Jenny Strong

Cluster analysis of self-awareness levels in adults with traumatic brain injury and relationship to outcome

The purpose of this study was to investigate the relationship between self-awareness, emotional distress, motivation, and outcome in adults with severe traumatic brain injury. A sample of 55 patients were selected from 120 consecutive patients with severe traumatic brain injury admitted to the rehabilitation unit of a large metropolitan public hospital. Subjects received multi disciplinary inpatient rehabilitation and different types of outpatient rehabilitation and community-based services according to availability and need. Measures used In the cluster analysis were the Patient Competency Rating Scale, Self-Awareness of Deficits Interview, Head Injury Behavior Scale, Change Assessment Questionnaire, the Beck Depression Inventory, and Beck Anxiety Inventory; outcome measures were the Disability Rating Scale, Community Integration Questionnaire, and Sickness Impact Profile. A three-cluster solution was selected, with groups labeled as high self-awareness (n=23), low self-awareness (n=23), and good recovery (n=8). The high self-awareness cluster had significantly higher levels of self-awareness, motivation, and emotional distress than the low self-awareness cluster but did not differ significantly in outcome. Self-awareness after brain injury is associated with greater motivation to change behavior and higher levels of depression and anxiety; however, it was not clear that this heightened motivation actually led to any improvement in outcome. Rehabilitation timing and approach may need to be tailored to match the Individuals level of self-awareness, motivation, and emotional distress

Adult attachment, anxiety, and pain self-efficacy as predictors of pain intensity and disability

Abstract Pain self‐efficacy and anxiety have each been shown to contribute substantially to pain intensity and pain‐related disability. Although adult attachment theory has been related separately to chronic pain, anxiety, and self‐efficacy, it has not before been investigated with either pain self‐efficacy or anxiety in the context of chronic pain. This study investigated the interrelations between these aspects of the chronic pain experience and their relative contributions towards pain intensity and disability. A clinical sample of 152 chronic pain patients participated in this study, completing self‐report measures of attachment, self‐efficacy, pain intensity, and disability, prior to attending a multidisciplinary pain clinic. Results revealed that fearful and preoccupied (anxious) attachment categories were associated with low pain self‐efficacy, while high scores on the attachment dimension of comfort with closeness were linked with high pain self‐efficacy, particularly for males. Insecure attachment (whether defined in terms of categories or dimensions) was related to higher levels of anxiety. Pain self‐efficacy proved a stronger predictor of pain intensity than did anxiety and was a stronger predictor of disability than pain intensity or anxiety. In addition, comfort with closeness moderated the associations between pain self‐efficacy and disability, pain self‐efficacy and pain intensity, and anxiety and disability. Together, these findings support the value of adopting an attachment theoretical approach in the context of chronic pain. Treatment considerations and future research directions are considered.

Prospective memory rehabilitation for adults with traumatic brain injury: A compensatory training programme

Primary objective: To describe a prospective memory rehabilitation programme based on a compensatory training approach and report the results of three case studies. Research design: Programme evaluation using pre- and post-intervention assessments and telephone follow-up. Methods and procedures: Three participants with traumatic brain injury completed 8 weeks of training with 1–2 hour individual sessions. Assessments were formal prospective memory assessment, self-report and measures of diary use. Experimental interventions: Intervention aimed to identify potential barriers, establish self-awareness of memory deficits, introduce a customized compensatory tool, a cueing system and organizational strategies. A significant other was involved in training to assist generalization. Main outcomes and results: All three participants improved on formal prospective memory assessment and demonstrated successful diary use after the programme. Self-report of prospective memory failure fluctuated and may reflect increased self-awareness. Conclusion: A compensatory approach may be useful in improving prospective memory performance following TBI.

The relationship of adult attachment to emotion, catastrophizing, control, threshold and tolerance, in experimentally-induced pain.

Abstract Although insecure attachment has been associated with a range of variables linked with problematic adjustment to chronic pain, the causal direction of these relationships remains unclear. Adult attachment style is, theoretically, developmentally antecedent to cognitions, emotions and behaviours (and might therefore be expected to contribute to maladjustment). It can also be argued, however, that the experience of chronic pain increases attachment insecurity. This project examined this issue by determining associations between adult attachment characteristics, collected prior to an acute (coldpressor) pain experience, and a range of emotional, cognitive, pain tolerance, intensity and threshold variables collected during and after the coldpressor task. A convenience sample of 58 participants with no history of chronic pain was recruited. Results demonstrated that attachment anxiety was associated with lower pain thresholds; more stress, depression, and catastrophizing; diminished perceptions of control over pain; and diminished ability to decrease pain. Conversely, secure attachment was linked with lower levels of depression and catastrophizing, and more control over pain. Of particular interest were findings that attachment style moderated the effects of pain intensity on the tendency to catastrophize, such that insecurely attached individuals were more likely to catastrophize when reporting high pain intensity. This is the first study to link attachment with perceptions of pain in a pain‐free sample. These findings cast anxious attachment as a vulnerability factor for chronic pain following acute episodes of pain, while secure attachment may provide more resilience.

The measurement of attitudes towards and beliefs about pain

&NA; This study compared the psychometric properties of two scales designed to measure attitudes towards and beliefs about pain. The Survey of Pain Attitudes (Revised) SOPA(R) (Jensen and Karoly 1987) and the Pain Beliefs and Perceptions Inventory (PBPI) (Williams and Thorn 1989) were examined in terms of internal consistency, discriminant validity, factor structure, construct validity and sensitivity to age and gender effects. Results provided strong support for the SOPA(R) as a useful measurement tool for use with patients with chronic low back pain. Further work is suggested for the PBPI, as the reported factor structure was not replicated. Discussion centred around the possible reasons for this finding, with issues such as the possible orientation of different treatment facilities, the possible differences in attitudes between patients with different types of pain, and the possible influence of length of years in pain or the receipt of workers compensation payments being considered.

A Longitudinal Study of Self-Awareness: Functional Deficits Underestimated by Persons with Brain Injury

A longitudinal study of 55 adults with severe traumatic brain injury (TBI) investigated the areas of function for which they lacked self-awareness of their level of competency. Data were collected at 3 and 12 months post-injury using the Patient Competency Rating Scale. Self-awareness was measured by comparing patient self-ratings with the ratings of an informant. The results were consistent with previous studies, indicating that self-awareness was most impaired for activities with a large cognitive and socioemotional component, and least impaired for basic activities of daily living, memory activities, and overt emotional responses. For most areas of function that were overestimated at 3 months post-injury, self-awareness subsequently improved during the first year after injury.

Self-Awareness of Deficits following Acquired Brain Injury: Considerations for Rehabilitation

Limitations in self-awareness of deficits after acquired brain injury can hamper client participation in rehabilitation programmes. The concept of self-awareness encompasses awareness of brain injury related deficits, an appreciation of the functional consequences of deficits, and the ability to translate that information into realistic goals. A literature review suggests that the development of self-awareness can be associated with emotional distress in the individual. Self-awareness and emotional adjustment factors may both affect behavioural change in the individual, which may influence outcome. The widely held belief that self-awareness is necessary for successful outcomes from rehabilitation requires further investigation.

A metacognitive contextual intervention to enhance error awareness and functional outcome following traumatic brain injury: A single-case experimental design

Very few empirically validated interventions for improving metacognitive skills (i.e., self-awareness and self-regulation) and functional outcomes have been reported. This single-case experimental study presents JM, a 36-year-old man with a very severe traumatic brain injury (TBI) who demonstrated long-term awareness deficits. Treatment at four years post-injury involved a metacognitive contextual intervention based on a conceptualization of neuro-cognitive, psychological, and socio-environmental factors contributing to his awareness deficits. The 16-week intervention targeted error awareness and self-correction in two real life settings: (a) cooking at home; and (b) volunteer work. Outcome measures included behavioral observation of error behavior and standardized awareness measures. Relative to baseline performance in the cooking setting, JM demonstrated a 44% reduction in error frequency and increased self-correction. Although no spontaneous generalization was evident in the volunteer work setting, specific training in this environment led to a 39% decrease in errors. JM later gained paid employment and received brief metacognitive training in his work environment. JMs global self-knowledge of deficits assessed by self-report was unchanged after the program. Overall, the study provides preliminary support for a metacognitive contextual approach to improve error awareness and functional outcome in real life settings.

Adult attachment variables predict depression before and after treatment for chronic pain.

The complex relationship between chronic pain and depression has long been of clinical and empirical interest. Although attachment theory has been described as a “theory of affect regulation”, and has been lauded as a developmental framework for chronic pain, surprisingly little research specifically considers the links between adult attachment variables and pain‐related depression. A sample of 99 participants with chronic pain of non‐cancer origin was evaluated before and after pain rehabilitation. Results demonstrated that two attachment dimensions (comfort with closeness and relationship anxiety) were related to pre‐ and post‐treatment depression. Of particular interest was the finding that comfort with closeness was the unique predictor of lower levels of post‐treatment depression, usurping pain intensity and pre‐treatment depression. These results are discussed in terms of clinical implications, and suggest that adult attachment theory may prove a valuable perspective in pain treatment programs.

Awareness typologies, long-term emotional adjustment and psychosocial outcomes following acquired brain injury

Previous research suggests considerable heterogeneity within groups of individuals identified as having low self-awareness or good self-awareness following acquired brain injury (ABI). The present study aimed to identify typologies of individuals according to neuropsychological and psychological factors related to awareness deficits and compare emotional adjustment and psychosocial outcomes at the initial assessment and 12-month follow-up. Eighty-four participants with ABI (mean time since injury = 3.9 years) were assessed on the Self-Awareness of Deficits Interview, Awareness Questionnaire, Symptom Expectancy Checklist, Marlowe-Crowne Social Desirability Scale, Hospital Anxiety Depression Scale, Sydney Psychosocial Reintegration Scale, and an error self-regulation index. A 12-month follow-up assessment of emotional adjustment and psychosocial outcomes was conducted. A hierarchical cluster analysis distinguished four awareness typologies, namely, “poor self-awareness” (n = 12), “high defensiveness” (n = 13), “high symptom reporting” (n = 15), and “good self-awareness” (n = 44). An overall comparison of outcomes indicated that the poor self-awareness and high symptom reporting typologies experienced poorer outcomes than the high defensiveness and good self-awareness typologies. The findings confirm that there are different awareness typologies and highlight the need to tailor interventions according to the nature of awareness deficits.