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Impaired Self-Awareness

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Handbook on the Neuropsychology of Traumatic Brain Injury

Part of the book series: Clinical Handbooks in Neuropsychology ((CHNEURO))

Abstract

Persons with neurologic disorders often show impaired ability to accurately perceive the effects of their disorders on their physical, cognitive, and behavioral abilities. For conditions that have a sudden onset such as stroke or traumatic brain injury (TBI) the degree of impairment of this ability is greatest early after onset so that, for example, soon after right hemisphere stroke, the person with stroke may not perceive motor impairment on the left side of the body, but gradually becomes more aware of this impairment as he/she recovers. For progressive conditions such as the various dementias, the degree of impairment of self-awareness worsens as the condition progresses so that a person with Alzheimer’s disease may be aware of subtle memory impairment in early stages of the disease, but unaware of very severe memory impairment once the disease has progressed. In either case, the perception of impairment is least when the actual impairment is greatest and greatest when the actual impairment is least.

Impaired self-appraisal of functioning is referred to as anosognosia in conditions such as the neglect syndrome after right hemisphere stroke or Anton’s syndrome (unawareness of cortical blindness) after bilateral posterior cerebral artery strokes where the lack of awareness may be complete. In TBI, this condition is simply called impaired self-awareness (ISA) as persons with injury usually have some awareness of their deficits once they recover from the confused state (post-traumatic amnesia).

For persons with TBI, severity of ISA is greatest in early recovery. By definition, patients in coma or the vegetative state have no self-awareness. Though not directly assessed, minimally conscious patients are assumed to have extremely limited self-awareness. Once patients recover to the confused state, they remain with very severe impairment of self-awareness. Often after resolution of confusion, patients may deny that they have sustained TBI at all and deny any residual effects of the injury. Even when acknowledging injury, we have seen patients insist that their cognitive abilities after severe TBI are much better than they were prior to sustaining TBI. Patients who are unable to walk safely may attempt to remove restraints to leave their beds or wheelchairs to go to the toilet or simply to attempt to leave the room. Patients may refuse therapies because they do not believe that they have impairments that need to be treated. In the post-acute period of recovery, patients may attempt to drive in spite of motor and sensory deficits or pursue employment or independence goals that are at odds with their current functional limitations. To ensure patient safety, compliance with needed therapies, and the best possible outcomes for patients, neuropsychologists and others treating persons with TBI must assess and, when needed, provide treatment for deficits in self-awareness.

This chapter will: (1) review the nature of ISA after TBI and describe its impact on rehabilitation therapies and patient outcome, (2) describe approaches to assessment of ISA, (3) review the literature on interventions to improve self-awareness in persons with TBI, and (4) provide practical guidance illustrated with clinical cases for intervening with patients with ISA.

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Acknowledgement

Preparation of this chapter was partially supported by the U.S. Department of Education National Institute on Disability and Rehabilitation Research (NIDRR) grants H133A070043, H133B090023, and H133A120020.

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Authors and Affiliations

  1. TIRR Memorial Hermann, Houston, TX, USA

    Mark Sherer Ph.D., ABPP, FACRM

  2. University of Texas Medical School at Houston, Baylor College of Medicine, Houston, TX, USA

    Mark Sherer Ph.D., ABPP, FACRM

  3. University of Queensland School of Health and Rehabilitation Sciences and Princess Alexandra Hospital, Brisbane, QLD, Australia

    Jennifer Fleming Ph.D.

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  1. Mark Sherer Ph.D., ABPP, FACRM
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  2. Jennifer Fleming Ph.D.
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Correspondence to Mark Sherer Ph.D., ABPP, FACRM .

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Editors and Affiliations

  1. TIRR Memorial Hermann, Baylor College of Medicine, University of Texas Medical School at Houston, Houston, Texas, USA

    Mark Sherer

  2. Baylor College of Medicine/Harris Health System, Brain Injury Research Center, TIRR Memorial Hermann, Houston, Texas, USA

    Angelle M. Sander

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Sherer, M., Fleming, J. (2014). Impaired Self-Awareness. In: Sherer, M., Sander, A. (eds) Handbook on the Neuropsychology of Traumatic Brain Injury. Clinical Handbooks in Neuropsychology. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-0784-7_12

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