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

Abstract

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.

Impaired Self-Awareness and Denial During the Postacute Phases After Moderate to Severe Traumatic Brain Injury

“…However ( Prigatano, 2012 ) suggested that patients who present with DD may “show greater indications of denial by their verbal responses obtained from the Thematic Apperception Test using the indicators of denial….” in the Cramer (2003) scoring system, denial is reflected “by statements of negation, blatant or clear omission of ominous components of reality when telling or relating a story, over-maximizing the positive or minimizing the negative, describing unexpected goodness, optimism, positiveness, or gentleness” ( Prigatano, 2012 ). This approach was used in a recent study by Belchev et al (2017) . These investigators had 43 postacute patients with varying levels of severity of TBI complete the PCRS and compared their ratings on this scale with therapist ratings.…”

“…The fact that the overestimators did not have more severe brain injuries and showed no difference on the majority of neuropsychological tests compared to good and underestimators highlights the central problem that this review paper attempts to address. Without independent classification of postacute patients with TBI showing high levels of ISA (i.e., clinically significant ISA) (and low or non-existent DD) versus those showing high levels of DD (and low to non-existent ISA), the meaning of the projective test findings reported by Belchev et al (2017) remains unclear. We would suggest that experienced clinicians independently identify a group of patients with TBI that show clinically significant ISA with minimal or low DD and compare them to patients with TBI showing clinically significant DD with minimal or low ISA on several measures.…”

Increasing Mentalization to Reduce Maladaptive Defense in Patients With Mental Disorders

“…(5,8,11,13,73,74), our results suggest that through an increase in mentalization, patients may adapt a healthier overall defense style by reducing maladaptive elements. Since numerous studies have highlighted the importance of well-performing psychological defense in the rehabilitation and preservation of mental health (22,24,28,29) as well as on humans' ability to adapt to and cope with severe medical conditions (27,30,31) and other forms of traumatizing life events (24,75,76), we consider interventions to foster mentalization as necessary in the reduction of maladaptive defense styles in psychotherapy. Regarding future research on psychological defense, our results suggest taking mentalization into account.…”

“…Furthermore, research has revealed links between physical impairment and the use of different forms of defense styles. For example, studies found that the use of immature defense mechanisms may be associated with somatic symptom severity (30) and may contribute to impaired awareness in patients with traumatic brain injury (31). Other studies identified the role of psychological defense mechanisms in patients with cancer [see (27) for a review].…”

Cognition and Intervention in Traumatic Brain Injury

“…Neurobehavioral problems, mood and cognition disorder, especially with regard to memory performance, attention, planning and executive functioning are invariably impaired in individuals afflicted by TBI, a major and leading cause of chronic disability over the globe. All of these signs and symptoms in various wound-combinations, intensities and severities, locations and stages will offer the determination of the dimensions of short-term and long-term disruption of physical, sensory-motor, cognitive-emotional, behavioral and emotional domains [7][8][9]. Efforts to establish diagnostic and symptomatic instruments for establishing deficits in cognitive domains of TBI, not least regarding self-awareness [10,11] and mindfulness [12][13][14], have produced several essential methodological ingredients.…”