In Part I of this series I gave an introduction to anosognosia, a lack of awareness experienced regarding deficits which occur following a brain injury (http://tlcrehab.wordpress.com/2013/04/17/anosognosia-part-i/). This lack of sufficient awareness of injury-caused deficits can be frustrating for both the brain injury survivor and the survivor’s family and can often lead the survivor to make poor decisions. In this installment, I will address strategies by which a survivor can effect improvement of that awareness.
Anosognosia is particularly common when individuals who have suffered moderate to severe brain injuries are first coming out of their comas. These individuals often suffer from Post-Traumatic Amnesia (PTA). At this early stage, brain injury survivors are just beginning to heal. They may walk or talk but will tend to say and do things stridently out of character, such as physically assaulting health care professionals and caretakers or making wild accusations (“You’ve poisoned my food”, etc.). They also have a very poor understanding of the world around them and new memories established tend not to be very strong ones. It can be argued that during PTA most brain injury survivors lack a full awareness of their injury. After all, they are not really well enough connected to reality to allow for a full understanding of all that has happened and often cannot hold on to new memories for a long enough time in order to remember things they have been told. Many brain injury survivors’ anosognosia simply improves as they gradually emerge out of PTA and attain a better understanding of their situation.
Anosognosia is improved by successfully teaching the brain injury survivor about his or her deficits. Many people take it for granted that a patient in a wheelchair will automatically understand that he or she is unable to walk. This is often not the case, particularly in the immediate aftermath of an injury. Sometimes family and friends can forget that the brain injury survivor may not have all of the information about the injury to which they’ve been exposed. After all, the survivor may have been unconscious or in PTA while doctors shared such information with the family and friends. It is important that the brain injury survivor be taught, with rigorous repetition, about his or her brain injury and subsequent deficits. It often helps to review medical records with the brain injury survivor so the survivor is able to see what happened laid out in an “official” form. Since many survivors have deficits in memory and comprehension, it is generally helpful to review the information with the survivor on an excessively regular basis until he or she demonstrates a strong understanding of the injury and its consequences.
Brain injury survivors with anosognosia often benefit greatly from feedback on their performance during tasks. This can aid in a very specific manner in efforts to teach them about their deficits. For instance, a survivor with reading deficits may not believe he has a deficit until he attempts a reading test and learns that he got half the comprehension questions wrong. Therapists may employ a method termed “guided failure.” In this method, the patient is allowed to attempt a task (with safety precautions in place, as necessary) that the patient believes he or she is capable of completing but which the therapist knows will serve as a substantial obstacle. This gives the patient an opportunity to try the task and learn from his or her struggles. In some cases, the survivor may benefit from seeing a video which documents the attempted task and resultant poor performance. Some survivors who minimize their difficulties quickly gain appreciation for their deficits when they see their difficulties on video. The video provides objective evidence of performance. Another method that therapists often use is asking patients to rate how they will do on a task prior to starting it and then comparing that rating with the actual results of the attempt. This method allows the therapist to show patients the difference in performance between what those patients believe they are capable of achieving and what actually occurs. As an example, a patient may estimate that he can walk 5 miles but when he tries to walk he is only able to accomplish 10 feet. The therapist will then review with him the difference between his estimated performance and his actual performance.
Improvement in anosognosia, particularly for survivors with more serious injuries, can be a long, slow process. Most survivors do show improvement over time. Unfortunately, there are some cases in which a survivor does not make appreciable improvement in their anosognosia despite considerable effort. In these cases, it is vital that the survivor’s family and treatment team develop a safety plan in order to minimize the impact anosognosia is allowed to have on the survivor’s general welfare and overall quality of life.
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