Citation:
Prigatano, G.P. & Sherer, M. (2020). Impaired self-awareness and denial during the post-acute phases of moderate to severe traumatic brain injury. Frontiers in Psychology, 11, Article 1569 doi: 10.3389/fpsyg.2020.01569
Summary:
This is a narrative review article written by two highly regarded TBI experts. The manuscript describes how person’s capacity or willingness to acknowledge and address TBI related impairments is a combination of neurologically-based impaired self-awareness (IAS) and psychologically-based denial of disability (DD). The authors perform a selective review of the literature on ISA and DD. They define ISA as “a failure to experience (as assessed via subjective reports) a disturbance in higher integrative brain functions due to a disruption or damage to regions of the brain that are important for the normal performance of those higher integrative brain functions.” They note that patients with ISA are often observed to be neutral, bland, perplexed or indifferent regarding impairments. In contrast, denial is a defense mechanism “by which the individual attempts to deal with emotional conflicts in the presence of external stressors…a complex cognitive-behavioral-emotional reaction.” In DD patients may disavow the importance of a problem, become angry or anxious and seek to avoid discussing the impairment. The literature review focuses on measurement of ISA and DD, the epidemiology of the two conditions, neurological and neuropsychological correlates, and relationship to outcomes. One obvious point they make is that DD is vastly understudied. Table 3 on page 8 is perhaps the most useful element of the manuscript. Therein they summarize different approaches to treating/managing ISA and DD.
The reasons I chose this article are: (1) because I think we all recognize, mostly from Prigatano’s classic studies, that unawareness has both neurological and psychological underpinnings, yet there is a dearth of theoretical and practical information on the topic of treatment, and (2) the authors draw parallels between denial of disability and denial thought to be associated with substance use disorders (SUD). Regarding this latter point, motivational interviewing (MI) has been found to be an effective brief intervention for SUDs and, in my experience, MI has also helped me to address denial of disability. I have found that strategic open questions, reflective listening, affirmations and asking permission before giving information or feedback have greatly enhanced my ability to manage denial of disability.
This month’s Rehabilitation Science Spotlight was chosen by Charles H. Bombardier, PhD, ABPP. Dr. Bombardier is a clinical psychologist at the Rehabilitation Medicine Clinic at Harborview, head of the Clinical and Neuropsychology Department at University of Washingoton (UW) Medicine, and a UW professor of Rehabilitation Medicine. Dr. Bombardier is also a member of the APAP Division 22 Science Committee. Thank you for your valuable contribution, Dr. Bombardier!