DIFFERENTIATING BETWEEN PSYCHOGENIC AND NEUROGENIC DENIAL IN PERSONS WITH TBI AND SUBSTANCE ABUSE
DISSERTATION
Presented in Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy in the Graduate School of The Ohio State University
By
Denise Elizabeth Rabold, M. A.
The Ohio State University 1996
Dissertation Committee:
Johannes Rojahn, Ph.D. /. Approved b\^
David Hammer, Ph.D. / Adviser ' W. Bruce Walsh, Ph.D. ' DepartmentHfinarfmant nof f Pctm Psychology hrxlnm ; UMI Number: 9639332
UMI Microform 9639332 Copyright 1996, by UMI Company. All rights reserved.
This microform edition is protected against unauthorized copying under Title 17, United States Code.
UMI 300 North Zeeb Road Ann Arbor, MI 48103 ABSTRACT
This study further investigates the differences between psychogenic and
neurogenic denial in a population of individuals who have been diagnosed with substance
abuse following traumatic brain injury (TBI). The SOCRATES was utilized to
operationalize psychogenic denial; and discrepancies between the individual and a staff
member on the Patient Competency Rating Scale (PCRS) was used to operationalize
neurogenic denial. Forty subjects from the TBI Network participated and four groups
emerged: those with pure neurogenic denial; pure psychogenic denial; both denials; and neither denial. Selected neuropsychological assessments and emotional status inventories were administered to each subject. Principal a priori hypothesis were: that individuals exhibiting neurogenic denial would perform more poorly on measures of neuropsychological functioning than individuals exhibiting psychogenic denial; and individuals with psychogenic denial would display greater emotional maladjustment and less life satisfaction than individuals with neurogenic denial. Kruskal-Wallis one way analyses of variance by ranks and Mann-Whitney U - Wilcoxon Rank Sum W tests were performed on the neuropsychological and emotional measures. A significant result was found between pure psychogenic and pure neurogenic groups on the depression measure. There were three limitations to this study. The first was in regard to the small subject size.
The second limitation was concerned with the operationalization of the subject groups by means of rating scales only. Future research may benefit from incorporating a combination of self rating scales, questionnaires, structured interviews, and observations. The final limitation was in the choice of neuropsychological instruments. This study chose neuropsychological measures based on their lateralization potential which was not significant. Future studies may benefit from neuropsychological measures that assess verbal and executive function skills that may be more reflective of the diffuse nature of
TBI.
iii To my family, Randy, Carey, Ryan, and Carney, with love and appreciation. ACKNOWLEDGEMENTS
I would like to express sincere appreciation to my adviser, Dr. Johannes Rojahn , for his valuable guidance, support, and patience throughout my graduate career and the completion of this project. I very much appreciated his willingness to allow students to develop their own areas of special interest. Thanks also goes to other faculty members,
Dr. David Hammer, Dr. W. Bruce Walsh and Dr. John D. Corrigan, for their suggestions and support. Sincere gratitude is expressed to the TBI Network and their clients, without their involvement this project would not have been possible. Finally, I would like to thank my family, Randy, Carey, Ryan, and Carney, for supporting me through this endeavor and allowing me to reach my goal. VITA
August 13, 1958...... Born - Lockport, New York
1980...... B.A., The Ohio State University
1982...... M.A., Clinical Speech Pathology, The Ohio State University
1982-1984...... Staff Speech Pathologist Miami Valley Hospital Dayton, Ohio
1984-1985...... Speech Pathologist Mt. Carmel Hospital Columbus, Ohio
1984-1992...... Cognitive Rehabilitation Specialist, Rehabilitation Psychology, Inc., Columbus, Ohio
1988-1991...... Adjunct Professor Department of Speech and Hearing Science The Ohio State University
1991-1994...... Graduate Research Assistant Department of Physical Medicine and Rehabilitation The Ohio State University
1993...... M.A., Psychology The Ohio State University
1994-1995...... Psychology Intern Department of Physical Medicine and Rehabilitation The Ohio State University PUBLICATIONS
Research Publication
Rojahn, J. & Rabold, D. E. (1995). Emotion specificity in mental retardation. American Journal on Mental Retardation. 99(5), 477-486.
FIELDS OF STUDY
Major Field: Psychology
Studies in Mental Retardation and Developmental Disabilities, Johannes Rojahn, Ph.D. TABLE OF CONTENTS Page Abstract ...... ii
Dedication...... iv
Acknowledgments ...... v
Vita...... vi
List of Tables ...... x
List of Figures...... xi
Chapters:
1. Introduction...... 1
1-1 Goals and Hypotheses...... 7
2. A Review of the Literature...... 10
2-1 Denial...... 10 2-2 Theoretical and Clinical Concerns of Psychogenic Denial...... 11 2-3 Theoretical and Clinical Concerns of Neurogenic Denial...... 14 2-4 Denial and Rehabilitation ...... 17 2-5 Distinguishing Factors Between Psychogenic andNeurogenic Denial 24 2-6 Denial with Substance Abuse and ...... TBI...... 26
3. Methodology...... 32
3-1 Subjects ...... 32 3-2 Instruments...... 34 3-3 Procedure...... 44 3-4 Analyses...... 45
4. Results...... 47 4-1 Descriptive Analysis of Subjects...... 47 4-2 Data Analysis...... 51
5. Discussion...... 58
5-1 Relationship of Results to Hypotheses...... 58 5-2 General Discussion and Limitations...... 62 5-3 Directions for Future Research...... 66
References...... 69
Appendices...... 74
A. Recruitment Letter and Oral Script for Case Managers...... 74 B. Recruitment Letter for Subjects ...... 77 C. Follow-Up Recruitment Letter...... 80 D. Oral Script for Subjects...... 82 E. SOCRATES...... 84 F. Patient Competency Rating Scale...... 91 G. Zung Self-rating Depression Scale...... 101 H. Zung Self-rating Anxiety Scale...... 103 I. Satisfaction With Life Scale...... 105 J. Consent Form...... 107 K. Raw Data...... 109
ix
X LIST OF TABLES
Table Page
1. Results of Preliminary Study: Stages of Change as Related to Level of Awareness...... 29
2. Distribution of Psychogenic and Neurogenic Denial for the Preliminary Study...... 30
3. Distribution of Scores on the PCRS ...... 41
4. Descriptive Information on Subjects Presented Across Groups by Means, Standard Deviations, and Ranges...... 50
5. Medians and Mean-Ranks of the Neuropsychological Measures Across Groups...... 53
6. Medians and Mean-Ranks of the Emotional Measurers Across Groups...... 55
x LIST OF FIGURES
Figure Page
1. Precontemplative Profile...... 36
2. Ready Profile...... 37
3. Ambivalent Profile ...... 38
xi CHAPTER 1
INTRODUCTION
Unawareness of one's cognitive state is both a sign and symptom following traumatic brain injury (TBI). Recently, there has been an increased interest in the phenomenon of unawareness of cognitive states in the literature (McGlynn & Schacter,
1989; Wagner & Cushman, 1994; Prigatano & Schacter, 1991; Prigatano & Altman,
1990; Gasquoine & Gibbons, 1994; Lam, McMahon, Priddy, & Gehred-Schultz., 1988).
The lack of awareness in individuals with TBI typically incurs debilitating unawareness of the effects of injury or disease, and the rather unrealistic prospects of recovery. This lack of awareness may lead to social maladaption or isolation.
Unawareness as a symptom has both theoretical and clinical significance.
McGlynn and Schacter (1989) and Lewis (1991) describe unawareness of deficits as a form of denial resulting from either psychogenic or neurogenic causes. Psychogenic denial is traditionally viewed as a motivated defense mechanism and thereby considered to be primarily a psychological phenomenon. It is a form of denial that allows an individual to repress information and avoid unpleasant reality (Levine & Zigler, 1975; Rosenthal, 1983).
Psychogenic denial has its theoretical underpinnings in psychoanalysis. Goldberger (1983) described it as a refusal to identify the reality of a traumatic perception. He suggested that it may be an adaptive response by postponing action. According to McGlynn and
Schacter (1989) psychogenic denial is a motivated reaction by an individual who is at some level aware of his or her deficits, but who is unwilling to acknowledge this weakness. A typical example of psychogenic denial is seen in alcoholism. Indeed, alcoholism has been termed the “disease of denial” (Smith, 1986). Individuals with alcoholism may deny the amount of alcohol consumption, their lack of control, and need for treatment.
In order to operationalize the concept of psychogenic denial, DiClemente and
Hughes (1990) evaluated an assessment device, the University of Rhode Island Change
Assessment Scale, designed to identify and classify the stages individuals pass through during the changing of addictive behaviors. They identified five stages: Precontemplative,
Ambivalent, Participation, Uninvolved, and Contemplation. The results indicated that those individuals in the Contemplation group were more ready for change than the
Precontemplative group. The authors equated the Precontemplative group as those who are denying their alcohol problem.
Neurogenic denial is the result of organic lesions that create difficulty integrating and perceiving new information about one’s self and one’s circumstances. McGlynn and
Schacter (1989) cite unawareness of deficits, lack of insight, and imperception of disease as suggestive of neurogenic denial.
Unawareness of cognitive function has been studied since the early 1900's. Several syndromes such as anosognosia, Anton's syndrome, Wernicke's aphasia, and various amnesia syndromes involve unawareness of deficits, Wagner and Cushman (1994) studied the incidence of unawareness and the impact of neurocognitive factors along with the organic lesion sites as predictors of unawareness. They found a strong association between the general degree of neurocognitive impairment and unawareness. A trend was also noticed for more anterior and right hemisphere lesions to produce greater unawareness. Anderson and Tranel (1989) also found that unawareness of cognitive deficits was common after brain injury. Fordyce and Roueche (1986) and Prigatano and
Altman (1990) further clarified the possible brain region responsible for unawareness.
This region was described as the heteromodal cortex, a term coined by Mesulam (1985).
The heteromodal cortex integrates perceptual information regarding external reality with internal perceptual information and contains prefrontal, inferior parietal, supramarginal gyrus, and sections of the temporal lobes.
Recent interest has focused attention on the important role that awareness plays in rehabilitation or other processes of change. According to Prochaska, Norcross, and
DiClemente (1994) individuals who attempt to modify their behavior without awareness and readiness only bring about temporary change. Individuals who are unaware that a deficit exists are impaired in their progress toward rehabilitation. Specific rehabilitation concerns are: lack of motivation, failure to utilize compensatory strategies, maintenance of unrealistic goals and lack of therapeutic gains (McGlynn & Schacter, 1989).
Several studies of individuals with TBI have found a relationship between awareness and outcome (Deaton, 1986; Lam et al., 1988), with better outcomes being obtained when awareness and acknowledgement of deficits are present. Allen and Ruff (1990) describe awareness as the ability to attend, encode, and retrieve information. Thus
an individual with a lack of awareness has difficulty attending to everyday problems and
remembering difficulties. Without these cognitive abilities it is difficult for an individual to effectively learn and monitor their behaviors. Lam et al. (1988) studied awareness of deficits in relation to treatment performance. They found that individuals who were aware of their deficits were more prepared to change and performed better in treatment. Allen and Ruff (1990) studied whether the degree of severity and chronicity of TBI affected self- ratings of cognitive functioning. Their results suggested that individuals with TBI consistently rated themselves lower than controls and not as cognitively impaired.
Chronicity affected attention, memory, and arithmetic. Individuals with severe TBI displayed a positive correlation between reasoning ratings and inefficiency of planning.
Another study by Gasquoine and Gibbons (1994) found that individuals who were more disoriented showed little awareness of deficits, while oriented individuals displayed greater awareness of overt deficits but still underestimated their level of impairment compared to staff reports.
McGlynn and Schacter (1989), in their review on unawareness, identified several areas for future research. One such area was that of investigating the differences between neurologically based unawareness (neurogenic denial) and defensive or motivated denial
(psychogenic denial). The authors observed that there is a lack of firm criteria for differentiation. One possibility McGlynn and Schacter (1989) cited was that neurogenic denial may be characterized by neuropsychological signs not observed in individuals exhibiting psychogenic denial. Lewis (1991) describes three ways by which psychogenic and neurogenic denial can be differentiated; time course, patterns of functional and structural deficits, and level of emotional arousal. Individuals with neurogenic denial display; a lesser degree of denial over time; patterns of neurologic deficits; and are emotionally unresponsive when confronted. Individuals with psychogenic denial display: a persistent denial over time; no neurological deficits as a primary etiological factor; and will demonstrate psychological distress. The difference between psychogenic and neurogenic denial is thought to be of importance in understanding why some patients with TBI benefit from rehabilitation efforts while others do not (McGlynn & Schacter, 1989).
For effective rehabilitation it is important to determine if an individual is exhibiting psychogenic or neurogenic denial, so that appropriate treatment methods may be employed and maximum benefit realized. An individual exhibiting psychogenic denial may benefit more from a dynamic or humanistic approach consisting of confrontations, grieving losses, and empowering (Prochaska, Norcross, & DiClemente, 1994). Someone experiencing neurogenic denial would tend to benefit from a cognitive-behavioral approach utilizing computers, videotaping, community outings and group therapy focusing on increasing awareness (Deaton, 1986).
Conceptually, these approaches are at opposite ends of the continuum, with the dynamic approach based in abstraction and the cognitive-behavioral being more concrete.
Individuals displaying psychogenic denial are best served by approaches that assist the individual in carefully uncovering and analyzing emotionally based issues, which they may be repressing and avoiding by maladaptive coping mechanisms. Individuals with neurogenic denial benefit from a more direct, concrete approach that forces them to observe and experience their inabilities and weaknesses in vivo. This idea of the importance of different treatment methods was discussed in some detail by Langer and
Padrone (1991) in their article on the tripartite model for conceptualizing unawareness.
Rehabilitation is a costly endeavor, and with the changes in health care it is critical that health care professionals have the ability to properly designate treatment procedures thus providing a more clearly defined treatment plan and outcome prognosis.
In a review of substance abuse and traumatic brain injury, Corrigan (1995) reported that nearly two thirds of adolescent and adult rehabilitation patients may have had a premorbid history of substance abuse. Individuals with a history of substance abuse and TBI are likely to experience both psychogenic and neurogenic denial. This combination of substance abuse and TBI may impede recovery and increase the probability of additional TBI's. Due to the increased risk these individuals experience it is critical that rehabilitation efforts are focused in the most appropriate direction.
In 1991, a pilot program was initiated to address the needs of individuals experiencing both substance abuse and TBI (Corrigan, Lamb-Hart, & Rust, 1995). This program, called the TBI Network, is community-based and comprised of an interdisciplinary staff who facilitate treatment in the individual's local community. The individual's current attitudes or beliefs regarding alcohol or drug use is not utilized as a criterion for inclusion in the TBI Network. Rather, these attitudes are "viewed as targets for intervention" (223, Corrigan, Lamb-Hart, & Rust, 1995). The TBI Network performs case management services, including: comprehensive assessment; integrated service planning; service coordination; and monitoring. The TBI Network is different from many
other programs because of several innovative features: the use of the Stages of Change
Model (Prochaska, DiClemente, and Norcross, 1992) for conceptualization of the
individuals attitude regarding their substance abuse; and the identification and application
of community interdisciplinary teams.
In order to determine if in fact individuals with substance abuse and TBI do
exhibit both types of denial, a preliminary study was conducted. Subjects were randomly
selected from the TBI Network. These subjects had completed the Stages of Change
Readiness and Treatment Eagerness Scale (SOCRATES, version 5; Miller, 1991) and both
the subjects and a significant other completed the Trauma Complaints List (TCL, van
Zomeren & van den Burg, 1985). The SOCRATES assessed psychogenic denial, while the TCL assessed neurogenic denial. The study found relatively equal proportions of
those exhibiting psychogenic denial, those exhibiting neurogenic denial, those exhibiting
neither, and those exhibiting both. Individuals with both types of denial tended to show
less well-defended psychogenic denial.
Goals and Hypotheses
Based on the above cited literature - specifically the need identified by McGlynn and Schacter (1989) to investigate further the differences between psychogenic and neurogenic denial - the current study is designed to analyze the phenomena of psychogenic and neurogenic denial in a population of clients who have been diagnosed with substance abuse following TBI. The SOCRATES will be utilized to operationalize psychogenic denial; and discrepancies between the individual and a staff member on the Patient Competency Rating Scale (PCRS) will be used to operationalize neurogenic denial. This
method is similar to the Anderson and Tranel (1989) study. To investigate differences
between the two forms of denial, as described by Lewis (1991), selected
neuropsychological assessments and emotional status inventories will be administered. A priori hypotheses are:
Hypothesis 1: Null Hypothesis: Individuals with neurogenic denial and individuals with psychogenic denial will perform equally well on the following indices of brain injury:
Finger Oscillation Test, Grip Strength, and Reitan-Klove Sensory-Perception
Examination.
Alternative Hypothesis: Individuals displaying neurogenic denial will perform more poorly on the above measures than individuals who are exhibiting psychogenic denial.
Hypothesis 2: Null Hypothesis: Individuals with psychogenic denial and individuals with neurogenic denial will achieve the same scores on measures of psychological well being and life satisfaction as reflected from performances on the Zung Self-rating
Depression Scale (SDS), Zung Self-rating Anxiety Scale (SAS), and Satisfaction with
Life Scale (SWLS; Diener, 1985) scores.
Alternative Hypothesis: Individuals with psychogenic denial will display greater emotional maladjustment and less life satisfaction than individuals exhibiting neurogenic denial as expressed by their scores on the above stated measures.
Hypothesis 3: Null Hypothesis: The presence or absence of neurogenic denial in persons with psychogenic denial will have no effect on measures of psychological well being as compared to individuals with only psychogenic denial.
8 Alternative Hypothesis: The presence of neurogenic denial in persons with psychogenic denial will reduce the negative emotional effect thus they will score better on measures of psychological well-being as compared to individuals with only psychogenic denial.
Hypothesis 4: Null Hypothesis: The presence or absence of psychogenic denial in persons with neurogenic denial will have no effect on neuropsychological functioning as compared to individuals with only neurogenic denial.
Alternative Hypothesis: The presence of psychogenic denial in persons with neurogenic denial will improve the neuropsychological functioning, thus they will score better on measures of neuropsychological functioning than individuals with only neurogenic denial.
9 CHAPTER 2
A REVIEW OF THE LITERATURE
In the first section of this chapter a brief introduction of psychogenic and
neurogenic denial will be presented, followed by a review of theoretical and clinical
concerns of these types of denial. Next, a discussion of the distinguishing factors between
psychogenic and neurogenic denial will be explored. Finally, a discussion on individuals
with both TBI and substance abuse and how they exhibit both types of denial will follow.
Denial
Many view unawareness as a process of denial, a psychological defense mechanism
that allows an individual to repress information about themselves so as to avoid unpleasant
reality or to reduce anxiety (Levine & Zigler, 1975; Rosenthal, 1983). Others, in contrast
to the psychological denial interpretation, view this unawareness of cognitive deficits as
arising out of an organic lesion that specifically interferes with the ability to integrate new
information about one's self and circumstances (Lezak, 1978). Lewis (1991) discusses
denial as either psychogenic or neurogenic in origin. Both of these forms of denial are grossly similar. The commonality is that cognitions are impaired due to the inability to
adequately integrate and symbolize certain information (Dorpat, 1985). The presence and
10 ability to volitionally control denial is unknown to the individual. Psychogenic denial, or conventional denial, evolves from unconscious psychological efforts to avoid a painful reality. While neurogenic denial, either anosognosia or unawareness, arises from an organic lesion.
A review by Deaton (1986) identified that denial is typically measured by the use of questionnaires or interviews verses behavioral indices and specifically it is the difference between one's reality and one's perception of reality that is in conflict. Fleming, Strong, and Ashton (1996) studied how to best measure this phenomena and suggested the use of multiple measures, including direct observation. Measurement of denial is defined as the difference between the two perspectives such as: ratings between patient and family members; estimates of own abilities and test results; and under/overestimates of deficits by patients and the rehabilitation staff.
Theoretical and Clinical Concerns of Psychogenic Denial
Psychogenic denial has its theoretical roots in psychoanalytic theory. This type of denial is a defense mechanism, motivated by the unconscious to minimize pain and promote adaptive equilibrium (Lewis, 1991). Goldberger (1983) defined denial as a defensive endeavor directed toward extrinsic stimuli or a refusal to identify reality of a traumatic perception. Denial may be an adaptive response by conserving energy and postponing action. A basic premise is that the denial "signifies a motivated reaction by a patient who may be in some sense aware of his or her deficits but is unwilling to confront them" (145, McGlynn & Schacter, 1989).
11 Studies indicate that psychogenic denial is one of the first defenses to appear in early childhood. Lewis (1991) states that between the ages of 1 and 2, denial begins to appear. Breznitz (1983) distinguishes a developmental sequence for denial and identifies seven stages: denial of personal relevance, denial of urgency, denial of vulnerability, denial of responsibility, denial of affect, denial of affect relevance, and denial of threatening information. Each stage involves the implementation of cognitive strategies to protect against perceived danger. As one advances to the next stage of denial, greater amounts of energy must be invested. Breznitz (1983) further states that implied in his denial stages are directionality and intensity.
Dorpat (1985) discussed four phases of denial. His central hypothesis was that cognitive arrest occurs as an effect of denial and this cognitive arrest protects against painful affect. His four phases of denial are: I) preconscious appraisal of danger; 2) painful affect; 3) cognitive arrest; and 4) screen behavior. When individuals are presented with a situation that they either preconsciously or consciously view as potentially traumatic or dangerous, painful affect is produced. The painful affect (eg: depression, shame, guilt, anxiety, grief, and, helplessness) activates a reaction that causes the individual to divert their focal attention from what is disturbing to something less painful or pleasant. This process involves fantasies of destroying or rejecting the painful affect.
By creating a cognitive arrest of higher level cognitive processes the individual no longer thinks about the pain. Screening behaviors (eg: ideas, fantasies, affects and overt behaviors) are then employed to fill in the gaps between reality and unconscious representations. Clinically, psychogenic denial has been viewed as a major contributor to
12 alcoholism and other forms of substance abuse. Smith (1986) discussed alcoholism as the
"disease of denial". It is noted that psychogenic denial is commonly seen with alcoholics who deny their level of consumption, lack of control, and need for treatment.
DiClemente and Hughes (1990) studied 224 adults who were requesting outpatient treatment for their serious drinking problems. Their study evaluated an assessment designed to identify and classify the stages of change an individual moves through while intentionally changing an addictive behavior. Denial, resistance, and motivation are variables that impede treatment participation and outcome. The University of Rhode
Island Change Assessment Scale (URICA), developed by McConnaughy, Prochaska, and
Velicer, was administered to assess the stage of change an individual was in. The URICA defines the following four stages: Precontemplation, Contemplation, Action, and
Maintenance. Subjects were also given the Alcohol Use Inventory (AUI) and the Alcohol
Abstinence Self Efficacy Scale (SE). All of the instruments were self rating scales completed by the subject. A cluster analysis was performed and the 224 subjects were divided into five groups based on their responses to the questionnaires. The results were as follows: 63 subjects were in the Precontemplation Cluster and identified as neither contemplating nor engaging in change; 30 subjects were in the Ambivalent cluster and identified as somewhat reluctant about change; 51 subjects were in the Participation
Cluster and reported a high level of investment in changing behaviors; 27 subjects were in the Uninvolved or Discouraged Cluster and represented individuals who had given up on changing; and 53 subjects were in the Contemplation Cluster and described as seriously thinking about change however not yet ready for action. These five groups did not vary on demographic characteristics but did vary on responses to the self-efficacy measure in
the AUI. The ability to differentiate these individuals into distinct profiles provided
support and confirmation of the stages of change and appeared to give useful information
on the identification of individuals ready for change. The Contemplation group appeared
more ready for change than the Precontemplation group. The Precontemplation group
was described as possibly denying they have an alcohol problem and this denial appeared
consistent over all dimensions. The authors identified the self-report measures utilized
were a limitation in that the data has restricted generalizability.
Theoretical and Clinical Concerns of Neurogenic Denial
Theoretical underpinnings of neurogenic denial arise from understanding the
nature of the processes and the mechanisms that normally permit individuals to be aware
of their cognitive functioning (McGlynn & Schacter, 1989). McGlynn and Schacter
(1989) cited other terms that may be suggestive of neurogenic denial, including unawareness of deficits, lack of insight, and imperception of disease. Historically,
unawareness of cognitive function has been studied since the early 1900's. There are
several syndromes that involve unawareness of deficits, such as anosognosia, Anton's
syndrome, Wernicke's aphasia, and various amnesia syndromes. Anosognosia was introduced in 1914 by Joseph F. F. Babinski. The term refers to a lack of awareness or
recognition of left hemiplegia following a right brain insult (Prigatano & Schacter, 1991).
In Anton's syndrome, Wernicke's aphasia and the various amnesia syndromes individuals will deny their loss of vision, auditory comprehension and memory, respectively, in the
presence of documented brain damage. Unawareness of cognitive deficits was investigated by Wagner and Cushman
(1994) in 108 individuals who sustained a cerebral vascular accident (CVA). This study had three objectives: investigate the incidence of unawareness; determine if neurocognitive factors were predictive of unawareness; and determine which organic lesion sites were predictive of unawareness. Their subjects had suffered a single recent CVA that required inpatient rehabilitation. They also had 30 control subjects who had experienced orthopedic problems. The lesion location of the experimental subjects was identified by computed tomography (CT) or magnetic resonance imaging (MRI). A majority of the cortical injuries involved the middle cerebral artery, while a majority of the subcortical injuries affected the blood supply to the basal ganglia and internal capsule. The subjects were administered the Mini-Mental Status Exam (Folstein, Folstein, & McHugh, 1975), an
Unawareness Interview, and the Functional Independence Measure (Granger, Hamilton,
Keith, Zielezny, & Sherwin, 1986). Results of this study revealed significant group differences. Individuals who had sustained a CVA displayed greater unawareness (40% some degree and 10% moderate to severe symptoms) than the control group, which displayed almost no unawareness. A relatively strong association was shown between the general degree of neurocognitive impairment and unawareness across several measures.
Individuals with injury to cortical areas displayed greater unawareness then those with subcortical lesions. Left/right and anterior/posterior location of lesions were not significantly related to unawareness, though a trend was observed for more anterior lesions to produce greater unawareness. It was also found that a frequent unawareness symptom was the unawareness of a perceptual deficit which was localized in the right
15 cerebral hemisphere. These data suggested that multiple types of unawareness overlap and may be associated with different lesion sites, such as association cortices, thus not distinctly localized as with language and perceptual deficits,
In 1989, Anderson and Tranel studied the awareness of cognitive and motor deficits in individuals who had sustained cerebral infarctions (CVA), dementia (DEM), or
TBI utilizing a standardized interview. The authors operationalized unawareness as a
"discrepancy between the subject's description of abilities, and measurement of those abilities with neuropsychological and neurological evaluations". They hypothesized that individuals with right hemisphere CVA's would have a more defined unawareness-than left hemisphere CVA's. Their subjects consisted of 100 individuals: 32 right handed, unilateral
CVA; 49 progressive DEM; and 19 TBI. The subjects were all administered an
Awareness Interview, developed by the authors, and a neuropsychological assessment including: Benton Orientation Questionnaire, Wechsler Adult Intelligence Scale-Revised,
Rey Auditory-Verbal Learning Test, Benton Visual Retention test, Rey-Osterrieth
Complex Figure Recall Test, Multilingual Aphasia Examination, Test of Facial
Recognition, and Judgement of Line Orientation. Results indicated that all three subject groups exhibited a diverse range of unawareness. A multiple regression analysis was performed and indicated that the specific group membership was not a significant factor in determining Awareness Index scores. The DEM and TBI subjects displayed a correlation between Awareness Index and VIQ and temporal disorientation. All subjects with an unawareness of their hemiparesis were also unaware of cognitive deficits. These data suggest that unawareness of cognitive deficits is common after brain damage
16 Denial and Rehabilitation
Clinically, denial is an obstacle for rehabilitation efforts. When an individual is
unaware of existing deficits, they are unlikely to benefit from or participate in remediation
efforts (Fordyce & Roueche, 1986; Deaton, 1986; Lam, McMahon, Priddy, & Gehred-
Schultz, 1988; Prigatano & Altman, 1990). An unrealistic view of one's ability creates
further problems for family members and caretakers due to the fact that the individual with
TBI may insist on performing activities that they are unable to achieve. Denial in individuals with TBI can be evidenced in lack of motivation, failure to implement compensatory strategies, unrealistic expectations, and insensitivity to the impact of their behavior on others (Prigatano & Schacter, 1991). Deaton (1986) discusses the importance of balancing the positive and negative elements of denial during the rehabilitation process. She further emphasizes the need to understand the underlying cause and function of denial, along with considering both its cognitive/verbal and behavioral characteristics.
Fordyce and Roueche (1986) studied the changes in behavior competency of severely brain injured individuals before and after a six month intensive day treatment program. Part of this rehabilitation program included self-awareness exercises. The subjects consisted of 28 seriously brain injured individuals, the mean age and date of onset were 24.5 years and 19 months, respectively. Subjects, relatives, and staff members completed a Patient Competency Rating Scale (PCRS), both pre and post rehabilitation.
This 30-item questionnaire asks the informant to judge the competency with which the subject performs activities of daily living. Systematic measures of emotional, neuropsychological, and psychosocial functioning were also utilized and included: the
Minnesota Multiphasic Personality Inventory (MMPI), Katz Adjustment Scale, and parts of the Halstead-Reitan Neuropsychological Test Battery, respectively. Based on the
PCRS scores three comparison groups were identified. These groups were differentiated on levels of rater consistency. Group one had similar ratings, group two and three had more divergent ratings, with the patient initially greatly underestimating their abilities.
Group two was further divided into two subgroups (A and B) based on discrepancies between staff and subject's perspectives of competency. These two subgroups greatly underestimated their initial impairments. After rehabilitation, group A affiliated more with reports of staff and relatives, while group B was more diverged. Group three subjects also reported being more emotionally distressed after rehabilitation. The groups did not differ in neuropsychological impairment, however all groups displayed equal improvement neuropsychologically.
In 1988, Lam et al. studied awareness of deficits in relation to treatment performance of 45 individuals with severe TBI's. The median age of the sample was 28 .5 years and median education 12 years. The subjects averaged, approximately 10 months post-injury and were receiving rehabilitation. The Change Assessment Questionnaire
(CAQ, cited earlier as the URICA) was used to assess subjects perceptions of their problems in cognitive abilities, ie., memory, attention, concentration, and learning.
Subjects were also rated by their case managers and personal adjustment counselors on the
Treatment Performance Scale (TPS), which measured compliance and progress in treatment, awareness of strengths and weaknesses, and motivation. CAQ scores were used to classify subjects into three clusters and then compared on their TPS scores. The three clusters obtained were: Pre-contemplative group, Ambivalent group, and Participant group. These clusters were consistent with patient subtypes formed by Prochaska,
DiClemente and colleagues. There were significant differences in TPS scores among the three clusters. These findings support the hypothesis that individuals who are aware of their deficits are more prepared to change and will perform better in treatment.
Allen and Ruff (1990) studied whether the degree of severity and chronicity of TBI affected self-ratings of cognitive functioning. In order to examine this question, self- ratings were compared with neuropsychological test performances. They had 87 adult subjects divided into three groups: 31 normal controls, 28 mild-moderate TBI, and 28 severe TBI. Severity of TBI was determined by Glasgow Coma Scale scores, length of coma, and post-traumatic amnesia (PTA). Chronicity was divided by onset of less than one year and greater than one year. The control group was matched on age and education. The subjects were administered the following instruments: San Diego
Questionnaire, Grooved Pegboard, Ruff 2 and & Selective Attention Test, Ruff Language
Screening Examination, Partial Wechsler Adult Intelligence Scales-Revised (Information,
Digit Span, Vocabulary, Comprehension, and Similarities subtests), Selective Reminding
Test, and Ruff Fluency Test. The results indicated that individuals with TBI consistently rated themselves lower functioning than the controls and as not cognitively impaired on the San Diego Questionnaire. Furthermore, no disparity was evident between the mildly and severely impaired individuals with TBI. Chronicity affected attention, memory, and arithmetic with those individuals injured greater than one year rating these abilities as more
19 severe. The control group had a higher association between self-ratings and neuropsychological performance. While individuals with mild TBI displayed a significant correlation between ratings of language and test performance. Individuals with severe
TBI displayed a positive correlation between reasoning ratings and inefficiency of planning as measured by the Figural Fluency Test. Functionally, this correlation can be expressed in their feelings of adequacy in participating in activities that require planning. They engage in such activities and fail without displaying attention to these difficulties and remembering them for the future. Thus they are exhibiting neurogenic denial.
Similar to Fordyce and Roueche's (1986) study, Prigatano and Altman (1990) focused on individuals with TBI who exhibited an overestimation of abilities as compared to relatives' reports. They attempted to further clarify differences in severity of injury, neuropsychological impairment, and organic brain lesions between the overestimaters and other individuals with TBI. Subjects consisted of 64 individuals who had a mean age of
29.7 years, mean educational level of 13.3 years, and mean chronicity of 16 months.
Forty-nine of the subjects were right handed, four left handed, and one ambidextrous.
Each of the subjects had been administered the following instruments: Patient Competency
Rating Scale (PCRS), Computed tomography/MRI, Wechsler Adult Intelligence Scale-
Revised (block design, digit symbol, information, and similarities), Wechsler Memory
Scale or revised version, and Wisconsin Card Sorting Test. In addition, Halstead Finger
Tapping Test was administered. The subjects were divided into three groups based on their PCRS ratings. Group I overestimated abilities, Group II had similar ratings to relatives, and Group III underestimated abilities. Initial severity of injury was evenly
20 distributed throughout the groups. Results indicated that individuals who overestimated behavioral competencies did not display worse performance on visuospatial problem solving or visuospatial memory. The three groups did differ on verbal learning and long term verbal information. They also did not differ on abstract reasoning and speed of new learning. Group I differed from the others in that left-hand finger tapping was slower.
This group also had a higher rate of frontal and parietal lesions, however all groups displayed bilateral lesions with Group I containing the highest percentage. The authors suggest that neuropsychological tests are unable to adequately assess the brain region that is responsible for unawareness. They describe this region responsible for unawareness as the heteromodal cortex, coined by Mesulam. The heteromodal cortex integrates perceptual information regarding external reality with internal perceptual information.
This area contains prefrontal, inferior parietal, supramarginal gyrus, and sections of the temporal lobes.
Insight into impairments, emotional dysfunction, and the relationship between them was studied by Godfrey, Partridge, Knight, and Bishara (1992). They utilized a cross- sectional design in which data from three distinct TBI subject groups were collected. The groups were comprised of 66 individuals who had sustained a TBI either 6 months
(n =24), 1 year (n = 19), or 2-3 years (n = 23) prior to evaluation. Subjects were matched to a control group of 27 orthopedic subjects of similar age and education. The
Head Injury Behavior Scale (HIBS), developed by the authors, the Neuropsychological
Impairment Scale (NIS), a video-recorded Social Skill Assessment, and three emotional adjustment measures: The Zung Self-Rating Depression Scale, the Anxiety Trait scale of Spielberger State-Trait Anxiety Inventory, Form Y, and the Rosenberg Self-Esteem
Inventory were utilized. The results showed that individuals at 6 months postinjury underestimated both behavioral and neuropsychological problems, while overestimating their social skills. These individuals were assessed to be more impaired than the controls.
The authors termed this lack of insight, Post-Traumatic Insight Disorder, In contrast, individuals 1,2, or 3 years post-injury identified more behavioral problems than the controls. Their results were more consistent with significant others' reports. These individuals also reported a much higher level of emotional distress. This study suggests that increased insight and awareness of impairment is associated with an increased risk of emotional dysfunction.
Gasquoine and Gibbons (1994) studied whether self awareness of impairment could be reliably assessed after severe TBI and considered the possibility of distinct types of deficits in self-awareness. They administered a questionnaire assessing orientation, awareness of injury, and physical/cognitive impairments to nine institutionalized survivors of severe TBI. The mean age of the sample was 28 years and mean time post injury was five years. Staff familiar with each resident were also asked to rate the individual on 20 impairment questions. Two patterns of awareness of deficit were found. Subjects who were more disoriented showed little awareness of deficits, while oriented subjects displayed a greater awareness of overt deficits but still underestimated their level of impairment compared to staff reports.
Boake, Freelands, Ringholz, Nance, and Edwards (1995) approached awareness as it related to memory loss after severe TBI. Subjects were 48 individuals who had
22 sustained a severe TBI and were involved in a post-acute rehabilitation center for the 2 1/2 year period of the study. Their mean age was 24.8 years and mean education 12.5. The
Everyday Memory Questionnaire (EMQ) was utilized to measure subjective memory.
While the Selective Reminding Test, California Verbal Learning Test, and Rivermead
Behavioral Memory Test measured objective memory. In order to measure emotional symptoms, the Zung Self-rating Depression Scale and Zung Self-rating Anxiety Scale were administered. CT scans, for 46 subjects, were also utilized to distinguish presence and side of focal lesion. Six EMQ items that describe atypical memory failures were used to identify twenty-four subjects as invalid responders and twenty-three as valid responders. One subject was excluded from the study because they gave a zero self-rating on all the EMQ items. Results indicated that the frequency of self-reported memory failure was low in both valid and invalid responders; however, invalid responders reported poorer memory performance and had an increased tendency of left-sided focal lesions.
Emotional symptoms were equivalent between the two groups. Correlations between memory tests and memory self-ratings revealed a weaker correlation among invalid responders; while stronger correlations were noted among valid responders, especially those who were not depressed. This study demonstrated that memory self-reports are influenced by both neurogenic and psychogenic factors. The authors further noted that the complexity of it also brings to light the problem of self-rating scales. These scales may elicit invalid responses from individuals with TBI.
Rebmann and Hannon (1995) studied the notion of unawareness of memory deficits after traumatic brain injury as it relates to the development of rehabilitation
23 strategies. A single-subject design, involving three clients, was utilized in order to demonstrate that a decrease between predicted scores and actual scores would occur due to treatment. The Brief Multiparametric Memory Test was used to assess memory.
Unawareness of memory was measured by the discrepancy between predicted scores and actual performance. Treatment consisted of twice a week sessions for 5-6 weeks. The sessions contained the use of the Brief Multiparametric Memory Test. The subjects were given both visual and verbal feedback along with positive reinforcement when the difference between predicted scores and actual scores decreased. All of the clients benefited from the treatment and displayed a decrease in discrepancy between scores, thus indicating a increase in awareness of memory deficits.
Distinguishing Factors Between Psychogenic and Neurogenic Denial
Lewis (1991) concluded that psychogenic and neurogenic denial can be differentiated by three factors: the time course; the patterns of functional and structural deficits; and the level of emotional awareness. Time course referred to the duration of onset of the denial. Neurogenic denial usually, although not invariably, remits within hours or days as the brain heals and is related to damage in the anterior brain regions, particularly the right hemisphere. Psychogenic denial, except as a reaction to acute trauma or disease, generally is more persistent across time. The time course of denial was documented by Ruff and Allen (1990) who found that individuals with TBI greater than one year displayed greater awareness of deficits than those at less than one year.
Lewis' (1991) second distinguishing characteristic was the presence of functional or structural deficits. An individual in neurogenic denial will have a pattern of neurologic
24 deficits and structural findings that implicate central nervous system dysfunction as a primary etiological factor. These deficits are identified by neurological examination, neuroradiological studies, and neuropsychological testing. This was studied by Wagner and Cushman (1994), and Anderson and Tranel (1989) who found a relationship between brain lesions localized in the right cortical hemisphere and unawareness.
Lewis' third characteristic was the level of emotional awareness is a distinguishing factor between neurogenic and psychogenic denial. Individuals with psychogenic denial become increasingly agitated, while individuals in neurogenic denial typically are emotionally unresponsive when confronted with the denied reality. Over longer time periods, persons with psychogenic denial will demonstrate psychological distress, while those with neurogenic denial will not. Godfrey, et al. (1992) supported this characteristic with their findings indicating that when an individual's awareness increases their emotional response heightens.
Langer and Padrone (1992) proposed a tripartite model for conceptualizing unawareness in TBI where they attempt to integrate both the psychological and neuropsychological factors. They identified three sources of "not knowing" or unawareness: 1) "not knowing" information; 2) "not knowing" how to glean information
(neuropsychologically based - neurogenic); and 3) "not knowing" or denial (emotionally based - psychogenic), in that the individual has the information and the ability to realize implications, but proceeds as if the information was absent. With their tripartite model they derived five predictions: 1) early in the acute phase unawareness in general is more
25 likely; 2) the more severe the cognitive/neuropsychological deficit the more difficult it is for the individual to "discover, learn, or know about it" (64, Langer & Padrone, 1992);
3) individuals with a premorbid tendency to use denial are more likely to do so after a
TBI; 4) both responsiveness and effectiveness of treatment may be directly related to the origin of the "not knowing"; and 5) a negative correlation should exist between denial and level of depression, conversely awareness of deficit should be associated with some level of depression.
Langer and Padrone (1992) stress the importance of understanding the causes of unawareness prior to implementing treatment. Individuals with neurogenic denial should be working on building strategies that would support the introduction of knowledge concerning their strengths and weaknesses, eg; an individual with a left visual field deficit initially works on visual cancellation tasks then attempts checkbook activities. While individuals with psychogenic denial would benefit more from ego strengthening so that knowledge could be supported, eg: analyzing resistance in order to increase the individual's tolerance of their deficit.
Denial with Substance Abuse and TBI
Persons with problems of substance abuse following TBI may have the propensity to exhibit both psychogenic and neurogenic denial. Alcohol is involved in one third to one half of all accidents that result in head injuries (Corrigan, 1995). Approaching two-thirds of adolescents and adults treated in rehabilitation settings have a history of substance abuse (Corrigan, 1995). The use of alcohol or other drugs after head injury may impede recovery in general and increase the probability of another TBI. A preliminary study was conducted to investigate the likelihood for individuals with substance abuse and TBI to display psychogenic and neurogenic denial. Subjects were randomly selected from the TBI Network, a treatment program for persons who have problems with substance abuse following TBI (Corrigan, Lamb-Hart, & Rust, 1995).
The clients at TBI Network are at least at risk of substance abuse, though most have diagnosed substance abuse or substance dependence disorders. These clients have also incurred an acquired brain injury with consequent cognitive disability.
The criteria for inclusion in this study was that each individual had received a comprehensive assessment including: the client’s completion of the Stages of Change
Readiness and Treatment Eagerness Scale (SOCRATES, version 5; Miller, 1991); and the client and a significant other completion of the Trauma Complaints List (TCL, van
Zomeren, & van den Burg, 1985). The SOCRATES, as we will describe in more detail later, assesses the individuals readiness to change an addictive behavior, and is based on the theoretical work of Prochaska and colleagues (Prochaska, DiClemente, & Norcross,
1992). The Trauma Complaints List is a 27 item questionnaire that assesses residual psychological complaints following head injury. These complaints contain items assessing both cognitive and emotional functioning, along with other symptoms frequently endorsed by individuals who have sustained TBI. The client and significant other differences on the
TCL were used as the measure of neurogenic denial, while results from the SOCRATES were used to operationalize psychogenic denial.
Thirty subjects were initially selected. Four subjects had to be eliminated from the study because they did not have a diagnosed substance abuse or substance dependency
27 disorder based on DSM-III-R criteria (American Psychiatric Association, 1987). This was done because in order for a person to display psychogenic denial they must have a diagnosable substance abuse disorder. The remaining twenty-six subjects were than analyzed. The average age was 27 years. Eighty-five percent were male and 77%
Caucasian. The average education was 11.31 years, with 42% having less than 12 years education. The sample was an average of 47.22 months post onset with the range being 6 weeks to 20 years. The severity range was from mild to profound, with 10% having two or more TBI's.
Based on the results of the SOCRATES, the subjects were divided into three groups following simplified method of stage determination as used by Lam, McMahon,
Priddy, & Gehred-Schultz (1988). Subjects were classified as either being precontemplative, ambivalent, or in a stage indicating readiness to change. Individuals who were in the precontemplative and ambivalent stages were considered to be displaying psychogenic denial. The distribution was six subjects in precontemplative stage, nine in the ambivalent stage, and 11 ready for change (see Table 1).
In order to make a group assignment as to whether an individual was displaying neurogenic denial the mean score was used to divide the sample into those who display neurogenic denial and those who did not. Using this criterion, 12 of the 26 subjects were categorized as displaying neurogenic denial, while the remaining 14 were categorized as not displaying neurogenic denial (see Table 2). Only one of the six individuals categorized as precontemplative was also categorized as displaying neurogenic denial. In contrast, seven of the nine subjects categorized as ambivalent were also displaying neurogenic Unaware Aware
Precontemplative 1 5
Ambivalent 7 2
Ready 4 7
Table 1: Results of Preliminary Study . Stages of Change as Related to Level of Awareness. Psychogenic Denial
Present Absent
Neurogenic Present Denial
Absent
Table 2: Distribution of Psychogenic and Neurogenic Denial for the Preliminary Study.
30 denial. For the 11 subjects displaying some readiness to change (a lack of psychogenic denial) there was approximately equal representation of both the presence and absence of neurogenic denial, with four of the 11 exhibiting neurogenic denial.
This study has defined four groups of individuals with substance abuse and TBI.
The first group is comprised of individuals exhibiting psychogenic denial, the second group exhibits neurogenic denial, the third group exhibits both psychogenic and neurogenic denial, and the fourth group contains individuals exhibiting neither psychogenic nor neurogenic denial.
31 CHAPTER 3
Methodology
Subjects
The subjects for this study were drawn from individuals who were receiving
services from the TBI Network. The TBI Network, or the Traumatic Brain Injury and
Substance Abuse Vocational Rehabilitation Center, is a community-based resource and
coordination model of treatment for individuals with both TBI and substance abuse problems (Corrigan, Lamb-Hart, & Rust, 1995). Clients of the TBI Network must at least be at risk of substance abuse following TBI, though most have diagnosed substance abuse or substance dependence disorders. Clients must also have an acquired brain injury with documented cognitive disability. Subjects who met the following criteria were recruited for the study: 1) significant TBI that required inpatient treatment in a rehabilitation facility or a loss of consciousness of at least 24 hours; 2) documented DSM III-R or DSM IV diagnosis of either substance abuse or dependency; and 3) having been involved with the
TBI Network for a period of at least 2 months.
According to recommendations by the Behavioral and Social Sciences Human
Subjects Review Committee, subject recruitment occurred indirectly. First, each case
32 manager was approached to request their participation as a recruiter and staff informant
(see Appendix A), They reviewed their caseload to identify individuals that met the above
stated criteria. Each potential subject was then assigned a code number and the case
manager sent out the recruitment letter (see Appendix B). The letter contained a self-
addressed, stamped response card which included their code number. The potential
subjects were requested to return the card indicating whether or not they wished to
participate in the study. If within two weeks a response card was not received by the
investigator, the case manager sent out a second recruitment letter (see Appendix C).
Once a subject indicated a willingness to participate the case manager gave their name and
phone number to the investigator. The subject was then contacted by phone to schedule a testing time and answer any further questions (see Appendix D).
A total of 115 recruitment letters were sent out. The following is a break down of responses: 61 (53%) replied "yes" to participation; 20 (17.4%) replied "no" to
participation; 25 (22%) did not respond; 8 (6.9%) were never contacted due to wrong address; and 1 (.87%) was deceased. Of the 61 who responded positively to participation, 40 (65%) actually participated. Loss to participation among those volunteering was due to two primary reasons inherent to this population. First, based on clinical experience, cognitive impairments interfered with the ability to follow through and participate at the scheduled times. Despite multiple reminder calls there was a no show rate of 26% for scheduled interviews. Second, lack of transportation restricted participation. Many of these individuals did not have a valid drivers license or access to reliable transportation. Instruments
SOCRATES
The Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES)
(Miller, 1991; see Appendix E) was utilized to measure the presence or absence of
psychogenic denial. The SOCRATES is a 40 item questionnaire designed to assess an
individual's readiness to change. Responses are scored on 5-point Likert rating scales
ranging from "strongly disagree" to "strongly agree". There are two versions, one for alcohol abuse, the other for other drugs.
The SOCRATES has five subscales that correspond with the following stages of change: Precontemplative, Contemplative, Determination, Action, and Maintenance. Raw scores for each of the five stages of change can range from 8 to 40. For the current study a method proposed by Lam, et al, (1989) was used to identify three profiles of change scores. This method reduces the five stages of change (Precontemplation, Contemplation,
Determination, Action, and Maintenance) into three profiles (Precontemplative,
Ambivalent, and Ready). The subjects raw scores for each stage were converted into z- scores on the basis of a normative sample. The normative sample consisted of 70 individuals from the TBI Network who have sustained a traumatic brain injury and have a documented alcohol or substance abuse problem. These scores were then plotted into a graph that was viewed by two expert judges in order to determine profile membership.
The subjects completed either the alcohol or the drug version depending on the drug of choice that constituted the basis for their DSM diagnosis. Two (5%) respondents were considered other drug abusers, 37 (95%) were alcohol abusers. Subjects were considered to have a Precontemplative profde (Figure 1) if their
Precontemplative scale score was at least one half standard deviation above the mean, while other scale scores fell at or below their means. In contrast, subjects were considered to have a Ready profile (Figure 2) if their precontemplative scale score was at or below the mean, while other stage scores were consistently above the mean. In between theses two stages were those subjects who displayed an Ambivalence profile
(Figure 3). These scores were characterized by a relatively flat profile, most commonly with scores clustering around the average for each stage. The distribution was 22 precontemplative, 6 ambivalent, and 12 ready. For the purpose of this study a subject war; considered to be displaying psychogenic denial if their scores fell in the Precontemplative profile stage.
Miller and Tonigan (1996) performed test-retest reliability and internal item consistency measures on a 19-item version of the SOCRATES with a sample size of 82 heavy drinkers. Cronbach alphas were .82 for Ambivalence, .94 for Recognition
(Precontemplative), and .91 for Taking Steps (Ready). Pearson r values for test-retest reliability were .83, .99, and .93, respectively (Miller & Tonigan, 1996). The authors report the reliability to be the same for the 40-item version as the 19-item version.
35 MEAN 18.056044 19.4285714 28.7802106 31.3846154 29.8241758 STD DEV 7.38233127 6.16044804 0.40367707 7.11563240 7.85301458 PRECONTB4P. CONTEMP. PREPARATION ACTION MAINTEN. STD SOOflE 1.22508131 1.06671277-1.14638345 •0.33512346 •0.23226326 ENTER RAW SCORE: 28 26 18 20 28
y ■ PREOONTEMP. *
CONTEMP. ' p Z T — 3
■ s PREPARATION
f ACTION
MAINTEN.
. 1 ~ i r - ~ "- ™ — 1 - 1 "f -1.5 *1 -0.5 0 0.5 1 1.5 Standard Score.
1 i ■ __i __ __ I. 1 1 i
Figure 1: Precontemplative Profile MEAN 18.956044 19.4285714 28.7802198 31.3846154 29.8241758 STD DEV 7.38233127 6.1604.4804 9.40367707 7.11563249 7.85391458 PREOCNTEMP. CONTEMP. PREPARATION ACTON MAINTEN. STD SCORE -0.6713388 0.09275763 0.76776139 1.210768630.78833707 ENTER RAW SCORE: 14 20 36 40 36
PflECCNTEMP. ■ ' ^ 7 ------'r CONTEMP.
PREPARATION i ..
ACTION — /r------MAINTEN. —. ------X------.------~ r • ~*t — ta-----vi ■ ■ -i------1------r •0.8 -0.6 >0,4 -0.2 0 0.2 0.4 0.6 0.8 1 1.2 1.4 Standard Score
- - I— - I ~ ' T . — -.-.“1 I” '——A—
Figure 2: Ready Profile MEAN 18.956044 19.4285714 28.780219831.3846154 29.8241758 STD DEV , 7.38233127 6.16044804 9.40367707 7.11563249 7.85391456 PflECCNTEMP. CONTBAP. PREPARATION ACTION MAINTEN. STDSCORE 1.08962274 1.71601819 0.66142001 0.92969734 0.91366211 ENTER RAW SCORE 27 30 35 38 37
f . PRECONTBAP. ■i CONTEMP.
PREPARATION ■z ACTION z MAINTEN.
— i— — i— — i— — i— =7 0.2 0.4 0.8 0.8 1 1.2 1.4 1.8 1.8
Standard Score i :r.::~:zn
Figure 3: Ambivalent Profile Patient Competency Rating Scale
The Patient Competency Rating Scale (PCRS) (Rouche & Fordyce, 1983; see
Appendix F) was utilized to determine the presence or absence of neurogenic denial. The
PCRS is a 30 item questionnaire designed to assess an individual's perceived ability to perform a variety of practical skills: activities of daily living; emotional control; and complex social interaction. Items are scored on a 5-point rating scale containing the following descriptions: "can't do"; "very difficult to do"; "can do with some difficulty";
"fairly easy to do"; and "can do with ease". There are two versions of the questionnaire, a patient's form and a relative's form. The relative's form was completed by the subject's case manager at the TBI Network. Research on test-retest reliability revealed r = .97 for patients and r = .92 for relatives (Prigatano, Altman, & O'Brien, 1991). Neurogenic denial was measured by the correspondence between the subject's and their case manager's response on the PCRS. The subject and case manager's responses were considered item by item. If the case manager checked an item as "can't do" or "very difficult to do" while the subject indicated "can do with ease" or "fairly easy to do" then that item was considered to reflect neurogenic denial. If either the case manager or the subject were ambivalent and checked "can do with some difficulty" the item was not used to indicate neurogenic denial. For each subject a neurogenic denial score was calculated based on the number of symptoms for which the case manager indicated "can't do" or "very difficult to do" but the subject checked "can do with ease" or "fairly easy to do". The scores ranged from 0 to 14 with 22 individuals obtaining a 0 while 18 were between 1 and 14. A median
39 split was planned, however due to this distribution it was not feasible. The scores were divided with 1-14 indicating neurogenic denial and a 0 indicating awareness
(see Table 3).
The Halstead-Reitan Neuropsychological Test Battery
Selected tests from The Halstead-Reitan Neuropsychological Test Battery
(HRNTB) (Reitan & Wolfson, 1985) were administered. The HRNTB was originally developed by Ward C. Halstead (1947) and modified by Ralph Reitan and Deborah
Wolfson. It is a comprehensive assessment battery used to measure brain-behavior relationships. Description of the tests selected for this study follow.
1) The Finger Oscillation Test is a measure of finger-tapping speed. A manual tapper attached to a clip board is utilized with the subject using the index finger of the preferred hand first followed by the non-preferred hand. The subject is encouraged to tap as fast as possible. The score is the average number of taps across five consecutive 10 second trials. Lateralization was determined by dividing the score of the dominant hand by the nondominant hand and subtract from 1.0 (Jarvis & Barth, 1984; Reitan & Wolfson,
1993).
2) The Grip Strength is a measure of motor strength for the upper extremities.
The subject places a dynamometer first in the preferred hand then alternates to the non- preferred hand twice in sequence. The average strength for each hand is calculated in kilograms. The preferred hand should be 10% greater than the non-preferred hand.
Lateralization is determined the same as with finger oscillation (Jarvis & Barth, 1984;
Reitan & Wolfson, 1993).
40 Scores Number of Subjects Achieving 0 22 1 6 2 3 3 2 4 1 5 2 6 1 8 1 10 1 14 I
Table 3; Distribution of Scores on the PCRS.
41 3) The Reitan-Klove Sensory-Perceptual Examination are tests that attempt to determine the subject's ability to perceive accurately bilateral simultaneous sensory stimulation. These tests can not be used if a subject has a serious lateralized loss of touch, hearing, or vision. Tactile function is examined by separately touching each hand. Once unilateral stimulation is accurately identified the unilateral stimulation is mixed with bilateral stimulation. Unilateral stimulation can be detected but bilateral stimulation is undetected in subjects with lateralized cerebral lesions. Auditory perception is tested by the examiner rubbing their thumb and index finger together next to the subject's ear. The subject identifies the side the sound is heard. Visual perception is similarly tested by the examiner requesting the subject focus on the examiner's nose white he/she makes discrete finger movements. The subject then identifies the side the finger movement was perceived. The score for tactile function, auditory perception, and visual perception is recorded as number of errors. Parietal lesions affect tactile perception, temporal lesions affect auditory perception, and posterior lesions affect visual perception.
An increase number of errors on a particular side (left/right) suggest damage to the contralateral hemisphere (Jarvis & Barth, 1984; Reitan & Wolfson, 1993).
4) Tactile Fineer Recognition assesses the subjects ability to identify each finger individually on both hands when they are tactually stimulated. The score is the number of errors for each hand over twenty trails per hand. Contralateral parietal lesions, to the defective hand, and posterior cerebral lesions impair performance (Jarvis & Barth, 1984;
Reitan & Wolfson, 1993).
42 5) Finger-tip Number Writing Perception assesses the subject's ability to identify numbers written on the fingertips of both hands without the use of vision. Four trials on each finger, with a standard sequence of the numbers 3,4,5, and 6 is administered. The score is the number of errors per hand. When one hand is definitely more deficient than the other contralateral parietal lobe damage is suspected (Jarvis & Barth, 1984; Reitan &
Wolfson, 1993).
Zune Self-rating Depression Scale and Zung Self-rating Anxiety Scale
The Zung Self-rating Depression Scale (SDS) (Zung, 1965; see Appendix G) and the Zung Self-rating Anxiety Scale (SAS) (Zung, 1975; see Appendix H) both consist of
20 items which describe emotional symptoms. The individual is to respond to each question by indicating frequency of each symptom. Frequency is rated on a four-point scale with a " 1" indicating "none or a little of the time" and "4" indicating "most or all of the time". The index ranges from 25 to 100 and 50 is the lowest clinically significant score. There has been no recent published reliability data for the SDS and SAS; however, both are widely used in medical settings.
Satisfaction With Life Scale
The Satisfaction With Life Scale (SWLS) (Diener, 1985; see Appendix I) is a 5- item questionnaire designed to assess an individual's global judgment of life satisfaction and general well being. The responses are rated on a 7-point scale with 111" indicating
"strongly disagree" and "7" indicating "strongly agree". A higher score reflects higher satisfaction with life. Psychometric data show good convergent validity with other assessments of subjective well-being (Pavot & Diener, 1993).
43 Wisconsin Card Sorting Test
The Wisconsin Card Sorting Test (WCST) (Heaton, 1981) was administered in order to obtain a standard measure of severity of impairment to be used as a descriptive statistic. The WCST assesses an individual's ability to form abstract concepts.
Specifically it is sensitive to lesions in the frontal lobe region. The test uses four stimulus cards containing various forms, colors, and numbers. The subject is then given 64 response cards with similar designs and the task is to match the cards to one of the four stimulus cards. The subject is told whether they are right or wrong. The sorting procedure requires 10 consecutive correct responses. It follows six sorting categories initially beginning with color, then moving through form, number, color, form and number.
Subject responses are converted into the total number of errors, total number of correct responses, and number of categories completed. Perseverative responses are also recorded. Indeed, they are the most useful diagnostic measure in predicting the presence or absence of brain damage (Heaton, 1981; Spreen & Strauss, 1991). Thus the perseverative responses were utilized to determine level of impairment. This test was scored using the WCST-CV2 (Heaton and PAR Staff, 1993) and the norms from Heaton,
Grant and Matthews (1991).
Procedure
Testing either took place in an interview room on the second floor of Dodd Hall or in an empty classroom at the Ohio University Lancaster campus. The rooms were distraction free. The interview room contained a table and two chairs while the classroom contained numerous desks. A large table was used to display testing materials in the
44 classroom, instead of the smaller desks. The primary investigator performed all the testing.
Upon first meeting, each subject was asked to sign the informed consent (see Appendix
K). The subjects were then administered the instruments in the following order: PCRS,
SAS, SDS, SWLS, Handedness, HRNTB, WCST and SOCRATES. With the exception of the SOCRATES the questionnaires were administered first so that interference from the more standardized tests would not occur. The SOCRATES was presented last because of some concern that subjects may become defensive. The evaluation process took approximately 1.5 to 2 hours. The subjects received a 3 minute break after the questionnaires and before the HRNTB and WCST.
The obtained information was treated as confidential. Each subject was given a code number and all material pertaining to this study was identified by that code number only. All relevant materials and protocols were kept under lock and key.
Analyses
Given the properties of our data, all hypotheses were tested utilizing a Kruskal-
Wallis one way analysis of variance. Hypothesis 1 predicted that individuals displaying neurogenic denial would perform more poorly than individuals who display psychogenic denial on seven measures of neuropsychological functioning. The second hypothesis stated that individuals with psychogenic denial would display greater emotional maladjustment and less life satisfaction as measured on the SDS, SAS, and SWLS than individuals exhibiting neurogenic denial. Hypothesis 3 predicted the presence of neurogenic denial in individuals with psychogenic denial would reduce the negative effect o f the emotional reaction to the injury. These individuals exhibiting both forms of denial would thus be better adjusted and more satisfied with life than individuals with only psychogenic denial. The fourth hypothesis stated that the presence of psychogenic denial in individuals with neurogenic denial would improve neuropsychological functioning.
These individuals exhibiting both forms of denial would score better on the measures of neuropsychological functioning than individuals exhibiting only neurogenic denial.
46 CHAPTER 4
RESULTS
This chapter includes a description of the subjects in the study and presents the results from the data analyses performed. Alt raw data are presented in Appendix K.
Repeated Kruskal-Wallis one way analyses of variance by ranks were performed on seven neuropsychological and three emotional measures. This nonparametric statistic was chosen because of its utility with small groups of unequal size. The Kruskal-Wallis test assumes that the variables have a continuous distribution and are measured on an ordinal scale (Siegel & Castellan, 1988). The test ranks the observations and assess the differences between the ranks in order to test if they were drawn from the same population. Although it is a nonparametric test, the Kruskal-Wallis is comparable to a one-way ANOVA. Even if the data did meet all ANOVA assumptions, the Kruskal-Wallis test is 95.5% as effective. This statistic represents the test's power-efficiency (Siegel &
Castellan, 1988).
Descriptive Analysis of Subjects
Based on the findings of this study, the subjects are assumed to constitute a representative sample of individuals who have sustained a TBI. The percentage of males
47 (77.5%) to females (22.5%) is approximately the same as that found in the general
population of individuals with a TBI (4:1; Caplan, 1987). The mean age was 34.18 years, with a standard deviation of 9.20, ranging from 19 years to 55 years. The mean number of
months since the critical injury was 54.0 months, with a standard deviation 44.92, and a
range from 3 months to 192 months.
Length of time these persons remained in coma was obtained from each individual's file. Data were missing on eight of the individuals. The mean length of coma was 443,62 hours (18.5 days), standard deviation 408,14, and the range was from 2 hours to 1968 hours (82 days).
Using the WCST as an indicator, individuals in the group defined as having neurogenic denial were the most impaired with a mean WCST T score of 31.29, standard deviation 9.76, indicating a mild-moderate impairment of brain functioning. The individuals exhibiting both neurogenic and psychogenic denial were least impaired with a mean T score of 48 .91, and a standard deviation of 48 .91, which is indicative of average brain functioning (Heaton, Chelune, Talley, Kay, & Curtiss, 1993). Finally, the mean number of years of education for these subjects was 12.92 years, with a standard deviation of 1.84, and a range from 9 years to 17 years. This is relatively consistent with the expected <12 years of education typically seen in the general TBI population (Caplan,
1987; see Table 4).
The results of the Kruskal-Wallis tests found no significant differences between the four groups (individuals with psychogenic denial, neurogenic denial, both denials and neither denials) on any of the following subject characteristics: time post injury (Chi-
48 square = 1.99, d f= 3, g = .57), WCST (Chi-square = 5.06, d f= 3, g = .17), education
(Chi-square = 2.13, df = 3, g = .55), and length of coma (Chi-square = 4.75, df = 3, g =
.19). A significant difference was found between groups on age (Chi-square = 9,22, d f=
3, g = .02). The Mann Whitney U - Wilcoxon Rank Sum W test was performed and results were significant for individuals exhibiting neurogenic and both denials (Z = -1.95, d f=1, g = .05) and individuals exhibiting both denials and neither denials (Z = -2.99, df =
1, g = .002).
49 Psychogenic Neurogenic Both Neither
Age X = 32.18 40.29* 28.64* ** 37.82** SD = 9.21 13.19 5.78 5.38 rg = 20-46 20-55 19-36 27-45
Education X = 13.36 11.71 12.18 12.73 (years) SD = 1.86 2.21 1.60 1.68 rg = 11-17 9-16 10-15 10-16
Time X = 38.36 59.29 50.45 69.64 Post Injury SD = 21.77 52.18 51.08 50.79 (months) rg = 9-68 7-156 3-192 12-156
Length X = 271.78 699.60 465.00 468.20 of Coma SD = 220.99 481.53 276.32 555.83 (hours) rg = 96-730 240-1344 192-1056 2-1968
WCST1 = 41.45 31.29 48.91 40.27 SD = 14.21 9.76 19.12 11.14 rg = 20-63 20-51 20-80 20-57
'Legend: WCST = Wisconsin Card Sorting Test, scores: 30-34 mild to moderate, 35-39 mild, 40-44 below average, 45-54 average * p = .05, ** p = .002
Table 4: Descriptive Information on Subjects Presented Across Groups by Means, Standard Deviations, and Ranges.
50 Data Analysis
The first hypothesis predicted that individuals displaying neurogenic denial would perform more poorly than individuals who display psychogenic denial on the following indices of brain injury: Finger Oscillation test, Grip Strength, Tactile Finger Recognition,
Finger-tip Number Writing Perception, and Reitan-Klove Sensory-Perception
Examination.
Table 5 presents the results of the Kruskal-Wallis tests. They demonstrated no significant differences between individuals with neurogenic denial and psychogenic denial on the Finger Oscillation test (Chi-square = 2.38, df = 3,_g = ,50), Grip Strength (Chi- square = .07, df = 3, g = .99), Tactile Finger Recognition (Chi-square = 3.36, df = 3,_g =
.34), Finger-tip Number Writing Perception (Chi-square = 4.76, d f= 3, g = . 19). There were also no significant differences on the Reitan-Klove Sensory-Perception Examination
(Tactile: Chi-square = 4.58, df = 3, g = .21; Auditory: Chi-square = 1.60, df = 3, g = ,66 ;
Visual: Chi-square =12, df = 3, g= .99). Although differences were not statistically significant, slight trends in the predicted direction were observed for the Finger-tip
Number Writing Perception and the Tactile portion of the Reitan-Klove Sensory-
Perceptual Examination,
Additional paired comparisons were performed to determine if the neurogenic group and psychogenic group differed significantly from each other on any of the neuropsychological measures. The Mann Whitney U - Wilcoxon Rank Sum W test found significant differences Z = -1.98, df = 1, g = .05 on the Finger Oscillation T est. All other neuropsychological measures demonstrated no significant differences on Grip
51 Strength (Z = 15, df = I, p = .88), Tactle Finger Recognition (Z = -.88, df=1, 2 =
Finger-tip Number Writing (Z= -1.31, df = 1, p = .19), and the Reitan-Klove Sensory-
Perception Examination (Tactile: Z = -.10, df = 1, p = .92; Auditory: Z = -1.22, df = 1, p_
= .22; Visual: Z = -.19, df = 1, p = .84).
52 Psychogenic Neurogenic Both Neither
(n = 11) (n = 7) (n=ll) (n = 11) Finger Median = 3 2 2 3 Oscillation Mean-=23.73 15.79 19.41 21.36 Test Rank
Grip Strength Median = 2 3 3 2 Mean - = 9.82 20.71 21.05 20.50 Rank
Tactile Finger Median = 0 0 0 1 Recognition Mean- = 21.32 16.50 18.00 24.73 Rank
Finger-tip Median = 0 1 2 1 Number Mean - = 15.41 21.36 25.73 19.82 Writing Rank
Reitan-Klove Sensory Perceptual Examination:
Tactile Median = 0 0 0 2 Mean - = 22.68 22.93 15.09 22.18 Rank
Auditory Median = 0 1 0 0 Mean - = 18.41 42.50 19.36 21.18 Rank
Visual Median = 0 1 1 0 Mean - = 19.95 21.14 21.18 19.95 Rank
Table 5: Medians and Mean-Ranks of the Neuropsychological Measures Across Groups.
53 The second hypothesis stated that individuals with psychogenic denial would display greater emotional maladjustment and less life satisfaction as measured on the SDS,
SAS, and SWLS than individuals who exhibited neurogenic denial.
The Kruskal-Wallis tests found no significant differences between individuals with psychogenic denial and neurogenic denial on SDS (Chi-square = 3.15, df = 3, p = .37),
SAS (Chi-square = 3.20, df = 3, p = .36), and SWLS (Chi-square = 1.00, df = 3, p = .80)
Table 6 shows the medians and mean ranks of the emotional measures across groups.
An additional analysis was performed to determine if the extreme groups, psychogenic denial and neurogenic denial, differed significantly from each other on any of the emotional measures. The Mann Whitney U - Wilcoxon Rank Sum W test was performed and the results were significant Z = -1.73, df = I, p< .05 on the SDS measure.
Thus, individuals exhibiting psychogenic denial scored significantly higher on the measure of depression than individuals with neurogenic denial. Additional paired comparisons indicated no significant differences between the groups on SAS (Z = -1.50, df = 1, p =
.13) and SWLS (Z = -.32, df = l,p = .75).
54 Psychogenic Neurogenic Both Neither n = 11 n = 7 n = 11 n = 11
SDS1 Median= 42 37 42 43
Mean-Rank= 22.73 13.64 22.50 20.64
SAS Median= 36 30 38 40
Mean-Rank= 22.45 13.57 21.18 23.27
SWLS Median= 15 11 14 17
Mean-Rank- 20.59 18.93 18.68 23.23
'Legend: SDS = Zung self-rating depression scale; SAS = Zung self-rating anxiety scale; SWLS = Satisfaction with Life Scale
Table 6: Medians and Mean-Ranks of the Emotional Measures Across Groups.
55 The third hypothesis stated that individuals exhibiting both psychogenic and
neurogenic denial would be better adjusted emotionally and more satisfied with life than
individuals displaying only psychogenic denial as measured by their scores on the SDS,
SAS, and SWLS.
This hypothesis was tested by the same Kruskal-Wallis test used for the second
hypothesis. As stated above, there were no significant differences between individuals with both psychogenic and neurogenic denial and only psychogenic denial on SDS, SAS,
and SWLS.
Paired comparisons were performed to determine if the psychogenic and both
denial groups differed significantly from each other on any of the emotional measures.
The Mann Whitney U - Wilcoxon Rank Sum W test found no significant differences on
SDS (Z = -.26, df = 1, E = .79), SAS (Z = -. 10, df = 1, p = .92), and SWLS (Z = -.33, df
= 1,11 =.74).
The fourth hypothesis predicted that the presence of psychogenic denial in
individuals with neurogenic denial would improve neuropsychological functioning on the following indices of brain injury; Finger Oscillation test, Grip Strength, and Reitan-Klove
Sensory-Perception Examination. Individuals exhibiting both forms of denial were
expected to perform better on the neuropsychological measures than individuals exhibiting pure neurogenic denial.
This hypothesis was tested by the same Kruskal-Wallis test computed for the first
hypothesis. They found no significant differences between individuals with both
neurogenic and psychogenic denial and only neurogenic denial on the Finger Oscillation
56 test, Grip Strength, Tactile Finger Recognition, Finger-tip Number Writing Perception.
There were also no significant differences on the Reitan-Klove Sensory-Perception
Examination. Since a slight trend in the predicted direction was noted on the Tactile portion of the Reitan-Klove Sensory-Perception Examination a Mann-Whitney U -
Wilcoxon Rank Sum W test was performed to look at the effects of group membership on tactile performance and the results were significant Z = -1.74, df = 1, £< 05, with individuals exhibiting neurogenic denial performing more poorly than individuals exhibiting both forms of denial. Other paired comparisons found no significant differences on Finger Oscillation Test (Z = -.62, df = 1, £ = .53), Grip Strength (Z = -. 10, d f= I, £ =
.92), Tactle Finger Recognition (Z = -.32, d f=1, £ = .74), Finger-tip Number Writing (Z=
-.94, d f= 1, £ = .34), and the Reitan-Klove Sensory-Perception Examination (Auditory: Z
= -.93, df = 1, £. = .35; Visual: Z = -.05, df = 1, £ = .96).
A final analysis was performed to determine if lateralization of impairment was significant between groups on the neuropsycological measures. A Chi-Square test found no significant differences Pearson = 7.07, df = 6, £ = .31.
All the analyses were performed on a Packard Bell, Pentium Processor (Force 479
CD) computer at The Ohio State University utilizing the SPSS for Windows, Release 6.1 statistical package (SPSS Inc., 1994).
57 CHAPTER 5
DISCUSSION
Clinical practice of persons with TBI has shown that some individuals tend to respond more favorably to rehabilitation than others. McGlynn and Schacter (1989) proposed that one important predictor of rehabilitation success may be whether the individual has either neurogenic or psychogenic denial. Very little empirical research exists that would confirm McGlynn and Schacter's (1989) assumptions. The purpose of this study was to analyze the constructs of psychogenic and neurogenic denial in a population of individuals who have been diagnosed with substance abuse following traumatic brain injury. Psychogenic denial was operationalized by the SOCRATES, while neurogenic denial was operationalized by response discrepancies between the PCRS scores obtained from the individual and those obtained from a staff member. Four subject groups emerged, one that had only neurogenic denial, another with pure psychogenic denial, a kind that had both forms of denial, and finally one that had neither form of denial.
Dependent measures were the subject's scores on the seven neuropsychological assessments and the three emotional well-being questionnaires.
Relationship of Results to Hypotheses
The first hypothesis predicted that individuals displaying neurogenic denial would perform more poorly indices of brain injury ( Finger Oscillation Test, Grip Strength,
58 Tactile Finger Recognition, Finger-tip Number Writing Perception, and Reitan-Klove
Sensory-Perception Examination) than individuals who were exhibiting psychogenic denial. This prediction was not confirmed statistically. However, some of the neuropsychological measures showed a tendency in the predicted direction. Individuals with neurogenic denial performed more poorly than individuals with psychogenic denial on
Finger-tip Number Writing Perception (p = . 19) and the Tactile
(p = .21) portion of the Reitan-Klove Sensory-Perceptual Examination.
One reason why our prediction may have failed to be confirmed in this study was the possibility that the seven indices chosen were not as sensitive to brain impairment as assumed. These measures were chosen because of their known ability to assess briefly both sensory and motor functions and their lateralization potential. Other studies of neurogenic denial (Anderson & Tranel, 1989; Fordyce & Roueche, 1986; Allen & Ruff,
1990; and Prigatano & Altman, 1990) incorporated many more neuropsychological and intelligence measures such as Wechsler Adult Intelligence Scale-Revised, Wechsler
Memory Scale, and various attentional, planning, and problem solving assessments.
Utilizing a wider variety of instruments would also increase the opportunity to obtain more information on localization of injury (anterior/posterior). It may also provide a more sensitive measure of functional brain ability. The disadvantage of using a greater number of measures is that they require more time to administer.
The WCST, used as a control variable, also displayed a discrepancy in the scores between individuals with neurogenic and psychogenic denial. Individuals with neurogenic denial displayed mild-moderate impairment of brain functioning while individuals with
59 psychogenic denial were in the below average area, indicating better neuropsychological functioning.
Hypothesis 2 posited that individuals with psychogenic denial would be emotionally more vulnerable and that they would be more unsatisfied with their life than those with neurogenic denial. Unfortunately, this hypothesis was not supported.
Although the SDS and SAS scores were in the correct direction, suggesting that individuals with psychogenic denial had greater emotional adjustment problems than individuals with neurogenic denial the results were statistically not significant. The psychogenic denial group scored higher on both the depression and anxiety scales and lower on the life satisfaction and general well being questionnaire than individuals exhibiting neurogenic denial. Mean SDS and SAS scores of the psychogenic denial group,
43.45 and 39.55 respectively, fell below the 50 point cut off considered to signal significant anxiety and depression. The SWLS mean score of 16.18 categorized the individuals as slightly dissatisfied with life. An important result appears when extreme groups on measures of emotional functioning are compared significant differences appear in measures of depression. Individuals exhibiting psychogenic denial score higher on measures of depression.
For future research it may be advisable to include a structured interview in addition to the self rating measures. This was done in a recent study by Van Reekum, Bolago, Finlayson,
Garner, and Links (1996). They studied 18 individuals with TBI and found an increase in the occurrence of major depression.
60 The Van Reekum et al. (1996) study shed light on the potential frequency of certain psychiatric disorders in post-TBI patients. They found that individuals with TBI are at risk for subsequent psychiatric illness (Van Reekum et al., 1996), particularly major depression and generalized anxiety disorder. Within this group, individuals who concurrently abuse alcohol and who also exhibit psychogenic denial appear to have a greater predisposition for depression. Both TBI and psychiatric disorders impact daily functioning and the subjective sense of well being. Thus they will also have an impact on rehabilitation success. If emotional and psychiatric functioning could be adequately evaluated and treated following TBI potential future problems such as substance abuse, recurrent TBI, continued unemployment, and loss of significant relationships could be avoided (Van Reekum et al., 1996).
Assessing emotional maladjustment through the use of self rating scales as attempted in this study is problematic. Self rating scales are inherently questionable due to the possibility of under or overestimation of feelings (Fleming, Strong, & Ashton., 1996).
A combination of self rating scales and a structured interview such as the Schedule for
Affective Disorder and Schizophrenia-Lifetime Version used in the Van Reekum et al.
(1996) study may assure a more accurate diagnosis.
Hypothesis 3 predicted that the presence of neurogenic denial in individuals with psychogenic denial would have a significant negative effect on the measures of emotional well-being. Because of the reducing effect of the neurogenic denial individuals with both forms of denial would be better emotionally adjusted and more satisfied with their life than individuals displaying only psychogenic denial. This hypothesis was found not to be statistically significant either. In terms of suggested directionality in the data, individuals displaying both neurogenic and psychogenic denial scored slightly lower on both the depression and anxiety scales and slightly lower on the life satisfaction and general well being questionnaire than individuals exhibiting psychogenic denial only. This is consistent with our assumption that neurogenic denial masks the emotional reactions of the injury.
This group also tended to score lower than all others on life satisfaction and general well being. This may be because they have slightly more awareness of their current condition and its ramification on their life. Their score on the WCST was the highest (average range) thus indicating intact frontal lobe functions (Heaton, 1981), which would support this notion.
Hypothesis 4 predicted that the presence of psychogenic denial in persons with neurogenic denial would have a significant positive effect on measures of neuropsychological functioning. Individuals exhibiting both neurogenic and psychogenic denial would perform better on the neuropsychological measures than individuals exhibiting only neurogenic denial. As with the other hypotheses this one was statistically not confirmed either. Contrary to what was hypothesized, individuals with both forms of denial had slightly poorer scores on five of the seven indices of neuropsychological functioning than those individuals exhibiting neurogenic denial. This may be due again to the selection of instruments and their level of sensitivity.
General Discussion and Limitations
The motivation behind this study came from clinical experience with individuals who have sustained traumatic brain injury. Clinically, it was noted that some individuals
62 benefited more from a cognitive-behavioral approach while others performed better with a more humanistic approach to their rehabilitation efforts. In observing these individuals it became apparent that there were certain underlying tendencies that predisposed them for the particular therapeutic approaches. This study was an initial effort to categorize these individuals by the type of denial exhibited and then further analyze the impact of functional/structural deficits and emotional maladjustment. Unfortunately, the results of this study did not prove to be statistically significant; however, the outcome may have some heuristic value.
In reviewing the literature the notion of these two types of denials are frequently mentioned. These denials are similar in many respects yet differ in their origins. Most researchers appear to be struggling with how to operationalize these concepts. The premise of psychogenic denial rests in the notion of repression and reduction. Individuals experiencing psychogenic denial are not able to readily acknowledge or admit to their problems, thus they are unable to change behaviors that are maladaptive. As McGlynn and Schacter (1989) mentioned they may be somewhat aware but unwilling to confront their problems, The SOCRATES has been established as a measure of individuals readiness to change. In order to change a behavior one most acknowledge its existence.
The various stages identified in the SOCRATES appear to adequately categorize individuals based on their self ratings as to presence or absence of psychogenic denial.
Neurogenic denial, on the other hand, arises from an organic lesion. It is thought of as an unawareness of deficits or a lack of insight. Currently, the trend is to operationalize neurogenic denial by identifying discrepancies between the individual with
63 the TBI and an informant. It is felt that this discrepancy is an indication of the unrealistic perception the individual has of their current situation/condition.
One problem of the present study may have been the operationalization of the subject group by means of rating scales only. Although this had been common practice until recently, Fleming et al. (1996) suggested that using only self rating questionnaires for identifying neurogenic denial may be problematic. They discuss the potential biases of the staff informant such as inter and intrapersonal factors. Another point they discuss is a breakdown of unawareness into developmental stages: intellectual awareness, emergent awareness, and anticipatory awareness. Intellectual awareness deals with gaining the intellectual knowledge and recognition of a deficits existence. Emergent awareness occurs when an individual can actually recognize a problem that is caused by the deficit when it is occurring. While anticipatory awareness, is at the most integrated level in that the individual can anticipate a problem that may occur due to their deficit. Fleming et al.
(1996) state that questionnaires and interviews only identify intellectual awareness and observation is required to accurately assess emergent and anticipatory awareness.
Therefore, it may be of benefit for future research to expand measures of neurogenic denial to incorporate both a brief interview and observational assessment so that a more sensitive system of identification can occur like that of psychogenic denial.
The choice of the neuropsychological measures used in this study was another possible limitation. It appeared that the measures selected may not have been adequately sensitive to brain impairment. Lateralization of injury for individuals with TBI may not be as strong an indicator of neurogenic denial as originally thought. Two of the studies
64 (Wagner & Cushman, 1994; Anderson & Tranel, 1989) that indicated a relationship between brain lesions localized in the right cortical hemisphere and neurogenic denial contained a greater number of individuals who had sustained a cerebral vascular accident versus TBI. Cerebral vascular accidents tend to be more localized than the more diffuse damage of a TBI. The study by Prigatano and Altman (1990) highlighted the possibility that neuropsychological tests are unable to adequately assess the brain region responsible for unawareness. They describe this region as the heteromodal cortex. This region contains the preffontal, inferior parietal, supramarginal gyrus, and sections of the temporal lobes. The use of assessments that would more effectively evaluate these areas (such as the Wechster Adult Intelligence Scale-Revised, portions of the Halstead-Reitan
Neuropsychological Test Battery, and the Wechsler Memory Scale) may be more informative.
Another major limitation to this study was the small number of subjects and unbalanced cells in the 2X2 design. Originally, recruitment was to be direct which means that a) I could have obtained names, phone numbers, and addresses of eligible candidates from the case manager, and b) a phone call could have been placed directly to the eligible individual for recruitment. However, the Behavioral and Human Subjects Research
Committee ruled this to be unethical due to our implied breach in confidentiality, and requested that recruitment be conducted indirectly, through the case manager by mail.
This recruitment method proved to be cumbersome and inefficient in obtaining the number originally stated (80). Regardless, 61 individuals did express willingness to participate yet only 40 actually followed through with the study. The low number of participants was
65 due to two primary reasons typical for this population. The first was that the cognitive impairments these individuals exhibit tend to interfere with their ability to follow through on activities. Secondly, many of these individuals did not have a valid drivers license or access to reliable transportation. There were also several response cards returned that indicated limited willingness and expressed anxiety and stress regarding "not putting oneself through anymore".
In general it appears that many studies involving this population are plagued with small subject samples. In reviewing the samples cited in this paper the N's range from 9 to
66. Wagner and Cushman (1994) and Anderson and Tranel (1989) had 108 and 100 subjects, respectively, but the largest percentage were individuals who had suffered a cerebral vascular accident not TBI. The Van Reekum et al. (1996) study actually made mention of a 26.5% participation rate and indicated this was a limitation in their study.
The question also arises as to the possibility of selection bias in the present study.
However this can not be evaluated because there was no participant consent to review records of individuals who did not follow through on participation.
Directions for Future Research
Future research should initially focus on validating the measures used to categorize psychogenic and neurogenic denial. As mentioned, a combination of self rating questionnaires, interviews and observations should be employed. The Self-Awareness of
Deficits Interview (Fleming et al., 1996) or the Awareness Interview (Anderson & Tranel,
1989) may be appropriate additions for better determination of neurogenic denial. The neuropsychological instruments should also be expanded to include assessment of verbal
66 and executive function skills. Specific tests that may enhance the assessment would be the
Wechsler Adult Intelligence Scales-Revised and the Wechsler Memory Scale. A review of the literature suggests that most research on neurogenic denial has been based on persons with focal brain lesions (CVA, gunshot, tumor). Present research suggests that past methods are inadequate in evaluating neurogenic denial in persons with diffuse injury.
Finally, the emotional assessment should also contain a structured interview, such as the
Schedule for Affective Disorders and Schizophrenia (Van Reekum et al, 1996), in conjunction with the questionnaires.
In order for the research to be successful it would be advantageous to obtain funding so that subjects could be offered transportation and compensation for their time.
This monetary incentive may be a valuable recruitment tool and thus assist in significantly increasing the sample size. It also may reduce potential selection bias.
Another interesting question that has not been evaluated would be to compare individuals on the dimension of the passage of time since the critical injury. Lewis (1991) identified the duration of time the denial exists as a discriminator of psychogenic and neurogenic denial. Individuals with neurogenic denial display a lesser degree of denial over time while individuals with psychogenic denial display persistent denial over time. It would be beneficial to recruit individuals while they are in a rehabilitation facility or immediately upon discharge to more adequately assess this point.
67 There still is much to learn regarding the concepts of psychogenic and neurogenic denial and their subsequent effect on rehabilitation outcome. We are constantly definingand refining our techniques to assist individuals in returning to a productive life after TBI.
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73 APPENDIX A RECRUITMENT LETTER AND ORAL SCRIPT FOR CASE MANAGERS
74 November 21,1995
Dear TBI Network Case Managers,
This letter is a request for Tour participation in my research study. I am a graduate student in psychology at the Ohio State University. Currently, I'm working on my doctoral dissertation under the supervision of Johannes Rojahn, Ph.D. As part of my dissertation, I am recruiting individuals who have sustained a traumatic brain injury (TBI) and use alcohol and other drugs.
The dissertation involves understanding how people view the use of alcohol and other drugs, as well as the effects of their TBI. Persons who participate in the study will be individually administered several questionnaires and tests evaluating substance use, severity of brain injury, and emotional impact of the TBI. * I would appreciate if you would consider being involved in this study. Tour involvement would consist of mailing out recruitment letters to individuals on your caseload along with filling out a questionnaire. The questionnaire is the Patient Competency Bating Form which addresses a staff informant's perceptions of an individuals abilities to perform a variety of practical skills. This questionnaire contains 30 items and is scored on a 5 point rating scale. The questionnaire will take approximately 15 minutes to complete. The information you provide will remain confidential. Please consider participating in this research study, if you are willing to participate please indicate by signing’-your name and title to the bottom of this letter. Thank you for your time and consideration.
Tours truly ,7
Denise Rabold, M.A.
Caqjb
75 Oral Script £or Case Managers
I am contacting you to see if you are willing to participate in my research study. As mentioned in the letter the study involves investigating individuals with both a TBI and diagnosed’substance abuse. I am specifically investigating the differences between psychogenic denial (traditional defense denial) and neurogenic denial (unawareness). This will be of benefit to you by hopefully increasing your ability to better treat these individuals so that rehabilitation will be more successful.
I need you to send out recruitment letters to individuals on your caseload that meet the following criteria:
1) sustained a significant TBI that required inpatient treatment in a rehabilitation facility or a loss of conscious of at least 24 hours;
2) have a documented DSM III-R or DSM IV diagnosis of either substance abuse or dependency;
3) have been involved with the TBI Network for a period of at least 2 months.
The letters will contain a response card and self addressed, stamped envelope for the individual to return to me. Each individual is to be assigned a code number which will be recorded on the response card. The response cards are to be returned whether or not the individuals wish to participate. If they indicate they are willing to participate I will contact you for their name and phone number. If they do not respond within three weeks a second mailing will be sent out by you. Once the individual has completed the testing you will be contacted again to fill out the Patient Competency Rating Scale. This should only take about IS minutes. Do you have any further questions or concerns? If you are willing to participate will you please sign the bottom of my recruitment letter.
76 APPENDIX B RECRUITMENT LETTER FOR SUBJECTS
77 T • H - E The TBI Network 106 McCanMcOmpbeH Hell IS81I Dodd On V* OHIO Columbus, OK 4321WJSO Phone 616*292-6559 SlftTE FAX 6t 4-684*3737 UNIVERSITY
January 2,1996
Dear (Subject's Name)
This letter is a request for your participation in a research study. The study is being conducted by Denise Rabold, who is a doctoral student in psychology at the Ohio State University. Currently, she is working on her dissertation und^r the supervision of Professor Johannes Rojahn.
Ms. Rabold will study how people with a traumatic brain injury view the use of alcohol *nd other drugs, fco do that Ms. Rabold wiLl individually administer several questionnaires and tests evaluating substance use, severity of brain injury, and emotional impact. She would also be reviewing your file to obtain information regarding your head injury. Tour case manager will complete one of the questionnaires. The testing will be performed at the TBI Network, McCampbell Hall, the Ohio State University and will take approximately two hours.
Ks. Rabold would appreciate if you would participate in this study. Tour name will remain confidential along with all information obtained. Tour decision to participate in this study will in no way effect your treatment at the TBI Network. Whether or not you agree to participate, please complete the response card indicating your decision. Place the response card in the self-addres.sed envelope and promptly return it to Ks. Rabold. Only if you wish to participate, will she then contact the TBI Network to obtain your name and phone number. She will call you in order to answer any questions you may have and to set up the testing date at your convenience. Thank you for your time and consideration.
Yours truly,
Case Manager TBT Network He U m 'JohannesJohann es Rojahn, PhPh.D. Denise Rabold,M.A ProfessorProfes of Psychology and Psychiatry Doctoral Student Nisonger Center, 614-292-9605 614-293-3830
78 Response card
Code number:_____
I am interested in participating in Denise Rabold's study. She may call me to further explain the study and schedule the 2 hour testing session.
I am not interested in participating in Denise Rabold’s study.
79 APPENDIX C FOLLOW - UP RECRUITMENT LETTER
80 T • H • E The TBI Network 106 McGunpbcU K ill 1S91 D odd D rive OHIO Cotumbu*. OH 43210-1290 Phone 614-292-4559 FAX 614-686*3737 SUNIVERSITY1ATE January 16,1996
Oear (Subject's Name)
Several weeks ago you received a letter regarding your participation in a research study. This letter is the second request for your participation in the study. The study is being conducted by Denise Rabold, who is a doctoral student in psychology at the Ohio State University. Currently, she is working on her dissertation under the supervision of Professor Johannes Rojahn.
Hs. Rabold will study how people with a traumatic brain injury view the use of alcohol ,and other drugs. To do that Hs. Rabold will individually administer several questionnaires and tests evaluating substance use, severity of brain injury, and emotional impact. She would also be reviewing your file to obtain information regarding your head injury. Tour case manager will complete one of the questionnaires. The testing will be performed at the TBI Network, McCampbell Hall, the Ohio State University and will take approximately two hours.
Hs. Rabold would appreciate if you would participate in this study. Tour name will remain confidential along with all information obtained. Your decision to participate in this study will in no way effect your treatment at the TBI Network. Whether or not you agree to participate, please complete the response card indicating your decision. Place the response card in the self-addressed envelope and promptly return it to Ms. Rabold. Only if you wish to participate, will she then contact the TBI Network to obtain your name and phone number. She will call you in order to answer any questions you may have and to set up the testing date at your convenience. Thank you for your time and consideration.
Yours truly.
Case Manager
Johannes Rojahn. Ph.D.Ph.D Denise Rabold,M.A. Professor of PsychologyPsycholo and Psychiatry Doctoral Student Nisonjer Center, 614-292-9605 614-293-3030
81 APPENDIX D ORAL SCRIPT FOR SUBJECTS
82 Oral Script for Subjects t am Oeaise Rabold and I am calling in response to your willingness to participate in my research study. Thank you far agreeing to participate. As indicated in the letter, you will be administered several tests evaluating your substance use, severity of brain injury, and its emotional impact on your life. This testing will take approximately two hours and be performed at the TBX network. Z will also be reviewing your file to obtain information regarding your injury such as: length of coma, length of hospitalisation, and length of post traumatic amnesia. Tour case manager will also be asked to -complete one of the questionnaires. Do you have any questions before X schedule you for your testing date? X want you to know that your decision to participate or complete this study will in no way effect your treatment at the TBI Network. When you come in for your testing I will have a consent form for you to sign. Again your involvement and any information obtained will be kept confidential.
83 APPENDIX E SOCRATES
84 SOCRATES Alcohol
Flfit N«mt Mid I nit Uflit H«m« Ol I Please read me following statements carefully. Each one describes a way that you might (or might not] feel about voctr drinking. For each statement, circle one number on the scale at the right to indicate how much you agree or disagree with it richt now. Please check one and only one number for every statement
1 2 3 4 S Strongly OlsagrM UtutacMad AgrM Strongly OlMgrM or Unaura Agree
1. 1 really want to make changes in my drinking. □ 1 □ 2 □ 3 0 4 OS
2, 1 am uncertain whether 1 drink too much. □ 1 □ 2 □ 3 0 4 □ 5 3. I definitely have seme problems related to my drinking. a i 0 2 □ 3 0 4 a s 4. 1 have already started making some changes in my drinking. □ f □ 2 □ 3 0 4 □ s 5. 1 was drinking too much at one time, but I've managed to change my drinking. □ i □ 2 0 3 0 4 □ 5
6. The only reason I'm here is that somebody made me come. □ 1 □ 2 □ 3 □ 4 □ s
7. Sometimes I wonder if I am an alcoholic.' □ 1 0 2 □ 3 □ 4 O S
8. I really want to do something about my drinking. □ 2 0 3 □ 4 □ 5 9. I'm not just thinking about changing my drinking. I'm already doing something about it □ i □ 2 □ 3 □ 4 a s
V* I have already changed my drinking, and 1 am looking for □ 1 Q 2 0 3 □ 4 □ S ways to keep from slipping back to my old pattern.
11. 1 have serious problems with drinking. □ i □ 2 0 3 0 4 □ S
12. Sometimes 1 wonder if my drinking is hurting other people. □ : □ 2 0 3 □ 4 □ S 13. 1 drink too much at a time. □ 2 0 3 0 4 □ s
14. 1 am actively doing things now to cut down or stop drinking. Q 1 0 2 0 3 0 4 a s
IS. I used to have problems with alcohol, but not any more. □ 2 Q 3 □ 4 a s
85 SOCRATES Alcohol
1 2 3 4 S Strongly Disagree Undecided Agra* Strongly Disagree or Unsure - Agra* 16. 1 think 1 need to b e coming to a treatment program for a i 0 2 0 3 CP □ S help with my drinking.
17. 1 question whether drinking is good for me. □ 1 Q 2 0 3 a * 0 5 18. If 1 don't change my drinking soon, my problems are going to get worse. □ 1 □ 2 0 3 0 4 0 5 19. 1 have already been trying to change my drinking and 1 am here to get some more help with it □ 1 0 2 0 3 0 4 0 5 20. Now that 1 have changed my drinking, it is important for me to hold onto the change I’ve made. □ 1 □ 2 0 3 0 4 0 5 2t. 1 know that 1 have a drinking problem. □ f □ 2 □ 3 0 4 0 5
22. 1 am uncertain whether 1 drink too much. □ 1 0 2 0 3 0 4 a s 23. It is definitely time for me to da something about the problems I have been having with alcohol. □ 1 □ 2 □ 3 0 4 □ 5 24. 1 have started to cany out a plan to cut down or stop my drinking. a i 0 2 0 3 0 4 0 5 25. 1 want help to keep from going back to the drinking problems that 1 h ad before. □ 1 0 2 0 3 0 4 OS
26. 1 am a fairly normal drinker. CP 0 2 0 3 0 4 a s 27. Some'.1'nes 1 wonder if 1 am in control of my drinking. CP 0 2 0 3 0 4 a s
28. I am an alcoholic. □ 1 0 2 □ 3 □ 4 a s
29. 1 am working hard to change my drinking. □ 1 0 2 □ 3 0 4 a s 30. 1 am worried that my previous problems with drinking might come back. □ 1 0 2 0 3 0 4 a s 31. I've had more trouble because of my drinking than most people do. □ 1 0 2 0 3 0 4 a s 32. 1 don’t think 1 have *a problem* with drinking, but there are times when 1 wonder if l drink too much. CP 0 2 □ 3 0 4 a s
86 SOCRATES Alcohol
1 2 3 4 8 Strongly Olsagreo UndocWod Agroo Strongly Olugrco orUfwura Agn*
33. 1 am a problem drinker. □ 1 0 2 0 3 0 4 0 5 34. 1 know that my drinking has caused problems, and 1 ami trying to do something about it □ 1 0 2 0 3 0 4 a s
35. 1 have made some changes In my drinking.' and 1 want some help to keep from going back to the way 1 used to drink. D ’ □ 2 0 3 0 4 a s
36. My problems are at least partly due to my own drinking. □ 1 □ 2 0 3 0 4 a s
37. I don't know whether or not 1 should change my drinking. □ 1 0 2 0 3 □ 4 □ s 36. My drinking is causing a tot of harm. □ 1 0 2 0 3 □ 4 0 5 39. 1 have a serious problem with drinking, and I have □ 2 □ 3 □ 4 □ S already started to overcome it □ 1
40. I'm sober, and I want to stay that way. □ 1 □ 2 □ 3 □ 4 □ 5
\
PraCsnUmptative Contamplotlva Oatarmlnatton Action Ualntananea .
87 Personal Drug Use SOCRATES
Please read me following statements carefully. Each one describes a way that you might (or might not) feel about voJr drinking. For each statement, drde one number on the scale at the right to indicate how much you agree or disagree with It right now. Please check one and only one number for every statement
1 2 3 4 5 Strongly Olsegree Undecided Agree Strongly ■ Disagree or Unsure Agree
1. I really want to m ake changes in my use of drugs. ai 0 2 0 3 □ 4 Os
2. I am uncertain whether I use drugs too much. Q i □ 2 0 3 □ * O s
3. I definitely have som e problems related to drugs at □ 2 □ 3 0 4 a* 4. I have already started making some changes in my use of drugs.. □ i 0 2 0 3 □ 4 as S. I was using drugs too much at one time, but I've managed to change that □ t 0 2 0 3 0 4 as
6. Tne only reason I'm here is that somebody made me come.D i □ 2 0 3 0 4 o s
7. Sometimes I wonder if 1 am an addict 0 2 03 0 4 a*
8. 1 really want to do something about my use of drugs. □ 1 0 2 03 0 4 OS 9. I'm not just thinking about changing my drug use. I'm already doing something about it Oi 0 2 0 3 0 4 OS 10. 1 have already changed my drug use. and 1 am looking for ways to keep from slipping back to my old pattern. O i □ 2 □ 3 0 4 as
11. 1 have serious problems with drugs. □ > □ 2 □ 3 □ 4 as
12, Sometimes 1 wcnder if my drug use is hurting other people. Q i 0 2 □ 3 □ 4 as
13. 1 use drugs too much at a time. at 0 2 □ 3 □ 4 as 14. 1 am actively doing things now to cut down or stop my use of drugs. □ i □ 2 □ 3 □ 4 as
IS. 1 used to have problems with drugs, but not any more. □ i □ 2 0 3 0 4 as
88 Personal Drug Use SOCRATES
1 2 . 3 4 S Strongly Olsagree UndeeMed Agroe Strongly Disagree or Unsure Agroe
16. I think I need lo be coming to a treatment program for helpwith my drug problems. O i 0 2 0 3 O a .O s 17. I question whether using drugs is good for me. □< 02 03 □« Os
18. If I don't change my drug use soon, my problems are going to get worse. Q r 0 2 0 3 0 4 Q s
19. I have already been trying to change my drug use and I am here to get some more help with it O t 0 2 C13 0 4 O s 20. Now that I have changed my drug use. it is important for me to hold onto the change I've made. □ l 02 03 □* Os 21. I know that I have a drug problem. Ot 02 03 04 Os
22. I am uncertain whether I use drugs too much. Q1 02 03 04 OS 23. It is definitely time for me to do something about the problems I have been having with drugs. O i 02 03 04 OS 24. I have started to carry out a plan to cut down or stop my drug use. OI 02 03 0 4 O S
25. I want help to keep from going back to the drug problems that I had before. di 02 03 04 a s 26. I am fairly normal in my use c? drugs. a t 02 03 04 os
27. Sometimes I wonder if I am in control of my drug use. at 02 as 04 as 26. I am a drug addict. Qi 02 03 04 as 29. I am working hard to change my drug use. ai aa 03 04 as 30. I am worried that my previous problems with drugs might come back. Oi 02 03 04 as
31. I've had more trouble because of drugs than most people do. ai 0 2 0 3 04 as
89 Personal Orug Use SOCRATES
1 2 3 4 5 Strongly Disagree Undecided Agroe Strongly Disagree or Unsure . Agroe
3 2 . 1 don't think 1 have *a problem* wtth drugs, but there □ i a * a a □ * OS are times when 1 wonder if I use drugs too much.
33. 1 have a drug problem. □ t □ 2 0 3 0 4 as
3 4 . I know that my drug use has caused problems, and 1 am 1 am trying to do something about it □ t □ 2 0 3 0 4 as
35. 1 have made some changes in my drug use, and 1 want some help to keep going. a i a * 0 3 0 4 o s
3 6 . My problems are at least partly due to my own drug use. ai □ 2 □ 3 □ 4 o s
3 7 . 1 don’t know whether or not 1 should change my drug use.. □ i 0 2 □ 3 0 4 as
38. My drug use is causing a lot of harm. a i 0 2 a s 0 4 as
39. 1 have a serious problem with drugs, and 1 have already started to overcome it a i □ 2 0 3 0 4 a s
40. 1 am dean and sober, and 1 want to stay that way. a i 0 2 0 3 0 4 a s
PrcConumpUtlv* Contemplative determination A ction M iln K m o ca
90 APPENDIX F PATIENT COMPETENCY RATING SCALE
9 1 Patient Competency Rating (Patient’s Form), Neuropsychological Rehabilitation Program, Presbyterian Hospital
Idea Afr i t bfonHdo* Pwicnt'i Name: . -
Patient's A * c ______
H m r r
Im traetk Ha -Tbc foDowinx a a questionnaire that asks you to judge your abillry to do & variety of very practical skills. Some o f the questions may not. apply di rectly to (hints you o fte n d o . h u t you are asked to com plete each question as if h were somethin# you “had to do.* On each qiiesdoo, you should judte how easy or difficult a particular activity is for you and mark the ap propriate space.
’ompeteacy Raring C an do V ery w ith C an diffi som e F airly d o C an 't cu lt 92 3. How much of a problem do 1 hav« in taking o re o f my personal hygiene? 4. How much of a problem do Ihave in washing the dishes? 3. How modh of a problem do I have in doing the laundry? d. How much of a problem do ( have in taking care, of my finances? 7. How much of a problem do I have in keeping ap- .poiatments on time? 5. How much of a problem' do I have in starting coo* vcrsadoo in a group? 9. How much of a problem do I have tn staying in volved in work activities even when bored or dred? 10. How much of a problem do ( have in remembering what 1 had for dinner last night? 11. How much of a problem do I have in remembering names of people I see often? 12. How much of a problem do 1 have in remembering my daily schedule? 13. How m uch o f a problem do I have in remembering important things t must do? 14. How much o f problema would (have driving a ear if ( had to? 15. How much of a problem da t have in getting help when I'm confined? Id. How much o f a ptobkm do I have is adjusting to unexpected changes? 17. How much of a problem do 1 have in handling arguments with people t know wdl? 13. How much of a problem do I have in accepting cridssm from othtf people? 19. How much of a proWetn- do I have in controlling - crying? 20. How much of a problem do I have in acting appro priately when I’m around friends? 21. How much of a problem do I have in showing af fection to people? 22. How much of a problem do I have in participating in group activities? 23. How much of a problem do 1 have in recognizing when something I say or do has upset someone else? C an do Very with ' * Cia tone Ftidy do C an’t cult dUH< ea*y ‘ with do todo catty id do' cue 2*. How much of a problem do ( have in scheduling daily aofvidct? 23. Kow much of a problem do I have in undcnaad* lag acw tratntctfoas? 26. How much of a piobttm do t have in contatendy meeting my daily respon sibilities? 27. How much of a problem do t have in controlling my temper when some thing upsets me? 22. How much of a problem do t have in keeping from bein g^icprcucd? 29. How;much of a problem do I 'haye in keeping my emotions from affecting my ability to go about the day's activities? 30. How niuch of a problem do ( have in controlling my laughter? 95 Patient Competency Rating (Relative's Form), Neuropsychological Rehabilitation Program, Presbyterian Hospital Patient's Name: - Patient's A te ______ D a te :. .. infot mam 's ndariooship to patient (dreJe ooe): 1. .M other 8. Niece or aepbew 2. Father 9. Cousin 3. Spouse 10. Friend 4. Child 11. ta-law 5. Sibling 12. W ard attendant 6. Grandparent 11 O th e r 7. A unt or unde Sex of informant: M ale______Female - How *eQ is informant acquainted with patient’s behavior? 1. Hardly at aO 4. Pretty wefl 2. Not so well 5. Very »cfl 3. Fairly well Instructions The following is a questionnaire that asks you to judge this person's ability to do a variety of very practical ilalls. Some of the questions may not apply directly to things they often do. but you are asked to complete each question as if it were something they “had to do." On each question, you 96 should judge how easy or difficult & particular activity ^ for them and mark (*« aboropriate space. Coapmser Radn| Can do • Very with' Can d iffi aotac Fairly do Can't cult diffi easy with do to do culty to do case 1. How much of a problem do they have in preparing their own meals? ____ 2. How much of a problem do they have in dressing theouelvci? ____ 3. How much of a problem do they have in taking _eare of their personal hygiene?______а. How much of a problem do they have in washing the dishes? - J. Kow^much of a problem do they have in doing the laundry? - б. Mow much of a problem do they have in taking care of their finances? ____ 7. How much of a problem do thf y have in keeping appointments on time? . 8. Haw much of a problem do they have in starting conversation in a g ro u p ? _ 9. H o w much of a problem do they have in staying involved in work activities even when bored or tired? ____ 97 U S do Very * Can dUtt* a m Fattty do Caoft auk 401■ easy ' Wflfc da ta da catty to d o earn 10. How much o f a problem do they have la remem bering wtar dtcytadfbr dinner lam night? It. How much af m problem do they have ia w aa » beriag tam es of people they *ee often? 12. How much of a problem do they have la remem bering thdr daily . schedule? 1J. How much-of a problem do they have in remem bering important they muff do? U. How much of a problem would they have driving a car if they had to? IJ. How much of a problem do they have In getting help when they are confused? Id. How much of a p roblem do they have in adjusting to unexpected changes? |7. How much of a problem do they have in handling arguments with people they know well? 11. H o* m uch o f a problem do they have in accepting criticism from other people? 98 19. How much of a problem do they have in ooneral- Uttg crying? 20. How much of a problem do they have in actinf ap propriately when they are around friends? 21. How much of a problem do they have in showing affeaion to people? 22. How much of a problem do they have in participat ing is group activities? 23. How much of a problem, do, they have in recogniz ing when something they say or do has upset-some one else? How much of a problem do they have in schedul ing daily activities? 23. How much of a problem do they have in under standing new instructions? 26. How much of a problem do they have in consist ently meeting their daily responsibilities? 27. How much of a problem do they have in control ling their temper when something upsets them? 23. How much of a problem Kowaoefcof • probkm do A*r h m fa fcafatag MratdMftMtf- te d a s (M r abflqr m to •boot A* far* aaMtksf i a Ha* modi of a problem do tbey hove ia controt- Bot ihetr Iwjheor? APPENDIX G ZUNG SELF-RATING DEPRESSION SCALE 101 Zung Setf-nrdng Oopruosloa Seal# Indicate which g f the four responses applies for each statement given below. Responses 1 ■ N o se ,or a little of the time 2 > Some of (he tune 3 a Good pen o f the time 4 aM octo r all o f the time No. Answer Statement 1.______I feci down-hearted, blue, and sad. 2. ____ Morning is when I feel the best. 3. - - 1 have crying spells orfed like it. 4. — .. I have trouble sleeping through the night. 3. . I eat as much as 1 used to. 6. _ . . I enjoy looking at, calking to, and being with attractive men/ w om en. ■ 7.______1 notice that I am losing weight. 8. ____ I have trouble with constipation. 9. ____ My heart beau faster than usual. 10. ____ I get tired for no reason. 11. ____ My mind is as clear as it used to be. 12. ____ I find it easy to do the thingsI used to . 13. ____ I am restless and can’t keep stiQ. U. . I feel hopeless about the fature. 1 3 . I am more irritable (has usual. 16. ____ I find it easy to make decisions. 17. . I feci that 1 am useful and needed. 18. ____ My life is pretty full. 19. ____ 1 feel that others wouid be better off if 1 were dead. 20. ____ I still enjoy the things I used to. 102 APPENDIX H ZUNG SELF-RATING ANXIETY SCALE 103 T a b l e m — The SeU-catirtg Axtxiecy Scale (S A S ) !UKE ______AGE SEE: H F SO. OATX Mono OB A U n i t Sana Caad pare Matt OB U l •( tha tlaa • t tit* t l a a a( ek* tlaa •C tha H a t 1. t (tat aar* m k m i u 4 •n tm tfcah aattal J. X tn l tlraU te e m n u n ae all I. X »*t n u t au ltf w fool panicky A. X fail lUu t'a (illlH m 4 M tH M 9. X taat that m tycklat 1* all rl|fcc urf wtM ni bad vtll tiaapao t . K]r armj and la g i ihafca and ( c u b i t 7. I aa latlittK by haadachaa, sack tab back paint 1. X faal utk ana («e ctrad u tlly 9. t Xaal calu ait eta ate tclll tailly 10. X c n ft* I w f haart bat tin* (tic • 11.- 1 m knOiirK by dlxcy (Falla IX. X haw* (tin tin g ap alla a r (a a l Ilk a (C 13. X c to bcttcke la and cut a n a lly 1 14. X | t c IttU n g t of auabnaaa and tin g lin g la ay ftn g ara, Caac 1). X aa bocharad by aeaaachactiaa or tndlftatlon IT. Ky handt art utually dry and war* . , 1 ( a l l talaaa a a iily and gac a load nttbe't rest 20. X hjv* nigheaaett 104 APPENDIX I SATISFACTION WITH LIFE SCALE 105 Flrat Nam* L**t Mum * SWLS 4 5.6 11. bi moot m y* my Of* to dou to fny MmL Q1 02 Ql Q4 OS Qs O? j 2. Th« condition* of my Ilf* «t* oxcottoitt. Q1 02 03 04 Qs OSj 07 3. I im HtW M wKh my Itta. Oi 02 03 04 OS Q6 0 7 j 4. So far I hav* gotMn tha Important thing* 1 want In Of*. O t 0 2 - 0 3 O * Q * 0 3 0 7 I 5. W I could llv* my Of* ovor. I would chang* *lme*t nottilng.Q1 0 2 0 3 0 4 Q s □ « Q 7 | T otal \ CSck hora to continue. FamSal i* naod. 106 APPENDIX J CONSENT FORM 107 Nijongrr Cenier UAP 1561 Dodd Drive Columbus, OH -13210-12% OHIO Phone 614-292-8365 SIAIE FAX 614-292-3727 u n iv ersity Protocol ID:______ CONSENT FOR PARTICIPATION IN SOCIAL AND BEHAVIORAL RESEARCH I agree to participate in a study with the title DIFFERENTIATING BETWEEN PSYCHOGENIC AND NEUROGENIC DENIAL. The study is conducted by Denise Rabold, H.A. (psychology graduate student) and supervised by Professor Johannes Rojahn from the Ohio State University. The purpose of the study, the procedures to be followed, and the expected duration of my involvement have been explained to me. In addition, I understand that my records will be reviewed in order to obtain Information regarding the specifics of my brain injury and course of hospitalization. A staff informant will also be involved in the study. I acknowledge that I have had the opportunity to obtain additional information regarding the study and that any questions I have raised have been answered to my full satisfaction. Further, I understand that I am free to withdraw consent at any time and to discontinue participation in the study without prejudice to me. Finally, I acknowledge that I have read and fully understand the consent form. I sign it freely and voluntarily. A copy has been given to me. Signatures: Subject: Date: ______ Advisor: Date; /'S' Johannes Rojann, Ph.D. Profebsor of Psychology and Psychiatry ‘Nisonger Center, 614-292-9605 Witness: Date: ______ 108 APPENDIX K RAW DATA 109 Legend for Appendix L Id - Identification Number Age - Age in Years Sex - 1 = Male, 2 = Female Ed - Education in Years Coma - Length of Coma in Hours Group - 1 = Psychogenic, 2 = Neurogenic, 3 = Both, 4 = Neither DOM - Dominance: 1 = Right, 2 = Left DOI - Date Since Injury in Months Neuro - Neurogenic Denial: 1 = Present, 2 = Absent Psych - Psychogenic Denial: 1 = Present, 2 = Absent Tapping - Finger Oscillation Test: 0 = Normal, 1 = Normal, 2 = Miid - Moderate, 3 = Severe Grip - Grip Strength: 0 = Normal, 1 = Normal, 2 = Mild - Moderate, 3 = Severe Tactile - Tactile Portion of Reitan - Klove Sensory - Perceptual Examination: 0 = Normal, 1 = Normal, 2 = Mild - Moderate, 3 = Severe Auditory - Auditory Portion of Reitan - Klove Sensory - Perceptual Examination: 0 = Normal, 1 = Normal, 2 = Mild - Moderate, 3 = Severe Visual - Visual Portion of Reitan - Klove Sensory - Perceptual Examination: 1 = Normal, 2 = Mild - Moderate, 3 = Severe TFR - Tactile Finger Recognition. 0 = Normal, 1 = Normal, 2 = Mild - Moderate, 3 = Severe FNW - Finger - Tip Number Recognition: 0 = Normal, 1 = Normal, 2 = Mild-Moderate, 3 = Severe SAS - Zung Self-rating Anxiety Scale: Raw Scores SAD - Zung Self-rating Depression Scale: Raw Scores SWLS - Satisfaction with Life Scale: Raw Scores WCST - Wisconsin Card Sorting Test: 1 = Mild, 2 = Moderate, 3 = Severe Global - Total of Neuropsychological Scores Lateral - Lateralization in Brain of Impairment: 1 = Right, 2 = Left, 3 = Mixed 110 10* dam psycho vliiul £21 336 730 722 437 C04 216 236 106 166 96.0 536 240 317 336 651 420 375 489 1006 720 601 1344 151 676 170 604 £05 216 fnwr MS sid twls west globit lateral 1 1 20 40 29 83 6 1 2 3 66 60 7 30 21 1 3 1 29 42 12 48 9 1 4 0 72 66 6 27 12 2 6 0 37 36 23 20 9 3 e 1 46 43 15 48 7 2 7 0 38 43 18 40 6 1 8 0 35 49 12 61 11 2 8 0 36 39 29 41 2 2 10 0 33 39 23 63 6 3 11 1 36 41 7 29 6 1 12 1 36 37 9 61 9 1 13 2 26 46 22 32 4 1 14 2 41 40 47 30 I t 3 18 1 27 35 10 33 7 3 16 2 29 35 13 20 10 3 17 0 33 36 11 26 13 3 18 0 30 39 10 28 3 » 19 3 38 48 7 80 8 2 20 1 34 36 11 28 9 1 21 1 26 47 32 69 4 1 22 2 62 49 18 20 8 1 id ■B* MX td com* group dam dot (Muro ptycho tapping grip (Milt audit ory vtiual t(r 23 3 36 1 16 3 1 192 1 1 3 3 0 3 0 1 24 no 24 1 14 192 3 1 44 1 1 3 3 0 0 3 0 25 7IS 34 1 12 604 3 1 60 1 1 1 3 0 0 2 0 36 495 33 1 12 • 3 1 19 1 1 I 1 0 0 0 0 27 853 19 1 11 336 3 I 3 1 1 1 3 0 3 1 0 38 549 38 1 12 1056 3 1 48 1 1 2 3 0 0 0 0 29 189 29 1 12 336 3 1 28 1 1 3 3 1 0 1 2 30 726 40 1 14 120 4 1 84 2 2 3 2 1 3 3 1 31 617 27 1 16 264 4 1 32 2 2 1 3 1 0 0 1 32 267 41 1 12 1968 4 1 57 2 2 3 1 0 1 0 1 33 647 40 1 12 336 4 2 17 2 2 0 3 0 0 0 2 34 321 34 1 13 364 4 1 140 2 2 2 3 0 0 0 0 36 700 42 1 14 • 4 1 12 2 2 3 2 0 3 3 2 36 487 32 1 12 166 4 1 120 2 2 0 3 t 0 1 0 37 2 37 1 11 336 4 1 60 2 2 3 1 0 . 0 J 1 38 614 46 1 10 600 4 72 2 2 3 3 3 3 3 3 39 793 43 1 12 2.00 4 1 166 2 2 1 2 1 1 0 1 823 38 1 14 604 4 1 16 2 2 3 0 0 0 0 0 40, 1 tnw ((• ltd twit WClt Olobil lateul 23 36 42 6 47 2 1 0 10 24 3 63 60 6 76 12 1 26 1 41 47 14 37 7 3 26 3 39 37 17 64 6 1 27 2 27 39 9 63 10 1 26 0 36 42 17 39 6 3 23 2 28 29 25 36 12 2 30 0 60 43 6 31 13 3 3t 2 39 39 17 67 6 2 32 3 27 41 27 65 9 1 33 0 42 46 12 46 6 1 34 2 36 36 24 47 7 2 36 1 26 36 10 20 14 1 36 0 27 43 30 41 6 2 37 3 40 46 26 29 9 3 36 0 46 46 11 37 16 2 36 1 61 42 16 39 7 2 40 0 40 44 17 39 3 t