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

2 Measurement and Assessment of Post-Traumatic Brain Injury (TBI) Anxiety Introduction Post-traumatic brain injury anxiety poses major public health concerns in the United States and other developed economies. Both mild and severe post-traumatic brain injury anxiety adversely affect patients’ mental and socioeconomic well-being. According to Gaudette et al. (2022), persons with such conditions are predisposed to unemployment, poverty, and depression. Thus, the development of anxiety disorders after a traumatic brain injury is a critical indicator of social, personal, and work dysfunction. The burden of psychiatric ailments after a head injury also has implications on the disease prognosis. Traumatic brain injury (TBI) may also stem from a wide range of symptoms that affect patients’ cognition and psychological well-being ( Al-Kader et al., 2022) . A significant fraction of TBI cases globally and within the United States culminate in the development of either mild or severe symptoms, also referred to as concussions. The symptoms that develop after TBI are often temporary, including neurological conditions such as mood disorders, depression, irritability, and anxiety ( Al-Kader et al., 2022) . Persons with TBI anxiety are also vulnerable to sensory and somatic complaints, which include sleep-related disorders, headaches, blurred vision, and dizziness. TBI anxiety is an anxiety disorder that arises from an acquired disruption of the normal functioning or structure of the brain caused by a head impact or external force (Tucker & McCabe, 2021). While many tools for measuring, diagnosing, and assessing TBI anxiety exist, there are still major literature gaps in the studies that attempt to evaluate their reliability and accuracy. Therefore, this systematic literature aims to seal the existing knowledge gaps by investigating the measures, reliability, validity, and timing of TBI anxiety.

3 Measures for Assessing Post-TBI Anxiety Accurate post-TBI anxiety is critical in developing evidence-based interventions for reversing its adverse impact on individuals’ psychosocial well-being. Numerous scholars propose different tools, strategies, and instruments for evaluating the level of severity of this psychological condition. The State-Trait Anxiety Inventory (STAI) and the Hospital Anxiety Depression Scale (HADS) are some of the leading metrics for assessing post-TBI anxiety ( Knowles & Olatunji, 2020). STAI is a 40-item self-reporting scale that evaluates separately the dimensions of state and trait anxiety. Some of the anxiety indicators that it measures include feelings of apprehension, tension, nervousness, and worry. It also evaluates the extent to which an individual feels ‘right now’ or in the present ( Knowles & Olatunji, 2020). It requires respondents to rate the intensity of their nervousness in terms of: not at all, somewhat, moderately so, or very much so. This anxiety metric also addresses the degree to which individuals generally feel by rating themselves using a four-point Likert scale: almost never, sometimes, often, or almost always. Since its adoption in 1966, STAI has been translated into more than 48 languages and has been broadly researched in many clinical and institutional contexts ( Knowles & Olatunji, 2020). Most significantly, the evidence of its construct validity stems from a wide range of sources, including correlations with anxiety metrics. HADS is an instrument that is widely utilized to measure psychological distress among post-TBI patients. It has been translated into many languages, including French, German, Dutch, Chinese, and Arabic (Stern, 2014). It generates clinically meaningful results as a psychological screening instrument, particularly in group comparisons and studies with different aspects of disease or quality of life. It is a 14-item questionnaire that comprises seven questions for anxiety and seven for depression (Stern, 2014). Due to its ease of use, it takes only two to five minutes to fill out and generate outcomes. While the anxiety and

4 depression questions are interspersed within the questionnaire, they must be scored separately. In that respect, cut-off scores are available for estimation. For instance, scores of 8 or more for anxiety have a specificity of 0.78 and a sensitivity of 0.9 (Stern, 2014). Those for depression have a specificity of 0.79 and a sensitivity of 0.83. Reliability and Pre-Post Assessment Assessing the reliability and validity of the selected post-TBI anxiety instruments is important in understanding their accuracy. Reliability refers to the extent to which measurements are repeatable when different people perform them on different occasions under different conditions supposedly with alternative instruments (Kubai, 2019). A reliable instrument should capture accurately the intended construct under investigation and ensure the meaningfulness of the study findings (Kubai, 2019). Reliable measurement instruments increase the believability and trustworthiness of the findings, particularly if the investigations are repeated by different researchers within similar conditions or different research instruments that assess the same construct (Kubai, 2019). This study will use a systematic review method to evaluate the reliability of the two post-TBI anxiety measurement instruments. Most specifically, articles that examine the reliability of the selected instruments will be searched, analyzed, and synthesized. Literature Review STAI and Hospital Anxiety and HADS as Assessment Tools Investigations into the reliability, accuracy, and validity of post-TBI anxiety measuring instruments have attracted significant scholarly attention. Knowles and Olatunji (2020), for instance, utilize a meta-analysis to compare STAIT scores among individuals with depressive and anxiety disorders. The researchers also analyze the correlations with measures of anxiety and depressive symptom severity to determine the discriminant and convergent

5 validity. After searching identifying and analyzing 388 published peer-reviewed journal articles, they found that individuals with anxiety disorders and those with depressive symptoms showcased significantly elevated scores on the STAIT tool compared to the non- clinical comparison groups. The results further demonstrate that anxiety and depressive symptoms severity were strongly correlated with the STAIT scores (mean- 0.59, r =0.61). However, people persons with depressive disorders reported significantly higher STAIT scores than their counterparts with an anxiety disorder. Owing to these outcomes, the researchers propose the consideration of STAIT as a non-specific metric for evaluating negative affectivity rather than trait anxiety. While anxiety and depressive symptoms are widely experienced after TBI, studies that validate the instruments of anxiety and depression are scarce. Carmichael et al. (2023) utilize an empirical research design to evaluate the effectiveness of HADS in measuring post- TBI anxiety. Using novel indices drawn from symmetrical bi-factor modeling, they examine whether HADS reliably differentiated anxiety and depression among 874 adult participants with moderate and severe TBI anxiety. The results demonstrate a dominantly general distress factor that accounts for 84% of the systematic variance in HADS total scores. Additionally, the researchers find that the specific anxiety and depression factors account for minimal residual variance in the respective subscale scores (12% and 20%, respectively). From these findings, clinicians and researchers should exercise caution when interpreting the individual HADS subscales and instead consider adopting the totals cores as a more valid, transdiagnostic measure of general distress in persons with TBI. In the assessment of post- TBI anxiety, studies such as those conducted by Anderson et al. (2023) and Chen et al. (2020) have utilized measurement tools such as the State-Trait Anxiety Inventory (STAI) and the Hospital Anxiety and Depression Scale (HADS). These measures are designed to assess anxiety symptoms specifically related to TBI.

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