Self-awareness following traumatic brain injury: the role of biopsychosocial factors

Changes in self-awareness of injury-related difficulties are common sequelae of traumatic brain injury (TBI). Inaccurate appraisal of current capacities and limitations can affect engagement in rehabilitation, as well as return to previous activities and relationships with family and friends. Both the aetiology and trajectory of changes in awareness after TBI are likely to be multifactorial, being influenced by various demographic and biopsychosocial factors. The current lack of understanding of the long-term course of awareness and its associated factors post-TBI is, in part, due to challenges and inconsistencies in conceptualising the construct of awareness, in its measurement and a lack of studies examining various potential biopsychosocial influences. The overarching aim of the current doctoral thesis was to extend current understandings of the trajectory of self-awareness and associated biopsychosocial predictors after TBI using psychometrically valid measurement tools. These aims were assessed across three separate studies. Study One examined self-awareness, as measured on the Awareness Questionnaire (AQ), and injury-related, emotional and demographic factors across acute/sub-acute (3-12 months), medium-term (24-60 months) and long-term (120-240 months) time periods post-injury. In contrast to findings from previous studies, awareness was not significantly greater at longer term time periods compared to medium or acute/sub-acute time periods. Combining this with previous research findings suggests that the period over which awareness changes the most may be the first 12 months post-injury. For the AQ motor/sensory domain only, awareness of deficits was greater at longer time periods than earlier time periods. Reduced awareness in the individuals with TBI was associated with more severe injuries and with increased depressive symptoms in close-others. Greater awareness was associated with increased depressive symptoms in the individuals with TBI. These findings shed light on the limitations of discrepancy scores, as they can be influenced by the mood of the rater, as well as level of injury severity. In light of previous studies revealing the efficacy of structured feedback interventions in improving awareness, Study Two explored the relationship between the nature of feedback provided by close-others in the home environment and self-awareness. Injury-related and emotional variables did not emerge as mediating or moderating factors between frequency of feedback and self-awareness. Cognitive and/or behavioural changes post-injury were identified in 97% of individuals with TBI with the majority of these being provided regular feedback by close-others after making errors. Almost 60% of individuals with TBI were reported to identify an error once they received feedback, yet they displayed reduced acceptance/acknowledgement in response. This disparity between high rates of feedback by close-others but low acceptance/acknowledgement by individuals with TBI highlights the need for clinicians to work in partnership with close-others to build supportive relationships for more efficient provision of feedback. Given the inconsistencies in the literature regarding the course of awareness and the limited application of a biopsychosocial framework in the acute/sub-acute stages of recovery following TBI, Study Three adopted a longitudinal design to map the trajectory of awareness, assessed on the Self-Awareness Deficits Interview (SADI), and its association with demographic and biopsychosocial factors in a group of individuals with TBI. Awareness increased significantly over the first year post-injury. However, analysis of the association of biological, cognitive, psychological and social-environmental factors with awareness did not reveal any significant contributions above and beyond the influence of time alone. Gender played a role in awareness of deficits in relation to goal setting, with females setting more realistic goals early in recovery compared to males. Overall it appears that time may be the strongest predictor of change in awareness over the first year post-injury, but beyond this period, injury severity and emotional factors become influential. These findings may be used to guide implementation of interventions to maximise rehabilitative outcomes. Study limitations were explored, highlighting caveats for the interpretation of the results, and directions for further research were discussed.