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

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.

Assessing Level of Personality Organization With the Psychodiagnostic Chart: A Validity Study.

Heterogeneity within diagnostic types and comorbidity across diagnostic groups render a specific personality disorder anything but specific, leading researchers and clinicians to increasingly focus on the general severity of personality pathology. Personality pathology severity is reflected in one's level of personality organization (LPO) and research has demonstrated that LPO is a significant predictor of treatment response. This investigation examined the reliability and validity of the Psychodiagnostic Chart (PDC) in assessing the LPO dimension of the Psychodynamic Diagnostic Manual (PDM; PDM Task Force, 2006). Among a sample of 88 urban-dwelling women seeking primary medical care, the LPO dimension of the PDC received fair to good interrater reliability among 6 psychodynamic psychologists. Convergent validity was demonstrated with contrast analysis and individual correlations that yielded statistically significant associations between LPO scores and conceptually related psychodynamic variables (e.g., defensive functioning, object relations) and self-reported personality pathology scores. Support for discriminant validity was limited by the modest power associated with the sample size. Exploratory analyses examining LPO scores and measures of physical health and intimate partner violence were conducted. Our results supported the reliability, validity, and practical use of the LPO dimension of the PDC.

Defensive projection, superimposed on simplistic object relations, erodes patient-provider relationships in high-risk pregnancy: an empirical investigation.

In an attempt to illustrate the relevance of psychoanalytic theory and research to behavior medicine, an empirical investigation was conducted of females treated at a high-risk pregnancy specialty clinic (N = 58). Drawing from psychoanalytic object relations theory, it was hypothesized and confirmed that use of projection as a defense mechanism during pregnancy, superimposed on simplistic object relations, predicted an erosion of patient-provider relationships during the pregnancy/postdelivery period. Findings are interpreted through the perspective of mentalization, pertaining to individuals' ability to understand the mental states of self and others, specifically under significant stress. Implications for psychoanalytically oriented assessment and treatment, and for the rift between psychoanalysis and research, are discussed.

Convergent validity of the Defense Mechanisms Manual and the Defensive Functioning Scale.

We examined the convergent validity of Cramer's Defense Mechanisms Manual (DMM; Cramer, 1991b) by comparing it to the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) Defensive Functioning Scale (DFS). A total of 60 low income urban women from a primary care medical facility responded to four Thematic Apperception Test (TAT; Murray, 1943) cards and an interview of early memories and descriptions of significant others. We scored the TAT narratives with the DMM, and we coded the interview narratives with the DFS. DMM Denial and Projection scales were negatively correlated with the DFS Overall Defensive Functioning scale (r = -.28, p< .01 and r = -.22, p< .10, respectively) and were positively correlated with a DFS pathological composite score (r = .36, p< .01 and r = .32, p< .05, respectively). These findings support the convergent validity of the DMM Denial and Projection scales.

Defense and object relational maturity on Thematic Apperception Test scales indicate levels of personality organization.

Psychoanalytic theories describe defense mechanisms and object relations as psychological structures that have functions vital to personality regulation. In theory, these structures develop in stages and emerge as a coordinated, stable system in early adulthood. However, different levels of maturity of systemic function predominate in various individuals so that people exhibit levels of personality organization (LPO; Kernberg, 1975) differing in degree of maturity. Moreover, the various LPO of adults parallel various developmental stages of maturity of these structures in childhood and predispose to varying psychopathologies. We call this the parallelism hypothesis: Adult LPO parallels the stages of childhood development of these structures. In 2 studies (Study 1, students, n = 301; Study 2, diagnosed and presumed normal people, n = 155), we compared indicators of LPO with relative maturity of defenses and object relations using Thematic Apperception Test (Murray, 1943) scales (Cramer, 1991; Westen, Lohr, Silk, Kerber, & Goodrich, 1989). We compared scores to other indicators of participants' LPO. The parallelism hypothesis was largely supported in both studies.

Defense mechanisms and self-reported violence toward partners and strangers.

We examined the relationship between defense mechanisms and self-reported violence toward partners and toward strangers in a sample of college student men. Fifty men completed the Thematic Apperception Test (TAT; Murray, 1943) and the Conflict Tactics Scale (CTS; Straus, 1979), a self-report measure of strategies (including violence) for resolving conflicts with partners and strangers. The TAT responses were coded for defense mechanisms with the Defense Mechanisms Manual (Cramer, 1991b). The relative use of identification was negatively correlated (r = -.49, p <.001), and the relative use of projection was positively correlated (r =.49, p <.001) with the most extreme CTS report of violence toward partners. The relative use of identification was negatively correlated with the most extreme CTS report of violence toward strangers (r = -.34, p <.05). The relative use of denial was positively correlated with the most extreme CTS report of violence toward strangers (r =.32, p <.05).