The contribution of injury severity, executive and implicit functions to awareness of deficits after traumatic brain injury (TBI)

Abstract Deficits in self-awareness are commonly seen after Traumatic Brain Injury (TBI) and adversely affect rehabilitative efforts, independence and quality of life (Ponsford, 2004). Awareness models predict that executive and implicit functions are important cognitive components of awareness though the putative relationship between implicit and awareness processes has not been subject to empirical investigation (Crosson et al., 1989; Ownsworth, Clare, & Morris, 2006; Toglia & Kirk, 2000). Severity of injury, also thought to be a crucial determinant of awareness outcome post-insult, is under-explored in awareness studies (Sherer, Boake, Levin, Silver, Ringholz, & Walter, 1998). The present study measured the contribution of injury severity, IQ, mood state, executive and implicit functions to awareness in head-injured patients assigned to moderate/severe head-injured groups using several awareness, executive, and implicit measures. Severe injuries resulted in greater impairments across most awareness, executive and implicit measures compared with moderate injuries, although deficits were still seen in the moderate group. Hierarchical regression results showed that severity of injury, IQ, mood state, executive and implicit functions made significant unique contributions to selective aspects of awareness. Future models of awareness should account for both implicit and executive contributions to awareness and the possibility that both are vulnerable to disruption after neuropathology. (JINS, 2010, 16, 1089–1098.)

[1]  S. MacDonald,et al.  Self-awareness after traumatic brain injury: a comparison of measures and their relationship to executive functions. , 2003, Journal of the International Neuropsychological Society : JINS.

[2]  S. D'Amore,et al.  [Hospital anxiety and depression]. , 2011, Reumatismo.

[3]  N. King,et al.  Mild head injury: neuropathology, sequelae, measurement and recovery. , 1997, The British journal of clinical psychology.

[4]  R. Zajonc.  Feeling and thinking : Preferences need no inferences , 1980 .

[5]  Giuseppe Vallar,et al.  Left hemisphere damage and selective impairment of auditory verbal short-term memory. A case study , 1982, Neuropsychologia.

[6]  M. Pépin,et al.  Impaired Awareness of Deficits and Treatment Adherence Among People With Traumatic Brain Injury or Spinal Cord Injury , 2006, The Journal of head trauma rehabilitation.

[7]  T. Coughlan,et al.  Social adjustment after closed head injury: a further follow-up seven years after injury. , 1985, Journal of neurology, neurosurgery, and psychiatry.

[8]  H S Levin,et al.  Frontal Lobe Dysfunction following Closed Head Injury. A Review of the Literature , 1990, The Journal of nervous and mental disease.

[9]  E. Bernat,et al.  Brain Indices of Nonconscious Associative Learning , 1997, Consciousness and Cognition.

[10]  P. Munk-Jørgensen,et al.  Acta Psychiatrica Scandinavica , 1998 .

[11]  C. Boake,et al.  Characteristics of impaired awareness after traumatic brain injury , 1998, Journal of the International Neuropsychological Society.

[12]  L. Barker,et al.  Investigating the ‘latent’ deficit hypothesis: Age at time of head injury, implicit and executive functions and behavioral insight , 2010, Neuropsychologia.

[13]  M. Linden,et al.  Are central executive functions working in patients with focal frontal lesions? , 2002, Neuropsychologia.

[14]  Paul W. Burgess,et al.  Behavioural Assessment of the Dysexecutive Syndrome , 1997 .

[15]  J. Ashe,et al.  Neural correlates of encoding and expression in implicit sequence learning , 2005, Experimental Brain Research.

[16]  J. Forgas.  On being happy and mistaken: mood effects on the fundamental attribution error. , 1998, Journal of personality and social psychology.

[17]  S. Weintraub,et al.  Generalized and symptom-specific insight in behavioral variant frontotemporal dementia and primary progressive aphasia. , 2009, The Journal of neuropsychiatry and clinical neurosciences.

[18]  D. Wilkin,et al.  Neuron , 2001, Brain Research.

[19]  S. Dehaene,et al.  Levels of processing during non-conscious perception: a critical review of visual masking , 2007, Philosophical Transactions of the Royal Society B: Biological Sciences.

[20]  T. Ownsworth,et al.  An integrated biopsychosocial approach to understanding awareness deficits in Alzheimer's disease and brain injury , 2006, Neuropsychological rehabilitation.

[21]  Uta Frith,et al.  Implicit and Explicit Processes in Social Cognition , 2008, Neuron.

[22]  W. Sturm,et al.  Neuropsychological assessment , 2007, Journal of Neurology.

[23]  Ron Dumont,et al.  Delis‐Kaplan Executive Function System , 2008 .

[24]  Daniel L. Schacter,et al.  Awareness of deficit after brain injury : clinical and theoretical issues , 1991 .

[25]  J. Becker,et al.  Cognitive neuropsychology of Alzheimer's disease , 2004 .

[26]  B. Milner,et al.  Deficits on subject-ordered tasks after frontal- and temporal-lobe lesions in man , 1982, Neuropsychologia.

[27]  Á. Pascual-Leone,et al.  Prefrontal lesions impair the implicit and explicit learning of sequences on visuomotor tasks , 2002, Experimental Brain Research.

[28]  L. Barker,et al.  Implicit cognition is impaired and dissociable in a head-injured group with executive deficits , 2006, Neuropsychologia.

[29]  J. Fleming,et al.  Convergent validity of self-awareness measures and their association with employment outcome in adults following acquired brain injury , 2005, Brain injury.

[30]  E. Grant,et al.  The associations among self-awareness, emotional well-being, and employment outcome following acquired brain injury: A 12-month longitudinal study. , 2006 .

[31]  T. Nick,et al.  Measurement of impaired self-awareness after traumatic brain injury: a comparison of the patient competency rating scale and the awareness questionnaire , 2003, Brain injury.

[32]  Tim Shallice,et al.  The Hayling and Brixton Tests , 1997 .

[33]  J. Fleming,et al.  A Longitudinal Study of Self-Awareness: Functional Deficits Underestimated by Persons with Brain Injury , 1999 .

[34]  J. Fleming,et al.  Cluster Analysis of Self-Awareness Levels in Adults with Traumatic Brain Injury and Relationship to Outcome , 1998, The Journal of head trauma rehabilitation.

[35]  Ursula Kirk,et al.  Understanding awareness deficits following brain injury. , 2000, NeuroRehabilitation.

[36]  J. Ponsford.  Cognitive and behavioral rehabilitation : from neurobiology to clinical practice , 2004 .

[37]  K. Cicerone,et al.  Definition of mild traumatic brain injury , 1993 .

[38]  Michael Weiner,et al.  Neuroanatomical correlates of cognitive self-appraisal in neurodegenerative disease , 2010, NeuroImage.

[39]  Carol A. Seger,et al.  Two Forms of Sequential Implicit Learning , 1997, Consciousness and Cognition.

[40]  M. J. Emerson,et al.  The Unity and Diversity of Executive Functions and Their Contributions to Complex “Frontal Lobe” Tasks: A Latent Variable Analysis , 2000, Cognitive Psychology.

[41]  J. Kihlstrom,et al.  Anosognosia, consciousness, and the self , 1991 .

[42]  J. Whyte,et al.  Neuroanatomic Basis of Impaired Self‐awareness After Traumatic Brain Injury: Findings From Early Computed Tomography , 2005, The Journal of head trauma rehabilitation.

[43]  T. Ownsworth,et al.  Development and Standardization of the Self-Regulation Skills Interview (SRSI): A New Clinical Assessment Tool for Acquired Brain Injury , 2000, The Clinical neuropsychologist.

[44]  M. Nissen,et al.  Attentional requirements of learning: Evidence from performance measures , 1987, Cognitive Psychology.

[45]  G. Huston.  The Hospital Anxiety and Depression Scale. , 1987, The Journal of rheumatology.

[46]  Junghoon Kim,et al.  Executive Function and Self‐awareness of “Real‐world” Behavior and Attention Deficits Following Traumatic Brain Injury , 2005, The Journal of head trauma rehabilitation.

[47]  R. Zajonc.  Attitudinal effects of mere exposure. , 1968 .

[48]  L. Abramson,et al.  Judgment of contingency in depressed and nondepressed students: sadder but wiser? , 1979, Journal of experimental psychology. General.

[49]  J. Fleming,et al.  Self-awareness of deficits in adults with traumatic brain injury: how best to measure? , 1996, Brain Injury.

[50]  J. Dougherty,et al.  Loss of awareness in Alzheimer’s disease (AD): Considerations of lack of insight and legal liabilities in the United States , 2005, Alzheimer's & Dementia.

[51]  Sterling C. Johnson,et al.  Neural correlates of self-evaluative accuracy after traumatic brain injury , 2006, Neuropsychologia.

[52]  J. Brandt,et al.  Self-ordered pointing performance in Huntington's disease patients , 1996 .

[53]  J. Fleming,et al.  The Relative Importance of Metacognitive Skills, Emotional Status, and Executive Function in Psychosocial Adjustment Following Acquired Brain Injury , 2005, The Journal of head trauma rehabilitation.

[54]  T. Hart,et al.  A longitudinal study of awareness of deficit after moderate to severe traumatic brain injury , 2009, Neuropsychological rehabilitation.

[55]  Matthew D. Lieberman,et al.  Intuition: a social cognitive neuroscience approach. , 2000, Psychological bulletin.

[56]  D. Stuss,et al.  Is there a dysexecutive syndrome? , 2007, Philosophical Transactions of the Royal Society B: Biological Sciences.

[57]  D L Schacter,et al.  Toward a cognitive neuropsychology of awareness: implicit knowledge and anosognosia. , 1990, Journal of clinical and experimental neuropsychology.

[58]  L. Barker,et al.  Impaired Implicit Cognition with Intact Executive Function After Extensive Bilateral Prefrontal Pathology: A Case Study , 2004, Neurocase.

[59]  Laura A Flashman,et al.  Lack of awareness and its impact in traumatic brain injury. , 2002, NeuroRehabilitation.

[60]  Teresa C. Brobeck,et al.  Training awareness and compensation in postacute head injury rehabilitation. , 1989 .

[61]  R. Knight,et al.  Course of insight disorder and emotional dysfunction following closed head injury: a controlled cross-sectional follow-up study. , 1993, Journal of clinical and experimental neuropsychology.

[62]  P. Dockree,et al.  Awareness of deficits in traumatic brain injury: A multidimensional approach to assessing metacognitive knowledge and online-awareness , 2006, Journal of the International Neuropsychological Society.