Awareness of behavioral, cognitive, and physical deficits in acute traumatic brain injury

Objective: To compare awareness of deficit in 3 domains of function (physical, cognitive, behavioral/emotional) in acute traumatic brain injury (TBI), controlling for severity of impairment in the different domains. Design: Inception cohort. Setting: Three inpatient rehabilitation programs. Participants: People with acute TBI (N=161), tested as soon as feasible after posttraumatic amnesia. Interventions: Not applicable. Main Outcome Measures: Awareness Questionnaire (AQ) completed by the person with TBI and the treating neuropsychologist; and self- and clinician-rating scores calculated in the 3 domains. Results: For participants who were rated by clinicians as more impaired in at least 1 domain (ie, scored lower on the AQ), self-ratings differed significantly from one another in all 3 domains, with behavioral self-ratings highest, physical self-ratings lowest, and cognitive self-ratings intermediate. In subgroups of participants rated at the same level by clinicians in all 3 domains, physical self-ratings were also lowest, that is, more consonant with clinician ratings. Participants tended to rate themselves as relatively unchanged in cognitive and behavioral domains regardless of the level of clinician ratings on these factors. Conclusions: Patterns of discrepant awareness of deficit in different functional areas seen in postacute TBI also appear to be present acutely and are not entirely related to differential severity of deficit. We discuss several possible reasons for discrepant awareness of deficit, including differences in internal and external feedback, cultural and psychologic factors, and different levels of ambiguity inherent in causal explanations for different types of problems.