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............................................................................