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Self-Awareness and Neurobehavioral Outcomes, 5 Years or More After Moderate to Severe Brain Injury

Kelley, Elizabeth MS; Sullivan, Campbell PsyD; Loughlin, Jennifer K. PhD; Hutson, Lee PhD; Dahdah, Marie N. PhD; Long, Margaret K. MS; Schwab, Karen A. PhD; Poole, John H. PhD

Section Editor(s): Caplan, Bruce PhD, ABPP; Bogner, Jennifer PhD, ABPP

The Journal of Head Trauma Rehabilitation: March/April 2014 - Volume 29 - Issue 2 - p 147–152
doi: 10.1097/HTR.0b013e31826db6b9
Original Articles

Objective: To examine self-awareness 5 years or more after traumatic brain injury (TBI) and its relation to outcomes.

Participants: Sixty-two adults with moderate to severe TBI and significant other (SO) informants (family or close friend).

Setting: Regional veterans medical center.

Main Measures: TBI Follow-up Interview, Community Integration Questionnaire, Satisfaction with Life Scale, and Caregiver Burden Inventory.

Design: Five to 16 years after acute inpatient rehabilitation, separate staff contacted and interviewed subjects and SOs. Subject awareness was defined as inverse subject-SO discrepancy scores.

Results: Subjects significantly underreported neurologic symptoms and overreported their work and home functioning; their self-ratings of emotional distress and social functioning did not differ from SO ratings. Employment was associated with greater self-awareness of cognitive deficits, even after controlling for injury severity. Subjects' life-satisfaction was associated with better self-reported neurologic functioning, which frequently did not agree with SO ratings. Caregiver burden was worse as SOs perceived subjects as having worse symptoms and poorer work and social integration.

Conclusions: Impaired self-awareness remains evident more than 5 years after TBI. People with TBI are more likely to gain employment when they are aware of their cognitive deficits and abilities. However, subjective quality of life, for subjects and SOs, was related to their own perception of the TBI outcomes.

Defense and Veterans Brain Injury Center (Mss Kelley and Long, and Drs Sullivan, Loughlin, Hutson, Dahdah, and Poole) and Psychology Service (Drs Sullivan, Hutson, and Poole, and Ms Long), Veterans Affairs Health Care System, Palo Alto, California; Pacific Graduate School of Psychology, Palo Alto University, Palo Alto, California (Mss Kelley and Long, and Drs Sullivan, Loughlin, Hutson, and Dahdah); and Defense and Veterans Brain Injury Center, Silver Spring, Maryland (Dr Schwab).

Corresponding Author: John H. Poole, PhD, Veterans Affairs Health Care System, 3801 Miranda Ave (116B), Palo Alto, CA 94304 (

This work was supported by a grant from the Defense and Veterans Brain Injury Center. Dr Jean Langlois Orman of the Centers for Disease Control and Prevention collaborated in developing the TBI Follow-Up Interview and adapting it for this study's military and veteran population. The authors thank Dr Elaine Date for helping plan this long-term outcome study; Rose Salerno, RN, for facilitating participants' informed consent, tracking and periodic follow-up evaluations; and Dr Odette Harris and Dr Darryl Thomander for their thoughtful comments on the manuscript.

The authors declare no conflicts of interest.

© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins