A longitudinal study of a prospective series of 55 adults with severe traumatic brain injury was conducted to investigate the development of self-awareness in patients over the first year after injury. The development of self-awareness has, in the past, been associated with enhanced motivation to participate in rehabilitation and with increased emotional distress. However, research to date has been inconclusive about the effect of self-awareness of deficits on an individual's outcome from rehabilitation.
In Chapter 1, a conceptual model is proposed postulating that an interplay of self-awareness, motivation, and emotional distress occurs following traumatic brain injury which ultimately influences the level of functional outcome achieved by the patient. A working definition of self-awareness following traumatic brain injury is introduced in Chapter 2 which identifies three levels of self-awareness: 1) self-awareness of the injury-related deficits, 2) self-awareness of the consequences of deficits, and 3) the ability to set realistic goals.
Various means of evaluating self- awareness are reviewed in Chapter 3. A self-awareness assessment battery was compiled incorporating the Patient Competency Rating Scale, the Head Injury Behaviour Scale, the Change Assessment Questionnaire, and the Self- Awareness of Deficits Interview (which was developed for the purposes of this study). The Beck Depression Inventory and the Beck Anxiety Inventory were selected to measure emotional distress, and the Sickness Impact Profile, the Disability Rating Scale, and the Community Integration Questionnaire were incorporated to evaluate functional outcome. Data was collected at 3, 6, 9 and 12 months post-injury using the battery according to the methodology described in Chapter 4. The recovery pattern of the subjects as measured by the Sickness Impact Profile is described in Chapter 5 along with outcome data for the subject sample.
In Chapter 6, preliminary investigations on the reliability and validity of the questionnaires used in the study were found to be encouraging, although only limited correlation was found between assessments. A comparison of the brain injury sample with two control groups (a student group and a hand clinic group) was conducted to demonstrate the extent of disorders of self-awareness after brain injury.
The results, in Chapter 7, indicated that the brain injury sample showed significantly poorer self- awareness of deficits as measured by the Patient Competency Rating Scale and the Head Injury Behaviour Scale compared to the student group, but not compared to the Hand Clinic group. Additionally in Chapter 7, the nature of disorders of self-awareness in the TBI population was investigated by an item analysis of the Patient Competency Rating Scale. Self-awareness was most impaired for activities with a large cognitive and socio-emotional component, and least impaired for basic activities of daily living, memory activities, and overt emotional behaviours.
Chapter 8 reports on the longitudinal profiles of scores on the Patient Competency Rating Scale, the Self-Awareness of Deficits Interview, the Change Assessment Questionnaire (Action subscale), and the Beck Depression Inventory. Four profile analyses investigated the relationship of the scores over time to outcome (good or poor) at 1 year post-injury. Outcome had a significant relationship with recovery on the Self-awareness of Deficits Interview. The good outcome group showed significantly greater development of self-awareness over time.
A cluster analytical approach was taken in Chapter 9 to identify homogeneous groups of subjects at 12 months post-injury. Three clusters were retrieved which were consistent with the hypothesised model. Subjects in the "high self-awareness" cluster were significantly more emotionally distressed, and more motivated to change their behaviour than subjects in the "low self-awareness" cluster. However, there was no significant difference in functional outcome between the high and low self-awareness clusters. The third cluster, labelled as "good recovery", had a profile indicating rapid, and more complete recovery and consequently little emotional distress or motivation to change was seen. The three clusters are illustrated by case studies.
The process of development of self-awareness following traumatic brain injury and implications for rehabilitation are discussed in Chapter 10, along with methodological problems, and directions for future research. It is proposed that the development of self-awareness involves a period of self-discovery accompanied by a grieving process. Although self-awareness plays a part in influencing recovery from traumatic brain injury, it is only one of many determinants of outcome.