Research Reports - Psychological traits predict impaired awareness of deficits independently of neuropsychological factors in chronic traumatic brain injury

Br J Clin Psychol. 2017 Sep;56(3):213-234. doi: 10.1111/bjc.12134. Epub 2017 May

Belchev Z(1)(2), Levy N(3), Berman I(3), Levinzon H(3), Hoofien D(4)(5), Gilboa

OBJECTIVES: To dissociate injury-related factors from psychological contributions
to impaired awareness of deficits following traumatic brain injury (TBI);
impaired awareness is theorized to partly reflect psychological factors (e.g.,
denial), but empirical evidence for this theory is scarce.
DESIGN: We examined how different factors predict awareness in patients
undergoing rehabilitation (N = 43). Factors included (1) neurological (injury
severity), (2) neuropsychological loss, (3) psychological (denial, projection,
identification), and (4) personality (narcissism).
METHODS/MAIN MEASURES: The Patient Competency Rating Scale, comparing patient
with clinician reports on different functional domains; the Thematic Apperception
Test, an injury-independent measure of the propensity to mobilize specific
defence mechanisms; and the Narcissism Personality Inventory.
RESULTS: Impaired awareness was not predicted by injury-related and
neuropsychological scores but was significantly predicted by use of primitive
defence mechanisms (denial and projection). Patients who underestimate their
abilities also demonstrated high denial levels, but contrary to underestimators,
this was positively related to depression and negatively to awareness.
CONCLUSIONS: Primitive defence mechanism use significantly contributes to
impaired awareness independent of injury-related factors, particularly in domains
associated with self-identity. Well-validated tests of defence mechanism
mobilization are needed to support clinical interpretation of and intervention
with impaired awareness. More research is needed to understand the psychology of
hypersensitivity to deficits.
PRACTITIONER POINTS: This study provides an empirical demonstration of
dissociable contributions of neurological and psychological factors to awareness
of deficits in TBI. Trait proclivity to mobilize defence mechanisms in response
to anxiety-provoking situations can be measured, and strongly predicts impaired
awareness. Importantly, measures of psychological reactions were independent of
responses to the neurological deficits themselves, discriminating between
psychological and neurological contributions to impaired awareness. The
importance of identifying psychological reactions to impaired awareness and
hindering rehabilitation success is highlighted, and vital for clinicians to
consider during the rehabilitation process. Psychological reactions to TBI can be
identified using well-validated, quantitative measures of the use of
psychological defences (e.g., Cramer's Thematic Apperception Test scoring
system), and the authors suggest this is a critical step to properly characterize
and manage awareness in patients during treatment. Although only TBI patients
were examined, the results may inform impaired awareness that occur as a result
of other disorders and illnesses. The patients in this study were in the chronic
stages of the injury, and therefore, the results may not generalize to patients
in more acute stages. 

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