Changes in Self-Awareness Following Traumatic Brain Injury: Assessment and Practical Treatment Considerations

Approximately 2.8 million Americans sustain a TBI each year, and TBI is a leading cause of death and disability among young adults under the age of 35.¹ Impaired self-awareness is a common consequence of brain injury, occurring in as many as 40% to 80% of individuals with moderate-to-severe TBI.² The likelihood of impairment in self-awareness increases with injury severity.² Impaired self-awareness following brain injury can negatively impact goal-setting, treatment compliance, motivation for therapy, and engagement with the rehabilitation process.³ In the longer term, impaired self-awareness can lead to difficulty with independent living and productive activities, including return to work.⁴

Conversely, individuals who are aware of deficits stemming from brain injury and who appreciate the impact of limitations on performance are more likely to set realistic goals, engage with treatment, use compensatory strategies, and experience greater community integration.^4,5 Addressing deficits in self-awareness, therefore, should be a target of aggressive intervention during post-acute brain injury rehabilitation.

Self-Awareness

The term for impaired self-awareness, anosognosia, is derived from a Greek word meaning, “lack of knowledge of a disease.” It refers to a lack of awareness of one’s limitations or cognitive status. According to the American Psychological Association, anosognosia is “a neurologically based failure to recognize the existence of a deficit or disorder, such as cognitive impairment, hearing loss, poor vision, or paralysis,”⁶ Behaviorally, anosognosia may present as overestimation of abilities, poor risk assessment, impulsivity and disinhibition, resistance to or limited use of compensatory strategies, and confabulation.^7,8

Anosognosia differs from psychological denial in that anosognosia results from neurological damage, whereas denial is a psychological response to stress or trauma. The person with anosognosia is genuinely unaware of cognitive changes, while someone in denial may acknowledge something is wrong but avoid confronting it. Denial can be temporary and may change over time, while anosognosia is often persistent; however, anosognosia can be effectively treated with evidenced-based interventions.^5,9

Theoretical Models

A number of theoretical models have been proposed to explain deficits in self-awareness following brain injury, including hierarchical models, integrative or multidimensional models, and neurological/neuropsychological models. Crosson et al proposed a hierarchical model, conceptualizing 3 independent levels of awareness.¹⁰ “Intellectual awareness” involves the capacity to recognize that a problem (deficit) exists, and appreciate the limitations caused by the deficit in everyday life. The second level of awareness is “Emergent awareness” which refers to a person’s ability to recognize a deficit in real-time as they are engaged in a task. That is, the person recognizes their difficulties as they are occurring during the performance of a task. The third and highest level of awareness is “Anticipatory awareness” which refers to a person’s ability to appreciate the difficulties that will be experienced in the future stemming from a deficit.

Integrative or multidimensional models, such as the model proposed by Toglia and Kirk, conceptualize a dynamic relationship, rather than a hierarchical relationship, between knowledge, beliefs, and task demands, as well as cognitive functions such as anticipation, planning, organization, initiation, execution, and self-regulation.¹¹ Neurological and neuropsychological models suggest deficits in self-awareness are caused by damage to the frontal-executive system and identify areas of the brain, particularly the frontal lobes, right parietal lobe, and thalamus as brain structures mediating self-awareness.¹²

Assessing Impairments in Self-Awareness

Formal and informal methods are used to assess deficits in self-awareness and design individualized treatment plans. Formal measures involve structured interviews using scales or questionnaires with sound reliability and validity. The Self-Awareness of Deficits Interview (SADI) uses general questions and specific prompts to gauge a person’s intellectual awareness of current physical, cognitive, behavioral and interpersonal difficulties.¹³ The measure includes 3 indices: (1) self-awareness of deficits, (2) self-awareness of the functional implications of deficits, and (3) ability to set realistic goals. Higher scores indicate a low level of self-awareness and a tendency to minimize the extent of deficits. The Self-Regulation Skills Interview (SRSI)involves asking 6 questions relating to a difficulty previously identified (ie, memory problem, depressed mood, anger and frustration, etc).¹⁴ The 6 questions assess emergent awareness, anticipatory awareness, motivation to change, strategy generation, strategy selection, and effectiveness of strategies. Responses to questions and standard prompts are scored on a 10-point Likert scale with 0 = very high and 10 = very low. Lower scores indicate poor self-awareness.The Awareness Questionnaire is an 18-item scale comparing self-rated abilities against evaluations from either clinicians or family members.¹⁵ Responses are rated on a 5-point Likert scale to assess changes in awareness pre- and post-injury.

Informal methods for assessing deficits in self-awareness involve evaluating discrepancies and predicting performance. Discrepancies between patient self-reports and observations or objective data obtained by clinical staff are compared and evaluated. The patient describes performance levels in various tasks/settings and staff share objective findings from formal testing or observations in the clinic. Discrepancies between self-report and objective data or observations are discussed in an effort to gauge the level of intellectual awareness. Performance prediction assessments involve a patient predicting their level of performance on a particular task and comparing actual performance to the prediction. Prior to engaging in a task, the patient is asked how much assistance they will need, or what percentage of the task they can perform independently. The patient engages in the task, and performance is observed and the outcome documented. Predictions are compared with actual outcome, and results are discussed to gauge the level of intellectual awareness.

Interventions to Improve Self-Awareness

A number of evidence-based interventions are available to improve self-awareness. Feedback interventions are commonly used and have been shown to improve self-awareness, task performance, and increase satisfaction with performance.⁴

Verbal feedback regarding performance can facilitate all levels of awareness (ie, intellectual, emergent, anticipatory). Verbal feedback is often delivered in the context of a Predict-Perform-Reflect intervention. Prior to engaging in a task, the patient predicts level of performance or task completion (ie, how much assistance will be needed; what percentage of the task can be performed independently). The patient engages in the task and the outcome is documented. The patient and therapist evaluate actual performance against the patient’s prediction. Best practices dictate that feedback should be specific, timely, consistent, and respectful. If verbal feedback is being provided across disciplines, consistent terminology should be used. Corrective feedback should always be followed by positive feedback, or a comment on patient strengths, or what went well during task performance. Commenting on improvements from previous sessions is also a way to deliver positive feedback. During the reflection component, the therapist may ask the patient what would improve the outcome in future sessions (ie, a strategy such as a checklist).

Visual feedback can enhance both intellectual and emergent awareness. As outlined in the previous section, the task is identified and the patient predicts level of performance. The patient engages in the task as the session is being video-recorded. Following completion of the task, the video recording is reviewed, and the therapist asks the patient to compare the outcome with the prediction. As the video is being reviewed, the tape can be paused as the patient and therapist discuss performance, identify problems or errors, and brain-storm strategies to improve performance. Another form of visual feedback involves role-reversal. In this intervention, the therapist engages in a task while the patient observes and evaluates performance. The therapist intentionally makes an error during performance of the task. The patient provides feedback and suggests strategies to improve performance.

Finally, experiential feedback can be a powerful intervention for increasing awareness.This intervention encourages patients to discover his/her own errors as difficulties are experienced in real-life settings. Other names for this intervention include “behavioral experiments” or “guided failure.” This intervention is useful for all levels of awareness, particularly emergent and anticipatory awareness. The patient is engaged in a higher-level task without cues or feedback. The patient is allowed to struggle with the task and experience difficulties. During reflection, patients are encouraged to evaluate performance and brainstorm strategies for improving performance. Care should be taken in selecting tasks for experiential feedback interventions. For example, difficulty completing a cooking task may be less threatening and less emotionally charged than failing to complete return-to-work task.

Confrontation and sole reliance on critical or negative feedback should be avoided as this can often lead to agitation, damage therapeutic relationships, and lead to emotional distress.¹⁶

Other strategies to improve self-awareness involve using guided questions to promote planning, problem identification, and self-reflection. The Goal-Plan-Do-Review strategy involves asking the patient, “what is your plan?”, “how long do you think it will take to accomplish?”, “what are problems you might encounter?”, “what strategy might you use to deal with the problem?”.After the patient engages in the activity, review or debrief by asking, “what worked well?”, “what might you change to make it better next time?”.

Interventions to improve self-awareness following TBI have been shown to improve performance and enhance rehabilitation outcomes.⁴ Clinical guidelines exist for the effective management of impaired self-awareness following brain injury.⁵

Concluding Thoughts

Impaired self-awareness is a common consequence of TBI that can interfere with goal setting, treatment engagement, safety, and successful community reintegration. Both formal measures and functional observations can clarify how a patient understands deficits, recognizes problems during activity, and anticipates future challenges. Evidenced-based interventions include verbal and visual feedback, performance prediction, guided reflection,experiential learning, and strategy development. These interventions are effective in assisting patients better recognize limitations and develop successful strategies for improving performance. When coordinated thoughtfully and consistently across disciplines, impaired self-awareness is a modifiable rehabilitation target that can improve participation, safety, independence, and long-term outcomes following TBI.

Dr Seale is the Regional Director of Clinical Services at the Centre for Neuro Skills, which operates post-acute brain injury rehabilitation programs in California and Texas. He is licensed in Texas as a psychological associate with independent practice. He is a certified brain injury specialist trainer and holds a clinical appointment at the University of Texas Medical Branch (UTMB) in Galveston in the Department of Rehabilitation Sciences.

References

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