https://orcid.org/0000-0003-3498-5824
ABSTRACT
Background
Self-awareness impairment is common following acquired brain injury and can impact rehabilitation outcomes. Knowledge of factors associated with impaired self-awareness may assist with rehabilitation planning.
Objectives
To identify factors associated with self-awareness and determine predictors of self-awareness impairment for adults with traumatic brain injury (TBI) and stroke.
Design and methods
A retrospective cohort study of rehabilitation inpatients was conducted by medical record audit. Self-awareness was measured using the Self-awareness of Deficits Interview (SADI). Relationships between SADI scores and demographic and clinical variables were identified with non-parametric statistics. Predictors of SADI scores were identified using ordinal regression analyses for TBI and stroke groups.
Results
Participants were 149 adults (18–70 years) with TBI (n = 110) and stroke (n = 39). For TBI, longer post-traumatic amnesia (PTA), lower functional cognition/communication, and behaviors of concern (BoC) were significantly associated with higher SADI scores (i.e. impaired self-awareness). For stroke, lower functional cognition/communication and motor scores were associated with higher SADI scores. Impaired self-awareness was predicted by PTA duration, acute length of stay and presence of BoC for the TBI group, and by functional cognition/communication for the stroke group.
Conclusion
Different factors were associated with impaired self-awareness for individuals with TBI and stroke during inpatient rehabilitation.
Introduction
Acquired brain injury (ABI) due to trauma, stroke or other causes, can lead to a range of cognitive, psychological, behavioral and physical changes. Impaired self-awareness of these changes is common following ABI and is characterized by difficulty recognizing impairments and associated functional implications, along with challenges recognizing errors and monitoring actions during activities (Citation1,Citation2). Low self-awareness can impact engagement in rehabilitation, compliance with safety recommendations, long-term functional outcomes, and has been found to contribute to caregiver stress (Citation3–7). The incidence of impaired self-awareness in the early stages following severe traumatic brain injury (TBI) and stroke is estimated to be up to 77% (Citation8) and 52% (Citation9) respectively.
There are a range of underlying factors that may contribute to impaired self-awareness, including neurological factors (e.g., brain regions affected), neuropsychological factors (e.g., cognitive and perceptual impairments), and psychological factors (e.g., denial) (Citation10–12). Time since onset of injury and brain injury severity have also been suggested to influence the clinical presentation of self-awareness (Citation13–15). Whilst studies suggest that several clinical variables may predict the presence of self-awareness impairment (i.e., age, functional status and cognitive status), there are conflicting findings in relation to which of these factors predict impaired self-awareness in the early stages post-ABI and large variation in the method for measuring self-awareness (Citation6,Citation16,Citation17). Research has largely focused on the presentation of self-awareness for the TBI population, with a lack of exploration of this issue for individuals post-stroke.
While neuropsychiatric variables such as anxiety and depression are often present in the ABI population, little is known about the relationship of these issues to self-awareness (Citation18). In a preliminary investigation of clinical correlates of impaired self-awareness following TBI, Bivona et al. (Citation19) found that higher levels of self-awareness impairment were correlated with lower levels of depression. Ownsworth et al. (Citation20) investigated the relationship between ratings of anxiety and depression and awareness typologies and found that patients with lower self-awareness displayed higher levels of anxiety and depression than those with high levels of defensiveness (i.e., the tendency to deny problems). Further exploration is required to enhance understanding of the relationship between neuropsychiatric variables and self-awareness.
Behaviors of concern (BoC) such as anger, irritability, impulsivity and verbal and physical aggression are common following TBI and can also impact individuals post-stroke (Citation21,Citation22). In addition to these features, disinhibition is commonly reported for the TBI population (Citation23). Such behaviors are known to negatively impact an individual’s ability to engage in rehabilitation and subsequent outcomes (Citation24–27). While little is known about the relationship between BoC and the clinical presentation of self-awareness in the early-phase post-TBI and stroke, several studies provide preliminary information about individuals’ self-awareness of BoC in the chronic phase post-TBI (Citation15,Citation23,Citation28). In a study investigating ‘maladaptive behaviours’ and impaired self-awareness of disability, Trudel (Citation28) found that individuals in the chronic phase post-TBI tended to under-report BoC when compared to independent-rater reports. Similarly, Vanderploeg et al. (Citation15) examined the degree of self-awareness of deficits (i.e., including BoC), with findings indicating that while individuals with TBI under-reported changes in impulsivity, they were more reliable with reports of interpersonal difficulties such as getting along with others. These studies are limited to the exploration of self-awareness of BoC with community-dwelling samples in the chronic-phase post-TBI, with an absence of studies exploring this concept in the early-phase post-TBI and stroke.
Studies investigating impaired self-awareness in the stroke population have demonstrated a focus on anosognosia for hemiplegia (Citation12,Citation29–32). The term ‘anosognosia’ is used interchangeably with impaired self-awareness, with ‘anosognosia for hemiplegia’ referring more specifically to an individual’s inability to recognize the presence or severity of their deficits and denial of disability (Citation29). Research in this area has been expansive with the establishment of frameworks that explain the underlying cognitive processing mechanisms for this phenomenon (Citation11,Citation12,Citation33), exploration of neuroanatomical correlates (Citation30), neuropsychological contributors (Citation34) and investigation of the clinical presentation of anosognosia (Citation31,Citation35). Beyond the proposed predictive neuroanatomical factors, there is a lack of knowledge about broader clinical factors that may predict impaired self-awareness, with further research required in this area.
There is currently a research gap in understanding predictors for impaired self-awareness across neurological diagnoses, with conflicting findings in the limited studies which have sought to clarify similarities and differences between TBI and stroke. A recent study investigating the patterns of self-awareness across TBI and stroke diagnostic groups (Citation36) suggested no significant differences in self-awareness scores between groups as measured by the Self-Awareness of Deficits Interview (SADI) (Citation28), while qualitative exploration of the expression of self-awareness suggested distinct differences across diagnostic groups. Compared with the TBI group, the stroke group were able to more readily identify their impairments and associated functional implications, and more frequently expressed the expectation that their brain injury would continue to impact their lives in the future. Importantly, the stroke group had higher cognition scores, which may be suggestive of a relationship between general cognitive functioning and impaired self-awareness. Further exploration of which factors predict impaired self-awareness across these diagnostic groups is required to inform practice when working with individuals post-TBI and stroke. The current study extends on these findings, with the following aims: 1/To identify the clinical factors associated with self-awareness for adults with TBI and stroke and 2/To identify which clinical factors predict self-awareness for adults with TBI and stroke.
Methods
Design
This retrospective cohort study involved an audit of medical records that included collection of quantitative data from Self-awareness of Deficits Interview (SADI) assessments and functional outcome measures completed by occupational therapy clinicians at a single site. Ethics approval was obtained from The University of Queensland and Alfred Health Human Research Ethics committees.
Participants
Medical records were screened from June 2017 to February 2022 to recruit patients who were admitted to an Acquired Brain Injury Rehabilitation Unit in Melbourne, Australia who met the following inclusion criteria: diagnosis of moderate-to-severe TBI or stroke, working age (i.e., between 18 and 70 years) and completed self-awareness assessment (i.e., SADI) with their occupational therapist. They were excluded if they had a diagnosis of a progressive or other neurological condition (e.g., encephalitis, brain tumor) or mild brain injury.
Measures
Self-awareness was measured with the Self-awareness of Deficits Interview (Citation37). The Self-Awareness of Deficits Interview (SADI) is a semi-structured interview that is designed to assess intellectual awareness in three areas: 1/self-awareness of deficits; 2/self-awareness of functional implications of deficits; and 3/ability to set realistic goals. Questions and associated prompts for the interviewer support exploration of the patient’s self-awareness in each of these three areas. Each area is assessed on a 4-point scale, with lower scores indicative of higher levels of self-awareness (i.e., 0 = no detected self-awareness impairment, 3 = severe self-awareness impairment). Total SADI score ranges can be used to represent self-awareness severity ratings (i.e., 0–1 = no impairment; 2–3 = mild impairment; 4–6 = moderate impairment; and 7–9 = severe impairment) (Citation38). The SADI was developed for a brain injury population and has been applied across TBI and stroke diagnostic groups (Citation39), and has established inter-rater reliability (Citation37), test-retest reliability (Citation40), and concurrent validity with the Awareness Questionnaire (Citation39) and measures of frontal lobe functioning (Citation41). The SADI is completed with each patient at the participating ABI Rehabilitation Unit at the time point at which they are able to participate in a semi-structured interview and are considered to have had adequate exposure to activities to comment on the functional impact of their brain injury as determined by their treating occupational therapist.
Functional abilities were measured using the Functional Independence Measure (FIM™), and the Functional Autonomy Measurement System (SMAF). The Functional Independence Measure (FIM™) is an 18-item clinician rating scale that was developed to measure burden of care across a range of diagnostic groups that includes TBI and stroke (Citation42). The FIM consists of two scales (motor and cognition) with multiple subscales in each. The motor scale comprises self-care (eating, grooming, bathing, dressing upper and lower body, and toileting), sphincter control (bladder and bowel management), transfers (bed, toilet and bath), and locomotion (walking/wheelchair and stairs). The cognition scale comprises communication (comprehension and expression), and social cognition (social interaction, memory and problem solving). Each item is scored on a 7-point scale, with a maximum score of 126 (low scores indicating a higher level of dependence, and higher scores indicating a higher level of independence). The FIM has established reliability and validity in our studied population (Citation43).
The Functional Autonomy Measurement System (SMAF) measures disability and considers an individual’s available social and/or material resources to partially or fully compensate for their disability (Citation44). The SMAF comprises 29 items across five areas of functional ability (activities of daily living, mobility, communication, mental functions, and instrumental activities of daily living). Each item within these scales is scored on a 4-level rating scale (Level 0 = complete autonomy, Level 1 = requires surveillance or stimulation, Level 2 = requires help, Level 3 = total dependence), with a maximum score of 87. Each item is then assessed in terms of whether the patient’s available physical and social resources are adequate to compensate for their disability. If resources completely compensate for the assessed disability, ‘the handicap is zero, if not, the handicap becomes proportional to the disability’ (44 p294), whereby the handicap score on an item becomes is equal to the disability score for that item. The SMAF has established reliability and validity (Citation45,Citation46).
Data collection
The principal investigator (DS) audited each participant file to extract the following participant demographic and clinical outcome measurement information: age, gender, diagnosis, date of onset of TBI or stroke, acute hospital length of stay (LOS), post-traumatic amnesia (PTA) duration (i.e., measured using the Westmead PTA scale), Glasgow Coma Scale (GCS) score, disorder of consciousness (DOC) duration (i.e., measured using the Coma Recovery Scale – Revised, and excluding individuals in medically induced coma), presence of behaviors of concern (BoC), mental health comorbidities (i.e., as identified by medical or psychology documentation), drug/alcohol history, premorbid living arrangements, employment status at time of brain injury, SADI scores, date of SADI completion, FIM admission scores and SMAF admission scores. All data were entered into a spreadsheet that was stored in a secure research data management system, accessed by only the research team.
Data analysis
Data were analyzed using IBM SPSS (version 28). Data were not normally distributed, with large variability in some variables (e.g., LOS), therefore non-parametric tests were used. In order to address aim 1, ‘To identify the clinical factors associated with self-awareness for adults with TBI and stroke,’ descriptive statistics were used to describe participant characteristics as they related to a range of clinical variables, with separate analyses completed for the TBI and stroke groups. Spearman’s correlations were used to determine the relationship between SADI scores and continuous variables (age, admission FIM cognition/communication scores, admission FIM motor score, admission SMAF total scores, PTA duration, and acute hospital LOS). Mann-Whitney U was used to determine the differences in SADI scores between groups for dichotomous variables (gender, BoC, mental health comorbidities, drug and alcohol history). In order to answer aim 2, ‘To identify which clinical factors predict self-awareness for adults with TBI and stroke,’ ordinal regression analysis was completed. For this analysis, the dependent variable was the total SADI score. Independent variables were clinical variables that met the assumptions for no multicollinearity and proportional odds (PTA duration, acute LOS, BoC, FIM cognition/communication, FIM motor), with models built for the two diagnostic groups based on sample size and relevance to clinical groups (i.e., PTA duration was only relevant for the TBI group).
Results
Participants included 149 patients with a diagnosis of TBI (n = 110) and stroke (n = 39). See for participant demographic and diagnostic characteristics. Across both group participants ranged in age from 18 to 70 years (mean age 44 years), and 72% were male. All participants were classified as having a moderate to severe brain injury. Twelve percent of participants had a prolonged DOC following their brain injury, with DOC duration ranging from 30 to 123 days. During their hospital admission, 40% of the participants demonstrated BoC resulting in development of a behavior support plan. Almost one-quarter (23%) of participants had a premorbid mental health diagnosis (i.e., this included anxiety and/or depression (n = 18), bipolar disorder (n = 9), PTSD (n = 2); and just over one-third (34%) of participants had a history of drug or alcohol use. Almost two-thirds (60%) of participants were employed at the time of their brain injury. Total FIM scores indicate a low level of independence for participants on admission to rehabilitation (mean 45). In addition, high support needs across personal care, cognition, mobility, and instrumental activities of daily living are indicated by low admission SMAF scores (mean −59). There was high variability in total hospital LOS range (16 to 813 days), with some participants exceeding the mean by several standard deviations outside the mean. The time point at which the SADI was completed during the inpatient admission ranged from 12 to 346 days post-ABI onset. More than half (56%) of the participants completed the SADI in the first 3 months post-ABI onset, with the mean SADI completion being 101 days post-brain injury. Total SADI scores ranged from 0 to 9, with almost three-quarters (70%) of participants scoring 4 or above, indicating moderate-to-severe self-awareness impairment.
Table 1. Participant demographics and diagnostic information: N(%) or m(SD); median(IQR).
A Chi-square test showed no significant relationship between demographic variables across TBI and stroke groups (i.e., BoC and mental health comorbidities, BoC and gender) with the exception of BoC and drug/alcohol history for the TBI group only, X2 (1) = 4.623, p = 0.032. Spearman’s correlation was completed to determine the relationship between SADI score and the following demographic and clinical variables: age, PTA duration, acute LOS, FIM scores and SMAF scores. See for details. For the TBI group, there was a significant positive correlation between SADI score and PTA duration, (rs (8) = .320, p = 0.001) and a significant negative correlation between SADI score and FIM cognition/communication score, (rs (8) = −.208, p = 0.030). For the stroke group there were significant negative correlations between SADI scores and both FIM motor score, (rs (8) = −.377, p = 0.023) and FIM cognition/communication score (rs (8) = −.533, p = 0.001).
Table 2. Spearman’s rho correlations between SADI scores and continuous variables.
Mann-Whitney U tests were performed to evaluate whether total SADI scores differed by demographic and clinical variables including gender, presence of drug/alcohol history, mental health comorbidities and presence of BoC. See for details. For both TBI and stroke groups, participants with BoC had significantly higher SADI scores than those without BoC, (TBI: U = 1004.0, p = 0.004; stroke: U = 89, p = 0.026). There were no significant differences for other variables.
Table 3. Mann-Whitney U comparisons of SADI score for dichotomous variables.
An ordinal logistic regression examined the effect of clinical factors including PTA duration, acute LOS, FIM cognition/communication scores, FIM motor scores and BoC on total SADI scores for the TBI group. See for details. Results indicate that an increase in PTA duration (in days) was associated with higher SADI scores, with an odds ratio of 1.028 (95%CI, 1.010 to 1.046), Wald χ2 (Citation1) = 9.667, p < 0.002. Increased acute LOS was also associated with higher SADI scores, with an odds ratio of .976 (95%CI, .957 to .995), χ2 (Citation1) = 6.285, p = 0.012. The odds of participants with BoC having higher SADI scores were 2.172 (95% CI, .987 to 4.781) times that of participants without BoC, which was approaching statistical significance, χ2 (Citation1) = 3.710, p = 0.054. No significant effects were found for FIM cognition/communication or FIM motor scores.
Table 4. Ordinal regression model examining associations between predictor variables and SADI scores: TBI group (n = 110).
The ordinal regression model for the stroke group to determine the effect of the clinical variables of acute LOS, FIM cognition/communication score, FIM motor score and BoC on total SADI score can be seen in . FIM cognition/communication scores had a statistically significant effect on SADI scores, Wald χ2 (Citation1) = 5.915, p = 0.015. No significant effects were found for FIM motor scores, acute LOS or BoC.
Table 5. Ordinal regression model examining associations between predictor variables and SADI scores: Stroke group (n = 39).
Discussion
This study aimed to identify the clinical factors associated with levels of self-awareness for adults with TBI and stroke and identify which of these factors predict self-awareness for a brain injury inpatient rehabilitation population. The sample included participants with moderate-to-severe brain injury following TBI or stroke. Findings indicated that for this population, clinical factors including longer PTA duration, lower FIM cognition/communication scores and presence of BoC were associated with higher SADI scores (i.e., lower levels of self-awareness). Predictors of higher SADI scores for the TBI group were PTA duration, acute LOS and presence of BoC, and for the stroke group FIM cognition/communication scores. Premorbid mental health diagnosis and drug/alcohol history were not predictors of self-awareness for either group.
In the current study, FIM cognition/communication scores were significantly correlated with SADI scores for the TBI group, however were not a significant predictor of SADI score in the regression. The significant correlation with FIM cognition/communication scores may be explained by other factors such as brain injury severity, given that PTA duration and LOS were significant predictors in the regression for the TBI group. The finding that cognitive impairment was associated with impaired self-awareness is supported by other studies of self-awareness in individuals with ABI (Citation16,Citation47,Citation48). More specifically, measures of episodic memory and executive functions have previously been found to be predictors of self-awareness for the ABI population (Citation16). When considering that updating knowledge is one of the key aspects to development of self-awareness (Citation2), it is not unexpected that episodic memory has been found to predict impaired self-awareness. The dynamic interaction between knowledge of tasks and strategies, recognition of challenges encountered within task performance, and the subsequent ability to evaluate performance following a task reflects a complex set of cognitive skills required for the development of self-awareness of abilities. The reliance on recall of task experience and performance in order to make an accurate estimation of performance, along with the ongoing need to update this knowledge over time with further exposure to tasks poses a significant challenge for those with memory impairment (Citation2).
In this study, the TBI group had very low FIM cognition/communication scores, with many individuals falling in the lower range of this measure. The use of FIM to measure cognition has some inherent challenges, with the lack of sensitivity at this subscale leading to difficulties with the interpretation of outcomes. Use of FIM+FAM in research may enhance the interpretation of cognition outcomes with greater sensitivity to detecting change, with this measure including additional cognitive/psychosocial items (Citation49).
Longer PTA duration was a predictor of lower self-awareness in the current study, however the correlation between PTA and SADI score in the TBI sample was low (r = .320) which is similar to other study findings (16). There are a number of plausible explanations for this finding. Other researchers have suggested that it is not necessarily the severity of injury but rather the location which most strongly correlates with self-awareness (Citation50). Correlation coefficients may also be lower if there is low variance in the characteristics of the sample; 96% of our sample were classified as having a severe or very severe brain injury, which may have led to our findings. Finally, other factors such as exposure to opportunities to engage in meaningful occupations in the inpatient setting (Citation2) may also account for the level of self-awareness. This outcome is expected when considering the clinical characteristics of PTA that include disorientation, retrograde and anterograde amnesia, and poor attention (Citation51). The lengthy PTA duration in both the current study and Noe et al. (Citation16). highlights a prolonged period of time where individuals with TBI had limited opportunity to update their personal database (i.e., knowledge about task performance) that would support both learning about abilities and limitations and subsequent development of self-awareness (Citation2).
In the current study, it was anticipated that premorbid mental health diagnosis or drug/alcohol history may have had a greater contribution to impaired self-awareness, however this was not the case. Findings indicated that neither of these variables had a relationship with impaired self-awareness for the TBI or stroke groups. In contrast, in a study exploring TBI outcomes for individuals with premorbid substance use disorder, Niemeier et al. (Citation52) found that premorbid substance use predicted impaired self-awareness as measured by both self and clinician ratings on the Patient Competency Rating Scale. Importantly, the mean age of this population was 7 years younger than that of the current study, with just over one-third (34%) of their sample being classified as having a moderate TBI. Whilst further research is required to form conclusions about the contribution of premorbid substance use to impaired self-awareness for individuals with brain injury, the findings from the current study and those of Niemeier et al. are suggestive of this factor potentially being a more relevant predictor for those with moderate compared to severe TBI. In relation to the contribution of premorbid mental health diagnoses to impaired self-awareness, a limitation of the current study was the inclusion of several different mental health diagnoses, limiting the ability to draw conclusions from these results. Whilst studies have explored the relationship between self-awareness and post-ABI onset psychological factors such as depression and anxiety (Citation20,Citation53,Citation54), there is a lack of research to inform the contribution of premorbid mental health diagnoses to impaired self-awareness for individuals with severe TBI or stroke. Further exploration of this factor with a larger sample that is focused on a specific premorbid mental health diagnostic group (e.g., depression or anxiety) may further inform the contribution of this variable to self-awareness.
Results from the current study highlight the high incidence of BoC for the TBI population, and the challenges with impaired self-awareness for inpatients with BoC, with participants with BoC in both TBI and stroke groups having lower self-awareness than those without BoC. In contrast to these findings, in a study exploring BoC in community-dwelling individuals with severe TBI, Hicks et al. (Citation23) found that patient self-reports of BoC indicated that a large proportion of the sample was able to acknowledge the presence of behavior changes (i.e., specifically issues with anger, frustration and irritability) since their injury. These results may reflect the benefits of exposure to the community context in order to support development of self-awareness of behavioral changes over time (Citation36). In this same study (Citation23) there were discrepancies between reports of those with TBI with their significant others in relation to support needs, with a low level of agreement regarding whether support was needed to address these behavioral changes (i.e., those with BoC were less likely to report needing further support). Importantly, this sample ranged in brain injury severity, with only 79% falling in the severe category. These results may be reflective of challenges for those with BoC making a link with the functional implications of their behaviors, or the impact of their BoC on others. There are very few studies that have explored self-awareness in relation to BoC, with self-awareness measures typically failing to yield information that covers the range of behaviors that can occur following ABI. Further research that applies a sound measure to support data collection on self-awareness of BoC is required in order to better understand this issue post-TBI and stroke. Despite apparent issues in the measurement of self-awareness of BoC, there have been some developments in frameworks to guide intervention for people with BoC and self-awareness impairments following brain injury. The Positive Behavior Support framework (Citation55) applies a person-directed approach to promoting an understanding of the individual’s expectations of behavior change. This approach has demonstrated some promising outcomes in supporting online awareness (i.e., predicting triggers for behaviors and monitoring behavior in the moment) (Citation56). Further exploration of this approach using self-awareness measures would be beneficial to establish the role of this intervention in development of self-awareness of BoC for individuals with ABI.
The findings of the current study suggest that there are several clinical factors that contribute to impaired self-awareness, with measures of brain injury severity (i.e., PTA duration), presence of BoC, and cognitive impairment being predictors of impaired self-awareness for this population. These findings build on those of other studies exploring predictors of self-awareness (Citation16,Citation47,Citation48).
Limitations
This study had both strengths and limitations; a strength is the novel exploration of these clinical factors during the inpatient phase of rehabilitation, with much of the literature focused on predictors for long-term outcomes for community-dwelling individuals post-ABI. Another strength is the inclusion of a range of factors such as BoC, mental health comorbidities and premorbid substance use that have not been highlighted in other studies. A limitation is the small sample size of those with stroke; with further studies with larger samples required to further inform predictors of impaired self-awareness for this population. The use of FIM to measure cognition also has limitations, with reduced sensitivity of this measure-holding challenges with interpretation of outcomes. In addition, the inclusion of individuals with premorbid mental health issues that ranged in diagnoses warrants further exploration with a larger sample with a more focused diagnostic group. It is also recognized that denial may play an important role in some individuals with impaired self-awareness, however we did not collect any information on denial and were unable to investigate it in this study.
Conclusions
This study provides important information about factors for consideration when working with individuals in the early phase of rehabilitation following brain injury. Results highlight that further exploration is required to understand the interaction between self-awareness impairment and clinical factors such as BoC and denial in order to consider how to best support the rehabilitation of individuals with severe brain injury.
Authors’ declaration of authorship contribution
The authors confirm contribution to the paper as follows: study conception and design: all authors; data collection: D.S.; data analysis: D.S., J.F.; interpretation of results: all authors; draft manuscript preparation: D.S. All authors reviewed the results and approved the final version of the manuscript. This paper adheres to ethical standards.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Additional information
Funding
References
- Fleming J, Strong J. Self-awareness of deficits following acquired brain injury: considerations for rehabilitation. Br J Occup Ther. 1995;58(2):55–60. doi:10.1177/030802269505800204.
- Toglia J, Kirk U. Understanding awareness deficits following brain injury. NeuroRehabilitation. 2000;15(1):57–70. doi:10.3233/NRE-2000-15104.
- Ergh T, Rapport L, Coleman R, Hanks R. Predictors of caregiver and family functioning following traumatic brain injury: social support moderates caregiver distress. J Head Trauma Rehabil. 2002;17(2):155–74. doi:10.1097/00001199-200204000-00006.
- Kelley E, Sullivan C, Loughlin J, Hutson L, Dahdah M, Long M, Schwab K, Poole J. Self-awareness and neurobehavioral outcomes, 5 years or more after moderate to severe brain injury. J Head Trauma Rehabil. 2014;29(2):147–52. doi:10.1097/HTR.0b013e31826db6b9.
- Lam C, McMahon B, Priddy D, Gehred-Schultz A. Deficit awareness and treatment performance among traumatic head injury adults. Brain Inj. 1988;2(3):235–42. doi:10.3109/02699058809150947.
- Sherer M, Hart T, Nick T, Whyte J, Thompson R, Yablon S. Early impaired self-awareness after traumatic brain injury. Arch Phys Med Rehab. 2003;84(2):168–76. doi:10.1053/apmr.2003.50045.
- Sherer M, Fleming J. Impaired Self-awareness. In: Sherer M Sander A, editors Handbook on the neuropsychology of traumatic brain injury. New York: Springer; 2014. pp. 233–55.
- Geytenbeek M, Fleming J, Doig E, Ownsworth T. The occurrence of early impaired self-awareness after traumatic brain injury and its relationship with emotional distress and psychosocial functioning. Brain Inj. 2017;31(13–14):1791–98. doi:10.1080/02699052.2017.1346297.
- Hartman-Maeir A, Soroker N, Oman S, Katz N. Awareness of disabilities in stroke rehabilitation - a clinical trial. Disabil Rehabil. 2003;25(1):35–44. doi:10.1080/0963828021000007897.
- Prigatano G, Sherer M. Impaired self-awareness and denial during the postacute phases after moderate to severe traumatic brain injury. Front Psychol. 2020;11:1569–1569. doi:10.3389/fpsyg.2020.01569.
- Stuss D, Anderson V. The frontal lobes and theory of mind: Developmental concepts from adult focal lesion research. Brain Cognition. 2004;55(1):69–83. doi:10.1016/S0278-2626(03)00271-9.
- Vocat R, Vuilleumier P. Neuroanatomy of impaired body awareness in anosognosia and hysteria: a multi-component account. In: Prigatano G, editor. The study of anosognosia. USA: Oxford University Press; 2010. pp. 359–403.
- Dirette D, Plaisier B. The development of self-awareness of deficits from 1 week to 1 year after traumatic brain injury: preliminary findings. Brain Inj. 2007;21(11):1131–36. doi:10.1080/02699050701687326.
- Hart T, Seignourel P, Sherer M. A longitudinal study of awareness of deficit after moderate to severe traumatic brain injury. Neuropsychol Rehabil. 2009;19(2):161–76. doi:10.1080/09602010802188393.
- Vanderploeg R, Belanger H, Duchnick J, Curtiss G. Awareness problems following moderate to severe traumatic brain injury: Prevalence, assessment methods, and injury correlates. J Rehabil Res Dev. 2007;44(7):937–50. doi:10.1682/JRRD.2006.12.0163.
- Noe E, Ferri J, Caballero M, Villodre R, Sanchez A, Chirivella J. Self-awareness after acquired brain injury: Predictors and rehabilitation. J Neurol. 2005;252(2):168–75. doi:10.1007/s00415-005-0625-2.
- Wheeler M, Williams O, Johns L, Chiu E, Slavkova E, Demeyere N. Unravelling the complex interactions between self-awareness, cognitive change, and mood at 6-months post-stroke using the Y-shaped model. Neuropsychol Rehabil. 2023;33(4):680–702. doi:10.1080/09602011.2022.2042329.
- Prigatano G, Maier F. Neuropsychiatric, psychiatric, and behavioral disorders associated with traumatic brain injury. In: Grant I Adams K, editors Neuropsychological assessment of neuropsychiatric and neuromedical disorders. 3rd ed. New York: Oxford University Press; 2009. pp. 618–31.
- Bivona U, Costa A, Contrada M, Silvestro D, Azicnuda E, Aloisi M, Catania G, Ciurli P, Guariglia C, Caltagirone C, et al. Depression, apathy and impaired self-awareness following severe traumatic brain injury: a preliminary investigation. Brain Inj. 2019;33(9):1245–56. doi:10.1080/02699052.2019.1641225.
- Ownsworth T, Fleming J, Strong J, Radel M, Chan W, Clare L. Awareness typologies, long-term emotional adjustment and psychosocial outcomes following acquired brain injury. Neuropsychol Rehabil. 2007;17(2):129–50. doi:10.1080/09602010600615506.
- Kim J. Post-stroke mood and emotional disturbances: pharmacological therapy based on mechanisms. Jour Of Stroke. 2016;18(3):244–55. doi:10.5853/jos.2016.01144.
- Kneebone I, Lincoln N. Psychological problems after stroke and their management: state of knowledge. Neurosci Med. 2012;3(1):83–89. doi:10.4236/nm.2012.31013.
- Hicks A, Gould K, Hopwood M, Kenardy J, Krivonos I, Ponsford J. Behaviours of concern following moderate to severe traumatic brain injury in individuals living in the community. Brain Inj. 2017;31(10):1312–19. doi:10.1080/02699052.2017.1317361.
- Arnould A, Dromer E, Rochat L, Van der Linden M, Azouvi P. Neurobehavioral and self-awareness changes after traumatic brain injury: towards new multidimensional approaches. Ann Phys Rehabil Med. 2016;59(1):18–22. doi:10.1016/j.rehab.2015.09.002.
- Benedictus M, Spikman J, van der Naalt J. Cognitive and behavioral impairment in traumatic brain injury related to outcome and return to work. Arch Phys Med Rehab. 2010;91(9):1436–41. doi:10.1016/j.apmr.2010.06.019.
- Draper K, Ponsford J, Schoenberger M. Psychosocial and emotional outcomes 10 years following traumatic brain injury. J Head Trauma Rehabil. 2007;22(5):278–87. doi:10.1097/01.HTR.0000290972.63753.a7.
- Tate R, Broe G. Psychosocial adjustment after traumatic brain injury: what are the important variables? Psychol Med. 1999;29(3):713–25. doi:10.1017/S0033291799008466.
- Trudel T, Tryon W, Purdum C. Awareness of disability and long-term outcome after traumatic brain injury. Rehabil Psychol. 1998;43(4):267–81. doi:10.1037/0090-5550.43.4.267.
- Orfei M, Robinson R, Prigatano G, Starkstein S, Rüsch N, Bria P, Caltagirone C, Spalletta G. Anosognosia for hemiplegia after stroke is a multifaceted phenomenon: a systematic review of the literature. Brain. 2007;130(12):3075–90. doi:10.1093/brain/awm106.
- Heilman K. Possible mechanisms of anosognosia of hemiplegia. Cortex. 2014;61:30–42. doi:10.1016/j.cortex.2014.06.007.
- Marcel A, Tegner R, Nimmo-Smith I. Anosognosia for plegia: specificity, extension, partiality and disunity of bodily unawareness. Cortex. 2004;40(1):19–40. doi:10.1016/S0010-9452(08)70919-5.
- Vallar G, Ronchi R. Anosognosia for motor and sensory deficits after unilateral brain damage: a review. Restor Neurol Neurosci. 2006;24(4–6):247–57.
- Vuilleumier P. Anosognosia: The Neurology of Beliefs and Uncertainties. Cortex. 2004;40(1):9–17. doi:10.1016/S0010-9452(08)70918-3.
- Keenan JP, Gorman J. The causal role of the right hemisphere in self-awareness: it is the brain that is selective. Cortex. 2007;43(8):1074–82. doi:10.1016/S0010-9452(08)70705-6.
- Prigatano GP. Anosognosia and patterns of impaired self-awareness observed in clinical practice. Cortex. 2014;61:81–92. doi:10.1016/j.cortex.2014.07.014.
- Sansonetti D, Fleming J, Patterson F, Lannin N. Profiling self-awareness in brain injury rehabilitation: A mixed methods study. Neuropsychol Rehabil. 2023;1–26. doi:10.1080/09602011.2023.2282656.
- Fleming J, Strong J, Ashton R. Self-awareness of deficits in adults with traumatic brain injury: How best to measure? Brain Inj. 1996;10(1):1–16. doi:10.1080/026990596124674.
- Fleming J, Tooth L, Connell J, Strong J. A comparison of self-awareness and adjustment in adults with traumatic brain injury and spinal cord injury: the transition from hospital to community. Jourl Of Cognitive Rehabilitation. 2002;20(3):28–36.
- Wise K, Ownsworth T, Fleming J. Convergent validity of self-awareness measures and their association with employment outcome in adults following acquired brain injury. Brain Inj. 2005;19(10):765–75. doi:10.1080/0269905050019977.
- Simmond M, Fleming J. Occupational therapy assessment of self-awareness following traumatic brain injury. Br J Occup Ther. 2003;66(10):447–53. doi:10.1177/030802260306601003.
- Bogod N, Mateer C, Macdonald S. Self-awareness after traumatic brain injury: a comparison of measures and their relationship to executive functions. J Int Neuropsychol Soc. 2003;9(3):450–58. doi:10.1017/S1355617703930104.
- Granger C, Hamilton B, Keith R, Zielezny M, Sherwin F. Advances in functional assessment for medical rehabilitation. Top Geriatr Rehabil. 1986;1(3):59–74. doi:10.1097/00013614-198604000-00007.
- Tate R. A compendium of tests, scales, and questionnaires: the practitioners guide to measuring outcomes after acquired brain impairment. East Sussex: Psychology Press; 2010.
- Hebert R, Carrier R, Bilodeau A. The functional autonomy measurement system (SMAF): description and validation of an instrument for the measurement of handicaps. Age Ageing. 1988;17(5):293–302. doi:10.1093/ageing/17.5.293.
- Desrosiers J, Bravo G, Hébert R, Dubuc N. Reliability of the revised functional autonomy measurement system (SMAF) for epidemiological research. Age Ageing. 1995;24(5):402–06. doi:10.1093/ageing/24.5.402.
- Desrosiers J, Rochette A, Noreau L, Bravo G, Hébert R, Boutin C. Comparison of two functional independence scales with a participation measure in post-stroke rehabilitation. Arch Gerontol Geriat. 2003;37(2):157–72. doi:10.1016/S0167-4943(03)00044-X.
- Villalobos D, Caperos J, Á B, López-Muñoz F, Pacios J. Cognitive predictors of self-awareness in patients with acquired brain injury along neuropsychological rehabilitation. Neuropsychol Rehabil. 2021;31(6):983–1001. doi:10.1080/09602011.2020.1751663.
- Ownsworth T, McFarland K, Young R. The investigation of factors underlying deficits in self-awareness and self-regulation. Brain Inj. 2002;16(4):291–309. doi:10.1080/02699050110103986.
- Turner-Stokes L, Nyein K, Turner-Stokes T, Gatehouse C. The UK FIM+FAM: Development and evaluation. Funct Assess Meas Clini Rehabilitation. 1999;13(4):277–87. doi:10.1191/026921599676896799.
- Ham T, Bonelle V, Hellyer P, Jilka S, Robertson I, Leech R, Sharp DJ. The neural basis of impaired self-awareness after traumatic brain injury. Brain. 2014;137(2):586–97. doi:10.1093/brain/awt350.
- Ponsford J, Trevena-Peters J, Janzen S, Harnett A, Marshall S, Patsakos E, Kua A, McIntyre A, Teasell R, Wiseman-Hakes C, et al. INCOG 2.0 guidelines for cognitive rehabilitation following traumatic brain injury, part i: posttraumatic amnesia. J Head Trauma Rehabil. 2023;38(1):24–37. doi:10.1097/HTR.0000000000000840.
- Niemeier J, Leininger S, Whitney M, Newman M, Hirsch M, Evans S, Sing RF, Huynh TT, Guerrier TP, Perrin PB. Does History Of Substance Use Disorder Predict Acute Traumatic Brain Injury Rehabilitation Outcomes? NeuroRehabilitation (Reading, Mass). 2016:38(4):371–83. 10.3233/NRE-161328.
- Evans C, Sherer M, Nick T, Nakase-Richardson R, Yablon S. Early impaired self-awareness, depression, and subjective well-being following traumatic brain injury. J Head Trauma Rehabil. 2005;20(6):488–500. doi:10.1097/00001199-200511000-00002.
- Malec J, Testa J, Rush B, Brown A, Moessner A. Self-assessment of impairment, impaired self-awareness, and depression after traumatic brain injury. J Head Trauma Rehabil. 2007;22(3):156–66. doi:10.1097/01.HTR.0000271116.12028.af.
- Feeney T. There’s always something that works: principles and practices of positive support for individuals with traumatic brain injury and problem behaviors. Semin Speech Lang. 2010;17(3):145–61. doi:10.1055/s-0030-1257531.
- Gould K, Ponsford J, Hicks A, Hopwood M, Renison B, Feeney T. Positive behaviour support for challenging behaviour after acquired brain injury: An introduction to PBS + PLUS and three case studies. Neuropsychological Rehabilitation. 2021;31(1):57–91. doi:10.1080/09602011.2019.1656647.