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

Abstract

While a number of empirical studies have appeared on impaired self-awareness (ISA) after traumatic brain injury (TBI) over the last 20 years, the relative role of denial (as a psychological method of coping) has typically not been addressed in these studies. We propose that this failure has limited our understanding of how ISA and denial differentially affect efforts to rehabilitate persons with TBI. In this selective review paper, we summarize early findings in the field and integrate those findings with more recent observations (i.e., 1999-2019). We believe that this synthesis of information and expert clinical opinion will inform future research on ISA and denial as well as approaches to rehabilitation for persons with TBI.

Maladaptive Denial of Severe Pain and Acute Orthopedic Injuries in a Patient With a Schizoaffective Disorder

“…There was no evidence of underlying neuropsychological difficulties that could account for this patient's intense verbal responses and behaviors regarding her pain. Her disturbed "sensorimotor awareness" was characterized by emotional reactions not considered in cognitive models of conscious awareness (Morin, 2006) nor observed in patients with underlying brain pathology (Prigatano, 2010). Rather this patient's clinical presentation is best explained on the basis of psychodynamic models that emphasize denial is associated with avoidance of anxiety producing experiences.…”

“…765). While clinically significant, maladaptive denial can be associated with various cognitive, emotional, and behavioral reactions (Prigatano and Sherer, 2020), one defining feature has been the phenomenon of actively avoiding a discussion of what problems the person attempts to deny. The patient may not respond to questions or may attempt to change the topic of discussion.…”

“…The scientific literature on disorders of consciousness and self-awareness is quite diverse and often focuses on either neurological explanations (Posner et al, 2007), different neuropsychological models (see Prigatano, 2010) or theories emanating from cognitive psychology (see Morin, 2006). To add to this complicated literature, different types and levels of conscious experiences have been described by several investigators which often use different terms when describing seemingly the same or similar phenomena (Morin, 2006).…”

“…Understanding persistent impaired self-awareness (ISA) in patients with post-acute severe traumatic brain injury (TBI) has been more challenging. Recently Prigatano and Sherer (2020) noted that research on the neurological correlates of commonly used measures of ISA in post-acute TBI have revealed only moderate size effects. They suggest this may due to the fact denial phenomena contributes to some TBI patients underreporting their neuropsychological and behavioral limitations.…”

“…Her psychiatric management is also briefly summarized. Following the suggestion of Prigatano and Sherer (2020) of the potential use of the Conscious Avoidance subscale of the Illness Denial Questionnaire (IDQ) for measuring clinically significant levels of denial, we specifically evaluated this patient's behavior and verbalizations using this subscale. We conclude with suggestions for briefly assessing medical and psychiatric patients suspected of presenting with clinically significant (maladaptive) denial.…”