When stroke survivors’ self-ratings are inconsistent with the ratings of others: a cohort study examining biopsychosocial factors associated with impaired self-awareness of functional abilities

Kate V. Cameron; Jennie L. Ponsford; Dean P. McKenzie; Renerus J. Stolwyk

doi:10.1071/IB23064

RESEARCH ARTICLE (Open Access)

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When stroke survivors’ self-ratings are inconsistent with the ratings of others: a cohort study examining biopsychosocial factors associated with impaired self-awareness of functional abilities

Kate V. Cameron

^A , Jennie L. Ponsford

^A ^B , Dean P. McKenzie

^C ^D and Renerus J. Stolwyk

^A ^B ^*

+ Author Affiliations

- Author Affiliations

^A School of Psychological Sciences, Monash University, Melbourne, Vic., Australia.

^B Monash-Epworth Rehabilitation Research Centre, Melbourne, Vic., Australia.

^C Epworth HealthCare, Office for Research, Melbourne, Vic., Australia.

^D School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic., Australia.

^* Correspondence to: rene.stolwyk@monash.edu

Handling Editor: Grahame Simpson

Brain Impairment 25, IB23064 https://doi.org/10.1071/IB23064

Submitted: 19 May 2023 Accepted: 15 January 2024 Published: 27 February 2024

© 2024 The Author(s) (or their employer(s)). Published by CSIRO Publishing on behalf of the Australasian Society for the Study of Brain Impairment. This is an open access article distributed under the Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC)

Abstract

Background

Stroke survivors’ self-ratings of functional abilities are often inconsistent with ratings assigned by others (e.g. clinicians), a phenomenon referred to as ‘impaired self-awareness’ (ISA). There is limited knowledge of the biopsychosocial contributors and consequences of post-stroke ISA measured across the rehabilitation journey. This multi-site cohort study explored biopsychosocial correlates of ISA during subacute rehabilitation (inpatient) and at 4 months post-discharge (community-dwelling).

Methods

Forty-five subacute stroke survivors participated (Age M (s.d.) = 71.5 (15.6), 56% female), and 38 were successfully followed-up. Self-assessments were compared to those of an independent rater (occupational therapist, close other) to calculate ISA at both time points. Survivors and raters completed additional cognitive, psychological and functional measures.

Results

Multivariate regression (multiple outcomes) identified associations between ISA during inpatient admission and poorer outcomes at follow-up, including poorer functional cognition, participation restriction, caregiver burden, and close other depression and anxiety. Regression models applied cross-sectionally, including one intended for correlated predictors, indicated associations between ISA during inpatient admission and younger age, male sex, poorer functional cognition, poorer rehabilitation engagement and less frequent use of non-productive coping (adjusted R² = 0.60). ISA at community follow-up was associated with poorer functional cognition and close other anxiety (adjusted R² = 0.66).

Conclusions

Associations between ISA and poorer outcomes across the rehabilitation journey highlight the clinical importance of ISA and the value of assessment and management approaches that consider the potential influence of numerous biological and psychosocial factors on ISA. Future studies should use larger sample sizes to confirm these results and determine the causal mechanisms of these relationships.

Keywords: acquired brain injury, appraisal discrepancy, biopsychosocial, cognition, insight, rehabilitation, self-awareness, stroke.

References

Addis ME, Mahalik JR (2003) Men, masculinity, and the contexts of help seeking. The American Psychologist 58, 5-14.
| Crossref | Google Scholar | PubMed |

Alston M, Jones J, Curtin M (2012) Women and Traumatic Brain Injury: “It’s not visible damage”. Australian Social Work 65, 39-53.
| Crossref | Google Scholar |

Amanzio M, Vase L, Leotta D, Miceli R, Palermo S, Geminiani G (2013) Impaired Awareness of Deficits in Alzheimer’s Disease: The Role of Everyday Executive Dysfunction. Journal of the International Neuropsychological Society 19, 63-72.
| Crossref | Google Scholar | PubMed |

Austin PC, Steyerberg EW (2015) The number of subjects per variable required in linear regression analyses. Journal of Clinical Epidemiology 68, 627-636.
| Crossref | Google Scholar | PubMed |

Australian Institute of Health and Welfare (2018) ‘Australia’s health 2018.’ Australia’s health series. (Canberra) Available at https://www.aihw.gov.au/reports/australias-health/australias-health-2018/contents/table-of-contents

Avlund K (1997) Methodological challenges in measurements of functional ability in gerontological research. A review. Aging Clinical and Experimental Research 9, 164-174.
| Crossref | Google Scholar | PubMed |

Barskova T, Wilz G (2006) Psychosocial functioning after stroke: psychometric properties of the patient competency rating scale. Brain Injury 20, 1431-1437.
| Crossref | Google Scholar | PubMed |

Belchev Z, Levy N, Berman I, Levinzon H, Hoofien D, Gilboa A (2017) Psychological traits predict impaired awareness of deficits independently of neuropsychological factors in chronic traumatic brain injury. British Journal of Clinical Psychology 56, 213-234.
| Crossref | Google Scholar | PubMed |

Bjelland I, Dahl AA, Haug TT, Neckelmann D (2002) The validity of the Hospital Anxiety and Depression Scale. An updated literature review. Journal of Psychosomatic Research 52, 69-77.
| Crossref | Google Scholar | PubMed |

Brott T, Adams HP J, Olinger CP, Marler JR, Barsan WG, Biller J, Spilker J, Holleran R, Eberle R, Hertzberg V (1989) Measurements of acute cerebral infarction: a clinical examination scale. Stroke 20(7), 864-70.
| Crossref | Google Scholar | PubMed |

Byun E, Evans LK (2015) Concept Analysis of Burden in Caregivers of Stroke Survivors During the Early Poststroke Period. Clinical Nursing Research 24(5), 468-86.
| Crossref | Google Scholar | PubMed |

Cameron KV, Ponsford JL, Stolwyk RJ (2020) Do stroke survivors agree with their clinicians on the extent of their post-stroke activity limitation and participation restriction? Neuropsychological Rehabilitation 30, 1430-1448.
| Crossref | Google Scholar | PubMed |

Clare L (2004) The construction of awareness in early-stage Alzheimer’s disease: a review of concepts and models. British Journal of Clinical Psychology 43, 155-175.
| Crossref | Google Scholar | PubMed |

Clare L, Nelis SM, Martyr A, Roberts J, Whitaker CJ, Markova IS, Roth I, Woods RT, Morris RG (2012) The influence of psychological, social and contextual factors on the expression and measurement of awareness in early-stage dementia: testing a biopsychosocial model. International Journal of Geriatric Psychiatry 27, 167-177.
| Crossref | Google Scholar | PubMed |

Cnossen MC, Winkler EA, Yue JK, Okonkwo DO, Valadka AB, Steyerberg EW, Lingsma HF, Manley GT (2017) Development of a Prediction Model for Post-Concussive Symptoms following Mild Traumatic Brain Injury: A TRACK-TBI Pilot Study. J Neurotrauma 34(16), 2396-2409.
| Crossref | Google Scholar | PubMed |

Crosson B, Barco PP, Velozo CA, Bolesta MM, Cooper PV, Werts D, Brobeck TC (1989) Awareness and compensation in post-acute head injury rehabilitation. Journal of Head Trauma Rehabilitation 4, 46-54.
| Crossref | Google Scholar |

Dattalo P (2013) ‘Analysis of multiple dependent variables.’ (Oxford University Press: Oxford, UK)

Donovan NJ, Kendall DL, Heaton SC, Kwon S, Velozo CA, Duncan PW (2007) Conceptualizing Functional Cognition in Stroke. Neurorehabilitation and Neural Repair 22, 122-135.
| Crossref | Google Scholar | PubMed |

Dromer E, Kheloufi L, Azouvi P (2021) Impaired self-awareness after traumatic brain injury: a systematic review. Part 2. Consequences and predictors of poor self-awareness. Annals of Physical and Rehabilitation Medicine, 64, 101542.
| Crossref | Google Scholar | PubMed |

Engel GL (1980) The clinical application of the biopsychosocial model. American Journal of Psychiatry 137, 535-544.
| Crossref | Google Scholar | PubMed |

Ergh TC, Rapport LJ, Coleman RD, Hanks RA (2002) Predictors of caregiver and family functioning following traumatic brain injury: social support moderates caregiver distress. Journal of Head Trauma Rehabilitation 17, 155-174.
| Crossref | Google Scholar | PubMed |

Finset A, Andersson S (2000) ‘Coping strategies in patients with acquired brain injury: relationships between coping, apathy, depression and lesion location.’ (Taylor & Francis: UK)

Fischer S, Gauggel S, Trexler LE (2004) Awareness of activity limitations, goal setting and rehabilitation outcome in patients with brain injuries. Brain Injury 18, 547-562.
| Crossref | Google Scholar | PubMed |

Fleming J, Strong J (1995) Self-Awareness of Deficits following Acquired Brain Injury: Considerations for Rehabilitation. British Journal of Occupational Therapy 58, 55-60.
| Crossref | Google Scholar |

Fleming JM, Strong J, Ashton R (1996) Self-awareness of deficits in adults with traumatic brain injury: how best to measure? Brain Injury 10, 1-15.
| Crossref | Google Scholar | PubMed |

Frank L, Lenderking WR, Howard K, Cantillon M (2011) Patient self-report for evaluating mild cognitive impairment and prodromal Alzheimer’s disease. Alzheimer’s Research & Therapy 3, 35.
| Crossref | Google Scholar | PubMed |

Frydenberg E, Lewis R (1996) ‘Manual: Coping scale for adults.’ (Australian Council for Educational Research: Melbourne, Vic., Australia)

Gialanella B, Monguzzi V, Santoro R, Rocchi S (2005) Functional recovery after hemiplegia in patients with neglect: the rehabilitative role of anosognosia. Stroke 36, 2687-2690.
| Crossref | Google Scholar | PubMed |

Giles GM, Edwards DF, Morrison MT, Baum C, Wolf TJ (2017) Screening for Functional Cognition in Postacute Care and the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014. The American Journal of Occupational Therapy 71, 7105090010p1-7105090010p6.
| Crossref | Google Scholar | PubMed |

Giles GM, Edwards DF, Baum C, Furniss J, Skidmore E, Wolf T, Leland NE (2020) Making Functional Cognition a Professional Priority. The American Journal of Occupational Therapy 74, 7401090010p1-7401090010p6.
| Crossref | Google Scholar | PubMed |

Gracey F, Evans JJ, Malley D (2009) Capturing process and outcome in complex rehabilitation interventions: a “Y-shaped” model. Neuropsychological Rehabilitation 19, 867-890.
| Crossref | Google Scholar | PubMed |

Granger CV, Hamilton BB, Keith RA, Zielezny M, Sherwin FS (1986) Advances in functional assessment for medical rehabilitation. Topics in Geriatric Rehabilitation 1, 59-74.
| Crossref | Google Scholar |

Greenwood N, Mackenzie A, Cloud GC, Wilson N (2008) Informal carers of stroke survivors–factors influencing carers: a systematic review of quantitative studies. Disability & Rehabilitation 30, 1329-1349.
| Crossref | Google Scholar | PubMed |

Hair JF, Black WC, Babin BJ, Anderson RE, Tatham RL (2010) ‘Multivariate Data Analysis.’ (Pearson: New York, NY, USA)

Harrell FE (2015) ‘Regression modeling strategies: with applications to linear models, logistic and ordinal regression, and survival analysis.’ (Springer: New York, NY, USA)

Hartman-Maeir A, Soroker N, Oman SD, Katz N (2003) Awareness of disabilities in stroke rehabilitation – a clinical trial. Disability & Rehabilitation 25, 35-44.
| Google Scholar | PubMed |

Hawthorne G, Osborne R (2005) Population norms and meaningful differences for the Assessment of Quality of Life (AQoL) measure. Australian and New Zealand Journal of Public Health 29, 136-142.
| Crossref | Google Scholar | PubMed |

Heilman KM, Barrett AM, Adair JC (1998) Possible mechanisms of anosognosia: a defect in self–awareness. Philosophical Transactions of the Royal Society of London. Series B: Biological Sciences 353, 1903-1909.
| Crossref | Google Scholar | PubMed |

Hertzog C, Dunlosky J (2011) Metacognition in Later Adulthood: Spared Monitoring Can Benefit Older Adults’ Self-Regulation. Current Directions in Psychological Science 20, 167-173.
| Crossref | Google Scholar | PubMed |

Hier DB, Mondlock J, Caplan LR (1983) Behavioral abnormalities after right hemisphere stroke. Neurology 33, 337-344.
| Crossref | Google Scholar | PubMed |

Ismail Z, Elbayoumi H, Fischer CE, Hogan DB, Millikin CP, Schweizer T, Mortby ME, Smith EE, Patten SB, Fiest KM (2017) Prevalence of Depression in Patients With Mild Cognitive Impairment: A Systematic Review and Meta-analysis. JAMA Psychiatry 74, 58-67.
| Crossref | Google Scholar | PubMed |

Jehkonen M, Ahonen JP, Dastidar P, Koivisto AM, Laippala P, Vilkki J, Molnár G (2001) Predictors of discharge to home during the first year after right hemisphere stroke. Acta Neurologica Scandinavica 104, 136-141.
| Crossref | Google Scholar | PubMed |

Jehkonen M, Laihosalo M, Kettunen J (2006) Anosognosia after stroke: assessment, occurrence, subtypes and impact on functional outcome reviewed. Acta Neurologica Scandinavica 114, 293-306.
| Crossref | Google Scholar | PubMed |

Jenkinson PM, Preston C, Ellis SJ (2011) Unawareness after stroke: a review and practical guide to understanding, assessing, and managing anosognosia for hemiplegia. Journal of Clinical and Experimental Neuropsychology 33, 1079-1093.
| Crossref | Google Scholar | PubMed |

Kelleher M, Tolea MI, Galvin JE (2016) Anosognosia increases caregiver burden in mild cognitive impairment. International Journal of Geriatric Psychiatry 31, 799-808.
| Crossref | Google Scholar | PubMed |

Khamis HJ, Kepler M (2010) Sample Size in Multiple Regression: 20 + 5k. Journal of Applied Statistical Science 17, 505-517.
| Google Scholar |

Kirpich A, Ainsworth EA, Wedow JM, Newman JRB, Michailidis G, Mcintyre LM (2018) Variable selection in omics data: a practical evaluation of small sample sizes. PLoS One 13, e0197910.
| Crossref | Google Scholar | PubMed |

Kortte KB, Falk LD, Castillo RC, Johnson-Greene D, Wegener ST (2007) The Hopkins Rehabilitation Engagement Rating Scale: Development and Psychometric Properties. Archives of Physical Medicine and Rehabilitation 88, 877-884.
| Crossref | Google Scholar | PubMed |

Krpan KM, Levine B, Stuss DT, Dawson DR (2007) Executive function and coping at one-year post traumatic brain injury. Journal of Clinical and Experimental Neuropsychology 29, 36-46.
| Crossref | Google Scholar | PubMed |

Lacerda IB, Santos RL, Belfort T, Neto JPS, Dourado MCN (2020) Patterns of discrepancies in different objects of awareness in mild and moderate Alzheimer’s disease. Aging & Mental Health 24, 789-796.
| Crossref | Google Scholar | PubMed |

Lakens D (2022) Sample Size Justification. Collabra: Psychology 8, 1-27.
| Crossref | Google Scholar |

Lam CS, Mcmahon BT, Priddy DA, Gehred-Schultz A (1988) Deficit awareness and treatment performance among traumatic head injury adults. Brain Injury 2, 235-242.
| Crossref | Google Scholar | PubMed |

Lezak MD (1993) Newer contributions to the neuropsychological assessment of executive functions. The Journal of Head Trauma Rehabilitation 8, 24-31.
| Crossref | Google Scholar |

Mackenzie CS, Gekoski WL, Knox VJ (2006) Age, gender, and the underutilization of mental health services: the influence of help-seeking attitudes. Aging & Mental Health, 10, 574-582.
| Crossref | Google Scholar | PubMed |

Malec JF, Lezak MD (2003) Manual for the Mayo-Portland Adaptability Inventory (MPAI-4). Available at http://www.timbs.org/combi/mpai [accessed 28 November 2012]

Malec JF, Smigielski JS, Depompolo RW (1991) Goal attainment scaling and outcome measurement in postacute brain injury rehabilitation. Archives of Physical Medicine and Rehabilitation 72, 138-143.
| Google Scholar | PubMed |

Marcel AJ, Tegnér R, Nimmo-Smith I (2004) Anosognosia for plegia: specificity, extension, partiality and disunity of bodily unawareness. Cortex 40, 19-40.
| Crossref | Google Scholar | PubMed |

Martyr A, Gamble LD, Nelis SM, Collins R, Alexander CM, Morris RG, Quinn C, Pentecost C, Rusted JM, Victor C, Thom JM, Matthews FE, Clare L, on behalf of the IDEAL Study Team (2022) Predictors of Awareness of Functional Ability in People with Dementia: The Contribution of Personality, Cognition, and Neuropsychiatric Symptoms – Findings from the IDEAL Program. Dementia and Geriatric Cognitive Disorders 51, 221-232.
| Crossref | Google Scholar | PubMed |

McGlynn SM, Schacter DL (1989) Unawareness of deficits in neuropsychological syndromes. Journal of Clinical and Experimental Neuropsychology 11, 143-205.
| Crossref | Google Scholar | PubMed |

Moretti R, Torre P, Antonello RM, Cazzato G (2006) Behavioral alterations and vascular dementia. Neurologist 12, 43-47.
| Crossref | Google Scholar | PubMed |

Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, Cummings JL, Chertkow H (2005) The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. Journal of the American Geriatrics Society 53, 695-699.
| Crossref | Google Scholar | PubMed |

Niemeier JP, Perrin PB, Holcomb MG, Rolston CD, Artman LK, Lu J, Nersessova KS (2014) Gender differences in awareness and outcomes during acute traumatic brain injury recovery. Journal of Women’s Health 23, 573-580.
| Crossref | Google Scholar | PubMed |

Noé E, Ferri J, Caballero MC, Villodre R, Sanchez A, Chirivella J (2005) Self-awareness after acquired brain injury: predictors and rehabilitation. Journal of Neurology 252, 168-175.
| Crossref | Google Scholar | PubMed |

Nurmi ME, Jehkonen M (2014) Assessing anosognosias after stroke: a review of the methods used and developed over the past 35 years. Cortex 61, 43-63.
| Google Scholar |

Orfei MD, Robinson RG, Prigatano GP, Starkstein S, Rüsch N, Bria P, Caltagirone C, Spalletta G (2007) Anosognosia for hemiplegia after stroke is a multifaceted phenomenon: a systematic review of the literature. Brain 130, 3075-3090.
| Crossref | Google Scholar | PubMed |

Orfei MD, Caltagirone C, Spalletta G (2009) The evaluation of anosognosia in stroke patients. Cerebrovascular Diseases 27, 280-289.
| Crossref | Google Scholar | PubMed |

Ownsworth T, Clare L (2006) The association between awareness deficits and rehabilitation outcome following acquired brain injury. Clinical Psychology Review 26, 783-795.
| Crossref | Google Scholar | PubMed |

Ownsworth T, Fleming J (2005) The Relative Importance of Metacognitive Skills, Emotional Status, and Executive Function in Psychosocial Adjustment Following Acquired Brain Injury. The Journal of Head Trauma Rehabilitation 20, 315-332.
| Crossref | Google Scholar |

Ownsworth T, Clare L, Morris R (2006) An integrated biopsychosocial approach to understanding awareness deficits in Alzheimer’s disease and brain injury. Neuropsychological Rehabilitation 16, 415-438.
| Crossref | Google Scholar | PubMed |

Pia L, Neppi-Modona M, Ricci R, Berti A (2004) The Anatomy of Anosognosia for Hemiplegia: A Meta-Analysis. Cortex 40, 367-377.
| Crossref | Google Scholar | PubMed |

Pound P, Gompertz P, Ebrahim S (1998) Illness in the context of older age: the case of stroke. Sociology of Health and Illness 20, 489-506.
| Crossref | Google Scholar |

Prigatano GP, Fordyce DJ, Zeiner HK, Roueche JR, Pepping M, Wood BC (1986) ‘Neuropsychological rehabilitation after brain injury.’ (Johns Hopkins University Press: Baltimore, MD, USA)

Robertson K, Schmitter-Edgecombe M (2015) Self-awareness and traumatic brain injury outcome. Brain Injury 29, 848-858.
| Crossref | Google Scholar | PubMed |

Schwarz G (1978) Estimating the dimension of a model. The Annals of Statistics 6, 461-464.
| Crossref | Google Scholar |

Seltzer B, Vasterling JJ, Yoder JA, Thompson KA (1997) Awareness of deficit in Alzheimer’s disease: relation to caregiver burden. Gerontologist 37, 20-24.
| Crossref | Google Scholar | PubMed |

Sherer M, Hart T, Nick TG (2003a) Measurement of impaired self-awareness after traumatic brain injury: a comparison of the Patient Competency Rating Scale and the Awareness Questionnaire. Brain Injury 17, 25-37.
| Google Scholar |

Sherer M, Hart T, Nick TG, Whyte J, Thompson RN, Yablon SA (2003b) Early impaired self-awareness after traumatic brain injury. Archives of Physical Medicine and Rehabilitation 84, 168-176.
| Google Scholar |

Sherer M, Hart T, Whyte J, Nick TG, Yablon SA (2005) Neuroanatomic basis of impaired self-awareness after traumatic brain injury: findings from early computed tomography. Journal of Head Trauma Rehabilitation 20, 287-300.
| Crossref | Google Scholar | PubMed |

Smeets SM, Ponds RW, Verhey FR, Van Heugten CM (2012) Psychometric properties and feasibility of instruments used to assess awareness of deficits after acquired brain injury: a systematic review. The Journal of Head Trauma Rehabilitation 27, 433-442.
| Crossref | Google Scholar | PubMed |

Smeets SM, Vink M, Ponds RW, Winkens I, Van Heugten CM (2017) Changes in impaired self-awareness after acquired brain injury in patients following intensive neuropsychological rehabilitation. Neuropsychological Rehabilitation 27, 116-132.
| Crossref | Google Scholar | PubMed |

Starkstein SE, Fedoroff JP, Price TR, Leiguarda R, Robinson RG (1992) Anosognosia in Patients With Cerebrovascular Lesions: A Study of Causative Factors. Stroke 23, 1446-1453.
| Crossref | Google Scholar | PubMed |

Stein MS, Reynolds FA (2020) How is carer strain related to the recovery of stroke survivors with right hemisphere dysfunction? Implications for practice. Disability and Rehabilitation 44, 693-701.
| Crossref | Google Scholar | PubMed |

Tagai K, Nagata T, Shinagawa S, Shigeta M (2020) Anosognosia in patients with Alzheimer’s disease: current perspectives. Psychogeriatrics 20, 345-352.
| Crossref | Google Scholar | PubMed |

Terneusen A, Winkens I, Van Heugten C, Stapert S, Jacobs H, Ponds R, Quaedflieg C (2022) Neural Correlates of Impaired Self-awareness of Deficits after Acquired Brain Injury: A Systematic Review. Neuropsychology Review 33, 222-237.
| Crossref | Google Scholar | PubMed |

Thompson AE, Anisimowicz Y, Miedema B, Hogg W, Wodchis WP, Aubrey-Bassler K (2016) The influence of gender and other patient characteristics on health care-seeking behaviour: a QUALICOPC study. BMC Family Practice 17, 38.
| Crossref | Google Scholar | PubMed |

Tibshirani R (1996) Regression Shrinkage and Selection via the Lasso. Journal of the Royal Statistical Society. Series B (Methodological) 58, 267-288.
| Crossref | Google Scholar |

Toglia J, Kirk U (2000) Understanding awareness deficits following brain injury. Neurorehabilitation 15, 57-70.
| Google Scholar | PubMed |

Trigg R, Jones RW, Skevington SM (2007) Can people with mild to moderate dementia provide reliable answers about their quality of life? Age and Ageing 36, 663-669.
| Crossref | Google Scholar | PubMed |

Vandenbroucke JP, Von Elm E, Altman DG, Gøtzsche PC, Mulrow CD, Pocock SJ, Poole C, Schlesselman JJ, Egger M, Strobe I (2007) Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration. PLoS Medicine 4, e297.
| Crossref | Google Scholar | PubMed |

Vittinghoff E, Shiboski SC, Glidden DV, Mcculloch CE (2005) ‘Regression Methods in Biostatistics: Linear, Logistic, Survival, and Repeated Measures Models.’ (Springer: New York, NY, USA)

Vocat R, Staub F, Stroppini T, Vuilleumier P (2010) Anosognosia for hemiplegia: a clinical-anatomical prospective study. Brain 133, 3578-3597.
| Crossref | Google Scholar | PubMed |

Vogel A, Waldorff FB, Waldemar G (2010) Impaired awareness of deficits and neuropsychiatric symptoms in early Alzheimer’s disease: the Danish Alzheimer Intervention Study (DAISY). The Journal of Neuropsychiatry and Clinical Neurosciences 22, 93-99.
| Crossref | Google Scholar | PubMed |

von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, Initiative S (2007) The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. The Lancet 370, 1453-1457.
| Crossref | Google Scholar | PubMed |

Weinstein EA, Kahn RL (1955) ‘Denial of Illness.’ (Charles C. Thomas Publisher: Springfield, IL, USA)

Wesson J, Clemson L, Crawford JD, Kochan NA, Brodaty H, Reppermund S (2017) Measurement of Functional Cognition and Complex Everyday Activities in Older Adults with Mild Cognitive Impairment and Mild Dementia: Validity of the Large Allen’s Cognitive Level Screen. The American Journal of Geriatric Psychiatry 25, 471-482.
| Crossref | Google Scholar | PubMed |

Wheeler M, Williams OA, Johns L, Chiu EG, Slavkova ED, Demeyere N (2022) Unravelling the complex interactions between self-awareness, cognitive change, and mood at 6-months post-stroke using the Y-shaped model. Neuropsychological Rehabilitation 33, 680-702.
| Crossref | Google Scholar | PubMed |

Wolf TJ, Edwards DF, Giles GM (2019) ‘Functional cognition and occupational therapy: a practical approach to treating individuals with cognitive loss.’ (AOTA Press: Bethesda, MD, USA)

Wood W, Christensen PN, Hebl MR, Rothgerber H (1997) Conformity to sex-typed norms, affect, and the self-concept. Journal of Personality and Social Psychology 73, 523-535.
| Crossref | Google Scholar | PubMed |

World Health Organization (2019). ICD-11: international classification of diseases. Retrieved from https://icd.who.int/

Yeates G, Henwood K, Gracey F, Evans J (2006) Awareness of Disability after Acquired Brain Injury: Subjectivity within the Psychosocial Context. Neuropsychoanalysis, 8, 175-189.
| Crossref | Google Scholar |

Zamboni G, Drazich E, Mcculloch E, Filippini N, Mackay CE, Jenkinson M, Tracey I, Wilcock GK (2013) Neuroanatomy of impaired self-awareness in Alzheimer’s disease and mild cognitive impairment. Cortex 49, 668-678.
| Crossref | Google Scholar | PubMed |

Zarit SH, Reever KE, Bach-Peterson J (1980) Relatives of the impaired elderly: correlates of feelings of burden. Gerontologist 20, 649-655.
| Crossref | Google Scholar | PubMed |

Zigmond AS, Snaith RP (1983) The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica 67, 361-370.
| Crossref | Google Scholar | PubMed |

Zimmermann N, Mograbi DC, Hermes-Pereira A, Fonseca RP, Prigatano GP (2017) Memory and executive functions correlates of self-awareness in traumatic brain injury. Cognitive Neuropsychiatry 22, 346-360.
| Crossref | Google Scholar | PubMed |