Hostname: page-component-669899f699-swprf Total loading time: 0 Render date: 2025-04-26T08:39:31.610Z Has data issue: false hasContentIssue false
  • English
  • Français

Metacognitive unawareness correlates with executive function impairment after severe traumatic brain injury

Published online by Cambridge University Press:  29 January 2010

PAOLA CIURLI ,
UMBERTO BIVONA ,
CARMEN BARBA ,
GRAZIANO ONDER ,
DANIELA SILVESTRO ,
EVA AZICNUDA ,
JESSICA RIGON  and
RITA FORMISANO
PAOLA CIURLI*
Affiliation:
Post-Coma Unit, Santa Lucia Foundation, Rome, Italy
UMBERTO BIVONA
Affiliation:
Post-Coma Unit, Santa Lucia Foundation, Rome, Italy
CARMEN BARBA
Affiliation:
Pediatric Neurology Unit, Children’s Hospital “Meyer”, Florence, Italy
GRAZIANO ONDER
Affiliation:
Geriatric Department, Catholic University, Rome, Italy
DANIELA SILVESTRO
Affiliation:
Post-Coma Unit, Santa Lucia Foundation, Rome, Italy
EVA AZICNUDA
Affiliation:
Post-Coma Unit, Santa Lucia Foundation, Rome, Italy
JESSICA RIGON
Affiliation:
Neuropsychological Department, San Camillo Hospital, Venice Lido, Italy
RITA FORMISANO
Affiliation:
Post-Coma Unit, Santa Lucia Foundation, Rome, Italy
*
*Correspondence and reprint requests to: Paola Ciurli, Servizio di Diagnosi e Riabilitazione Neuropsicologica, Fondazione Santa Lucia, Via Ardeatina 306, 00179 Roma, Italy. E-mail: [email protected]
Get access Rights & Permissions [Opens in a new window]

Abstract

The aim of this study was to evaluate clinical, neuropsychological, and functional differences between severe traumatic brain injury (TBI) outpatients with good and/or heightened metacognitive self-awareness (SA) and those with impaired metacognitive SA, assessed by the Patient Competency Rating Scale (PCRS). Fifty-two outpatients were recruited from a neurorehabilitation hospital based on the following inclusion criteria: 1) age ≥ 15 years; 2) diagnosis of severe TBI; 3) availability of neuroimaging data; 4) post-traumatic amnesia resolution; 5) provision of informed consent. Measures: A neuropsychological battery was used to evaluate attention, memory and executive functions. SA was assessed by the PCRS, which was administered to patients and close family members. Patients were divided into two groups representing those with and without SA. Patients with poor SA had more problems than those with good SA in some components of the executive system, as indicated by the high percentage of perseverative errors and responses they made on the Wisconsin Card Sorting Test. Moreover, a decrease in metacognitive SA correlated significantly with time to follow commands (TFC). This study suggests the importance of integrating an overall assessment of cognitive functions with a specific evaluation of SA to treat self-awareness and executive functions together during the rehabilitation process. (JINS, 2010, 16, 360–368.)

Keywords

Executive functionsMetacognitive self-awarenessPerseverative errorsSevere TBINeuropsychological rehabilitationSA assessment
Type
Research Articles
Information
Journal of the International Neuropsychological Society , Volume 16 , Issue 2 , March 2010 , pp. 360 - 368
Copyright
Copyright © The International Neuropsychological Society 2010

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Article purchase

Temporarily unavailable

References

REFERENCES

Allen, C.C., & Ruff, R.M. (1990). Self-rating versus neuropsychological performance of moderate versus severe head-injured patients. Brain Injury, 4, 7–17.CrossRefGoogle ScholarPubMed
Anson, K., & Ponsford, J. (2006). Who benefits? Outcome following a coping skills group intervention for traumatically brain injured individuals. Brain Injury, 20, 1–13.CrossRefGoogle ScholarPubMed
Apollonio, I., Leone, M., Isella, V., Piamarta, F., Consoli, T., Villa, M.L., et al. . (2005). The Frontal Assessment Battery (FAB): Normative values in an Italian population sample. Journal of the Neurological Sciences, 26, 108–116.CrossRefGoogle Scholar
Bach, L.J., & David, A.S. (2006). Self-awareness after acquired and traumatic brain injury. Neuropsychological Rehabilitation, 16, 397–414.CrossRefGoogle ScholarPubMed
Basso, A., Capitani, E., & Laiacona, M. (1987). Raven’s Coloured Progressive Matrices: Normative values on 305 adults normal controls. Functional Neurology, 2, 189–194.Google ScholarPubMed
Ben-Yishay, Y., Rattok, J., Lakin, P., Piasetsky, E.B., Ross, B., Silver, S., et al. . (1985). Neuropsychological rehabilitation: Quest for a holistic approach. Seminars in Neurology, 5, 252–259.CrossRefGoogle Scholar
Bivona, U., Ciurli, P., Barba, C., Onder, G., Azicnuda, E., Silvestro, D., et al. . (2008). Executive function and metacognitive self-awareness after severe traumatic brain injury. Journal of the International Neuropsychological Society, 14, 862–868.CrossRefGoogle ScholarPubMed
Boake, C., Freeland, J.C., Ringholz, G.M., Nance, M.L., & Edwards, K.E. (1995). Awareness of memory loss after severe closed-head injury. Brain Injury, 9, 273–283.CrossRefGoogle ScholarPubMed
Borgaro, S., & Prigatano, G. (2002). early cognitive and affective sequelae of traumatic brain injury: A study using the BNI screen for higher cerebral functions. Journal of Head Trauma Rehabilitation, 17, 526–534.CrossRefGoogle ScholarPubMed
Borgaro, S., & Prigatano, G. (2003). Modification of the Patient Competency Rating Scale for use on an acute neurorehabilitation unit: The PCRS-NR. Brain Injury, 17, 847–853.CrossRefGoogle Scholar
Cicerone, K.D. (1991). Psychotherapy after mild traumatic brain injury: Relation to the nature and severity of subjective complaints. Journal of Head Trauma Rehabilitation, 6, 30–43.CrossRefGoogle Scholar
Crosson, C., Barco, P.P., Velozo, C., Bolesta, M.M., Cooper, P.V., Werts, D., et al. . (1989). Awareness and Compensation in postacute head injury rehabilitation. Journal of Head Trauma Rehabilitation, 4, 46–54.CrossRefGoogle Scholar
De Renzi, E., & Vignolo, L.A. (1962). The Token Test: A sensitive test to detect receptive disturbances in aphasics. Brain, 85, 556–678.CrossRefGoogle Scholar
Dirette, D.K., & Plaisier, B.R. (2007). The development of self-awareness of deficits from 1 week to 1 year after traumatic brain injury: Preliminary findings. Brain Injury, 21, 1131–1136.CrossRefGoogle ScholarPubMed
Fischer, S., Gauggel, S., & Trexler, L.E. (2004). Awareness of activity limitations, goal setting and rehabilitation outcome in patients with brain injuries. Brain Injury, 18, 547–562.CrossRefGoogle ScholarPubMed
Flashman, L.A., Amador, X., & McAllister, T.W. (1998). Lack of awareness of deficit in traumatic brain injury. Seminars in Clinical Neuropsychiatry, 3, 201–210.Google ScholarPubMed
Fleming, J.M., Strong, J., & Ashton, R. (1996). Self-awareness of deficits in adults with traumatic brain injury: How best to measure? Brain Injury, 10, 1–15.Google ScholarPubMed
Fleming, J.M., Strong, J., & Ashton, R. (1998). Cluster analysis of self-awareness levels in adults with traumatic brain injury and relationship to outcome. Journal of Head Trauma Rehabilitation, 13, 39–51.CrossRefGoogle ScholarPubMed
Fordyce, D.J., & Roueche, J.R. (1986). Changes in perspectives of disability among patients, staff and relatives during rehabilitation of brain injury. Rehabilitation Psychology, 31, 217–229.CrossRefGoogle Scholar
Formisano, R., Bivona, U., Penta, F., Giustini, M., Buzzi, M.G., Ciurli, P., et al. . (2005). Early clinical predictive factors during coma recovery. Acta Neurochirurgica; 93, 201–205.CrossRefGoogle ScholarPubMed
Hagen, C., Malkmus, D., & Durham, P. (1972). Levels of cognitive functioning. Downey, CA: Rancho Los Amigos Hospital.Google Scholar
Hanks, R.B., Rappaport, L.J., Millis, S.R., & Deshpande, S.A. (1999). Measures of executive functioning as predictors of functional ability and social integration in a rehabilitation sample. Archives of Physical Medicine and Rehabilitation, 80, 1030–1036.CrossRefGoogle Scholar
Hart, T., Seignourel, P.J., & Sherer, M. (2009). A longitudinal study of awareness of deficit after moderate to severe traumatic brain injury. Neuropsychological Rehabilitation, 19, 161–176.CrossRefGoogle ScholarPubMed
Hart, T., & Sherer, M. (2005). Preface to special edition. Journal of Head Trauma Rehabilitation, 20, 285–286.CrossRefGoogle Scholar
Hart, T., Whyte, J., Kim, J., & Vaccaro, M. (2005). Executive function and self-awareness of “real-world” behavior and attention deficits following traumatic brain injury. Journal of Head Trauma Rehabilitation, 20, 333–347.CrossRefGoogle ScholarPubMed
Heaton, R.K., Chelune, G.J., Talley, J.L., Kay, G.G., & Curtiss, G. (1993). Wisconsin Card Sorting Test. Florida: Psychological Assessment Resources, Inc.Google Scholar
Heaton, R.K., Chelune, G.J., Talley, J.L., Kay, G.G., & Curtiss, G. (2000).WCST: Wisconsin Card Sorting Test. Forma completa revisionata. Adattamento italiano a cura di Hardoy, M.C., Carta, M.G., Hardoy, M.J. e Cabras, P.L. in O.S. Organizzazioni Speciali (Ed) it. Firenze.Google Scholar
Hoofien, D., Gilboa, A., Vakil, E., & Barak, O. (2004). Unawareness of cognitive deficits and daily functioning among persons with traumatic brain injuries. Journal of Clinical and Experimental Neuropsychology, 26, 278–290.CrossRefGoogle ScholarPubMed
Hoofien, D., & Sharoni, L. (2006). Measuring unawareness of deficits among patients with traumatic brain injury: Reliability and validity of the Patient Competency Rating Scale–Hebrew version. Israel Journal of Psychiatry & Related Sciences, 43, 296–230.Google ScholarPubMed
Johnstone, B., Hexum, C.L., & Ashkanazi, G. (1995). Extend of cognitive deficit in traumatic brain injury based on estimates of premorbid intelligence. Brain Injury, 9, 377–384.CrossRefGoogle Scholar
Jorge, R., & Robinson, R.G. (2002). Mood disorders following traumatic brain injury. Neurorehabilitation, 17, 311–324.CrossRefGoogle ScholarPubMed
Kennedy, R.E., Livingston, L., Riddick, A., Marwitz, J.H., Kreutzer, J.S., & Zasler, N.D. (2005). Evaluation of the Neurobehavioral Functioning Inventory as a depression screening tool after traumatic brain injury. Journal of Head Trauma Rehabilitation, 20, 512–526.CrossRefGoogle ScholarPubMed
Kreutzer, J.S., Seel, R.T., & Gourley, E. (2001).The prevalence and symptom rates of depression after traumatic brain injury: A comprehensive examination. Brain Injury, 15, 563–576.CrossRefGoogle ScholarPubMed
Krikorian, R., Bartok, J., & Gay, N. (1994). Tower of London procedure: A standard method and developmental data. Journal of Clinical and Experimental Neuropsychology, 16, 840–850.CrossRefGoogle Scholar
Leathem, J.M., Murphy, L.J., & Flett, R.A. (1998). Self- and informant ratings on the Patient Competency Rating Scale in patients with traumatic brain injury. Journal of Clinical and Experimental Neuropsychology, 20, 694–705.CrossRefGoogle ScholarPubMed
Levin, H.S., O’Donnel, V.M., & Grossman, R.G. (1979). The Galveston orientation and amnesia test: A practical scale to assess cognition after head injury. Journal of Nervous and Mental Disease, 167, 675–684.CrossRefGoogle Scholar
Malec, J.F., & Moessner, A.M. (2001). Self-awareness, distress, and postacute rehabilitation outcome. Rehabilitation Psychology, 45, 227–241.CrossRefGoogle Scholar
Mattson, A.J., & Levin, H.S. (1990). Frontal lobe dysfunction following closed head injury. A review of the literature. The Journal of Nervous and Mental Disease, 178, 282–291.CrossRefGoogle ScholarPubMed
McMillan, T.M., Jongen, E.L., & Greenwood, R.J. (1996). Assessment of post-traumatic amnesia after severe closed head injury: Retrospective or prospective? Journal of Neurology, Neurosurgery, and Psychiatry, 60, 422–427.CrossRefGoogle ScholarPubMed
Mukhopadhyay, P., Dutt, A., Das, S.K., Basu, A., Hazra, A., Dhibar, T., et al. . (2008). Identification of neuroanatomical substrates of set-shifting ability: Evidence from patients with brain focal lesions. Progress in Brain Research, 168, 95–104.CrossRefGoogle Scholar
Noè, E., Ferri, J., Caballero, M.C., Villadre, R., Sanchez, A., & Chirivella, J. (2005). Self-awareness after acquired brain injury. Predictors and rehabilitation. Journal of Neurology, 252, 168–175.CrossRefGoogle ScholarPubMed
Novelli, G., Papagno, C., Capitani, E., Laiacona, M., Vallar, G., & Cappa, S.F. (1986). Tre test clinici di ricerca e produzione lessicale. Taratura su soggetti normali. Archivio di Psicologia, Neurologia e Psichiatria, 47, 477–506.Google Scholar
O’Keeffe, F., Dockree, P., Moloney, P., Carton, S., & Robertson, I.H. (2007). Awareness of deficits in traumatic brain injury: A multidimensional approach to assessing metacognitive knowledge and online-awareness. Journal of the International Neuropsychological Society, 13, 38–49.Google ScholarPubMed
Orsini, A. (2003). La memoria diretta e la memoria inverse di cifre in soggetti dai 16 ai 64 anni. Bollettino di Psicologia Applicata, 239, 73–77.Google Scholar
Ownsworth, T., & Clare, L. (2006). The association between awareness deficits and rehabilitation outcome following acquired brain injury. Clinical Psychology Review, 26, 783–795.CrossRefGoogle ScholarPubMed
Ownsworth, T., Fleming, J., Strong, J., Radel, M., Chan, W., & Clare, L. (2007). Awareness typologies, long-term emotional adjustment and psychosocial outcomes following acquired brain injury. Neuropsychological Rehabilitation, 17, 129–150.CrossRefGoogle ScholarPubMed
Pagulayan, K.F., Temkin, N.R., Machamer, J.E., & Dikmen, S.S. (2007). The measurement and magnitude of awareness difficulties after traumatic brain injury: A longitudinal study. Journal of the International Neuropsychological Society, 13, 561–570.CrossRefGoogle ScholarPubMed
Port, A., Willmott, C., & Charlton, J. (2002). Self-awareness following traumatic brain injury and implications for rehabilitation. Brain Injury, 16, 277–289.CrossRefGoogle ScholarPubMed
Prigatano, G.P. (1996). Behavioral limitations TBI patients tend to underestimate: A replication and extension to patients with lateralized cerebral dysfunction. The Clinical Neuropsychologist, 10, 191–201.CrossRefGoogle Scholar
Prigatano, G.P., & Altman, I.M. (1990). Impaired awareness of behavioral limitations after traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 71, 1058–1064.Google ScholarPubMed
Prigatano, G.P., Altman, I.M., & O’Brien, K.P. (1991). Behavioural limitations traumatic brain-injured patients tends to understimate. BNI Quarterly, 7, 27–33.Google Scholar
Prigatano, G.P., Bruna, O., Mataro, M., Munoz, J.M., Fernandez, S., & Junque, C. (1998). Initial disturbances of consciousness and resultant impaired awareness in Spanish traumatic brain injured patients. Journal of Head Trauma Rehabilitation, 13, 29–38.CrossRefGoogle Scholar
Prigatano, G.P., Fordyce, D.J., Zeiner, H.K., Roueche, J.R., Pepping, M., & Wood, B.C. (1986). Neuropsychological rehabilitation after brain injury. Baltimore: Johns Hopkins University Press.Google Scholar
Prigatano, G.P., & Schacter, D.L. (1991). Awareness of deficit after brain injury: Theoretical and clinical issues. New York: Oxford University Press.Google Scholar
Rao, V., & Lyketsos, C. (2000). Neuropsychiatric sequelae of traumatic brain injury [Review]. Psychosomatics, 41, 95–103.CrossRefGoogle ScholarPubMed
Rappaport, M., Hall, K.M., Hopkins, H.K., Belleza, T., & Cope, D.N. (1982). Disability rating scale for severe head trauma: Coma to community. Archives of Physical Medicine and Rehabilitation, 63, 118–123.Google ScholarPubMed
Roueche, J.R., & Fordyce, D.J. (1987). Perceptions of deficits following brain injury and their impact on psychosocial adjustment. Cognitive Rehabilitation, 1, 4–7.Google Scholar
Sbordone, R.J., Seyranian, G.D., & Ruff, R.M. (1998). Are the subjective complaints of traumatically brain injured patients reliable? Brain Injury, 12, 505–515.CrossRefGoogle ScholarPubMed
Sherer, M., Bergloff, P., Boake, C., High, W. Jr., & Levin, E. (1998). The Awareness Questionnaire: Factor structure and internal consistency. Brain Injury, 12, 63–68.CrossRefGoogle ScholarPubMed
Sherer, M., Hart, T., & Nick, T.G. (2003). Measurement of impaired self-awareness after traumatic brain injury: A comparison of the patient competency rating scale and the awareness questionnaire. Brain Injury, 17, 25–37.CrossRefGoogle ScholarPubMed
Sherer, M., Hart, T., Nick, T.G., Whyte, J., Thompson, R.N., & Yablon, S.A. (2003). Early impaired self-awareness after traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 84, 168–176.CrossRefGoogle ScholarPubMed
Sohlberg, M.M., Mateer, C.A., Penkman, L., Glang, A., & Todis, B. (1998). Awareness intervention: Who needs it? Journal of Head Trauma Rehabilitation, 13, 62–78.CrossRefGoogle Scholar
Stablum, F., Mogentale, C., & Umiltà, C. (1996). Executive functioning following mild closed head injury. Cortex, 32, 261–278.CrossRefGoogle ScholarPubMed
Teasdale, G., & Jennett, B. (1974). Assessment of coma and impaired consciousness. A practical scale. Lancet, 13, 81–84.CrossRefGoogle Scholar
Toglia, J., & Kirk, U. (2000). Understanding awareness deficits following brain injury. Neurorehabilitation 15, 57–70.CrossRefGoogle ScholarPubMed
Trudel, T.M., Tyron, W., & Purdum, C. (1998). Awareness of disability and long-term outcome after traumatic brain injury. Rehabilitation Psychology, 43, 276–281.CrossRefGoogle Scholar
Vanderploeg, R.D., Belanger, H.G., Duchnick, J.D., & Curtiss, G. (2007). Awareness problems following moderate to severe traumatic brain injury: Prevalence, assessment methods, and injury correlates. Journal of Rehabilitation Research and Development, 44, 937–950.CrossRefGoogle ScholarPubMed
Walker, D.E., Blankenship, V., Ditty, J.A., & Lynch, K.P. (1987). Prediction of recovery for closed-head-injured adults: An evaluation of the MMPI, the Adaptive Behavior Scale, and a “Quality of life” Rating Scale. Journal of Clinical Psychology, 43, 699–707.3.0.CO;2-9>CrossRefGoogle Scholar
Watanabe, Y., Shiel, A., Asami, T., Taki, K., & Tabuchi, K. (2000). An evaluation of neurobehavioral problems by family members and level of family stress after 1-3 years after following traumatic brain injury in Japan. Clinical Rehabilitation, 14, 172–177.CrossRefGoogle Scholar
Wilson, J.T., Pettigrew, L.E., & Teasdale, G.M. (1998). Structured interviews for the Glasgow Outcome Scale and the Extended Glasgow Outcome Scale: Guidelines for their use. Journal of Neurotrauma, 15, 573–585.CrossRefGoogle ScholarPubMed
Zimmerman, P., & Fimm, B. (1992). Test Batterie zur Aufmerksamkeitsprüfung (TAP). Würselen: Psytest.Google Scholar