Perception of illness in patients with traumatic brain injury.

BACKGROUND: Perception of illness plays an important role in recovery process. It affects our coping behaviors, adherence to treatment and preventive measures taken for healthy recovery. AIMS: The aim of the study is to examine perception of illness in patients with traumatic brain injury (TBI).
MATERIALS AND METHODS: This was a cross sectional study design done on sample of 31 patients with mild to moderate TBI. Depression anxiety stress scales-21 (DASS-21), Brief illness perception questionnaire (IPQ) and Rivermead Post Concussion Symptoms Questionnaire (RPQ) was used. STATISTICAL ANALYSIS: Descriptive and correlational statistics was used.
RESULTS: The results indicated that overall higher percentage falls within low and medium range of IPQ. However higher percentage falls within higher range, on coherence and emotional response subscales of IPQ. Consequence, timeline, personal control, treatment control, concern, emotional control, and total of the subscales of IPQ were positively correlated with RPQ3 and RPQ13 at 0.01 and 0.05 level of significance. A significant correlation was found between demographic variables and subscales of IPQ at 0.01 and 0.05 level of significance.
CONCLUSION: The study shows one to one relationship between symptoms experienced by patients, how they perceive their illness and socio demographic variables.

INTRODUCTION

An estimated 57 million individuals have been hospitalized with traumatic brain injury (TBI) worldwide.[1] In India 30,000 people die and 1, 25,000 become disabled due to TBI every year. The highest risk group includes children, adolescents, and young adult men in the age range of 15 to 25 years.[2] Brain injury affects who we are, the way we think, act, and feel in seconds. The commonly seen cognitive deficits after TBI are in attention,[3] information processing, memory[4] and behavioral problems. Gradual improvement in the cognitive domain within five-to-six month duration is reported, but some difficulties may continue.[3] Many patients may recover with treatment, but some may experience ongoing symptoms of the injury or side effects of the drugs. All these deficits may have a direct or indirect effect on the way they perceive their symptoms, which may impact their daily functioning.

Perception is a subjective phenomenon, which varies from individual to individual. This subjective phenomenon has an immense impact on our behavior and attitude. When it comes to perception of illness, it has been shown that perception of illness plays an important role in adherence to treatment, recovery, and outcome.[5] Perception is usually based on early schemes,[6] which help the individual to cope with the illness. Illness perception can be positive or negative. The different components of illness perception include consequences, timeline, personal control, treatment, control, identity, coherence, concern, emotional response, and causes.[7] The studies that are available online conclude that there is a strong association between illness perception, duration of recovery, and outcome.[89]

MATERIALS AND METHODS

Participants

A sample of 31 married male patients, post three months of mild-to-moderate (Mean=12.77 and SD=1.85) traumatic brain injury were taken from the outpatient services of the Department of Neurosurgery and Neuropsychology of the National Institute of Mental Health and Neurosciences, Bangalore. The age range was between 20 and 55 years (Mean=38.13 and SD=8.82). The mean educational qualification was 10.67 (SD=3.47). The mean Glasgow Coma Scale (GCS) score was 12.77 (SD=1.85). The duration of injury ranged from 3 to 53 months, with a mean of 12.43 (SD=12.95). Other neurological and psychiatric histories were excluded.

Tools

A sociodemographic sheet was developed to collect information about the participants. All the subjects were tested individually. Questionnaires were translated into regional language.

Depression Anxiety Stress Scale (DASS)[10]: Consists of a set of three self-report scales, containing 14 items, each designed to measure the negative emotional states of depression, anxiety, and stress. The subjects were asked to rate the extent to which they had experienced each, over the previous week. The internal consistency of the DASS subscales was high (Cronbach's alphas) 0.94, 0.88, and 0.93 for depression, anxiety, and stress, respectively.

Brief Illness Perception Questionnaire (IPQ)[11]: This is a nine-item self-report scale, measures patient's cognitive and emotional representations of their illness including consequences, timeline, personal control, treatment, control, identity, coherence, concern, emotional response, and causes. The test demonstrates a good Pearson's test retest correlation coefficient.

Rivermead Post Concussion Symptoms Questionnaire (RPQ)[12]: Is a symptom checklist scored in two groups. The first group (RPQ-3) consists of the first three items (headaches, feeling of dizziness, and nausea) and the second group (RPQ-13) comprises of the next 13 items. A higher score reflects greater severity of postconcussive symptoms.

RESULTS

All the patients in the current study were symptomatic. Forgetfulness (67.7%), irritability (58%), longer to think (41.9%), depressed (35.5%), poor concentration (32.2%), noise sensitivity (32.3%), fatigue (32.3%), dizziness (29.1%) and nausea (29%) were the predominant symptoms. Table 1 shows an overview of the percentage of scores on different subscales of IPQ and RPQ, with overall mean and SD.

Table 1

Percentage of patients who scored low, medium, and high on subscales of IPQ with overall mean and SD

It is evident that a higher percentage of patients on timeline, treatment control, and identity subscales of IPQ fall in the lower range. On the consequence, concern, personal control, emotional control, and the coherence subscales of the IPQ, a higher percentage of patients fall in the medium range. However, on the coherence and emotional response subscales of the IPQ, a higher percentage of patients falls in the higher range. Overall, a majority of the total cases fall in the low and medium range of IPQ.

Table 2 shows an overview of correlation between subscales of IPQ and RPQ. It is evident from the table that consequence, timeline, personal control, treatment control, concern, emotional response and overall total of subscales of IPQ were found positively correlated with RPQ3 and RPQ13 at 0.01 and 0.05 level of significance.

Table 2

Correlation between subscales of IPQ and RPQ

Table 3 shows an overview of correlation between demographic variables and subscales of IPQ. The table shows significant positive correlation between duration of illness, economic status, and subscales of IPQ. However significant negative correlation was found between age, marriage duration, concern and total of subscales of IPQ.

Table 3

Correlation between demographic variables and subscales of IPQ

DISCUSSION

In the present study all the patients had experienced postconcussive symptoms. The symptoms were higher on cognitive domain of RPQ. Less than 10% patients met the criteria for depression and anxiety on DASS-21, but no one reported stress.

From the study it is evident that different domains of illness perception were found affected post TBI. A higher percentage of patients fell in the lower range on the subscales of IPQ like timeline, treatment control, and identity which indicate that patients were optimistic about recovery time and had belief in treatment which in turn was good for healthy recovery process. The theory of valence in psychology states that people had a tendency to move toward a positive valence rather than a negative which explained their behavioral motivation.[13] However higher percentage of patients fell in the medium and high range on coherence, consequence, concern, personal control and emotional control subscales of IPQ, which highlighted the need to make patients aware about their illness and handle the psychological reactions which could decrease negative reactions like worry, threat and fear.[714]

Understanding of illness plays an important role in recovery process of any illness. It has an impact on level of concern, affective response, and sense of control over the illness.[1415] Most of the subscales and overall perception of illness are found significantly correlated with postconcussive symptoms which signify perception of illness varies with postconcussive symptoms experienced by the patients.[9] However severity of illness is not found correlated with subscales of IPQ but number of symptoms experienced, recovery time, concern, consequence, personal control, and overall perception of illness were found positively correlated with number of years of illness. Injury to brain is usually considered as serious. Therefore it depends on how the individual reacts to it.[14]

Demographic variables like age were found negatively correlated with concern subscale of IPQ which meant that early injury might lead to more concern toward the illness which could lead to increased sense of postconcussive symptoms and might hinder the recovery process and vice versa. The number of years of marriage found have a negative impact on overall perception of illness which might be because of the increased responsibility and difficulty individual and his family had experienced in dealing with the illness.