Brain Injury

Brain Injury
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A retropsective study of heterogeneity in neurocognitive

profiles associated with traumatic brain injury
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Journal: Brain Injury

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Manuscript ID: TBIN-2009-0116.R1
Manuscript Type: Original Paper

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Keywords: cognitive, head Injury, cluster analysis, assessment

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URL: http://mc.manuscriptcentral.com/tbin
Page 1 of 48 Brain Injury
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1 Heterogeneity in TBI
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4 November 30, 2009 Deleted: November 30, 2009
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6 Traumatic Brain Injury 1
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8 Running Head: Heterogeneity in TBI
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10 A Retrospective Study of Heterogeneity in Neurocognitive Profiles Associated
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12 with Traumatic Brain Injury
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November 30, 2009
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Deleted: November 25, 2009
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17 Gerald Goldstein1, Daniel N. Allen2 and Janelle M. Caponigro1
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19 Mental Illness Research, Educational, and Clinical Center (MIRECC), Veterans
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21 Affairs Pittsburgh Healthcare System
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Department of Psychology, University of Nevada Las Vegas
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27 Corresponding Author: Gerald Goldstein VA Pittsburgh Healthcare System 7180

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29 Highland Drive (151R) Pittsburgh, PA 15206 Phone: 412-954-5356 FAX: 412-
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31 954-5371 E mail: ggold@nb.net

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Brain Injury Page 2 of 48
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4 Abstract
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6 Primary Objective: To establish empirical subtypes, based upon cognitive test
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8 results, of individuals who had sustained traumatic brain injury.
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10 Research Design: The study was retrospective, applying cluster analyses and
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12 associated statistical tests to an established database.
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Methods and Procedures: Neuropsychological data from veterans with brain
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17 trauma were cluster analyzed using the WAIS-R and Halstead-Reitan Battery
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19 (HRB). External validity of the cluster solutions was evaluated.
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21 Experimental interventions: The study was based upon use of an established
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database that contained cognitive test data and information regarding diagnosis
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25 and clinical history
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27 Main Outcomes and Results: The WAIS-R clusters described subgroups with
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29 near normal function, preserved verbal but impaired problem solving abilities, or
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31 global impairment. The HRB clusters differed in level of performance with Near
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33 Normal, Moderately Impaired, and Globally Impaired clusters. Cluster
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35 membership was associated with age and employment status, and but not with
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neurological findings.
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Conclusion: The outcome of traumatic brain injury is heterogeneous, and mainly
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42 associated with demographic considerations.
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44 Key Words: Brain Injury, Assessment, Cluster Analysis, Intelligence, Brain Injur
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4 Much of the cognitive research with brain injury has traditionally focused
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6 on localization of cognitive abilities, in the case of focal wounds, or alternatively
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8 identifying a pattern of cognitive deficits that is associated with the more diffuse
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10 injuries associated with closed head injuries (1). However, a number of studies
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12 have suggested that brain injury does not have any protoypical pattern of
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cognitive performance and outcome but may be best characterized by
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17 heterogeneity both in regard to neurocognitive deficit and ultimate level of
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19 functioning. To examine this heterogeneity, empirical classification methods,
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21 notably cluster analysis, have been applied to both children and adults with
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traumatic brain injury (TBI) (2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13). This work has
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25 primarily focused on measures of intellectual abilities and memory, and as might
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27 be expected some variability in results have been present from one study to the
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29 next. However, these studies have provided evidence for homogeneous clusters
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31 that are often differentiated by level of performance, although pattern of

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33 performance differences have been reported as well.
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35 An investigation of the WAIS III (14) in TBI conducted by van der

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Heijden and Donders (12) demonstrated that when subjected to cluster analysis,
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the WAIS III index scores produced three clusters of patients. The clusters were
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42 differentiated largely by level of performance with one cluster characterized by
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44 above average performance, a second by average performance, and a third by
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46 below average performance. Among the three clusters there were substantially
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4 different mean scores on the Verbal Comprehension (VC), Perceptual
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6 Organization (PO), Working Memory (WM), and Perceptual Speed (PS) factor
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8 index scores, with no overlap of profiles or other sign of configuration
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10 differences. The authors concluded that there was no cognitive profile that was
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12 unique to TBI although a relative decrease in Processing Speed scores was present
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in all clusters.
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17 In addition to WAIS performance, evidence for such heterogeneity comes
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19 from a number of studies that concentrated on memory, showing that there are
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21 clusters representing subtypes of memory disorder such as a subgroup with
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limited capacity to benefit from repetition and another subgroup that showed an
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25 unusually high rate of intrusion errors (6, 9). Chan et al. (3) described three
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27 subtypes of combinations of attentional deficits. Thus, cluster analysis has

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29 revealed the presence of heterogeneity in general intelligence, memory, and
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31 attention, suggesting the possibility of its appearance in other cognitive functions.

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33 A main objective of the current study was to examine this possibility by extending
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35 the findings with IQ, memory, and attention tests to a more comprehensive
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evaluation of neurocognitive abilities. We were specifically interested in refining

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the cluster analysis based classification of patients provided by van der Heijden
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42 and Donders (12) with regard to cognitive profile detail and specificity through
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44 utilizing additional tests, in this case major components of the Halstead-Reitan
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46 Neuropsychological Test Battery (HRB) (15) which assesses a large number of

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4 cognitive abilities. Based on van der Heijden and Donders (12) and much of the
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6 previous literature described in Reitan and Wolfson (15) we hypothesized that we
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8 would find a generalized pattern of performance across abilities, but substantial
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10 heterogeneity with regard to level of performance. Such heterogeneity might
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12 provide the basis for formation of a number of valid, separable clusters. Both van
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der Heijden and Donders (12) and Millis and Ricker (9) recommended use of
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17 additional, more comprehensive tests to confirm and extend their findings.
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19 Comparisons between our WAIS-R cluster solution and that obtained using the
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21 HRB were therefore of particular interest. Thus, the present study provides a
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classification system based upon cluster analysis of a comprehensive battery of
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25 tests assessing a broader scope of cognitive abilities than was employed in past
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27 efforts at classification.
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29 Another objective was to determine if heterogeneous patterns and levels of
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31 performance may vary as a result of recovery of cognitive abilities as the length of

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33 time since brain injury increases (9). Patients in the Millis and Ricker’s study (9)
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35 had a mean post-injury time of less than 2 years. Heijden and Donders (12)
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participants had their injuries an average of about 3 months post-injury. Thus, the
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present study, while involving a wide time post-injury range, focused on
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42 relatively long term outcome patterns of cognitive function in a very
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44 heterogeneous sample. The possibility of different clusters produced in the
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46 present study from those obtained by van der Heidjen and Donders (12) appeared
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4 to be real given that with passage of time profiles based on sparing, recovery, and Deleted: A final objective was to
5 determine what influence, if any,
effort might have on heterogeneity of
6 persisting deficits may be expected to emerge which might not be apparent in the neuropsychological test performance
7 in patients with TBI. In recent years,
8 months immediately following injury. This view is supported by the fact that there has been a extensive literature
that has documented the importance
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of effort in neuropsychological test
10 Millis and Ricker (9) obtained substantial time post-injury differences among performance among individuals with
11 TBI, yet cluster analytic studies that
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their CVLT-based clusters. heterogeneity have not considered
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14 contributing factor to difference in
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15 performance among neurocognitive
16 clusters. While modern methods to
17 This study is retrospective, based upon data obtained during the 1960s and evaluate effort were not used in this
study, embedded measures from the
18 Category Test were available and
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19 70s. It is derived from a group of veterans who served in the military in World used to investigate this issue.
Specifically, Forrest, Allen and
20 Goldstein (20) reported that the best
21 War II, the Korean War and the Vietnam conflict. It was done primarily because Category Test indices of effort were
22 more than five errors on subtests I
availability of this sample provided the opportunity to consider outcome of brain and II, both of which are simple
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number identification and counting
24 tasks, and lack of improvement on
25 injury over a lengthy range of time that cannot be assessed through exclusive subtest VI relative to subtest V, both
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the same principle. It was noted in

27 study of acute patients, and provided a possible basis for comparison with brain their study that while patients with
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29 injuries associated with recent military activity. The availability of a improvement, coached malingerers
30 showed less improvement than
patients with structural brain
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31 heterogeneous sample for classification studies is also advantageous, since it damage. It was also found that
32 coached malingerers produced an
33 permits basing findings on distributions in a natural environment before excessive number of errors on
34 Subtests I and II. These indexes
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were used to evaluate effort in the

35 heterogeneity is attenuated by sample selection requirements of some particular overall sample, and as external
36 validity criteria to determine if
37 differences in neuropsychological
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study. test performance among the clusters

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The neuropsychological assessments were accomplished during inpatient
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42 treatment unrelated to the acute trauma, such as acquisition of another medical or
Deleted: While modern
43 procedures and technologies were
44 psychiatric illness, or a residual consequence of the trauma, such as seizures. not available during the time when
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46 Modern procedures and technologies were not available during the time when the Deleted: t
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4 patients were hospitalized. Assessment and documentation procedures that were
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6 available then included direct observation at or close to the time of injury, review
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8 of medical records during first and subsequent hospitalizations, taking of a
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10 detailed medical and social history, physical neurological examination, and
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12 laboratory procedures available at the time, mainly EEG and skull X-ray, with
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rare use of pneumoencephalography and nuclear brain scans. Often neurosurgical
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17 reports were available. In each case, there was a definitive neurological diagnosis Deleted: Assessment and
18 documentation procedures that were
available then included direct
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19 such as “trauma, bone defect right frontal parietal area” or “right frontal subdural
observation at or close to the time of
20 injury, review of medical records
21 hematoma.” The neuropsychological assessment was done as part of during first and subsequent
hospitalizations, taking of a detailed
22 medical and social history, physical
comprehensive general medical, psychiatric, and neurological evaluations using
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24 laboratory procedures available at
25 procedures available at the time. The advantages of utilizing this opportunity to the time, mainly EEG and skull X-
ray, with rare use of
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27 do long term studies of TBI outcome has also been illustrated in an investigation brain scans. Often neurosurgical
28 reports were available. In each case,
there was a definitive neurological
29 by Teiler, Adams, Walker, and Rourke (16) who evaluated psychosocial diagnosis such as “trauma, bone
30 defect right frontal parietal area” or
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31 adjustment in veterans with penetrating brain injury forty years after they were “right frontal subdural hematoma.”
32 Comment [DA1]: Jerry, I think
33 wounded during World War II. The research reported here should be understood we should refer to the demographic
34 and clinical characteristics from the
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outset, so I have moved the

35 in the context of that type of study. references to Tables 1 and 2 here. I
36 have also provided a little discussion
37 of the data presented in those Tables
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METHODS (e.g. education, gender) \. I also

38 moved some of the description you
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Participants
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42 Demographic, psychometric and clinical data for the participants are moved the description of the
outcome of the chart evaluation on
43 causes of injury, surgery, etc., from
44 provided in Tables 1 and 2. As can be seen from the Table, the sample was 34.6 the “Procedures” to here.
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46 years old when assessed with approximately 12 years of education and was line: 0 pt
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4 predominantly male. Full scale IQ was in the average/low average range, although
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6 the extreme range of scores at the low end may reflect the presence of impairment
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8 acquired as a result of TBI. Individuals with IQs within much of this low range
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10 are ineligible for enlistment in military service, suggesting that scores within this
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12 range reflect acquired cognitive impairment rather than preexisting low
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intellectual function. Eighty months had elapsed between the time of initial injury
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17 and neuropsychological assessment. By far, the major cause of injury was car
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19 accident (see Table 2). About a third of the participants received surgery, and
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21 about a quarter of them had seizures following the TBI. 71% of the participants
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had a period of unconsciousness reported, but reliable information concerning
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25 actual length of time unconscious was not generally available. Using the
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27 definition employed here of open head injury alternatively requiring significant

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29 skull fracture, surgical debridement or related procedures, presence of a subdural
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31 hematoma, or observation of brain tissue extrusion to the surface of the skull,

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33 almost half the sample had this condition with the others having closed head
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35 injury. The psychiatric information indicated that diagnoses used at the time, such
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as “organic brain syndrome” was given in 46 cases, but the prevalence of other
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disorders was relatively low. All patients provided informed consent to allow their
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42 results and clinical records to be used for research purposes in accordance with
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6 of testing (WAIS or WAIS-R), HRB and associated clinical records for veterans
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8 with histories of significant TBI hospitalized at the Topeka, KS, or Pittsburgh, PA
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10 veterans (DVA) hospitals. These hospitals are both large DVA centers for
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12 treatment of psychiatric and neurological disorders from two different regions of
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the United States, and are thereby likely to have produced a reasonably
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17 representative and diverse sample of veterans with TBI. Cases were drawn from a
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19 database of DVA patients containing HRB test data and copies of pertinent
20 Comment [DA2]: I moved this
clinical records. Patients in the database were referred for neuropsychological statement about the completeness of
21 the data, etc., to the Procedures
22 section because it seemed to fit better
testing, suggesting concern by clinicians regarding cognitive function.
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23 there.
24 Deleted: Complete data sets for
25 Evaluations included thorough physical neurological examinations and clinical the cluster analyses described below
were available for 80 participants for
26 the analysis of the HRB and 78 for
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27 histories, and use of the diagnostic technologies available at the time. The CT the analysis of the WAIS-R. Since
28 the study was retrospective, and
29 clinical and historical data were
scan only came into use during the later stages of data collection and the MRI had obtained from clinical records, there
30 are varying amounts of missing data
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31 not been available then. However, earlier methods such as among the variables studied.
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33 pneumoencephalograms, brain scans, or EEGs were used as indicated. The brain
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35 injuries were well documented and described, and there were often actual
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descriptions of the injury itself or neurosurgical data. While at the VA facility,

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patients received thorough general medical and neurological evaluations in
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42 connection with the neuropsychological assessment.
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44 Participants were hospitalized at the time they received their
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46 neuropsychological assessments. They had sustained a TBI between 1942 and

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4 1982. The test data for the present study were not obtained at the hospitalization think that we need to include this
statement here, because it is repeated
5 again when we discuss Table 2
6 for the immediate, acute consequences of the trauma but for follow-up evaluation (Above).
7 Deleted:
8 and treatment of residual symptoms of their TBI, or treatment of another illness. Deleted: While all of the
9 participants were veterans, the TBIs
10 The most recently injured participant was injured 3 months prior to testing were not necessarily combat-related
11 but were more often sustained in
civilian life or while the participant
12 ranging to a participant who sustained his injury 33 years prior to testing. Our was still in the military but not
13 engaged in combat.
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average participant had his injury about 6 and ½ years prior to testing, which is a
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17 much longer recovery period than other studies. Only 17 (20.5%) of the patients
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19 had sustained their injuries less than one year prior to testing. Data regarding
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21 evaluation procedures conducted during the acute phase of the TBI and social and
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medical history were available in the clinical records and were utilized for
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25 establishment of external validity of the cluster solutions.
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27 Cases rated as having sustained brain trauma were identified, and

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29 individuals with the additional diagnoses of schizophrenia or a substance use
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31 disorder were excluded. The database contained 31 patients who had a TBI and
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33 substance abuse, and 9 patients with TBI and schizophrenia. A small number of
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35 individuals with remote histories of alcoholism not diagnosed in VA medical

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records were retained. Individuals whose clinical records did not contain
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substantial amounts of information needed for the study were also excluded. All
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42 participants had definitive evidence of a TBI and, with few minor exceptions,
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44 complete data for the neuropsychological tests. The wide age range indicates that
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46 the sample included older veterans from the times of the Second World and
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4 Korean Wars and younger individuals in the military at the time of the Vietnam
6 conflict. statement to the beginning of the
Participants section, since we are
7 talking about the demographic,
8 Insert table 1 about here psychometric and clinical
9 information there.
10 Insert table 2 about here Deleted: Demographic and
11 psychometric data for these
12 participants are provided in Table 1.
Procedure
14 information about IQ testing to the
A standardized review of the clinical records was conducted using a participants section above
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16 Deleted: The IQ data suggest
17 schedule developed for that purpose. The schedule supported a review of that while the mean scores were in
the average range, the extreme range
18 of scores at the low end may reflect
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19 demographic information, phenomenology of the brain trauma, course, surgical the presence of impairment acquired
as a result of TBI. Individuals with
20 IQs within much of this low range
21 and medical diagnostic procedures and psychiatric findings. Information are ineligible for enlistment in
22 military service, suggesting that
concerning these areas was contained in the clinical records or obtained during scores within this range reflect
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acquired cognitive impairment rather
24 than preexisting low intellecutal
25 history taking done at the time of the neuropsychological assessment with the function. Considering that the age
26 range is compatible with
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27 employment, the employment data

patient and/or informants. With regard to demographic information we recorded may reflect the presence of sufficient
28 disability in many of the patients to
29 age, age at time of injury, education, and employment status at the time of prevent employment. All patients
30 provided written informed consent to
allow their results and clinical
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31 assessment, at the time of injury, and total time employed between the injury and records to be used for research
32 purposes in accordance with
33 the time of assessment. Data available indicated that 48 (56.5%) cases were established hospital policies at that
34 time. ¶
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35 Formatted: Indent: First

employed, mainly in military service, at time of injury while 32 (37.6%) were not line: 36 pt
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37 Deleted: for those individuals
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employed at time of injury. Under phenomenology of the injury we obtained who were no longer in military
38 service when the injury occurred
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information about whether it was a closed or open head injury, its location on the Deleted: ,
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42 skull when applicable in regard to lobe or hemisphere, history of a subdural
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44 hematoma, existence of visible skull fractures, and cause of injury such as
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46 gunshot wound or car accident. Medical findings recorded included

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4 neuroimaging, EEG, and physical neurological examination results, when
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6 available. Physical neurological examinations were considered to be abnormal
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8 when the results of such an examination were positive for cranial nerves, reflexes,
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10 sensory or motor dysfunction or gait disorders. Indications of psychiatric
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12 problems in the records were noted (e.g., suicidal behavior) and it was noted when
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examining clinicians used terminology indicating a neurobehavioral disorder
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17 suggesting dementia, amnesia or aphasia. They all had neurological diagnoses
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19 such as post-traumatic encephalopathy indicating localization when appropriate,
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21 and other diagnostic information such as subdural hematoma or skull fracture.
Comment [DA6]: The following
22 sentences were moved here, from
Individuals without such documentation were not included in the study. For many
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23 another part of the document
24 Deleted: The specific details are
25 patients, the terms from DSM-II “Organic Brain Syndrome” or “Chronic Brain described in Table 2.
26 Deleted: Insert table 2 about
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27 Syndrome” were in common use (17). This procedure resulted in complete data here¶
28 Deleted: Prior to conducting the
29 sets for the cluster analyses described below for 80 participants for the analysis of cluster analyses, effort was evaluated
30 using the Subtest I and II subtests of
the Category Test and the amount of
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31 the HRB and 78 for the analysis of the WAIS-R. However, since the study was change in error score between
32 Subtests V and VI. More than five
33 retrospective, and clinical and historical data were obtained from clinical records, errors on subtests I and II and lack of
improvement on subtest VI relative
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to subtest V were examined as

35 there are varying amounts of missing data among the variables studied. indicators of diminished effort.
36 These indexes were used to evaluate
37 effort in the overall sample, as well
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Data Analysis as among the clusters identified in

38 the cluster analyses. ¶
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Two cluster analyses were conducted one for the WAIS-R and another for Formatted: Indent: First
40 line: 36 pt
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42 the HRB. For both cluster analyses, cases were classified into clusters using Deleted: probably
43 Deleted: the most

44 Ward’s method, which is commonly used in neuropsychological studies (18). As Deleted: method
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Deleted: of several hierarchical

46 is also customary, squared Euclidean distance was used as the similarity measure. agglomerative methods
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4 The number of clusters was determined by two methods. First, preliminary
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6 evaluations with varying numbers of cluster solutions aimed at avoiding trivial
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8 clusters in a manner similar to “scree testing,” and more definitively plotting
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10 clusters in discriminant function space, finding adequate separation among group
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12 centroids, as recommended by Aldenderfer and Blashfield (18) in the absence of
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objective methods for definitive determination of number of clusters. The use of
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17 these heuristic methods does not rule out alternative cluster solutions, but does
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19 suggest the location of the point at which further clustering is not productive
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21 because of reduced distance among the cluster spaces. We also examined the
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stability of the cluster solution structure using various algorithms. In this regard,
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25 a frequently used procedure is to compare a hierarchical agglomerative method
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27 with an iterative partitioning method. Thus, we compared Ward’s method with

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29 the K-Means method to determine if similar clusters would be present regardless
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31 of the algorithm used to derive them. An analysis cross-tabulating cluster

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33 memberships derived from the two solutions was used for this purpose testing the
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35 hypothesis that there was a significant agreement between corresponding clusters

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obtained from Ward’s method and K-means solutions.

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The WAIS-R cluster analysis used the eleven subtests of the WAIS-R in
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Deleted: &
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44 reported by van der Heijden and Donders (12). This earlier versions of the WAIS
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4 order to compare our findings with those of van der Heijden and Donders (12) we
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6 examined the traditional three factors derived from the WAIS and WAIS-R,
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8 including Verbal Comprehension (VC), Perceptual Organization (PO), and
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10 Freedom from Distractibility (FFD).
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12 The second cluster analysis used major components of the HRB including
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the Halstead Category Test (total errors), the Tactual Performance Test (Total
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17 Time, Memory, and Location scores), the Speech Perception Test (errors), the
Deleted: ,
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19 Seashore Rhythm Test (errors), Trail Making B (time in seconds), and Finger
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21 Tapping (dominant hand-taps), for a total of eight variables. This analysis was
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accomplished to extend the results of prior studies of the Wechsler scales and
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25 primarily memory tests to a broader range of cognitive abilities using tests that
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27 have been repeatedly demonstrated to be sensitive to TBI (1).

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29 Following the completion of the cluster analysis, external validity studies
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31 were conducted for the HRB analysis in which cluster membership was used as an
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33 independent variable and inter-cluster differences among the variables obtained
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35 from the clinical records were examined. While satisfactory clusters can be
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derived mathematically, they may not reflect actual subgroups or types of a

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disorder unless there has been validation against criteria consisting of relevant
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42 variables not included in the cluster analysis itself. This process has been
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4 validation criteria, which might be predictive of cluster membership. In cluster
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6 analytic work these external validity variables aside from not being included in
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8 the cluster analysis itself could reasonably be hypothesized to be associated with
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10 cluster membership. Typically, validity level is evaluated by testing for statistical
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12 significance among clusters on the variables under consideration. That is, if there
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is a large effect size for the difference among clusters, that would support the
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17 presence of external validity. In the case of TBI there are clearly a substantial
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19 number of variables that would be appropriate for evaluating a proposed cluster
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21 solution. As an example, age at time of injury might differ substantially among
22
clusters based only on neuropsychological test performance. For purposes of this
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25 study, these external variables were divided into several components including
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27 demographic and historical factors, the phenomenology of the injury itself

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29 including cause and damage inflicted, the immediate outcome, notably presence
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31 of unconsciousness, the long term outcome, notably post-injury employment or

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33 educational status, psychiatric consequences and medical/neurological
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35 consequences as assessed by psychiatric and neurological evaluations.

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Since the HRB tests are scored in different ways, HRB raw test scores
38
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were converted to T-scores using normative data corrected for mean age and
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42 education (19) for purposes of graphic profiling, but the raw scores were used in
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44 the statistical analyses. For comparisons among the clusters on the external
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46 validity variables (age, education, age at time of injury etc.), one way analyses of
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4 variance (ANOVA) were used for continuous variables and because of small Deleted: several instances
5 Deleted: Effort was also
6 sample sizes in some cells for some variables, Fisher’s exact tests rather than χ2 evaluated using the Subtest I and II
7 subtests of the Category Test and the
amount of change in error score
8 tests were used for frequency data. In addition to the clinical record items between Subtests V and VI.
9 Separate symptom validity tests were
10 presented here we also had available information about location of the brain not available at the time of
11 acquisition of the data. Forrest, Allen
and Goldstein (20) reported that the
12 injury, particularly in cases in which there was a penetrating wound and surgery. best Category Test indices were
13 more than five errors on subtests I
14 and II, both of which are simple
However, preliminary analysis of the data found no significant differences among
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number identification and counting
15 tasks, and lack of improvement on
16 subtest VI relative to subtest V, both
17 the HRB or WAIS-R clusters when left or right hemisphere or frontal, temporal, of which require learning of exactly
18 the same principle. It was noted in
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19 parietal, or occipital lobe localization were used as dependent measures in the their study that while patients with
structural brain damage showed such
20 improvement, coached malingerers
21 ANOVAs performed for these variables. The details are therefore not provided in showed less improvement than
22 patients with structural brain
damage. It was also found that
the presentation of the external validity results.
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23 coached malingerers produced an
24 excessive number of errors on
25 RESULTS Subtests I and II. These indexes ...
were [1]
26 Comment [DA7]: Jerry – I
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27 Cluster Analyses moved this section to the description

of the Participants, in the Method
... [2]
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29 The WAIS/WAIS-R subtests Deleted: Effort Testing¶
Analysis of effort indicators for the
30 entire sample indicated that the mean
... [3]
ev
31 In choosing the number of clusters, we compared Ward’s method with the Deleted: ¶
32 An abnormality on the physical
33 K-Means method and found good agreement (kappa = .64, p < .001) regarding neurological examination was noted
... [4]
34 Formatted: Font: Italic
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35 classification of cases with a three-cluster solution, but not as satisfactory with a Deleted: The psychiatric
36 information indicated that diagnoses
37 used at the time, such as “organic
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four cluster solution. Similarly, when the clusters were plotted in ... [5]
38 Formatted: Font: Italic
39
multidimensional space, separation among cluster centroids was clear for a three Formatted: Font: Italic
40
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41 Deleted: Description of the

42 cluster solution but not as clear for a four cluster solution. We therefore adopted a Total Sample ¶
A summary of the information... [6]
43
three cluster solution. The cluster profiles are presented in Figure 1. The first Deleted: ¶
44
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4 cluster obtains roughly average mean subtest scores with the exception of Digit
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6 Symbol, which is below average.
7
8 Insert figure 1 about here
9 Deleted: Symbol,
10 The second cluster has a profile characterized by average range Verbal Deleted: which is below
11 average.
12 subtests and substantially impaired Performance subtests, except that Picture Formatted: Indent: First
13 line: 36 pt
14
Completion approaches the average range. Recent considerations concerning the Deleted: subtest scores with the
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15 exception of Digit Symbol,
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17 factor analysis of the WAIS have supported a distinction within the PO factor
Deleted: , 22
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19 between tests of visual organization and visual reasoning (20, 21). This
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21 distinction has been based to a large extent on the addition of new tests such as
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Matrix Reasoning, but it can be supported to a limited extent in the WAIS/WAIS-
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25 R, since Block Design, Picture Arrangement and Object Assembly all require
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27 some form of conceptual reasoning, while Picture Completion only requires

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29 limited analytic reasoning ability and would appear to be more dependent upon
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31 visual organization and knowledge of general information. Since the mean score
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33 for Picture Completion is substantially higher than the mean scores for Block
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35 Design, Picture Arrangement and Object Assembly, and since the VC scores in
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this cluster approach or are at the average range, we would suggest that the
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39
second cluster can be characterized as a “Visual Reasoning” subgroup. The third
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42 cluster could be characterized as a globally impaired intellectual function cluster
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44 as impairment is present on both the Verbal and Performance scales.
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4 Thus, we have characterized the clusters with the terms Near Normal,
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6 Visual Reasoning and Globally Impaired, recognizing that level of performance
7
8 predominantly separates the clusters. However, there is also evidence for
9
10 differences in pattern of performance particularly for the Visual Reasoning
11
12 cluster. There is also some crossing over of subtests among clusters (e.g., Block
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Design and Object Assembly between Clusters 2 and 3) although these
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17 differences are relatively small. While the Near Normal cluster reflects several
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19 average or above intellectual abilities, there still appears to be a deficit in
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21 processing speed as evidenced by a low score on Digit Symbol. The Visual
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Reasoning cluster has well preserved language ability, but relatively impaired
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25 attentional and spatial-constructional skills.
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27 The profile for the WAIS-R factor index scores is also presented in Figure
28
29 1. Level of performance provides the main basis for differences among the
30
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31 clusters, but they have different profiles as well. The Visual Reasoning cluster
32
33 does better on VCI and FFD than on POI, while POI is slightly higher in the
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35 Globally Impaired cluster. In the Near Normal cluster the mean scores for VCI
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and POI are higher than FFD.

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The Halstead-Reitan Battery
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42 Again, a three cluster solution was chosen for the HRB on the same bases
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44 as were used for the WAIS-R. The comparison between Ward’s method and K-
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46 means solutions yielded a kappa of .92 (p < .001) indicating excellent agreement
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4 between the two algorithms. The profile is presented in Figure 2. Table 3
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6 provides quantitative raw score information that may be useful in judging
7
8 magnitude of impairment and the Russell, Neuringer, and Goldstein (20) rating
9
10 equivalents for the mean raw scores. These ratings range from 0 indicating
11
12 excellent performance to 5 indicating severely impaired performance. Use of
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14
these ratings is particularly appropriate since they were constructed using a
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17 sample of veterans who constituted the Topeka portion of the sample used in the
18
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19 present study. They provide information concerning severity of impairment as
20
21 compared with a sample of non-brain damaged veteran patients.
22
Insert figure 2 about here
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25 Insert table 3 about here
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27 As with the Wechsler subtests, separation among the HRB clusters is

28
29 primarily on the basis of level of performance. There is a Globally Impaired
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31 cluster that does relatively poorly on all of the tests, a cluster that reflects Normal
32
33 or Close to Normal performance and an Intermediate group that appears to have
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35 moderately impaired function in some cases performing more like the Near
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Normal cluster and in some more like the Globally Impaired cluster. The Globally
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Impaired cluster appears to be most impaired in processing speed as measured by
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42 the Trail Making Test, and shows little more impairment than the Moderate
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44 cluster on scores obtained from the Tactual Performance Test.
Formatted: Font: Bold,
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46 Comparisons between the WAIS-R and HRB clusters Formatted: Font: Bold
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4 In order to determine to what extent the WAIS-R and HRB classified the
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6 same cases into comparable subgroups, cluster memberships were cross-tabulated.
7
8 The results are presented in Table 4. The degree of agreement was low
9
10 (kappa = .21, p = .006) with the HRB classifying substantially more cases as
11
12 impaired than did the WAIS-R. Overall, twenty five cases (31.6%) were placed
13
14
into the Near Normal cluster by the HRB while 41 cases (51.9%) were placed in
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17 the Near Normal cluster in the WAIS-R cluster analysis. Thus, since all of the
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19 cases had documented brain injuries, it is apparent that the HRB has greater
20
21 sensitivity to its presence than the WAIS-R.
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Insert table 4 about here
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26 Formatted: Font: Bold,
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Not Italic
27 External Validity
28
29 Given this greater sensitivity to brain damage external validity data are
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31 only presented for the HRB cluster analysis. The results contained in Table 5
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33 present a pattern of significant and non-significant differences among clusters.
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35 Neurological factors such as type, cause, and location of injury, or abnormalities

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found on physical examination, skull-X-Ray, or EEG were not associated with

38
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significant intercluster differences. On the other hand, significant differences were
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42 found for sociodemographic variables including age at time of assessment, age at
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44 time of injury, and employment status. The Globally Impaired cluster was older at
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46 time of injury and assessment and had a lower percentage of employed

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4 individuals than was the case for the other clusters. Education was of borderline
5
6 significance (p = .08) indicating that the Globally Impaired cluster had a lower
7
8 mean educational level than did the other clusters.
9 Deleted: With regard to
10 differences in effort among the
11 clusters, no significant differences
were present for
12 Insert table 5 about here
13 Deleted: effort, the mean score
for
14
Discussion
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15 Deleted: Category Test Subtests
1 and 2,
16
17 A sample of veterans who sustained TBI was found to have an outcome Deleted: for the total sample was
.14 (SD=.47) and .54 (SD=.83) for
18 Subtest II with nonsignificant
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19 pattern largely involving marked variation in level, with some indication of differences among the clusters.
20 There was a
21 differences in pattern, of cognitive function. Three cluster solutions were Deleted: or for the mean
22 improvement on Subtest V relative
identified for both analyses of WAIS/WAIS-R and HRB data with level of to VI.
ee
23
24 Deleted: of 5.35 (SD=5.40) for
performance being the major consideration separating the clusters. However, in the total sample again with a
25 nonsignificant difference among the
26 clusters. Errors on Subtests I and II
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27 an analysis performed using the 11 WAIS-R subtests, one of the clusters had a were substantially lower than those
28 obtained by Forrest et al.’s (20)
coached malingering group and
29 clear performance pattern marked by relatively intact verbal abilities and impaired improvement from Subtest V to VI is
30 also greater. Not all participants
ev
31 visual reasoning abilities. In their WAIS-III cluster analytic study, van der improved on Subtest VI relative to
V, but only 6 participants made more
32
than one more error on Subtest VI
33 Heijden and Donders (12) also proposed a three-cluster solution but it was relative to V while 80% of the
34 participants showed some
ie
35 improvement.
essentially entirely based upon level of performance without a dissociation
36 Deleted: Thus, overall findings
37 and intercluster differences are not
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between verbal abilities and visual reasoning. readily attributable to effort related
38 considerations.
39
With regard to generalizeabilty of the current findings, while the current Deleted: ,
40
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41 Deleted: proposed
42 sample consisted entirely of veterans, it had different characteristics from those Deleted: ¬
43 Deleted:
44 involved in numerous studies of veterans with focal brain wounds sustained in
Deleted: W
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46 combat, notably the studies of the Teuber group (e.g., 21). Only 10 of our
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4 patients sustained brain injury from gun shot or shrapnel wounds, a proportion
5
6 that is probably higher than what would occur in the general population (1) but
7
8 clearly not common in this sample. These results may enhance the
9
10 generalizability of the findings since the proportions of various causes of brain
11
12 injury would appear to be little different between what is found in veterans and
13
14
non-veterans. It is also likely that the sample obtained represented a substantially
Fo
15
16
17 impaired subgroup of a larger population containing less ill or disabled
Deleted: they
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19 individuals. Furthermore, subjects were tested while hospital inpatients for an
20
21 event unrelated to the acute trauma, including health problem associated with the
22
brain jury (e.g., seizure control). Nevertheless one of the clusters obtained, for
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25 both the Wechsler and HRB analyses, identified a reasonably intact subgroup
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27 consisting of individuals functioning in the average range of general intelligence,

28
29 and with adequate problem solving abilities. As a group they did show slowness
30
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31 of processing speed, but in isolation from other relatively intact abilities.

32
33 However, the Globally Impaired clusters contain individuals with rather
34
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35 devastating, generalized cognitive dysfunction. Only about a third of these

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individuals were employed at the time of testing as opposed to 72% in the Near
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39
Normal cluster.
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42 Comparing the present cluster analytic findings with those of van der
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44 Heijden and Donders (12) indicates that subgroups described shortly following
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46 brain injury appear to persist on a long-term basis. However, the WAIS-R

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4 analysis was particularly helpful in characterizing what we have called the Visual
5
6 Reasoning cluster, which did not appear in the van der Heijden and Donders
7
8 study. Individuals in this cluster appeared to have suffered from substantial
9
10 impairment of complex problem solving abilities, as measured by such procedures
11
12 as Block Design and the Category Test. However, they seemed to have preserved
13
14
or recovered their language abilities, and have average level vocabularies and
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15
Deleted: really
16
17 language comprehension. Van der Heijden and Donders did not have a Visual
18
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19 Reasoning cluster as identified in our cluster analysis, but a subgroup that could
20
21 be better characterized as having moderate generalized impairment with relatively
22
greater impairment on the PS factor index. This cluster was similar to the one
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25 found here if one uses WM as the equivalent of FFD. That is WM was slightly
26
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27 better than VC and PO. However, there was not a substantial split between the VC
28
29 and PO indices as was found here. Therefore, while the differences in profiles
30
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31 from both studies can be generally attributed to level of performance differences,

32
33 there is an indication that pattern of performance also distinguishes the clusters in
34
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35 the case of the present study. Our Near Normal and Global profiles are quite
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similar to those obtained by van der Heijden and Donders (12). Their highest
38
39
functioning cluster had higher VCI and POI mean scores, while their lowest
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42 functioning cluster had a slightly higher POI than VCI score, both being higher
43
44 than the FFD equivalent Working Memory (WM) and Perceptual Speed (PS)
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46 indices.
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4 One possibility is that the difference between the cluster patterns between
5
6 the van der Heijden and Donders and present study had to do with time since
7
8 injury. Shortly after injury, both language and problem solving abilities may be
9
10 impaired but as time passes, it is possible that language recovers substantially in
11
12 some individuals, but reasoning and problem solving abilities do not. This
13
14
dissociation between relatively intact language and impaired problem solving
Fo
15
16
17 abilities was made possible by considering both the WAIS/WAIS-R and the HRB
18
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19 in the neuropsychological evaluation. The HRB based analysis provided
20
21 information concerning status of reasoning and problem solving abilities in the
22
three clusters, while the WAIS-R analysis identified a dissociation in a group of
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24
25 individuals between relatively intact and impaired abilities. The HRB data for the
26
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27 Moderate cluster did not reflect a dissociation between impaired and intact
28
29 abilities. All of the Russell, Neuringer and Goldstein ratings reflected mild or
30
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31 greater impairment and none of the Heaton et al. (19) mean T scores for the
32
33 Moderate cluster reached 50. However, several of the mean WAIS-R subtest
34
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35 standard scores fell within one standard deviation from the mean for the general
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population.
38
39
Neurological examinational methods did not appear to separate the
40
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42 clusters, possibly because of low sensitivity of these methods. In the total sample
43
44 only 32% of the EEGs and 19% of the skull X-rays were abnormal. It is possible
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46 that application of advanced neuroradiological techniques may have altered

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2
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4 matters, although the extensive recent literature in this area is somewhat
5
6 inconclusive. For example, Lewine, Davis, Bigler, Thoma, Hill, Funke, Sloan,
7
8 Hall, and Orrison (22) reported that only four of their 30 patients with TBI had
9
10 abnormal MRI findings.
11
12 Considering the external validity data utilized in this study, the variables
13
14
that best separated the clusters were demographic in nature. As might be
Fo
15
16
17 anticipated, individuals in the globally impaired clusters were least likely to be
18
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19 employed, but were also older than members of the other clusters. Individuals
20
21 who were relatively young at the time of injury were more likely to be in the Near
22
Normal clusters. Education also significantly separated the clusters in the
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24
25 expected direction.
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27 Part of the explanation for the positive findings for demographic external
28
29 validity variables may be that the cognitive reserve associated with young age and
30
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31 advanced education may protect the brain from a poor outcome (23). The
32
33 participants in the Near Normal cluster were younger and better educated than
34
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35 was the case for the other clusters. Thus, having a TBI in an individual who is
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relatively young and well educated may presage a better outcome than if the
38
39
reverse were true.
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42 A final consideration was the performance of the overall sample and the
43
44 individual clusters on the embedded measures of effort. While the importance of
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46 the evaluation of effort has been emphasized in studies of patients with TBI who
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2
3
4 are seeking legal remedies to cognitive disabilities associated with their brain
5
6 injuries, there has not been a systematic attempt to determine whether variability
7
8 in effort accounts for the neurocognitive clusters identified in prior studies. To
9
10 address this issue, the current investigation examined embedded measure of effort
11
12 in the Category test and found that effort had little to do with cluster membership.
13
14
No differences were present among the clusters on our effort indices, suggesting
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15
16
17 that the neurocognitive heterogeneity noted in TBI does not results from differing
18
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19 levels of motivation between the clusters.
20
21 Several conclusions can be suggested from this study. Cognitive outcome
22
following the acute phase of injury is heterogeneous, but does not appear to be
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24
25 associated with severity of injury. This result runs parallel with the finding that
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27 psychosocial outcome is also not associated with severity (28). Cluster analyses
28
29 of extensive neuropsychological assessments separated the cases studied into
30
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31 three subgroups varying substantially in level of performance, but also in pattern

32
33 to a lesser extent. A Globally Impaired subgroup demonstrated generalized
34
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35 cognitive impairment resulting in an apparent diminution of general intelligence

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and a number of adaptive abilities assessed by the HRB. Consistent with the
38
39
literature, processing speed was particularly impaired. A Moderately Impaired
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42 cluster produced a higher level of performance with reasonably good preservation
43
44 of language or crystallized skills and relatively poor performance on tests of
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46 problem solving. The term moderate would appear to be appropriate for the HRB
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2
3
4 based cluster analysis, but in the case of the WAIS-R, what we have called the
5
6 “Visual Reasoning” cluster performed at an average or close to average level on
7
8 measures of some abilities and at a clearly impaired level at other abilities. These
9
10 individuals cannot be reasonably described as moderately impaired in general
11
12 since they maintain some intact abilities as well as some significantly impaired
13
14
abilities. A third cluster performed at an average level on all of the WAIS-R
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16
17 subtests with the exception of measures of attention and processing speed,
18
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19 particularly as reflected by the FFD Wechsler factor index score, and did not
20
21 receive a worse than mildly impaired HRB rating. A number of findings that
22
could be interpreted as indirect indicators of severity did not effectively separate
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24
25 the clusters. However, significant separation was obtained for age at injury, age at
26
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27 assessment, and employment status. Borderline significance was obtained for

28
29 education. However, it might be of interest that only one of the 25 Near Normal
30
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31 cluster members had less than a 10th grade education (4%), 8 of the 18 Globally
32
33 Impaired cluster members (44.4%) had less than a 10th grade education.
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35 This type of retrospective study provides a long-term perspective on the

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outcome of brain injury well beyond its acute phase. A retrospective design has
38
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the obvious limitations of unavailability of modern technologies. However, the
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42 opportunity to study the long term outcome of TBI among patients who have been
43
44 evaluated sometimes over many years does not occur frequently, and can provide
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46 insights not obtainable from acute studies since it addresses issues associated with
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2
3
4 persistence of TBI related symptoms over a long time period. Thus, the
5
6 limitations might not outweigh the advantages of retrospective research and does
7
8 not compromise the general conclusion that outcome of brain injury is diverse but
9
10 may be organized into subtypes utilizing classification statistics such as cluster
11
12 analysis. Nevertheless, these limitations are significant, particularly regarding the
13
14
absence of consistently reliable and complete information about the acute
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17 histories, particularly regarding period of unconsciousness and posttraumatic
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19 amnesia, as well as because of absence of modern diagnostic procedures. We
20
21 would therefore encourage pursuit of prospective studies that systematically
22
investigate the complexities of determination of outcomes identified here utilizing
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25 contemporary methods and technologies.
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4 References
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6 1. Reitan, R. M., Wolfson, D. Mild head injury: Intellecutal, cognitive, and
7
8 emotional consequences. Tucson, AZ: Neuropsychology Press; 2000.
9
10 2. Allen, DN, Mayfield J, Strauss G P. Neuropsychological subtypes of childhood
11
12 traumatic brain injury. Presented at the meeting of the American Psychological
13
14
Association, New Orleans, LA. 2006, August.
Fo
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17 3. Chan, R. C., Hoosain, R., Lee, T. M., Fan, Y. W., Fong, D. Are there sub-types
18
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19 of attentional deficits in patients with persisting post-concussive symptoms? A
20
21 cluster analytical study. Brain Injury 2003; 17:131-148.
22
4. Curtiss, G., Vanderploeg, R. D., Spencer, J. Patterns of verbal learning and
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25 memory in traumatic brain injury. Journal of the International Neuropsychological
26
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27 Society 2001; 7: 574-585.

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29 5. Demery, J. A., Pedraza, O., Hanlon, R. E. Differential profiles of verbal
30
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31 learning in traumatic brain injury. Journal of Clinical and Experimental

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33 Neuropsychology 2002; 24: 818-827.
34
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35 6. Deshpande, S. A., Millis, S. R., Reeder, K. P., Fuerst, D., Ricker, J. H. Verbal
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learning subtypes in traumatic brain injury: a replication. Journal of Clinical and

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Experimental Neuropsychology 1996; 18: 836-842.
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42 7. Greve, K. W., Love, J. M., Sherwin, E., Mathias, C. W., Ramzinski, P. Levy, J.
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44 Wisconsin Card Sorting Test in chronic severe traumatic brain injury: factor
45
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46 structure and performance subgroups Brain Injury 2002;16:29-40.

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4 8. Lange, R. T., Iverson, G. L., Franzen, M. D. Neuropsychological functioning
5
6 following complicated vs. uncomplicated mild traumatic brain injury. Brain
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8 Injury 2009; 23:83-91.
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10 9. Millis, S. R., Ricker, J. H. Verbal learning patterns in moderate and severe
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12 traumatic brain injury. Journal of Clinical and Experimental Neuropsychology
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1994; 16: 498-507.
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17 10. Moore, A. D., Stambrook, M. Peters, L. C. Coping strategies and adjustment
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19 after closed-head injury: a cluster analytical approach Brain Injury 3;1989:171-
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21 175.
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11. Mottram, L., Donders, J. Cluster subtypes on the California verbal learning
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25 test-children's version after pediatric traumatic brain injury. Developmental
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27 Neuropsychology 2006; 30: 865-83.

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29 12. van der Heijden, P., Donders, J. (2003). WASI-III factor index score patterns
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31 after traumatic brain injury. Assessment 2003; 10: 115 – 122.

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33 13. Wiegner, S., Donders, J. Performance on the California Verbal Learning Test
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35 after traumatic brain injury. Journal of Clinical and Experimental

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Neuropsychology 1999; 21: 159-170.

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14. Wechsler D. WAIS-III: Wechsler Adult Intelligence Scale-Third Edition.
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42 San Antonio TX: The Psychological Corporation; 1997.
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4 15. Reitan, R. M., Wolfson, D. The Halstead-Reitan Neuropsychological Test
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6 Battery: Theory and clinical interpretation (2nd ed.). Tucson, AZ:
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8 Neuropsychological Press; 1993.
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10 16. Teiler, A., Adams, K. M., Walker, A. E. Rourke, B. P. Long-term effects of
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12 severe penetrating head injury on psychosocial adjustment. Journal of Consulting
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and Clinical Psychology, 1998; 58:531-537.
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17 17. American Psychiatric Association. Diagnostic and statistical manual of
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19 mental disorders (2nd ed.) Washington DC: Author; 1952.
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21 18. Aldenderfer, M, S., Blashfield, R.K. Cluster analysis. Beverly Hills, CA:
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Sage Publications; 1984.
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25 19. Heaton, R. K., Miller, S. W., Taylor, M. J., Grant I. Revised comprehensive
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27 norms for an expanded Halstead-Reitan Battery. Lutz, Fl: Psychological

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29 Assessment Resources, Inc.; 2004.
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32 20. Russell, E. W., Neuringer, C., Goldstein, G Assessment of brain damage. New
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34 York: Wiley-Interscience; 1970.
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36 21. Teuber, H.-L. (1964). The riddle of frontal lobe function in man. In Warren
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38 JM, & Akert K, editors. The frontal granular cortex and behavior New York:
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40 McGraw-Hill 1964, pp 410-444.
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22. Lewine, J. D., Davis, J. T., Bigler, E. D., Thoma, R., Hill, D., Funke, M.,
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Sloan, J. H., Hall, S. Orrison, W. W. Objective documentation of traumatic brain
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4 injury subsequent to mild head trauma: Multimodal brain imagining with MEG,
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6 SPECT, and MRI. Journal of Head Trauma Rehabilitation 2007; 22: 141 – 155.
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8 23. Stern, Y. What is cognitive reserve? Theory and research application of the
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10 reserve concept. Journal of the International Neuropsychological Society 2002; 8:
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12 448-460.
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7 Figure Captions and Legends
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9 Figure 1. Performance on WAIS-R subtests and Index Scores as a function of
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11 cluster membership: I –Information; C = Comprehension; A = Arithmetic; D =
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Digit Span = V = Vocabulary; DS = Digit Symbol; PC = Picture Completion; BD
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= Block Design; PA = Picture Arrangement; OA = Object Assembly; VCI =
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18 Verbal Comprehension Index; POI = Perceptual Organization Index; FFD =
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20 Freedom From Distractibility Index
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22 Figure 2. Performance on Halstead-Reitan Battery as a function of cluster
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24 membership: CAT = Category Test; TPT = Tactual Performance Test-Total Time;
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26 M = Tactual Performance Test-Memory; L = Tactual Performance Test-Location;
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28 SP = Speech Perception Test; RHY = Rhythm Test; TRB = Trail Making Test,
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30 Part B; TAP = Finger Tapping-Right Hand
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Scaled Scores
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27 7 Global
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37 WAIS-R Subtests
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40 Moderate
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22 Normal
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33 HRB Tests
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8 Table 1
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10 Demographic and IQ Data
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13 Variable Mean SD Range
14 Age 34.6 12.2 19-63 Deleted: 5.0
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15 Years of Education 11.8 2.2 3-16 Deleted: 3
16 Verbal IQ 94.3 14.1 46-121 Deleted: 9
17 Performance IQ 90.8 15.1 53-129 Deleted: 0
18 Full Scale IQ 92.2 13.5 60-120
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19 Deleted: 9
Months Between TBI and 80.0 98.2 3-400
20 Testing Deleted: 0
21 Deleted: 1
22 N % Deleted: 4
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23 Male Participants 77 98.7 Deleted: 78.1
24 Employed At Time of Injury 44 56.4
25 Deleted: 7.7
Employed Since Injury 57 73.1
26 Deleted: 2
Employed at Time of 41 52.6
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27 Deleted: 86
Assessment
28 Deleted: 9
29
Deleted: 8.7
30
Deleted: 8
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32 Deleted: 7.3
33 Deleted: 2
34 Deleted: 4.5
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4 Table 2
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6 Clinical variables
7
8 Variable N %
9 Type of Injury
10 Open Head 36 45.0
11
Closed Head 44 55.0
12
Subdural Hematoma 11 13.8
13
Multiple Fractures 24 30.4
14
Cause of Injury
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16 Gun Shot Wound 9 11.4
17 Blast 3 3.8
18 Assault 2 2.6
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19 Vehicle Accident 47 60.3
20 Home Accident 3 3.8
21 Industrial Accident 4 5.1
22 Fall 7 8.9
Unknown 5 6.3
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24 Positive Diagnostic Procedures
25 Abnormal Skull X-Ray 16 20.3
26 Abnormal EEG 25 31.3
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27 Abnormal Physical Neurological Examination 21 26.3

28 History of Seizures 22 25.9
29
Visible Skull Marking 14 17.5
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Received Surgery 29 36.6
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Reported to Be Unconscious 61 70.1
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33 Positive Psychiatric Findings
34 Diagnosis of Organic Mental Disorder 46 57.5
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35 Depression 10 12.5
36 Anxiety 6 17.1
37 Suicidality 2 2.5
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38 Disinhibition 6 7.5
39 Alcohol or Drug Abuse History 8 9.2
40 Psychosis History 6 7.6
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5 Table 3
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7 Comparisons of HRB Raw Score Results Among the Three Clusters
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9 Test Cluster Mean1 SD RNG Rating2 T-Scores3
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11 CAT Errors Moderate 74.2 28.2 2 35
12 Normal 60.0 29.6 2 39
13 Severe 103.9 25.5 3 27
14 Total 76.5 32.0 3 35
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15 TPT Minutes Moderate 24.7 48.2 3 32
16 Normal 11.3 41.0 1 48
17 Severe 27.2 37.0 3 32
18 Total 21.1 79.8 3 36
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19 M Correct Moderate 5.8 2.0 1 37
20 Normal 8.1 1.2 1 53
21 Severe 5.2 1.6 2 33
22 Total 6.4 2.1 1 37
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23 L Correct Moderate 1.9 2.1 3 8-41
24 Normal 4.5 2.6 2 52
25
Severe 1.1 1.4 3 37
26
Total 2.5 2.5 2 45
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27
SP Errors Moderate 13.1 8.8 2 32
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Normal 8.7 5.0 2 40
30 Severe 22.6 6.8 3 24
Total 13.9 8.9 2 32
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32 RHY Errors Moderate 7.5 3.7 2 37
33 Normal 6.2 3.8 2 40
34 Severe 11.8 3.9 3 31
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35 Total 8.1 4.3 2 37

36 TRB Second Moderate 118.7 38.0 2 36
37 Normal 73.4 19.2 1 50
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38 Severe 252.3 45.3 4 23

39 Total 134.6 75.3 3 32
40 TAPD Taps Moderate 42.8 10.4 2 35
On
41 Normal 47.8 7.3 2 44

42 Severe 41.9 10.6 3 31
43 Total 44.2 9.8 2 35
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4 (table 3 continued)
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6 1
All intercluster differences were statistically significant (p>001) with the
7 exception of Tapping (p = .054)
8 2
Russell, Neuringer and Goldstein (1970) Ratings: 1=Normal; 2=Mildly Impaired;
9 3=Moderately Impaired
10 3
Heaton, Miller, Taylor, & Grant I. (2004).
11 Note: CAT = Category Test; TPT=Tactual Performance Test (Time); M=TPT
12 (Memory); L=
13
TPT (Location); SP= Speech Perception; RHY=Rhythm Test; TRB=Trail Making
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B; TAPD=
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Finger Tapping (Dominant Hand).
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4 Table 4
5 Relations Between WAIS-R and HRB Based Cluster Analyses
6 HRB Based Clusters
7 Normal Moderate Severe Total
8 WAIS Based Normal 23 17 1 41
9 Clusters Visual 0 9 5 14
10
Global 2 10 10 22 Deleted: 2
11
Total 25 36 16 77 Deleted: 4
12
13
(χ2 (4) = 31.06, p<.001) Deleted: 8
14 Deleted: 9
Fo
15 Deleted: 3.88
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4 Table 5
5 External Validity Data for HRB Cluster Solution
6 Cluster
7 Formatted Table
8 Moderate Normal Global
9 N=37 N=25 n=18
10
11
Interval Data Mean and SD F p
12
13
Age 32.2+11.3 29.6+10.1 42.8+10.4 7.85 .001 3…5…0
Deleted: ... [7]
14 Years of Education 12.00+2.07 12.40+1.4 10.8+3.3 2.61 .08 6…2
Deleted: ... [8]
Fo
15 Age at Injury 26.0+9.6 24.9+10.9 32.7+10.5 5.14 .05 4…6…1.2
Deleted: ... [9]
16 Months Between Injury 81.92+102.7 56.58+62.12 111.53 +137.2 .94 .25 98
Deleted:
17 and Assessment Formatted: Underline
18 Nominal Data % Exact P
rP
19 Test Deleted: .65+133.3 ... [10]
20 Employed at 51.4 72.0 33.3 5.85 Deleted:
.06 χ2
21
Assessment
22
Employed Since Injury 79.4 76.0 78.6 .20 .93 5.0
Deleted: ... [11]
ee
23
24
Employed at Injury 55.9 76.0 42.9 4.61 .11 37.5
Deleted: ... [12]
25 Type of Injury
26 Open Injury 43.2 44.0 56.3 Deleted: 0.0
rR
27 .86 .67 24
Deleted: ... [13]
Closed Injury 56.8 56.0 43.8
28 Deleted: 50.0
29 Subdural Hematoma 13.5 12.0 18.8 .56 .83 16.7
Deleted: ... [14]
30 Multiple Fractures 36.1 20 25.0 1.91 .39 33.3
Deleted:
ev
31 Cause of Injury
32
33 Gun Shot Wound 8.3 12.0 18.8 1.36 .47 16.7
Deleted: ... [15]
34 Vehicle Accident 69.4 44.0 60.0 3.91 .15
Deleted: 4.7 ... [16]
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35 Fall 8.3 12.0 6.3 .51 .88

Deleted: 5.6 ... [17]
36
37 Positive Diagnostic Procedures and Observations
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38
39 Nominal Data % Exact Test p
Deleted: …χ2 … ... [18]
40 Abnormal Skull X-Ray 21.6 16.7 18.8 .27 .93 22.2
Deleted:
On
... [19]
41 Abnormal EEG 35.1 32.0 18.8 1.37 .59 22.2
Deleted: ... [20]
42
43 Abnormal Examination 24.3 28.0 31.3 .41 .85 27.8
Deleted: ... [21]
44 History of Seizures 24.3 34.8 25.0 2.07 .88 22.2
Deleted: ... [22]
45 Visible Skull Marking 21.6 16.0 12.5 ..63 .80 11.1
ly
Deleted: ... [23]

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2
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4 Received Surgery 35.1 36.0 43.8 .08 .96 38.9
Deleted:
5 (table continues)
6 % Exact Test p χ2
Deleted:
7 Reported Unconscious 67.6 76.0 69.2 .63 .73
Formatted: Left
8 Positive Psychiatric Findings Deleted:
9 Organic Mental Disorder 62.2 52.0 62.5 .77 .73
10 Deleted:
Depression 8.1 16.0 18.8 1.72 .45
11 Anxiety 15.4 23.1 12.5 .54 Deleted:
1.0 66.7
12 Disinhibition 5.4 12.0 6.3 1.1 Deleted:
.75 55.6
13
Alcohol Abuse 5.4 12.0 6.3 1.1 .75
Deleted: .67
14
Drug Abuse 0.0 4.0 6.3 2.48 .27
Deleted: .72
Fo
15
16
Psychosis History 8.1 4.2 12.5 1.1 .75
Deleted: 6.7
17 Deleted: 1.22
18 Deleted: .54
rP
19 Deleted: 1.1
20
Deleted: .58
21
22 Deleted: .75
ee
23 Deleted: 5.6
24 Deleted: 1.06
25 Deleted: .59
26
rR
Deleted: or Drug Abuse

27
28 Deleted: 11.1
29 Deleted: .98
30 Deleted: .61
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31 Deleted: 1.1
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Deleted: .73
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34 Deleted: .69
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4 Acknowledgements: This research was supported by the DVA VISN IV Mental
5
6 Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare
7
8 System, Pittsburgh, PA and the Medical Research Service, Department of
9
10 Veterans Affairs.
11
12 Declaration of Interest: The authors report no conflicts of interest. The authors
13
14
alone are responsible for the content and writing of the paper.
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4
Effort was also evaluated using the Subtest I and II subtests of the Category Test
5
6
7 and the amount of change in error score between Subtests V and VI. Separate symptom
8
9 validity tests were not available at the time of acquisition of the data. Forrest, Allen and
10
11
12
Goldstein (20) reported that the best Category Test indices were more than five errors on
13
14 subtests I and II, both of which are simple number identification and counting tasks, and
Fo
15
16 lack of improvement on subtest VI relative to subtest V, both of which require learning of
17
18
exactly the same principle. It was noted in their study that while patients with structural
rP
19
20
21 brain damage showed such improvement, coached malingerers showed less improvement
22
ee
23 than patients with structural brain damage. It was also found that coached malingerers
24
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26 produced an excessive number of errors on Subtests I and II. These indexes were used to
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28 evaluate effort in the present data set and were treated as external validity criteria.
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32 Jerry – I moved this section to the description of the Participants, in the Method section, as that is what the
33 reviewers seemed to want.
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35 Effort Testing
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Analysis of effort indicators for the entire sample indicated that the mean score for
38
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40 Category Test Subtest 1 for the total sample was .14 (SD = .47) and .54 (SD = .83) for
On
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42 Subtest II. There was a mean improvement on Subtest V relative to VI of 5.35 (SD =
43
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5.40) for the total sample. In comparison, errors on Subtests I and II were substantially
ly
46
47 lower than those obtained by Forrest et al.’s (20) coached malingering group and
48
49 improvement from Subtest V to VI is also greater. Not all participants improved on
50
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52 Subtest VI relative to V, but only 6 participants made more than one error on Subtest VI
53
54 relative to V while 80% of the participants showed some improvement. Thus, the
55
56 findings suggest that overall the sample exhibited adequate effort.
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1
2
3
5
6
7
8 An abnormality on the physical neurological examination was noted when the
9
10 results of such an examination appeared in the records and were positive for cranial
11
12 nerves, reflexes, sensory or motor dysfunction or gait disorders. Presence of scars on the
13
14
head from the injury itself or surgery was also noted. Other available diagnostic
Fo
15
16
17 procedures (e.g. pneumoencephalogram) were rarely used. As can be seen in Table 2,
18
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19 these variables were positive in a minority of cases, with having received surgery being
20
21
22 the most common positive sign (36.6%).
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26 The psychiatric information indicated that diagnoses used at the time, such as “organic
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28 brain syndrome” was given in 46 cases, but the prevalence of other disorders was
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relatively low.
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35 Description of the Total Sample

36
37 A summary of the information obtained from the clinical records are contained in
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Table 2. Using the definition employed here of open head injury alternatively requiring
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42 significant skull fracture, surgical debridement or related procedures, presence of a
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44 subdural hematoma, or observation of brain tissue extrusion to the surface of the skull,
45
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47 almost half the sample had this condition with the others having closed head injury. By
48
49 far, the major cause of injury was car accident. About a third of the participants received
50
51 surgery, and about a quarter of them had seizures following the TBI. 71% of the
52
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54 participants had a period of unconsciousness reported, but reliable information
55
56 concerning actual length of time unconsciousness was not generally available. The
57
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1
2
3
Glasgow Coma Scale or related procedures were not in common use at the time patients
4
5
6 in the sample sustained their injuries.
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18 9.81
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.024
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48 5.0
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51 16
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1
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6.16
4
6 05
8
9 24
11 .89
12
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14 16.7
Fo
16 .20
17
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19 91
21 16.7
22
ee
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24 .84
26
.66
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42 76
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47 χ2
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52 22.2
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55 8
57 87
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22.2
5
7 .95
9
10 62
12 27.8
13
14
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17 94
18
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20 22.2
22 2.1
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25 .72
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30 98
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Brain Injury

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Brain Injury

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Brain Injury

A retropsective study of heterogeneity in neurocognitive

Journal: Brain Injury

Manuscript ID: TBIN-2009-0116.R1

Manuscript Type: Original Paper

Keywords: cognitive, head Injury, cluster analysis, assessment

27 Corresponding Author: Gerald Goldstein VA Pittsburgh Healthcare System 7180

31 954-5371 E mail: ggold@nb.net

31 that are often differentiated by level of performance, although pattern of

35 An investigation of the WAIS III (14) in TBI conducted by van der

27 subtypes of combinations of attentional deficits. Thus, cluster analysis has

31 attention, suggesting the possibility of its appearance in other cognitive functions.

evaluation of neurocognitive abilities. We were specifically interested in refining

46 Neuropsychological Test Battery (HRB) (15) which assesses a large number of

31 performance may vary as a result of recovery of cognitive abilities as the length of

the same principle. It was noted in

were used to evaluate effort in the

study. test performance among the clusters

outset, so I have moved the

METHODS (e.g. education, gender) \. I also

41 fit better here. So, for example, I

Formatted: Indent: First

27 definition employed here of open head injury alternatively requiring significant

31 hematoma, or observation of brain tissue extrusion to the surface of the skull,

descriptions of the injury itself or neurosurgical data. While at the VA facility,

46 neuropsychological assessments. They had sustained a TBI between 1942 and

27 Cases rated as having sustained brain trauma were identified, and

35 individuals with remote histories of alcoholism not diagnosed in VA medical

27 employment, the employment data

35 Formatted: Indent: First

46 gunshot wound or car accident. Medical findings recorded included

to subtest V were examined as

Data Analysis as among the clusters identified in

43 Deleted: the most

Deleted: of several hierarchical

27 with an iterative partitioning method. Thus, we compared Ward’s method with

31 of the algorithm used to derive them. An analysis cross-tabulating cluster

35 hypothesis that there was a significant agreement between corresponding clusters

obtained from Ward’s method and K-means solutions.

27 have been repeatedly demonstrated to be sensitive to TBI (1).

derived mathematically, they may not reflect actual subgroups or types of a

46 and is accomplished through consideration of a number of variables acting as

27 demographic and historical factors, the phenomenology of the injury itself

31 of unconsciousness, the long term outcome, notably post-injury employment or

35 consequences as assessed by psychiatric and neurological evaluations.

27 Cluster Analyses moved this section to the description

41 Deleted: Description of the

27 some form of conceptual reasoning, while Picture Completion only requires

and POI are higher than FFD.

27 As with the Wechsler subtests, separation among the HRB clusters is

35 Neurological factors such as type, cause, and location of injury, or abnormalities

found on physical examination, skull-X-Ray, or EEG were not associated with

46 time of injury and assessment and had a lower percentage of employed

27 consisting of individuals functioning in the average range of general intelligence,

31 of processing speed, but in isolation from other relatively intact abilities.

35 devastating, generalized cognitive dysfunction. Only about a third of these

46 brain injury appear to persist on a long-term basis. However, the WAIS-R

31 from both studies can be generally attributed to level of performance differences,

46 that application of advanced neuroradiological techniques may have altered

31 three subgroups varying substantially in level of performance, but also in pattern

35 cognitive impairment resulting in an apparent diminution of general intelligence

27 assessment, and employment status. Borderline significance was obtained for

35 This type of retrospective study provides a long-term perspective on the

27 Society 2001; 7: 574-585.