological and psychological stressors, such as mild traumatic brain injury (mTBI). This hormone is accumulated in hair over longer periods of time, reflecting both acute and chronic forms of stress, allowing for retrospective analyses within certain timeframes. The main objectives of this study were to analyze pre- and post-injury hair cortisol concentrations, and to explore possible associations with personality and recovery after mTBI. Hair samples of 61 mTBI patients were collected at 4–6 weeks post-injury and divided into pre- (1 cm) and post-injury (1 cm) segments. For comparison, hair samples of 24 age, sex and education matched healthy controls (HC) were collected and divided into similar segments. Cortisol was quantified using liquid chromatography-tandem mass spectrometry (LC-MS/MS). At two weeks post-injury, post-traumatic symptoms (PTS), emotional distress (anxiety/depression), and the personality trait neuroticism were measured. At six months post-injury, PTS and functional recovery (Glasgow Outcome Scale Extended) were determined. A significant increase in hair cortisol concentration from pre- to post-injury was found for both mTBI patients and HC, likely due to washout effects, with similar concentrations in both groups. Neither hair cortisol, nor the interaction with neuroticism, were associated with long-term PTS or functional recovery. Additionally, no differences in hair cortisol were observed between patients with a higher and lower risk of developing persistent PTS based on a modified Post-Concussion Symptoms Rule (PoCS Rule) including demographics, acute symptoms, pre-injury mental health and head CT. Altogether, our findings do not support the current use of hair cortisol as a potential marker of stress in mTBI.

Mild traumatic brain injury (mTBI) is one of the most common neurological disorders worldwide. Posttraumatic complaints are frequently reported, interfering with outcome. However, a consistent neural substrate has not yet been found. We used graph analysis to further unravel the complex interactions between functional brain networks, complaints, anxiety and depression in the sub-acute stage after mTBI. This study included 54 patients with uncomplicated mTBI and 20 matched healthy controls. Posttraumatic complaints, anxiety and depression were measured at two weeks post-injury. Patients were selected based on presence (n = 34) or absence (n = 20) of complaints. Resting-state fMRI scans were made approximately four weeks post-injury. High order independent component analysis resulted in 89 neural components that were included in subsequent graph analyses. No differences in graph measures were found between patients with mTBI and healthy controls. Regarding the two patient subgroups, degree, strength, local efficiency and eigenvector centrality of the bilateral posterior cingulate/precuneus and bilateral parahippocampal gyrus were higher, and eigenvector centrality of the frontal pole/ bilateral middle & superior frontal gyrus was lower in patients with complaints compared to patients without complaints. In patients with mTBI, higher degree, strength and eigenvector centrality of default mode network components were related to higher depression scores, and higher degree and eigenvector centrality of executive network components were related to lower depression scores. In patients without complaints, one extra module was found compared to patients with complaints and healthy controls, consisting of the cingulate areas. In conclusion, this research extends the knowledge of functional network connectivity after mTBI. Specifically, our results suggest that an imbalance in the function of the default mode- and executive network plays a central role in the interaction between emotion regulation and the persistence of posttraumatic complaints.

The terminology used to describe components of social cognition lacks clarity and specificity. Recent studies have tried to reach consensus on definitions of social cognition based on expert opinion. These efforts resulted in semantically well-defined terms and distinct concepts, but it remains unclear whether these terms also align with empirical data and existing theoretical models of social cognition. In this commentary, we examine whether the proposed definitions for social cognition are supported by clinical observations and the extant knowledge base on the underlying neural substrates of these skills. In addition, we consider how the proposed definitions align with existing theoretical models of social cognition. We argue that consensus should not be based solely on expert opinion. Therefore, we propose an updated biopsychosocial model of social cognition that integrates proposed expert definitions with a theoretical model of social cognition based on empirical data: the Hierarchical Interdependent Taxonomy of Social cognition (HITS) model. The HITS model guides future research, helps to address the poor construct validity that has been revealed for several tests of social cognition, and provides a framework for the assessment of social cognition.