Impaired self-awareness and denial of disability in a community sample of people with traumatic brain injury

Anneke Terneusen*, Ieke Winkens, Sanne Smeets, George Prigatano, John Porcerelli, Ray Kamoo, Caroline van Heugten, Rudolf Ponds

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review


PURPOSE: To examine the nature and severity of impaired self-awareness (ISA) and denial of disability (DD) in a community-dwelling traumatic brain injury (TBI) population. Additionally, to investigate reliability, internal consistency, and feasibility of the Clinician's Rating Scale for evaluating Impaired Self-Awareness and Denial of Disability after brain injury (CRS-ISA-DD).

MATERIALS AND METHODS: ISA and DD were studied using the CRS-ISA-DD in a cross-sectional study with 78 TBI patients (3.1 years post-injury).

RESULTS: 42% of individuals approached consented to participate in this study. Most participants showed one or more symptoms of ISA and DD, but severity scores were in the lower range (ISA: 13.2 ± 16.2; DD: 9.4 ± 10.7). The CRS-ISA-DD takes <10 min to complete, has excellent inter-rater reliability (ISA: ICC(2,1) = 0.928; DD: ICC(2,1) = 0.835), and acceptable-good internal consistency (ISA: α = 0.819; DD: α = 0.645). ISA severity correlated with neuropsychological test scores (rs = -0.30 to -0.47) and injury severity. DD severity correlated with anxiety (rs = -0.22) but not with avoidance coping or defense mechanisms.

CONCLUSIONS: Low levels of ISA and DD occurred in this sample of TBI patients. The CRS-ISA-DD is a reliable and feasible instrument. We recommend using it as a diagnostic tool to differentiate between ISA and DD once self-awareness problems have been identified.IMPLICATIONS FOR REHABILITATIONUnawareness of deficits can persist into the chronic stage when rehabilitation treatment has ended.The two main factors of unawareness, impaired self-awareness and denial of disability, are related to different neurological and psychological mechanisms.The Clinician's Rating Scale for evaluating Impaired Self-Awareness and Denial of Disability after brain injury (CRS-ISA-DD) can be used to distinguish the two main factors of unawareness.

Original languageEnglish
Pages (from-to)6633-6641
Number of pages9
JournalDisability and Rehabilitation
Issue number22
Early online date26 Aug 2021
Publication statusPublished - 23 Oct 2022


  • Self-awareness
  • community-dwelling traumatic brain injury
  • denial of disability
  • neuropsychological assessment
  • rehabilitation

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