Objectives/Aims Impaired self-awareness of the executive emotional and physical consequences of moderate to severe brain injuries are reported during the recovery phase. It plays a crucial role in patients’ engagement and utilisation of rehabilitation and adversely affects functional outcomes following a brain injury. We aim to describe disorders of self-awareness after acquired brain injury, including prevalence within a post-acute rehabilitation setting, clinical presentation, association with different types of brain injury, neuropsychological impairments, and functional ability. We then consider its potential impact within the legislative frameworks and summarise possible interventions integrated within a holistic neurobehavioural approach to rehabilitation. Methods In a large sample (N=1120 ), the prevalence and severity of self-awareness impairments were captured using Mayo-Portland Adaptability Inventory-4 (MPAI-4) at admission and discharge from our neurobehavioral rehabilitation services. These scores are analysed against a range of neuropsychological parameters and functional outcomes. Results 79% of the sample had self-awareness deficits that affected their functioning, and in two thirds, to a significant level. The severity of self-awareness impairments across „different causes of brain injuries was comparable with no notable differences. Most individuals with mild or no self-awareness deficits were able to engage in restorative rehabilitation, whilst those with severe impairment in self-awareness mainly required scaffolding of their functioning, including some restrictions. Self-awareness impairment on admission was found to be strongly related with the level of self-awareness on discharge (rs = 0.53, N = 841). Self-awareness was also moderately associated with impairments in problem solving (rs = 0.37, N = 841), memory (rs = 0.30, N = 841), attention (rs = 0.31, N = 841) and money management (rs = 0.35, N = 841). Abstract 24 Figure 1 Severity of self-awareness impairment by medical diagnosis Abstract 24 Figure 2 Severity of self-awareness impairment by clinical stream Abstract 24 Table 1 Prevalence and severity of self-awareness impairment by chronicity Level of self-awareness impairment Time Since Injury 0–6 months N (%) 6–12 months N (%) 13+ months N (%) 0 – None 73 (8%) 5 (5%) 13 (8%) 1 – Very mild: does not interfere with activities 110 (13%) 13 (12%) 17 (11%) 2 – Mild 174 (20%) 24 (23%) 31 (20%) 3 – Moderate 234 (27%) 35 (33%) 63 (40%) 4 – Severe 267 (32%) 28 (27%) 33 (21%) Conclusions Disorders of self-awareness are prevalent in people with brain injury and can be persistent. Our data suggest that impaired self-awareness is not exclusively related to the cause/nature of the brain injury, but it is associated with impaired problem solving, memory and attention. The level of self-awareness on admission was also related to social participation and psychological adjustment on discharge. Further studies are required to assess the outcomes of targeted interventions (pharmacological and neurobehavioral) on the executive and emotional deficits that underpins self-awareness.

Several neurological patient populations, including traumatic brain injury (TBI), appear to produce an abnormally utilitarian' pattern of judgements to moral dilemmas; they tend to make judgements that maximize the welfare of the majority, rather than deontological judgements based on the following of moral rules (e.g., do not harm others). However, this patient research has always used extreme dilemmas with highly valued moral rules (e.g., do not kill). Data from healthy participants, however, suggest that when a wider range of dilemmas are employed, involving less valued moral rules (e.g., do not lie), moral judgements demonstrate sensitivity to the psychological intuitiveness of the judgements, rather than their deontological or utilitarian content (Kahane etal., Social Cognitive and Affective Neuroscience, 7, 2011, 393). We sought the moral judgements of 30 TBI participants and 30 controls on moral dilemmas where content (utilitarian/deontological) and intuition (intuitive/counter-intuitive) were measured concurrently. Overall TBI participants made utilitarian judgements in equal proportions to controls; disproportionately favouring utilitarian judgements only when they were counter-intuitive, and deontological judgements only when they were counter-intuitive. These results speak against the view that TBI causes a specific utilitarian bias, suggesting instead that moral intuition is broadly disrupted following TBI.

Effective pragmatic comprehension of language is critical for successful communication and interaction, but this ability is routinely impaired following Traumatic Brain Injury (TBI) (1,2). Individual studies have investigated the cognitive domains associated with impaired pragmatic comprehension, but there remains little understanding of the relative importance of these domains in contributing to pragmatic comprehension impairment following TBI. This paper presents a systematic meta-analytic review of the observed correlations between pragmatic comprehension and cognitive processes following TBI. Five meta-analyses were computed, which quantified the relationship between pragmatic comprehension and five key cognitive constructs (declarative memory; working memory; attention; executive functions; social cognition). Significant moderate-to-strong correlations were found between all cognitive measures and pragmatic comprehension, where declarative memory was the strongest correlate. Thus, our findings indicate that pragmatic comprehension in TBI is associated with an array of domain general cognitive processes, and as such deficits in these cognitive domains may underlie pragmatic comprehension difficulties following TBI. The clinical implications of these findings are discussed.

Primary objectives: This study examined the role of expressed emotion (EE) in post-stroke depression (PSD) and the extent to which partner/spouse EE interacted with lesion laterality in PSD. The relationship between (i) lesion location and levels of PSD and (ii) levels of EE and levels of PSD were investigated. The role of perceived EE in PSD was also explored. Design: Cross-sectional, between-subjects design. Methods: Measures applied to stroke survivors included Extended Activities of Daily Living Scale (EADL), Post-Stroke Depression Rating Scale (PSDRS) and Level of Expressed Emotion Scale (LEE); spouses/partners completed the LEE. Results: The interaction between lesion laterality and levels of partner/spouse EE on PSD was not statistically significant (p = 0.63, F = 0.24, df = 1,56). However, a clear relationship was found between lesion laterality and PSD (p = 0.028). As levels of spouse/partner LEE scores increased, levels of PSD also increased (p = 0.039). Perceived EE scores illustrated a significant interaction between lesion laterality and levels of EE on PSD (p = 0.005, F = 8.591, df = 1,56). Conclusion: Whilst spouse/partner EE scores showed no interaction with lesion laterality to determine levels of PSD, a significant interaction was found when compared with stroke survivor perceived EE scores. Furthermore, left hemisphere (LHS) stroke survivors reported higher levels of depression than right hemisphere (RHS) stroke survivors. As levels of EE increased, PSD also increased, with LHS being greater than RHS.