Assessment of impaired self-awareness after moderate-to-severe traumatic brain injury: a comparison of assessment tools.

OBJECTIVE: To compare different assessment methods of impaired self-awareness (ISA). METHODS: We included 37 patients with moderate-to-severe traumatic brain injury (TBI) at a subacute/chronic stage, and 33 healthy controls. ISA was assessed with three methods: discrepancy scores (comparison between patient and proxy ratings) on three scales (Patient Competency Rating Scale (PCRS), Awareness Questionnaire (AQ) and Dysexecutive Questionnaire (DEX)); clinician rating with the Self-Awareness of Deficits Interview (SADI); and the difference between prediction or estimation of performance and actual performance on two cognitive tasks. RESULTS: Clinician-patient discrepancy scores appeared more sensitive than relative-patient discrepancy. The AQ was the most sensitive. The discrepancy scores were strongly correlated one with each other. Correlations with the SADI were weaker. Patients did not overestimate their performance on cognitive tasks, and the prediction did not significantly correlate with other measures of ISA. DISCUSSION/CONCLUSION: Results support the multidimensional nature of ISA: discrepancy scores assess meta-cognitive knowledge (understanding that a function/skill is affected), while the SADI takes into account anticipatory awareness (ability to set realistic goals) and estimation of performance assesses anticipatory and situational awareness. Assessment of these different domains may provide a comprehensive overview of an individual's self-awareness.

Impaired self-awareness after traumatic brain injury: A systematic review. Part 2. Consequences and predictors of poor self-awareness.

BACKGROUND: Impaired self-awareness (ISA) has frequently been found both frequent and deleterious in patients with moderate to severe traumatic brain injury (TBI). OBJECTIVES: This is the second of a two-part systematic review on ISA after TBI, focusing on the consequences and predictors of ISA after TBI. METHODS: Following the PRISMA guidelines, 95 articles meeting the inclusion criteria were included; 46 were specifically related to this second part of the review. RESULTS: Among 16 studies that investigated the effect of ISA on outcome, most (n=13) found poor self-awareness associated with poor rehabilitation, functional, social and vocational outcome and with increased burden on relatives. Multiple factors have been found associated with increased frequency of ISA. ISA was found significantly related to injury severity in 8 of 10 studies, impaired executive functions in 12 of 15 studies, and poor social cognition in 3 studies, but paradoxically inverse associations were repeatedly found between self-awareness and emotional status (11 of 12 studies). Finally, although research in the field is still scarce, ISA seems associated with a dysfunction within brain networks involving the anterior cingulate cortex, anterior insula and fronto-parietal control network. CONCLUSIONS: ISA is a complex and multifaceted disorder associated with poor rehabilitation outcome, severe injuries, and deficits of executive functions and social cognition but has an inverse association with mood impairments.

Impaired self-awareness after traumatic brain injury: a systematic review. Part 1: Assessment, clinical aspects and recovery.

BACKGROUND: Impaired self-awareness (ISA) has frequently been found to be both frequent and deleterious in patients with moderate to severe traumatic brain injury (TBI). OBJECTIVES: The present paper is the first of a two-part systematic review of ISA after traumatic brain injury (TBI), focusing on assessment methods, clinical aspects and recovery. METHODS: Following the PRISMA guidelines, 95 articles meeting the inclusion criteria were included. RESULTS: ISA occurs in 30% to 50% of patients with moderate to severe TBI, although it tends to improve with time. There is no one single gold-standard measure of ISA. Self-proxy discrepancy scores, with scales such as the Patient Competency Rating Scale or the Awareness Questionnaire, or a structured interview such as the Self Awareness of Deficits Interview, are the most frequently used assessment methods, with adequate psychometric properties. Scores on these different scales correlate only moderately with each other, which suggests that they may address different aspects of self-awareness. ISA mainly concerns cognitive and behavioral problems rather than physical or sensory impairments and may concern different areas of functioning, such as anticipatory, emergent or meta-cognitive awareness. CONCLUSION: ISA is a complex and multifaceted issue that should be systematically assessed in rehabilitation settings using a range of relatively well-validated tools. The consequences and predictors of ISA after TBI will be addressed in a companion paper.

Does multitasking mediate the relationships between episodic memory, attention, executive functions and apathetic manifestations in traumatic brain injury?

Apathy is frequently described in patients with traumatic brain injury (TBI); its negative consequences particularly affect functional independence. Among apathetic manifestations, lack of initiative and lack of interest have mainly been associated with cognitive impairments. However, few studies have been conducted to precisely identify the underlying cognitive processes. Our aims were (1) to determine the best predictor of apathy from among several cognitive processes, including episodic memory and attention/executive mechanisms and multitasking, and (2) to examine to what extent multitasking could mediate the relationships between specific cognitive processes and lack of initiative/interest. Seventy participants (34 patients with TBI matched with 36 control participants) were given a questionnaire to assess anxio-depressive symptoms, four tasks to assess specific cognitive processes, and one task to assess real-life multitasking. Participants' relatives completed an apathy questionnaire. Multitasking, as assessed by the number of goals not achieved, was the only significant predictor of apathetic manifestations. In addition, the mediation analyses revealed that multitasking performance mediated the relationships between verbal episodic memory and lack of initiative/interest, whereas executive and attentional functions were only indirectly related to lack of initiative/interest due to their significant impacts on multitasking. These results shed new light on the aetiology of apathetic manifestations in patients with TBI, indicating how specific cognitive deficits are expressed in real-life multitasking, and consequently, how they may lead to the development and/or maintenance of apathetic manifestations.